Iliac Crest Bone Flap

  • Klaus-Dietrich Wolff
  • Frank Hölzle


The possibility to transfer bone blocks of the ileum as parts of composite flaps from the groin donor site was described in anatomical studies by Taylor and Watson in 1978 [531]. These authors used this flap pedicled on the superficial circumflex iliac artery (SCIA) for reconstruction of compound defects of the lower leg. Whereas the blood supply of the SCIA was excellent to the skin, the bone blocks of the iliac crest were only perfused marginally by these vessels. Other vascular pedicles around the hip, such as the ascending branch of the circumflex femoral artery or the superior gluteal artery, were also used for microvascular transfer of composite flaps containing bone from the iliac crest [28, 230]. Although the vascular anatomy of the groin region, which was the first donor site for free flaps [15], was already investigated by Taylor and Daniel in 1973 [529], it took until 1979, when Taylor et al. [531] and Sanders and Mayou [454] described the first transfer of the iliac crest bone, using the deep circumflex iliac artery (DCIA) as the vascular pedicle. Both groups independently identified the DCIA to be the main nutrient vessel of the whole ileum. Since these first reports, the iliac crest proved to be a useful and reliable donor site, which, due to its anatomical shape, is ideally suited for the harvest of bone flaps to reconstruct defects of up to half a mandible [4, 40, 41, 112, 131, 146, 255, 256, 427, 524, 525, 553, 554]. Because of the high amount of bone available, endosseous dental implants can be inserted without problems, making the iliac crest the donor site of the first choice for functional masticatory reconstruction of the mandible and maxilla [427]. Sanders and Mayou also have shown that the DCIA provides blood supply to the overlying skin of the iliac crest by myocutaneous vessels [454]; thus, a skin paddle from the groin region can additionally be included and used for extraoral or intraoral reconstruction [255, 427, 553, 554]. Other flaps, such as the anterolateral thigh flap has been additionally transferred together with the iliac crest [293] to extend the skin territory for soft tissue reconstruction, performing additional anastomoses at the descending branch of the circumflex femoral artery. Because of the bulk and the limited maneuverability of the iliac crest skin paddle. Urken and coworkers introduced the inclusion of the internal oblique muscle into the iliac osteomyocutaneous flap [550, 553, 554]. He proposed to use this flat and flexible muscle for intraoral lining instead of the voluminous skin paddle. Although it was shown by Ramasastry et al. already in 1984 [417], that the internal oblique muscle is safely perfused by the ascending branch of the DCIA, thus offering the possibility to build a vascularised myo-osseous iliac flap pedicled on the DCIA, the internal oblique muscle was only used as an isolated muscle flap until Urken’s description. Apart from the decreased bulk, covering the iliac crest with the internal oblique muscle is advantageous for prosthetic rehabilitation following the insertion of endosseous dental implants. Due to the secondary atrophy of the muscle, a tight and flat residual tissue, similar to that of the attached gingiva will develop, allowing for good hygiene and loadability around the implants. The iliac crest internal oblique flap also has proven to be useful in covering skull base defects and to reconstruct the hard palate.

Supplementary material

Video 10.1

Iliac crest bone flap (MPG 122578 kb)


