Use of the calvarium for bone grafting in cranio-maxillo-facial surgery

Bone grafts's traditional donor sites in cranio-maxillo-facial surgery have been for many years and are still in some occasions the ribs, iliac crest and tibia. Bone grafts taken from the calvaria have been used by some surgeons in the past but its wide acceptance was only achieved after Paul Tessier had reported his own experience. The calvaria is composed of inner and outer tables that encloses a layer of cancellous bone called the diploe. A high degree of variability exist with respect to skull thickness. Nevertheless parietal bones is the preferable site for the harvesting of the graft. The embryonic origin of the cranium should be responsible for greater survival of the graft. Membranous bone would maintain its volume to a greater extent than endochondral bone when autografted in the cranio-facial region. However this remains controversial. Two techniques can be used for the harvesting of a calvarial bone grafts. A split thickness calvarial graft involves removal of the outer table while leaving the inner layer in place. Its main disadvantage is the relatively thinness of the bone transferred. A full thickness segment of skull involves the cranium cavity be entered. A half of the graft can be split along the diploe space and returned to fill the donor site. The other half is used for reconstruction. It is a more complicated procedure. Cranial grafts have been used in the following cases. Correction of contour defect of the forehead and zygomatic bones, orbital floor reconstruction, restoration of the nasal bridge, bone grafting of the maxilla and mandibule. The advantages are the following: the donor and recipient sites are in adjacent surgical fields, the donor site scar is hidden in the scalp, morbidity associated with removing the graft is almost inexistent. (ABSTRACT TRUNCATED AT 250 WORDS)     

Superficial skin texture: a study on full-thickness skin grafting in facial reconstruction

Usually in harvesting a full-thickness skin graft, we match color, skin thickness, and the presence of hair in the potential donor site with the recipient site to obtain as good an esthetic result as possible. Superficial skin texture is, in part, responsible for the esthetic result in facial reconstruction. Full-thickness skin grafts harvested from the supraclavicular region in 20 patients operated on for facial skin tumors and immediate reconstruction, were included in this study. The superficial skin texture was reproduced using a silicone cast technique; a polyvinylsiloxane derivative was used and it was analyzed by scanning electron microscopy (SEM) in order to detect and measure morphological features of the skin surface. The mechanism affecting superficial skin texture was studied to elucidate the importance of the superficial skin texture of the graft donor site and consequently the intraoperative orientation of the graft into the recipient area to improve the esthetic outcome. Our study shows that the forces of the recipient site are able to modify full-thickness skin graft dermis and as a result change the overlying superficial skin pattern. The graft always tends to change to the features of the recipient area after 24 months because of the environment of the new site. These findings suggest that color and thickness of the donor site still remain more important than intraoperative graft orientation in the recipient area in order to achieve good esthetic results in skin grafting.     

Full-thickness skin graft from the ulnar aspect of the wrist to cover defects on the hand and digits

Skin defects on the volar surface of the hand and digits are commonly treated with skin grafts. Many donor sites capable of providing adequate skin have already been reported. Ideal conditions for the donor site depend on skin color, texture, durability, and size. The authors describe the use of a new donor site for harvesting skin grafts to repair relatively small skin defects on the hand and digits. They used full-thickness skin grafts from the ulnar aspect of the wrist to reconstruct burn contractures and syndactyly in 20 patients. Their grafts provided an ideal color and texture match, and normal function of the hand and digits was restored. The donor site was closed directly, and the resulting scar was inconspicuous.     

Calvarial bone graft donor site: a histological study in a rabbit model

Recently the calvarium has become a popular site for harvesting bone grafts because of its low incidence of morbidity, its proximity to the operative site, and the decreased amount of resorption as a result of its membranous nature. However, information regarding the phenomenon of repair at the donor site itself remains lacking. This investigation was initiated in 40 adult white New Zealand rabbits as an experimental model to study the process of repair at the donor site and to examine the possible use of hydroxyapatite to reconstruct the residual donor site deformity. Our experimental protocol closely followed our clinical procedure for the harvesting of split calvarial bone grafts. Our conclusions in the rabbit model were: (1) each of the commonly used hemostatic agents (bone wax and gelfoam) inhibit osteoneogenesis to varying degrees, (2) hydroxyapatite shows promise in the reconstruction of the donor site defect, and (3) if the periosteum comes in direct contact the defect repairs itself.     

