Robert E.

Marx, DDS
Professor and Chief
Division of Oral and Maxillofacial Surgery
Miller School of Medicine
University of Miami
Miami, Florida

Mark R. Stevens, DMD

Professor and Chair
Division of Oral and Maxillofacial Surgery
School of Dentistry
Medical College of Georgia
Augusta, Georgia

Q..uintessence Publishing Co, Inc

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Library of Congress Catal~in-Publlcation Data

Marx, Robert E.
Atlas of oral and cxtraoral bone harvesting I Robert E. Marx, Mark R. Stevens.
P· ;cm.
Includes bibliographical references and index.
ISBN 978-0-86715-482·5 (hardcover)
1. Bone-grafting--Atlases. 2. Mouth-Surgery--Atlases. 3. Jaws-Surgery--Atlascs. 4. Dental implants-Atlases. I. Stevens, Mark
R. II. Title.
[DNLM: 1. Bone and Bones-surgery-Atlases. 2. T 1Ssue and Organ Harvesting-methods- Atlases. 3. Bone Transplantation-
-Atlases. 4. Oral Surgical Procedures- Atlases. 5. Transplantation, Autologous--Atlascs. WE 17 M392a 2010]
RD123.M37 2010
617.4'7105920223-dc22
2009047169

0 2010 Qyintessence Publishing Co, Inc

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Contents
Dedication vi
Preface vii

1 History and General Principles 1

2 Tibia 7

3 Posterior Ilium 19

4 Anterior Ilium 39

5 Rib 61

6 Cranial Bone 79

7 Chin 101

8 Mandibular Ramus 111

9 Maxillary Tuberosity 123

10 Recombinant Human Bone Morphogenetic

Protein-2/Acellular Collagen Sponge 133

11 Bone Marrow Aspiration and Aspirate

Concentrate 141

Index 151
Dedication

1bis book is dedicated to all past, present, and future oral and maxillofacial
surgeons in the United States military services. The first chapter briefly chron-
icles the fundamental wartime contributions of several US military "dental sur-
geons" (as they were then known) and other surgical specialists in devdoping
the guiding principles of bone healing and harvesting: In the Civil War,
Thomas Gunning devdoped the Gunning splint; in World War I, Robert H.
Ivy and Joseph D. Eby innovated the use of block tibia grafts; in World War
II, T.G. Blocker Jr and Roy A. Stout introduced iliac crest grafts; and in the
Vietnam War, there was a burst of contributions from US Navy oral and max-
illofacial surgeons such asJames F. K.elley, Robert (Gil) Triplett, Philip J. Boyne,
Bill C . Terry, Ronald F. Baker, and Peter Connole, among others. Our pro-
fession has been expertly led by such individuals with great vision and inno-
vation.
& former US Air Force oral and maxillofacial surgeons who served in Op-
eration Desert Storm, we understand what it means to be "war ready" and the
emphasis it places on reconstruction and rehabilitation of the unique injuries
that occur during a military conflict. Today, as in the past, military oral and
maxillofacial surgeons assume and discharge that responsibility with great
pride and self-sacrifice. And because "only the dead have seen the last of war"
(a quote from the philosopher Plato as paraphrased by General Douglas
McArthur in 1964), it is inevitable that future military oral and maxillofacial
surgeons will do the same. I am confident they will lead the way as their pred-
ecessors have. With this book, we salute them all.

Robert E. Marx, Lt Col USAF, DC, Retired

Mark R. Stevens, former Maj USAF, DC

vi
Preface

As a dental student at Northwestern University in the late 1960s aspiring to

become an oral surgeon (as they were known at the time), I was allowed to
assist in the examination, treatment planning, and follow up of cancer and
tumor patients at Cook County Hospital in Chicago. I learned a great deal
observing the lengthy but precise surgeries that were performed by ablative
surgeons in the anatomically complex areas of the jaws and neck. However,
reconstruction of these patients was rare; most were left deformed and func-
tionally compromised, suffering from jaw deviations, malocclusions, and
drooped lips and shoulders and plagued by drooling and other maladies. The
main rationale for leaving these people unreconstructed was to spare them the
pain and permanent limp that would inevitably result from harvesting bone
from the anterior hip. "The patient is better off without a jaw than crippled"
was the explanation I was given again and again. As a consequence of these
experiences, I have dedicated my career to developing techniques that reduce
morbidity related to jaw reconstruction at both the recipient and donor sites
so that the outcome outweighs the drawbacks.
I first met my coauthor, Mark Stevens, when he was a resident under my di-
rection in the Air Force training program at Wilford Hall United States Air
Force Medical Center; later I recruited him to join my faculty at the Univer-
sity of Miami Miller School of Medicine, where we committed ourselves to re-
fining the anatomic knowledge and surgical techniques related to harvesting
bone from the posterior ilium, anterior ilium, cranium, and tibia. From chap-
ter 1 through chapter 9, this book presents everything we have learned and the
techniques we developed in a logical, step-by-step fashion, including indica-
tions, utility, contraindications, cautions, anatomy, surgical technique, drains
and dressings (where indicated), postoperative care, and complications. The
anatomy and surgical techniques are beautifully illustrated by one of the great
medical artists of our time, Dr Gerald Harper, a fellow oral and maxillofacial
surgeon. Our own supporting case photographs complement his fine work.
We also had an eye on the ultimate goal of jaw reconstruction without open
bone harvesting altogether. Consequently, as readers progress to chapters 10
and 11, they are introduced to the tantalizing potential for no harvest site
morbidity. The use of recombinant human bone morphogenetic protein-2
(rhBMP-2) combined with autologous stem cells derived from bone marrow as-
pirate concentrations (BMAC) has already proven successful in reconstrncting
several patients 'With large contirmity defects •Nith no open bone :harvest. These

vii
advances in biotechnology may play a significant role in the future of recon-
structive jaw surgery.
It is our hope that the techniques presented in this atlas help other sur-
geons provide reconstructive jaw surgery to more individuals in need of it and
at the same time reduce their pain, swelling, disability, and time away from
work and family.

Robert E. Marx, DDS

 Chapter One

History and General Principles

1
 1 IHistory and General Principles

Fig 1-1 Ivy and Eby's concept of a block

tibial graft to reconstruct the mandible.

-~ .

While there is some evidence of early modern man's attempts to remove por-
tions of the skull and other bones and perhaps replace them, and that ancient
Egyptian, Greek, and Roman civilizations performed a small amount of bone
grafting, it was not until World War I that maxillofacial bone grafting and
bone harvesting devdoped to the levd of science. 1 The two preceding wars-
the Civil War and the Spanish American War-resulted in relatively few facial
deformities, but these regrettably remained unreconstructed. 2 Additionally,
those who developed jaw tumors at that time were treated rarely, if at all.3
The development of radical surgery to treat oral cancers began around
1906.4 That effort, together with the influx of war-related maxillofacial defects
that began in 1914,1.5•6 served as the impetus for innovative surgeons of the era
to begin a bone-grafting initiative that has continued to this day. Lieutenant
Colonel Robert H. Ivy of the US Army Medical Corps and MajorJoseph D.
Eby of the US Army Dental Corps began with a block graft harvest from the
lateral tibia (Fig 1-1) and reported a "success rate" of 64.50/o. 1•5•6•7 Although
"success" was not defined and no information about donor site morbidity or
complications was provided, the harvesting and placement alone were re-
markable achievements in this pre-antibiotic era. 7 Even more remarkable is
the fact that these surgeries were mostly performed under procaine local anes-
thesia8 supplemented with nitrous oxide or chloroform. 9
During the interwar period of 1918 to 1941, anesthesia became more reli-
able.10 The study of bone science and the practice of bone harvesting, mostly
from the ilium (iliac crest) and ribs, were introduced by Converse, 11 Mowlem, 12
Thoma,13 and others and were utilized in World War II-related jaw recon-
structions. A survey by Blocker and Stout14 during World War II found that
one-piece iliac block grafts were used 81 O/o of the time, ribs 150/o, one-piece
tibia grafts 20/o,7 and so-called chip grafts only 1%. 1 When Mowlem12 intro-
duced the use of "iliac cancellous bone chips" in 1944 and reported 36 con-
secutive successful results, it began a trend toward what we know today as
cancellous marrow grafting. As time progressed, civilian-related defects in-
creased in numbers to match those of war injuries so that after World War II,

2
 Care of Harvested Bone

tumor and civilian trauma were the main indications for mandibular recon-
struction, and cancellous marrow grafts were the most common. 9
Ths type of grafting was popularized by Boyne,15 who published numerous
articles on the subject in the 1970s and 1980s, and its principles and science
were refined by Marx and colleagues16 in the 1990s and early 2000.
Nevertheless, numerous indications remain for block grafts from the ilium,
particularly in orthognathic surgery and in horizontal or vertical ridge aug-
mentations.16 In addition, free microvascular transfers of the fibula are often
used today by nondental surgeons to reconstruct continuity defects of the
mandible.17 Although these grafts are popular in some facilities, their harvest
morbidity, size, and shape deficiencies raise questions concerning their true
functional benefit in most cases. And as of today, recombinant human bone
mo:rphogenetic protein (rbBMP) has shown significant bone regeneration ca-
pabilities in nearly all oral and maxillofacial bony defects. Its use holds great
promise for the immediate future as either a supplement or an alternative to
autogenous grafting so that bone harvesting may be avoided altogether in
many cases.

Care of Harvested Bone

Wbatto do
When a bone graft of any type is harvested, there is almost always a period that
elapses before it is placed into the recipient site. Although it is prudent to restrict
this "out of body" time to a minimum, it can sometimes extend up to 2 hours.
Because the principle of autogenous bone harvesting is to transplant viable os-
teocompetent cells along with a matrix (the. mineralized portion) that contains a
signal for bone regeneration (BMP, insulin-like growth factors 1 and 2 [ILG1
and ILGi], it is necessary to maintain the viability of the graft. Studies have shown
that room-temperature saline preserves :more than 950/o of graft cell viability for
at least 4 hours.18 Tiris can be done by keeping the graft in a saline-soaked sponge
or in a container with a small amount of saline. Enriched media commonly used
in laboratory settings is attractive in theory but has not been shown to provide
greater viability and may risk contamination in their preparation. 18 Today many
surgeons use platelet-rich plasma (PRP) at the recipient site and store the graft in
PRP during the interval between harvest and placement.19.2° The growth factors
in PRP bind to cell membranes and act to upregulate osteocompetent cell prolif-
erations during this time, and their cell adhesion molecules enhance the matrix
of the graft by connecting the mineral components.

JVhat not to do
Because autogenous osteocompetent cells and bone marrow stem cells are rel-
atively hardy, they will survive to regenerate bone in most cases unless they
are lysed or destroyed during the time between harvest and placement. The
most common cause of loss of cell viability is contact with sterile distilled water.

3
 l IHistory and General Principles

Some surgeons believe that water is the purest solution into which a graft can
be placed, only to find out later that the graft remained in particulate form
without regenerating new bone. Scrub technicians and circulating nurses often
keep sterile water on the instrument table for cleaning instruments so as to
prevent rust. Due to an osmotic gradient, the hypotonicity of water causes
cells to swell and burst. Therefore, ths: surgeon must make every effort to keep
water or any hypotonic solution from coming into contact with a cellular graft.
The use of warmed saline is another cause of graft cell death. Although
wanned irrigating solution can promote vasodilation and perfusion in soft tis-
sue flap surgery, it can be harmful to exposed bone graft cells. Warmed solu-
tions increase the metabolic rate of graft cells that are separated from their
nutrient blood vessels; if their temperature rises much above lOO°F (3 8°C), it
can also cause direct damage to cell membranes.
Drying out of the graft also should be avoided. Some surgeons allow the
graft to remain on a surgical sponge or in some container, expecting the asso-
ciated blood clot to prevent drying of the graft cells. This concept is valid for
only a short time in the dehumidified atmosphere of the operating room or
clinic. If the interval between graft harvest and graft placement exceeds 30
minutes, some graft cells are likely to die.

Principles of Autogenous Bone.Grafting

There clIC four basic principles of autogenous bone grafting.

1. Choose the least morbid harvest site, and harvest the graft with the
least morbidity.
·This atlas guides the reader in the choice of harvest site& as well as the princi- l'
I
ples and techniques of harvesting with reduced morbidity. )

The 1·emaining three pnnaples pertain to the recipient tissue bed. .i

2. Graft into a vascular tissue bed.

A vascular tissue bed ~ required because an autogenous graft represents a cel-
lular transplant. The graft cells must survive transplantation by maintaining
their viability not only between graft harvest and placement but al!>o after they
have been placed at the reap1ent site. Graft cells must imbibe nutrients from
the recipient tissue bed by diffusion for the first 3 to 5 days. This process, often
referred to as p!asmatr.c circulation, is enhanced if the recipient tissue bed has a
good capillary density. Capillary ingrowth into the graft begms dunng day 3
and is usually complete by day 21. These vessels ingrow from the surround-
ing soft tissue in the recipient.bed and are dependent on the number of ves-
sels present at the time the graft is placed.
 References

3. Graft into an infection-free and contamination-free tissue bed.

Because a bone graft IB not completely revascularized for 14 to 21 days, im-
munoglobulins and wlute blood cells have little access to the graft site, mak-
ing the graft prone to infection during this period. Therefore, sterile technique
and a tissue bed that is free of contamination are critical to its survival Grafts
that are placed into a site that contains microorganisms 01 that become ex-
posed to the oral environment dUllilg the first 2 weeks have a !ugh rate of in-
fection, resulting in partial or complete loss. Grafts that become exposed to
the oral environment after revasculanzatiori generally develop granulation as-
sue and epithelialize without devdopment of an infection or loss.

4. Ensure the stability of the graft for at least 21 days.

Stability of a graft is often an overlooked principle of autogenous bone graft-
ing, yet it is just as important as the others. The growth factor-promoted cel-
lular repheation and vascular mgroV\'th duifu.g the first 14 to 21 days of a graft
IS vuh1erable to shear forces. In particular, the cap:illari.es sprouting into the
graft from the recipient tissue during this time. are only 6 tq 8 µm iri diameter
and do not as yet possess the adventitial cells necessary to resist compressive
or more in:lportantly shear forces. Di~mption of the capillary mgrowth results
in death of graft cells, leaving a &teii.Ie but nonregenerative graft. Such stabil-
ity can be obtained m many ways, depending on the loc:a.t:Ion and size of the
graft: claSSic maxtllom.anc:libular fixanon, titanium plates, titanium. mesh, re-
inforced and everi nonreinfon.ed membranes~ occlusal splints. relieving the oc-
clusion, and temporarily discontinuing dentures, among others.

References
1. Kelly JF (eel). Management of War Injuries to the Jaws and Related
Structures. US Government Printing Office Stock No. 008-045-00018-
6, WaBhington, DC 20402, 1977:1-15.
2. Gunning TB. Simple intcrdental splint. Richmond Med] 1866;1:318.
3. Kingsley NW (ed}. Treatise on Oral Deformities. New York: D Ap·
pleton, 1880:377-392.
4. Crile G. Excision of cancer of the head and neck.JAMA 1906;47:1750-
1788.
5. McGee RP. The maxillofacial surgeon in a mobile hospital. JAMA
1919;73:1114-1118.
6. Hayes GB (ed}. Maxillofacial surgery: Histories of 146 selected cases
of facial wounds treated at the American Ambulance, Paris, France
(1914-1917}, 1920 [unpublished]. Reported in Kclly.1(1-4)
Z Ivy RH, EbyJD. Maxillofacial Surgery. (Surgery) Part 2, Vol Il The
Medical Department of the US Army in World War. Washington DC,
US Government Printing Office, 1924:400-470.
8. J arm.an R, Abel AL. Intravenous anesthesia with pentothal sodium.
Lancet 1936;1:422.
9. Marx RE. Mandibular reconstruction, 1943-1993.J Oral Maxillofac
Surg 1993;51:466-479.

5
 11 His~ory and General Principles

10. Robatham S. Intratracheal anesthesia via the nasal route for operatioru
of the mouth and lips. Br MedJ 1920;2:590-591.
11. Converse JM. War injuries to the face. Trans Am Aca.d Ophthalmol
1941 ;46:250...:.255_
12. M owlem R. Cancellous chip bone grafts. Lancet 1944;2:746-748.
13. Thoma KH. A new method of intermaxillary fixation for jaw fractures
in patients wearing artificial dentures. AmJ Oral Surg 1943 ;29:433-
441.
14. Blocker TG, Stout RA. Mandibular reconstruction. World War IL
Plast Reconstr Surg 1949;4:153-159.
15. Boyne PJ. Autogenous cancellous bone and marrow transplants. Clin
Orthop 1970;73:199-208.
16. Marx RE, Ehler~, Peleg M. Mandibular rcconstruction-rehabilita-
tion of the head and neck cancer patient. Bone 1996;190:595-625.
17. Pikes MA. Block autografts for localized ridge augmentation. Part II.
The posterior mandible. Implant Dent 2000 ;9 :67.
18. Hidalgo DA. Fibula free flap. A new method of mandible reconstruc-
tion. Piast Reconstr Surg 1989;84:71-82.
19. Marx RE, Snyder R, Kline SN. Cellular survival of human marrow
during placement of marrow-cancellous bone grafts. J Oral Surg
1979;37:712-717.
20. Marx RE, Carlson ER, Schimmcle SR, Eickstaedt RM, Strauss JE,
GeorgeffK. Platelet-rich plasma: Growth factor enhancement for bone
grafts. Oral Surg 1998;85:638-646.

6
Chapter Two

Tibia

7
 2lnbia

Indications
• Bone grafts requiring- 5 to 40 mL of uncompressed autogenous cancellous
marrow in an outpatient, clinical, or inpatient setting

Utilization
• Sinus devati.on graft
• Adult alveolar cleft graft
• Ridge preservation
• Horizontal ridge augmentation
• Vertical ridge augmentation
• Socket graft
• Dental implant salvage
• Mandibular continuity defect of 4 an or less
• Nonunion or malunion of the mandible

Contraindications
•Metabolic bone disease (eg, osteopetrosis, osteogenesis imperfecta, pykno-
dysostosis)
• Osteomyelitis
· ·Acute knee injury or inflammation
• Histqry of multiple knee surgeries
• Local radiotherapy

Cautions
• Single previous knee surgery
• Growing child
• Rheumatoid arthritis
• Chemotherapy
• Intravenous or oral bisphosphonate history or current use

Anatomy
s
The preferred harvest site is the lateral tibial plateau known as Gerdy tubercle
(Fig 2-la), an oblique ridge located 1.5 on inferior to the tibial plateau (articulat-
ing surface) and one-tlrird the distance from the midline to the head of the fibula

8
 Anatomy

Fig 2-1 a Gardy's tubercle outlined as the entry site for

harvesting bone from the lateral tibial plateau.

Fig 2-1 b Musculoskeletal anatomy

of the lateral tibia harvest site (left leg).

Femur

Patella

Tensor fascia lata tendon

Patellar tendon
Ridge of Gerdy's tubercle

Anterior tibialis muscle

Tibial shaft
Fibula

(Fig 2-1 b). The iliotibial tract {ie, the tensor fascia lata muscle and the tensor
fascia lata proper) attaches to the ridge from above. The anterior tibialis
muscle from below attaches to a concave fossa just inferior to this ridge.

9
 2 l1ibia

Fig 2-2 Vascular and neural anatomy

of the lateral tibia harvest site.

