Craniomaxillofacial Reconstructive and Corrective Bone Surgery - part 5 pot

the ilium in the fascia of the iliac muscle 1 to 3 cm from the inner cortex of the iliac crest. Overlying and superior to the iliac crest a skin island can be harvested. The skin portion is nourished by perforating vessels from the DCIA and DCIV, which reach the surface on the medial aspect of the iliac crest at a distance of 1 to 2 cm. The axis of the skin flap lies between the superior infe- rior iliac spine and tip of the scapula. Dissection starts with the exposure of the femoral artery, which can be easily palpated caudally to the inguinal ligament. Further dissection in the proximal direction leads to the DCIA, which leaves on the lateral aspect of the vessel, now called the external iliac artery, normally 1 to 3 cm cranially to the inguinal ligament (Figure 25.15). After that the DCIA and frequently the two accompanying veins are dissected as a bundle in a craniolat- eral direction. Dissection comes to a stop at 2 to 3 cm from the anterior superior iliac spine (Figure 25.16). To raise an osteomuscular bone flap with a skin island, the desired skin portion is now dissected free. The incision di- vides skin and subcutaneous tissues down to the underlying abdominal fascia. Medially to the anterior superior iliac spine, the lateral cutaneous femoral nerve should be exposed and preserved. The external and internal oblique as well as the transverse abdominal muscles are now incised 3 to 4 cm cranially to the iliac crest (Figure 25.17). The muscle portion of the flap must remain attached to the fascia and the skin so as not to harm the blood supply of the skin. The strip of abdominal muscle attached to the medial aspect of the iliac crest contains the perforating vessels, which are very sensitive and may be harmed even by shearing the different soft tissue layers against each other. At 3 to 4 cm superior to the iliac crest, the transverse abdominal muscle is represented through the transverse fascia, which is also incised. The abdominal wall is retracted medially, and the junction between transversal fascia and the fascia of the iliac muscle is identified (Figure 25.18). The vascular pedicle lies in the duplication of the two fascias and can be palpated at this stage. The muscles on the lateral aspect of the ilium are then stripped. The periosteum can either be elevated or left in place if additional soft tissue coverage of the bone is desired. The 302 M. Ehrenfeld and C. Hagenmaier FIGURE 25.16 The vascular pedicle containing the DCIA and in most cases two accompanying veins is dissected. F IGURE 25.18 The fascia of the iliacus muscle together with a 2- to 3-cm strip of muscle must also be included in the flap. The iliacus muscle can be divided by blunt dissection. F IGURE 25.15 The femoral artery and vein are identified. After that the skin overlying the inguinal ligament is incised and the junction of the fascias of the abdominal wall and the thigh is exposed. The inguinal ligament is cut parallel to the axis of the DCIA and DCIV. F IGURE 25.17 The edges of the skin island are cut down to the underlying fascia after the vascular pedicle has been isolated. The three layers of the abdominal muscles are divided leaving a muscle strip 3 cm wide attached to the bone and the overlying skin. The vascular pedicle lies in the junction of the iliacus and the transversalis fascia. bone is then osteotomized with an oscillating saw in the desired size and shape (Figure 25.19). The osteotomy site is sealed with bone wax (Figure 25.20). The iliac bone flap is completely freed from all surrounding tissues and remains only connected to the vascular pedicle. If there is any delay in the craniofacial part of the operation (tumor ablation, prepa- ration of the recipient site), the flap is deposited in a subcutaneous pocket. Shortly before transplantation, the DCIA and then the DCIV are ligated and transected. The flap may be ir- rigated with saline solution but is not routinely rinsed with anticoagulants. For raising of an osteomuscular iliac bone flap without a skin or a separate muscle island, the dissection is performed very similarly to the procedure just described. Because no skin is taken, the abdominal skin overlying the iliac crest is incised parallel to the bone. On the medial aspect of the ilium, the transverse and oblique abdominal muscles are cut close to the bone; only a strip of iliac muscle and fascia containing the vascular pedicle is left attached to the medial aspect of the ilium. 16,51,52 A special consideration, in obese patients, is that the composite osteomusculocutaneous iliac bone flap provides too much bulk for intraoral soft tissue reconstruction. As an important variation, a osteomuscular flap with a large fas- ciomuscular soft tissue island from the internal oblique muscle can be harvested. 