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Systematic Review and Meta-Analysis of the Versatility of the Deep Circumflex Iliac Artery Free Flap: A Forgotten Flap?
Joseph M. Escandon1, Valeria P. Bustos2, Lauren Escandon3, Eric Santamaria4, Miguel Angel Gaxiola-Garcia5, Beatriz Hatsue Kushida-Contreras5, Antonio J. Forte6, Pedro Ciudad7, Howard N. Langstein1, Oscar J. Manrique1.
1Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA; 2 Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 3 Universidad El Bosque School of Medicine, Bogota&; DC, Colombia; 4 Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, National Cancer Institute, Mexico City, DF, Mexico; 5 Plastic and Reconstructive Surgery, Mexico's Children Hospital Federico Gomez, Mexico City, DF, Mexico; 6 Plastic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA; 7 Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru

Purpose: While many reports provide allusions about the reliability of the Deep Circumflex Iliac Artery (DCIA) free flap, prior studies are restricted to limited areas of application. In this context, further comprehensive investigations of the literature concerning the authentic versatility of the DCIA free flap are indispensable. Therefore, we performed a systematic review of the literature and meta-analysis to assess the reliability and versatility of the DCIA free flap during the reconstruction of different anatomical units.
Methods: A systematic review was conducted in accordance with the PRISMA guidelines across PubMed, Web of Science, Cochrane CENTRAL, and SCOPUS from database inception through August 2020. Original research articles evaluating reconstructive procedures for any body part and outcomes with a DCIA free flap were included. A meta-analysis of proportions was conducted to examine the pooled rates of flap failure and complications.
Results: Our comprehensive search yielded 62 articles. However, seventeen studies reporting outcomes for complete flap loss of 304 flaps were selected for the present meta-analysis. The main recipient sites were head and neck (72.35%), lower extremity (20.67%), and upper extremity (6.74%). The main indications for reconstruction were tumor resection (73.8%) and trauma (17.43%). Fifty non-DCIA additional flaps were required to finalize the reconstruction. The Pooled flap failure rate using the DCIA free flap was 4% (95%CI: 1%8%). No significant heterogeneity was present across studies (Q statistic 22.12, p=0.14; I2=27.68%, p=0.139). 228 complications were reported. The complication rate for head and neck reconstruction and limb reconstruction was 57.37% and 40.16%, respectively. The pooled incidence of hematoma was 1% (95%CI: <16%), of neurosensory deficit following flap harvest was 4% (95%CI: <110%), of flaps requiring revision surgery was <1% (95%CI: <12%), and of partial skin paddle necrosis was 4% (95%CI: <111%). From all these pooled estimates, significant heterogeneity between the studies was observed except for revision surgery. The average area and length of bone flaps were 22.8cm2 and 7.79cm, respectively. The average area of the skin paddles was 117cm2.
Conclusion:: The DCIA free flap has shown to be a versatile reconstructive alternative for head and neck and short-medium size limb defects, displaying a low flap failure rate. However, potential large defect size following tumor ablation or trauma, poor quality of recipient's vessels, contaminated and radiated surgical fields, and the implications of potential donor site morbidity when a large flap is required, can detract the use of the DCIA free flap.


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