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)     

Update on cranial bone grafts in craniofacial surgery

A large series of cranial bone grafts performed during a 6-year period is presented. The types of grafts are discussed and the techniques of taking the grafts are described. The complications have been few. Full-thickness skull penetration occasionally occurs but should not be a cause for concern. The skull has gradually become our main bone graft donor site.     

Multilevel anterior cervical fusion using skull bone grafts. Case report.

The successful use of autogenous skull bone grafts for a C3-7 anterior cervical fusion is reported and compared with results using other bone grafts. A 51-year-old man with C4-7 anterior cord compression due to spurs and ossified posterior longitudinal ligaments developed progressive tetraparesis following a minor head injury. He underwent anterior decompression and fusion. On two occasions an iliac graft had failed; however, a graft of autogenous skull bone was successful. The skull bone was found superior to bone from other sites, such as the iliac crest, rib, tibia, and fibula, showing sufficient strength and less morbidity. The skull may be a better source of graft material for multilevel anterior cervical fusion, which requires long and strong grafts.     

Nasal reconstruction in surgery of the anterior skull base.

OBJECTIVES: We sought to evaluate the effectiveness of a number of surgical maneuvers in nasal reconstruction of a diverse population of patients undergoing skull base surgery.Study design We conducted a retrospective review of a cohort of patients undergoing nasal reconstruction during surgery of the anterior skull base and craniovertebral junction. METHODS: All patients undergoing skull base surgery and nasal reconstruction by the senior author (Y.D.) with a minimum follow-up of 12 months from 1997 to 2001 were evaluated. Preoperative and postoperative photographs and clinical evaluation were examined in detail with particular attention focused on the nasal complex. RESULTS: A total of 47 patients were evaluated for this study, including those who had undergone anterior craniofacial resections (n = 14), Le Fort osteotomies (n = 5), subcranial approaches (n = 10), maxillotomies (n = 8), and midfacial disassemblies (n = 10). Primary calvarial bone graft reconstruction of the anterior craniofacial group was facilitated with the use of positioning plates and resuspension of the upper lateral cartilages when available. In contradistinction to secondary bone grafting, dorsal grafts in this group extended to the native nasal bone length. A small overlay bone graft was thought to be necessary when the nasal root was osteotomized in conjunction with the orbital and/or maxillary segments to maintain dorsal height in the long term. Le Fort osteotomy patients require refixation of the septum to the anterior nasal spine region for stability. CONCLUSIONS: Use of the techniques outlined in this article appears to be associated with gratifying long-term nasal form in reconstruction of the anterior skull base.     

RETRACTED ARTICLE: A Different Approach to the Reconstruction of the Stubborn Crooked Nose with a Different Spreader Graft: Nasal Bone Grafts Harvested from the Removed Nasal Hump

Background Correction of a crooked or deviated nose is a complex cosmetic and functional problem as well as a big challenge for the rhinoplasty surgeon. Although corrections using a wide range of surgical techniques to straighten the nose and maximize nasal function have been proposed, recurrence is very common because of cartilage memory and scar contracture. Therefore, to prevent recurrence and maintain the correction of the septum, a permanent support that is stable and strong with the ability to maintain its given shape after placement on one or both sides of the septum is needed. Methods The author used a nasal bone graft. In this study, the concept and technique for correction of the crooked nose and the author’s experience using it are presented. Results This graft material was used for 12 patients with crooked noses (8 with C-type and 4 with S-type noses). During a mean follow-up period of 20 months (range, 12–36 months), there were no complications, recurrences, or extrusions. Functional evaluations were performed using a visual analog scale before surgery and 6 months after surgery. Patients were asked to score their nasal breathing on a scale ranging from 0 to 100. The mean preoperative value was 17.67% ± 1.22% (range, 15–25%), and the postoperative value was 89.88% ± 1.24% (range, 85–95%). Conclusion Use of nasal bone grafts as the spreader graft is a safe, effective, reliable, and permanent method for correction of the crooked nose. The author advises using this technique with nasal bone grafts for functional recovery and increased strength against further trauma or forces of scar contracture. This technique may prevent recurrence attributable to cartilage memory.     