53 Therefore, the fascia of the transverse abdominal and external oblique muscles is cut close to the iliac crest. The internal oblique, underlying the external fascia and muscle, is now exposed. A nonconstant separate branch of the DCIA, which leaves the artery on its way between the internal iliac artery and anterior superior iliac spine, may go directly to the internal oblique muscle in a mediocranial direction and should be preserved when present. The internal oblique muscle and its fascia are dissected in the desired length and remain attached to the medial aspect of the iliac crest. A strip of iliac muscle containing the vascular pedicle is also included in the flap. The result is a compound flap of solid iliac bone with a potentially large soft tissue island of internal oblique muscle and fascia (Figure 25.21), which can be used to replace resected intraoral mucosa (Figure 25.22). Therefore, the intraorally placed muscle and fascia are left to granulation (Figure 25.23) and subsequent secondary epithe- lialization from the surrounding mucous membrane. Despite a certain amount of shrinkage, usually good functional results can be obtained (Figure 25.24). Flap Contouring Especially in chin reconstruction, the only slightly curved iliac bone must be bent to adapt it to the shape of a mandible. For this purpose, the outer cortex (lateral cortex) of the flap’s bony portion is osteotomized with an oscillating saw (Figure 25.25). The bone cut goes through the outer cortex and the cancellous portion of the flap. Care must be taken not to pen- etrate the medial cortex, because in so doing the attached segment of iliac muscle, the periosteum, and the vascular pedi- 25. Autogenous Bone Grafts in Maxillofacial Reconstruction 303 F IGURE 25.19 After stripping of muscles and periosteum attached to the lateral aspect of the iliac crest, the bony portion is cut with an oscillating saw. F IGURE 25.20 The vascular pedicle is ligated and divided after complete isolation of the flap. After sealing the iliac bone with bone wax, the abdominal wall is closed layer by layer. F IGURE 25.21 Osteomuscular bone flap from the hip with attached internal oblique muscle. cle may be injured, thus compromising the blood supply. Af- ter that the bone can be bent in the desired fashion (Figure 25.26). Scapular Bone and Combined Flaps The scapula is a triangular-shaped bone with a very thin center portion, whereas the borders of the scapula are composed of more solid bone. The lateral border of the scapula provides sufficient bone for craniomaxillofacial reconstruction pur- poses. Pedicled on the circumflex scapular artery and frequently two accompanying veins, bone flaps with a thickness of approximately 1.5 cm, a height of approximately 3 cm, and a length of 10 to 14 cm can be harvested. Although the 304 M. Ehrenfeld and C. Hagenmaier F IGURE 25.22 The internal oblique muscle can be used to cover defects of the oral mucosa, in this clinical case, of the anterior floor of the mouth. FIGURE 25.23 The muscle granulates after transplantation and is sec- ondarily epithelialized from the surrounding mucosa. FIGURE 25.24 Clinical situation after the granulation process is fin- ished. F IGURE 25.25 An osteotomy of the former lateral cortex of the hip now included in osteomuscular iliac bone flap is necessary if the bone must be bent to adjust it to a special clinical situation. F IGURE 25.26 Bone flap after multiple monocortical osteotomies. De- pending on the desired length of the flap, the bone can either be contoured by removing wedges from the lateral aspect of the hip or by monocortical osteotomies and bending to the medial aspect as shown. The bone gaps at the osteotomy sites are then filled with cancellous bone and marrow. absolute amount of bone depends very much on the individual patient’s condition, the lateral border of the scapula is usually composed of enough bone even for mandible reconstruction. The vascular axis containing the circumflex scapular artery can be elongated in dissecting the subscapular vessels up to the axilla. Through this technique a long vascular pedicle of approximately 12 to 14 cm can be created, which has advantages for special indications, among them reconstruction of the maxilla or mandible in a compromised vessel situation. On the common subscapular vascular pedicle, the scapular bone flap can be combined with a scapular or parascapular fasciocutaneous and a musculocutaneous flap from the latissimus dorsi muscle. Various flap combinations are also possible. Flap dissection is usually performed with the patient turned on their side. Important anatomic landmarks are the scapular spine, the lateral border of the scapula, and the muscle gap between major and minor teres muscles on one side and the long triceps head on the other side. This muscle gap lies cranially to the middle portion of the lateral margin of the scapula. The bone is supplied via vessels run- ning in a deep plane parallel to the lateral margin of the bone, whereas two other small terminal branches of the circumflex scapular artery nourish the scapular and parascapular flaps, respectively (Figure 25.27). The scapular flap is raised over a vascular axis that runs parallel to the scapular spine approximately in the middle between scapular tip and scapular spine. The parascapular flap vessel axis also lies parallel to the lateral margin of the scapula, but in