Advanced Craniomaxillofacial Surgery E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1268

Veröffentlichungsjahr: 2020

Beschreibung

Featuring more than 1,300 expertly drawn illustrations and images, the Advanced Craniomaxillofacial Surgery book is the comprehensive, highly anticipated follow-up to the original work on Principles of Internal Fixation of the Craniomaxillofacial Skeleton that was published in 2012.

With detailed contributions from more than 80 renowned international authors, Advanced Craniomaxillofacial Surgery significantly builds on the solid foundation laid by the previous textbook. The new book comprises sophisticated techniques in skeletal and soft-tissue analysis for the disciplines of craniomaxillofacial, trauma, tumor, orthognathic surgery, as well as facial and esthetic surgery.

The focused expertise of seven disciplines is synthesized together to offer comprehensive and unique interdisciplinary perspectives, necessary to create the "team" approach fundamental to achieving the progress required and expected in high-level medical centers: oral and maxillofacial surgery, plastic and reconstructive surgery, otolaryngology, neurosurgery, ophthalmology, oculoplastic surgery, and head and neck surgery. Nowhere else has there been such a thorough and comprehensive multispecialty approach presented in the head and neck region.

The advent of microvascular surgery, skeletal analysis, computerized surgical planning, personalized implant creation, and comprehensive radiographic analysis have given rise to new principles, techniques and possibilities, which are explored extensively in this new textbook. Advanced Craniomaxillofacial Surgery should be part of every surgeon's library.

Leseprobe

Michael Ehrenfeld | Neal D Futran | Paul N Manson | Joachim Prein

Advanced Craniomaxillofacial Surgery

Tumor, Corrective Bone Surgery and Trauma

Includes over 1,300 figures

Library of Congress Cataloging-in-Publication Data is available from the publisher.

Hazards Great care has been taken to maintain the accuracy of the information contained in this publication. However, the publisher, and/or the distributor, and/or the editors, and/or the authors cannot be held responsible for errors or any consequences arising from the use of the information contained in this publication. Contributions published under the name of individual authors are statements and opinions solely of said authors and not of the publisher, and/ or the distributor, and/or the AO Group. The products, procedures, and therapies described in this work are hazardous and are therefore only to be applied by certified and trained medical professionals in environments specially designed for such procedures. No suggested test or procedure should be carried out unless, in the user‘s professional judgment, its risk is justified. Whoever applies products, procedures, and therapies shown or described in this work will do this at their own risk. Because of rapid advances in the medical sciences, AO recommends that independent verification of diagnosis, therapies, drugs, dosages, and operation methods should be made before any action is taken. Although all advertising material which may be inserted into the work is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement by the publisher regarding quality or value of such product or of the claims made of it by its manufacturer.

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Copyright © 2020 by AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland Distribution by Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany, and Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA

ISBN: 9783132428393                                                  1 2 3 4 5 6 e-ISBN: 9783132428409

Introduction

Seven years after the publication of the manual on Principles of Internal Fixation of the Craniomaxillofacial Skeleton—Trauma and Orthognathic Surgery, the second volume entitled Advanced Craniomaxillofacial Surgery—Tumor, Corrective Bone Surgery and Trauma is now available. It is a project of AOCMF, a clinical division of the AO Foundation. According to the interdisciplinary nature of AOCMF, this advanced manual includes chapters and contributions from oral and maxillofacial surgeons, plastic surgeons, otolaryngologist oculoplastic surgeons, head and neck surgeons, and researchers.

Medical knowledge is growing rapidly, and the way it is disseminated is changing from printed media toward digital presentations including video channels. On the other hand, principles of operative medicine and surgical standards remain relatively stable and do not change that fast. Therefore, the editors of this book believe that it still makes sense to produce a book that captures current aspects of advanced craniomaxillofacial bone surgery.

This advanced manual is divided into six sections. The first section presents an overview of bone grafts/flaps, bone replacement materials and techniques. Sections two and three cover various aspects of ablative and reconstructive surgery of the mandible, midface, and craniofacial junction. Section four deals with corrections of complex deformities and conditions of the craniofacial skeleton; section five with imaging and planning technologies; and the last section with principles and techniques for facial allotransplantation.

More than 1,300 figures are included to focus on practical surgical details. The combination of text and illustrations is meant to support practical training during surgical specialization, and in addition will allow the experienced surgeon to look up and refresh surgical knowledge.

This advanced manual comprises chapters from many individual surgeons, and great efforts have been made to create a consistent textbook without much overlap. We sincerely hope that the readers will find this book valuable, and we are happy to receive comments and feedback.

Preface

Seven years after publication of the first volume of the manual on Principles of Internal Fixation of the Craniomaxillofacial Skeleton—Trauma and Orthognathic Surgery, in 2012, Professors Ehrenfeld, Prein, and Manson are joined by Professor Futran to produce volume 2 of the manual on advanced techniques in craniofacial surgery, titled Advanced Craniomaxillofacial Surgery—Tumor, Corrective Bone Surgery and Trauma. Renowned international experts have contributed to provide one of the most comprehensive works on sophisticated surgical analysis and treatment of complex conditions of the face, head and neck from a multidisciplinary perspective previously not possible except in a worldwide and comprehensive craniomaxillofacial faculty such as that within the interdisciplinary AO Foundation. The past 40 years have witnessed an explosion of progress in the knowledge and treatment of diseases of the head and neck and the craniofacial skeleton, with new methods of surgery, fixation, grafting and especially planning analysis and implants. These advances create new and innovative treatment concepts especially in surgery. Rigid internal fixation techniques, craniofacial exposures as well as modern planning algorithms are today applied to trauma, tumor surgery, orthognathic and craniofacial surgery for the benefit and improvement of all reconstructive and esthetic skeletal procedures in the head and neck region.

This advanced manual and companion to the Principles of Internal Fixation of the Craniomaxillofacial Skeleton adds to the information of the first volume sophisticated techniques in skeletal and soft-tissue analysis for the disciplines of craniofacial surgery, trauma, tumors, orthognathic, facial and esthetic skeletal surgery. This volume 2 complements the basic principles in volume 1. It covers information required to manage the challenging problems beyond the basic information and procedures presented in volume 1 and permits the acquisition of comprehensive treatment planning techniques and improvements required to achieve good results in more challenging specialty procedures throughout the entire region.

The expertise of several disciplines offers a comprehensive and unique interdisciplinary perspective necessary to create the “team” approach fundamental to achieving the progress required and expected in sophisticated medical centers: Oral and Maxillofacial Surgery, Plastic and Reconstructive Surgery, Otolaryngology and Facial Plastic and Reconstructive Surgery, Ophthalmology and Oculoplastic Surgery, Neurosurgery, and Head and Neck Surgery. The focused expertise of each discipline is assembled and combined to produce an all-inclusive volume which delivers excellent insight into the developments of the past 40 years in all techniques of facial bone surgery. Indeed, the advent of microvascular surgery, skeletal analysis, computed surgical planning, sophisticated personalized implant creation, comprehensive radiographic analysis, and thorough planning such as model surgery, patient-specific implants, detailed preoperative computerized planning and analysis have brought new principles, techniques, and possibilities that allow the individual surgical practitioner to achieve sophisticated goals more efficiently with reduced surgical time, frustration, and revolutionary outcomes.

Importantly, these new techniques of radiographic analysis and computerized planning permit a wide range of less common and highly sophisticated operations to be undertaken by all practitioners. The same techniques of analysis, when used postoperatively, generate data from results which directly translate into improvements and recommendations for new and better treatments, permitting a cycle of constant improvement which continues to generate new and better operations. The vast volume of this new material may at first seem overwhelming to the individual practitioner, but these chapters segment the knowledge into compartments which seem scalable and possible for the individual practitioner to incorporate into his or her own treatment algorithms.

It has been an enormous task to collect and to coordinate this talented group of international experts and specialty communities into this volume. The production of uniform detailed and comprehensive artwork itself is far beyond the limited quality of the usual contributions available in standard multiauthor textbooks, and the quality and numerous illustrations allow a knowledge and mastery of the principles discussed so that individual practitioners can predictably improve their knowledge and skill in any of the areas covered. The references indicate further enhancements in knowledge and practice through additional study.