Role of bone graft in reconstruction of skull base defect: is a bone graft necessary

Ten patients underwent reconstruction of skull base defects between 1989 and 1992. In this series, the maximum size of the skull base defect was 6 x 5 cm. Three patients underwent bone grafts to reinforce the skull base. The postoperative course of seven patients without bone grafts was uneventful. There was no cerebrospinal fluid leakage, meningitis, extradural abscess, on brain herniation. On the other hand, two of the three patients with bone grafts developed extradural abseesses requiring the bone grafts to be removed. Although the number of patients in this series is not large, this study demonstrates that the use of bone grafts in reconstruction of skull base detects could be one of the factors in increasing the chances of infectious complications. We think that a bone graft is not necessary to reconstruct moderate-sized skull base defects.     

自体颅骨移植在眶底重建中的应用

目的 评价自体颅骨移植在治疗面部外伤致眶底缺损中的作用。方法 对34例面部创伤眶底爆裂骨折（以下简称眶底骨折）有骨质缺损者,采用冠状切口取自休遭受,结膜切口加外眦切开入路进行骨移植修复缺损。结果 所有病例术后创口愈合良好,无感染。供骨区无并发症发生。1例术后3个月内有轻微下睑外翻,通过自行按摩半年后已不明显,8例术前有眶下区麻木者,术后1-6个月全部恢复,4例有复视者术后消失,通过半年至5年（平衡11个月）的随诊,移植骨成活良好,供受骨区切口瘢痕不明显,均取得了满意的临床疗效。结论 自体颅骨移植并发症少,对眶底的重建有许多优点。是眶底重建的理想移植材料。     

Saddle and boxer's nose

The deformities known as saddle nose and boxer's nose result from injuries or poorly planned nasal surgery. Boxer's nose may eventually be corrected using Straith's method. It is possible to correct both deformities by simply using a bone graft. Neither the use of cartilage grafts nor organic or inorganic inclusions are recommended, the former because they tend to deform, and the latter because they are not well tolerated. There are many advantages to using bone grafts taken from the tibia, including good integration and successful results. This personal method has been used by us since 1948, and is based on the principle of the first-class lever.     

Role of Bone Graft in Reconstruction of Skull Base Defect: Is a Bone Graft Necessary

Ten patients underwent reconstruction of skull base defects between 1989 and 1992. In this series, the maximum size of the skull base defect was 6 × 5 cm. Three patients underwent bone grafts to reinforce the skull base. The postoperative course of seven patients without bone grafts was uneventful. There was no cerebrospinal fluid leakage, meningitis, extradural abscess, on brain herniation. On the other hand, two of the three patients with bone grafts developed extradural abseesses requiring the bone grafts to be removed. Although the number of patients in this series is not large, this study demonstrates that the use of bone grafts in reconstruction of skull base detects could be one of the factors in increasing the chances of infectious complications. We think that a bone graft is not necessary to reconstruct moderate-sized skull base defects.     

Nasal reconstruction using split calvarial grafts.

The reconstruction of nasal deformities after trauma or surgical procedures presents an arduous task for the reconstructive surgeon. The anatomic alteration of supporting cartilage and nasal bones, as well as scar formation, compound the difficult nature of this type of reconstruction. In the past, multiple autogenous and alloplastic implants have been used in nasal reconstruction. Autogenous implants include auricular and septal cartilage as well as rib and iliac crest bone grafts. Alloplastic materials include acrylic, supramid mesh, Gortex, and silicone rubber. Autogenous grafts have been shown to provide excellent long-term reliable results in nasal reconstruction. In our study, autogenous split calvarial bone grafts were used in the nasal reconstruction of 17 patients. Among the corrective procedures were dorsal augmentation for saddle-nose deformities, insertion of columella struts for nasal tip ptosis, and insertion of nasal battens for nasal valve collapse. Patient followup has been from 1 to 5 years, with no significant resorption noted during that time. Complications were limited to one seroma at the donor site before wound drains were routinely used. No major complications, including hematoma formation, CSF leak, or infection, have been observed.     

The use of lower turbinate bone grafts in the treatment of saddle nose deformities

Saddle nose reconstruction is based on the use of support grafts to manage aesthetic and functional problems. Bone (calvarial, iliac crest, costal, nasal hump, ulnar, and heterogeneous origin), cartilage (septal, costal, heterogeneous), and synthetic materials (silicon, silastic, polyethylene) were used as support grafts. Three patients have been included in this study to define the surgical management and long-term aesthetic and functional results of patients undergoing rhinoplasty with support grafts for a saddle nose deformity. Open rhinoplasty was employed. Both the lower turbinates were excised and the bone dissected from the soft tissues in two cases and in one case, only mucosa was removed. The amount of support needed was measured by using bone wax. The bone was used shaped in layers, according to the defect, and sutured to each other by vycril suture, and wrapped around by surgicell. The graft was then inserted in its place and fixed with external prolene sutures. Results were satisfactory in both function and aesthetics. Ten to 16-month follow-ups had no complications. Saddle nose surgery basically requires the use of a support graft to repair the nasal dorsum. A lower turbinate bone graft procedure has some advantages: it is cheap and safe, it is ready to use and not time-consuming, there is no donor area and no additional donor site morbidity, and it enlarges the airway and the passage to prevent nasal airway obstruction.     