a subcutaneous plane. To make microvascular anastomoses easier, it is advisable to include the subscapular artery and vein in the pedicle and therefore prepare as much vessel length as possible. The dissection of the axillary and subscapular vessels starts with a skin incision over and parallel to the anterior axillary fold. In the loose subcutaneous tissues, the junction between axillary and subscapular vessels is exposed. The circumflex scapular artery leaves the subscapular artery normally 2 to 4 cm caudally to the axillary vessels. As an important variation, sometimes both arteries leave the axillary artery separately. Two veins normally run with the circumflex scapular artery; both should be dissected and preserved. The vascular pedicle is further dissected medially into the lateral muscular gap. Care- ful ligation of small vessels to the surrounding muscles is mandatory. To gain better access, the skin overlying the vascular pedicle can be incised. The muscle gap beside the lateral scapular border is palpated and localized. After retrac- tion of the latissimus dorsi and teres major muscles, the vascular pedicle can be seen in the muscle gap. There the subscapular vessels divide into three terminal branches, one to the bony portion and the remaining two to the scapular and parascapular skin islands. If a combination of a bone flap together with a scapular or a parascapular flap is desired, the size of the soft tissue island must be defined at that stage of the operation. This is usually performed with the help of an individual template. Then, an incision is made through skin and underlying fascia and the soft tissue flap is raised from the muscle. This is performed from medially to laterally in the case of the scapular and in a caudal-cranial direction so far as the parascapular flap is concerned. Lateral to the bony border, in the region of the muscle gap, both skin flaps must remain in connection with the circumflex scapular vessels. If a osteomuscular bone flap without additional skin flaps is desired, the skin overlying the scapula is simply incised parallel to the lateral bone margin from the scapular spine to the tip. On the lateral aspect of the scapula, the teres minor muscle inserts cranially and the teres major muscle inserts caudally. The muscles are cut leaving a muscle strip at least 1 cm wide attached to the bone. The vascular pedicle is thus protected. Osteotomy of the bone is now performed from posterior with a saw (Figure 25.28). The upper osteotomy line must remain approximately 2 cm from the glenoid fossa. Now the one strut, which is still connected to the underlying muscles, is elevated. The subscapular muscle, which has its origin on the costal aspect of the scapula, is incised leaving a muscle strip of approximately 1 cm attached to the bone. The bone or combined bone and soft tissue flap is now completely isolated on its vascular pedicle, and the latter is ligated in the desired length (Figure 25.29). If the subscapular vessels are included in the vascular axis, the thoracodorsal artery and vein must also be ligated. Preserving these vessels allows various flap combinations potentially including a scapular bone flap, scapular and parascapular soft tissue flaps, and 25. Autogenous Bone Grafts in Maxillofacial Reconstruction 305 F IGURE 25.27 Bone grafts from the glenoid fossa to the tip can be taken from the lateral aspect of the scapula. Pedicled on the cutaneous branches of the circumflex scapular artery, a scapular or parascapular skin flap (or both) can be harvested in addition. Before dissection of the lateral border of the scapula, the crista scapulae and the muscular gap between teres minor and major muscles and the long head of the triceps muscle are palpated and marked. a musculocutaneous latissimus dorsi flap, 19,51,52 (Figure 25.30). Fibula Bone and Combined Flaps The fibula is a source for long bone flaps with a compact bone structure. The flap can be harvested with the patient lying on the back, side, or abdomen. A two-team approach in maxillofacial reconstructive surgery can usually only be achieved with the patient in a supine position. The patient’s leg is flexed in both hip and knee with the hip joint in inward rotation. In this position the complete fibula can normally be palpated through the skin from the fibula head to the lateral malleolus (Figure 25.31). The supplying vessel of the fibula bone and combined flap is the peroneal artery, which rarely is also the dominant vascular supply for the foot. Therefore, before flap harvesting an angiogram is mandatory. The vascular axis of the bone flap lies medial to the fibula. The bone itself is nourished mainly via perforators to the medial periosteum. As a consequence, stripping of the medial periosteum during dissection or flap fixation must be avoided. Dissection of the bone flap starts with the incision of the skin on the lateral aspect of the fibula. 