Surgical Highlights

The skin paddle is outlined in the form of an ellipse centered over the iliac crest, along a line from the pubic tubercle to the tip of the scapula. The anteriormost portion of the skin paddle is placed over the ASIS, and may be up to 12 cm wide by | 25 cm long. The skin paddle must be of sufficient size to capture reliably at least ยป one of the septocutaneous perforators along the iliac crest (Fig. 62). c

The lateral femoral cutaneous and ilioinguinal nerves cross the DCIA and d should be preserved during the dissection. Occasionally, the lateral femoral >3

cutaneous nerve is so intimately involved with the DCIA that extensive dissection is necessary to separate them. Injury to the nerve is more likely in these cases and the patient should be warned preoperatively that lateral thigh numbness might occur.

Figure 62 Iliac crest osteocutaneous flap surface landmarks. Prior to flap harvest, the skin paddle is outlined over the iliac crest bone. Also note the position of the feeding vessels (DCIA and ascending branch) and the likely course of the lateral femoral cutaneous nerve (T12).

If the internal oblique muscle is harvested, the ascending branch of the DCIA must be preserved. The ascending branch is found just anterior to the ASIS as a discrete artery in 80% of patients. In the remaining 20%, the internal oblique muscle is supplied by smaller vessels along the DCIA and is therefore not harvestable as a separate component.

In preparation for bone harvest, the iliacus muscle is sharply incised approximately 1 cm inferior to the vascular bundle and the periosteum stripped along the planned cut. The tensor fascia lata and periosteum are stripped from the outer iliac crest, and a reciprocating saw is used to cut the bone from the outer aspect. A hand is placed over the inner cortex to protect the abdominal contents. The use of chisels is discouraged since this may lead to occult fractures and splintering of the bone at the donor site.

The wound is closed in several layers using heavy nonabsorbable suture for the first two layers. The transversalis fascia is sutured to the tensor fascia lata inferior to the iliac crest or to the iliac crest directly with holes drilled through the bone to anchor the suture. The external oblique muscle is sutured to the fascia lata over the iliac crest, followed by routine closure of the subcutaneous tissues and skin. Two large drains are placed medial to the iliac crest and brought out separate stab incisions.

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