Today, the wide range of surgical possibilities, implant materials, and techniques of planning and analysis allow our patients better outcomes through easier and more straightforward surgery for the practitioners who despite the added expense of the implants, analysis and techniques can even offer their patients less costly operations made possible by reduced operative time, reduced possibility of complications, reduced secondary or revisional surgery, and the improved outcomes that fully justify the results achieved.

It has been our privilege to benefit from the associations with multiple generations of surgeons worldwide in multiple disciplines through the unique structure of the AO Foundation. All specialties have been united to produce the comprehensive interdisciplinary knowledge available in these volumes. We believe we have learned as much by editing and organizing this advanced volume as anyone having this textbook.

We the editors thank the AO Foundation and its sponsors for providing the educational network that has made the interdisciplinary exchange of this knowledge advancing progress possible.

Good luck and good learning as you appreciate the special treat offered by this international multidisciplinary effort of the AOCMF.

Michael Ehrenfeld, MD, DDS, ProfNeal D Futran, MD, DMD, ProfPaul N Manson, MD, ProfJoachim Prein, MD, DDS, Prof

Acknowledgment

The editors express their appreciation to the authors for contributing chapters to this book and sharing their knowledge and experience with the reader. We are convinced that this effort will contribute significantly to the education of craniomaxillofacial surgeons. We are also grateful to the authors for understanding that the editors needed to update the original manuscripts in order to exclude overlap and ensure consistency throughout the book.

Special thanks go to Almuth Nussbaumer who has been of invaluable help to the editors in the coordination of this book project.

The AO Education Institute team has provided significant resources and expertise without which this book would not have been possible. We thank Vidula H Bhoyroo for the overall planning and management of this project, as well as Urs Rüetschi, Robin Greene, Carl Lau, and Jecca Reichmuth for their dedicated support.

Many thanks to all illustrators, especially the main illustrator Marcel Erismann. And our appreciation to Roman Kellenberger who did a tremendous job in typesetting the book.

We convey our appreciation and deep gratitude to Prof Hans F Zeilhofer and Prof Christoph Kunz for their logistical support to Prof Prein in the production of this project by generously providing the infrastructure within their unit.

We are also grateful to the former and current Executive Directors of AOCMF, Tobias Hüttl and Erich Roethlisberger for their unwavering support of this very important project.

Contributors

Editors

Michael Ehrenfeld

, MD, DDS, Prof

Professor and Chair Department for Oral and

Maxillofacial Surgery

Ludwig-Maximilians-University

Lindwurmstrasse 2a

80337 Munich

Germany

Paul N Manson

, MD, Prof

Johns Hopkins

Plastic, Reconstructive and Maxillofacial Surgery

8152 R McElderry Wing

601 North Caroline Street

Baltimore, MD 212870981

USA

Neal D Futran

, MD, DMD, Prof

Professor and Chair of Otolaryngology-HNS Director of Head and Neck Surgery

University of Washington

1959 NE Pacific Street

Box 356515

Seattle, WA 98195

USA

Joachim Prein

, MD, DDS, Prof

University Hospital

Reconstructive Surgery

Spitalstrasse 21

4031 Basel

Switzerland

Authors

Gregorio Sánchez Aniceto, MD, PhD Hospital Doce de Octubre Maxillofacial Surgery service Ctra. Andalucía Km. 5.4 28041 Madrid Spain

Suad Aljohani, DMD Department of Oral and Maxillofacial SurgeryLudwig Maximilian UniversitätLindwurmstrasse 2a 80337 Munich Germany

Faisal Al-Mufarrej, MD Seattle Children’s Hospital Division of Craniofacial & Plastic Surgery 4800 Sand Point Way NE Seattle, WA 98105 USA

Jörg Beinemann, MD University-Hospital Basel Clinic of Oral-, Cranioand Maxillo-Facial Surgery Spitalstrasse 21 4031 Basel Switzerland

R Bryan Bell, MD, DDS, FACS Oral and Maxillofacial Surgery Oregon Health & Science University/ Providence Cancer Center 1849 NW Kearney Suite #300 Portland, OR 97209 USA

Gido Bittermann, MD Universitätsklinikum Freiburg Department für Zahn-, Mundund Kieferheilkunde Klinik für Mund-, Kieferund Gesichtschirurgie Hugstetter Strasse 55 9106 Freiburg Germany

Remy H Blanchaert, Jr, MD, DDS 1919 N Webb Road Wichita, KS 67206-3405 USA

Marc Bohner, MSc, EOFL, PhD Rober t Mathys Foundation Skeletal Substitutes roup Bischmat tstrasse 12, POB 203 2544 Bet tlach Switzerland

Rolf Bublitz, Dr, Ltd Oberarzt Klinikum Stut tgar t, Katharinenhospital Klinik für MKG-Chirurgie Zentrum f. Implantologie Kriegsbergstrasse 60 70174 Stut tgar t Germany

Daniel Buchbinder, DMD, MD, Prof Continuum Health partners Institute for Head and Neck and Craniofacial Diseases 10 Union Square East, Suite 5B New York, NY 10003 USA

Peter Bucher, CDT CFC Hirslanden Hirslanden Medical Center Rain 34 5000 Aarau Switzerland

Carl-Peter Cornelius, MD, DDS, Prof Ludwig Maximilians-Universität, Klinikum Innenstadt Klinik und Poliklinik für Mund-, Kiefer-, Gesichtschirurgie Lindwurmstrasse 2a 80337 Munich Germany

Marcin Czerwinski, MD, FRCS Scott & White Memorial Hospital Section Cleft-Craniofacial Surgery 2401 S 31st Street Temple, T X 76508 USA

Stéphanie Dakpé, MD Department of Maxillofacial Surgery University Hospital Avenue Laennec CHU Amiens-Picardie 80000 Amiens France

Bernard Devauchelle, MD, Prof, Dr, FRCS(Eng) Chirurgie Maxillofaciale Hôpital Nord Place Victor Pauchet 80054 Amiens cedex 1 France

Edward Ellis III, DDS, MS, Prof University of Texas Health Science Center at San Antonio Department Oral Maxillofacial Surgery 7703 Floyd Curl Drive, MC-7908 San Antonio, T X 78229-3900 USA

Gregory RD Evans, MD, FACS, Prof University of California, Irvine Aesthetic and Plastic Surgery Institute 200 S Manchester Suite 650 Orange, CA 92868 USA

Jamie Gateno, MD, DDS Chairman Oral and Maxillofacial Surgery Department Houston Methodist Hospital 6560 Fannin Suite 1280 Houston, TX 77030 USA

Nils-Claudius Gellrich, MD, DDS, Prof Medical University Hannover Department of Oral and Maxillofacial Surgery Carl-Neuberg-Strasse 1 30625 Hannover Germany

Michael P Grant, MD, PhD, FACS Division Head, Oculoplastic Surgery Director Ocular and Orbital Trauma Center Wilmer Ophthalmological Institute The Johns Hopkins Hospital 600 North Wolfe Street Maumenee 505 Baltimore, MD 21287 USA

Raquel Guijarro-Martínez, MD, DMD Maxillofacial Institute Quirón-Teknon Hospital Vilana St 12, D-185 08022 Barcelona Spain

Patrick J Gullane, CM, MB, FRCS, FACS, Prof University of Toronto Department of Otolaryngology/ Head and Neck Surgery Room 8N-877 200 Elizabeth Street Toronto, ON M5G 2C4 Canada

Ralf Gutwald, MD, Prof University Hospital Freiburg Department of Oral and Maxillofacial Surgery Hugstetter Strasse 55 79106 Freiburg Germany

Christine Hagenmaier, DMD Herkomerplatz 2 81679 Munich Germany

Jeffrey Haller, MD Rocky Mountain Eye Center 700 W Kent Ave Ste 1 Missoula, MT 59801 USA