Femur

Lateral superior genicular artery

Patella

Patellar tendon Lateral inferior genicular artery

Recurrent anterior tibial artery Fibula

Anterior tibial artery

Tibia

Peroneal nerve and artery

The ridge is covered only by skin and subcutaneous tissues and lies 0.6 to 1.8
cm below the skin surface. There is no major blood vessel or nerve in the
planned surgical field. The site of the incision is inferior to the lateral superior
genicular artery and the lateral inferior genicular artery. In addition, the ante-
rior tibial artery emerges onto the anterior tibia 4 cm below Gerdy' s tubercle.

10
 Surgical Approach

Fig 2-3 The ideal patient position in the dental chair is to

have the leg in the flexed position and supported with a
pillow.

Its recurrent branch courses medial to the planned incision site. This incision
is also superior to the common fibular (peroneal) nerve and is lateral to its re-
current branch along the patellar tendon (Fig 2-2). The patellar tendon is in the
midline and also away from the surgical field.

Patient Positioning
For office procedures, the standard dental chair position is ideal. A pillow is
placed below the knee joint to set the leg in a moderately flexed position (Fig
2-3). The authors recommend use of the left leg for right-handed surgeons and
the right leg for left-handed surgeons because the natural angle for bone entry
will be caudad and hence away from the knee joint.
For operating room procedures, either a supine position or a dental chair
position is satisfactory. In either case, the placement of a pillow to flex the knee
joint and the selection of the leg are the same as for an office procedure. H the
patient will receive general anesthesia, it is recommended to tape the selected
leg into a slightly medial (inward) rotation to allow better access to the lateral
tibial plateau.

Surgical Approach
A 2.0-cm incision is made directly over the palpable ridge known as Gerdy's
tubercle (see Fig 2-la). The incision should be oblique in relation to the long axis
of the lower leg. For office procedures under local anesthesia and intravenous
sedation, the incision is preceded by subdermal infiltration of 1.8 mL of Septo-
caine with 1:100,000 epinephrine (Septodont USA) over the planned incision

11
 2ITibia

Fig 2-4 Local anesthesia is begun with a subdermal infil- Fig 2-5 Local anesthesia is completed by infiltration onto
tration along the oblique path of the planned incision. the periosteum by a right angle entry through the previ-
ously anesthetized skin.

Fig 2-6 The incision to access Gerdy's tubercle incises

through the thick white fascia with the superior attachment
of the anterior tibialis muscle inferior to the incision.

area (Fig 2-4). Allow 1 minute for anesthesia development, then inject a second
1.8-mL volume onto the periosteum by inserting the anesthetic needle at a right
angle to the skin surface and touching the bone (Fig 2-5).
The incision will extend through the skin and subcutaneous tissue and to the
periosteum of Gerdy's tubercle. This palpable ridge will have a visibly thick.,
white fascia-periosteum complex attaching from above (the iliotibial track) (Figs
2-6 and 2-7). An incision is made oblique!)' along this ridge for a distance of
2.0 cm. A small portion of the anterior tibialis muscle and the periosteum
below it is reflected inferiorly. In most cases, small releasing incisions need to
be placed at each end of the incision to gain maximum reflection.
A small portion of the anterior ttbialis muscle is reflected to expose a concav-
ity below the ridge. At this point, the cortex is entered with the use of a no. 702
tapered fissure bur; a 1.5-cm diameter circle is outlined by making bur holes and
then connecting them (Fig 2-8). The circular cortical plug created by the bur,

12
 Smgical Approach

Fig 2-7 Exposure of Gerdy's tubercle by reflection of

periosteum and a small portion of the superior
attachment of the anterior tibialis muscle.

Femur

Patella

Patellar tendon

Anterior tibial is muscle reflected from bone

Tibia Fibula

Fig 2-8 Access to the cancellous marrow of the tibia is

begun by plating bur holes through the lateral cortex.

Handpiece with no. 702 bur

making initial bur holes in a 1.5-cm circle

Fibula

Retractor retracting anterior tibial is muscle

13
 2ITibia

Fig 2-9 A cortical plug is wedged out to allow entry to

the cancellous marrow of the tibia.

Retraction of the anterior tibialis muscle

.·

Fig 2-10 Cancellous marrow is harvested through a cor-

tical opening of only 1.5 cm in diameter.

which is the only cortical bone obtained by this approach, is wedged out (Fig 2-9).
The resultant opening into the tibial plateau allows access to a large reservoir of
cancellous marrow within (Fig 2-10). A no. '4 Molt curette or orthopedic bone
curettes are inserted and used in a rotational manner to remove cancellous mar-
row in a sequential fashion. The angle of entry should be across the tibia and
downward (Fig 2-11). Although an upward trajectory· would not necessarily pen-
etrate the thick subchondral bone to enter the knee joint, it does increase the
risk. As cancellous marrow is sequentially harvested, the curette must be inserted
at a gradually increased depth, and it becomes increasingly difficult to extract the

14
 Surgical Approach

Fig 2-11 The angle of entry into the tibia should be

across and downward.

No. 4 Molt curette

rotating clockwise

Tip of no. 4 Molt

curette in marrow space

Fig 2-12 Cancellous marrow is manipulated

to the exit window.

Patella

Tensor fascia lata tendon

Access site and exit window

for cancellous marrow

Anterior tibialis muscle and skin retracted

loosened cancellous marrow through the relatively small opening. 'Ibis can be
overcome by working the loosened cancellous marrow along the :inner cortical
surface to the exit window (Fig 2-12).

15
 2ITibia

Fig 2-13 Placing of microfibrillar bovine collagen (Avi- Fig 2-14 A three-layer closure is ideal. Here the subcu-
tene, Davol) with either platelet-rich or platelet-poor taneous layer is closed after approximation and suturing
plasma into the harvested site will assist hemostasis. of the periosteum-anterior tibialis-fascia lata complex.

Fig 2-15 A pull-out dermal-level closure approximates Fig 2-16 A dermal closure supported by Steri-Strips is a
the skin edges well. good surface-layer closure.

Once the desired amount of bone has been harvested, hemostasis can be
achieved by applying one of three types of maneuvers: a 0.5- X 3-inch cot-
tonoid (Codman Surgical Patti.es,Johnson &Johnson) saturated with 40/o co-
caine or 1:100,000 epinephrine for 5 minutes; 1 g of microfi.brillar bovine
collagen (Avitene, Davol) (Fig 2-13); or activated platdet-rich plasma (PRP) or
platdet-poor plasma (PPP).
Closure is straightforward. The periosteum-fascia layer and the subcutaneous
layer are each closed with a 3-0 resorbable suture (Fig 2-14). The skin is closed
with either a subcuticular closure (Fig 2-15) supported with Steri-Strips (3M
Health Care) (Fig 2-16) or a 4-0 nylon mattress suture at the surface.

16
 Complications

Fig 2-17 A broad band-aid dressing alone usually is suf- Fig 2-18 Minor swelling and ecchymosis usually develop
ficient. around the ankle area and leg below the harvest site. In
rare situations these conditions may become prominent,
as shown here.

Dressing
A simple broad-surfaced band-aid alone is all that is needed in most cases (Fig
2-17). If more bleeding occurred during the procedure than anticipated, or if
hemostasis was not complete, use a light pressure dressing consisting of three
gauze sponges over the site and circumferentially wrap the leg with a Kerlix
(Dukal) wrap. A drain is not needed.

Postoperative Instructions
Sutures may be removed in 7 days. Normal walking is permitted, but the pa-
tient must not engage in any sports, exercise program involving the legs, jog-
ging, bicycling, or walking up more than one flight of stairs for 6 weeks. Ice is
not required if intravenous steroids were given. When used, steroids should be
limited to 48 hours. Elevation of the leg when resting and a general reduction
in activities are recommended for 2 weeks.

Complications
Complications are quite rare-less than 40/o. The most common quasi-compli-
cations, because they will generate concern by the patient and his or her fam-
ily if they are not forewarned, are ecchymosis and swelling around the ankle
area (Fig 2-18). These complications are caused by gravity and the lymphatic
drainage pattern of the natural tissue fluid flow of the lower leg; they sponta-
neously resolve. Other potential complications include wound dehiscence, in-
fection, fracture of the knee joint at the harvest site entrance, gait disturbance,
chronic pain, and a reoperation.

17
 2ITibia

Wound dehiscence is managed by wound care, dressing, and an extended use

of antibiotic coverage with an emphasis on staphylococcal coverage. In almost
all instances, the wound heals by secondary intention; rarely, a secondary clo-
sure must be accomplished. Should an infection occur, cultures, wound irri-
gations, dressings, staphylococcal antibiotic coverage, and radiographs to rule
out an osteomyelitis would be appropriate. Should a fracture of the tibia or a
knee joint entrance occur, splinting of the leg and staphylococcal antibiotic cov-
erage would be the best initial management, followed by a consultation with
an orthopedic surgeon.

18
 Chapter Three

Posterior Ilium

19
 3 IPosterior Ilium

Indications

11Bone grafts requiring 40 to 120 mL of uncompressed autogenous

cancellous marrow
• Corticocancellous bone blocks in an operating room inpatient setting

Utilization
1: Continuity defects of the mandible ranging from 4 to 12 cm in length
(those greater than 12 cm require an acfditional harvest site)
• Corticocancellous block graft to maxilla or mandible
• Hemimaxillary graft reconstruction after tumor surgery
• Ridge augmentation to the maxilla
• Edentulous Le Fort I maxillary downfracture graft
• Mandibular soft tissue matrix expansion graft (ie, the tent pole graft)
I

Limitations
Compared to harvesting bone from the anterior ilium, this surgical procedure
requires approximately 2 additional hours of operating time because the patient
must be turned over and placed in a prone position. Also, because of the prone
position requirement, two surgical teams cannot operate simultaneously. An
operating room and strict sterile technique are needed to perform this proce-
dure.

Contraindications
• Metabolic bone diseases (eg, osteopetrosis, osteogenesis imperfecta, pykno-
dysostosis, etc)
• Previous fracture at the site
• Osteomyelitis at the site
• Local radiotherapy

Cautions

• Intravenous or oral bisphosphonate histo~T or current use

• Chemotherapy
11 History of long-term steroid or methotrexate use

20
 Anatomy

Fig 3-1 Right posterior ilium osteology.

Posterior tubercle of ilium

Anterior tubercle of ilium

Sacrum
Anterior superior spine

Anatomy

The largest reservoir of bone lies beneath the area where the gluteus maximus
muscle inserts via Sharpey fibers into a palpable triangle-shaped tubercle (Fig
3-1), often referred to as the posterior tuberde efthe ilium. In the adult, the ilium
articulates with the sacrum just medial and posterior to this area as the sacroiliac
joint. The triangle-shaped tubercle continues as a ridge from the crest of the pos-
terior ilium 9 to 12 an inferiorly to the greater sciatic notch. The posterior ilium
ends 1.5 to 2.0 cm posterior to this ridge in a rounded fashion. Anterior to this
ridge is a shallow fossa, into which the gluteus medius muscle rests (Fig 3-2).

21
 3 IPosterior Ilium

Fig 3-2 Muscle origins of the right ilium.

Latissimus dorsi
via the thoracodorsal fascia

External abdominal oblique muscle

Tensor fascia lata muscle

Gluteus maximus muscle

Gluteus medius muscle

Sacrum
Gluteus minimus muscle

The gluteus maximus muscle originates from a tenacious attachment into this
triangular posterior nibercle as well as the dorsal surface of the sacrum and coc-
cyx; these muscle fiber extensions are sometimes referred to as the saavtuberous
ligament, which inserts into the posterior aspect of the iliottbial tract and a portion
of the greater trochanter of the femur as well as the lateral base of the greater
trochanter. The gluteus maximus muscle is activated to extend the leg, mostly
during extensive effort and primarily to rise from a sitting position. It is not
usually activated in the normal walking motion. Therefore, patients are able
to walk with minimal pain, and gait disturbance after a posterior ilium bar-

22
 Anatomy

Fig 3-3 Lateral view of posterior ilium, showing the

medial course of the deep circumflex iliac artery.

Medial course of the

External iliac artery
DCIA with branches
and bony perforators

Deep circumflex
iliac artery (DCIA)

vest is temporary. For the first month, patients are advised to use the opposite
leg to stand from a sitting position.
The gluteus medius muscle lies in a large, shallow fossa anterior to the glu-
teus maxim.us muscle. It originates from the crest of the posterior ilium and the
anterio:r gluteal line, which separates the origins of the gluteus medius muscle
below to the triangular ridge origins of the gluteus maxim.us muscle above (see
Fig 3-2). The gluteus medius muscle inserts into the greater trochanter of the
femur. Tbis muscle medially rotates the leg and is not activated in normal
walking, so its reflection during bone harvesting is not associated with signif-
icant pain or gait disturbance.
The blood supply to the posterior ilium is via perforating branches entering
the medial cortex from the deep circumflex iliac artery (Fig 3-3). This vessel then
courses inferiorly through the greater sciatic notch and turns superiorly once
again on the lateral surface to terminate as the subgluteal artery (see Fig -3-3).
This harvest site is at the terminal end of its vascular territory, helping to reduce
the blood loss associated with this approach.

23
 3 IPosterior Ilium

The pertinent nerves in the vicinity of the posterior ilium where bone is har-
vested are the superior cluneal and middle cluneal sensory nerves (Fig 3-4).
The superior cluneal nerves are dorsal rami from the Ll, L2, and L3 segments
that pierce the thoracolumbar fascia superior to the iliac crest and ramify in the
skin over the superior portion of the posterior ilium. The middle cluneal nerves
are dorsal rami from the Sl, S2, and S3 segments that emerge through foram-
ina in the paramidline area of the sacrum and course laterally to ramify over
the inferior portion of the posterior ilium. The curvilinear incision for this sur-
gery is placed between these major nerve fibers, resulting in little or no sensory
loss (Fig 3-5).

Patient Positioning
Proper positioning of the patient is critical to the measured reduced blood loss
associated with this procedure, which is achieved in part by reduction of the
local venus pressure. It also makes the triangular tubercle more clearly identi-
fiable with the use of palpation throughout the procedure. The position is
prone with the arms forward on an arm rest and a support roll placed in each
axilla. A larger support roll is placed under the anterior thighs caudad to the
pubic area. The table must be configured into a reverse flex position of about
210 degrees (Fig 3-6). This position elevates the buttocks and hence the area
of the posterior ilium harvest above the lower extremities and the thorax,
thereby reducing the local venous pressure. The surgeon must ensure that the
anterior thigh roll is not placed cephalad to the pubis, where it might compress
the abdomen and hence the inferior vena cava; this would actually increase the
local venous pressure.

Surgical Approach
h is advisable to prepare and drape the surgical site widely to include both of
the posterior ilium sites even if bone harvesting is planned in only one site.
Doing so helps the surgeon maintain the anatomical orientation of the patient
and perspective in the surgical field. The usual incision is a 10-cm curvilinear
incision centered over the palpable triangular origin of the gluteus maximus
muscle (see Fig 3-5). This places the incision between the main sensory
branches of the superior and middle cluneal nerves. The incision will carry
through the full thickness of skin, the subcutaneous tissue, and then the tho-
racolumbar fascia and periosteum over the posterior iliac crest. It is best to use
sharp dissection to transsect the tenacious origins of the gluteus maximus mus-
cle into the bone at the tubercle. The authors use either electrocautery or a
sharp scalpd against the cortical surface from the crest of the triangular tu-
bercle to its end point at the gluteal line (about 2.5 to 3.0 cm) (Fig 3-7). Once
the reflection of the gluteus maximus muscle is complete, a Keyes periosteal d -
evator can be used to reflect the gluteus medius muscle and the periosteum on

24
 Surgical Approach

Fig 3-4 Sensory nerves related to the posterior ilium harvest.

Superior cluneal nerves

(dorsal cutaneous rami of L1, L2, L3)

Middle cluneal nerves

(dorsal cutaneous rami of 51, 52, 53)

I.

.. '.,,,
). , ... .......

. : .\!...~i .:. ':' ;,. ,

"' ' ..,:. • -~ J ..

• • t •
·· .... .

Fig 3-5 The authors recommend preparing and draping Fig 3-6 The patient should be in a prone position with
out both sides of the ilium and then drawing the bilateral axillary support and an anterior thigh roll. The
anatomy to maintain orientation and perspective during table should be reverse flexed in a 210-degree position.
the bone harvest.

25
 3 IPosterior Ilium

Fig 3-7 Electrocautery sharply reflecting

gluteus maximus muscle attachment.

Bovie rubber guard

Bovie ti

Gluteus medius muscle

Gluteus maximus muscle

Sacrum

its deep surface (Fig 3-8). The reflection should be sufficiently thorough as to
allow insertion of the standard posterior ilium retractors and visualization of
a 6 X 6 cm portion of the lateral cortex (Fig 3-9). At this time, bleeding points
will emerge through the lateral cortex; these are controlled directly with elec-
trocautery.

26
 Surgical Approach

Fig 3-8 Keyes periosteal elevator reflecting the gluteus

medius muscle below the gluteal line.

Keyes periosteal elevator

- Reflected gluteus maximus muscle

Uncovered cortex of
posterior tubercle of ilium

Fig 3-9 The triangular insertion of the gluteus medius, Fig 3-10 The most posterior ostectomy is a vertical 5-cm
represented by a tubercle of bone, is an important visi- cut down the ridge of the posterior tubercle. It begins a
ble and palpable landmark for this dissection. rectangular ostectomy anterior to this location, as shown.

The bone harvest procedure begins with the outlining of a 5 X 5 cm square

on the lateral cortex with the electrocautery instrument and a marking pen
(Fig 3-10). A smaller square (4 X 4 cm) can be used for smaller bone require-
ments. The posterior leg of this square should begin at the crest and course 5
cm inferiorly along the crest of the triangular tubercle (Fig 3-11). It is impor-

27
 3 IPosterior Ilium

Fig 3-11 Correct position of

ostectomy for bone harvest.

Posterior hip retractor

Reflected periosteal edge and
reflected gluteus maximus
and medius composite

Fig 3-12 Incorrect position of ostectomy

for bone harvest (risks fracture).

Reflected periosteal edge and

reflected gluteus maximus
and medius composite

Incorrect ostectomy too far

posterior to ridge of tubercle

tant not to place this ostectomy posterior to the ridge crest (Fig 3-12) or extend
it more than 5 cm inferiorly, as either variation would significantly increase
the risk for fracture (Fig 3-13). The 5 X 5 cm square should then extend 5 cm

28
 Surgical Approach

Fig 3-13 Fracture resulting from incorrect position of

ostectomy for bone harvest.

Reflected periosteal edge and

reflected gluteus maximus
and medius composite

Fig 3-14 The saw should penetrate only the lateral cortex.

Reciprocating saw with

blade just past cortex

anteriorly along the crest of the posterior ilium and 5 cm inferiorly at that
point so that the anterior and posterior vertical limbs can be connected at their
most inferior extent. The square configuration is ostectomized using a recip-

29
 3 IPosterior Ilium

Fig 3-15 Order of saw cuts for posterior ilium harvest.

Reciprocating saw making

fourth and final cut

Completed bone cuts

rocating saw under saline irrigation. The saw should penetrate just through the
lateral cortex, which is only 1 mm thick (Fig 3-14). The authors have found it
best to make the first cut down the center of the crest of this triangular ridge,
followed by the superior cut at the ridge 5 cm anteriorly and then 5 cm down-
ward at this anterior extent. This completes legs 1 through 3 of the square and
is followed by the fourth leg, which connects them at the bottom (Fig 3-15).
The resultant cortical cancellous block is then separated using a 1-inch (2.5-cm)
curved osteotome. The separation of this cortical cancellous block is accom-
plished gradually to avoid fracturing the ilium. The surgeon is advised to first
mallet the osteotome in a superior to inferior direction along the course of the
superior ostectomy (Fig 3-16), then to direct the osteotome "across the square"
from a posterior-superior position to an anterior-inferior position (Fig 3-17).
Once this block of bone is mobilized, it is removed and stored temporarily in
either saline or anti.coagulated platelet-rich plasma PRP (Figs 3-18 to 3-20).

