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Using the anterior iliac crest as donor-site for free osseous, osseomuscular, and osseomyocutaneous flaps has proven itself an important reconstructive instrument both in maxillofacial and in orthopaedic surgery. We present a long-term retrospective evaluation of the donor-site situation after vascularized free anterior iliac crest transfer. The study is based in 95 cases from the years 1985 to 1993 including 11 cases from Switzerland (Kantonsspital Aarau). The patients were examined, looking for objective complications and asked questions about their subjective symptoms at the donor site. These objective and subjective results were then correlated. Herniation developed in 3% of cases, loss of sensibility in the region of the N. cutaneous femoris lateralis occurred in 9.5% and was in 6% reversible. Scars were in 7% aesthetically not satisfying with no keloids or hypertrophic scarring after all wounds healed per primam intentionem. Mostly minor alteration of the outer surface of the donor site was notable in 20 to 25% of the patients. Pain was a problem for an average of 7% of cases. Impairment in private life was named in 3.5%, in professional life in 4.7%, and in daily life in 11.9% of cases. Not content with the donor-site situation were 13.5%, not content with the preoperative information were 12% of the patients. Nonetheless were 98.8% of the patients willing to, if necessary, undergo the same operation again. Surprisingly, there is a negative correlation between objective and subjective results: Merely 25% of the patients with sensibility loss were not content with the donor-site result of the operation and vice versa only 1% of the dissatisfied patients had objectively measurable minor complications.

At the present time the vascularised bone graft is the best procedure for reconstruction of mandibular defects in poor recipient tissues. We obtained 23 drill biopsies from different regions of vascularised bone transplants during the removal of the osteosynthesis plates from 14 patients who had poor recipient tissues. For comparison, we took five biopsies from the native iliac crest and eight biopsies from six patients with avascular bone transfer into unimpaired surrounding tissues. Microradiographs of the bone preparations were used for a computerised semi-automatic morphometric analysis. We evaluated the volumetric density (VV, %) and the mean trabecular diameter (D-TRAB, micron). In the central regions, the revascularised transplants decreased in volumetric density and in mean trabecular diameter. Compared with the average values of iliac crest bone, the avascular grafts increased in both parameters. The revascularised grafts showed significantly lower volumetric density and significantly lower mean trabecular diameters in the central regions than in the regions near to the mandibular stump. The avascular grafts actually showed the reverse effect. The results are discussed with particular reference to the quality of the recipient tissues, to the maintenance of graft viability, to functional stress, and to the design of the transplant.

Since 1985 76 revascularized osseous and osseocutaneous flaps collected from different donor sites were transferred. The overall rate of success amounted to 94.7%, 48.7% of the patients had previously undergone radiotherapy with tumor dose. Even though an elevated number of certain complications in cases of an irradiated recipient area occurred a critical analysis reveals the high value of the reanastomized flap in this situation. Proven indications are described in detail.

Differing views on the nutritional status of revascularized bone in animal studies and in human transfer have been expressed. Normal viability is reported as well as single cell necrosis and devitalized areas and, finally, necrosis of the complete graft. From 19 patients with revascularized bone transfer into injured recipient tissues, we obtained 32 drill biopsies out of the centre of the graft and near the mandibular stump during the removal of the osteosynthesis plates. The histological preparations were examined for bone viability. In 58% of all patients, there occurred partial necroses in the grafted bone and in 26% single cell necroses; 16% of the transplants maintained normal viability. The areas with disturbed nutrition were found more frequently in peripheral areas than in central regions of the graft (p < 0.05, chi 2 test). The overall graft failure rate was 6.8%. The results of this clinical study are discussed with particular reference to the technical procedure, the recipient tissue quality, and the design of the graft. The indication for using revascularized bone transfer in difficult local conditions of the recipient tissues has been confirmed. The viability of the grafts cannot always be maintained entirely. The particular risk to the viability of the graft in the peripheral regions requires careful technical procedures.

A review is presented of the classic vascularized iliac crest transfer and to show useful variations on this technique. A technical variation to reconstruct mandibular defects, the semisegmented iliac crest graft, is described. Another variation, the half iliac crest graft, is presented for use in the neovascularization of avascular necrosis of the femoral head. When such a flap is raised with a large periosteal flap and overlying muscle or skin, or both, as a composite flap, a primary osteoperiosteal tube can be created to reconstruct segmental defects in long bones. This primary osteoperiosteal tube is secondarily transformed into a completely osseous tube.

In this follow-up study the height of avascular and microsurgically reanastomosed osseous transplants serving for mandibular reconstruction is compared. For analysis a new computer-assisted method is applied which evaluates the plane of the transferred bone. As a result, it is revealed that the reanastomosed bone exhibits the better shape consistency than the avascular flap.