Beat Hammer, MD, DMD, Prof Hirslanden Medical Center Cranio-Faciales-Centrum Rain 34 5000 Aarau Switzerland

Henning Hanken, MD Wilhelm-Bock-Weg 5 22297 Hamburg Germany

Max Heiland, MD, DMD, PhD Klinik für Mund-, Kieferund Gesichtschirurgie CVK Charité Campus Virchow-Klinikum Augustenburger Platz 1 13353 Berlin Germany

Alexander Hemprich, MD, DMD, Prof Universität Leipzig Klinik und Poliklinik für Mund-, Kieferund Plastische Gesichtschirurgie Liebigstrasse 10 -14 04103 Leipzig Germany

Thomas Hierl, MD, DDS, PhD Department of Oral and Maxillofacial Surgery/ Plastic Facial Surgery Helios Vogtland-Klinikum Plauen Roentgenstrasse 2 08529 Plauen Germany

Jürgen Hoffmann, MD, DMD, Prof Department of Oral and Maxillofacial Surgery National Cancer Center University Hospital Heidelberg Im Neuenheimer Feld 400 69120 Heidelberg Germany

Dominik Horn, MD, DMD Ärztlicher Mitarbeiter Klinik und Poliklinik für Mund-, Kieferund Gesichtschirurgie Universitätsklinikum Heidelberg Im Neuenheimer Feld 400 69120 Heidelberg Germany

Richard A Hopper, MD, Prof University of Washington Seattle Children’s Hospital Craniofacial Center Division of Pediatric Plastic Surgery 4800 Sand Point Way NE Seattle, WA 98105 USA

Keith A Hurvitz, MD Long Beach Medical Center 2880 Atlantic Avenue Suite 290 Long Beach, CA 90806 USA

Keith Jones, MD, BDS, FRCS The Old Rectory Main Street Tatenhill, Staffs DE13 9SD UK

Leonard B Kaban, DMD, MD, FACS, Prof Harvard School of Dental Medicine Massachuset ts General Hospital Department of Oral and Maxillofacial Surgery 55 Fruit Street Warren 1201 Boston, MA 02114 USA

Robert M Kellman, MD, FACS, Prof SUNY Upstate Medical University Department of Otolaryngology & Communication Sciences 750 East Adams Street Syracuse, NY 13210 -2339 USA

Douglas W Klotch, MD, FACS Tampa General Hospital Department of Craniomaxillofacial Surgery 3450 East Fletcher Avenue Suite 260 Tampa, FL 33613 USA

Christoph Kunz, MD, DMD, Prof Head Oral and Craniomaxillofacial Surgery Department of Surgery University Hospital Spitalstrasse 21 4031 Basel Switzerland

Risto Kontio, MD, DDS, PhD Helsinki University Hospital Department of Oral and Maxillofacial Surgery Kasarminkau 11-13, POB 263 00029 HUS Helsinki Finland

Chen Lee, MD, FRCSC, FACS Aesthetica MD Clinique de Chirurgie Plastique & Esthétique 4055 Ste-Catherine Ouest Suite 100 Westmount, Quebec H3Z 3J8 Canada

Nicholas R Mahoney, MD Assistant Professor of Ophthalmology Johns Hopkins University Wilmer Eye Institute 600 N Wolfe Street Maumenee 505 Baltimore, MD 21287 USA

Gerson Mast, Dr med, Dr med dent, PhD Klinikum der Universität München Innenstadt Klinik für Mund-, Kiefer-, Gesichtschirurgie Lindwurmstrasse 21 80337 Munich Germany

Alexander Metz, MD Kliniken Essen Mit te, Evang. Huyssens-Stiftung/ Knappschaft GmbH OMF Surgery, Plastic Surgery Henricistrasse 92 45136 Essen Germany

Marc C Metzger, MD, DDS, Prof University Hospital Freiburg Oral and Maxillofacial Surgery Hugstetter Strasse 55 79106 Freiburg Germany

Christopher Mohr, Prof, Dr med, Dr med dent Kliniken Essen-Mit te Evangelische Huyssens- Stiftung/Knappschaft Klinik für Mund-, Kiefer-, Gesichtschirurgie Henricistrasse 92 45136 Essen Germany

Reid V Mueller, MD, Prof Oregon Health Sciences University Division of Plastic and Reconstruction Surgery 3303 SW Bond Ave, CH5P Portland, OR 97239-4501 USA

Peter C Neligan, MB, FRCSC(I), FRCS, FACS, Prof University of Washington Department of Surgery, Division of Plastic Surgery 1959 NE Pacific Street Box 356410 Seattle, WA 981956410 USA

Christine B Novak, PhD, Prof Hand Program Division of Plastic and Reconstructive Surgery 399 Bathurst Street, EW2-422 Toronto, ON M5T 2S8 Canada

Sven Otto, PD, Dr med, Dr med dent Department of Oral and Maxillofacial Surgery Ludwig Maximilian Universität Lindwurmstrasse 2a 80337 Munich Germany

Nicholas J Panetta, MD Department of Plastic Surgery University of Pit tsburgh Medical Center 3550 Terrace Street 6B Scaife Hall Pit tsburgh, PA 15261 USA

Maria E Papadakis, MD, DMD, PhD Harvard School of Dental Medicine Massachuset ts General Hospital Department of Oral and Maxillofacial Surgery 55 Fruit Street Warren 1201 Boston, MA 02114 USA

Roman P Pförtner, MD Kliniken Essen Mit te, Evang Huyssens- Stiftung/Knappschaft OMF Surgery, Plastic Surgery Henricistrasse 92 45136 Essen Germany

Jeffrey C Posnick, DMD, MD Posnick Center Facial Plastic Surgery 5530 Wisconsin Avenue, Suite 1250 Chevy Chase, MD 20815 USA

Florian A Probst, MD, DMD, PhD Facharzt für Mund-, Kieferund Gesichtschirurgie Klinikum der Universität München Klinik und Poliklinik für Mund-, Kieferund Gesichtschirurgie Lindwurmstrasse 2a 80337 Munich Germany

Berton Rahn†, MD, DMD Professor of Maxillofacial Surgery Vice-Director AO Research Institute Clavadelerstrasse 8 7270 Davos Switzerland † Deceased

Majeed Rana, PD, Dr med, Dr med dent Facharzt für Mund-, Kieferund Gesichtschirurgie Plastische und Ästhetische Operationen Fachzahnarzt für Oralchirurgie Klinik für Mund-, Kieferund Plastische Gesichtschirurgie Zentrum für operative Medizin II (ZOM II) Heinrich-Heine-Universität Düsseldorf Moorenstrasse 5 40225 Düsseldorf Germany

Ignacio Ismael García Recuero, MD Oral & Maxillofacial Surgery Department Craniofacial Surgery Unit HU 12 deOctubre, HU Quirón Madrid Spain

Geoff Richards, Dr Sci, MSc AO Research Institute Clavadelerstrasse 8 7270 Davos Switzerland

Michel Richter, Prof, Dr med, Dr med dent Former Chairman of Oral and Maxillofacial Surgery Clinic Hôpitaux Universitaires de Genève Rue Gabrielle-Perret-Gentil 4 1205 Genève Switzerland

Dennis Rohner, Prof, Dr med, Dr med dent Hirslanden Medical Center Craniofacial Center Rain 34 5000 Aarau Switzerland

Martin Rücker, Prof, Dr med, Dr med dent Zentrum für Zahnmedizin Privatpraxis für Mund-, Kieferund Gesichtschirurgie Pestalozzistrasse 10 8032 Zurich Switzerland

Larry A Sargent, MD Sargent Plastic Surgery of Utah 620 East Medical Drive No. 310 Bountiful, UT 84010 USA

Sebastian Sauerbier, PD, Dr med, Dr med dent Mund-, Kieferund Gesichtschirurgie Pacelliallee 4 36043 Fulda Germany

Rainer Schmelzeisen, MD, DDS, Prof, FRCS (London) University Hospital Freiburg Department Oral Maxillofacial Surgery Hugstetter Strasse 55 79106 Freiburg im Breisgau Germany

