Atlas Oral Maxillofacial Surg Clin N Am 13 (2005) 151–171

Microvascular Free Bone Flaps

Remy H. Blanchaert, Jr, MD, DDSa,*,
Christopher M. Harris, MD, DMDb
a
Oral and Maxillofacial Surgery Associates, 1919 N. Webb Road, Wichita, KS 67206, USA
b
Department of Oral and Maxillofacial Surgery,
University of Missouri-Kansas City School of Dentistry, University of
Missouri-Kansas City School of Medicine, 2301 Holmes Street, Kansas City, MO 64108, USA

In the not-so-distant past, composite bone-containing defects of the maxillofacial region

were reconstructed in a series of staged operations over a long period of time. The development
and refinement of microvascular free bone flaps has revolutionized the management of such
cases by allowing immediate one-stage reconstruction. The advantages of such an approach are
obvious. Restoration of facial form, before the development of the scarring process, provides
a more natural facial appearance. Economic advantages include decreased direct costs because
hospital stay is markedly reduced and total surgical time is decreased. Patients benefit by
avoiding a series of operations that require time away from work and family. Complication
rates of microvascular free bone flaps paralleldor are better thandthose published for bone
grafting procedures. Perhaps most importantly, with proper planning, microvascular free bone
flap reconstruction allows for definitive dental implant-based mandibular reconstruction
(Fig. 1A–D). Reconstruction is important because the ability to eat and speak normally
correlates strongly with patient quality of life after maxillofacial reconstruction, as demon-
strated in many clinical studies.
Why do some surgeons within the field of oral and maxillofacial surgery condemn the use of
free bone flaps for mandibular reconstruction? Perhaps their experience is limited to cases in
which appropriate planning and proper attention to detail were not exercised and the outcome
was suboptimal. Microvascular free bone flaps are challenging. This article was designed to
address the challenges associated with microvascular free bone flaps. The intent is to guide
readers through the process of applying microvascular free bone flaps in their practice by
outlining the lessons learned through 8 years of extensive involvement in maxillofacial
reconstruction. General principles are discussed first, followed by a discussion of the various
flaps applicable to maxillofacial reconstruction. Several site-specific case examples also are
provided to emphasize the challenges faced in mandibular reconstruction.

Basic principles

Reconstructive surgeons must understand fully the anticipated defect before preoperative
planning can begin. It is important that surgeons carefully evaluate the operative site, review
appropriate imaging, and discuss the planned operation with other surgeons involved in the case
to comprehend the anticipated defect in three dimensions. Microvascular surgeons must select
the most appropriate donor site, consider the vessel geometry, and devise a plan for shaping,
contouring, and insetting the flap in an expedient manner to minimize the ischemia time and
facilitate the microvascular anastomosis.

* Corresponding author.
E-mail address: [email protected] (R.H. Blanchaert, Jr).

1061-3315/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.cxom.2005.05.002 oralmaxsurgeryatlas.theclinics.com
152 BLANCHAERT & HARRIS

Fig. 1. (A–D) This series of images illustrates anterior mandibular reconstruction with a free fibula flap. Note the
character of the healing at the sites of osteotomy of the fibula. Dental implant-based rehabilitation completed the
reconstruction.

In most cases of composite bone-containing defects of the maxillofacial region, fibula flaps
and deep circumflex iliac artery (DCIA) flaps are the most suitable choices. In rare instances, the
scapula flap and the free radial forearm osteocutaneous flap may prove useful. The fibula flap
is generally favored over the DCIA flap because of ease of harvest, minimal donor site
complications, and length of the vascular pedicle. The major advantage of the DCIA flap is that
the donor site is completely hidden.
The donor site should be examined carefully to determine suitability. The vascular supply to
the flap and the remaining tissues must be assured. Prior surgery can compromise the blood
supply (ie, axillary dissection, scapula flap), and vascular anomalies can put the foot or hand at
risk after flap harvest (fibula, free radial forearm flap). The site selected for flap harvest affects
the orientation of the vascular pedicle and must be considered in designing the flap to ensure
appropriate vessel geometry. In general, the vessels of free flaps do not tolerate tension,
redundancy, or sharp angles, which can kink the vein obstruction outflow. In the case of
mandibular reconstruction, the vessels should be oriented in a manner that protects them from
compression by orienting the flap to place the vascular pedicle along the medial aspect of the
inferior border of the neomandible. The flap should be designed so that the vessels extend from
the flap as near the recipient vessels as possible. For example, if the flap pedicle is to exit the flap
at the angle of the right mandible and the skin paddle is to cross over the lateral surface of the
neomandible, then the right fibula should be used. Likewise, if the flap is to be similarly oriented
but the pedicle must leave the flap at its anterior aspect (ie, angle and ramus reconstruction),
then the left leg should be used.
The recipient site must be prepared appropriately before the flap is harvested. Often, the flap
can be elevated and allowed to reperfuse while the recipient site is prepared. If surgery involves
a patient who underwent irradiation or is a reoperation on a neck that underwent previous neck
dissection, however, it may be better to delay flap elevation until after ensuring the presence of
acceptable recipient vessels. In either setting, it is best to restore the continuity of the mandible
with a reconstruction bar before flap harvest. This approach ensures that the shape of the
mandible and drape of the facial tissues are acceptable. The flap can be adapted to this shape
at the time of flap inset. In many instances, the reconstruction plate can be adapted before
resection, removed for resection, and replaced. When there is lateral expansion or full-thickness
 MICROVASCULAR FREE BONE FLAPS 153

tumor involvement, alternate means of plate adaptation must be considered. Stereolithographic