30
 ·Surgical Approach

'fi ~"1-J'Uf'lll.
.: -~hi
,;.::~:- .l7il:

Fig 3-16 A curved osteotome is malleted between the Fig 3-17 The final osteotome trajectory should be from
lateral and medial cortex beginning in the area of the the posterior-superior corner obliquely to the anterior-
posterior tubercle, which represents the thickest part. inferior corner. This will separate a lateral corticocancel-
lous block without perforating the medial cortex.

Fig 3-18 The corticocancellous block is removed, re- Fig 3-19 A 5 X 5 cm corticocancellous block can be used
vealing a large reservoir of cancellous marrow for direct as a block graft, or it can be particulated in a bone mill
harvesting. to yield 20 to 25 ml of particulate graft material.

Fig 3-20 The posterior ilium yields 2.25 to 2.50 times the
amount of graft material as the anterior ilium and may
be temporarily stored in room temperature saline or PRP.

31
 ., . -~· ... ·· ~ ... ________
3 IPosterior Ilium

Fig 3-21 A bone gouge will quickly harvest cancellous

marrow when used with a reciprocal rotary wrist motion.

3/8-inch bone gouge

Curl o f cancellous marrow

Bone cortex

Cancellous marrow

• L
'""' .,., I

Fig 3-22a The first harvest maneuver with a bone gouge Fig 3-22b A good quantity of cancellous marrow is har-
requires the use of a rotating wrist motion. vested with each maneuver of a bone gouge.

At this time, the large reservoir of cancellous marrow within the posterior
ilium is directly accessible. First, a bone gouge is used with a rotational wrist mo-
tion through the cancellous marrow (Figs 3-21 and 3-22). 1bis will yield large
curls of cancellous bone. When no more cancellous marrow can be removed
with the bone gouge, back-action curettes and straight curettes are employed.
It is recommended to scrape all of the cancellous marrow from the inner sur-
face of the medial cortex (Fig 3-23), not only to enhance the yield but also to
remove the greatest number of stem cells, which are known to be concentrated
in this area. The surgeon can estimate a yield of 25 mL of particulated bone
from the 5 X 5 on block of bone. The surgeon should then harvest sufficient

32
 Surgical Approach

Fig 3-23 The final cancellous marrow harvest is accom-

plished with a bone curette used in a scraping fashion .

Inner (medial) cortex scraped clean of

marrow and minor scrape marks

Fig 3-24 A drain should be placed within the excavated
bony cavity because it is the location where a postoper-
ative hematoma may form.
Fig 3-25 Use of bone wax in areas of a brisk marrow
ooze, followed by 1 g of microfibrillar bovine collagen
(Avitene, Davol) delivered as a spray from a dry bulb sy-
ringe, will ensure hemostasis in all recesses of the har-
vest site.

additional cancellous marrow for the anticipated need at the recipient site using
the approximation that 8 to 10 mL of uncompressed cancellous bone is required
for every 1 cm of mandibular continuity defect. Once the cancellous bone has
been harvested, sharp bony edges of the osteotomy are reduced, and a 7-mm suc-
tion drain is introduced into the bony defect (Fig 3-24). The drain should exit an-
terior to the incision line so that the patient does not lie directly on it. The authors
recommend using a small amount of bone wax in areas of a brisk marrow ooze
and either 10 mL of activated platelet-poor plasma (PPP) or 1 g of microfibrillar
bovine collagen (Avitene, Davol) (Fig 3-25) to obtain maximum hemostasis.

33
 3 IPosterior Ilium

Fig 3-26 Closure of muscle and fascia.

Thoracolumbar fascia

Gluteus maximus muscle and overlying fascia

(/
I

Fig 3-27 A layered closure and bulb suction are recom-

mended. A strong wall suction will actually aspirate bone
marrow and blood and therefore should not be used.

During closure, pay particular attention to repositioning of the gluteus max-

imus and gluteus medius muscles. Use of a 2-0 resorbable suture to suspend these
muscles to the thoracolwnbar fascia at the ridge crest works best (Fig 3-26). The
remaining subrutaneous and dermal layers are closed with a 3-0 resorbable suture,
followed by small skin staples (Fig 3-27) or a 4-0 nonresorbable surface closure.

34
 Complications

Fig 3-28 The drain should exit anterior to

the incision so that the patient will not lie
directly on it. Placement of a pressure
dressing over the site completes the pro-
cedure.

Dressing and Drain

The drain is activated only with the compressed bulb. Do not activate the
drain to a wall suction because it may actually promote active bleeding by cre-
ating excessive negative pressure within the bony cavity (Fig 3-28).
A pressure dressing is applied and should be placed inferior to the suture
line, which is over the bony crest. The most straightforward dressing is the
use of fluffed gauze over which an elastic tape is applied (see Fig 3-28).

Postoperative Care and Instructions

The dressing is usually removed after 2 days and the sutures removed between
day 7 and day 10. The drain is assessed daily and removed when the drainage
trend is decreasing and measures less than 50 mL over a 24-hour period.
The first postoperative day is bed rest followed by assisted ambulation from
day 2 to day 4. Upon discharge from the hospital, normal walking is permit-
ted, but spor~s , exercise programs involving the legs, jogging, bicycling, or
walking up more than one flight of stairs is not permitted for the first 6 weeks.
Ice is ineffectual and not recommended.

Complications
Although actual complications are rare, there are many potential complica-
tions, some of which are serious. Potential complications are presented below
in order of most to least common.

35
 3 IPosterior Ilium

Seroma
The most common complication, seroma is often caused by failure to use a
drain, premature removal of the drain, or exercise during the early postoper-
ative course. Treatment of a seroma consists of aspiration and a pressure dress-
ing. H the seroma rerurs after a second aspiration, a radiograph of the area is
recommended along with the placement of a drain.

Hematoma or acute bleeding

A stable hematoma usually arises from persistent oozing of marrow after the
drain has been removed. Most hematomas will reabsorb and require only ob-
servation and a pressure dressing.
An expanding hematoma is much more serious and indicates an active bleed-
ing vessel in the wound. As with pelvic fractures, a significant volume of blood
can be lost in the ilium/pelvic area before ecchymosis or a hematoma is clini-
cally apparent. Therefore, the surgeon must assess for developing hypovolemic
shock. Certainly, blood pressure, pulse rate, urine output, and a complete
blood count are needed as part of the assessment. Once shock is initially man-
aged, a reentry into the wound to control the active bleeding site is required.
The surgeon should specifically look for either a brisk marrow bleed, which
is best controlled with bone wax, or a specific soft tissue or bony bleeding ves-
sel that can be cauterized or tied off.

Fracture
Fracture of the posterior ilium is very rare and usually the result of a combi-
nation of risk factors. Among the risk factors for fracture are previous entry
into the site, severe osteoporosis, smoking, and misalignment of the ostectomy
that undermines the posterior edge of the ilium and usually propagates a frac-
ture, either through the posterior edge of the ilium or through the sciatic notch
(see Fig 3-13).
The treatment for a fracture at the posterior ilium harvest site is extended
bed rest and pain control. Open reduction and plate fixation of the fracture site
are rarely necessary and should be reserved for cases of continued pain and
nonhealing that persist beyond 6 weeks.

Gait disturbance
Permanent gait disturbance also is very rare. It may occur as a sequela of a frac-
ture complication or a closure that did not reposition the gluteal muscles. Phys-
ical therapy is recommended for the rare event of a gait disturbance, although
open surgery may be required if a bone or muscle malalignment is identified.

36
 Modifications for Children

Fig 3-29 The very same access and bone removal

approach is used in children, except that the ostectomy is
made just below the cartilage cap at the crest.

Cartilage cap

.·
Ostectomy site

Modifications in Children
Both the anterior and posterior iliac crest cartilage represent an ossification site
rather than a true growth center site, such as an epiphyseal plate. For this rea-
son, few modifications are necessary in the approach to the posterior (and ante-
rior) ilium in children. The soft tissue dissection in children is the same as that
for adults, and the bony harvest is modified only by the preservation of the car-
tilage cap. As the gluteus maximus muscle is sharply reflected from its combined
cartilage and bony insertions and the gluteus medius muscle is reflected off its
combined cartilage and bony insertions with a Keyes periosteal elevator, the
junction between the cartilage cap and the bone will become evident (Fig 3-29).
Instead of placing the superior osteotomy at the crest of the ilium as in adults, it
is placed at the cartilage-bone junction in children. This cartilage cap will later
ossify to create the anticipated morphology of the posterior ilium. The cortical
cancellous block of bone in children is taken from below this cartilage cap.

37
 Chapter Four

Anterior Ilium

~---- --- -
\

.
:__.--

-- --
t

..
!it•f I l,; ~

·~.f:~ L,'·;:i~·~

39
 41 Anterior Ilium

Indications
•Bone grafts requiring 30 to 50 mL of uncompressed autogenous cancellous
marrow or a corticocancellous bone block

In this regard, both the anterior ilium and the posterior ilium offer several ad-
vantages over the tibia. The volwne of bone provided by the anterior ilium is
somewhat greater than that provided by the tibia (10 to 30 mL), and the bone
can be harvested in a block form to create a shape that closely corresponds to
a specific defect.

Utilization
• Continuity defects of the mandible ranging from small fibrous unions to
those up to 5 cm in length
•For sinus augmentations (especially bilateral cases), alveolar clefts, and soft
tissue matrix expansion grafts (eg, tent pole procedure)
• For horizontal and vertical ridge augmentation of the maxilla or mandible

Limitations
Harvesting of the anterior ilium should generally be performed in the operat-
ing room under strict sterile technique. Large mandibular continuity defects (ie,
those greater than 5 cm) cannot be reconstructed with the bone harvested from
a single ilium; both anterior ilia can be harvested to increase graft volume if
necessary. However, this leads to increased donor site morbidity. Obese pa-
tients may also present a challenge because of distortion of anatomy and dif-
ficulty in achieving the proper depth of dissection and retraction. Previous
appendectomy scars do not present a difficulty, but a history of a hernia may
increase the risk of inadvertent abdominal penetration.
ff the patient has a hip prosthesis, bone from the ipsilateral ilium can be har-
vested with additional risk. However, the opposite side is recommended only
because unrelated pain and complications of the hip prosthesis may be attrib-
uted to the donor site.

Contraindications
•Metabolic bone diseases (eg, osteopetrosis, osteogenesis imperfecta, pykno-
dysostosis, etc)
• Previous fracture at the site
• Osteomyelitis at the site

40
 Anatomy

Fig 4-1 a Anatomical landmarks of the ilium.

Anterior tubercle
of ilium

Fig 4-1 b Area of ilium best suited for an anterior ilium

bone graft harvest is around the anterior tubercle.

Cautions
• Intravenous or oral bisphosphonate history or current use
• Current or long-term chemotherapy treatment
• History of long-term or current steroid therapy
• Radiotherapy at the site

Anatomy
The anterior iliac crest, posterior to the anterior superior spine and around
the anterior tubercle of the ilium (located about 6 on posterior), is the bone
graft harvest site (Fig 4-1). In this location, the tensor fascia lata muscle, which
is overlaid by the tight tensor fascia lata proper, attaches to the lateral edge of

41
 41 Anterior Ilium

Fig 4-2 Musculoskeletal anatomy pertinent to the anterior ilium.

EXte rnal abdominal

oblique muscle

Tensor fascia
lata band
flliotibial tract)

Midline raphe

"
~

~-
..
~

Tensor fascia lata muscle Pate lla

.....
Gerdy's tubercle

the anterior iliac crest (Fig 4-2). This muscle courses past both the hip joint and
the knee joint to insert onto the lateral ridge of the tibia known as Gerdy's tu-
bercle. Because it flexes the knee and hip joints to elevate the leg, this muscle is
activated in all phases of normal walking. Its reflection from its bony attach-
ments is therefore responsible for most of the pain and temporary gait distur-
bance associated with harvesting of bone from the lateral anterior ilium.
The external abdominal oblique muscle attaches to the height of the midcrest
(see Fig 4-2).Just inferior to this muscle is the internal abdominal oblique mus-
cle and the transversus abdominis muscle, which attaches to the medial edge

42
 Anatomy

Fig 4-3 Muscle attachments to the lateral surface and crest of the ilium.

Thoracodorsal fascia

External abdominal obli ue attachment

Gluteus maximus muscle

Gluteus medius muscle

Sacrum
Gluteus minimus muscle

of the iliac crest. The lateral cortex in this area receives the anterior slip of the
gluteus medius muscle near the crest, whereas the larger surface anterior and
inferior to this attachment is the broad attachment of the gluteus :m.inimus mus-
cle (Fig 4-3) . This muscle inserts on the greater trochanter of the femur to ad-
just and stabilize the leg on that side when the opposite leg is elevated and
extended in the normal walking motion. The importance of this anatomy is
that reflection of the tensor fascia lata muscle and gluteus mini.mus muscle in
the anterior lateral approach results in pain and temporary alteration of the gait
because of its active contraction during walking.

43
 41 Anterior Ilium

Fig 4-4 Musculoskeletal anatomy of the medial surface of the ilium.

Psoas major muscle

lliacus muscle

Sacrum

Greater trochanter

lliopsoas tendon

..·, Femur

The medial cortex is concave and houses the iliacus muscle, which origi-
nates from the entire medial cortex and portions of the sacrum, to course an-
terior inferiorly into a tendon that fuses with the tendon of the psoas major
muscle. This fused tendon, often referred to as the iliop.soas tendon, inserts onto
the lesser trochanter of the femur (Fig 4-4) . This anatomy is important because
the iliopsoas tendon causes the psoa5 major muscle to activate and flex the hip
in walking if the iliacus muscle (which normally performs this function) is re-
flected, as it is in the anterior medial approach, thus resulting in less pain and
less temporary gait disturbance. It is the basiS for preferring a medial approach
to harvesting bone from the anterior ilium.
 Anatomy

Fig 4-5 A fracture of the anterior spine of the ilium may occur if the
osteotomy is placed too close to the anterior superior spine.

Anterior superior spine

Attachment area
of the sartorius muscle

Ant erior inferior spine

Attached to the anterior superior spine is the inguinal ligament, which ex-
tends to the pubic bone (see Figs 4-2 and 4-4). Below the anterior superior
spine is a fossa that curves inward for 1 cm, then outward for 3 cm to form the
anterior inferior spine. The sartorius muscle originates from this fossa and the
anterior inferior spine to insert on the medial aspect of the tibia; its action is
to rotate the leg outward. The importance of this anatomy relates to the fossa:
If an osteotomy to harvest bone is placed too close (less than 1.5 cm) to the an-
terior superior spine, it risks extending into this fossa or undermining the an-
terior superior spine, which can lead to a fracture (Fig 4-5).

45
 4 IAnterior Ilium

Fig 4-6 Normal course of the three sensory nerves

pertinent to the anterior ilium har¥est.

lliohypogastric nerve

Subcostal nerve

Lateral femoral cutaneous nerve

.. .

All of the nerves in the area of the anterior ilium harvest are sensory nerves,
and all are avoidable except the iliohypogastric nerve, which sits in the direct
path of all incisions to the anterior ilium (Fig 4-6). It arises from dorsal rami of
Ll and L2 and courses anteriorly and laterally over the tubercle of the ante-
rior ilium to innervate the skin over the lateral anterior ilium. The subcostal
nerve arises from the dorsal ram.us of T12 and courses anteriorly and laterally
over the edge of the anterior superior spine to innervate the skin of the groin
(see Fig 4-6). The importance of this anatomy is that (a} some paresthesia in
the iliohypogastric nerve distribution is unavoidable and to be expected, and
(b) incisions that extend over the anterior superior spine may transsect the sub-
costal nerve. The lateral femoral cutaneous nerve arises from dorsal rami of
L2 and L3 but courses between the iliacus and the psoas major muscles, then
deep to the inguinal ligament to emerge and innervate the lateral thigh below

46
 Anatomy

Fig 4-7 Anatomical anomaly of the lateral

femoral cutaneous nerve.

llioh

Subcostal neNe

Aberrant course of the lat eral

femoral cutaneous nerve

the ilium (see Fig 4-6). The importance of this anatomy is that hematomas in
the iliacus muscle may cause temporary but reversible paresthesia, known as
meralgja paresthetUa, in the distribution of this nerve. The lateral femoral cuta-
neous nerve is not otherwise at significant risk in the standard anterior ilium
approach. However, an anatomical variation occurs in about 2.50/o of the pop-
ulation whereby the lateral femoral cutaneous nerve courses over the inguinal
ligament and the anterior superior spine alongside the subcostal nerve, plac-
mg it at risk when the incision extends over the anterior superior spine (Fig 4-
7).
Blood is supplied to the anterior ilium via the perforating vessels from the
deep circumflex iliac artery, which courses within the iliacus muscle beneath
the medial periosteum of the ilium. The gluteus medius muscle, the gluteus
minimus muscle, and the upper portion of the tensor fascia lata complex on the
lateral side are supplied by branches of the superficial circumflex iliac artery.

47
 41 Anterior Ilium

Fig 4-8 External view of right anterior hip, outlining the

ilium to indicate the skeletal orientation beneath the skin.

Patient Positioning
The standard anatomical supine position is used for this procedure. The left
hip is most often chosen because of the greater use of the right leg, especially
for driving a vehicle. The surgical table is laid flat, and a soft roll is placed
under the buttock of the donor site to elevate the hip (Fig 4-8). The operating
room table can also be rotated along its long axis (airplaned) for optimal vi-
sualization. A vinyl drape is used to prevent contamination from the genital
area. In combination with an appropriate surgical prep, shaving the area in
certain individuals is helpful for applying the drapes and promoting an asep-
tic surgical field.

Surgical 1'.-.pproacb
The medial approach is preferred because it is associated with less pain and
morbidity than other approaches. However, the same incision is used for both
the medial and lateral approach; it begins 2 cm lateral to the iliac crest so that
it is not compressed or abraded by a belt or a tight waistband (Fig 4-9). The
incision should parallel the anterior crest, stopping 1.5 cm short of the anterior
superior spine to avoid the subcostal nerve (and the lateral femoral cutaneous
nerve in the 2.5% of the population in whom it courses over the anterior su-
perior spine (Figs 4-9 and 4-10). As the skin is incised, the incision is displaced

48
 Surgical Approach

Fig 4-9 Ideal plac:ement of the incision (dashed line) for an anterior ilium
harvest.

Fig 4-10 External view of right anterior ilium

showing incision plac:ement related to the
course of local nerves.

2.5% robability of path of lateral femoral cutaneous nerve

. _. . . ... ..

.. .. : ..

49
 4 IAnterior Ilium

Figs 4-11 a and 4-11 b Gloved hand compression above the anterior ilium
on the abdomen to bring the incision over the crest of the ilium.

over the anterior crest by gentle abdominal pressure and then maintained by
retraction (Fig 4-11). This incision will be deepened through the full thickness
of the skin and the subcutaneous tissue and oriented to the height of the crest.
At the height of the crest, a dry sponge or Kitner pledget can be used to dis-
place any fat lobules remaining over the muscles attached to the anterior crest.
Here, the external abdominal oblique muscle courses over the medial one-half
of the ilium and attaches at the crest while the tensor fascia lata muscle courses
over the lateral one-half of the crest (Fig 4-12). The periosteal incision is made
between these two muscle attachments.