Maximillian Schöllchen, Dr med Arzt in der For tbildung zum Facharzt für Mund-, Kieferund Gesichtschirurgie Klinik und Poliklinik für Mund-, Kiefer und Gesichtschirurgie Universitätsklinikum Hamburg-Eppendorf Mar tinistrasse 52 20246 Hamburg Germany

Ralf Schumacher, Dipl Ing Leiter Medical Additive Manufacturing Hochschule für Life Sciences FHNW Gründenstrasse 40 4132 Mut tenz Switzerland

Alexander Schramm, Prof, Dr med, Dr med dent Military Hospital Ulm, Academic Hospital, University of Ulm Oral and Maxillofacial Surgery Oberer Eselsberg 40 89081 Ulm Germany

Warren Schubert, MD, FACS, Associate Prof Regions Hospital Department of Plastic and Hand Surgery Mail Stop 11503 B 640 Jackson Street St Paul, MN 44101 USA

Navin K Singh, MD Washingtonian Plastic Surgery 5454 Wisconsin Ave, Ste 1710 Chevy Chase, MD 20815 USA

Martin Stoddart, MD, PhD AO Research Institute Clavadelerstrasse 8 7270 Davos Switzerland

E Bradley Strong, MD, Prof University of California, Davis Department of Otolaryngology-Head and Neck Surgery 2521 Stockton Blvd, Suite 7200 Sacramento, CA 95817 USA

Adrian Sugar, Dr. h.c., FRCS Morriston Hospital Maxillofacial Unit West Glamorgan Swansea, SA6 NL, Wales UK

James Q Swift, DDS, Associate Prof University of Minnesota School of Dentistry Division of Oral and Maxillofacial Surgery 515 Delaware Street SE 7-174 Moos Tower Minneapolis, MN 554550329 USA

Jesse A Taylor, MD, Assistant Prof The University of Pennsylvania Children’s Hospital of Philadelphia Plastic, Reconstructive and Craniofacial Surgery, Co-Director, CHOP Cleft Team 3400 Spruce St 10 Penn Tower Philadelphia, PA 19104 USA

John F Teichgraeber, MD, Prof Division of Pediatric Plastic Surgery Department of Pediatric Surgery University of Texas Houston Health Science Center 6410 Fannin Street Suite 950 Houston, TX 77030 USA

Sylvie Testelin, PhD, MD Department of Maxillofacial Surgery University Hospital Avenue Laennec Chu Amiens Picardie 80000 Amiens France

Florian M Thieringer, MD, DDS, MHBA Oral and Cranio-Maxillo-Facial Surgery University Hospital Basel Spitalstrasse 21 4031 Basel Switzerland

Maria J Troulis, MD Chief Oral and Maxillofacial Surgery Massachuset ts General Hospital Walter C. Guralnick Professor and Chair Oral and Maxillofacial Surgery Harvard School of Dental Medicine Warren 1201 55 Fruit Street Boston, MA 02114 USA

Dieter Weingart, Prof, Dr med, Dr med dent Klinikum Stut tgar t, Katharinenhospital Aerztlicher Direktor Klinik für Mund-, Kieferund Gesichtschirurgie Plastisch-ästhetische Operationen Zentrum für Implantologie Leiter Kopfzentrum Kriegsbergstrasse 60 70174 Stut tgar t Germany

Frank Wilde, MD, DMD Military Hospital Ulm Academic Hospital Ulm University Oberer Eselsberg 40 89081 Ulm Germany

Hans-Florian Zeilhofer, Prof, Dr med, Dr med dent University Hospital Basel Clinic and Policlinic for Maxillofacial Surgery Spitalstrasse 21 4031 Basel Switzerland

James J Xia, MD, PhD, MS, Prof Professor of Oral and Maxillofacial Surgery Director of Surgical Planning Laboratory Houston Methodist Hospital 6560 Fannin Street Suite 1280 Houston, TX 77030 USA

Table of Contents

Introduction

Acknowledgment

Preface

Contributors

1 Bone grafts, bone flaps, bone replacement materials and techniques

Christopher Mohr, Roman P Pförtner, Alexander Metz

1.1 Types and harvest of bone grafts and bone flaps

Michael Ehrenfeld, Christine Hagenmaier, Remy H Blanchaert Jr

1.2 Bone lengthening by distraction

Leonard B Kaban, Maria E Papadaki, Maria J Troulis

1.3 Ceramic bone substitute materials

Marc Bohner, Berton Rahn†

1.4 Growth factors for craniomaxillofacial applications

Martin Stoddart, Geoff Richards

2 Ablative and reconstructive surgery of the mandible

2.1 Access osteotomies in the mandible in tumor surgery and osteosynthesis

Keith Jones

2.2 Mandible resections without loss of continuity (rim resections)

Sebastian Sauerbier, Ralf Gutwald, Rainer Schmelzeisen

2.3 Benign noncontinuity intraosseous lesions

Michel Richter

2.4 Segmental defects, defect bridging, reconstruction with free nonvascularized bone grafts

Edward Ellis

2.5 Reconstruction of the condyle

James Q Swift

2.6 Mandible reconstruction with microvascular free flaps

Michael Ehrenfeld, Keith A Hurvitz, Gregory RD Evans

2.7 Reconstruction with prefabricated flaps

Dennis Rohner, Raquel Guijarro-Martínez, Peter Bucher, Beat Hammer

3 Ablative and reconstructive surgery of the midface and craniofacial junction

3.1 Approaches and access osteotomies to the midface

Douglas W Klotch, Nicholas J Panetta

3.2 Midface resection and reconstruction

Neal D Futran

3.3 Ablative and reconstructive surgery of the orbit

Christopher Mohr, Roman P Pförtner, Alexander Metz

3.4 Secondary frontal sinus surgery

Jeffrey Haller, Neal D Futran

3.5 Access surgery to the skull base

Neal D Futran

3.6 Reconstruction of the skull base

Patrick J Gullane, Peter C Neligan, Christine B Novak

3.7 Reconstruction of the cranial vault

Jesse A Taylor, Navin K Singh

3.8 Secondary corrections after orbital/nasoethmoidal fractures

Beat Hammer

4 Correction of complex deformities and conditions of the craniofacial skeleton

4.1 Treatment of gunshot injuries

Warren Schubert

4.2 Treatment of malalignment and incorrect occlusion

Daniel Buchbinder

4.3 Treatment of ankylosis

Risto Kontio

4.4 Ridge augmentation of the atrophic maxilla and mandible

Dieter Weingart, Rolf Bublitz, Michael Ehrenfeld

4.5 Hemifacial microsomia—diagnosis, classification, and management

Adrian Sugar

4.6 Cleft bone grafting and management of the alveolar ridge defect

Jeffrey C Posnick

4.7 Orthognathic surgery for unilateral and bilateral total clefts

Jeffrey C Posnick

4.8 Distraction osteogenesis of the maxilla with external devices

Alexander Hemprich, Thomas Hierl

4.9 Midface advancement with internal distractors

Jaime Gateno, James J Xia, John F Teichgraeber

4.10 High midface osteotomies

Richard A Hopper, Faisal Al-Mufarrej

4.11 Craniosynostosis

Ignacio Ismael García Recuero, Gregorio Sánchez Aniceto

4.12 Orbital hypertelorism

Larry A Sargent

4.13 Encephaloceles

Neal D Futran

4.14 Medication-related osteonecrosis of the jaw

Sven Otto, Suad Aljohani

5 Imaging and planning technologies

5.1 Endoscopy in mandibular condyle and midfacial trauma care

Marcin Czerwinski, Chen Lee, Reid V Mueller, Rainer Schmelzeisen, Robert M Kellman

5.2 3-D manufacturing technologies and their applications in craniomaxillofacial surgery

