Donor site morbidity after computer assisted surgical reconstruction of the mandible using deep circumflex iliac artery grafts: a cross sectional study

(2023) 23:4 Brandenburg et al. BMC Surgery https://doi.org/10.1186/s12893-022-01899-z BMC Surgery Open Access RESEARCH Donor site morbidity after computer assisted surgical reconstruction of the mandible using deep circumflex iliac artery grafts: a cross sectional study Leonard Simon Brandenburg1*†, Pit Jacob Voss1†, Thomas Mischkowsky1, Jan Kühle2, Michael Andreas Ermer1, Julia Vera Weingart1, René Marcel Rothweiler1, Marc Christian Metzger1, Rainer Schmelzeisen1 and Philipp Poxleitner1 Abstract Background Computer Assisted Design and Computer Assisted Manufacturing (CAD/CAM) have revolutionized oncologic surgery of the head and neck. A multitude of benefits of this technique has been described, but there are only few reports of donor site comorbidity following CAD/CAM surgery. Methods This study investigated comorbidity of the hip following deep circumflex iliac artery (DCIA) graft raising using CAD/CAM techniques. A cross-sectional examination was performed to determine range of motion, muscle strength and nerve disturbances. Furthermore, correlations between graft volume and skin incision length with postoperative donor site morbidity were assessed using Spearman’s rank correlation, linear regression and analysis of variance (ANOVA). Results Fifteen patients with a mean graft volume of 21.2 ± 5.7 cm3 and a mean incision length of 228.0 ± 30.0 mm were included. Patients reported of noticeable physical limitations in daily life activities (12.3 ± 11.9 weeks) and athletic activities (38.4 ± 40.0 weeks in mean) following surgery. Graft volume significantly correlated with the duration of the use of walking aids (R = 0.57; p = 0.033) and impairment in daily life activities (R = 0.65; p = 0.012). The length of the scar of the donor-site showed a statistically significant association with postoperative iliohypogastric nerve deficits (F = 4.4, p = 0.037). Patients with anaesthaesia of a peripheral cutaneous nerve had a larger mean scar length (280 ± 30.0 mm) than subjects with hypaesthesia (245 ± 10.1 mm) or no complaints (216 ± 27.7 mm). Conclusions Despite sophisticated planning options in modern CAD/CAM surgery, comorbidity of the donor site following iliac graft harvesting is still a problem. This study is the first to investigate comorbidity after DCIA graft raising in a patient group treated exclusively with CAD/CAM techniques. The results indicate that a minimal invasive approach in terms of small graft volumes and small skin incisions could help to reduce postoperative symptomatology. † Leonard Simon Brandenburg and Pit Jacob Voss contributed equally to this work *Correspondence: Leonard Simon Brandenburg Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Brandenburg et al. BMC Surgery (2023) 23:4 Page 2 of 12 Trial registration Retrospectively registered at the German Clinical Trials Register (DRKS-ID: DRKS00029066); registration date: 23/05/2022 Keywords Mandible reconstruction, Deep circumflex iliac artery, Comorbidity Background Oral squamous cell carcinoma (OSCC) is the sixth most common cause of death among all cancer-related diseases with an increasing incidence, [1] especially in younger patients [2]. In 2018, approximately 700,000 new cases and 350,000 deaths due to OSCC were estimated worldwide, making it a global health issue [3]. Especially advanced cases of OSCC need fast and radical treatment to enable adequate long-term survival [3–5]. In surgical treatment of OSCC, tumor-free resection is aspired and therefore radical surgery is performed [3, 6]. OSCC mostly affects the mandible, [7] therefore resections of the mandible are frequently required, leading to large defects of the lower jaw [8]. Subsequent plastic reconstruction of the mandible is crucial to enable a proper rehabilitation of the stomatognathic system including mastication, deglutition and speech as well as the aesthetic appearance of the face [9–11]. The current gold standard in reconstructing bony defects of the mandible are microvascular free flaps [3]. After the introduction of microsurgical techniques, different donor-sites were described for harvesting of osteocutaneous free flaps [12]. The first successful free flap surgery was performed using an autotransplant of omentum to a large scalp defect [13]. Hidalgo first described the free fibula flap (FFF) as a microvascular transplant to be used in the head and neck area [14]. The scapula osteocutaneous free flap (SOFF) and the iliac crest flap supplied by the deep circumflex artery (DCIA) present valuable alternatives for bony reconstruction in maxillofacial surgery and were described shortly after [15, 16]. Depending on the localization and the size of the defect, the choice of specific graft may provide particular advantages in the reconstruction process. The FFF has emerged to be the workhorse flap in the reconstruction of the mandible. Due to the wide section of dense cortical bone supplied by the fibula, it became indispensable when forming a neo-mandible [17]. The SOFF, on the other hand, is used preferably for the reconstruction of the temporomandibular joint, as the scapular tip can be used for anatomical replacement of the condylar head. Moreover, by raising the latissimus dorsi muscle, a high volume of soft tissue can be harvested alongside the SOFF [18, 19]. The DCIA graft provides anatomically shaped bone with sufficient vertical height resembling the anatomical form of the mandibular body [20]. Therefore, it offers excellent conditions for subsequent placement of osseointegrating dental implants [21, 22]. Due to its favorable characteristics some authors even proposed the DCIA graft as transplant of choice for reconstruction of the mandible [10, 11]. Due to the widespread use of computed tomography (CT) and computer-assisted image processing, the options for preoperative planning have improved significantly in recent decade (...truncated)