50
 Surgical Approach

Fig 4-12a Anterior ilium skin incision is carried down to the

fascia over the bony crest and between the external
abdominal oblique and tensor fascia lata muscles.

External abdominal oblique muscle

Stop the incision about 1-2 cm short
of the anterior superior spine

Tensor fascia lata muscle

Fig 4-12b The external abdominal oblique musde from above and the tensor
fascia lata musde from below attach to the crest of the anterior ilium.

51
 4 IAnterior Ilium

Fig 4-13 Clamshell approach.

Rake retractor

·.. '-/> .
. .. · 1 .
'. .. \'
. :. . \ '

Osteotome

Tensor fascia
lata muscle

Gluteus medius
muscle

... :" ,
.,
..
r
/

Surgical Approaches

Clamshell approach
Once the roidcrest periosteal incision is made, an osteotome or reciprocating saw
can be inserted directly on the bone for a midcrestal split. If a saw is used, it is
recommended to deepen the osteotomy with a 1-inch straight osteotome to a
depth of 3 to 4 cm. An osteotome is then used to accomplish a greenstick frac-
ture of the lateral and medial cortical plates and displace them outward, similar
to an open clamshell. This affords the surgeon access to the cancellous marrow
between the two cortices, which is harvested with a bone curette or bone gouge
(Fig 4-13). Once the bone has been harvested, the medial and lateral cortical
plates are compressed together manually, and the soft tissues are closed with a

52
 Surgical Approaches

Fig 4-14 The periosteum-fascia represents the first layer of closure.

(
I
I
I.
-·-
'.1. -
.. \"

Fig 4-15 Closure ofthe periosteum and muscle fascia

will reposition the split cortices.

External abdominal oblique muscle

Tensor fascia lata muscle

lliacus muscle

Gluteus medius muscle

"
layered approach (Fig 4-14). H the cortical plates have been extensively outfrac-
tured and cannot be recompressed to a reasonable degree, bur holes can be made
through each cortex and wires passed through them for a more effective reduc-
tion. However, the periosteal closure alone will usually bring the expanded cor-
tices together (Fig 4-15). This approach is limited to the harvest of a small amount
of cancellous marrow and therefore is mostly used in alveolar cleft grafts,
nonunions, sinus augmentation procedures, and ridge augmentation procedures.
It has generally been replaced by the 11bial harvest.

53
 4 IAnterior Ilium

Figs 4-16 and 4-17 Medial trap door approach to the

anterior ilium.

lliacus muscle

Medial trap door approach

Once the midcrestal periosteal incision is made, an osteotome or reciprocating
saw is inserted directly on the bone for a midcrestal split. To complete the trap
door concept, two vertical cortical osteotomies are also made through the me-
dial cortex between the muscle fibers of the iliacus muscles. The anterior ver-
tical osteotomy is placed 2 cm posterior to the anterior superior spine and the
posterior vertical osteotomy 7 cm posterior to the anterior superior spine in the
general area of the tubercle of the anterior ilium (Fig 4-16), creating a 5-cm
length of graft site. These osteotomies can be accomplished with either a re-
ciprocating saw or a one-half-inch osteotome. The osteotome is then malleted
through the midcrestal osteotomy to a depth of 5 cm and levered medially to
outfracture the medial cortex (Fig 4-17). This will expose more cancellous mar-
row than the clamshell approach but, like the clamshell, is not designed to
yield a corticocancellous block. The exposed cancellous marrow is gouged or
curetted from the site and from the outfractured medial cortex (Fig4-18). The
medial cortex, with its muscle attachments undisturbed, is repositioned and
usually can be stabilized with periosteal sutures {Figs 4-19). If not, wire fixation
can be used.

54
 Surgical Approaches

Fig 4-18 Harvesting cancellous marrow using

medial trap door approach.

External abdominal
oblique muscle

lliacus muscle

a b

Fig 4-19 Closure ofthe periosteum and

muscle fascia will reposition the outfractured trap door.

Umbilicus

... .. lliacus muscle

.
.·· .
.
Tensor fascia
·· · lata muscle

Gluteus medius muscle

a Blood dot in harvest cavity b

55
 4 IAnterior Ilium

Figs 4-20 and 4-21 Harvesting cancellous marrow using a

bilateral trap door approach.

Bilateral trap door approach

Once the midcrest periosteal incision is made, an osteotome or reciprocating
saw is inserted cfuectly onto the crest and a cortical rut is made. With both the
medial soft tissue attaclunents (external and internal abdominal oblique, trans-
versus abdominis, and iliaais muscles) and the lateral soft tissue attachments
(tensor fascia lata and gluteus medius and minimus muscles) left attached, bi-
lateral osteotomies are made in a beveled fashion from the midcrest toward the
lateral and medial cortices (Fig 4-20). This leaves a central segment of steeple-
shaped cancellous bone that can be removed either as a cancellous block or as
particulate cancellous marrow. The medial and lateral cortices are then repo-
sitioned and sutured at the periosteal level, leaving a closed space in the
medullary cavity encased by the repositioned cortices (Fig 4-21).

Medial corticocancellous harvest

Once the midcrestal incision is made, the abdominal oblique muscles and
transversus abdominis muscle attachments are reflected from the midcrest to
the medial edge of the crest. At that point, the Keyes periosteal elevator is

56
 Surgical Approaches

Fig 4-22 Osteotomies of the medial corticocancellous Fig 4-23 An osteotome is used to separate the medial
bone harvest from the anterior ilium. corticocancellous block before surgery.

Fig 4-24 Removal of the medial corticocancellous block. Fig 4-25 Exposed cancellous marrow after the medial
corticocancellous block has been harvested.

turned downward to reflect the iliacus muscle from the medial cortex for a
length of 5 to 7 cm; some bleeding points will be noted on the medial cortex,
and these can be cauterized for control. The osteotomies are then outlined on
the cortex to split the crest at the midcrest and extend vertical osteotomies 4
to 5 cm inferiorly (Fig 4-22) . The anterior vertical osteotomy should be placed
2 cm posterior to the anterior superior spine and the posterior vertical os-
teotomy 7 cm posterior to the anterior superior spine, to yield a corticocan-
cellous block 5 X 5 cm. These osteotomies are then connected at the inferior
extent of each vertical osteotomy. Each osteotomy is best accomplished with
a reciprocating saw. It is only necessary to penetrate the thin cortex, which ·is
only 1 mm thick, as the remainder of the osteotomy is completed with a 1-
inch osteotome. Once the reciprocating saw has completed the four legs of the
osteotomy, the osteotome is malleted along the length of the crestal osteotomy
to the inferior osteotomy and levered medially (Fig 4-23) to deliver a cortico·
cancellous block of bone and expose the cancellous marrow of the region (Figs
4-24 and 4-25).

57
 4 I Anterior Ilium

Fig 4-26 A back-action bone
curette is used to scrape the
cancellous marrow from the lat-
eral cortex.
Fig 4-27 The storage of harvest-
ed bone using either room tem-
perature saline or anticoagulated
PRP provides the best cell sur-
vival.
Fig 4-28 Microfibrillar bovine collagen fluffed
into the donor site using a dry bulb syringe
to assist hemostasis.

. ,· ,
. . , .I:. . ~.;
.., : .·
·
• ' --'-~ . . . . .: • • : ; .# ~· ~
. .. ••

Fig 4-29 Repositioning of the reflected muscles and clo- Fig 4-30 The skin closure completes a multilayered clo-
sure of the periosteum/muscle complex reduces the po- sure that retains the contour of the iliac crest.
tential for a gait disturbance and prevents a contour
deformity.

First, bone gouges are used in a rotating-wrist manner to separate large curls
of cancdlous marrow. Next, bone curettes are used to harvest the remaining
cancellous marrow, taking special care to scrape the cancellous marrow from
the endosteal surface of the intact lateral cortex (Fig 4-26). The harvested bone
is temporarily stored in saline or anticoagulated platelet-rich plasma (PRP)
(Fig4-27).
The edges of the resultant bony defect should be smoothed with a bone file,
and a 7-mm suction drain is inserted, sutured to the skin, and exited posterior
to the incision. Bleeding points in the bony defect may be cauterized. However,
a bleeding point that is unresponsive to cautery or a brisk marrow ooze is best
controlled with bone wax. In addition, the authors use either activated platelet-
poor plasma (PPP) or 1 g of microfi.brillar bovine collagen to obtain complete he-
mostasis (Fig 4-28). The follow-on soft tissue closure should reposition the iliacus,
the transversalis, and abdominal oblique muscles to the crest, requiring the use
of a strong resorbable suture such as a 2-0 size (Fig 4-29). The skin closure may

58
 Surgical Approaches

Figs 4-31 and 4-32 Lateral corticocancellous harvest.

Umbilicus
Umbilicus
Osteotomy for
a lateral cortico-
cancellous harvest
.. ·:• .. •' ..
. .. . .
...
·.. . . . .:·
...
.. . :
. ' !:
./
·.
.1

.,
.. . ..' \ . .. ~

' .
..
·.. : .· ..
~· ;

External abdominalftV' Lateral corticocancellous

Tensor fascia
obli ue muscle block removal
lata muscle

be accomplished with a 4-0 nylon suture or small skin staples (Fig 4-30). 11lls ap-
proach yields the greatest amount of graft that an anterior ilium harvest can pro-
vide and is therefore chosen for larger defects.

Lateral corticoc,ancellous katvest

The lateral corticocancellous harvest offers no advantage over the medial cor-
ticocancellous harvest with regard to the amount or the shape of the harvested
bone. Some surgeons prefer (or have been instructed to use) the lateral ap-
proach based on an unfounded concern that the medial approach could pro-
duce a hernia, and are therefore more comfortable with it. However, the lateral
approach is known to produce more discomfort and a longer time to normal
ambulation due to the reflection of the tensor fascia lata and gluteus medius
and gluteus minimus muscles (Figs 4-31 and 4-32).

59
 4 Anterior Ilium
J

Fig 4-33 Area of bone inferior to the cartilage cap that can
be harvested in children.

Children
Harvesting bone from the anterior ilium in children is essentially the same ex-
cept that the crest is cartilaginous and represents an ossification center. Be-
cause the anterior ilium crest is only an ossification center and not a tru.e
growth center like an epiphyseal plate, bone harvests below this cartilage do
not affect growth. However, to prevent a contour deformity in the hip, the car-
tilage itself is not harvested or otherwise operated. Instead, the periosteum-
perichondrium complex is reflected on one side (usually the medial side) , and
bone below this small cap of cartilage can be harvested (Fig 4-33). The re-
maining cartilage will retain its vitality and hence its ossification due to the
vascular pedicle from the side of unreflected periosteum-perichondrium (usu-
ally the lateral side).

Dressing
Once the surgical site is closed, the incision is covered with a topical antibiotic
ointment or antibiotic-impregnated gauze (Xeroform, Kendall) . A pressure
dressing is then applied using "fluffs" (nonmarked, spread-out sterile gauze)
and foam tape that is applied and stretched over the dressing to exact pres-
sure.
The soft tissue closure is identical in adults and children. The periosteum is
closed first with a 2-0 or 3-0 resorbable suture followed by a layered closure at
the subcutaneous and dermal layers, also with a resorbable suture. The skin
surface may be closed using a dermal closure or interrupted sutures with 4-0
nylon or small skin staples (see Fig 4-30).

60
Chapter Five

61
 I s Rib

Indications
• Articulation graft in adults
• Independent articulation and growth graft in growing children
• Strut graft to complement an autogenous cancellous marrow graft harvested
from another site (less common)

Utilization
• Costochondral growth grafts in children who have syndromic conditions or
have lost mandibular growth potential due to trauma, tumor surgery, or ra-
diation therapy
• Costochondral articulation replacement in adults who have lost their natural
condyle due to trauma, tumor surgery, or bony ankylosis of the temporo-
mandibular joint
• Crib containment support for a cancellous marrow graft

Limitations
The rib graft constitutes a block corticocancellous graft with a hyaline cartilage
cap and therefore is not a good source of osteogenic cells. Although it will
achieve an articulation and form a bony union to host bone, a second donor
site (anterior ilium, posterior illium, or tibia) is often required to reconstruct the
horizontal and vertical height of the mandibular ramus.
In adults, 12 to 17 cm of rib can be harvested from the lateral border of the
latissimus dorsi muscle to the costochondral junction with the sternum. The
latissimus dorsi muscle restricts access and will limit the length of rib that can
be harvested. In children, 7to10 cm can be harvested with the same anatom-
ical limitations.

Contraindications
• Presence of a pneumothorax or bullous emphysema that might eventuate
into a pneumothorax
• Severe restrictive pulmonary disease, such as pulmonary fibrosis and muco-
viscidosis (cystic fibrosis)
•Metabolic bone diseases (eg, osteopetrosis, osteogenesis imperfecta, pykno-
dysostosis)
• Osteomyelitis of the ribs or sternum
• Radiation to the chest
• History of a crushing chest injury with multiple rib fractures

62
 Anatomy

Fig 5-1 Anatomy of the rib cage.

Manubrium of sternum

Ribs 1-7
(true ribs}
Body of sternum

Xiphoid process
of sternum

Cautions
" Moderate emphysema
• History of single rib fractures.
• Intravenous or oral bisphosphonate history or use
• Chest deformity (eg, pectus excavatum)
• Chondritis
• Rheumatoid arthritis

Anatomy
The usual ribs of interest (ribs 4, 5, 6, 7) arise from their demifacets on two ad-
jacent thoracic vertebrae and course in a curvilinear arc to insert into the ster-
num with a hyaline cartilage union (Fig 5-1). The eighth rib is the first one
that does not directly insert onto the sternum because its cartilage fuses to the
cartilage of the seventh rib. Therefore, the four common ribs used in jaw re-
construction all directly attach to the sternum via a hyaline cartilage union and

63
 I s rub

Fig 5-2 Muscle attachments to the

rib cage pertinent to a rib harvest procedure.

Clavide

Sternum

Humerus
...

Pectoralis major muscle '.

Midsection of rib 6,
where pectoralis major ·
muscle inserts from :
above and rectus
abdominis muscle
inserts from below.

Horizontal fascia!
bands in rectus
abdominis muscle

are termed true rihs. These four ribs of interest are covered by the rhomboid
muscles, trapezius muscle, and latissimus dorsi muscle in their proximal one-
third. In their distal two-thirds, ribs 4, 5, and 6 are covered by the pectoralis
major muscle (Fig 5-2). Rib 7 is covered by the rectus abdominis muscle. The
pectoralis major muscle inserts into the sixth rib from above and the rectus
abdominis muscle inserts into the sixth rib from below, affording the surgeon
a dissection plane to the sixth rib between these two muscles and thus avoid-
ing the need to dissect through any muscle. Each rib is covered by a periosteum
that becomes a perichondrium at its cartilaginous insertion into the sternum.
Blood and sensory innervation of the rib are supplied mostly through the pe-
riostewn from the intercostal artery and vein and respective dorsal rami, which
course just below the inferior edge of each rib and are positioned within the
intercostal muscles (Figs 5-3 and 5-4). However, there is a branch of each in-
tercostal vessel that enters its respective rib near its midlength to supply the
marrow. Nevertheless, harvesting of the rib creates a free nonvascular graft, just
as the outmoded procedure of attempting to transfer a viable rib on the end of

64
 Anatomy

Rg 5-3 Internal and external intercostal

muscle positions in the rib cage.

Internal
intercostal muscles

External
intercostal muscles

Fig 5-4 Vascular and neural anatomy of the ribs.

lntercostal artery,
vein, and nerve
Artery enters
rib to supply marrow space

External Sternum
intercostal muscles
Internal intercostal muscles

65
 I 5 Rib

Fig 5-5 Two ribs harvested from a 6-year-old child. The

cartilage has separated from one rib, underscoring its
tenuous attachment.

a pectoralis major flap also creates a nonvascular rib. In the latter example,
nonvascularity results because the blood supply from the pectoralis major mus-
cle does not contain perforating vessels into the rib periosteum. The blood
supply to the rib is solely via the intercostal vessels from the aorta.
Each rib is connected to its adjacent ribs via external and internal intercostal
muscles (see Figs 5-3 and 5-4). Deep to the ribs lie the subcostal muscles, al-
though they do not cover the entire deep surface of the rib. In these areas, the
deep rib periosteum lies directly upon the parietal pleura of the lung.
In adults, the cartilage is intimately fused to the rib and cannot be separated
short of transsection. In children, the cartilage is very loosely connected to the
bone and will separate easily (Fig 5-5).

Patient Positioning
Most nb harvest surgeries can be accomplished with the patient in the standard
supine position. In rare cases, a very long rib may require the use of a lateral chest
roll or even a lateral decubitus position to rotate the thorax toward the midline.
However, as access is gained proximally, an equal amount is lost distally.

Surgical Approach
The ideal rib for harvesting is the right sixth rib, for the following reasons:

1. The incision can be placed into the inframammary crease for the best cos-
metic outcome in both men and women (Fig 5-6).
2. This incision can be carried down to the rib between the pectoralis major
muscle above and the rectus abdominis muscle below, so as to avoid mus-
cle dissection, which would contribute to pain and swelling (Fig 5-7).

66
 Surgical Approach

Fig 5-6 The incisional access to the sixth rib is placed in

the inframammary crease.

Fig 5-7 The inframammary crease incision can

approach the external surface of the sixth rib
without transsecting through muscle.

Sternum

Scalpel or Bovie
electrocautery incision Pectoralis major muscle
on sixth rib between
pectoralis major and
rectus abdominis muscles

Rectus abdominis muscle

 I s Rib

Fig 5-8 Placing one finger in the fifth intercostal space

and another in the sixth intercostal space and incising
from distal to proximal will keep the periosteal incision
on the outer rib surface.

3. The sixth rib has a long available length yet possesses a direct cartilage fu-
sion to the sternum.
4. Postoperative pain is less likely to be confused with cardiogenic pain, which
can be a problem when a rib has been harvested from the left side.

For harvesting of the right sixth rib, the incision is made in the inframammary
crease and sharply ex.tended to the sixth rib. The surgeon should place one fin-
ger in the fifth intercostal space and another finger of the same hand in the sixth
intercostal space, thus straddling the sixth rib. The two fingers are then slowly
moved from the costochondral junction toward the back while the periosteum
is cut through directly in the center of the outer nb cortex (Fig 5-8). 'Ibis prevents
the dissection from slipping into the intercostal space and creating a pneumoth-
orax or lacerating the intercostal vessels to cause excessive bleeding.
Once the periosteum has been incised, it needs to be reflected circumferen-
tially around the rib. Here, care should be taken not to tear the periosteum and
the parietal pleura on the deep rib surface. This area is vulnerable because in
many locations the parietal pleura is fused to the periosteum, and the deep
surface of the rib cortex often has small stalactite-like bony projections (Fig
5-9). Therefore, avoid using the common thoracic instrument called the Duyen
rib stripper (Fig 5-10); this curved instrument is made to rapidly strip the pe-
riosteum from the rib, but in doing so it frequently tears the parietal pleura to
create a pneumothorax as it is brought over one of these bony projections (see
Fig 5-9). Instead, the authors recommend using the standard oral and max-
illofacial no. 9 periosteal elevator or no. 4 Molt curette to carefully reflect the
periosteum, taking care to keep these instruments in contact with bone

68
 Surgical Approach

Fig 5-9 Stalactite-like bony projections on the deep

surface of the rib can lead to a pneumothorax.

