Osteocutaneous flap prefabrication in rats

Composite tissue defects may involve skin, mucosa, muscle, and bone together or in combinations of two or three of these tissues. Defects involving bone and skin are frequently encountered. Osteocutaneous flaps may be used to reconstruct these composite tissue defects. Sometimes, it is not possible to obtain a vascular osteocutaneous flap. Another way of producing an osteocutaneous flap that has the desired feature is prefabrication. Prefabrication of osteocutaneous flaps can be performed in two ways: (1) a vascularized osseous flap may be grafted with skin and (2) an osteocutaneous flap can be prefabricated by implanting an osseous graft into an axial island flap. There are many articles describing osteocutaneous flap prefabrication, but there is no comparison of both methods in the literature. As an experimental model for osteocutaneous flap prefabrication, rat tail bone was chosen. For the experiments, five groups were formed. Each group contained 10 rats. In the first experimental group, a vascularized osseous segment was skin grafted and an osteocutaneous flap was prefabricated. In the second experimental group, an osseous graft was implanted into an axial skin flap. To compare viability of skin and bone components of the two prefabrication groups, vascularized tail bone was elevated with overlying skin in the third group, a bone flap was elevated in the fourth group, and a skin flap that had been prefabricated by using vascular implantation was elevated in the fifth group. The authors examined five rats in each group by microangiography at the end of 4 weeks. On microangiographic analysis, all groups showed patency of vascular pedicles. There was no difference among the groups from the point of view of vascular patency and bone appearance. Bone scintigraphy was performed on the five rats in each group. On bone scintigraphic scans, the bone component of flaps was visualized in all groups except for group 5. The mean radioactivity value on the flap side was 10,362 +/- 541.1 in group 1, 10,241 +/- 1173 in group 2, 10,696 +/- 647.1 in group 3, and 10,696 +/- 647.1 in group 4. When the radioactivity values on the flap side were compared, no statistically significant difference among groups was seen, except for group 5 (p < 0.05). To evaluate bone metabolic activity, the bone component of flap and remaining last tail bone was harvested and the radioactivity of each specimen was measured with a well-type gamma counter. The parameter of percentage radioactivity in counts per minute per unit per gram of tissue was calculated. The value of the bone component of the flap side and the value of normal bone were estimated and results were compared. The mean result was 0.86 +/- 0.08 in group 1, 0.88 +/- 0.07 in group 2, 0.87 +/- 0.07 in group 3, and 0.81 +/- 0.04 in group 4. The difference among all groups was not statistically significant. Histologic examination was performed on all rats in each group and demonstrated that the bony component was viable, showing a cellular bone marrow, osteoblasts along bony trabeculae, and vascular channels in bone-containing groups. There were no significant microangiographic, histologic, or scintigraphic differences between the two experimental methods.     

Prefabricated sensate myocutaneous and osteomyocutaneous free flaps: an experimental model. Preliminary report

Principles of neovascularization have been reported for the successful creation of a variety of muscle and bone free flaps. This study demonstrates a simple and effective technique for construction of prefabricated sensate myocutaneous and osteomyocutaneous free flaps in a rat model. These experiments were carried out in 20 Sprague-Dawley male rats. In half the animals, a sensate myocutaneous flap was constructed by sandwiching the superficial inferior epigastric vessels between a laterally based external abdominal oblique muscle flap and a laterally based skin flap served by an identified cutaneous nerve. A similar preparation included a piece of iliac crest bone. Two to three weeks later, now neovascularized by the sandwiched vessels, the flaps were harvested and transferred as free flaps with high reliability. An increased number of potential donor sites, the versatility of design, and the ability to customize flaps to the specific recipient-site needs are proffered.     

The thigh flap: an osteomyocutaneous free-flap model in the rat

A new experimental model for free-flap transfer has been developed in the rat. This "thigh flap" is an osteomyocutaneous free flap of bone (femur), muscle (thigh), and skin (groin) based on the femoral vessels. The flap is harvested from the left groin and thigh of an inbred female rat and is transferred to a subcutaneous pocket in the left groin of a male rat of the same inbred strain. The femoral vessels supplying the flap are anastomosed end-to-end with the femoral vessels of the recipient. Thirty flaps have been transferred, with 5 technical failures. Three of the remaining 25 flaps developed necrosis within 24 hours. The other 22 flaps remained viable until the rat was sacrificed at 7 days. The survival rate of the thigh flap was thus 88 percent. The model is suitable for use in metabolic, vascular, and immunologic studies of composite free flaps.     