models or CAD-CAM polymer models can be created from CT scans, and the reconstruction
plate can be adapted to these models after recontouring to a more normal mandibular anatomy
(Fig. 2). The need for such a model must be appreciated at the time of initial patient evaluation
before imaging is ordered, because special imaging protocols may be required. In some instances
it may be helpful to use an external fixation device applied away from the area of the mandible
involved in the resection. The device holds the remaining segments of the mandible in place to
allow for plate contouring, adaptation, and stabilization (Fig. 3A, B). In other instances, the
mandibular contour must be established by placing the teeth in occlusion and repositioning
segments that are non–tooth bearing in appropriate position by reference to lateral and
posteroanterior cephalometric radiographs. Sometimes a surgeon must adapt the bone plate
using only the opposing dental arch as a guide, based on knowledge of normal jaw anatomy. In
such cases it is necessary to view the plate adaptation from multiple angles to ensure appropriate
positioning (Fig. 4A, B).
The authors favor the use of locking reconstruction plates for stabilization of microvascular
free bone flaps in mandibular reconstruction. Larger plates were used initially; however, these
newer plates have advantages in many applications, particularly for segmental resection. The
larger plates are still used when reconstructing massive resections and for condylar re-
construction. The small 2-mm plates are lower in profile but possess more than enough rigidity
to stabilize the bone segments until bone healing is complete. Because of the excellent blood
supply, bony union is achieved rapidly (4–6 weeks). This union depends on excellent adaptation
of the bone, however. The osteotomies should be created to ensure intimate contact between
segments of the flap and between the flap segments and the native mandible. Failure to do so
may result in nonunion and subsequent hardware failure (Fig. 5). Standard screws (nonlocking)
are used to secure the bone segments to the reconstruction bar. The use of the miniplate
technique provides adequate stability if applied properly, using paired plates at each osteotomy
or flap-native mandible interface. A single miniplate provides insufficient stability (Fig. 6). The
authors do not use miniplate technique because the use of a previously adapted and applied
reconstruction plate provides such a useful guide for bone flap recontouring.
Revascularization of the flap is completed after recontouring, stabilization and skin paddle
inset, and suturing. Manipulation of the flap while it is ischemic simplifies this process. The flap
inset is completed before revascularization to ensure that the vessel geometry is appropriate.
Microvascular anastomosis is completed with the use of the operating microscope. The
microscope has significant advantages over the use of loupe magnification. The scope offers
excellent illumination, variable magnification, and equal visualization of the field by the
operator and assistant. The practice of heparinization of the patient at the time of microvascular
anastomosis has been shown to be unnecessary and associated with increased local wound
complications (hematoma). Irrigation of the vessels is accomplished with a solution of 500 U
heparin per 100 mL of saline. An anterior chamber irrigating needle on 5-mL syringes provides

Fig. 2. Preoperative adaptation of a mandibular reconstruction plate to a CAD-CAM model is accomplished after
recontouring the site of tumor expansion to approximate a more normal mandibular anatomy.
154 BLANCHAERT & HARRIS

Fig. 3. (A,B) This case series demonstrates the use of a mandibular bridge (temporary external fixator device) to
maintain the position of the proximal mandibular segments after mandibulectomy. The second image illustrates the
appearance after inset of a fibula free flap. Note the position of the vascular pedicle along the medial surface of the
neomandible and the lateral position of the vascular perforators to the skin paddle after inset in the mouth.

a suitable irrigation stream. The authors use standard interrupted technique with 9-0 nylon for
vessel anastomosis. Disposable approximation clamps are used because they provide reliable
clamping forces. End-to-end technique is used most commonly for microvascular anastomosis.
The artery is typically approximated first because it is generally deeper than the vein. The facial
artery, superior thyroid artery, and external carotid artery are the most commonly used
recipient arteries. The common facial vein and external jugular vein are the typically used
recipient veins.

Fibula flap

Background

The fibula flap has gained a well-deserved reputation for reliability, ease of harvest, and
suitability for definitive implant-supported dental rehabilitation. A few oral and maxillofacial

Fig. 4. (A,B) This series of images demonstrates the challenges faced in secondary reconstruction. This case involved
multiple operations and bone grafts after shotgun injury. The two images show how viewing the reconstruction from
multiple angles facilitates anatomic mandibular reconstruction.
 MICROVASCULAR FREE BONE FLAPS 155

Fig. 5. This image displays hardware failure caused by nonunion of the DCIA flap to the native mandible. The source of
this problem seems to be inadequate flap inset.

surgeons proclaim this flap unsuitable for mandibular reconstruction. The fibula mandibular
reconstruction is different in appearance and height in comparison to the native mandible in
some cases. The literature that describes success with the flap for this purpose and the senior
author’s extensive experience dispute those who downplay the use of this flap. The flap height
and shape of the flap resemble closely the structure of an atrophic edentulous mandible.
Throughout the world, the fibula flap has become the most common means of primary
mandibular reconstruction. The distance of the donor site from the head and neck field is an
advantage because it allows for simultaneous surgery. Likewise, the lack of significant morbidity
of the flap harvest with proper attention to detail is also a significant advantage of the flap.
Early reports of poor reliability of the skin paddle have proved to be related to a poor
understanding of the flap anatomy, which has led to errors in flap harvest rather than a true
problem with the flap itself. These errors occurred because the vascular perforators to the skin do
not always pass to the skin within the lateral intramuscular septum and can be musculocuta-
neous perforators (Fig. 7). The presence of musculocutaneous perforators complicates the
harvest and limits the mobility of the skin paddle slightly, but it is managed easily by an
experienced surgeon.
The fibula flap is based on the peroneal artery and vein. These vessels are of good diameter
and quality. Preoperative evaluation of the perfusion of the lower extremity should be
performed before planning surgery. The authors perform a clinical assessment and determine
the necessity for additional studies based on the findings of that examination. The examination
should consider color and character of the skin, hair distribution, temperature, nail thickness,
and the character and quality of the pulses within the foot. Identification of any abnormality
should trigger a vascular imaging study. The authors prefer magnetic resonance angiography
(Fig. 8) over arteriography because of the radiation and the dye load required for the