Periosteum

Bony projections on undersurface of ribs

Reflected periosteum

Fig 5-10 Use of the Doyen rib stripper increases the

risk of a pneumothorax.

Reflected periosteum

Doyen rib stripper

Tear in parietal pleura

69
 I s Rib

Fig 5-11 For best results, reflect the periosteum of the

rib using a standard periosteal elevator and begin on the
superficial surface of the rib.

Fig 5-12 A standard periosteal elevator can be

used to reflect the rib periosteum on its deep
surface without tearing the parietal pleura.

Lung

Reflected periosteum

Reflected periosteum

No. 9 periosteal elevator

throughout the entire procedure (Fig 5-11). These instruments will separate
the periosteum even from these bony projections without creating tears (Fig
5-12). After completing the periosteal elevation, transsect through the carti-
lage, leaving 3 mm of cartilage on the rib in adults and children (Figs 5-13 and

70
 Closure

Fig 5-13 A full length of the right sixth rib is exposed to Fig 5-14 It is best to transsect through the cartilage first,
the costochondral junction. allowing 3 mm of cartilage to remain on the rib.

Fig 5-15 For elevation, place a Seldin elevator under the

rib to facilitate transsection of the proximal end with ei-
ther a rib cutter or a reciprocating saw, thus delivering
the harvested rib.

5-14). Tbis effort can also be further facilitated by placing a Seldin elevator
under the rib and elevating the rib slightly (Fig 5-15).
Once the desired length of rib is reflected from its periosteum, the rib is cut
and delivered as a graft. This can be accomplished with standard rib cutters
(see Fig 5-15) or via a reciprocating saw with protection at the deep surface.
The sharp ends of the resection margin should be rounded, and small pe-
riosteal bleeding vessels that are usually present should be cauterized.

Closure
Closure is accomplished without a drain. The closure begins with the pe-
riosteal incision, which is closed with a 3-0 resorbable suture (Fig 5-16), fol-
lowed by the fascia between the pectoralis major and the rectus abdoroinis
muscles; the subcutaneous level; and then the skin surface (Fig 5-17).

71
 5 Rib

Fig 5-16 Closing the periosteum will allow some age-

dependent regeneration of the rib.
-----

Sternum

Periosteal closure after rib harvest

Fig 5-17 After the periosteum is closed, the

subcutaneous and skin levels are closed, thus
realigning the chest and breast contour.

72
 Modifications in Children

Fig 5-18 Harvesting a rib graft in a child

requires a careful technique so as to maintain
3 mm of cartilage on the rib.

Fifth rib

Reflected periosteum

Seventh rib

No. 15 scalpel

Modifications in Children
The basic surgical approach for children is the same as that for adults with
one exception. The costochondral junction area must be managed differently
in children due to the potential for the cartilage to become separated from the
rib. There are two general approaches that can be used to minimize this
potential. The first is to cut sharply through the cartilage with a no. 15 blade
once the periosteum and perichondrium have been reflected, taking care to
avoid traction on the rib until this cut is completed and to include no more than
3 mm of cartilage on the child's nb (Fig 5-18). In the past, the recommenda-
tion was to include 1 cm of cartilage on the rib, which was thought to be
required for growth. Actually, the rib growth originates from the cartilage-bone
junction, and including more than 3 mm of cartilage increases the risk not only
of separating the cartilage from the bone by its long lever arm, but also of over-
growth of the rib graft and hence that side of the mandible once puberty
occurs. Harvesting a child's rib graft, leaving only 3 mm of cartilage, has a
very low propensity for separation of the cartilage from the rib.

73
 I 5 Rib

Fig 5-19 A second approach in harvesting

a rib graft in a child is to leave a periosteal-
perichondrial sheath on the harvested rib.

'
'
Reflected periosteu ' Sternum

Reflected perichondrium

Periosteal/perichondrial sheath
overlapping cartilage-bone junction

The second recommended approach is to leave a sleeve of periosteum and

perichondrium across the cartilage-bone junction (Fig 5-19). Although this will
further reduce the likelihood of cartilage separation from bone, it increases the
risk for pneumothorax. This approach should not be used to justify leaving
more than 3 mm of cartilage in the rib.

Dressing
The suture line should be coated with an antibiotic ointment, and a light cover
dressing should be applied (Fig 5-20). Drains are not necessary if hemostasis
was obtained before closure. Surgeons are cautioned not to place so-called
pressure dressings on the chest because they will restrict chest expansion and,
coupled with some anticipated postoperative pain, lead to atelectasis.

74
 Complications

Fig 5-20 A simple cover dressing that does not restrict

inspiratory movements is the only dressing required .

...~:; ..

,..,:-. .· ·
..
/. .
:-

' .·
. ··.·-·:..

/Y:.h~&:;. .,:..·:.
..· .-..-;·

r • .. ::: : :

···:·

Dressing wrth tape at periphery

-·~
'"-/,r

Postoperative Care and Instructions

A postoperative chest radiograph should be taken in the recovery room to rule
out a pneumothorax or hemothorax.. Su tures may be removed in 7 days. Nor-
mal activity is pennitted after 7 days, but sports, jogging, weightlifting, and
other activities requiring exertion and prolonged deep breathing should be
curtailed for 6 weeks.

Complications
Although uncommon, the most likely complication is a pneumothorax.. Most
are small (less than 100/o in size) and are the result of a relatively small tear in
the parietal pleura. If the pneumothorax is recognized during surgery, it can

75
 5 Rib

Fig 5-21 Decompression of a small intraoperative

pneumothorax can be accomplished
with a suction catheter.

Sternum

Purse-string suture

Suction catheter

Fig 5-22 Withdrawing the suction catheter while

tightening the purse string suture will resolve a small
pneumothorax and reseal the pleura

Sternum

Reflected periosteum

Closed purse-string suture

Suction catheter

usually be eliminated with the following maneuver: Place a small suction

catheter around which a purse-string suture has been placed (Fig 5-21) !hrough
the tear, then withdraw the catheter under suction while simultaneously tight-
ening the purse string (Fig 5-22). ff the pneumothorax is not recognized until

76
 Complications

Fig 5-23 Both a pneumothorax and a hemothorax

are drained through the fifth intercostal space in the
midaxillary line and connected to a water-sealed
. suction drainage system.

\
.
.::·.~~:f~~ ~·
'!•

Partially deflated lun

'
'·
Space between fifth
and sixth ribs
" Fully aerated lung

Skin incision with

purse-string suture

Air fluid level

Chest tube drain

Note: Drain is placed over the top of the sixth

rib in the fifth intercostal space.

a chest radiograph is taken and it is 100/o or less in size, it can be left to reab·
sorb without the placement of a chest tube provided it is followed to resolution
by serial postoperative chest radiographs. Ha small pneumothorax does not re-
solve in 1 week or the pneumothorax is greater than 100/o in size, it is best to
place a chest tube in the fifth intercostal space at the midaxillary line for water·
sealed drainage (Fig 5-23). Previously, it was recommended to place such
drains in the second intercostal space for a pneumothorax and in the fifth in·
tercostal space for a hemothorax. However, due to the risk of injury to the ax-
illary or subclavian vessels and the fact that water-sealed suction drainage is
effective from nearly any intercostal space, ahnost all chest tube drams are now
placed in the fifth intercostal space whether for a pneumothorax or a hemo·
thorax (Fig 5-24).

77
···-···- - - - - - -

5 Rib

Fig 5-24 Despite working against gravity in the

upright position, a water-sealed suction drainage
system will effectively evacuate a hemothorax
from the fifth intercostal space.

Pneumothorax

Space between fifth

and sixth ribs

Hemothorax

Diaphragm

Water-sealed drainage

Other rare complications include pleuritis with pain on inspiration (mostly

seen when multiple adjacent ribs are harvested) , hemothorax, wound dehis-
cence/infection, and chondritis.
Pleuritis and chondritis are usually transitory and will diminish over time.
Early management with nonsteroidal anti-inflammatory agents usually relieves
the pain. If pain persists, an exploration and revisional surgery might be nec-
essary. Wound infections are treated with debridement, cultures, irrigation,
antibiotics, and open packing until healing by secondary intention occurs or a
secondary closure is achieved.

78
 Chapter Six

Cranial Bone

79
 6 ICranial Bone

Indications
• Block graft of p~y cortical bone with a small amount of cancellous bone
• Particulated graft, if needed, requiring the use of a bone mill

Utilization
Block. form:

• Onlay graft for midface, orbital, zygomatic, and nasal bone reconstructions
• Onlay graft for horizontal or vertical ridge augmentation of the maxilla or
mandible (less common)
• Strut graft in osteotomy gaps in orthognathic and craniofacial surgery

Particulated form:

• Alveolar cleft graft

• Sinus augmentation
• Osteotomy gap filling ~ess conunon)

Contraindications
• Previous head trauma, resulting in a thin skull thickness
•Metabolic bone diseases (eg, osteopetrosis, osteogenesis imperfecta, Paget
disease of the skull, pyknodysostosis)
• Radiation to the skull
• Osteomyelitis

Cautions
• Deformities of the skull associated with syndromic conditions
111 Children younger than 8 years

• Male pattern baldness

• Fibrous dysplasia of the skull
• Intravenous or oral bisphosphonate history or current use
• Previous skull trauma or surgery
• Adults older than 65 years

80
 Anatomy

Fig 6-1 a Osteology of the cranium, lateral view.

Coronal suture Parietal bone

Frontal bone
Squamoparietal suture

Sphenoid bone
(greater wing) Occipital bone

Temporal bone

Fig 6-1 b Osteology of the cranium, posterior view.

Sagittal suture

/.·. ; Parietal bone

~· .·
- ...
~
:.·

-~: . . . . . .
~\:·· ·::_ ... .. L.ambdoid suture

Occipital bone

Anatomy

The cranium consists of the frontal, occipital, sphenoid, and paired parietal
and temporal bones (Fig 6-1). The cranial bones are divided by four suture
lines: coronal, sagittal, lambdoid, and squamosal. The skull itself is divided

81
 6 ICranial Bone

Fig 6-2 Cross-sectional view through parietal bone and scalp.

Diploetic vasculature
(connects intracranial to
·; extracranial blood flow)

Outer cortex

Diploetic marrow space

Inner cortex

Sagittal venous sinus

into three distinct layers consisting of the outer and inner cortical tables sepa-
rated by a spongy cancellous diploe (Fig 6-2). Although the pliability of the
bone is different in a child, the layers are sufficiently defined by the age of 5
years. The thickness of the diploe varies considerably depending on age, the
specific cranial bone, and specific areas within that bone. The mean skull thick-
ness in the adult varies between 6.80 and 7.72 mm, and the calvarium of a
male measures approximately 1 to 2 mm thicker than that of a female. Because
the parietal bones are the thickest and the least variable, they are the site of
choice for a cranial bone harvest.
The blood supply to the calvarium is from intracranial and extracranial
blood vessels. The largest intracranial sources are the bilateral middle
meningeal arteries and their branches. The extracranial source is the perfo-
rating vascular network of the scalp. Th.is anastomotic network arises from
the bilateral superficial temporal, occipital, posterior auricular, supraorbital,
and supratrochlear vessels (Fig 6-3). These vessels have numerous perforators
from the scalp that penetrate through the galea aponeurotica to the periosteum
(pericranium) to enter the skull. Directly related to cranial bone harvesting is
the location of the superior sagittal venous sinus, which lies directly under the
sagittal suture and extends about 5 mm on each side of the midline (Fig 6-4).
The middle meningeal artery courses anterior to posterior just deep to the

82
 Anatomy

Fig 6-3 Extracranial vascular network arising from the

external carotid artery.

Supratrochlear artery

Supraorbital artery

ital artery

Posterior auricular artery

Fig 6-4 Harvest site in parietal bone.

Planned harvest of
outer table graft
Sagittal suture

Su rior sagittal venous sinus

Outer cortex

Inner cortex

Dura mater

83
 6 !Cranial Bone

Fig 6-Sa Harvest site of cranial graft from parietal bone.

Coronal suture

Parietal bone

Squamoparietal suture

gt.'
Thin portion of ,,..
squamotemporal bone

Course of middle
meningeal artery
in epidural space

Fig 6-Sb Relationship of middle meningeal artery to harvest site in parietal bone.

Harvest site

S uamotemporal bone

Middle meningeal artery

inner portion of thin squamotemporal bone (Fig 6-Sa) and superficial to the
dura mater (Fig 6-Sb). Tbis location is known occasionally to form an epidural
hematoma in response to a skull fracture from a traumatic incident. For this
reason and because of its thinness, which does not allow for an adequate graft,
elective bone harvesting of the temporal bone is not recommended.

84
 Patient Positioning

Fig 6-6 The patient should be positioned with a slight el-

evation of the head and 180-degree access around the
cranium.

Limitations
The amount of bone available in the parietal bone is limited to 2 cm from the
midline superior sagittal sinus and 2 cm from the thin squamous portion of the
temporal bone inferiorly. The thickness is usually limited to only the outer
table and the thin marrow space between the outer and inner tables. Cranial
bone grafts are mainly cortical in nature with little cancellous marrow. Owing
to their cortical mature and their thinness, they may fracture during harvest-
ing, thus limiting the size of a single piece of graft.

Patient Positioning
Cranial bone graft harvesting should be performed under sterile conditions in
an operating room facility. The table is usually turned 90 to 180 degrees from
the anesthesia machine to provide for the greatest circumferential access to the
head. With the patient in the supine position, this arrangement provides excel-
lent access to the entire head with the exception of the occipital region, which
is not an area for calvarial bone harvest (Fig 6-6). The table should be flexed
for a 30-degree elevation to gain the best angle of entry to the parietal area as
well as to reduce venous pressure, which will decrease bleeding and hence in-
traoperative blood loss. The head is usually stabilized by simply placing 5-lb
sandbags or 1 L intravenous solution bags on each side of the head. A Mayfield
head frame can also be used; however, care must be taken to support the head
during positioning because the head frame extends past the operating table's
edge and requires tightening of multiple mobile joints before it becomes rigid.
There is no need to shave the head for routine elective harvesting of parietal
bone. Instead, the authors recommend lubricating the hair with a gel to iden-

85
 6 I Cranial Bone

Fig 6-7 Parting and preparation of the hair (with the aid of a
lubricant gel) for a coronal incision to access the parietal bone.

tify the planned incision line. Tufts of hair are then twisted together and se-
cured with small rubber elastics (Fig 6-7). In cases where an open trauma in-
jury has occurred and the oral and maxillofacial surgical team is working with
a neurosurgical team, the scalp may be shaved and an antiseptic vinyl drape
placed to reduce the potential for contamination.
In most operating rooms, sterile water-impermeable catchall bags are avail-
able; when affixed to the drapes, these bags will collect irrigation fluids and pre-
vent wetting of the drapes and a slippery floor. The surgical fi.dd should be
widely exposed with sterile drape towels either sutured or stapled to the pe-
riphery. If the facial area is included in the field, the authors recommend the
use of plastic corneal protectors and/or suturing the eyes closed. The oral cav-
ity is usually sealed off with a semipermeable occlusive drape, such as a Tega-
derm (3M) or OpSite (Smith & Nephew).

Surgical Approach

Outer table grafts

Split calvarial grafts consisting of the outer table cortex and a small amount of
cancellous marrow are the most COIIllllon; these can vary in size according to
the requirement at the recipient site. However, the larger the graft, the more
likely that it cannot be harvested as a single piece.

86
 Surgical Approach

Fig 6-8 Location of incision for a coronal flap to access the parietal bone.

Fig 6-9 Location of incision for a bicoronal flap to access t he parietal bone.

The scalp incision begins in line with the top edge of the helix of the ear and
extends to the midline (Fig 6-8). For larger grafts, this incision can be extended
to the preauricular area and across the midline. For extended and bicoronal
flaps, it is best to curve the incision slightly in the anterior direction to paral-
lel the hairline (Fig 6-9). The incision is immediately carried through the skin,
subcutaneous, and galea aponeurotica levels and then quickly undermined

87
 6 jCranial Bone

Fig 6-10 Raney clips must be placed quickly and include all layers of the
scalp superficial to the periosteum.

both anteriorly and posteriorly so as to allow for the placement of Raney clips
(Fig 6-10). This maneuver must be performed quickly, or the robust blood
supply of the scalp will result in an Wllleeded excess blood loss. In cases re-
quiring a longer scalp incision, it is advisable to accomplish the incision in
shorter sequential segments so as to control the bleeding more quickly.
Once the Raney clips are in place over the full length of the incision, a sep-
arate incision is made through the periosteum, which is reflected as necessary
to expose sufficient parietal bone for the intended graft and to identify the
midline suture and the squamoparietal suture (Fig 6-11) . Self-retaining retrac-
tors (eg, Wheatlander) or assistant-held retractors should maintain sufficient
visualization for the harvest site and these two sutures.
A rectangular or oval graft outline is marked on the bone surface with al-
lowance given for 2 cm of clearance each from the sagittal suture at the mid-
line and the squamoparietal suture (Fig 6-12). The outlined area is then
perforated along its periphery with a no. 702 bur to the endpoint of the fluted
portions of the bur (4 mm) or until bleeding is observed (Fig 6-13). These bur

88
 Surgical Approach

Fig 6-11 Exposed parietal bone har-

vest site.

Fig 6-12 For best results, the harvest

should be outlined first and should be
at least 2 cm from the sagittal suture
and the squamoparietal suture.

Fig 6-13 Connected bur holes to the

level of the marrow space outline the
depth as well as the size of the parietal
bone graft.

89
 6 ICranial Bone

Fig 6-14 Connect the initial bur holes to outline the periphery of the graft.

Fig 6-15 Beveling the bone adjacent to the graft will

allow a more direct access for osteotomes or a saw.

holes are then connected under copious irrigation (Fig 6-14). H desired, these
bone shavings (or bone "dust") can be collected and used in mortar fashion as
a bone paste in the spaces between bone segments at the recipient site. Once
the graft is outlined in this manner, it is best to bevel each edge using an acrylic
finishing bur under copious irrigation (Fig 6-15). This will improve the access
for the graft-harvesting instrument of the surgeon's choice.
The authors prefer to start the graft elevation with a saw cut of about 4 mm
into the graft beneath the outer cortex using a flexible reciprocating saw or a

90
 Surgical Approach

Fig 6-16 Begin the graft elevation using a flexible reciprocating

saw to allow a more firm purchase of a curved osteotome.

Fig 6-17b Move the curved osteotome circumferen-

Fig 6-17a A curved osteotome can be used to com- tially around the graft periphery several times to gradu-
plete the harvest of an outer table graft. ally elevate an outer table graft in one unit.

right-angle oscillating saw (Fig 6-16). This will begin the graft harvest and per-
mit the introduction of a curved osteotome (Fig 6-17a). The osteotome is mal-
leted from the periphery to the center of the graft and then advanced toward
the center 1 to 2 mm at a time as the osteotome is moved circumferentially
around the graft periphery (Fig 6-17b). It usually requires several complete

91
 6 I Cranial Bone

Fig 6-18 Outer table parietal graft elevated from the Fig 6-19 Bone cement is commonly used to re-create
inner table. the curvature of the cranium at the harvest site.