Current Concepts of Fat Graft Survival: Histology of Aspirated Adipose Tissue and Review of the Literature

BACKGROUND: Controversy remains about the longevity of correction in autologous fat grafts and its relation to adipocyte survival. Reported long-term fat graft survival rates differ widely, depending on harvesting method, means of reinjection, injection site, and evaluation methods. OBJECTIVE: To demonstrate histologic findings of aspirated adipose tissue and compare the findings to the reports in the literature. METHODS: Review of the literature and the histology of transplanted fat 7 years after subcutaneous implantation and trypan blue staining to determine the vitality of defrosted adipocytes. RESULTS: Fat cells survive aspiration with a suction machine or syringe equally well. Use of a liposuction cannula or 14-gauge needle gives comparable results. Local anesthesia or tumescent local anesthesia is recommended for the donor site, preferably with addition of epinephrine. CONCLUSION: Clinical longevity of correction after autologous fat transfer is determined by the degree of augmentation resulting from the amount of fibrosis induced and the number of viable fat cells. Survival of aspirated fat cell grafts depends mainly on the anatomic site, the mobility and vascularity of the recipient tissue, or underlying causes and diseases, and less on harvesting and reinjection methods.     

The Role of Frozen Storage in Preserving Adipose Tissue Obtained by Suction-Assisted Lipectomy for Repeated Fat Injection Procedures

BACKGROUND: The injection of autologous free fat obtained by suction-assisted lipectomy for the correction of soft tissue defects is a common procedure in plastic surgery. However, unpredictable partial absorption of the injected fat often necessitates repeated procedures. OBJECTIVE: To examine the role of frozen storage as a means of preserving the fat obtained by suction-assisted lipectomy for repeated procedures. METHODS: Human adipose tissue obtained by suction-assisted lipectomy was stored in a domestic refrigerator at -18 degrees C for 2 weeks. After thawing, the fat was injected into nude mice. In the control group, the fat was injected immediately after the harvesting procedure. Grafts were dissected out and compared 15 weeks postinjection. RESULTS: Injected fat survived in both study and control groups. No significant differences were found between fat graft weight and volume, or in any of the histologic parameters examined. CONCLUSION: Fat obtained by suction-assisted lipectomy may be preserved for future use by freezing.     

Cryopreservation of Fat Tissue and Application in Autologous Fat Graft: In Vitro and In Vivo Study

Background

Absorption of the autologous fat graft results in repeated harvesting procedures. The cost and complications increase with repeated procedures, but cryopreservation is one way to solve the problem. The aim of this study was to find an optimal temperature at which to store fat tissue with or without cryoprotective agents for long-term use.

Methods

Fat tissues harvested by liposuction were stored in normal saline, frozen in the freezer following the preset program, and cryopreserved at ?20, ?80, and ?196°C. The other group of fat tissues was stored in hydroxyethyl starch using the same frozen procedure. Two and 7 days after cryopreservation, viability tests were conducted. The fat tissues were injected into nude mice 2 and 4 weeks after cryopreservation. Three months later the fat grafts were harvested for histologic examination.

Results

No significant differences in cell viability were found in either in vitro or in vivo experiments for the three preserving temperatures. The cryoprotective agent HES did not influence cell viability.

Conclusion

There were no differences in cell viability among the three temperatures and with the use of a cryoprotective agent. Cryopreservation for salvage management is a clinically practical method.     

