The simultaneous preparation of the donor and recipient sites by two operative teams will considerably decrease operative time.
The VICG is harvested with the patient supine. The incision extends from the inguinal ligament to the anterior iliac crest and, if needed, incorporates a skin paddle centered on the longitudinal axis of the iliac crest. The inguinal canal is exposed and the deep circumflex iliac artery is dissected beginning at its origin from the external iliac artery and proceeding proximally. It ascends along the inner surface of the anterior ilium or within the iliac muscle, being 2 cm caudal to the iliac crest. Care should be taken to avoid severing the iliac muscle and fascia along the course of the vessels, but incise them at the same level as the osteotomy so as to incorporate the intact vessels. The soft tissue component should be elevated with caution to avoid any interference with its connections to the fascia overlying the external oblique muscle and the iliac crest. Musculotendinous attachments are reflected from the iliac crest. Osteotomy follows, the graft is observed for bleeding and the pedicle is divided. Wound closure should be carefully executed to avoid postoperative hernias.
The surgical technique is ideal to groin flap elevation with the additional inclusion of an iliac crest bone graft. Dissection is considerably easier and the inguinal canal is spared.
Dissection of the superficial in addition to the deep pedicle has been proposed by some authors as a means of increasing the reliability of the skin component of the composite VICG.
Recipient Site Preparation and Defect Reconstruction
Guidelines for preparation of the recipient site and reconstruction of the defect have already been discussed in Chapter 10A (free vascularized fibular graft). When a VICG is used, however, the surgeon should be familiar with the potential for graft configuration and aware of the limitations in graft fixation.
The VICG can undergo one or more osteotomies without any compromise in graft vascularity, due to the presence of multiple arterial branches supplying the bone. Therefore, it can be shaped appropriately in order to optimally reconstruct the existing defect. Taylor advocated a wedge osteotomy to straighten grafts longer than 8 cm and prevent stress fractures.
Screw purchase into the cancellous bone of the iliac crest is limited. Thus, internal fixation by plate and screws will not provide adequate stability. External fixation is preferable and can be supplemented by an additional Kirschner wire or screw.
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