306 M. Ehrenfeld and C. Hagenmaier FIGURE 25.28 After dissection of the circumflex scapular vessels, and, if a long vascular pedicle is required the subscapular vessels as well, the desired fasciocutaneous flap is elevated first. The muscles attached to the lateral border of the scapula are then divided leaving a strip of muscle approximately 2 cm wide attached to the bone. The muscles inserting on the posterior aspect of the scapula are also divided, leaving a thin muscle cuff in place. The bone is cut with a saw and elevated. After access is given to the costal surface of the scapula, the subscapular muscle is divided. FIGURE 25.30 Combination of osteomuscular and fasciocutaneous scapula and a musculocutaneous latissimus dorsi flap on the common subscapular vascular pedicle. F IGURE 25.29 The osteomuscular and the fasciocutaneous portions of the combined flap are isolated and pedicled on the common vascular axis represented by the circumflex scapular vessels. The latissimus dorsi muscle is elevated. Now the flap can be transposed anteriorly into the axilla, and the subscapular vessels can be dissected to gain a longer vascular pedicle. An additional portion of a latissimus dorsi flap pedicled on the thoracodorsal vessels can also be included in the flap. FIGURE 25.31 For harvesting of a fibula flap, the patient’s leg is flexed in both hip and knee with the hip joint in inward rotation. In this position the complete fibula is palpated through the skin from the fibula head to the external malleolus and marked. An ovally shaped skin island can be harvested parallel to the bone axis and overlying the proximal two-thirds of the bone. The common popliteal nerve, which runs in a subcutaneous plane lateral to the fibular head, is exposed and preserved. The subcutaneous tissues are separated down to the deep muscular fascia. After that, the so-called posterior intermuscular septum between the anteriorly (long and short peroneal muscles) and posteriorly located muscles (soleus muscle, long and short flexor hallucis muscles) is dissected (Figure 25.32). Blunt dissection of the anteriorly and posteriorly located muscles gives good access to the lateral surface of the fibula. The peroneal muscles are freed from the fibula, whereas the periosteum should remain attached to the bone because stripping of the lateral periosteum may lead to an elevation of the periosteum on the medial side, thus separating the vascular pedicle from the bone. Preservation of the periosteum is essential for the blood supply to the bony portion of the flap. This first step of the dissection ends when the anterior edge of the fibula is reached. Adherent to the anterior edge is the anterior intermuscular septum. It is cut close to the bone, and then the long and short extensor digitorum muscles are also separated from the bone again in an epiperiosteal plane. Di- rectly in front of the fibula, the anterior tibial artery and vein can be palpated and inspected after the extensor muscles have been cut. These vessels must be preserved; together with the extensor muscles they are retracted to the side. The interosseous membrane is exposed over and cut shortly above the fibula. The vascular axis of the fibula flap containing the peroneal vessels, lying on the medial aspect close to the bone, must be handled with great care. Now the fibula is osteotomized in the desired length to allow sufficient access to the soft tissues on the posteromedial side of the bone (Figure 25.33). The bony segment is mobilized laterally and posteriorly. Behind the distal osteotomy line the peroneal vessels are identified and ligated. The vascular pedicle lies posterior to the interosseous membrane embedded in loose connective tissues. In this stage of the dissection, care must be taken to not separate the vessels from the periosteum. Finally, the peroneal vessels are dissected proximally up to the popliteal vessel and then ligated. If a fibula flap with a skin paddle is required, the planning starts with the definition of the desired amount of skin. The axis of the skin portion overlies the lateral border of the fibular bone and the posterior intermuscular septum. Blood supply to the skin is brought by septocutaneous or musculocutaneous perforators out of the peroneal vessels, which are located in the posterior intermuscular septum and sometimes in the soleus muscle close to the muscle surface. To make perfusion of the skin island safer, it is recommended that a strip of soleus muscle adjacent to the intermuscular septum be included in the flap. The posterior and anterior edges of the flap are incised and the skin is elevated on both sides together with the deep fascia. Via the posterior intermuscular septum, the center of the flap always remains in close contact to the lateral aspect of the bone. The skin portion is now elevated anteriorly and the dissection is directed toward the posterior crural septum, un- til the perforators can be identified in the subcutaneous layer. The bone is now divided into the desired lengths, after which further soft tissue dissection is easier. The soleus muscle is separated from the fibula, leaving a thin strip of muscle (about 1.0 cm) attached to the bone. The flexor hallucis longus mus- 25. Autogenous Bone Grafts in Maxillofacial Reconstruction 307 F IGURE 25.33 Harvesting of a bone-only