  1. 4.
    Acland RD (1979) The free iliac flap: a lateral modification of the free groin flap. Plast Reconstr Surg 64(1):30–36CrossRefGoogle Scholar
  2. 15.
    Antia NH, Buch VI (1971) Transfer of an abdominal dermo-fat graft by direct anastomosis of blood vessels. Br J Plast Surg 24(1):15–19CrossRefGoogle Scholar
  3. 27.
    Ayoub N, Ghassemi A, Rana M, Gerressen M, Riediger D, Hölzle F, Modabber A (2014) Evaluation of computer-assisted mandibular reconstruction with vascularized iliac crest bone graft compared to conventional surgery: a randomized prospective clinical trial. Trials 15:114. doi:10.1186/1745-6215-15-114CrossRefPubMedPubMedCentralGoogle Scholar
  4. 29.
    Baker SR (1981) Reconstruction of mandibular defects with the revascularized free tensor fascia lata osteomyocutaneous flap. Arch Otolaryngol 107(7):414–418CrossRefGoogle Scholar
  5. 40.
    Bitter K (1980) Bone transplants from the iliac crest to the maxillo-facial region by the microsurgical technique. J Maxillofac Surg 8(3):210–216CrossRefGoogle Scholar
  6. 41.
    Bitter K, Danai T (1983) The iliac bone or osteocutaneous transplant pedicled to the deep circumflex iliac artery. I. Anatomical and technical considerations. J Maxillofac Surg 11(5):195–200CrossRefGoogle Scholar
  7. 42.
    Bitter K, Schlesinger S, Westerman U (1983) The iliac bone or osteocutaneous transplant pedicled to the deep circumflex iliac artery. II. Clinical application. J Maxillofac Surg 11(6):241–247CrossRefGoogle Scholar
  8. 84.
    Chen RS, Liu YX, Liu CB, Hu YS, Xu DC, Zhong SZ, Li ZH (1999) Anatomic basis of iliac crest flap pedicled on the iliolumbar artery. Surg Radiol Anat 21(2):103–107CrossRefGoogle Scholar
  9. 113.
    Daniel RK (1978) Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1(4):346–371CrossRefGoogle Scholar
  10. 132.
    Ehrenfeld M, Cornelius CP, Rossell L (1992) Microvascular bone transplantation. Developments and present concept. J Craniomaxillofac Surg 20:35–39Google Scholar
  11. 147.
    Ferreira MC, Rocha DL, Besteiro JM, Monteiro AA Jr (1985) Mandibular reconstruction with free osteocutaneous iliac crest based on the deep circumflex vessels. Chir Plast 8:83CrossRefGoogle Scholar
  12. 152.
    Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V (1992) The free vascularised iliac crest tissue transfer: donor site complications associated with eighty-two cases. Br J Plast Surg 45(2):89–93. doi:0007-1226(92)90163-R [pii]Google Scholar
  13. 235.
    Huang GK, Hu RQ, Miao H, Yin ZY, Lan TD, Pan GP (1985) Microvascular free transfer of iliac bone based on the deep superior branches of the superior gluteal vessels. Plast Reconstr Surg 75(1):68–74CrossRefGoogle Scholar
  14. 236.
    Huang GK, Liu ZZ, Shen YL, Hu RQ, Miao H, Yin ZY (1980) Microvascular free transfer of iliac bone based on the deep circumflex iliac vessels. J Microsurg 2(2):113–120CrossRefGoogle Scholar
  15. 260.
    Kärcher H (1986) Die Unterkieferrekonstruktion mit freien mikrovaskulären Knochentransplantaten. Acta Chir Australiaca 33:251Google Scholar
  16. 261.
    Karcher H, Borbely L (1988) Possibilities of vital bone grafts in the maxillofacial area. Dtsch Z Mund Kiefer Gesichtschir 12(2):124–134PubMedGoogle Scholar
  17. 276.
    Kimata Y (2003) Deep circumflex iliac perforator flap. Clin Plast Surg 30(3):433–438CrossRefGoogle Scholar
  18. 299.
    Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y, Nagayama H (1993) Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg 92(3):411–420CrossRefGoogle Scholar
  19. 333.
    Manktelow RT (1986) Microvascular reconstruction. Springer, BerlinCrossRefGoogle Scholar