Florian M Thieringer, Jörg Beinemann, Ralf Schumacher, Hans-Florian Zeilhofer

5.3 Navigation and computer planning in craniomaxillofacial reconstruction

5.3.1 Navigation and computer planning in craniomaxillofacial reconstruction—introduction

Nils-Claudius Gellrich, Majeed Rana

5.3.2 Image analysis: data acquisition and processing

R Bryan Bell

5.3.3 Virtual models and segmentation

Majeed Rana, Nils-Claudius Gellrich

5.3.4 Biomodels

Martin Rücker

5.3.5 Intraoperative navigation

Majeed Rana, Nils-Claudius Gellrich

5.3.6 Intraoperative imaging and quality control

Frank Wilde, Alexander Schramm

5.3.7 Surgically preformed implants: nonpatient specific

Nils-Claudius Gellrich, Majeed Rana

5.3.8 Industrially preformed orbital meshes

E Bradley Strong, Marc C Metzger

5.3.9 Preformed mandible plates

Marc C Metzger, Florian A Probst, Rainer Schmelzeisen, E Bradley Strong

5.3.10 Patient-specific mandible implants

Max Heiland, Maximillian Schöllchen, Henning Hanken

5.3.11 Patient-specific implants for craniofacial reconstruction

Dominik Horn, Jürgen Hoffmann

5.3.12 Computer-assisted surgical planning and execution: models, cutting and drill guides, positioning aids, and patient-specific implants

Carl-Peter Cornelius, Gerson Mast, Michael Ehrenfeld

5.3.13 Orthognathic surgery and automated splint manufacturing

Marc C Metzger, E Bradley Strong, Gido Bittermann, Rainer Schmelzeisen

5.3.14 Interspeciality interface in head and neck oncology—current clinical use of computer-assisted surgery and future perspectives

Majeed Rana, Nils-Claudius Gellrich

5.3.15 Computer-assisted techniques in orbital surgery for thyroid eye disease

Nicholas R Mahoney, Michael P Grant

6 Principles and techniques for facial a llotransplantation

Bernard Devauchelle, Sylvie Testelin, Stéphanie Dakpé

Index

1 Bone grafts, bone flaps, bone replacement materials and techniques

1.1 Types and harvest of bone grafts and bone flaps

1

Introduction

2

Nonvascularized bone grafts

Indications for nonvascularized bone grafts

2.1

Cancellous bone and marrow

2.1.1

Ilium

2.1.1.1

Ilium—anterior technique (medial harvest)

2.1.1.2

Ilium—posterior technique

2.1.2

Tibia

2.1.2.1

Harvest technique

2.2

Cortical bone

2.2.1

Mandible

2.2.1.1

Ramus

2.2.1.2

Symphysis

2.2.2

Maxilla

2.2.3

Cranial bone

2.2.4

Ilium

2.3

Corticocancellous bone grafts

2.3.1

Ilium

2.3.2

Rib

2.4

Bone dust

3

Microvascular bone flaps

3.1

Ilium

3.2

Fibula

3.3

Scapula

3.4

Radial forearm osteocutaneous free flap

4

Summary

5

References and suggested reading

1.1 Types and harvest of bone grafts and bone flaps

Michael Ehrenfeld, Christine Hagenmaier, Remy H Blanchaert Jr

1 Introduction

In craniomaxillofacial (CMF) surgery bone grafts and bone flaps are used to replace missing bone. Bone deficits or defects may result from congenital malformations and developmental disorders, or originate from tumor surgery, trauma, medication-related bone diseases, irradiation or infections. Bone grafts may also be indicated in esthetic surgery.

Today fresh autogenous bone is still the gold standard among all available bone replacement materials [Axhausen, 1962; Schweiberer, 1970; Tessier et al, 2005]. However, nonresorbable alloplastic materials (eg, porous polyethylene, silastic, ceramic materials) are preferred for contour augmentation procedures because they do not undergo the unpredictable initial remodeling and resorption seen with nonvascularized autogenous bone grafts. Bone graft harvest itself may be associated with complications and undesired adverse effects [Tessier et al, 2005].

Fresh autogenous bone in principle can be harvested as nonvascularized bone grafts, pedicled bone grafts, and microvascular bone flaps [Bardenheuer, 1892; Sykoff, 1900; Krause, 1907; Axhausen, 1908; Lexer, 1908; Rydygier, 1908; Lindemann, 1916; Matti, 1932; Converse, 1945; Conley, 1972; Boyne, 1973; Taylor et al, 1975; O'Brien, 1977; Taylor et al, 1979; Quillen, 1979; Ariyan, 1980; Swartz et al, 1986]. Pedicled bone grafts today are rarely used in CMF reconstructive surgery; thus they are not further discussed in this chapter. Nonvascularized autogenous bone can be harvested as cancellous bone and marrow, cortical bone, corticocancellous bone, and so-called bone dust, which is small particles of cortical bone.

In the preoperative planning phase, the surgeon must assess the patient carefully to determine the needed type of bone based on the characteristics of the defect, the quality and quantity of the surrounding soft tissues, and the specific clinical indication for surgery. Potential donor sites must then be considered and a surgical plan developed that balances the risk-benefit ratio of each of the suitable donor sites and graft/flap types. This chapter reviews the most commonly used bone graft and bone flap donor sites used in CMF reconstruction. The intent is to provide the surgeon with a review of the potential donor sites and an outline of the techniques used for bone graft/flap harvest and donor site management.

2 Nonvascularized bone grafts

Nonvascularized bone grafts are typically harvested from certain preferred donor sites. In the recipient site the bone must be revitalized mainly via tissue ingrowth. Therefore, the recipient site must be of good biological quality, especially well perfused, and allow for complete 360° coverage of the bone graft(s) to avoid exposure, contamination, and healing disturbances [Axhausen, 1962; Schweiberer, 1970; Axhausen, 1951; Axhausen, 1952; Chalmers, 1959; Williams, 1962; Heiple et al,1963; Ray, et al, 1963; Burwell, 1965]. Revitalization of a nonvascularized bone graft goes along with a process of resorption, remodeling, and maturation, which is typically associated with a loss of bone volume. The amount of resorption depends on many factors, such as the dimensions and the density of the grafted material (it takes longer to revitalize large and more dense bone grafts, and therefore they show a greater percentage of bone loss), the type of the bone (cortical, cancellous, corticocancellous, bone dust), tissue qualities at the recipient site (vascularization), biomechanical properties (functional loading), and fixation of the bone graft to surrounding bone [Lexer, 1908; Lentrodt et al, 1976; Eitel et al, 1980; Schweiberer et al, 1981; Lentrodt et al, 1987]. The amount of bone loss after nonvascularized bone transplantation is unpredictable.

Indications for nonvascularized bone grafts

Nonvascularized bone grafts are indicated for filling bone defects, for example, after extirpation of large cysts (see chapter 2.3). Another widespread indication is for ridge augmentation procedures in preprosthetic surgery and dental implantology (see chapter 4.4). Small mandibular or maxillary continuity defects can be treated with nonvascularized bone grafts; other indications include osteotomy gaps in orthognathic surgery, defect zones in fractures, and facial clefts (see chapters 4.6 and 4.7) [Steinhäuser, 1968]. Nonvascularized bone grafts have been used for augmentation procedures in esthetic surgery (malar augmentation, chin augmentation), but because of the potential loss of bone volume nonresorbable grafting materials like ceramic implants or porous polyethylene should be considered instead [Reuther, 1979; Bell, 1992].

2.1 Cancellous bone and marrow

Cancellous bone and marrow is commonly used in CMF reconstruction of small defect areas. It may be harvested from either the ilium or tibia using a trocar, when only small amounts of bone graft are needed, or via open techniques. Grafts obtained by trocar may be suitable for small defects, such as in a fracture nonunion or for sinus floor elevation procedures. Harvest of the bone graft is generally simple; however, proper selection of the most appropriate donor site and careful execution of the harvest are required to minimize donor site morbidity and potential complications. Recipient site preparation for cancellous grafting is perhaps more critical. Development of a well-vascularized, appropriately sized pocket of soft tissue is critical to containment of the graft and a prerequisite for revascularization. Avoidance of oral exposure and therefore bacterial contamination is also vital. Grafted sites, which require extensive softtissue dissection and creation of potential dead space, should be drained with a closed suction technique to avoid hematoma and seroma formation. Perioperative antibiotics are administered in the standard fashion. Compressed cancellous bone and marrow can be handled nicely and can be shaped and molded to achieve anatomically adequate filling of appropriate defects.