flap. After detaching the muscles on the lateral and anterior surface of the fibula, the bone is divided and transposed laterally. After that the peroneal vessels are easily identified. A strip of the posterior tibialis and hallucis longus muscles together with the periosteum remains attached to the bone. F IGURE 25.32 Cross cut through the lower leg. The supplying peroneal vessels are lying on the medial aspect of the bone. The skin island is nourished by perforators from the peroneal vessels, which come around the posterior surface of the fibula into the posterior intermuscular septum. Sometimes they are lying in the soleus muscle close to the muscle surface. Therefore, some authors recommend including a strip of soleus muscle in the flap. cle is separated, and then the peroneal vessels are ligated and cut at the distal end of the flap. The final steps of the dissection are similar to the dissection of a bone-only flap. 51–53 Radial Forearm Osteomuscular-Fasciocutaneous Flap The fasciocutaneous distal radial forearm flap today seems to be one of the most popular flaps for intraoral reconstruction. 54 The thin and pliable flap is pedicled on the radial artery and the deep venae commitantes. For venous drainage of the soft tissue flap, subcutaneous veins from the forearm are also sufficient. The radial artery and the accompanying veins lie in a duplicate of the antebrachial fascia. From there small vessels ascend to the overlying skin, and other vessels descend to the brachioradialis muscle. Together with a part of this muscle, a segment of the radius can be taken, thus turning the fasciocutaneous soft tissue into a fasciocutaneous-osteomuscular radial forearm flap. Harvesting of the composite radial forearm flap has quite a significant donor site morbidity; radius fractures in up to 20% of the cases have been reported. The available bone is very small in width, height, and length. Therefore, the radial forearm bone and soft tissue flap is not a flap of first choice for functional mandible reconstruction. References 1. Axhausen W. Die Bedeutung der Individual- und Artspezifität der Gewebe für die freie Knochenüberpflanzung. Hefte Unfall- heikunde. 1962;72:1. 2. Schweiberer L. Experimentelle Untersuchungen von Knochen- transplantaten mit unveränderter und denaturierter Knochen- grundsubstanz. Hefte Unfallheilk 103. Berlin: Springer; 1970. 3. Bardenheuer B. Über Unter- und Oberkieferresektion. Verh Dtsch Ges Chir. 1892;21:123–130. 4. Sykoff V. Zur Frage der Knochenplastik am Unterkiefer. Zen- tralbl Chir. 1900;27:81. 5. Krause F. Unterkiefer-Plastik. Zentralbl Chir. 1907;34:1045– 1046. 6. Axhausen G. Histologische Untersuchungen über Knochentrans- plantationen am Menschen. Dtsch Z Chir. 1908;91:388–428. 7. Lexer E. Die Verwendung der freien Knochenplastik nebst Ver- suchen über Gelenkversteifung und Gelenktransplantation. Arch Klin Chir. 1908;86:939. 8. Rydygier LRV. Zum osteoplastischen Ersatz nach Unterkiefer- resektion. Zentralbl Chir. 1908;35:1321–1322. 9. Lindemann A. Über die Beseitigung der traumatischen Defekte der Gesichtsknochen. In: Bruhn C, Hrg. Die gegenwärtigen Be- handlungswege der Kieferschußverletzungen. Hefte IV–VI. Bergmann Wiesbaden: 1916. 10. Matti H. Über freie Transplantation von Knochenspongiosa. Langenbecks Arch Clin Chir. 1932;168:236. 11. Converse JM. Early and late treatment of gunshot wounds of the jaw in French battle casualities in North Africa and Italy. J Oral Surg. 1945;3:112–137. 12. Conley JJ. Use of composite flaps containing bone for major re- pairs in the head and neck. Plast Reconstr Surg. 1972;49:522. 13. Boyne P. Methods of osseous reconstruction of the mandible following surgical resection. J Biomed Mat. 1973;4:195. 14. Taylor GI, Miller G, Ham F. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Recon- str Surg. 1975;55:553–554. 15. O’Brien B McC. Microvascular Reconstructive Surgery. Edin- burgh: Churchill Livingstone; 1977. 16. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Re- constr Surg. 1979;64:745. 17. Quillen CG. Latissimus dorsi myocutaneous flap in head and neck reconstruction. Plast Reconstr Surg. 1979;63:664. 18. Ariyan S. The viability of rib grafts transplanted with the peri- ostal blood supply. Plast Reconstr Surg. 1980;65:140–151. 19. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg. 1986;77:530– 545. 20. Axhausen W. Die Quellen der Knochenneubildung nach freier Transplantation. Langenbecks Arch Klin Chir. 1951;279:439– 443. 21. Axhausen W. Die Knochenregeneration—ein zweiphasiges Geschehen. Zentralbl Chir. 1952;77:435–442. 22. Chalmers J. Transplantation immunity in bone homografting. J Bone Joint Surg. 1959;41B:160–179. 23. Williams RG. Comparison of living autogeneous and homoge- neous grafts cancellous bone heterotopically placed in rabbits. Anat Rec. 1962;143:93. 24. Heiple KG, Chase SW, Herndon CH. A comparative study of the healing process following different types of bone transplantation. J Bone Joint Surg 1963;45A:1593. 25. Ray RD, Sabet TY. Bone grafts: cellular survival versus induc- tion. J Bone Joint Surg. 1963;45A:337. 