Fig 6-20 Commercial bone cements will osseointegrate, but place-

ment of undercuts improves their initial retention and stability.

trips around the periphery to advance the osteotome sufficiently toward the
center to be able to lift it off the inner table (Fig 6-18).
Once the graft is separated and placed in a moist saline or platelet-rich
plasma (PRP) environment, attention is turned to gaining hemostasis at the
harvest site. Bleeding points can be cauterized. However, bone wax will also
be needed to control the oozing type of bleeding in some areas of these grafts.
It is best to use the nllnimal amount of bone wax necessary to control bleed-
ing because excessive amounts will interfere with the adherence of the bone ce-
ments commonly used to reconstruct the skull contour (Fig 6-19).
The contour of the cranium is usually restored with a bone cement such as
Bone Source (Stryker CMF), Norean (Synthese CMF) , or Mimic Q§ (Biomet
Microfixation) (Fig 6-20). These are all essentially tricalcium phosphate ce-

92
 Surgical Approach

Fig 6-21 In large graft harvest sites, placing a thin tita-

nium mesh before the bone cement sets will increase re-
tention and resist particulation of the cement.

Fig 6-22 Fixation of the mesh is best acccomplished with the use of
4-mm monocortical screws at the periphery of the harvest site.

ments that, when mixed, isothermically set up into hydroxyapati.te and os-
seointegrate into the bone to stabilize the cement. Nevertheless, the authors
have found that placing undercuts beneath the outer table at the periphery of
the defect will assist its initial stabilization prior to setting in a manner similar
to dental plaster. V\lhile the cement is setting, a moistened instrument or gloved
finger is used to sculpt the ideal contour and smooth the surface.
In grafts of a very large surface area (ie, greater than 6 X 6 cm), it may be
necessary to place a thin titanium mesh over the site to add structural support
and retention to prevent cracking and particulation (Figs 6-21 and 6-22).

93
 6 ICranial Bone

Fig 6-23 Two deep layers are closed before the scalp surface is closed
with either 3-0 nylon sutures or skin staples.

Clomre
The closure is accomplished in layers with 2-0 or 3-0 resorbable sutures. The
authors place either a 1/4-inch Penrose drain or a 7-mm fully fluted, flat suction
drain in the subgaleal plane prior to the first layer of closure at the subgaleal
level. The drain is usually exited in the postauricular area over the mastoid
prominence. As part of the closure, the Raney clips must be removed. Usually,
bleeding points remain controlled; however, if bleeding points restart, the more
deeply located bleeding points can be electrocauterized. It is best to refrain
from cauterizing the more superficial bleeders because of the risk of damaging
hair follicles, which can lead to areas of alopecia. In such situations, injection
of a local anesthetic with 1:100,000 epinephrine and the suturing itself will
control these bleeding points. The dermal level is closed after the galea aponeu-
rotica, then the scalp surface is closed using either 3-0 nylon sutures or staples
(Fig 6-23).

Alternative technique using a Gigli unre saw

Some surgeons find the Gigli wire saw useful in harvesting outer table cranial
bone grafts, particularly when large grafts are needed. However, to use a Gigli
saw effectively, a much wider bicoronal flap reflection is required.
The same outline technique with a no. 702 bur and beveling of the entire
graft periphery are required when a Gigli saw is used. A short (51-cm) Gigli
wire saw (Zimmer) is then placed along the anterior or posterior aspect of the
outlined graft. As with the osteotome technique, starting the graft harvest with
an initial 4 mm of osteotomy into the cancellous marrow space is useful before
initiating the cutting action of the Gigli saw. The cutting action of the Gigli

94
 Surgical Approach

Fig 6-24 Separation of an outer table graft with a Gigli saw

using a back-and-forth rocking motion at an obtuse angle.

saw is created by the recommended back-and-forth rocking action of the saw

handles and is enhanced if the saw handles are angled at more than 90 de-
grees (obtuse) and in a slightly elevated position (Fig 6-24). The patient's head
will require stabilization by an assistant while the Gigli saw is in action, and the
portions of the saw blade not actively engaged should be covered with red
rubber catheters split longitudinally and placed over the round blade.

95
 6 ICranial Bone

~
l
'

Fig 6-25 A Barton pressure bandage is recommended.

Dressings
A pressure dressing is useful. The authors use fluffed gauze beneath a circum-
ferential head dressing of two Kerlix bandages (Kendall) supported by umbilical
tape ties, which provide additional pressure over the seal (Barton pressure band-
I
age) (Fig 6-25). In some cases, this type of dressing may also be overlaid with a
circumferential wrap with a 4-inch elastic tape, which will also provide additional
pressure over the scalp.

Postoperative Care and Instructions

Drains are removed after 48 hours if the drainage has decreased and there are
no signs of active oozing. The dressing can be removed after 2 days in smaller
graft harvests and after 3 to 5 days in larger graft harvests that required greater
reflection of scalp. Sutures are removed after 7 to 10 days depending on the pa-
tient's age (younger patients sooner than older patients) and the completeness
of the galeal and dermal levels of closure.
Basic neurosuxgical vital signs, including pupillary examination, state of con-
sciousness, response to commands, and sensory and motor changes, are con-
ducted every 4 to 6 hours. Postoperative as well as intraoperative antibiotics are
indicated. The authors prefer ampicillin 1 g with sulbactam 500 mg (Unasyn 3
g, Pfizer) intraoperatively and 1.5 g every 6 hours postoperatively for 3 days,
along with methylprednisolone sodium succinate (Solu-Medrol, Pfizer) 250 mg
intraoperatively and 125 mg every 6 hours postoperatively for 2 days. In peni-
cillin-allergic patients, doxycycline 100 mg daily or levofloxacin 500 mg daily
may be used. The scalp and hair should be washed and the incision coated with
an antibiotic ointment prior to placing the pressure dressing.

96
 Complications

Fig 6-26 A line of alopecia can result

from electrocoagulation of scalp vessels
or from the use of Raney dips over an
extended period.

Complications
Complications are rare and usually of minor consequence. However, because
this graft harvest is in such close proximity to the brain, very serious potential
complications can occur.
The most common complication is alopecia along the incision line (Fig 6-26).
Because this is caused by the use of electrocautery or extended graft harvest time
with Raney clips in place, a limited use of clectrocautery and an efficient graft
harvest technique can prevent this complication. In addition, releasing the Raney
clips intermittently along the wound margins will also minimize ischemic hair fol-
licle injury in cases of prolonged operating time. Bleeding from the bone harvest
site is the second most common complication. However, if the use of electro-
cautery, Surgicel hemostatic agent (Ethicon), topical microfibrillar collagen
(Avitene, Davol), and bone cement are insufficient, bone wax compressed into the
bleeding site is the best hemostatic maneuver.
Smaller inner table perforations sometimes occur and have no detrimental
consequences. Inner table perforations that include a dural tear will be asso-
ciated with a cerebrospinal fluid leak. If there is sufficient access to do so, su-
turing the dura mater will stop the leak (Fig 6-27). There is no contraindication
to placing modem bone cements directly on the dura in order to reconstruct
the defect, provided there is no dural tear. If the dura mater cannot be sutured,
use of Surgicel together with activated PRP or a commercial fibrin sealant (fis-
seal, Baxter) will effectively seal small leaks (see Fig 6-27). If there is a large
dural tear with no suspicion of a brain injury, or if the dural tear cannot be
sealed by other techniques, a patch of freeze-dried allogeneic dura can be used.
If there is a larger dural tear and a suspected brain injury, a neurosurgical con-
sultation is indicated.

97
 6 ICranial Bone

Fig 6-27 Though rare, small tears in the dura mater can be
sealed with direct suturing, a fibrin sealant, or PRP. For large
tears, an allogeneic dura mater patch should be used.

'I
·;

1
.
I

Placing the graft harvest site with a 2-cm clearance from the sagittal suture
will avoid an extensive bleeding episode from this area. However, if a surgical
misadventure extends the surgery into the venous sinus, the rapid bleeding
can be controlled by packing the opening with Surgicel and pressure. Because
the sagittal sinus contains only venous blood and there are numerous collat-
eral draining venous sinuses, this hemostatic control does not result in any
brain or scalp ischemia.
Placing the graft harvest site with a 2-cm clearance from the squamoparietal
suture will avoid injury to the middle meningeal artery. However, if a surgical
misadventure propagates a fracture that lacerates this vessel, an epidural
hematoma will result. The middle meningeal artery perfuses the meninges,
not the brain itself, and therefore does not pose a risk for ischemic brain injury,
the pressure from an expanding hematoma does. Therefore, this complication
requires an immediate neurosurgical consultation and will likely require a local
craniotomy to decompress the area and control the bleeding.

Inner Table Grafts

Inner table grafts are not generally used in elective oral and maxillofacial sur-
gery. However, they are occasionally undertaken by a head and neck trauma
team together with neurosurgeons for the immediate reconstruction of avulsive
injuries to other portions of the skull or midface, or as part of an elective in-
tracranial surgery.

98
 Inner Table Grafts

Fig 6--28 For full-thickness parietal bone harvesting,

bicortical bur holes are accomplished first.

Fig 6-29 A full-thickness parietal bone graft can be harvested without injury to the dura
mater by first reflecting it and then using a protective instrument during the saw cut.

In such cases, bur holes are first created through each table at the comers of
the intended graft (Fig 6-28). These are accomplished with Midas Rex instru-
ments, which protect the dura mater. The dura mater is then reflected from the
undersurface of the inner table so that the bur holes can be connected without
damaging the dura mater (Fig 6-29). A full skull thickness is then removed by

99
 6 ICranial Bone

Fig 6-30 Delivery of the full-thickness parietal graft is

accomplished by connecting the bicortical bur holes.

Full-thickness
cranial graft

Exposed dura mater

Parietal bone

Fig 6-31 A full-thickness parietal graft may be split so that the inner
table can be retained as a reconstruction graft for cranial contour.

f
~•" ' "
~ .·. . .. . ·. " ~~..'
' \:

• • ' . ... ...... .........,, . >

connecting the bur holes with a reciprocating saw (Fig 6-30). The graft is then
lifted off the dura mater and usually split into an outer table and inner table graft
(Fig 6-31). In this manner, the square surface area of the graft is doubled at the
expense of the thickness. Usually, the inner table is used to reconstruct the avulsed
portion of the cranium and placed at the level of the external surface. The brain
itself will expand into the small increased space (see Fig 6-31). The outer table is
placed onto the recipient site. Both grafts are affixed with 2.0-mm titanium plates
(see Fig 6-31).

100
Chapter Seven

Chin

101
 7ICbin

Indications
• Corticocancellous bl<;>ck graft of limited size (1.5 X 6 cm) if taken across the
midline
• Two (1.5 X 3 cm) corticocancellous block grafts if taken on each side of the
midline ·l
• Corticocancellous particulate graft (5 to 7 mL) if processed in a bone mill
.j
I

Utilizations
In block form:

• For horizontal and/or vertical augmentation of the maxillary or mandibular

j
alveolar ridge as site preparation for dental implants f
• Less commonly, for osteotomy gaps during orthognathic surgery l
In particulated form:

• For sinus augmentation grafting

l
J
I
i
j

Limitations
• The graft consists primarily of cortical bone.
• The maximum amount available is 0. 7 X 1.5 X 6 cm.

Contraindications
Ill Vertical resorption of the anterior mandible to a height of less than 1.5 an

• Previous alloplastic chin implant or advancement genioplasty surgery

•Presence of local apical dental infections, metabolic bone disease (eg, os-
.
4

,
1
teopetrosis, bisphosphonate-induced osteonecrosis, osteogenesis imperfecta, ;'
pyknodysostosis, etc) ,J
• Previous radiation therapy to the area
• Odontogenic cyst/tumor in the area

Cautions
• Preexisting mental nerve paresthesia
• Intravenous or oral bisphosphonate history or current use
• History of long-term or current methotrexate or steroid medications

102
 Anatomy

Fig 7-1 Topographic anatomy pertinent to the harvesting of bone from the chin.

Contours of
Contours of incisor incisor and
and canine roots canine roots

Mentalis fossa Mentalis fossa

Anatomy
In the dentate individual, the mental foramina lie at the apex of the second
premolars and about 1.5 cm superior to the inferior border of the mandible.
The buccal convex contours of the incisor teeth must also be identified. The
topography of the cortex usually includes a midline ridge and shallow fossa on
each side in which the bellies of the mentalis muscle reside (Fig 7-1). Within this
fossa are several small foramina where perforating branches of the incisive
branch of the inferior alveolar artery emerge and may cause some bleeding.
There are usually small mental tubercles at the inferior border on each side of
the midline where the mentalis muscle attaches (see Fig 7-1).
The buccolingual width of the chin ranges from 0.8 to 1.2 cm and averages
about 1.0 cm. Each cortex is 1.5 mm thick between which lies trabecular can-
cellous bone. The genial tubercles protrude from the midline of the lingual
cortex just superior to the inferior border.

103
 71Chin

Fig 7-2 Peripheral branches of the mental nerve lie just

below the mucosa! surface.

Mental foramen
Mental foramen

Branches of mental nerve

Branches of mental nerve
coursing just beneath mucosa! surface
coursing just beneath mucosal surface

In addition, the mentalis muscle originates from the labial mucosa and skin
of the chin to insert into the buccal surface of the mandible and the mentalis
tubercles in the chin area. Of partirular note is the labial branch of the mental
nerve, which courses just deep to the labial mucosa 1.5 cm orally and paralld
to the lower lip vermilion (Fig 7-2) . 'Ibis branch often lies in the path of the
labial incisional approach to the chin area and is often more superficial than ex-
pected.

Patient Positioning
A semireclining position of the dental·chair, as is used most frequently during
procedures in the dental office or outpatient setting, is recommended. For pro-
cedures in an inpatient operating room setting, the same position can be used,
but a fully supine position is also workable.

Surgical Approach
The authors prefer to position the initial incision through the labial mucosa 1
cm apical to the junction between the attached gingiva and unattached mu-
cosa (Fig 7-3). The incision should extend from the posterior aspect of one ca-
nine to the posterior aspect of the other. The initial incision is made lightly

104
 Surgical Approach

Fig 7-3 Position of incision for harvesting bone from the

chin.

Fig 7-4 Once the labial branch of the mental nerve is Fig 7-5 The periosteal reflection should expose the
identified and protected, the incision is carried down incisor root contours and should also stop short of
to the periosteum. the mentalis tubercles.

through the t:llln oral mucosa so as to avoid the labial branch of the mental
nerve. Once this nerve is identified by direct vision, the incision is deepened
through the mentalis muscle and periosteum lingual to it (Fig 7-4). The periosteum
is reflected superiorly to a sufficient degree to visualize the contours of the inci-
sor and canine roots and inferiorly to the mentalis tubercles (Fig 7-5). It is im-
portant to refrain from detaching the mentalis insertions to the mentalis tubercles
at the inferior border. To do so would not improve the surgical access and would
risk a chin proptosis.

105
 71Chin

Fig 7-6 Osteotomies used in a chin harvest.

Fig 7-7 Delivery of the corticocancellous block may

require the use of an osteotome to wedge it free.

Once the buccal cortex is fully visualized, a rectangular graft of the required
dimensions can be outlined with a marking pen. The graft outline should allow
a distance of 5 mm from the apices of the incisors and 1 cm from the inferior
border. Then follow this outline for a depth of 5 to 6 mm with the cutting in-
strument of your choice (Fig 7-6). Most surgeons use a no. 701 tapered fissure
bur under irrigation. Piezoelectric cutting instruments accomplish the same os-
teotomy with a finer cut, but the cutting time is longer. Those only interested
in a corticocancellous plug may use a trephine. With each of these instruments,
it is usually necessary to wedge out the graft using a fine osteome or p eriosteal
elevator (Fig 7-7).

106
 Surgical Approach

Fig 7-8 Smoothing the sharp edges of the harvest site

reduces postoperative discomfort.

Fig 7-9 Reconstructing the chin donor site will allow

chin contour to be maintained.

The harvested graft is then placed in saline or platelet-rich plasma (PRP).

The donor area is smoothed at the edges with a bone file or a round bur under
irrigation (Fig 7-8). The authors recommend grafting or otherwise recon-
structing the donor site defect (Fig 7-9). This can be accomplished with any of
the numerous allogeneic bone preparations, xenografts, or the tricalcium phos-
phate hydroxyapatite cements currently available.

107
 7ICbin

Fig 7-10 A chin dressing will reduce the chances of a

hematoma and also adapt the soft tissues.

The closure must reposition and close the mentalis muscle with as much
anatomical accuracy as possible, followed by a closure of the surface mucosa.
Resorbable sutures such as 3-0 chromic gut or 3-0 Vicryl are most commonly
used.
An alternative incisional approach used by some is a creviatlar (neck of tooth)
incision with vertical releases in the canine-first premolar region. Although this
flap has the advantages of avoiding the labial branch of the mental nerve and
not dissecting through the mentalis muscle, it may result in an apical reposi-
tioning of the flap, creating root exposures of the incisor and canine teeth.

Dressing
A classic chin dressing-that is, placement of fluffed sponges or cotton rolls
over the chin prominence and mentolabial crease followed by elastic tape (mi-
crofoam tape is best) with crossover slits-is recommended (Fig 7-10). These
crossover slits at the end of the elastic tape allows the inferior segment and su-
perior segments to overlap, which applies a greater adaptation to the chin and
makes it a true pressure dressing.

Postoperative Care and Instructions

Although the dressing is visible and limits the movement of the lower lip, it
does not significantly interfere with eating. A nonabrasive soft diet is recom-
mended for 1 week. The dressing may be removed after 5 days. Ice to the chin
area is not usually practical with the dressing in place, and at 5 days when the
dressing is removed it has lost its Yalue. Therefore, ice is not recommended.

108
 Postoperative Care and Instructions

Fig 7-11 Fracture at the chin harvest site usually requires an open re-
duction with rigid fixation.

Complications
Complications are rare. The most common is paresthesia of the lower lip ver-
milion. 'This complication can be avoided by identifying the superficial course
of the labial branch of the mental nerve and protecting it by the incision design
and/or direct visualization. Another potential complication is damage to the
apices of the incisor or canine roots. Allowing a 5-mm distance between the
apices of these roots and the superior osteotomy will avoid this type of damage.
Because of the vascularity of the region, intraoperative bleeding may occur.
Obvious pumping arterioles can be controlled with cautery. However, a brisk
marrow ooze requires bone wax for effective hemostasis. It is recommended
that bone wax be part of the armamentarium for this procedure. Otherwise,
Surgicel {Johnson &. Johnson) or temporary packing with epinephrine- or
thrombin-soaked sponges may be useful.
Hematomas are rare if a pressure dressing is used. Ecch.ymosis is much more
common, particularly in older women with fair skin. There is no specific treat-
ment for ecchymosis other than the surgeon's explanation and reassurance
that it is somewhat expected and self limiting.
A wound dehiscence can occur and may represent the first sign of a deeper
wound infection. However, if the dehiscence is not associated with an infection,
refreshing the wound margin and resuturing often corrects the opening. The
other option is to allow the wound to granulate for secondary healing and ac-
ceptance of a wider and thicker scar.
A mandibular fracture is possible but very rare because the inferior os-
teotomy leaves 8 to 10 mm of the inferior border. However, a fracture in this
area would require an open reduction with plate fixation due to the muscle
pull of the anterior digastrics working to displace the segments (Fig 7-11).

109
 7ICbin

Infections are also rare due to the robust blood supply in this region and the
use of intraoperative and postoperative antibiotics. It is reasonable to culture
any drainage or dehiscence and initially treat with extended antibiotics or the
addition of a second antibiotic of the surgeon's choice. However, if the site
worsens or does not show significant improvement after 3 days, a wound ex-
ploration for cultures, debridement, and irrigation with 0.120/o chlorhexidine
is recommended.

110
 Chapter Eight

Mandibular Ramu·s

111
 8 IMandt'bular Ramus

~ .. .: , ..
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~.-·
. ~.
...
Fig 8-1 A cortical block from the ramus placed for hori-
zontal ridge augmentation in the maxilla.