Sequential vascularized iliac bone graft and a superficial circumflex iliac artery perforator flap with a single source vessel for established mandibular defects

The major problems in dealing with established mandibular loss are severe soft-tissue contracture and a limited number of recipient vessels. The skin portion of the iliac osteocutaneous flap often necrotizes in cases without perforators of the deep circumflex iliac vessel. To overcome these problems, eight patients with established mandibular loss and no skin perforators of the deep circumflex iliac vessel were treated with a sequential vascularized iliac bone graft and a superficial circumflex iliac perforator flap with a single recipient vessel. Regarding the recipient vessels, the ipsilateral cervical vessels were used for four patients, and the contralateral facial and ipsilateral superficial temporal vessels were used for two cases each. The superficial circumflex iliac perforator flaps were 7 to 28 cm in length and 3 to 15 cm in width. The iliac bone grafts ranged from 7 to 13 cm in length, and three cases were repaired with the inner cortex of the iliac bone. There were no serious complications, such as flap necrosis or bone infection and resulting absorption. The advantages of this method are that both pedicles are very close to each other and of suitable diameter for anastomosis. Simultaneous flap elevation and preparation for the recipient site is possible. The skin flap and vascularized bone graft can be obtained from the same donor site. A single source vessel can nourish both the large skin area and bone sequentially. Longer dissection of the superficial circumflex iliac system to the proximal femoral division is unnecessary. A large flap can survive with a short segment of the superficial circumflex iliac system. Only the vascularized inner cortex of the iliac bone needs to be used, and the outer iliac cortex can be preserved, which results in less morbidity at the donor site.     

Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation

Lower-extremity injury may present as a composite soft-tissue and bone defect, resulting directly from trauma or subsequent debridements. These composite defects often require vascularized osteocutaneous flaps for an effective, staged reconstruction. Among various donor sites, the vascularized fibular flap is generally considered the best option because of its inherent advantages. However, when the fibular flap is not available, iliac and rib flaps become the alternative choices. The purpose of this retrospective study was to compare the functional results of the alternatively chosen bone flaps (iliac and rib flaps) with those of the fibular flaps.     

Reconstruction of Achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region

Eight patients had reconstructive surgery for soft-tissue, associated Achilles tendon, and calcaneus defects on the posterior aspect of the ankle. In group A, those patients with skin, soft-tissue, and Achilles tendon loss were treated with free groin flaps that included sheets of the external oblique aponeurosis based on the superficial circumflex iliac vessel. The groin flap provided skin coverage, and the aponeurosis was rolled to form a tendon-like structure to replace the Achilles tendon. In group B, those patients with an additional calcaneus bone loss were treated with free iliac osteocutaneous flaps, together with the external oblique aponeurosis based on the deep circumflex iliac vessel. The iliac bone was then utilized to reconstruct the calcaneus defect. All composite free tissue transfers were successful, except in two group B patients who suffered partial skin loss. The advantages of this technique are (1) a single, one-stage procedure, (2) faster wound healing with fewer adhesions of the reconstructed Achilles tendon, and (3) good cosmesis and minimal morbidity at the donor site.     

Functional oromandibular reconstruction with the microvascular composite groin flap

Ten patients were reconstructed with the microvascular osteocutaneous groin flap for oromandibular defects with the objective of improving function. The flap was based on the superficial and deep circumflex iliac vessels for optimal positioning of the bone and contouring of the skin. Patients with major glossectomies and arch resections had intelligible speech and were able to eat a soft diet without aspirating. Cineradiographic studies to evaluate swallowing in selected patients showed that the shape of the intraoral flap and the location of the bone graft played an important role in swallowing and prevention of aspiration.     

One-stage repair of compound leg defects with free, revascularized flaps of groin skin and iliac bone.

