Free Calvarial Bone Grafts Research Articles

Comment to Masaki Fujioka et al. to their accepted letter to the editor: Vascularized bone graft is a better option for the reconstruction of maxillary defects

Thank you for your interest in our study and also reconstructive criticism. I read it with great interest. Our previous article [1] described the use of pedicled temporal musculoperiosteal flap with or without free calvarial bone graft in maxillary reconstructions. There has been an increasing tendency to reconstruct maxillary defects using free vascularized bone-containing flap. Usually, from a prosthetic and esthetic point of view, the use of free bone-containing flap is superior. However, we have more and more elderly patients, and often patients with many diseases. Those patients may poorly tolerate a long-lasting microvascular surgery with a long postoperative treatment. Usually, when using pedicled flap, the operation time is shorter and postoperative recovery faster than with the use of free flaps. Thus, it is good that we have several options for repairing maxillary defects. Therefore, temporal musculoperiosteal flap is good to keep in mind, especially when repairing defects with elderly patients. The authors also reminded us of an option to use a parietal bone-fascial-periosteal flap based on superficial temporal vessels. This is also an interesting option and good to keep in mind among the other options.

The use of pedicled temporal musculoperiosteal flap with or without free calvarial bone graft in maxillary reconstructions

Various techniques have been used to repair maxillary defects. The aim of this study was to evaluate the suitability of pedicled temporal musculoperiosteal flap (PTMF) and free calvarial bone graft for the reconstruction of maxillary defects. In this retrospective series, 34 patients operated on from 1995 to 2006 at Turku University Central Hospital because of defects of maxilla reconstructed using PTMF with or without free calvarial bone graft were evaluated. The diagnosis, the indication for surgery, the location and staging of the tumours, and the type of radiotherapy used were reviewed. The classification of the maxillary defects was performed according to the classification of Brown (Br J Oral Maxillofac Surg 40:183-190, 2002) and the success rates of the reconstructions were evaluated. Of the patients, 32 had been operated on due to a malignant tumour, one due to a benign tumour and one due to posttraumatic palatal defect. Preoperative radiotherapy (n = 14), preoperative chemoradiotherapy (n = 2) or postoperative radiotherapy (n = 11) had been used in the tumour group. As a reconstructive method, PTMF had been used with (n = 21) or without (n = 13) free calvarial bone graft. The use of free calvarial bone graft did not have a significant effect on flap survival. At 1-month follow-up, the flap survival in the 32 patients was 71.9%, whereas 28.1% of the patients suffered from partial flap loss, but there was no total flap loss. At 6-month follow-up, the flap survival in 26 patients was 76.9%, whereas 7.7% of the patients suffered from partial flap loss, and there were four (15.4%) total flap losses. If unilateral alveolar maxillectomy had been performed (Brown classification a), at 1-month follow-up, the flap survival was 82.6%, 17.4% of the patients suffered from partial flap loss, and there was no total flap loss. At 6-month follow-up, the flap survival was 89.5%, while 10.5% of the patients suffered from partial flap loss, and there was no total flap loss. The application of PTMF with or without free calvarial bone graft for reconstruction of limited palatal and maxillary defects appears to be feasible.

Calvarial Bone Grafts and Temporalis Muscle Flap for Midfacial Reconstruction After Maxillary Tumor Resection

Midfacial reconstruction after radical oncological resection is a challenging endeavor and several options can be employed: prosthethic devices, pedicled flaps (with or without the aid of autologous or alloplastic grafts), and microvascular flaps. Each technique has specific indications, advantages and disadvantages. The use of traditional surgical reconstructive procedures seems to be shifted nowadays by microvascular free flaps. Nevertheless, in our experience the myofascial temporalis flap associated with free calvarial bone grafts demonstrate to be a safe and versatile option in primary midfacial reconstruction. From this point of view the authors have developed a technique for one-stage reconstruction of the orbito-maxillary skeleton and soft tissues and without the use of microsurgical flaps; this surgical procedure can be used only on patients for whom a resection of the cutaneous tissues and exenteratio orbitae are not necessary. The aims of this paper is to describe the surgical technique and to show a retrospective analysis on 17 patients which underwent midfacial radical resection and immediate reconstruction with calvarial bone grafts and temporalis muscle flap along 15 years.