Indications
• A thin cortical block of limited size (3 X 5 cm) for onlay grafting related to
vertical or horizontal ridge augmentation

Utilization
• Horizontal ridge augmentation in the anterior maxilla that overlaps onto the
ridge crest-known as a ' .J" gi-aft
• General horizontal or vertical ridge augmentation of either the maxillary or
mandibular ridge as site preparation for dental implants (Fig 8-1)
• Less commonly, for sinus augmentation grafting or for osteotomy separa-
tions in orthognathic surgery (in particulated or block form)

Limitations
• The graft is almost 1000/o cortical bone.
• The maximum size of the gi-aft is 0.4 X 3 X 5 cm.

Contraindications
11Existing odontogenic cyst/tumor at the site
• Presence of local infection (eg, pericoronitis or periodontitis)
• Metabolic bone disease (eg, osteopetrosis, bisphosphonate-induced osteo-
necrosis, osteogenesis imperfecta, pyknodysostosis, etc)
• Previous radiation therapy to the area

112
 Anatomy

Figs 8-2 and 8-3 Ramus anatomy pertinent to harvesting of a ramus graft.

Coronoid process

Condyle

,
\
;: External oblique ridge

External obligue ridge

Course of inferior alveolar neurovascular bundle

Cautions
Impacted mandibular third molar located directly in the harvest site
r;:

• Previous ramus surgery such as a sagittal split osteotomy or a fracture reduc-

tion
• Intravenous or oral bisphosphonate history or current use
• History of long-term or current use of methotrexate or steroid medications

.Anatomy
The ramus of the mandible should be familiar to all oral and maxillofacial sur-
geons and dentists. The important anatomy of this harvest site is the external
oblique ridge, which emerges adjacent to the posterior one-half of the second
molar and extends posteriorly and superiorly to become the coronoid process
(Fig 8-2). In the retromolar region, the ridge scallops concavely in a medial di-
rection and then curves convexly upward into the internal oblique ridge, which
also extends superiorly and eventually blends into the medial pole of the
condyle (Fig 8-3). In the bone harvest site, the distance between the external
oblique ridge and the internal oblique ridge is about 1 cm.

113
 8 IMandibular Ramus

Fig 8-4 The temporalis muscle and te ndon may attach at the harvest site.

Temporalis muscle and tendon attachment

External oblique ridge

Internal oblique ridge

The inferior alveolar neurovascular bundle courses halfway between the ex-
ternal oblique ridge and the inferior border of the mandible (see Fig 8-2). The
temporalis tendon and some muscle fibers attach to the external and internal
oblique ridges as well as the fossa in between (Fig 8-4). The lingual nerve
emerges into the retromolar area from between the medial pterygoid insertion
into the medial ramus and the temporalis muscle/tendon insertion on the in-
ternal oblique ridge to course just medial to the lingual cortex in the retromo-
lar, third molar, and second molar areas before turning more medial into the
floor of the mouth and tongue (Figs 8-5 and 8-6). The long buccal artery and
sensory nerve descend from the internal maxillary artery and mandibular
nerve, respectively, to follow the trajectory of the external oblique ridge on its
lateral aspect (see Fig 8-5).
The cortex in this area usually measures from I mm to as much as 3 mm
thick and contains a sparse cancellous marrow deep to the cortex. Note that
with advancing age (older than 50 years), this marrow space becomes more
fatty in a variable manner.

114
 Anatomy

Fig 8-5 Neurovascular anatomy pertinent to harvesting of bone from the ramus.

Temporalis muscle

Mandibular nerve

Long buccal nerve and artery

Inferior alveolar
neurovascular bundle

Medial pterygoid muscle

Lingual nerve

Fig 8-6 Lingual nerve emerging from between the tem-

poralis and medial pterygoid muscles.

115
 8 Mandibular Ramus
J

Figs 8-7 and 8-8 Incision design and soft tissue retraction for a ramus bone harvest.

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Incision over Retractor to expose a

external oblique ridge portion of the anterior ramus

Patient Positioning
A semireclinhig position of the dental chair, as is used most frequently during
procedures in the dental office or outpatient setting, is recommended. For pro-
cedures in an inpatient operating room setting, the same position can be used,
but a fully supine position is also workable.

Surgical Approach
The superior starting point of the incision is made at the level of the maxillary
occlusal plane and directly over the palpable external oblique ridge (Fig 8-7).
This will avoid damage to the long buccaI artery and nerve in most cases. The
incision is then carried forward along this ridge to end opposite the second
molar. An alternative approach extends the incision into the buccaI gingival sul-
cus of the second molar; however, a vertical releasing incision is often neces-
sary when this incision is used. Periosteum and the temporalis tendon are
reflected to the internal oblique ridge medially. Periosteum and the temporalis
tendon are also reflected from the external oblique ridge to the midramus
height or to the height of the observed antilingula bony expansion on the lat-
eral ramus after the masseter is reflected from this area. Curved Obwegeser soft
tissue retractors are helpful for retracting the lateral tissues, and a notched an-
terior ramus retractor is helpful for retracting the temporalis fibers and ante-
rior ramus mucosa superiorly (Fig 8-8).

116
 Surgical Approach

Fig 8-9 Outline of a precise graft harvest with a series of bur holes.

. It is best to start the osteotomy in the fossa between the external and inter-
nal oblique ridges at the level of the maxillary occlusal plane. The authors
make a series of bur holes from posterosuperiorly using a no. 702 tapered fis-
sured bur and stopping 5 mm from the distal root of the third molar (or sec-
ond molar if the third molar was removed) (Fig 8-9). A common error made
by some surgeons is to inadvertently remove the cortical bone over the third
or second molar r~ots, thus creating a periodontal defect or causing a healing
complication. Therefore, ending the initial osteotomy 5 mm short of the last
molar keeps the bone harvest in the ramus. The holes made with the no. 702
bur are made only through the cortex to outline the desired graft length and
thickness. The same bur is then used to connect these holes and to make cor-
tical osteotomies through the external oblique ridge at each end of the graft.
These cortical osteotomies should extend through the ramus cortex postero-

117
 8 IMandibular Ramus

Figs 8-10 and 8-11 Connecting the bur holes to

complete the rectangular graft.

I
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I
I
I
I
I
I
I

superiorly and through the buccal cortex at the anterior extent of the graft (Fig
8-10). The last osteotomy is made through the lateral ramus cortex poste.ro-
laterally to complete a rectangular cortical bone outline (Fig 8-11). Because ac·
cess is limited, most surgeons make a more shallow cortical scoring of this
osteotomy that facilitates an outfracture of the cortical plate graft with an os-
teotome later. Alternatively, this lateral and inferior osteotomy can be made
with a fine right-angle oscillating saw. Piezoelectric systems may be used as an
alternative cutting instrument that will make a finer cut but will require a
slightly longer time.
Once the cortical osteotomies are completed, a bibeveled osteotome is in-
serted at a lingual to buccal angulation and malleted inferiorly and posteriorly
(Fig 8-12). Tbis angulation will ensure that the blade of the osteotome remains
against the inner cortical surface of the buccal/lateral cortex to give maximum
protection to the inferior alveolar neurovascular bundle. The mostly cortical
graft is then wedged loose from the stable ramus and delivered with a hemo-
stat or a Coker instrument (Fig 8-13). ·
The edges of the donor site should be rounded off and the wound inspected
for adequate hemostasis. In most cases, no special hemostati.c agents are re·
quired. However, for any brisk bleeding, bone wax provides the most reliable
control. For a general ooze, platelet-poor plasma (PPP), platelet-rich plasma
(PRP), or microfibrillar bovine collagen (Avitene, Davol) are also useful. The
closure is accomplished in two layers: a periosteal layer and a surface mucosal
layer using 3-0 chromic suture for each layer (Fig 8-14).

118
 Surgical Approach

Fig 8-12 A bibeveled osteotome is useful for separat- Fig 8-13 A graft of mostly cortical bone is delivered on
ing the ramus graft from the harvest site. a hemostat or a Coker instrument.

I
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I
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,
.......
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',....,
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II
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Fig 8-14 Closure of the periosteum and surface mucosa

is sufficient.

119
 8 IMandibular Ramus

Dressing
No dressing is required. However, removable pressure packs, which are used
routinely following third molar slirgery, are recommended for the first few hours.

Postoperative Care and Instructions

There are no specific postoperative instructions beyond the common sense
precautions of a soft, nonabrasive diet. Ice to the side of the harvest site is rea·
sonable for 24 to 48 hours but not longer.

Complications
Complications are rare. Inferior alveolar nerve injury is the most likely and
raises the specter of a potential medicolegal issue. The technique described
here works against an irrjury to the inferior alveolar nerve. The salient points
of protection are to measure the graft size against the panoramic radiograph,
allowing for a 250/o magnification and concluding the inferiormost osteotomy
5 mm above the radiographic representation of the mandibular canal. In ad-
dition, maintaining the osteotome or the reciprocating saw against the inner
cortical wall allows a layer of trabecular bone between the graft and the
mandibular canal so as to prevent any sharp penetration of the canal.
Should a misadventure occur resulting in an observed partial or complete
transsection of the inferior alveolar nerve (Fig 8-15a) , it is ideal to accomplish
an immediate microneural reanastomosis/epineural nerve repair. If the surgeon
is not equipped to accomplish a microneural surgery (microscope or loop mag-
nification of 3 X or better) at the time of the observed irrjury, it is acceptable to
close the wound and refer the patient for an early secondary repair (Fig 8-15b).
The earlier the repair is accomplished yields the best results up to about 3
months. After 3 months, nerve regeneration rapidly declines up to about 6
months, after which time one cannot expect much further nerve regeneration
with a microneural repair.
If no nerve injury was observed and the likelihood of an unobserved nerve
injury is low, and yet the patient reports postoperative paresthesia or anesthe-
sia of the lip and chin region, it is best to avoid reentry and allow the nerve to
recover and/or regenerate undisturbed. Once again, the maximum return of
sensation is complete between 6 and 9 months.
A lingual nerve injury is also a possibility but less likely due to the graft har-
vest arising from the buccal cortex. The same nerve injury considerations
apply to an observed or unobserved lingual nerve injury as they did to the in-
ferior alveolar nerve.
A hematoma is also possible but unlikely. It would be characterized by a
tense swelling over the area and possibly blood oozing from around the mcision
line. Static hematomas can be left to resorb. However, continually expanding

120
 Complications

Fig 8-1 Sa An observed nerve injury or inadvertent

transsection is best treated immediately.

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Fig 8-1 Sb A nerve anastomosis using an epineurial closure under

loop or microscope magnification will attain the best outcome.

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121
 8 IMandibular Ramus

Fig 8-16 Open reduction and internal fixation using a

box plate to treat the rare occurrence of an angle frac-
ture secondary to a ramus graft harvest.

hematomas are best treated by reentry, evacuation of the hematoma, control

of bleeding, and reclosure or placement of a dram.
Wound infection may occur and may even lead to an osteomyelitis. It is rea-
sonable to culture such infections and treat with appropriate antibiotics. How-
ever, if the infection persists beyond 21 days, a wound reentry for debridement,
cultures, irrigation, and a course of intravenous anubiotic therapy is advisable.
A mandible fracture is also a possible complication. It may occur during the
procedure or within the first month of the postoperative course. If the fracture
occurs during surgery or in the early postoperative course, is not displaced,
and is unrelated to an infection, maxillomanclibular fixation is recommended.
If the fracture is displaced or unfavorable, an open reduction with internal fix-
ation is necessary (Fig 8-16).

122
~

I
Chapter Nine

Maxillary Tuberosity

: : t t"'•"'/ ,"::orCI. ": .,, s.t ,• .,!',...,._,,•. -,.., •:":

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123
 9 [Maxillary Tuberosity

Indications
• Autogenous cancellous marrow graft material for small defects

Utilization
• Socket grafting for ridge preservation and for periodontal and peri-implant
bony defects
• Small sinus augmentation procedures
• Large sinus augmentation procedures when mixed with allogeneic,
xenogenic, or bone substitute particles
• Small osteotomy gaps

Limitations
•The maxillary tuberosity contains a limited amount of bone (1 to 3 mL).
• The bone is only cancellous marrow and therefore cannot be used as a block
graft or strut.
•In patients older than 50 years, the tuberosity consists mostly of fatty mar-
row and is thus a limited source of osteogenic cells.

Contraindications
•A hyperpneumatized sinus extending into the tuberosity (no bone remains)
•Metabolic bone disease (eg, osteopetrosis, bisphosphonate-induced oste-
onecrosis, osteogenesis imperfecta, and pyknodysostosis)
c Local osteomyelitis
1>: Radiation to the tuberosity in excess of 5,000 cGy

Cautions
• Hyperpneumatized maxillary sinuses that partially extend into the tuberos-
ity, which increase the risk of an oroantral communication
• The presence of an impacted third molar
• Intravenous or oral bisphosphonate history or current use
11 History of long-term methotrexate or steroid use

124
 Anatomy

Fig 9-1 Harvest site of maxillary tuberosity related to maxillary sinus and
posterior superior alveolar neurovascular bundle.

Pterygomaxillary fissure
Posterior superior alveolar
neurovascular bundle

Lateral pterygoid plate

Maxillary sinus

Hamular notch

Anatomy
The maxillary tuberosity is essentially the alveolar bone for the third molars,
which will have usually been removed years before. It is the bone from the
posteriormost aspect of the maxillary alveolar crest anteriorly to the second
molar tooth. The maxillary tuberosity is bounded superiorly by the floor of the
maxillary sinus, inferiorly by the overlying gingiva, and posteriorly by the
pterygomaxillary fissure, where the pterygoid plates attach (Fig 9-1). It gets its
blood supply from the posterior superior alveolar artery above and its inner-
vation via the corresponding posterior superior alveolar nerve (see Fig 9-1).

Patient Positioning
The usual dental chair position with greater than usual recline is preferred.

125
 9 IMa.xiilary Tubcrosity

Fig 9-2 lncisional access for a maxillary tuberosity graft begins in the
hamular notch and may include a releasing extension.

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Fig 9-3 Identifying the approximate location of the maxillary sinus

floor is useful in gauging the amount of bone that can be removed.

Surgical Approach
A midcrestal incision is made beginning in the hamular notch and then carried
foiward to the second molar, where a crevicular incision to the mesial aspect
of the second molar extends the access of the reflected mucoperiosteal flap a
modest amount for a harvest under direct vision (Fig 9-2). The location and
level of the maxillary sinus floor are outlined on the lateral wall of the tuberos-
ity based on measurements taken from a panoramic radiograph or an office-
based computed tomography (GT) scan (Fig 9-3). A rongeur is used to "bite

126
 Surgical Approadi

Fig 9-4 A maxillary tuberosity graft can be harvested with a rongeur instrument.

: : t" ··~·.,,"f:lo rs... • '"'' ~~.r .... :-.~, ....... • ;~

·-·

Fig 9-5 Gentle use of a· bone file will eliminate sharp edges while avoiding injury to the sinus membrane.

off'' a segment or all of the tuberosity, allowing for a 2-mm clearance from the
maxillary sinus (Fig 9-4). It usually takes only one bite of the rongeur to ob·
tain the graft, although larger maxillary tuberosities may require two. The ir-
regular surface of the donor site is lightly smoothed with a bone file. To avoid
a sinus communication, use caution to limit the hand pressure on the bone file
(Fig 9-5). The reflected periosteum is directly closed in a single layer using a
3-0 resorbable suture.

127
 9 IMaxillary Tuberosity

Fig 9-6 Removal of extensive bone in the maxillary

tuberosity may resu lt in an oroantral communication.

Dressings
None.

Postoperative Care and Instructions

Nothing more than postoperative antibiotics and analgesics is required for the
complication-free tuberosity harvest. However, if the sinus floor is removed
with or without entry into the sinus cavity, postoperative decongestants and
sneezing precautions for a period of 5 to 7 days are advised.

Complications
Though rare, the most likely intraoperative complication is entry into the max-
illary sinus (Figs 9-6 and 9-7). However, even if this occurs, suturing the mu-
coperiosteal flap for a primary closure ahnost always results in uncomplicated
healing and avoidance of an oroantral fistula (Fig 9-8). Should the closure de-
hisce and result in an oroantral fistula, a secondary closure is necessary. Either
a sliding buccal flap over a membrane or a two-layer closure with utilization of

128
 Complications

Fig 9-7 Oroantral communication resulting from a maxillary tuberosity harvest.

. . - -···.. .

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. . /"

Fig 9-8 A primary closure, accomplished by advancing undermined buc-

cal mucosa, often successfully closes the oroantral communication.

129
 9 IMaxillary Tuberosity

Fig 9-9 A split-thickness incision of Fig 9-11 A palatal "finger flap" covers
mucosa will allow it to be inverted Fig 9-10 Closure of the inverted mu- the inverted mucosa for a double-
into the sinus and be confluent with cosa will seal the sinus membrane as layer closure. The exposed palate will
the sinus membrane. the first layer of closure. heal by secondary intention.

Fig 9-13 The buccal fat pad will appear at the wound
edge after the periosteum is incised .

....
........ ._...... ·.....
::
•' # •

:.~
·:~::

Fig 9-12 Oroantral communication.

a palatal finger flap over an inverted fistula closure can close these fistulae (Figs
9-9 to 9-11). For the most predictable closure in this area, however, the authors
prefer a buccal fat pad advancement (Figs 9-12 to 9-16).

130
 Complications

Fig 9-14 The buccal fat pad can be mobilized and

advanced by blunt dissection around its periphery.

Fig 9-15 The prominent vascularity

of the buccal fat pad will promote a
rapid healing and a permanent clo-
sure of the opening.

Fig 9-16 Although the buccal fat pad will epithelialize if left open,
advancing the buccal mucosa as a cover is recommended.

~/
(/
/

Another rare potential intraoperative complication is bleeding from the pos-

terosuperior alveolar artery or, even less likely, from the sphenopalatine artery
as it courses between the pterygoid plates and the posterior wall of the max-

131
 9 IMaxillary Tuberosity

ilia. Because each of these blood vessels is an artery that can cause significant
blood loss, a further local dissection would be necessary to visualize the ves-
sel for ligation or clirect cautery.
Yet another rare potential complication is a postoperative periostitis that can
result from sharp edges of the harvest site, causing injury and inflammation in
the periosteum. This complication is avoided by the maneuver of filing the
edge with a bone file. However, if a periostitis develops and a sharp or irreg-
ular bony shelf is palpated, a reentry into the site to eliminate it may be re-
quired.

132
 Chapter Ten

Recombinant Human
Bonel\tlorphogenetlc
Protein-2/Acellular
Collagen Sponge

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133
 10 IrhBMP-2/ACS

Fig 10-1 a The mechanism of rhBMP-2/ACS . involves
chemotaxis of osteoprogenitor cells, cell surface bind-
ing, cellular proliferation and differentiation, and bone
formation.
Fig 10-1b rhBMP-2/ACS regenerates osteoid, which
then undergoes resorption and remodeling into a more
mature ossicle as seen here. 0, osteoid; MB, mature
bone with lamellar architecture; R, osteoclastic resorp-
tion of osteoid.

Indications
Recombinant human bone morphogenetic protein-2/acellular collagen sponge
(rhBMP-2/ACS) (Infuse Bone Graft, Medtronic) was cleared by the US Food
and Drug Administration (FDA) for orthopedic lumbar spinal fusions in 2002,
for open tibial fractures in 2004, and for oral and maxillofacial sinus floor aug-
mentations and alveolar ridge preservations in March 2007. It offers an alter-
native to autogenous bone grafting without the morbidity of bone harvesting.
Like autogenous grafts and unlike allogeneic and xenogenic bone grafts and
all bone substitutes, it regenerates new bone on its own. Its mechanism is solely
through osteoinduction.