Vascularized omentum graft for the reconstruction of the skull base after removal of a nasoethmoidal tumor with intracranial extension: case report

A 16-year-old boy with rhabdomyosarcoma occupying the nasal cavities and the ethmoid sinus with intracranial extension underwent transcranial surgery. The intradural tumor was resected first with the affected dura of the anterior skull base, and the dural defect was repaired with fascia harvested from the sheath of the rectus abdominis muscle. The remaining tumor contiguous to the nasal cavities was completely extirpated. The cranial cavity was then exposed to the opened nasal cavities, where a revascularized omental graft was used to separate these compartments. Lyophilized dura was placed beforehand beneath the omental graft, as a roof to the nasal cavity, and was removed 3 weeks later through the nostril. A bony skull base repair was performed over the omentum using the inner table of the bone flap. Subcutaneous fat from the abdomen was placed on the bone graft for fixation and as an additional seal for the dural defect. Reconstruction of the anterior skull base with a vascularized omental transfer provides an efficient barrier to the nasal cavity. It also serves as an excellent supporting structure for regeneration of the mucosal epithelium of the nasal cavities.     

The use of bone grafts and alloplastic materials in cranioplasty

Trephination dates from prehistoric neolithic times (10,000-7000 B.C.) and is the oldest operation known. Cranioplasty with bone allografts dates from the Stone Age Celts. Through the millennia, generations of surgeons have tried bone autografts, allografts, and rarely xenografts for cranioplasty but abandoned these in favor of alloplastic metals and plastics, most recently methylmethacrylate. Disillusionment with bone cranioplasty has followed the recurrent experience that orthotopic transplantation of bone to skull is almost invariably accompanied by a striking propensity for resorption. Resorption coupled to new bone formation is the usual process of remodeling. A unique acellular nonosteoclastic resorption, antedating invasion of the graft by osteoprogenitor cells and unrelated to the remodeling, characterizes the initial response of bone placed in a skull bed. This previously undescribed resorption in the skull likely represents passive diffusion of mineral from an altered matrix (calciolysis) and varies directly with the degree the graft is denatured by processing. There is the least amount of resorption in the fresh autograft and the most in autoclaved or chemically treated frozen or freeze-dried grafts. Remodeling of this diminished template occurs centripetally from skull defect margins through osteoconductive mechanisms only. Marrow-poor skull with thin diploe provides few osteoprogenitor cells that slowly, incompletely remodel the reduced graft over years.     

Management and Aesthetic Results of Support Grafts in Saddle Nose Surgery

To define the surgical management and long-term aesthetic results of patients undergoing rhinoplasty with support graft for saddle nose, 147 patients have been included in this retrospective study. One hundred forty-four autogenous grafts (bone or cartilage) and three processed irradiated bovine cartilage grafts have been used during the period 1980–1997. Two approaches have been employed: open rhinoplasty and endonasal approach. Most of cases have been treated with bony grafts (116 bone graft versus 26 cartilage grafts). Global follow-up after surgery for long-term aesthetic study was 8.5 years. Among the different autogenous that have been used in our series, the calvarial bone had the most interesting results in terms of resorption. In patients with important saddle nose deformity, we recommend calvarial bone as a material of choice for dorsonasal reconstruction. It provides excellent and natural long-term feel to the nasal complex.     

Calvarial bone graft harvest: a new technique.

OBJECTIVE: This study evaluates the use of a new calvarial bone graft-harvesting device (BHD). STUDY DESIGN: A total of 18 calvarial bone grafts (CBGs) were harvested from 9 cadavers with the BHD. The recorded parameters included drilling time, graft harvest time, graft size, graft integrity, and violation of the calvarial inner table. Five CBGs were subsequently harvested in vivo and used for 2 nasal reconstructions and 3 orbital reconstructions. RESULTS: The CBG dimensions ranged from 1.25 to 2.5 cm in width and 3.0 to 16.0 cm in length. Graft harvest time ranged from 5 minutes, 55 seconds to 25 minutes, 30 seconds (mean 13 minutes, 7 seconds). There were no fractured grafts. The cadaveric inner table was violated twice with a cutting burr, and 1 dural exposure occurred in the clinical study. CONCLUSION: Although caution must be used with all CBGs, the BHD appears to be safe and more efficient than osteotomes or oscillating saws.     