Ortho- and heterotopic bone grafts in bifocal transport osteogenesis for craniofacial reconstruction—an experimental study in sheep

Bifocal transport osteogenesis (BTO) is a promising technique for the reconstruction of extended osseous craniofacial defects. Aim of this study was to determine the potential of this technique related to various donor sites of the transport segment. In 10 adult sheep critical size defects of the calvaria were treated by gradual movement of a transport segment consisting either of autogenous regional free calvarial bone grafts ( n=5) or autogenous illiac free bone grafts ( n=5). Latency period was 5 days; the rate of distraction was 1 mm per day and extended approximately 40 days. The consolidation period was 28 days. After harvesting, specimens were investigated by conventional radiography, CT-scans, histologically and by fluorescence. In both groups transport osteogenesis resulted in a complete closure of the critical size defect. Membranous bone formation and remodeling occurred during the entire period of distraction and consolidation. The volumes and thickness of newly formed bone at the defect site were increased significantly when calvarial bone grafts were used ( P<0.05). Iliac bone grafts became progrediently smaller during distraction, while the volume of calvarial grafts remained relatively constant ( P<0.05). In conclusion, transport segments consisting of calvarial and iliac bone resulted in a reliable closure of craniofacial critical size defects in adult organisms; the application of calvarial bone grafts resulted in an increased extend of bone formation.

Temporoparietal Fascial Flap in Orbital Reconstruction

To evaluate the success of the temporoparietal fascial flap (TPFF) in the primary or secondary reconstruction of difficult orbital defects and to review the surgical techniques. Retrospective analysis. Tertiary medical center. Nine patients with diverse orbital cavity or periorbital soft tissue and bony defects due to trauma, benign or malignant neoplasms, and radiation treatment. Temporoparietal fascial flap anatomy and techniques of harvest and inset are reviewed in detail. Four cases are presented to illustrate possible variables in orbital reconstruction. Variables examined include the location of defects, the success of flap survival in orbital cavities after primary or secondary reconstruction, the effects of prior irradiation on flap survival, and the possibility of concurrent osteointegrated implant placement with TPFF reconstruction. Functional and aesthetic outcomes were determined by physical examination and preoperative and postoperative photographs. All patients had successful transfer of TPFF grafts without flap compromise. Temporoparietal fascial flap was a viable option for subtle orbital and malar contour defects. In chronically inflamed wounds such as with osteoradionecrosis and orbitoantral fistula, TPFF successfully restored vascularity, obliterated the defects, and enabled the placement of osteointegrated implants. The TPFF also supported the concurrent placement of a free calvarial bone graft. Finally, split-thickness skin grafted onto a pedicled TPFF showed 100% survival. The TPFF is one of the most reliable and versatile regional flaps in the head and neck for orbital reconstruction. This study presents the use of TPFF in a variety of orbital defects, from lateral bony rim defects to total exenteration. Timing of repair in this study spans from immediate reconstruction to reconstruction delayed more than 50 years after the initial injury. In all cases, reconstruction with TPFF resulted in improved bony and soft tissue contours, and incurred minimal morbidity.

The viability of revascularized calvarial bone graft in a pig model.

This study compared the vascularity and resorption of calvarial bone flaps based on an undisturbed pedicle and on a previously (4 weeks) detached pedicle of the superficial fascia (galea) and periosteum and free calvarial bone grafts. Nine adult pigs were used, in three of which a silicone rubber compound was injected intravascularly immediately after the transfer confirmed the vascularity of both pedicled bone flaps. In six pigs, volume changes were assessed intraoperatively by a water displacement method and also 12 weeks postoperatively. Both pedicled bone flaps preserved their original volume, whereas free skull grafts showed approximately 50% of volume loss (p less than 0.001). Decalcified hematoxylin and eosin sections of the specimens obtained 12 weeks postoperatively showed a normal calvarial appearance in both pedicled bone flaps and extensive fibrous tissue infiltration into free grafts. It is suggested that a previous detachment of galea and periosteum does not interfere with the use of vascularized calvarial bone graft, which may provide a more predictable result than a free bone graft.

A free full-thickness calvarial bone graft to reconstruct a post-mandibular fracture deformity

A case of free calvarial bone grafting to reconstruct a post-mandibular fracture deformity with a 19 years' follow-up is reported. The grafted membranous calvarial bone has remained solid and stable with little resorption. The patient can wear a denture. This is the first successful and longest follow-up case report of a free calvarial bone graft in mandibular reconstruction.

The temporalis osteomuscular flap versus the free calvarial bone graft: An experimental study in the growing rabbit

The authors have conducted an experimental study on the evolution of temporalis osteomuscular flaps compared with calvarial free bone grafts in young rabbits. The evaluation of the results has been performed with macroscopic, radiological and histological investigations in an early and late postoperative phase. This study has confirmed that the bone flaps remain viable and are characterized by a normal evolution. There is no evidence of anomaly of craniofacial growth nor asymmetry when compared with the contralateral side. On the other hand, the free bone grafts show the typical signs of necrosis and resorption. Some asymmetries are produced in comparison with the contralateral side, these being particularly evident in the two-months samples, while the overall craniofacial growth is not seriously impaired. This experimental study confirms the reliability of the temporalis osteomuscular flap in facial reconstruction.