Correction of hemifacial atrophy with autologous fat transplantation

BACKGROUND: Autologous fat transplantation has frequently been used by many surgeons for facial recontouring in esthetic patients, with good long-term results. However, this technique has not been used primarily in treating patients with hemifacial atrophy, and its efficacy and long-term outcome remain unknown. METHODS: In a 7-year period, 31 patients with hemifacial atrophy were treated with autologous fat transplantation in our institution. All patients had been in their stable phase of the disease for at least 1 year. Autologous fat grafts were harvested from the lower abdomen or thigh with our preferred low-pressure syringe technique and then spun at the lower speed. The fat grafts were injected into multiple areas in multiple tissue planes and tunnels to the diseased side of the face. The same procedure was repeated once or twice as necessary after each injection in at least 3 months. All patients were followed up to 5 years, and their outcomes were evaluated by the patients, plastic surgeons, and laypersons separately. RESULTS: Obviously improved facial contour was evident in most patients after autologous fat transplantations. More than 65% of the patients in this series were assessed as satisfactory by all 3 groups. Between 10% and 30% of the patients were mostly satisfactory. Only less than 7% of the patients were unsatisfactory. No complications were seen in either donor sites or recipient sites in this series. CONCLUSIONS: Autologous fat transplantation can be a good treatment of choice for patients with hemifacial atrophy.     

A fortuitous donor site for full-thickness skin grafts in the correction of syndactyly

The ideal donor site for full-thickness skin grafts to the non hair-bearing areas of the fingers is the glabrous skin of other digits. The use of these sites is usually restricted because of the limited amount of skin available and the donor site morbidity. We were recently presented with a clinical situation in which one congenital abnormality of the fingers requiring full-thickness skin grafts for its correction was associated with another congenital abnormality of the digits: amputation of the supernumerary fingers and toes provided the ideal donor site for the full-thickness skin grafts needed in the hand.     

The cartilage of the tibiofibular joint: a source for autologous osteochondral grafts without damaging weight-bearing joint surfaces

Within the past few years, autologous osteochondral transplantation has become an established procedure in the therapy of articular cartilage defects of the knee. One significant disadvantage of this technique is the harvesting of grafts from the weight-bearing area. The tibiofibular articulation is less loaded. The purpose of this study was to evaluate the question of whether this joint is suitable as a donor site for osteochondral grafts. Ten fresh human knees were dissected to perform histology, immunohistochemistry, and thickness measurement of the tibiofibular cartilage. Favourable approaches and establishing of anatomical landmarks were investigated in 44 fixed tibiofibular joints. In knee extension, the shortest distance between the joint cleft and common fibular nerve was measured. A total of 389 bone specimens was analysed morphometrically (cartilage area, orientation of the joint line, signs of arthrosis). Histological and immunohistochemical examination showed hyaline cartilage and type II collagen. The area of cartilage amounted to 3.58 cm(2) (mean) at the tibia and at the fibula with a thickness of 1.6 mm (mean). The joint line is mainly orientated perpendicular to an axis course from craniomedioventral to caudolaterodorsal. Depending on the available instruments, two approaches are possible: from anteromedial or from posterolateral. The mean distance to the common fibular nerve was 19.5 mm. Signs of arthrosis were found in 1 of 10 fresh knee specimens and in 11.4% of the bone specimens. Transplantation into three patients showed no intra- or postoperative complications and a rapid and uneventful recovery. The proximal tibiofibular joint is an excellent donor site for autologous osteochondral grafts.     

Effects of Fat Preparation Methods on the Viabilities of Autologous Fat Grafts

Fat grafts are commonly used in plastic surgery, but their unpredictable absorption rates are a considerable disadvantage. Furthermore, no agreement has been reached regarding the method that best enables fat graft survival. This study aimed to evaluate the effects of different preparation methods on fat graft viability. Fat tissue was harvested from the remnants of transverse rectus abdominis musculocutaneous (TRAM) flaps by syringe aspiration. Harvested fat tissue was prepared using three different methods: centrifugation, metal sieve concentration, and cotton gauze concentration. To evaluate the viabilities of fat cells, XTT assays were performed. For the study, 18 nude mice were allocated to three groups: the centrifugation, metal sieve, and cotton gauze groups (6 mice per group). Prepared fat (1 ml) was injected into the nuchal area of the mice, and 12 weeks later, grafts were dissected to determine graft survival rates and subjected to histologic analysis. No significant differences were observed in graft survival rates and histologic findings (necrosis and vascularity) between the three groups. However, histologic analysis found the metal sieve group to have significantly lower fat cell viability and more inflammation than the other two groups. The findings suggest that the closed centrifugation technique has no advantage over the open cotton gauze technique in terms of fat graft viability, and that the metal sieve concentration method is deficient as a preparation method because it can cause grafted fat degradation.     