The successful revascularized free transfer of a composite flap of groin skin with attached iliac bone is presented in two patients. The findings in the preliminary dissections and injection studies in cadavers are discussed, and the superficial circumflex iliac system is recommended as a stem for free flaps of groin skin and iliac bone. If iliac bone alone is required for a revascularized graft, then the deep circumflex iliac system would seem suitable for the stem. Further clinical cases are necessary to determine the indications for this procedure, and patients should be carefully selected. The need for preoperative preparation and planning on a sound anatomical background is emphasized, and preoperative angiography seems advisable. The ability to sew small vessels together reliably is one thing: the when and where is another.     

Prefabrication of composite free flaps through staged microvascular transfer: an experimental and clinical study

The feasibility of prefabricating free flaps by inducing, through the process of staged reconstruction, an arteriovenous bundle and its surrounding fascia to perfuse a selected block of tissue was investigated experimentally and clinically. Sixteen rat knee joints were wrapped with their ipsilateral superficial inferior epigastric (SIE) fascia. In 8 joints, the composite flaps were resected en bloc and were immediately replaced orthotopically pedicled upon the superficial inferior epigastric vessels. In the remaining joints, the resection and orthotopic transfer were performed 2 weeks later. Only the joints in the latter group, which benefited from the staging period, were found to be perfused. The long finger proximal interphalangeal joint of a child was reconstructed by the staged microvascular transfer of his second toe proximal interphalangeal joint. At the first stage, a temporalis fascia flap was wrapped around the toe proximal interphalangeal joint and revascularized to the dorsalis pedis vessels. Six weeks later, the joint and its temporalis fascia envelope were dissected, and the "prefabricated" joint flap was transferred to the hand and revascularized to the wrist vessels. Bony union progressed uneventfully with excellent recovery of the range of motion. We conclude that regardless of the indigenous vascular anatomy, an unlimited array of composite free flaps can be constructed and transferred based on induced large vascular pedicles.     

Heel reconstruction with the deep circumflex iliac artery osteocutaneous flap

A patient with extensive loss of bone and soft tissue from the right heel is presented. The defect was reconstructed using an osteocutaneous flap based on the deep circumflex iliac vessels. Indications for this procedure include extensive loss of bone and soft tissue precluding the use of local flaps. A 30-month period has elapsed since her reconstruction. A single ulcer developed 13 months postoperatively that healed after flap revision. We feel that tailoring the flap to minimize redundancy at the initial operation, subsequent tissue excision if necessary, and reinnervation augment durability of the flap.     

A combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles

Although a free vascularized iliac bone graft has been successfully used for the reconstruction of large bone defects, there is a serious problem of how to repair in one stage patients having a large bone defect with a very wide skin defect. A free combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles seems to be one of the most suitable methods for patients having large defects of both bone and skin. Based on our patient, the main advantage of this flap is the extreme width of the skin territory. The pedicle vessels are large and long, and the donor scar can be made in an unexposed area. This flap should be considered for use in one-stage reconstructions of large defects of both bone and skin in the leg region.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

Prefabricated galeal flap based on superficial temporal and posterior auricular vessels

Scalp layers are widely used in reconstructive procedures. The authors used prefabricated galeal flaps based on the superficial temporal or postauricular vessels for ear, cheek, mandible, and cranium reconstructions in three cases. In case 1, synchronous beard and ear reconstructions were accomplished by using the temporoparietal and retroauricular flaps. In case 2, a buccomandibular defect was reconstructed by transposing the supra-auricular and retroauricular galea with prefabricated bone and skin. In case 3, an epidural hematoma in the left frontoparietal area was evacuated after a circular craniectomy. The harvested bone was not put back on the defect area but buried between the periosteal and galeal layers because of brain edema. These layers were raised as an osteogaleoperiosteal flap and transposed onto the defect area after 7 weeks. When used with a prefabrication method, scalp layers offer versatile options for repairing composite defects of the head region. A galeal flap based on the posterior auricular vessels is practical and reliable in reconstructive procedures. The authors suggest that this flap is an option in cases in which the temporoparietal fascia artery or the superficial temporal artery is not available. Prefabrication of the harvested cranial bone inside the adjacent tissues offers several advantages in that a viable bone is provided at the end of the procedure, intervention at a distant area is avoided, the graft is placed on osteogenic tissue (periosteum) that is also transposed onto the defect, and sophisticated procedures such as microsurgical techniques are not needed.     