Fig. 6. This image demonstrates the inadequate stability provided by a single miniplate. The free fibula flap did not heal
to the native mandible. The cause of this nonunion could be either inadequate stability or poor inset. Miniplates should
be applied in two planes as a paired plate construct.
156 BLANCHAERT & HARRIS

Fig. 7. This artist sketch is an excellent depiction of the flap harvest, character of the perforators, and proximity to
adjacent structures.

arteriography. Based on studies, it is estimated that 10% to 20% of lower extremities display
abnormal characteristics, which causes the harvest of the peroneal artery to potentially
compromise the vascularity of the foot. The rationale for not studying all legs is that with an
excellent clinical examination the likelihood of a significant abnormality is low and all three
major vessels will be seen in the course of flap elevation, which makes it possible to identify any
abnormality before flap harvest.

Fig. 8. This is an AP MRA image of the right leg. The detail seen with this imaging technique is remarkable.
 MICROVASCULAR FREE BONE FLAPS 157

The fibula flap offers flexibility in flap design and placement that provides reconstructive
surgeons with important options in the selection of appropriate recipient vessels. Surgeons
should select the donor leg and design the flap to simplify inset and maximize vascular pedicle
length. The length of the available fibula allows for nearly total mandibular reconstruction. The
character and quality of the bone, along with the excellent segmental vascular supply, allow
surgeons to custom contour the flap to the ideal dimensions of the mandible. Closing
osteotomies allow precision inset of the flap to ensure excellent, direct bone contact. When
properly recontoured and inset, the flap heals rapidly and restores mandibular continuity
despite the administration of postoperative adjuvant radiation therapy. The bone supports the
placement of dental implants immediately at the time of flap reconstruction, after bone healing,
or after resolution of the acute effects of the radiation therapy. Mandibular hardware should be
removed at the time of implant placement to ensure load transfer to the bone element of the flap.

Technique

A patient’s donor leg should be shaved with clippers and the surgical anatomic landmarks
outlined in detail. It is often possible to identify the location of the perforators to the skin with
a Doppler probe. Typically they are located near the junction of the middle and distal third of
the fibula. If they can be identified, they should be marked clearly, as in the clinical example
provided. Protection of the articulations of the fibula and peroneal nerve is enhanced by
appropriately marking the skin (Fig. 9A–C). Stabilization of the leg can be facilitated with the
placement of a bump at an appropriate location to serve as a foot rest. A sandbag or liter bag of
intravenous fluid secured with tape across the bed is appropriate for this purpose (Fig. 10). The
site is prepared simultaneously with the head and neck site. The two fields are kept isolated
throughout the procedure. Surgical skin prepping solution is excellent for site preparation, and
an extremity drape is used to isolate the field. A sterile tourniquet is placed above the knee. The
tourniquet is inflated to 100 mm Hg above systolic blood pressure after exsanguination of the
leg by elevation for 3 to 5 minutes.
Simultaneous flap harvest and head and neck surgical site preparation can be performed
in a two-team manner. The surgical time required for fibula flap elevation is approximately
70 minutes. Although the flap can be elevated and modified in situ while pedicled to decrease
ischemia time, the authors prefer not to do this. Instead, the authors design the flap backward,
beginning from the site of the vascular reanastomosis first to ensure acceptable vessel geometry.
The time required to osteotomize, recontour the flap, and complete the inset and reanastomosis
is well within the allowable time for warm ischemia. There is little advantage to complicating the
procedure by trying to perform osteotomies with the flap pedicled. The total ischemia time for
a fibula flap is approximately 3 hours 20 minutes, including tourniquet time.
The lateral intramuscular septum is easily palpable in all but the heaviest of patients. The skin
paddle is oriented over the perforating vessels and the lateral intramuscular septum (Fig. 11).
The anterior skin paddle elevation is completed first with dissection through the skin,
subcutaneous tissue, and fascia. Refinement of the location of the skin paddle later can be
made after visualizing the perforators. It is helpful to mark them on the skin paddle to assist in
creation of the posterior incision to center the perforators within the skin paddle.
The peroneus longus, peroneus brevis, and flexor hallicus longus are reflected from the
anterior and medial portion of the fibula to the intramuscular septum (Fig. 12A, B). This
procedure is best accomplished with electrocautery while taking care to preserve a small muscle
cuff. After incision of the intramuscular septum, the deep peroneal nerve and the anterior tibial
vessels are easily visualized at this point within the reflected medial tissue elevation (Fig. 13).
Gentle medial reflection is necessary to identify the interosseous membrane. The posterior skin
paddle elevation is then accomplished. It is necessary to remain subfascial throughout this
dissection and to remain vigilant for possible musculocutaneous perforators.
Proximal and distal osteotomies are made through the fibula at least 6 cm away from the
terminations of the fibula to maintain adequate stability of the knee and ankle joints. The fibula
is then rotated and the intraosseous membrane is incised along its length with a scissors to
expose the tibialis posterior muscle. Typically the most distal aspect of the peroneal vessels can
be seen easily at this point. Ligation of the vessels allows increased lateral movement of the flap
158 BLANCHAERT & HARRIS

Fig. 9. (A–C ) This series of images demonstrates the depiction of the relevant anatomy for the fibula harvest.
Maintenance of 6 to 8 cm of the fibula near the joints and the common peroneal nerve is depicted.

