The Evolution of the Iliac Crest Flap

The iliac crest free flap, although the gold standard for many years for mandibular reconstruction, remains an important option in the armamentarium for mandibular reconstruction. With the increasing popularity of the fibula osteocutaneous flap, which allows for more refined reconstruction and permits multiple osteotomies, the iliac crest flap is typically reserved for where the fibula flap is contraindicated, including in those with peripheral vascular disease, peroneal magnum, history of fibula fractures, and with previous bilateral fibular flaps. The many limitations of the traditional osteomusculocutaneous flap have been overcome by modified approaches to harvest, including the split iliac crest based on the inner cortex to preserve the thigh muscle attachments and reduce donor site morbidity, and the deep circumflex iliac artery perforator flap that does not include the bulky abdominal wall musculature and allows greater freedom of movement of the skin paddle. This chapter reviews the indications, anatomy, surgical techniques, and postoperative management for the free iliac crest flap.