26. Burwell RG. Osteogenesis in cancellous bone grafts: considered in terms of cellular changes, basic mechanisms and the per- spective of growth control and its possible aberrations. Clin Or- thop. 1965;40:35–47. 27. Lentrodt J, Höltje WJ. Tierexperimentelle Untersuchungen zur Revaskularisation autologer Knochentransplantate. In: Schuchardt K, Scheunemann H, eds. Fortschriffe der Kiefer-und Gesichts-Chirurgie, Vol. 20. Stuttgart: Thieme; 1976:17–21. 28. Eitel F, Schweiberer K, Saur K, Dambe LT, Klapp F. Theo- retische Grundlagen der Knochentransplantation: Osteogenese und Revaskularisation als Leistung des Wirtslagers. In: Hier- holzer G, Zilch H, eds. Transplantatlager und Implantatlager bei verschiedenen Operationsverfahren. Berlin: Springer, 1980. 29. Schweiberer L, Brenneisen R, Dambe LT, Eitel F, Zwank L. Derzeitiger Stand der auto-, hetero- und homoplastischen Knochentransplantation. In: Cotta H, Martini AK, eds. Implan- tate und Transplantate in der Plastischen und Weiderherstel- lungschirurgie. Berlin: Springer; 1981:115–127. 30. Lentrodt J, Fritzemeier CU, Bethmann I. Erfahrungen bei der osteoplastischen Unterkieferrekonstruktion mit autologen freien Knochentransplantaten. In: Kastenbauer E, Wilmes E, Mees K, eds. Das Transplantat in der Plastischen Chirurgie. Rotenburg: Sasse; 1987:59–61. 31. Steinhäuser EW. Unterkieferrekonstruktion durch intraorale 308 M. Ehrenfeld and C. Hagenmaier Knochentransplantate—deren Einheilung und Beeinflussung durch die Funktion—eine tierexperimentelle Studie. Schweiz Monatsschr Zahnheilk. 1968;78:213. 32. Reuther JF. Druckplattenosteosynthese und freie Knockentrans- plantation zur Unterkieferrekonstruktion. Berlin: Quintessenz; 1979. 33. Bell WH. Modem Practice in Orthognathic and Reconstructive Surgery. Philadelphia: WB Saunders; 1992. 34. Sailer HF. Transplantation of Lyophilized Cartilage in Maxillo- Facial Surgery. Basel: Krager; 1983. 35. Wolford LM. The use of porous block hydroxyapatite. In: Bell WH, ed. Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia: WB Saunders; 1992:854–871. 36. Hoppenreijs TJM, Nijdam ES, Freihofer HPM. The chin as a donor site in early secondary osteoplasty: a retrospective clinical and radiological evaluation. J Craniomaxillofac Surg. 1992;20:119–124. 37. Sailer HF, Pajarola GF. Plastische Korrekturen an Weichteilen und Knochen. In: Orale Chirurgie. Stuttgart: Thieme; 1996:308–309. 38. Schliephake H. Entnahmetechniken autologer Knochentrans- plantate. Implantologie 1994;4:317–327. 39. Tessier P. Autogenous bone grafts from the calvarium for facial and cranial application. Clin Plast Surg. 1982;9:531–538. 40. Maves MD, Matt BH. Calvarial bone grafting of facial defects. Otolaryngol Head Neck Surg. 1986;95:464–470. 41. Frodel JL, Marentette LJ, Quatela VC, Weinstein GS. Calvar- ial bone graft harvest: techniques, considerations, and morbidity. Arch Otolaryngol Head Neck Surg. 1993;119:17–23. 42. Payr E. Über osteoplastischen Ersatz nach Kieferresektion (Kieferdefekten) durch Rippenstücke mittels gestielter Brust- wandlappen oder freier Transplantation. Zentralbl Chir. 1908;35:1065–1070. 43. Klapp R. Über chirurgische Behandlung der Kieferschußbrüche. Z Ärztl Fortbild. 1916;13:225–232. 44. Rehrmann A. Das freie Knochentransplantat zum Unterkiefer- ersatz unter besonderer Berücksichtigung der Kinnrekonstruk- tion. In: Schuchardt K, Schilli W, eds. Fortschritte der Kiefer- und Gesichts Chirurgie, vol. 23. Stuttgart: Thieme; 1978:39. 45. Riediger D, Ehrenfeld M. Der vaskularisierte Knochenspan, experimentelle Grundlagen und klinische Anwendung. In: Kas- tenbauer E, Wilmes E, Mees K, eds. Das Transplantat in der Plastischen Chirurgie. Rotenburg: Sasse; 1987:4–9. 46. Esser E, Mrosk T. Langzeitergebnisse nach Unterkieferrekon- struktionen mit avaskulärem Spongiosatransfer und Titangitter. In: Schwenzer N, ed. Fortschritte der Kiefer- und Gesichts Chirurgie, vol. 39. Stuttgart: Thieme; 1994:90–92. 47. Michel C, Reuther J, Meier J, Eckstein T. Die Differen- tialindikation mikrochirurgischer und freier autogener Knochen- transplantate zur Rekonstruktion des Unterkiefers. In: Schwen- zer N, ed. Fortschritte der Kiefer- und Gesichts Chirurgie, vol. 39. Stuttgart: Thieme; 1994:96–100. 48. Riediger D, Schmelzle R. Modifizierte Anwendung des myoku- tanen Latissimus dorsi-Lappens zur Defektdeckung im Mund- KieferGesichtsbereich. Dtsch Z Mund Kiefer Gesichts Chir. 1986;10:364–374. 49. Jack U. Vergleichende Untersuchung zahnärztlicher Implantat- systeme auf ihre Eignung zur Implantation in Rippentransplan- tate. Thesis. Germany: University of Tübingen; 1994. 50. Hammer B, Prein J. Differentialindikation mikrochirurgischer Knochentransplantate für die Rekonstruktion des Unterkiefers. In: Bootz F, Ehrenfeld M, eds. Aktuelle Ergebnisse des mikro- vaskulären Gewebetransfers im Kopf-Hals-Bereich. Stuttgart: Thieme; 1995:149. 51. Strauch B, Yu HL. Atlas of Microvascular Surgery. New York: Thieme; 1993. 52. Riediger D, Ehrenfeld M. Mikrochirurgie. In: Hausamen JE, Machtens E, Reuther J, eds. Kirschnersche allgemeine und spezielle Operationslehre. Mund-, Kiefer- und Gesichtschirurgie. Heidelberg: Springer; 1995:559–615. 53. Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF. The internal oblique-iliac crest free flap in composite defects of the oral cavity involving bone, skin, and mucosa. Laryngoscope. 1991;101:257–270. 54. Soutar DS. The radial forearm flap in intraoral reconstruction. In: Riediger D, Ehrenfeld M, eds. Microsurgical Tissue Trans- plantation. Chicago: Quintessence; 1989:31–38. 25. Autogenous Bone Grafts in Maxillofacial Reconstruction 309 26 Current Practice and Future Trends in Craniomaxillofacial Reconstructive and Corrective Microvascular Bone Surgery Hubert Weinberg, Lester Silver, and Jin K. Chun The introduction of vascularized bone grafting has dramati- cally improved the potential for reconstruction of complex defects of the mandible, and it has improved the results of surgical restoration of the midface and cranial regions following tumor ablation or severe trauma. The reconstruction of the mandible in particular had been fraught with many difficul- ties, especially by the unfavorable milieu caused by oral con- tamination. The requirements of the reconstructed mandible include the maintenance of structural integrity for mastica- tion, the successful union of adjacent bone segments, and the continued mobility of the jaw. 1 Reconstruction of the midface and cranium, on the other hand, has different requirements for accurate three-dimensional stable bony replacement. The replacement bone in this region must often be thin and pliable to provide the proper shape and size. 2 The first vascularized bone grafts (VBGs) were described for lower-extremity reconstruction by Taylor et al. 3 and Buncke et al. 4 Shortly thereafter, McKee 5 described the microvascular rib transposition for mandibular reconstruction. Since then, there have been numerous studies both of the head and neck and of the extremities, which have examined the rel- ative merits of vascularized and nonvascularized bone grafts. While nonvascularized bone heals by resorption and creeping substitution, vascularized bone maintains live cells that are capable of regeneration and provides immediate structural support. 6-8 In addition, vascularized bone has been shown to continue to survive in a radiated bed with evidence of callus formation and a fully viable bone marrow with new bone formation in the subperiosteal and endosteal layers. 9 Mandibular Reconstruction Absolute indications for reconstructing the mandible with VBGs were given by Chen et al. 10 and include: (1) osteora- dionecrosis of the mandible or an irradiated tissue bed; (2) hemimandibular reconstruction with a free and facing glenoid fossa; (3) long segment mandibular defect, especially across the symphysis; (4) inadequate skin or mucosal lining; (5) defects demanding sandwich reconstruction; (6) inability to ob- tain secure immobilization on the reconstructed unit; (7) fail- ure of reconstruction by other methods; and (8) near-total mandibular reconstruction. The advantages of VBGs in these settings have been clearly demonstrated in extensive clinical studies. The early success rate in these studies has exceeded 90%, further demonstrating the safety and reliability of mandibular reconstruction with vascularized bone. 11,12 The ideal qualities of the vascularized bone graft for mandibular reconstruction have been described by Urken. 13 It should be well vascularized; of sufficient length, width, and height; easily shaped without compromise to its vascularity; accessible for a simultaneous two-team approach; and have minimum donor site morbidity. Particularly for the mandible, the ideal qualities of the composite soft tissue requirements also need to be considered. The soft tissue component should be again well vascularized, thin, pliable, abundant, sensate if possible, and well lubricated. Often it is the soft tissue component and not solely the restoration of bony continuity that will determine the ultimate success of the mandibular reconstruction. The soft tissue may be needed to restore external neck or facial skin, and it may be required for mucosal replacement of the mandible, tongue, or pharynx. Soft tissue reconstruction should maintain tongue mobility and allow unim- peded swallowing and articulation. The choice of donor sites available for mandibular reconstruction includes the iliac crest, fibula, scapula, metatarsus, cranium, rib, radius, ulna, and humerus. At present, in the vast majority of mandibular reconstructions, the iliac crest, fibula, or scapula is used. The iliac crest has proven to provide the best bone stock, especially for primary placement of en- dosseous dental implants (Figure 26.1). 14 A modification of the iliac crest osteomyocutaneous free flap including the internal oblique muscle has been described. 15–17 This latter muscle provides thin, well-vascularized soft tissue that upon denervation atrophy approximates the appearance of mucosa. The fibula provides the greatest bone length of all the VBGs and can be contoured to that of a mandible with numerous osteotomies (Figure 26.2). 