and eases visualization of the remainder of the dissection. The vascular pedicle is then dissected
free by dividing the overlying chevron-shaped tibialis posterior muscle. Many large branches
from the peroneal vessels to the soleus and gastrocnemius muscles require ligation to facilitate
retraction. As the dissection proceeds proximally, the posterior dissection also must be
completed. This procedure is slightly more difficult if the perforators are of the intramuscular
type. To facilitate this, it helps to put a finger along the medial aspect of the vascular pedicle and
directly visualize the perforators while cutting down with electrocautery to join the medial
dissection. A small muscle cuff also is usually harvested, which helps to fill the voids present
along the medial aspect of the mandibular reconstruction.
Throughout this portion of the dissection the posterior tibial vessels are visualized within the
medially retracted tissues. Extreme care should be given to avoid undue pressure on the posterior
tibial nerve. The operating surgeon must examine frequently the position of the retractors used to
ensure safe positioning because the retracting surgeon, who is frequently on the opposite side of
the table, has no direct view. The vascular pedicle should be skeletonized before flap harvest
(Fig. 14), which greatly facilitates subsequent microvascular anastomosis. There is routinely
a large soleus branch approximately 4 cm from the bifurcation that is often difficult to visualize.
Care should be taken to identify and ligate this branch because of the consequences of bleeding
obscuring visualization at this critical location. There is often what seems to be a cutaneous
perforator along the upper one third of the fibula length. The surgeon must take care not to rely
 MICROVASCULAR FREE BONE FLAPS 159

Fig. 10. This image demonstrates the value of a support placed on the operating table to allow hands-free support of the
leg to facilitate fibula harvest.

on this vessel unless he or she is certain that it arises from the peroneal vessels. This perforator is
often from a circumflex branch.
After complete isolation of the flap pedicle, the tourniquet should be released to visualize flap
perfusion and ensure hemostasis. Appropriate preparation of the recipient bed should include
thorough mobilization of recipient vessels and assurance of excellent flow at the site of planned
anastomosis. The field should be prepared to facilitate the flap modification and inset. If
possible, accommodation should be made for a contouring bur and a sagittal saw to be available
for use simultaneously, which avoids wasting time switching appliances. Division of the flap and
transfer to the head and neck field is accomplished when the site is appropriately prepared. The
donor site leg may be packed with lap sponges and wrapped in gauze for later management, or
a member from the operative team may close the leg over a drain while the flap inset is
occurring. Closure should be accomplished by loose approximation of the muscles, buried

Fig. 11. This image shows the positioning of the skin paddle of the fibula flap over the lateral intramuscular septum. The
location of the perforators to the skin paddle have been identified and depicted on the leg. The flap is oriented directly
over these vessels.
160 BLANCHAERT & HARRIS

Fig. 12. (A) The anterior incision and posterior dissection of the skin paddle of the fibula flap. The vascular perforator is
seen directly opposite the retractor. (B) The appearance of the donor site during the anterior-medial dissection.

closure of the dermis, and stabilization of the skin at the skin paddle donor site. The skin paddle
donor site is then grafted with split-thickness skin from the thigh. The graft should be secured
with resorbable suture and a tie-over bolster dressing. The foot and ankle should be stabilized in
a lower leg posterior splint that is well padded. If no skin paddle is harvested, the skin may be
approximated directly and the lower leg dressed with light elastic compression.
The osteotomies of the fibula are made precisely to allow maximum bone contact at the
interface of the fibula segments and the fibula-to-native-mandible interface. When the surgery is
properly performed, the bone flap literally snaps into place. Stabilization is limited to one or two
screws per segment. This portion of the reconstruction is critical to the outcome. Failure to
achieve proper bone inset can result in nonunion and subsequent hardware failure, which are
common reasons why the senior author sees other surgeons’ patients for revisions. The skin
paddle inset often requires customization of the skin paddle by excision of skin and dermis
where excess exists and maintenance of the underlying dermal plexus, fat, and fascia to ensure
adequate perfusion. The flap should be sutured into position without tension using horizontal
mattress sutures. A general principle that should be followed is that more tissue is better than
not enough; some degree of redundancy is shared across wounds to err on the side of excess
tissue maintenance.
Postoperative mobilization can begin immediately if there is no skin graft or at the time of
removal of the bolster dressing (5 days) if a skin graft is used. Donor site elevation is required

Fig. 13. The contents of the anterior compartment are visualized in this image. The interosseous septum is seen anterior
to the fibula. Beneath the septum the peroneal vessels are identified.
 MICROVASCULAR FREE BONE FLAPS 161

Fig. 14. Flap elevation and dissection of the proximal vascular pedicle.

throughout the first few weeks to prevent lymphedema in the leg. Return to normal activities
can be ensured as soon as 4 to 6 weeks after surgery.