  20. 375.
    Modabber A, Ayoub N, Möhlhenrich SC, Goloborodko E, Sönmez TT, Ghassemi M, Loberg C, Lethaus B, Ghassemi A, Hölzle F (2014) The accuracy of computer-assisted primary mandibular reconstruction with vascularized bone flaps: iliac crest bone flap versus osteomyocutaneous fibula flap. Med Devices (Auckl) 7:211–217. doi:10.2147/MDER.S62698. eCollection 2014CrossRefGoogle Scholar
  21. 376.
    Modabber A, Gerressen M, Ayoub N, Elvers D, Stromps JP, Riediger D, Hölzle F, Ghassemi A (2013) Computer-assisted zygoma reconstruction with vascularized iliac crest bone graft. Int J Med Robot 9(4):497–502. doi:10.1002/rcs.1557. [Epub 2013 Nov 6]CrossRefPubMedGoogle Scholar
  22. 377.
    Modabber A, Möhlhenrich SC, Ayoub N, Hajji M, Raith S, Dds SR, Steiner T, Ghassemi A, Hölzle F (2015) Computer-aided mandibular reconstruction with vascularized iliac crest bone flap and simultaneous implant surgery. J Oral Implantol 41(5):e189–e194. doi:10.1563/aaid-joi-D-13-00341. [Epub 2014 Jun 19]CrossRefPubMedGoogle Scholar
  23. 406.
    O’Brien B, Morrison WA (1987) Reconstructive microsurgery. Churchill, LivingstonGoogle Scholar
  24. 410.
    Ostrup LT, Fredrickson JM (1974) Distant transfer of a free, living bone graft by microvascular anastomoses. An experimental study. Plast Reconstr Surg 54(3):274–285CrossRefGoogle Scholar
  25. 426.
    Ramasastry SS, Tucker JB, Swartz WM, Hurwitz DJ (1984) The internal oblique muscle flap: an anatomic and clinical study. Plast Reconstr Surg 73(5):721–733CrossRefGoogle Scholar
  26. 436.
    Riediger D (1988) Restoration of masticatory function by microsurgically revascularized iliac crest bone grafts using enosseous implants. Plast Reconstr Surg 81(6):861–877CrossRefGoogle Scholar
  27. 463.
    Sanders R, Mayou BJ (1979) A new vascularized bone graft transferred by microvascular anastomosis as a free flap. Br J Surg 66(11):787–788CrossRefGoogle Scholar
  28. 477.
    Schmelzle R (1986) Vascular pedicled iliac crest transplant and its use in the jaw. Handchir Mikrochir Plast Chir 18(6):376–378PubMedGoogle Scholar
  29. 533.
    Taylor GI (1982) Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg 9(5):361–376CrossRefGoogle Scholar
  30. 534.
    Taylor GI (1983) The current status of free vascularized bone grafts. Clin Plast Surg 10(1):185–209PubMedGoogle Scholar
  31. 538.
    Taylor GI, Daniel RK (1975) The anatomy of several free flap donor sites. Plast Reconstr Surg 56(3):243–253CrossRefGoogle Scholar
  32. 540.
    Taylor GI, Townsend P, Corlett R (1979) Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Reconstr Surg 64(5):595–604CrossRefGoogle Scholar
  33. 559.
    Urken ML, Cheney ML, Sullivan MJ, Biller HF (1990) Atlas of regional and free flaps for head and neck reconstruction. Raven Press, New YorkGoogle Scholar
  34. 562.
    Urken ML, Vickery C, Weinberg H, Buchbinder D, Biller HF (1989) The internal oblique-iliac crest osseomyocutaneous microvascular free flap in head and neck reconstruction. J Reconstr Microsurg 5(3):203–214; discussion 215–206Google Scholar
  35. 563.
    Urken ML, Vickery C, Weinberg H, Buchbinder D, Lawson W, Biller HF (1989) The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases. Arch Otolaryngol Head Neck Surg 115(3):339–349CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Klaus-Dietrich Wolff
    • 1
  • Frank Hölzle
    • 2
  1. 1.Department of Oral and Maxillofacial SurgeryKlinikum rechts der Isar, Technische Universität MunichMunichGermany
  2. 2.Department of Oral and Maxillofacial SurgeryUniversity Hospital of RWTH Aachen UniversityAachenGermany

Personalised recommendations