This chapter outlines the most commonly used donor sites for maxillofacial bone graft reconstruction, which are the ilium and tibia. General characteristics of each site are described. A description of open harvesting techniques for the anterior and posterior ilium and the tibia are provided in the subsequent sections of this chapter.

2.1.1 Ilium

The ilium is a common donor site for autogenous cancellous bone used in CMF reconstruction. Bone can be harvested from either the anterior or posterior ilium. The anterior site is most often used because of its ease of access in comparison with the posterior ilium that requires the patient to be placed in a prone position. However, when large amounts of cancellous bone (> 35 cc compressed) are required, the posterior ilium is a more suitable donor site and a viable alternative to bilateral anterior harvests. The character of the bone is different from these two locations, which is, however, more important for the harvest of corticocancellous grafts. Major CMF reconstruction procedures typically require open techniques for harvest of appropriate and adequate amounts of bone. The posterior ilium provides a thin monocortical element and cancellous material, which often contains visible fat in adult patients. The anterior ilium may be harvested as either cancellous bone and marrow, or as a monocortical or bicortical graft. It has a much thicker cortical component and a less fatty appearing cancellous bone and marrow component.

2.1.1.1 Ilium—anterior technique (medial harvest)

The patient is positioned supine. In some cases, a folded sheet under the ipsilateral hip may make medial visualization easier. The ilium should be outlined on the skin with a surgical marker from the anterior superior iliac spine (ASIS) to the iliac tubercle. The site should be widely prepared and draped. The length of the incision depends on the volume of the harvest required. In general, a 2–6 cm incision is made parallel to the iliac crest either over or slightly lateral to the crest (Fig 1.1-1).

Fig 1.1-1 Approach to the anterior ilium.

The incision should be no closer than 1 cm to the ASIS to minimize injury to the lateral cutaneous femoral nerve. Incision is made through the skin and subcutaneous tissue, then through Scarpa fascia. Dissection is continued to the aponeurosis overlying the iliac crest (Fig 1.1-2).

Being careful to incise the aponeurosis minimizes bleeding and facilitates reapproximation. Careful subperiosteal dissection allows excellent exposure. Avoid overzealous softtissue retraction, as this is the likely cause of injury to the lateral femoral cutaneous nerve. For the harvest of cancellous material only, the crest may be split with chisels and the cancellous material removed with gouges and/or curettes (Fig 1.1-3).

In pediatric patients the iliac crest is still covered with cartilage. The cartilage can be easily separated from the bone with a scalpel and reflected medially pedicled on the adjacent soft tissues to allow access to the bone. The collected cancellous bone can be placed in a 30 cc syringe and compressed to better delineate the volume harvested (Fig 1.1-4).

The syringe can then be placed in a lap sponge moistened with chilled saline solution and set aside. This simplifies the collection of the bone, reveals the actual volume obtained, and facilitates the delivery of the bone to the recipient site. However, it must be noted that cancellous bone and marrow should never be placed in saline solution or similar or washed out with saline solution to avoid loss of cells and proteins.

Placement of a resorbable hemostatic agent in the harvest site often controls hemorrhage such that there is no need for a closed suction drain. The wound is then closed in layers.

2.1.1.2 Ilium—posterior technique

The patient is positioned prone. Extreme care in positioning with placement of appropriate lateral chest support and careful rotation of the arms is important to avoid elevated ventilation pressures and nerve injury. The bed is flexed, and reverse Trendelenburg applied to keep the upper body parallel to the floor (Fig 1.1-5).

Fig 1.1-2 After incision of the skin and subcutaneous tissue, the fascia is exposed.

Fig 1.1-3 Harvesting of cancellous bone and marrow with a curette.

Fig 1.1-4 The cancellous bone graft material has been placed in a 30 cc syringe and compacted.

Fig 1.1-5 Proper positioning for harvest of bone from the posterior ilium is critical. Note the lateral padding.

The surgical anatomical landmarks are then outlined with a marker to include the iliac crest, sacrum, and the insertion of the gluteus maximus muscle (Fig 1.1-6). Next, the operative field is scrubbed and then prepared and draped excluding the anal region from the field.

A curvilinear incision inferior to and parallel to the posterior iliac crest is then created. The incision should be placed 1–2 cm lateral to the sacroiliac joint to avoid the cluneal nerve. The dissection is deepened through fascia to the insertion of the gluteus maximus muscle. The periosteum is then incised and elevated exposing a triangular protuberance at the site of the muscle insertion. It is recommended that the location of the sciatic notch be determined by manual palpation to assure that no retractor is placed in its vicinity. A retractor is then placed to facilitate harvest. The lateral iliac cortex is removed with a saw and/or chisel and the underlying cancellous material collected with gouges and/ or curettes (Fig 1.1-7).

Avoid violation of the medial cortex and the sacroiliac joint. If pure cancellous bone and marrow are needed, the cortical bone may be replaced and fixed with miniplates. Often times, the application of a resorbable hemostatic agent obviates the need for a closed suction drain. The wound is closed in layers using resorbable sutures.

2.1.2 Tibia

The proximal tibial metaphysis has reemerged in recent years as an alternative site for the harvest of cancellous bone. After description of the harvest procedure and its applications in CMF surgery, the tibia has become an accepted and frequent alternative to the anterior ilium for defects requiring only small amounts of bone. The major reported advantage is decreased morbidity. Reports of tibial bone harvest with local anesthesia and deep sedation demonstrate the simplicity of the procedure and the utility of the technique in CMF surgery. Cancellous harvests of 15–25 mL uncompressed bone have been reported. This volume is perfectly suited for dentoalveolar reconstructions in preparation for implant placement (sinus augmentation, etc) and management of fracture nonunion where only cancellous material is needed [Herford et al, 2003].

Fig 1.1-7 After removal of a portion of the lateral cortex, excellent access to the cancellous bone and marrow is provided.

2.1.2.1 Harvest technique

Approaches lateral or medial to the patellar tendon are possible. The anatomy of the proximal lower leg should be outlined with a surgical marker to include the insertion of the patellar tendon and the tibial plateau (Fig 1.1-8).

The incision length depends on the harvest technique. A small stab is required if a trocar is used. Otherwise the incision is carried down to the periosteum which is incised and reflected. A bone window is then created with a sagittal saw or piezotome and removed (Fig 1.1-9).

Fig 1.1-8a–b Planning for a lateral bone harvest from the tibial head. The incision line (red) is obliquely orientated to the joint plane and is placed just above and over Gerdy tubercle. P indicates patella; AS, articulation surface, plane of the femoral tibial joint; and F, fibular head.

Fig 1.1-9a–b After osteotomy of the tibial cortex, cancellous bone and marrow can be harvested.

The cancellous bone is harvested with a curette, placed in a small container, and set aside. Operative site hemostasis is facilitated by the placement of a topical hemostatic agent. The wound is then closed in layers. After application of a wound dressing, the leg is covered in a soft roll and a gently compressive elastic bandage is applied. Ambulation is allowed immediately with a rapid return to normal exercise activities in a few weeks.

2.2 Cortical bone

Cortical bone grafts are used in CMF reconstruction for structural support and onlay augmentation. Examples of use of these grafts for structural support include maxillary lengthening with loss of bone contact and for restoration of the pillars of the facial skeleton in high-energy CMF trauma. In orthognathic surgery, cortical bone grafts are often available from the distal portion of the proximal segments after sagittal ramus osteotomies. These bone grafts can be used to augment the maxilla and to bridge gaps after maxillary advancements or maxillary lengthening procedures in bimaxillary cases. Cortical outer table bone grafts from the cranial vault or hip are alternatives, among others. Cortical bone grafts may be used for onlay augmentation in dentoalveolar reconstruction, for instance, after atrophy or traumatic bone loss, to allow placement of osseointegrated implants.