Deep circumflex iliac artery flap

Background

The DCIA flap was developed from early experience with the groin flap. The proper vascular
pedicle for the osteomusculocutaneous flap was determined to be the DCIA and vein. These
vessels arise from the external iliac artery and vein just above the inguinal ligament. They have
average diameters of 2 to 3 mm. The ascending branch of the DCIA provides the blood supply
to the internal oblique muscle, which has become the favored soft tissue for harvest with the
flap. Harvesting a well-vascularized muscle and allowing secondary epithelialization within
the oral cavity provides a character and quality of tissue that are well suited to reconstruction of
the dentoalveolar apparatus. The muscle undergoes a process of atrophy and mucosalization
that results in a fixed mucosal lining that adheres densely to the iliac bone over which it has been
draped. This process provides an ideal site for dental implant-based oral rehabilitation.
The flap initially was described to include the overlying skin and fat and the internal oblique
muscle. The skin is supplied by muscular perforators and is well vascularized. The only problem
with the skin element of the flap is that it is often too thick and immobile. The flap is commonly
used with only the internal oblique muscle.
The donor site provides some interesting challenges in the course of its reconstruction.
Potential exists for hernia formation through the bone harvest site and the weakened abdominal
wall. To avoid hernia, the iliac harvest defect is typically spanned with either titanium mesh or
polypropylene mesh, and the abdominal wall likewise is supported with polypropylene mesh. It
is not uncommon to spend twice as much time on the closure of the defect site as in the
harvesting of the flap. Proper patient selection is important. The authors prefer not to perform
the DCIA flap in active men or laborers. Instead, the DCIA flap has been used typically in thin
women and retired thin men. One surprising challenge encountered with the use of the DCIA
flap in mandibular reconstruction has been too much bone height, which interferes with the
interarch space required for implant-based dental rehabilitation. The DCIA flap is the clear
second choice for mandibular reconstruction after the fibula.
A significant advantage of the flap is that the distance from the head and neck field allows
simultaneous two-team surgery, which helps considerably to offset the challenges imposed by
the difficulty of the flap harvest and the donor site reconstruction.
162 BLANCHAERT & HARRIS

Technique

The patient is positioned supine with the table flat. It may be helpful to place a small bolster
under the hip opposite the harvest site to facilitate visualization of the vascular pedicle.
Assistance is mandatory and is best provided by a retractor holder opposite the surgeon and an
assistant on the same side as the surgeon. The site should be shaved, prepared, draped, and
covered with an occlusive barrier to isolate the field. The surgical anatomic landmarks should be
marked clearly (Fig. 15A). If a skin paddle is to be used, it should be oriented directly over the
iliac crest, should be elliptical shaped, and should be of sufficient width to ensure capture of the
musculocutaneous perforators. In the more typical flap harvest without skin paddle, the access
incision is placed in a natural skin crease within the groin that extends laterally superior to the
iliac crest. The skin is incised and the external oblique muscle is identified and incised
approximately 2 cm from the iliac crest (Fig. 15B). The external oblique muscle is then retracted
and the internal oblique muscle is dissected along its entire length to the linea semilunaris

Fig. 15. (A–F ) This series of images illustrates the harvest of a DCIA flap. The text supports these drawings well.
 MICROVASCULAR FREE BONE FLAPS 163

medially and superior to the inferior margin of the rib cage (Fig. 15C). The required amount of
internal oblique muscle is then incised and the muscle is elevated from the transversalis muscle.
The ascending branch of the DCIA is traced along the deep surface of the internal oblique
muscle to the major DCIA pedicle.
Upon identification of the major pedicle, it is wise to extend the dissection medially to the
external iliac vessels. There is substantial variability in the arrangement of the deep circumflex
vessels and the lateral femoral cutaneous nerve (Fig. 15D). The DCIV can provide surgeons
with some challenges because it may exist as two distinct vessels. The authors’ experience is that
these vessels always come together before draining into the external iliac vein. It is possible,
however, that they can remain separate, as described in the literature. If the veins remain
separate, it is possible to evaluate flow and reanastomose only the vein with the greatest flow.
After isolation of the flap pedicle, it is appropriate to begin the osteotomies required to
harvest the bone element of the flap. The transversalis muscle must be transected approximately
2 cm from the iliac crest or preferably with direct visualization of the vascular pedicle to avoid
its injury (Fig. 16A). The preperitoneal fat must be retracted medially and the iliacus muscle
must be transected to expose the iliac bone. The muscles are released laterally from the iliac crest
to the level of the planned osteotomy. Osteotomies are then completed to free the flap, which

Fig. 16. (A,B) The flap harvest and flap inset. Note the position of the vascular pedicle along the medial surface of the
neomandible.
164 BLANCHAERT & HARRIS

remains pedicled to the DCIA and DCIV at the external iliac vessels. The authors prefer to
maintain approximately 2 to 3 cm of iliac bone intact at the anterior superior iliac spine, which
facilitates reconstruction of the continuity of the iliac crest to avoid hernia formation. The
vascular pedicle is divided and the flap transferred to the recipient site after proper preparation
of the recipient site (Fig. 15E).
Inset of the bone flap is completed in such a way as to ensure protection of the vascular
pedicle on the medial aspect of the flap with the internal oblique muscle on the medial-inferior
aspect of the flap (ie, with the iliac crest positioned inferiorly and the cut surface superiorly) (see
Fig. 15F; Fig. 16B). Care must be taken in design of the flap because the somewhat limited
pedicle length must be allowed for. The maintenance of the ASIS assists in that regard by
effectively lengthening the vascular pedicle. Curvature of the bone element of the flap requires
creating opening osteotomies of the lateral cortex with greenstick fracture of the inner cortex.
The gap is packed with particulate cancellous bone (this is demonstrated in Fig. 15F). The
muscle is then draped around the neomandible. The muscle fascia is sutured to the mucosal
edges within the oral cavity to provide an effective seal. Rapid granulation of the exposed
muscle is common. The color and character of the exposed muscle provide an excellent means
of monitoring.
The donor site is reconstructed by stabilizing a double thickness of polypropylene mesh to
span the bone defect, which is secured via drill holes in the ilium. The transversalis and external
oblique muscles are then sutured to the aponeurosis and supported with another layer of mesh.
The skin is approximated in layers (Scarpa’s fascia, dermis, skin) over a closed suction drain. An
appropriate bowel regimen is recommended for use in the preoperative and postoperative time
frame to avoid constipation and straining at stool. Likewise, lifting weights of more than
15 pounds, strenuous exercise, and labor are delayed until at least 4 weeks after surgery to avoid
the development of hernia.