18 The height of the fibula is, however, somewhat restrictive in its capacity to accept an en- dosseous implant, although it can be sectioned and double- 310 26. Current Practice and Future Trends in Craniomaxillofacial Reconstructive and Corrective Microvascular Bone Surgery 311 a c b d FIGURE 26.1 Deep circumflex iliac artery osteocutaneous flap. (a) Flap design. (b) Harvested flap in situ. (c) Flap inset with rigid fixation. (d) Postoperative result. [...]... Silver, and J.K Chun a b c FIGURE 26.3 Temporoparietal osteofascial flap-superficial temporal artery (a) Preoperative mandibular contour defect (b) Harvested flap in situ (c) Transposition of flap prior to inset and rigid fixation 26 Current Practice and Future Trends in Craniomaxillofacial Reconstructive and Corrective Microvascular Bone Surgery 3 15 a c b FIGURE 26.4 Scapula osteocutaneous flap-circumflex... technique .5, 11,16 Decisions regarding reconstruction of ramus and/ or body mandibular defects, however, are clinically based and relate to the functional and cosmetic goals that are desired Bone Substitutes Numerous bone substitutes for mandibular defects have been tried Irradiated17,18 or cryopreserved mandible,19 standard autologous bone grafts, particulate corticocancellous grafts with and without... the bone b FIGURE 27.9 (a,b) Clinical and radiographic situation after immediate bone repair using a free nonvascularized iliac crest bone graft in a case of an ameloblastoma is not vital and is subsequently replaced by newly formed woven and lamellar bone Infection and loss of bone can occur In those cases fixation of the bone grafts to the remnants is achieved, for example, by using the AO-3-Dimensionally... reconstruction and functional rehabilitation of oromandibular defects with rigid internal fixation Laryngoscope 1988;98: 154 – 159 42 Prein J, Ettlin D, Hammer B Vor- und Nachteile unterschiedlicher Fixationstechniken für mikrovaskuläre Transplantate bei der Unterkieferrekonstruktion IV International Symposium on Microsurgery in Reconstructive and Plastic Surgery, Microsurgery ‘ 95 Jena 19 95; Publication... The free vascularized bone graft A clinical extension of microvascular techniques Plast Reconstr Surg 19 75; 55: 533 54 4 4 Buncke HJ, Furnas DW, Gordon L, Achauer BM Free osteocutaneous flap from a rib to the tibia Plast Reconstr Surg 1977 ;59 :799–804 5 McKee DM Microvascular bone transplantation Clin Plast Surg 1978 ;5: 283–292 6 Berggren A, Weiland AJ, Dorfman H Free vascularized bone grafts: factors affecting... Hidalgo DA Titanium miniplate fixation in free-flap-mandible reconstruction Ann Plast Surg 1989;23:498 50 7 35 Buchbinder D, Urken ML, Vickery C, Weinberg H, Biller HF Bone contouring and fixation in functional, primary microvascular mandibular reconstruction Head Neck 1991;13:191–199 326 36 Boyd JB, Mulholland RS Fixation of the vascularized bone graft in mandibular reconstruction Plast Reconstr Surg... 1989;1 15: 339–349 18 Hidalgo DA Fibula free flap: a new method of mandible reconstruction Plast Reconstr Surg 1989;84:71–79 19 Jones NF, Swartz WM, Mears DC, Jupiter JB, Grossman A The “double-barrel” free vascularized fibula bone graft Plast Reconstr Surg 1988;81:378–3 85 20 Stoll P Fibula double barrel technique In: Greenberg AM, Prein J, eds Craniomaxillofacial Reconstructive and Corrective Bone Surgery: ... into an anterolateral mandibular defect 332 P Stoll FIGURE 28.11 Positive technetium scintigraphy 3 days after mandibular bone repair using a fibula double-barrel vascularized graft a FIGURE 28.12 (a) X-ray showing the double-barrel fibula bone graft prior to removal of the reconstruction plate (b) Three-dimensional CT scan showing the double-barrel fibula bone graft after the re- b moval of the reconstruction... MA Use of the AO-plate for immediate mandibular reconstruction in cancer patients Plast Reconstr Surg 1991;88 :58 8 5 Kim MR, Donoff RB Critical analysis of mandibular reconstruction using AO-reconstruction plates J Oral Maxillofac Surg 1992 ;50 :1 152 6 Wächter R, Stoll P Komplikationen nach primärer Unterkieferrekonstruktion mit THORP-Platten In: Neumann H-J, Hrsg Ästhetische und plastisch-rekonstruktive... conventional autogenous bone grafts Plast Reconstr Surg 1984;73:382–386 9 Altobelli DE, Lorente CA, Handren JH, Young J, Donoff RB, May JW Free and microvascular bone grafting in the irradiated dog mandible J Oral Maxillofac Surg 1987; 45: 27–33 10 Chen YB, Chen HC, Hahn LH Major mandibular reconstruction with vascularized bone grafts: indications and selection of donor tissue Microsurgery 1994; 15: 227–237 11 Jewer . free vascularized bone graft. A clinical extension of microvascular techniques. Plast Recon- str Surg. 19 75; 55: 553 55 4. 15. O’Brien B McC. Microvascular Reconstructive Surgery. Edin- burgh: Churchill. inset and rigid fixation. 26. Current Practice and Future Trends in Craniomaxillofacial Reconstructive and Corrective Microvascular Bone Surgery 3 15 a c db FIGURE 26.4 Scapula osteocutaneous flap-circumflex. implant, although it can be sectioned and double- 310 26. Current Practice and Future Trends in Craniomaxillofacial Reconstructive and Corrective Microvascular Bone Surgery 311 a c b d FIGURE 26.1

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