The original DCIA flap was used when any defect of the mandible existed, from the condyle to the parasymphysis. Even defects that crossed the mentum could be reconstructed, and grafts up to 16 cm could be harvested along the crest. For extended defects that cross the mentum, a free osteotomized fibula is a better choice.

The DCIA osseous/osteocutaneous flap is better suited for reconstruction of the ramus, angle, and body of the mandible because of its natural curvature. When an osteocutaneous flap is involved, defects of the mucosa and extraoral skin can be replaced by using a large skin paddle. If the soft-tissue defect is relatively large, an accessory flap for mucosal or skin coverage may be required. The medial-wall DCIA free flap can be taken with bone alone or as a myooseous or even osteocutaneous flap, thus providing for oral lining and bone for the reconstruction, or even provision of external skin. The medial-wall flap has become the flap of choice for segmental mandibular defects.

Advantages of using the medial wall include significantly less donor-site morbidity, such as pain, hernia, deformity, and gait disturbance. The medial cortex is thinner and provides a flap that is less bulky, provides good contour, and is more cosmetically acceptable. Variations include the use of the internal iliac muscle for soft-tissue coverage (10), allowing the muscle to be rotated through any arc, for coverage of any defect, and provision of thin, pliable tissue. This flap allows soft-tissue coverage with reconstruction of almost any mandibular defect except defects that cross the mentum. The thickness of the iliac-crest flap allows placement of osseointegrated implants into the free vascularized bone graft.