Radial forearm osteocutaneous flap

Background

The free radial forearm fasciocutaneous flap has excellent use in head and neck surgery
primarily because of the thin, pliable character of the tissue and the reliability of its vasculature.
A major advantage of the flap is that the distant location of the flap donor site allows
simultaneous flap harvest and cancer resection or recipient site preparation. The use of this flap
as a bone-containing flap is, however, somewhat limited because of the minimal volume of bone
that can be harvested. The primary uses of the flap are to restore facial form and provide
support of adjacent structures, as in reconstruction of the premaxilla to provide nasal and lip
support. The senior author believes that the bone stock is insufficient for use in mandibular
reconstruction because it does not support endosseous dental implant rehabilitation. Dental
rehabilitation should be a primary goal of all mandibular reconstructions. Quality-of-life studies
demonstrate that for patients, the most important aspects that affect their quality of life are
eating normally and speaking clearly. Without dental rehabilitation, the achievement of these
goals would be impossible; the free radial forearm osteocutaneous flap remains a rarely used flap
in the surgical armamentarium.
The free radial forearm flap receives its vascular supply from the radial artery. The flap’s
venous drainage is from either the venae comitantes or the cephalic vein. The authors prefer the
cephalic vein because its size more closely approximates that of many potential recipient veins in
the neck and facilitates end-to-end anastomosis. These vessels average 2 mm in diameter. Before
flap harvest, a surgeon must ensure adequate communication between the superficial and deep
palmar arches, which is most easily done using the relatively simple Allen’s test. The absence of
an appropriate communication has been described in 12% of specimens investigated. Although
the nondominant hand is generally selected, a poor Allen’s test result has governed the selection
of flap donor site in several of the senior author’s cases. A positive Allen’s test result
demonstrates the absence of communication between the palmar arches in the patient being
evaluated (Fig. 17). Note that the portion of the hand that appears well perfused with the radial
 MICROVASCULAR FREE BONE FLAPS 165

Fig. 17. An Allen’s test that demonstrates the lack of communication between the superficial and deep palmar arches.
Note the pale character of the thumb and first finger.

artery occluded is limited to that area primarily supplied by the ulnar artery. In this instance,
selection of an alternate donor site is required.
The limitations of the bone stock available in the radial forearm fasciocutaneous flap already
have been outlined. The amount of bone that can be harvested is limited to 40% of the diameter
of the radius between the insertion of the pronator teres proximally and the brachioradialis
distally (Fig. 18). To avoid the creation of internal stress, the osteotomy should be completed
without sharp internal line angles. It is best to plate prophylactically across the defect at the
radius harvest site because the rate of fracture is approximately 25%. The deformity that results
from fracture of the radius is unacceptable. The blood supply to the radius is through segmental
periosteal branches within the anterolateral intramuscular septum and the flexor pollicis longus
muscle. The nature of this blood supply allows for osteotomies to be performed, provided
appropriate care is given to avoiding excessive periosteal elevation.

Technique

An appropriate donor site is selected based on the character of the tissue and the appearance of
the vasculature. An Allen’s test must confirm adequate ulnar artery perfusion of the thumb
with radial artery occlusion. If it is difficult to determine perfusion based on color of the skin (ie,

Fig. 18. A cross-section of the radius harvest site and the appropriate shape of the radius osteotomy.
166 BLANCHAERT & HARRIS

dark-skinned subject), a pulse oximeter probe can be attached to the thumb and the test repeated.
The appropriate donor site should be selected well before surgery and the cephalic vein should be
protected from venipuncture. On the day of surgery, the authors prefer to mark the radial artery
and cephalic vein with a surgical marker in the preoperative holding area. This preparation
facilitates design of the flap once the final dimensions of the defect site have been determined.
The donor site arm is prepared simultaneously with the resection/recipient site. The arm is
prepared to the axilla and draped with an extremity drape. A sterile tourniquet is applied to the
upper arm after the flap has been outlined on the ventral surface of the forearm overlying the
radial artery. Inflation of the tourniquet is accomplished after exsanguination of the arm with an
elastic bandage. The tourniquet should be inflated to 250 mm Hg or approximately 100 mm Hg
above systolic blood pressure. Dissection and flap elevation are aided by stabilizing the hand/
wrist with a lap sponge across the palm secured by nonpenetrating towel clamps.
The flap elevation is performed from the distal. The radial artery, its venae comitantes, and
the cephalic vein are ligated. A judgment call as to the fate of the dorsal radial nerve must be
made based on the degree of its exposure and the possibility of painful altered sensations upon
its postoperative stimulation. This nerve may be covered only by the skin graft and may be
prone to constant stimulation. It is perhaps best to sacrifice this nerve from the distal of the flap
harvest site to beneath the forearm musculature to avoid postoperative dysesthesia. The fascial
compartment that contains the vascular supply is dissected free from the underlying muscles
from the lateral aspect of the skin paddle. Proximal incision is made in the groove between the
flexor carpi radialis and brachioradialis muscle or along or near the cephalic vein. The dissection
is then carried down to the level of the brachioradialis muscle. The brachioradialis muscle can be
reflected laterally to expose the proximal vascular pedicle. The medial skin paddle elevation and
proximal dissection are then completed. The flexor carpi radialis can be retracted medially to
expose fully the vascular pedicle and the radius. The appropriate osteotomy site is then
identified and isolated. The osteotomy is made carefully to avoid creation of areas of isolated
stress and avoid removing more than 40% of the diameter of the radius. The flap then remains
pedicled on the proximal vascular pedicle. The proximal vascular pedicle is dissected free from
its venae comitantes at the site at which vascular anastamosis is likely to occur.
The authors prefer to allow reperfusion of the flap at this time to ensure adequate perfusion
and hemostasis. The flap may be repositioned and wrapped in lap sponges and gauze until the
preparation of the recipient site is ensured.
The head and neck field always must remain isolated from the donor site. The morbidity of
a local infection in the wrist is significant. Extreme limitation of mobility is the likely outcome.
The vascular pedicle of the flap is transected and the flap transferred to the recipient site. The
flap inset is completed and the bone stabilized with miniplates or a reconstruction plate before
vascular reanastomosis. The surgical team may be split, and a team member or members may be
left behind during the flap inset to complete the closure of the proximal portion of the donor site
over a drain, stabilization of the skin edges of the flap harvest site to the underlying fascia, and
coverage of the defect with a split-thickness skin graft. The arm should be splinted in the
position of maximum function (wrist dorsiflexed 45  ; fingers neutral) with a simple volar splint.