Comparison of three different supercharging procedures in a rat skin flap model

A significant clinical problem in reconstructive surgery is partial loss of a pedicled flap. To resolve this problem, various methods of vascular augmentation have been developed; "supercharging" is one of those techniques. A new rat flap model was developed for investigation of the supercharging procedure, and the efficacy of the arterial supercharging method was examined. The purpose of this study was to investigate how an arterial supercharging procedure could generate large flap survival areas with different supercharging positions in rats. On the basis of the vascular anatomical features of rats, a circumferential skin flap from the lower abdomen to the back, measuring 4 x 12 cm, was marked. The flap was divided along the dorsal midline. Forty rats were divided into four experimental groups, as follows: group 1 (control), flaps based only on the deep circumflex iliac artery and vein; group 2, flaps supercharged with the ipsilateral superficial inferior epigastric artery; group 3, flaps supercharged with the contralateral superficial inferior epigastric artery; group 4, flaps supercharged with the contralateral deep circumflex iliac artery. On the fourth postoperative day, the flaps were evaluated with measurements of necrosis and survival areas. Microfil (Flow Tech, Inc., Carver, Mass.) was then injected manually throughout the body, and the vascular changes produced by supercharging were angiographically evaluated. Compared with group 1 (control), the flap survival areas were significantly greater in distally supercharged flaps in groups 3 and 4 (mean flap survival, 91.2 +/- 5.2 percent and 90.5 +/- 10.6 percent, respectively; p < 0.001) and in proximally supercharged flaps in group 2 (45.9 +/- 4.1 percent, p < 0.05). Angiographic assessment of the flaps that survived completely revealed marked dilation of the choke veins among the territories and reorientation of dilated veins along the axes of the flaps. This study suggests that distal arterial supercharging (contralateral superficial inferior epigastric artery or contralateral deep circumflex iliac artery) is more effective than proximal arterial supercharging (ipsilateral superficial inferior epigastric artery) in increasing flap survival. Although the rat skin flap may not be analogous to human flaps, distal arterial supercharging might have useful therapeutic potential in increasing flap survival in clinical practice.     

Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work.

In this paper we present 16 cases of free transfer of compound flaps from the groin, 11 using the deep circumflex iliac vessels as a stem and 5 using the superficial circumflex iliac vessels as a stem. We found the deep vessels superior in many ways to the superficial vessels for this purpose; they are larger, permitting greater ease in anastomoses and providing more reliable blood flow. We believe that larger osteocutaneous or myocutaneous flaps can be transferred on the deep vessels than on the superficial ones-and that the deep circumflex iliac flap may supplant the conventional free going flap in most situations. The method evolved in response to patient need, not for surgical éclat.     

Groin flap design and versatility

The groin flap is a reliable and well-established reconstructive option for pedicled or free-tissue transfer. Concern regarding its variable vascular origin and caliber has limited its use. To overcome this, a simplified guideline based on the transverse diameter of the patient's index and long fingers at the distal interphalangeal level has been developed. Thus "rule of two finger widths" positions the origin of the vascular pedicle from the femoral vessels two finger widths below the inguinal ligament, the upper flap border two finger widths above the inguinal ligament, the lower flap border two finger widths below the vascular origin, and both parallel to the flap axis, which lies along a line from the vascular origin to the anterosuperior iliac spine. This new groin flap design provides the necessary guidelines for vascular identification, accommodates pediatric and adult stature, and ensures primary donor-site closure if flap dimensions are within the prescribed boundaries. In addition, a new sartorius-cutaneous groin flap is presented. This combines the cutaneous groin flap with the proximal sartorius muscle (up to 15 cm), which is supplied by the deep vessels of the superficial circumflex iliac system. The sartorius-cutaneous groin flap further emphasizes the concept of single-pedicle compound or combined flaps and additionally enhances the extensive reconstructive versatility of previously described groin flaps. Over 200 pedicled and free groin flaps have been performed according to the "rule of two finger widths" over the past 5 years. There have been no complications related to flap design, such as difficulty with flap elevation, marginal necrosis, or donor-site closure.(ABSTRACT TRUNCATED AT 250 WORDS)     