Vascularized periosteal bone graft from the supracondylar region of the femur

Free, vascularized thin corticoperiosteal grafts and small pe-riosteal bone grafts harvested from the supracondylar region of the femur are described. These grafts are nourished from the articular branch of the descending genicular artery and vein. Thin corticoperiosteal grafts consist of periosteum with a thin layer of outer cortical bone and include the cambium layer, which has a better osteogenic capacity. This graft is elastic and readily conforms to the recipient bed configuration. Thin corticoperiosteal grafts were used to treat 11 patients with fracture non-union of an upper extremity that had no massive bone defects. Early, rapid union occurred in all patients except three: one in which the anastomosed vessel became obstructed and two in which the internal fixation of the fracture was unsecured. The small bone grafts consist of periosteum, full thickness cortex, and the underlying cancellous bone. This graft can be successfully harvested without disturbing the vascularity, unlike the currently used vascularized bone grafts. This graft was used to treat three patients with avascular necrosis of the body of the talus and could prevent the necrotic talus body from progressive collapse in patients in early stages of the disease. One patient with an infectious bone defect of the first metatarsal bone was successfully treated by vascularized bone graft with an accompanying skin flap. © 1994 Wiley-Liss, Inc.     

Reconstruction of the anterior face of the base of the skull using coral grafts

Following experimental investigations on animals, small coral grafts have been utilized on patients since 1985 to fill in burr holes (42 patients). This first clinical experimental step has been satisfactory. Therefore, blocks of corals have since then been used as bone graft substitutes for anterior skull basis reconstruction (12 patients). Cheap and easily sterilized, coral implants have the advantage of being inert (99% of calcium carbonate), biodegradable and well reossified. They shorten surgical procedures by avoiding the use of iliac and/or costal grafts. No infectious complications have been noted.     

Histomorhological and clinical evaluation of maxillary alveolar ridge reconstruction after craniofacial trauma by applying combination of allogeneic and autogenous bone graft

A variety of techniques and materials for the rehabilitation and reconstruction of traumatized maxillary ridges prior to dental implants placement have been described in literature. Autogenous bone grafting is considered ideal by many researchers and it still remains the most predictable and documented method. The aim of this report is to underline the effectiveness of using allogeneic bone graft for managing maxillofacial trauma. A case of a 30-year-old male with severely atrophic maxillary ridge as a consequence of complex craniofacial injury is presented here. Augmentation procedure in two stages was performed using allogeneic and autogenous bone grafts in different areas of the osseous defect. Four months after grafting, during the implants placement surgery, samples of both sectors were withdrawn and submitted to histological evaluation. On the examination of the specimens, treated by hematoxylin and eosin staining, the morphology of integrated allogeneic bone grafts was revealed to be similar to the autologous bone. Our clinical experience shows how the allogeneic bone graft presented normal bone tissue architecture and is highly vascularized, and it can be used for reconstruction of severe trauma of the maxilla.     

Correction of complicated saddle nose — Report of 63 cases

Summary 63 cases of complicated saddle nose deformity are presented. Treatment was by wide subcutaneous dissection over the nose and over the maxilla. Lengthening of the nose was achieved with a mucoperiosteal flap from under the nasal bones being advanced caudally. Contours were provided with L-shaped iliac crest bone graft; pyriform aperture onlay bone grafts were occasionally performed. There was one failure due to loss of bone graft by infection. In four cases there was exposure of the bone graft at the nasal tip, but these healed spontaneously. The results of this procedure have been very satisfactory.     

Tip graft from the cartilaginous dorsum in rhinoplasty

A cartilage graft from the cartilaginous hump can be used in primary rhinoplasty for nasal tip projection. This technique has now been used for two years without complications in 35 patients with similar nose deformities, which included an inadequately projected tip and a high dorsal line. These grafts have proved to be another easy way to get an adequate tip projection in primary rhinoplasty.Paper presented at The Annual Meeting of the American Society for Anesthetic Plastic Surgery, in Los Angeles, California, April, 1983