Scapula flap

Background

The scapula free flap is based on the circumflex scapular artery and vein. These vessels are
of large caliber, with common diameters of 4 mm (range 2–6 mm). This flap has perhaps the
most versatility and adaptability of any of the bone-containing microvascular free flaps in
common usage. The flap is generally reserved for specific indications in head and neck
reconstruction because of the challenges imposed by the need to reposition the patient to allow
flap harvest and the donor site morbidity related to the flap harvest. Such indications include
through-and-through composite defects of the mandible and complex three-dimensional
defects of the maxilla. The major advantage of this flap is the availability of two separately
mobile cutaneous segments.
 MICROVASCULAR FREE BONE FLAPS 167

Approximately 8 cm of bone can be harvested along the lateral border of the scapula. The
bone is well perfused through numerous branches. Care must be taken to identify the origin of
the blood supply to the scapular tip via the angular artery if it is to be included. The angular
artery commonly arises from the thoracodorsal artery. Proximal dissection of the vascular
pedicle and transection of the flap pedicle at the subscapular artery and vein results in the ability
to transfer simultaneously the latissimus dorsi muscle and the serratus anterior muscle with the
flap. Although this is a common point of discussion, the authors know personally of no surgeon
who actually has performed such a flap.
The scapula bone is of acceptable quality and quantity for midface reconstruction in most
cases but may fall short of ideal for mandibular reconstruction because of its limitations in size
and volume. The bone is commonly insufficient in width to accept endosseous implants in
women and often is insufficient in men, which limits the flap’s acceptance.

Technique

The patient must be positioned in the lateral decubitus position. For use in head and neck
reconstruction, the primary operative site must be packed and covered before repositioning and
repreparation of the operative field. Lap sponges should be placed in the operative site, and
a large transparent adhesive drape should be used to cover the site of the resection and the neck
dissection. The surgeon also should realize that closure of the flap harvest site and repositioning
are required again after flap harvest and before flap inset and revascularization. This process
requires operative team coordination and planning to ensure a smooth transition with minimal
loss of time to limit flap ischemia. To avoid brachial plexus injury, careful support and
movement of the arm at the site of the flap harvest and support and protection of the
contralateral brachial plexus with an axillary roll are required.
The scapular outline should be marked, and the orientation of the cutaneous branches of the
circumflex scapular artery should be drawn to facilitate the orientation of the skin paddles. The
transverse cutaneous branch runs horizontally across the scapula midway between the scapular
spine and the scapular tip. The descending cutaneous branch is located vertically along a parallel
to the lateral border of the scapula. The origination of these two cutaneous branches from the
circumflex scapular artery is identified in the triangular space formed by the teres major, teres
minor, and the long head of the triceps brachii muscle (Fig. 19). This site typically can be
palpated or identified with a simple Doppler probe. The cutaneous elements should be dissected

Fig. 19. An excellent depiction of the scapula flap design and harvest.
168 BLANCHAERT & HARRIS

Fig. 20. (A–F) The use of a fibula flap in the reconstruction of osteoradionecrosis of the left mandible. The patient was
treated with combined modality chemotherapy and radiation for cancer of the base of the tongue. (A) Bone destruction
on the left posterior body and vertical ramus. (B) The character of the tissues and mandible within the radiated field.
Note the change in character of the mandible in the mid-body region. (C) The extracorporeal adaptation of the healthy
native condyle to the reconstruction plate. (D) The fibula before osteotomies and flap inset. (E) The completed inset of
the flap before vascular anastamosis. (F) Panorex demonstrates the character of the flap in the early postoperative time
frame.

first to allow identification of the vascular pedicle. The inferior margin of the cutaneous flap is
incised through skin and subcutaneous tissue down to the level of the fascia overlying the
rhomboid and infraspinatus muscles. When the teres major is identified in the course of the
dissection, the superior margin of this muscle is followed to the triangular space. The superior
margin of the skin paddle is then incised and elevated in a similar manner. Handling of the flap
is facilitated by harvesting a small cuff of the fascia overlying the infraspinatus muscle
surrounding the cutaneous branches near the vascular pedicle. After elevation of the skin
paddles, the bone exposure and osteotomies can be undertaken.
The blood supply to the lateral border of the scapula arises from multiple periosteal branches
of the circumflex scapular artery and vein. To preserve these branches, the teres major muscle
 MICROVASCULAR FREE BONE FLAPS 169

Fig. 21. (A) The use of a CAD-CAM model to adapt the reconstruction bar in a case of a hemimandibulectomy,
including the articulation of the mandible. (B) A panoramic radiograph shows the early postoperative appearance of the
flap.