An optimum donor site for venous grafting for microsurgery

We report the results of an anatomic study based on 10 cadavers. The aim of this work is to find an optimum donor site for venous grafts which is safe, reproducible, and suitable for microsurgery stitches especially in finger reimplantation, when a long and small calibre graft is needed. This study describes the deep venous network of the radial artery, an original donor site for microsurgical venous grafts. The second aim is to describe our technique of harvesting. Dissections always show two satellite veins, that can be harvested with optimal average diameter of 1.8mm constant over the whole length. The maximum length available is about 126.5mm for the radial satellite vein, and 125 mm for the ulnar one, with a few number of collateral ligatures needed. No tying is required in 60% cases for radial satellite vein, and one ligature for the other 40%, whereas in the ulnar satellite vein, no tying is needed in 80% and just one in the other 20%. This original site is advantageous in microsurgery of the upper limb, offering an easy, quick, safe and reproducible option in an emergency situation.     

Partial thickness scalp grafts: clinical experience of their use in resurfacing facial defects

Partial thickness scalp grafts provide a good cosmetic match for resurfacing small facial defects. The donor site is convenient for harvesting the graft, comfortable for the patient in the post-operative period and heals quickly with few complications. This paper outlines our experience with this procedure.     

The epididymal fat pad as a transplant site for minimal islet mass

The epididymal fat pad was evaluated as a site of islet transplantation in a syngeneic murine model of diabetes by comparing the transplant outcomes to that of islets transplanted intraportal. Mouse islets engrafted on the intra-abdominal epididymal fat pad ameliorated streptozotocin-induced hyperglycemia with similar efficacy as grafts implanted intraportally. Mice that received as few as 50 islets, either intraportal or in the epididymal fat pad, displayed similar glucose tolerance curves. Bioluminescence imaging and glucose measurement showed stable luminescence signals and blood glucose levels for over 5 months in both transplant sites using transgenic luciferase-positive islets. Prompt recurrent hyperglycemia occurred in all mice after removal of the epididymal fat pad bearing the islet graft. Histological examination of the grafts showed well-granulated insulin containing cells surrounded by healthy adipocytes. This study indicates that the epididymal fat pad maybe a useful islet transplant site in the mouse model for effective glycemic control.     

Use of split‐thickness plantar skin grafts in the management of leg and foot skin defects

The basic principle of donor site selection is to take skin from areas that will heal with minimal scarring while balancing the needs of the recipient site. For skin loss from the lower legs and feet, the most common harvest site for split‐thickness skin grafts is the anterior or posterior thigh; grafts from the plantar areas have been mostly used to cover the volar aspect of digits and palms. Between September 2015 and September 2017, 42 patients with areas of skin loss on the legs or feet were treated with plantar skin grafts because of their cosmetic benefits and the convenience of the surgical procedure and postoperative wound care. Our technique of harvesting a single layer of split‐thickness skin graft (0.014 in. thick) from a non‐weight‐bearing area of the foot of the injured leg is simple and provided good functional and cosmetic outcomes at both the donor and recipient sites. All patients were very satisfied with the recovery progress and final results. Therefore, in the management of skin defects in the lower legs or feet that comprise less than 1.5% of the total body surface area, our surgical method is a reliable alternative to anterior or posterior thigh skin grafting.     

Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases

OBJECT: The purpose of the paper is to review the results of free latissimus dorsi transfer for scalp and cranium reconstruction in case of large defects with exposed brain tissue, deperiosted cranial bone, and dura that cannot be reconstructed with local flaps or skin grafts. METHODS: Free latissimus dorsi transfer was carried out in an interdisciplinary approach involving neurosurgery and plastic surgery in seven patients with subtotal and total scalp defects (two reconstruction after tumor removal, two reconstructions after longstanding osteitis, 2x tissue break down after irradiation, 1x defect reconstruction after high voltage injury). There were three male and four female patients. The age ranged from 36 to 72 years. Reconstruction was carried out with a muscle flap (1x) or a myo-cutaneous flap (6x) in combination with a split thickness skin mesh (1:1.5) graft, done in a single-stage procedure. In a retrospective clinical study the following criteria were evaluated: 1) flap healing, 2) esthetic result, and 3) complications. All flaps healed primarily, and all wound remained closed without any signs of infection. Complete wound healing was achieved after 4-8 weeks, depending on the healing of the skin grafts. Secondary skin grafting was necessary in two patients, revision of the donor site in two patients. From an esthetic point of view four patients complained about the appearance of the retroauricular skin island. After removal of the skin island 6 months after the initial operation, all patient judged the result as good or acceptable. CONCLUSION: Besides the free omentum flap, the free latissimus dorsi transfer is the only option for coverage of subtotal or total scalp defects. Compared to the omentum flap, the latissimus dorsi offers more tissue, has less donor site morbidity, and secondary surgery such as cranial bone reconstruction is possible. Contrary to most authors, our preferred donor vessels are maxillary artery and the external jugular vein. To avoid any vascular compression we are using a myo-cutaneous flap. The skin island must be removed secondarily. In patients were no bone reconstruction is possible or planned, the deepithelialized skin paddle can be used for correction of a contour defect.     