The bipedicled osteocutaneous scapula flap: a new subscapular system free flap

Thirty-six adult dissections (14 cadaver and 22 operative) demonstrate the constant presence of the angular branch of the thoracodorsal artery as a vascular pedicle to the inferior pole of the scapula. This vessel originated in all cases just proximal or distal to the serratus branch of the thoracodorsal artery and arborized to the periosteum 6 to 9 cm from the bony branch of the circumflex scapular artery. In eight patients, scapular osteocutaneous flaps were raised preserving the angular branch and the circumflex scapular artery and dissecting up to the subscapular vessels. In all cases, bone was independently perfused by the angular branch. In all six cases where the angular branch was the sole supply to bone, technetium-99m scans demonstrated perfusion. Addition of this vascular pedicle to scapula bone allows two separate bone flaps with one microanastomosis and provides a longer arc of rotation between skin supplied by the circumflex scapular artery and bone. Donor-site morbidity was no greater than with the standard scapula flap.     

Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods.In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.     

Prefabrication of bone by use of a vascularized periosteal flap and bone morphogenetic protein.

The purpose of this pilot study was to prefabricate a vascularized bone graft by using a vascularized periosteal flap containing osteoprogenitor cells, a structural matrix, and recombinant human bone morphogenetic protein-2 (rhBMP-2). In a rat model, a periosteal flap vascularized by the saphenous artery and vein was dissected off the medial surface of the tibia. This flap consisted of three layers-periosteum, muscle, and fascia-and was tubed on itself to form a watertight chamber that was then transferred on its vascular pedicle to the groin. A total of 78 vascularized periosteal chambers were constructed in 39 animals and divided into 10 groups. In group 1, the periosteal chamber was left empty. Groups 2, 3, and 4 consisted of the periosteal flap and rhBMP-2, but in group 3, the proximal vascular pedicle was ligated, and in group 4, the flap was harvested without the periosteal layer and turned inside out. Groups 5 through 10 consisted of the vascularized periosteal flap containing several different structural matrices (calcium alginate spheres, polylactic acid, or demineralized bone matrix) with or without rhBMP-2. Animals were killed at 2, 4, or 8 weeks in each group. The presence and density of any new bone formation was evaluated both radiologically and histologically. Significant bone formation was seen only in those periosteal flaps containing rhBMP-2 and either the calcium alginate or polylactic acid matrix. New bone formation increased both radiologically and histologically from 2 weeks to 8 weeks only in the periosteal flaps containing the polylactic acid matrix and rhBMP-2. This preliminary study therefore suggests that four factors-blood supply, osteoprogenitor cells in the periosteal layer, a biodegradable matrix, and rhBMP-2-are required for optimal prefabrication of a vascularized bone graft.     

Mandibular reconstruction in the radiated patient: the role of osteocutaneous free tissue transfers

This paper discusses our experience with the second metatarsal and iliac crest osteocutaneous transfers for mandibular reconstruction. The prime indication for this type of reconstruction was for anterior mandibular defects when the patient had been previously resected. Midbody to midbody defects were reconstructed with the metatarsal and larger defects with the iliac crest. In most cases, an osteotomy was done to create a mental angle. The evaluation of speech, oral continence, and swallowing revealed good results in all patients unless lip or tongue resection compromised function. Facial contour was excellent in metatarsal reconstructions. The iliac crest cutaneous flap provided a generous supply of skin for both intraoral reconstruction and external skin coverage but tended to be bulky, particularly when used in the submental area. Thirty three of 36 flaps survived completely. Flap losses were due to anastomosis thrombosis (1), pedicle compression (1), and pedicle destruction during exploration for suspected carotid blowout (1). Ninety three percent of bone junctions developed a solid bony union despite the mandible having had a full therapeutic dose of preoperative radiation. Despite wound infections in 8 patients, and intraoral dehiscence with bone exposure in 12 patients, all but one of these transfers went on to good bony union without infection in the bone graft.