must be transected and a muscle cuff must be included along the lateral surface of the scapula.
The latissimus dorsi muscle can be preserved by dissecting it free from the lateral border of the
teres major muscle. Once this muscle transection is completed, excellent visualization of the
thoracodorsal, angular, and circumflex scapular artery is created. The thoracodorsal artery is
ligated and transected (unless the latissimus dorsi muscle is to be included in the flap), as is the
angular artery. The proximal dissection of the vascular pedicle is best completed at this time
while the structures are stable. The circumflex scapular artery and vein should be isolated to
facilitate the later anastomosis of these vessels to acceptable recipient vessels in the neck after
flap transfer.
The osteotomies of the lateral border of the scapular are accomplished after dividing the
infraspinatus muscled in a longitudinal direction to create a 3-cm muscle cuff along the lateral
border. With these muscles retracted, the bone is best cut with an oscillating saw. The tip of the
scapula is seldom harvested because of its separate blood supply. The available bone length is
approximately 8 cm. After completion of the osteotomies, the bone flap is elevated and the
subscapularis muscle is transected with a similar 3-cm muscle cuff to complete the mobilization
of the flap. The flap can be harvested with the desired length of vascular pedicle and set aside
while the donor site is closed.
The teres major muscle must be repaired via direct suture or sutured to the remaining scapula
through drill holes. Either method significantly reduces the function of the muscle. The functions
of the teres major muscle include internal rotation, extension, and adduction of the arm. The
limitation of these functions remains the primary drawback to the use of this flap. The overlying
skin is then advanced and reapproximated over a drain in layers. The operative site is dressed
and the patient repositioned for flap inset and vascular reanastomosis.

Clinical examples

Case #1: Lateral mandibular resection for osteoradionecrosis

The patient is a 45-year-old white man who 4 years ago underwent right radical neck
dissection and combined modality chemotherapy-radiation therapy for tongue base squamous
cell carcinoma. He had undergone extraction of partially impacted third molars 3 weeks before
initiation of radiation therapy. The left third molar site never healed, and osteoradionecrosis
developed. He received approximately 45 hyperbaric oxygen therapy treatments and numerous
courses of antibiotic therapy without resolution before being referred for definitive intervention.
Extensive bone destruction was seen on panoramic radiograph. The extent of the diseased
mandibular bone can be seen in a preoperative MRI study. The posterior body, angle, and
vertical ramus of the mandible clearly are affected. This case illustrates the use of the native
170 BLANCHAERT & HARRIS

Fig. 22. (A–G) The management of an anterior floor of mouth squamous cell carcinoma that infiltrates the mandible.
The reconstruction plate was adapted directly to the mandible and removed before resection. Flap inset and
reanastomosis are depicted, as is proper vessel geometry (E). The skin paddle provides excellent mobility of the tongue,
and the fibula is more than adequate to support dental implant-based rehabilitation.

condyle and its articular surface as a graft. The bone plate was placed before resection and
removed. The condyle was reattached and the plate replaced (Fig. 20A–F).

Case #2: Vertical ramus and condylar reconstruction: recurrent ameloblastoma

A 25-year-old patient presented with recurrent ameloblastoma that involved the posterior
body, angle, vertical ramus, and condyle. This case example demonstrates the use of a
microvascular free fibula flap in condylar reconstruction. A computer-generated model was used
to prebend the mandibular reconstruction plate. Suspension of the condylar reconstruction is
required at the articular fossa. Arch bars and elastic traction help suspend the neocondyle
throughout its early healing stages (Fig. 21A, B).
 MICROVASCULAR FREE BONE FLAPS 171

Case #3: Floor-of-mouth squamous cell carcinoma

A 64-year-old woman was referred with a large floor-of-mouth squamous cell carcinoma
infiltrating the mandible. This case illustrates adaptation of the 2-mm locking plate before resection,
flap inset, appropriate vessel geometry, and the mobility of the skin paddle. Definitive dental
rehabilitation was accomplished with endosseous implants. The implants are placed as soon as bone
healing is completed or after resolution of the acute effects of radiation therapy (Fig. 22A–G).

Summary

Microvascular free bone flaps are a modern means of restoring bone-containing composite
defects of the maxillofacial region. The techniques are simple and reliable. The results are
reproducible and offer significant advantages over staged mandibular reconstruction. In
particular, these techniques decrease costs and provide a means of rapid definitive reconstruc-
tion. Patients avoid multiple surgical procedures with immediate reconstruction that allows
them to return to productive lives in society. Proper selection of an appropriate donor site and
appropriate preoperative planning facilitate application of these techniques in an expedient
manner. Microvascular free bone flap reconstruction should be considered for all patients with
composite bone-containing defects of the maxillofacial region.

Further readings

Brown JS. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate
reconstruction of maxillectomy defect. Head Neck 1996;18:412–21.
Brown MR, McCulloch TM, Funk GF, et al. Resource utilization and patient morbidity in head and neck
reconstruction. Laryngoscope 1997;107:1028–31.
Frodel JL, Funk GF, Capper DT, et al. Osseointegrated implants: a comparative study of bone thickness in four
vascularized bone flaps. Plast Reconstr Surg 1993;92:449–55.
Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandibular reconstruction. Plast Reconstr Surg 1995;
96:585–96; discussion 597–602.
Kroll SS, Schusterman MA, Reece GP. Costs and complications in mandibular reconstruction. Ann Plast Surg 1992;29:
341–7.
Sullivan MJ, Baker SR, Crompton R, et al. Free scapula osteocutaneous flap for mandibular reconstruction. Arch
Otolaryngol Head Neck Surg 1989;115:1334–40.
Urken ML, Weinberg H, Vickery C, et al. The internal oblique-iliac crest free flap in composite defects of the oral cavity
involving bone, skin and mucosa. Laryngoscope 1991;101:257–70.
Vaughan ED. The radial forearm free flap in orofacial reconstruction: personal experience in 120 consecutive cases.
J Craniomaxillofac Surg 1990;18:2–7.