The use of lingual mucosal graft in adult anterior urethroplasty: surgical steps and short-term outcome

OBJECTIVES: Investigate the tolerability, safety, and efficacy of using the lingual mucosal graft (LMG) for anterior urethroplasty. METHODS: Ten patients (average age, 41 yr) underwent substitution urethroplasty LMG. Harvesting the graft from the tongue was performed by either the oral surgeon or the urologist. In five patients with penile urethral strictures, the grafts were placed on the dorsal urethral surface as a "dorsal inlay." In five patients with bulbar urethral strictures, the grafts were used as a "dorsal inlay" (3 cases) or "ventral onlay" (2 cases). The average follow-up was 5 mo (range: 3-12 mo). RESULTS: Nine cases (90%) were successful and one (10%) was a failure. Three patients who underwent bulbar urethroplasty showed prior failed repair using buccal mucosal grafts harvested from a single cheek (1 case), from both cheeks (1 case), or from the lip (1 case). The length of the lingual grafts was 4-6cm (mean: 4.5cm) with a width of 2.5cm. No patient developed early or late postoperative complications on the harvest site related to the tongue surgery. No difference was observed in patients in whom the graft harvesting was performed by the oral surgeon compared to the patients in whom the procedure was performed by the urologist. CONCLUSIONS: The surgical technique for harvesting a graft from the tongue is simple and safe. The tongue may be the best alternative donor site to the lip when a thin graft is required for urethroplasty or when the cheek harvesting is not possible.     

Oral complications after lingual mucosal graft harvesting for urethroplasty in 110 cases

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Lingual mucosal graft harvesting for urethroplasty is feasible, safe, provides long grafts and is easy to carry out. Most patients have minimal immediate or short‐term donor site complications. The oral complications appeared to be related to the graft length and patient age. Most complications resolved within 1 year. Oral complications after LMGs harvesting were related to the patient’s age at surgery. The children did not experience any persistent complications. Cases of bilateral or longer LMGs were associated with higher complication rates. However, most of these oral complications subsided gradually within 1 year. OBJECTIVE ? This study was to evaluate donor‐site complications of lingual mucosal graft harvesting for substitution urethroplasty. PATIENTS AND METHODS ? 110 patients with anterior urethral strictures or hypospadias underwent lingual mucosal grafts (LMGs) urethroplasty. Dual LMGs were harvested from both sites separately or a long mucosal graft was harvested from one side to other side of tongue in 29 patients (group one); a shorter mucosal graft was harvested from one side of tongue in 81 patients (group two). A standard proforma ( Appendix ) was used for all patients. RESULTS ? The mean follow up time was 22 months (range 6～41). At six months follow‐up, numbness of tongue was reported in 19 patients (17.27%), parageusias in six (5.45%) and slurring of speech in 9 (8.18%). ? Ninety‐six patients were followed up for more than 12 mo. Numbness in operative area of tongue was documented in seven patients (7.29%), parageusias in three (3.13%) and slurred speech in three (3.13%). ? None of these complications occurred in the six pediatric cases (<14 year) with a history of failed hypospadias repair. CONCLUSIONS ? LMGs urethroplasty, as most patients, were satisfied, but there were certain complications that have not been previously described in the literature. ? Most oral complications subsided gradually within the first year.     

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.