Cortical bone grafts require rigid fixation for optimal results. Whenever possible, a lag screw technique should be used for stabilization of the grafts after appropriate contouring. Miniplate/microplate fixation is an alternative. Failure to fixate the graft can result in migration, movement, infection, and rapid resorption.

2.2.1 Mandible

The harvest of cortical bone from the mandible is used for the purpose of onlay bone grafting in preparation for dental implant placement. The procedure is commonly performed with the patient under local anesthesia or local anesthesia and sedation. Patient acceptance of an oral donor site is high in comparison to a distant donor site.

Cortical bone from the mandible is typically harvested from either the ramus or symphysis (Fig 1.1-10).

Fig 1.1-10 Potential mandibular bone harvest sites.

2.2.1.1 Ramus

The ramus of the mandible is exposed through a standard posterior vestibular access identical to that used for orthognathic surgery. The mucosa is incised along the external oblique line and the soft tissues are reflected by subperiosteal dissection. Thus, a wide exposure is obtained. A small drill bit, a specially designed right-angle rotating saw or a piezotome is used to outline the graft harvest along the lateral portion of the ramus. A small curved chisel allows elevation of the graft. The graft is then immediately placed at the recipient site and rigidly stabilized or placed in a saline moistened sponge and placed aside. The site is thoroughly irrigated and closed in a single layer. A gentle compressive dressing can be placed on the face to assist in closure of the dead space created by the dissection.

2.2.1.2 Symphysis

The symphysis of the mandible is exposed through a standard vestibular access incision. It is important to maintain a suitable cuff of the unattached tissue by placing the incision labial to the junction of the attached and unattached mucosa. The mentalis muscles must be elevated, and the dissection completed widely to obtain adequate exposure. It is often best to dissect circumferentially around the mental nerve and release the periosteum at the mental foramina to avoid traction injury to the mental nerves. The bone harvest is then outlined with either a small fissure bur, a piezotome, or a specially designed rotating saw. Care must be taken to stay a few millimeters below the apices of the teeth. A curved osteotome is required to elevate the bone graft. For wound closure suturing in two layers, ie, muscle and mucosa, is required. Proper support of the mentalis muscles is necessary to achieve an esthetic outcome. If the mentalis muscle is not resuspended, chin ptosis will likely occur. Additional support of the mentalis muscle and closure of the dead space can be provided with tape or compressive dressing support of the chin. It appears that postoperative pain and local wound complications are more common when the symphysis is used to obtain cortical bone from the mandible.

2.2.2 Maxilla

From the maxilla small amounts of mostly cortical bone can be taken from the nasal aperture (Fig 1.1-11) or from the tuber maxillae. The maxilla is approached via transoral incisions in the upper vestibular mucosa.

Other than swelling and pain for a few days, there is no significant donor site morbidity. The bone volume is sufficient for small defects, such as localized ridge augmentations in dental implantology.

Fig 1.1-11 Bone harvest from the nasal aper ture.

2.2.3 Cranial bone

In adult patients the harvest of split thickness calvarium is typically accomplished by removal of the outer cortex; however, the inner cortex may also be separated from a previously elevated full thickness calvarial bone flap as it is commonly performed in craniofacial surgery. The description here will focus on the former technique (Fig 1.1-12). The well-developed diploe allows for easy harvest of the outer table. Donor site morbidity is low with proper technique [Jackson et al, 1986]. Younger children typically do not have a layered skull with outer table, diploe, and inner table. Here, harvest of outer table bone grafts is not possible; however, full thickness cortical bone grafts may be taken and split in two layers. One layer is usually replanted to maintain skull continuity for brain protection.

Fig 1.1-12a–e Outer table calvarial cortical bone grafts are outlined with a rose bur before harvest with a saw and/or chisel (a–b). Chisel is put underneath the outer cortical plate to elevate the bone graft (c). The donor site shows the areas lateral to the harvested grafts where the calvarium was tapered to allow access to the diploic space (d). Harvested outer table cranial bone grafts (e).

Access to the parietal bone is accomplished through either a curvilinear incision directly over the parietal area or by a coronal incision. Dissection widely beneath the galea allows wide exposure with gentle retraction. The planned bone harvest is outlined with a rose burr taking care to completely osteotomize the outer cortex without perforation of the inner cortex.

A saw or chisel is then used in the diploic space to complete the osteotomy. Angled saw blades may further facilitate the bone graft harvest. The cortical bone can be brittle; therefore, it is best to gently elevate the entire bone graft taking care to free the graft evenly. Excessive force on any portion of the graft will result in fracture or create cracks that will fracture while the graft is being stabilized or recontoured. The harvested bone graft should be wrapped in a saline moistened sponge and placed aside or immediately placed into the recipient site and stabilized rigidly. The donor site is closed over a closed suction drain after copious irrigation.

2.2.4 Ilium

The ilium is a rarely used donor site for the harvest of cortical bone only. Clinical conditions (ie, closed head injury), or operator experience may necessitate the use of this site in some instances. Cortical bone harvest from the ilium requires the identical exposure described in section 2.1.1. The most important modification of the technique is the utilization of a saw or piezotome for creation of the osteotomies. The cortex can then be easily removed with a straight or slightly curved chisel. The inner cortex is preferred to avoid deformity. The technique is similar to the one shown in Figs 1.1-1–1.1-13, but only the cortical bone is harvested. The cancellous bone exposed following removal of the cortical bone will tend to bleed. This technique, therefore, requires extreme attention to hemostasis before donor site closure, a suction drain may be indicated [Hall et al, 1981].

2.3 Corticocancellous bone grafts

2.3.1 Ilium

The exposure for harvest of corticocancellous bone from the ilium is outlined completely in section 2.1.1. In the anterior approach, corticocancellous blocks of bone may be harvested from the inner or outer aspect (Fig 1.1-13).

Bone blocks may be harvested with one or both cortices. The harvest can be performed including parts of the iliac crest or underneath the crest (Fig 1.1-14).

Fig 1.1-13a–b After outlining the desired style and height of a cortico-cancellous graft from the inner aspect of the ilium, the block is elevated with a chisel.

Fig 1.1-14 By taking bicorticocancellous bone from underneath the iliac crest, the outer contour of the iliac crest is preserved.

To routinely assure harvest of a complete corticocancellous block, it is recommended that saws be used. The saw provides a tactile sense of when the opposite cortex is encountered. It is important that the vertical and inferior bone cuts be made with diverging walls to allow easy and gentle elevation of the graft from the donor site. If the inferior cut is made first, hemorrhage will not complicate visualization of the field while the vertical and then superior horizontal cuts are made. The entire corticocancellous block may be transferred directly to the recipient site and stabilized with plate(s) and screws (Fig 1.1-15).

For segmental mandible reconstruction, a reconstruction plate placed along the lateral surface of the mandible provides stability. Additional cancellous bone and marrow may be placed at the intersection of the graft and native bone as well as into osteotomy gaps to improve contact and assure osseous union.

2.3.2 Rib

The ribs provide a significant donor site for the elective reconstruction of the orbit, calvarium, mandibular condyle, and ramus. For condylar head reconstruction, a costochondral graft, which is a variation of a rib graft, is indicated. In this setting a composite graft with a 5 mm cartilage cap is harvested. The perichondrium must be maintained on the junction of the bone graft and cartilage to provide stability to the cartilage cap/rib construct.

Some avoid the rib donor site in the setting of trauma because of concerns regarding postoperative splinting and less effective ventilation or atelectasis. Harvest of the 4th–6th rib is common. The shape of the ribs in this region is most suitable. Whenever possible, the opposite side rib should be used for mandible reconstruction to take full advantage of the natural curvature of the rib.

Fig 1.1-15 Stabilization of the bone graft in the chin area with a reconstruction plate. Cancellous bone and marrow may later be used to fill the osteotomy gap.

Harvest of the rib is completed with the patient in supine position. A small folded towel underneath the donor site is of assistance in gaining adequate exposure. Elective incision in the inframammary crease provides excellent exposure and an acceptable scar (Fig 1.1-16a).

Dissection requires incision and reflection of the fascia of the intercostal muscles. The rib is exposed in a subperiosteal plane laterally which facilitates rapid dissection (Fig 1.1-16b). For harvest of composite grafts, the medial harvest must be accomplished superficial to the periosteum/perichondrium at the costocartilage junction. This transition requires a precise and delicate approach. The cartilage is then incised with a blade and the deep dissection along the costocartilage junction completed. The rib is then gently retracted laterally and a piezotome or a saw is used to cut the rib at the lateral extent of the required harvest. Rib cutters tend to fracture the rib at the site of the osteotomy and should therefore not be used.

Fig 1.1-16a–b

aOutline of a planned incision in the inframammary crease for harvest of a composite costochondral graft.

bExposure of the rib at the bone/cartilage junction.

Rigid stabilization of the graft with lag screws should typically be completed after appropriate contouring. It is important to use a bone plate segment as a washer at each screw placement site to prevent splitting of the rib graft. Likewise, the screw sites selected should be staggered to prevent splitting the rib (Fig 1.1-17).

2.4 Bone dust

Small quantities of small particle nonvascularized bone, also called bone dust, can be harvested through bone scraping and bone dust collection from the surface areas of cortical bone. Bone dust can be used for defect filling of minor bone defects, periimplant augmentation, or filling of osteotomy gaps and burr holes.

Fig 1.1-17a–c

aCostochondral graft. Note the intact perichondrium/periosteum at the junction.

bThe costochondral graft has been inserted. Segments of a bone plate have been used as washers to help distribute the forces of the lag screw over the weak bone.

cPlacement and fixation of the graft and hardware can be seen in this postoperative image.

Bone scraping has been introduced with the advent of piezoelectric surgery. Special bone scrapers are available for piezotomes. They look like small chisels and are used to scrape off bone particles from cortical bone areas, such as the chin region, the mandibular body and angle, the zygomatic alveolar crest, or the cranial vault. The scraped off small cortical bone particles are collected in a bone collector, which is integrated into the suction device (Fig 1.1-18) [Benninger et al, 2012; Alt et al, 2003; Zaffe et al, 2007; Kainulainen et al, 2006; Graziani et al, 2007; Jackson et al, 1988].

Bone dust collection with a bone collector may also be used in conjunction with almost any bone cutting technology, such as a rose or Lindemann burr.

Fig 1.1-18a–c

aBone dust collected with a piezotome and bone scraper from the oblique ridge of the mandible.

bBone collector (metal piece) connected to suction device.

cBone collector opened, bone dust removed.

3 Microvascular bone flaps

3.1 Ilium

The microvascular iliac bone flap is based on the deep circumflex iliac artery (DCIA) and accompanying veins. The DCIA leaves the external iliac artery on its medial aspect normally 1–3 cm cranially to the inguinal ligament. Venous drainage is usually by two accompanying veins, which mostly form a common trunk 1–2 cm before the external iliac vein is reached. The two veins have complex connective branches and sometimes rather resemble a vascular network than two distinct vessels. The DCIA and accompanying veins run superior to the inguinal ligament and reach the inner aspect of the ilium underneath the fascia of the iliac muscle 1–3 cm from the inner cortex of the anterior ileum. An ascending branch of the DCIA supplies the internal oblique muscle allowing simultaneous transfer on one vascular pedicle (Fig 1.1-19). This tissue is most commonly used for replacement of missing mucosa or skin because of the thickness and immobility of the skin portion of the flap that is available. A skin island can also be harvested together with a microvascular iliac bone flap. The vascular supply to the skin is via musculocutaneous perforator vessels (Fig 1.1-20).

One significant advantage of the iliac free flap is that the surgeon can harvest bone of whatever height is necessary. This results in the ability to tailor the height of the reconstruction, which facilitates dental implant-based maxillofacial rehabilitation [Urken et al, 1991].

The patient is positioned supine, the donor area should be lifted by underlying sheets or a cushion (Fig 1.1-21). The operative field is prepared widely and draped. The area exposed should extend medially to the linea semilunaris, superiorly to the level of the lower ribs, laterally as far as possible (at least past the iliac tubercle), and inferior about 4 cm below the groin. If a skin paddle is desired, it must be created from directly over the iliac crest. Landmarks for dissection are the reliably palpable femoral vessels, the ASIS, and the iliac crest (Fig 1.1-22). Identification and preservation of the musculocutaneous perforators that supply the skin may be difficult intraoperatively. The perforators can be identified by Doppler ultrasound and marked on the skin before surgery. Many surgeons prefer to use the internal oblique muscle instead of a skin island for intraoral softtissue reconstruction.

Fig 1.1-19a–b

aThe vascular supply of the flap depends on the deep circumflex iliac artery (DCIA) and vein(s) (DCIV). The vessels originate from the external iliac vessels and run laterally and upward underneath and parallel to the inguinal ligament. They reach the ilium underneath the anterior superior iliac spine and continue in a groove between the transverse abdominis and iliacus muscle. An ascending branch runs upward underneath the internal oblique muscle.

bAn ascending branch from the DCIA is running superiorly underneath the obliquus abdominis muscle. Three main anatomical variations of the ascending branch have been described, which need to be respected during flap harvest. In 65% of cases, the ascending branch originates from the DCIA within 1 cm medial to the ASIS. In 20 % of cases there is no single dominant ascending branch. The internal oblique is supplied by a series of small branches of the DCIA . In 15% of cases, the ascending branch originates in a more medial and proximal location.

The flap can be harvested in two different sequences. After identification of the deep circumflex iliac vessels, the dissection can be performed by identification and dissection of the vascular pedicle, followed by separation of the softtissue flap components before finally the osteotomy is made to mobilize the bony portion (center to periphery). It is also possible to harvest the soft-tissue flap components (skin, internal oblique muscle) first, then follow the vascular pedicle down to its origin at the external iliac vessels, and then perform the osteotomy (periphery to center).

Fig 1.1-20 The skin island of an osteomusculo-cutaneous flap is nourished via perforating vessels, which are located medial to the iliac crest. They should be located centrally within the skin portion.

Fig 1.1-21 Patient position for iliac bone flap harvest.

Fig 1.1-22 Landmarks for dissection are the femoral artery, which can be reliably palpated, the anterior superior iliac spine (ASIS) and the iliac crest.

For a center to periphery approach, the vascular pedicle is identified through a skin incision, which follows the course of the inguinal ligament on a line between pubic tubercle and ASIS (Fig 1.1-23).

The femoral artery can be palpated and is exposed. Below the inguinal ligament the superficial circumflex artery usually leaves the femoral artery on its lateral aspect and is useful for intraoperative orientation. 2–3 cm above the superficial artery the DCIA will leave the external iliac artery in a lateral and upward direction. Medially, the inferior epigastric artery exits the external iliac artery and is another landmark for dissection. The deep circumflex iliac venous drainage system usually consists of two concomitant veins, which are also exposed. After identification of the vascular pedicle the aponeurosis of the abdominal wall musculature will be divided layer by layer within or above the inguinal ligament. The vascular pedicle is freed until immediately below the ASIS (Fig 1.1-24). In this area the lateral cutaneous femoral nerve needs to be identified to preserve it during further dissection.

To harvest an osteomusculo-cutaneous flap, the desired and previously marked skin portion is now incised down to the fascia of the external oblique muscle. The muscles are transsected 3–4 cm away from their bone attachment to preserve a muscle cuff containing the perforators (Fig 1.1-25).

Fig 1.1-23 Skin incision for harvest of an osteomuscular flap with or without additional internal oblique muscle.

Fig 1.1-24 The deep circumflex iliac vessels are dissected after identification of the external iliac vessels and division of the fascias of the abdominal wall.

Fig 1.1-25 transection of the abdominal wall muscles 3–4 cm away from their attachment to the iliac bone to preserve the perforators to the skin.