Mechanisms of Action
Placed into a bony defect, the bound BMP in the acellular collagen sponge is
chemotactic to stem cells and preosteoblasts. As these cells migrate into the
sponge, they undergo proliferation and differentiation into osteoblasts, which
then synthesize osteoid. Once this process is initiated, the osteoid will undergo
the standard resorption-remodeling cycle of bone to a mature ossicle in 6
months (Figs 10-1 a and 10-1 b).

134
 Utilization

Human DNA C-DNA Bacte~al

fI (i T
. BMP plasmid

/•=f+
Transfection Integration

hBMP gene

(~(~
~l~)
+r
Lyophilization
CC<+r
'j ) (~ ) Cell
(freeze ( ( culture
Vial of hBMP drying) mg/g/,kg hBMP
(1-1 2 mg) synthesis
hBMP

Fig 10-2 The cloning process used to produce rhBMP-2 involves gene isolation, t rans-
fection, biointegration, biosynthesis, purification, concentration, and lyophilization.

Production of rhBMP-2/ACS
The production of rhBMP-2 begins with restricted fragment enzymes, which
cleave the BMP-2 gene from chromosome 20 in the human genome. 1bis vi-
able human gene is then transfected into a bacterial plasmid, which is a circu-
lar portion of bacterial DNA outside its normal nucleus. This bacterial plasmid
is then transfected into a chromosome in Chinese hamster ovary (CHO) cells
and cultured to increase their numbers. As the CHO cells produce a variety
of hamster proteins, they also produce one unique human protein (BMP-2)
that is separated and purified by electrophoresis and nanofiltration to produce
a purely human protein free of bacterial or animal proteins and in sufficiently
high concentrations to regenerate bone in humans (Fig 10-2).

Utilization
On-label applicatiuru
• Sinus augmentation
• Localized alveolar ridge reconstruction

135
 10 I rhBMP-2/ACS

Fig 10-3 rhBMP-2/ACS is FDA cleared for sinus aug-

mentation as well as ridge preservation. Here, the
rhBMP-2-impregnated ACS is placed into a sinus eleva-
tion defect.

Off-label applicat'ions
•Supplement or alternative to autogenous, allogeneic, or xenogenic grafts for
reconsttuction of defects such as nonunions, larger ridge augmentations, alve-
olar clefts, implant salvage, osteotomy gaps, craniofacial defects, and conti-
nuity defects of the mandible.

Limitations

Biologic
The acellular collagen sponge is an ideal carrier for rhBMP-2 in terms of its
capacity to bind and release the protein. However, it is less than ideal as a ma-
trix upon which bone can regenerate because it resorbs too quickly; in larger
defects, the result can be voids or an insufficient bone regeneration. There-
fore, use of rhBMP-2/ACS with the sponge alone should be limited to the
FDA-cleared indications of sinus augmentation {Fig 10-3) and localized alveo-
lar ridge grafting.
The authors have found that larger sinus defects regenerate bone best if the
rhBMP-2/ACS is combined with freeze-dried allogeneic crushed cancellous
bone by cutting the rhBMP-2-impregnated sponge into squares and mixing
the two as a composite in a 1:1 ratio (Fig 10-4). In other larger defects, such as
horizontal and vertical ridge augmentations, the authors also add platelet-rich
plasma (PRP) to enhance the matrix with the cell adhesion molecules of fib-
rin, fibronectin, and vitronectin (Fig 10-5). In these situations, the crushed can-
cellous allogeneic bone with or without the PRP acts as an enhanced matrix
for bone regeneration (Figs 10-6 and 10-7).

136
 Contraindications

Fig 10-4 rhBMP-2/ACS is added to crushed cancellous Fig 10-5 rhBMP-2/ACS combined with PRP and crushed
freeze-dried allogeneic bone, which acts as an improved cancellous freeze-dried allogeneic bone provides a
matrix (scaffold) for bone regeneration. composite cell signal and matrix for maximum bone
regeneration.

Fig 10-6 Severely resorbed maxilla before composite Fig 10-7 Excellent bone formation and acceptance of
graft of rhBMP-2/ACS, PRP, and crushed cancellous implants.
freeze-dried allogeneic bone.

The cost of rhBMP-2/ACS is significant and varies according to the dose re-
quired. Therefore, the cost should be reviewed with the self-paying patient
prior to use and should be approved prior to use for the individual with third-
party coverage.

Contraindications
• Known hypersensitivity to type I bovine collagen or to rhBMP
•Active malignang.; whether or not in treatment
•Pregnancy
• Active infection at the recipient site

137
 10 IrhBMP-2/ACS

-_ '
~

:,.!-~~· . . ~SC- . : . ,• • ~- • • ')~: ~ t

·, ~····· ··· --

t'.I~~;·:.·~ . .· .·: ·~~· :.:

Fig 10-8 The lyophilized rhBMP-2 powder
. .···... ..,·.·:-.. ··
Fig 10-9 The rhBMP-2 in the solution should be uni-
• c..
=~·.-· ~

should be dissolved only with the volume of formly added to the acellular collagen sponge and al-
sterile water provided in the package, lowed to bind for a minimum of 15 minutes.
swirled (not shaken), and allowed 5 minutes
to dissolve completely.

Cautions
i:::Children younger than 18 years due to insufficient data in skeletally imma-
ture patients
•Nursing women
1:1 Women of childbearing age without pregnancy testing

Preparation
The preselected dose of rhBMP-2/ACS is packaged as a lyophilized white pow-
der that is dissolved in a packaged volume of sterile water (Fig 10-8). Caution:
Do not substitute saline or intravenous solutions to dissolve rhBMP-2, which
will make the solution much too hypertonic. The sterile water is drawn up
into the supplied syringe and injected into the vial of powdered rhBMP-2.
Allow 5 minutes for complete dissolution of rhBMP-2. Although dissolution
can be aided by swirling the vial, it should not be shaken. After 5 minutes, the
solution is drawn up and added to the acellular collagen sponge a drop at a
time until the entire sponge/sponges are wetted (Fig 10-9). Allow a full 15 min-
utes for rhBMP-2 to bind to the collagen in the sponge; 930/o of rhBMP-2
binds to the sponge in this 15-minute period. If left to the open air, the sponge
will dry out. Therefore, it is recommended that the rhBMP-2/ACS composite
be placed into the recipient site within 2 hours. The authors place the wetted
sponge in a sterile plastic container or plastic bag, which reduces the rate of
drying and may extend the time in which it may be used.

138
 Surgical Approach

Fig 10-10 A titanium mesh crib can serve as a

containment device for rhBMP-2/ACS grafts.

Fig 10-11 Freeze-Oried allogeneic bone can also Fig 10-12 Various membranes can also serve as con-
serve as a containment device for rhBMP-2/ACS tainment devices for rhBMP-2/ACS grafts.
grafts.

Surgical Approach
There is no need to harvest autogenous bone in most cases where rhBMP-2/
ACS is used, which constitutes its major advantage. However, in some in-
stances, such as large continuity defects or in radiated tissue beds, it is used to-
gether with a smaller amount of autogenous bone than would otherwise be
harvested. Placement at the recipient site is similar to that of any particulated
autogenous, allogeneic, xenogenic, or bone substitute graft. That is, it has no
compressive strength and must be contailled by either the walls of the defect
or by a containment device such as a titanium mesh crib (Fig 10-10), reinforced
membranes, or resorbable membranes of sufficient cross linking to gain some
rigidity {Figs 10-11 and 10-12). It should be noted that when rhBMP-2/ACS
is being handled and placed, some liquid may be expressed. This liquid is
water, not a loss of rhBMP-2; the protein at this time is chemically bound to
the collagen in the sponge.

139
 10 IrhBMP-2/ACS

Fig 10-13 Greater than usual postoperative edema should Fig 10-14 Titanium mesh that becomes exposed after 2
be anticipated when rhBMP-2/ACS is used. weeks can be left exposed until implant placement 6
months after graft-mesh placement.

Postoperative Care and Instructions

There are usually no donor site postoperative instructions necessary due to the
absence of a donor site in most cases. However, the patient should be warned
that rhBMP-2/ACS will produce more swelling than an identical surgery with-
out it, and the swelling will last longer due to the chemotactic action of rhBMP-2
and because the solution is hypertonic (Fig 10-13). Intraoperative/postoperative
steroids and ice to the face may be used but are often ofless impact than in sim-
ilar cases where rhBMP-2/ACS is not used.

Complications
The most common complication is the patient's concern over swelling. This is
best treated by forewarning the patient and their family and reassuring them
that it is expected and will diminish over the next few weeks.
Occasionally, dehiscence of the incision is observed, probably related to the
pressure of the edema caused by the enhanced swelling. Such dehiscences are
more common when a titanium mesh crib is used (Fig 10-14). This complica-
tion can generally be prevented by sufficient undermining to gain a tension-
free and multilayered closure. Should a dehiscence be noted within the first 2
weeks, the surgeon is advised to resuture the area and undermine the edges fur-
ther. If a dehiscence occurs after 2 weeks, there is usually sufficient angiogen-
esis for it to heal. If a titanium mesh becomes exposed after 2 weeks, it can be
left exposed; oral mucosa will proliferate under the mesh to cover the revas-
cularized graft at that time. The mesh can then be removed 6 months later at
the time of implant placement.

140
 Chapter Eleven

Bone Marrow Aspiration and

Aspirate Concentrate

141
 11 I Bone Marrow Aspiration and Aspirate Concentrate

Indications
A source of mesenchymal stem cells and osteoprogenitor cells that can be
added to:

• Allogeneic bone grafts

•Recombinant human bone morphogenetic protein-2/acellular collagen
sponge (rhBMP-2/ACS) grafts
•Composite graft of allogeneic bone and rhBMP-2/ACS
• The existing stem/osteoprogenitor cells in an autogenous graft

Utilization
• Sinus augmentation
• Horizontal and vertical ridge augmentations
• Implant salvage procedures
• Adult alveolar clefts
• Continuity defects

Limitations
11ris procedure requires a few specialized instruments and anticoagulants as
well as some training, which is straightforward and readily mastered. For con-
centrating a bone marrow aspirate (BMA) into a BMA concentrate {BMAC),
a dual-spin cell-separating/concentrating device, which operates on the same
principles as a platelet-rich plasma (PRP) device, is required. Such devices in-
crease the available osteocompetent cell population by four .t o seven times.

Contraindications
• Bone marrow malignancies such as multiple. myeloma
• Bone marrow dysplasias
• Metabolic bone diseases such as osteopetrosis, osteogenesis imperfecta,
pyknodysostosis, etc
11: Previous radiation to the harvest site

Cautions
• Previous surgery or trauma at or near the harvest site
• Anatomical deformity at the harvest site

142
 Bone Marrow Aspiration Approach

Rg 11-1 A sharp trocar within a hollow aspiration sleeve

and two sterile syringes are the basic: armamentaria for
BMA.

Anatomy
The preferred harvest sites are the anterior or posterior ilium (see the anatomy
discussion in chapters 3 and 4). The tibia can also be used; however, it does
not yield as large a concentration of mesenchymal stem cells and osteoprog-
enitor cells and is therefore recommended only as a second choice.

Patient Positioning
Aspiration of bone marrow from the anterior ilium can be accomplished in
the semireclined or dental chair position if the procedure is performed in an of-
fice. If performed in an operating room, the normal supine position is recom-
mended.
Aspiration of .bone marrow from the posterior ilium is usually accomplished
in an operating room with the patient in the prone position as described in chap-
ter 4 for an open bone harvest from the posterior ilium. In the office setting, a
lateral derubitus position allows straightfmward access to the posterior ilium for
bone marrow aspiration while still allowing for an uncomplicated return to the
dental chair position for development of the recipient site and graft placement.

Bone Marrow Aspiration Approach

To harvest a sufficient number of mesenchymal stem cells and osteoprogeni-
tor cells for oral and maxillofacial surgery, 60 mL of autologous bone marrow
is ideal. As an alternative, 120 mL can also be aspirated if the size of the graft
warrants additional bone marrow concentrate, and 30 mL can be aspirated
for smaller defects. To maximize stem cell/osteoprogenitor cell yields, it is best
to use two puncture sites regardless of the volume aspirated. Whether the an-
terior or the posterior ilium is used, the puncture site should place the aspi-
rating trocar (Fig 11-1) between the cortices and 1 to 4 cm within the bone
(see Fig 11-8).

143
 11 IBone Marrow Aspiration and Aspirate Concentrate

·~i;j,~1~;~:. . .
:·:.... ~ ~ ·-
. , ··~ • • • I ......:

:- . ~-._~,;- ·~·;·;\~:~
. ·.• ; .;l,,'.. < '.
,· ..
· "
',. _~,... ;
.
·"·;. .
:
.~· .. ~· ..,

: ·..'··: .f.'

Fig 11-2 Ideally, puncture sites for the anterior ilium are Fig 11-3 Puncture sites for the posterior ilium are best
placed 2 to 6 cm posterior to the anterior superior spine. placed in the area of the gluteus maximus muscle inser-
tion, which contains the greatest marrow volume.

Fig 11-4 A blood collection bag is provided in the BMAC

kit. Four ml of ACD-A anticoagulant solution should be
placed into the bag before the BMA is added.

For the anterior ilium, the best puncture sites are 2 to 6 cm posterior to the
anterior superior spine (Fig 11-2). For the posterior ilium, it is best to puncture
into the ilium in the area of the triangular insertion of the gluteus maximus
muscle (Fig 11-3), which is the same general area used for the open posterior
ilium bone harvest.
The harvested bone marrow must remain anticoagulated. The authors use
a blood-collection bag in which 4 mL of anticoagulant citrate dextrose-A
(ACD-A) solution has been placed (Fig 11-4). The trocar is wetted with a so-
lution of heparin 1,000 U /mL, and the plunger and internal surface of the bar-
rel of each aspiration syringe is coated with the same solution. For this purpose,
the authors prepare a 20-mL solution by adding 16 mL of saline to four vials
of heparin, which is packaged as 5,000 U/mL.
A 2-mm incision is made over the intended puncture site and a hemostat in-
serted to bluntly dissect a pathway to the cortex (Fig 11-5). This minimizes the

144
 Bone Marrow .Aspiration Approach

Fig 11-5 Blunt dissection through the small skin incision Fig 11-6 The sharp trocar hollow aspiration sleeve
will dear a pathway for the trocar to the bone surface should be stable between the cortices and 1 to 4 cm into
with less contact with subcutaneous fat. the bone.

Fig 11-7 The aspirated bone marrow

will have the appearance of blood,
but it actually contains a composite
of bone and other precursor cells not
found in peripheral blood in any sig-
nificant amount.

amount of subcutaneous fat that comes into contact with the aspiration trocar.
Subcutaneous fat contains tissue thromboplastin and thus can initiate clotting
within the aspirate. The sharp heparin-prepared trocar punch within the hol-
low aspiration sleeve is pressed through the outer cortex into the marrow space
by a steady back-and-forth rotating-wrist motion (Fig 11-6). The sharp inner
trocar punch is then removed, leaving the hollow aspiration sleeve in the mar-
row space. A 20-rnL syringe containing 0.5 mL of the heparin solution is then
attached to the Luer lock connector at its handle. The 0.5-mL volume of
heparin solution should be irtjected into the marrow space before the plunger
is drawn back to aspirate the bone marrow. As the plunger is pulled back, bone
marrow, which will look similar to a blood draw from a peripheral vein punc-
ture, will appear in the syringe (Fig 11-7). However, the aspirate is bone
marrow containing a mixture of hematopoietic precursors, megakaryocytes,
some mature platelets, mesenchymal stem cells, and osteoprogenitor cells

145
 11 IBone Marrow Aspiration and Aspirate Concentrate

Fig 11-8 Bone marrow aspiration with the cannula placed

between the cortices and 1 to 4 cm into the bone.

Syringe

Red bone marrow

(will look like blood}

Anterior hip

Bone marrow aspirated

into hollow sleeve

Fig 11 -9 To maximize the yield of mesenchymal stem cells

and osteoprogenitor cells, the hollow aspiration sleeve
should be rotated 360 degrees for every 5 ml of aspirate
and its position changed with every 5 ml of BMA drawn.

(Fig 11-8). To maximize the yield of mesenchymal stem cells and osteoprogeni-
tor cells, the trocar and syringe are rotated 360 degrees over each 5 mL drawn and
the trocar position changed either 5 mm deeper or more superficial for each 5 mL
drawn (Fig 11-9). The authors use two puncture sites for 30 mL of bone marrow
aspirate from each puncture site to maximize mesenchymal stem and osteoprog-
enitor cell yield. Each syringe of BMA is irtjected into the transfer bag containing
the 4 mL of ACD-A solution until 60 rnL of BMA is collected (Fig 11-10).

146
 Bone Marrow Aspiration Approach

Fig 11-10 Each of four 15-ml BMA
syringes anticoagulated with a small
amount of heparin is then placed
into the blood collection bag con-
taining 4 ml of ACD-A solution.
Fig 11-11 The 60 ml of BMA is
drawn into a syringe through a sim-
ple blood filter system provided in
the BMAC kit.

Fig 11-12 The BMA is placed into

the red-topped bone marrow cham-
ber of the BMAC container.

The 60 mL of anticoagulated BMA is then drawn into a 60-mL syringe

through the blood filter that is provided (Fig 11-11), to eliminate microscopic
blood clots before it is injected into the marrow chamber {red port) of the
BMAC container (Fig 11-12). The second chamber, known as the receiving
chamber (white port), contains 2 mL of ACD-A solution for the pwpose of
preventing clumping of the concentrated cell components. The container is
then placed into a centrifuge capable of a double spin (a separation spin and a
concentration spin) (Fig 11-13). The authors use a platelet concentration device
(Harvest Technologies) with a modified PRP container and the same cen-

147
 11 l Bone Marrow Aspiration and .Aspirate Conc.entrate

~ - · ·· .. · :• '. ·

~ :' ..:...

,,
Fig 11-13 BMA is concentrated into
a bone marrow aspirate concentrate
• Fig 11-14 The darker red liquid and its interface with the
lighter colored plasma faction represents the BMAC
(BMAC) using a double-spin cen- component.
trifuge (Harvest Technologies).

Fig 11-15 BMAC, the final product, contains CD90-pos-

itive, CD44-positive, and CD105-positive markers, which
are known to be osteoprogenitor cells.

trifugation scheme. Once the centrifugation is complete, the plasma fraction,

representing the acellular fraction of bone marrow containing the cell adhe-
sion molecules of fibrin, fibrinogen, and fibronectin as its key components, is
aspirated (Fig 11-14). The bottom 7- to 10-mL layer contains the cellular frac-
tion of bone marrow, including white and red blood cell precursors, as well as
platelets and platelet precursors (megakaryocytes) and mesenchymal stem cells
and osteoprogenitor cells (Fig 11-15). The presence of mesenchymal stem cells
and osteoprogenitor cells (also called stromal cells) has been positively docu-
mented by their CD90, CD44, and CD105 markers via specialized cell mem-
brane inununostaining.

148
 Complications

The BMAC can then be added to autogenous grafts, to allogeneic bone

grnfts, and to grafts containing rhBMP-2 as a source of cells that can proceed
to bone-fonning cells. The 2-mm introducing incisions are closed at the skin
level with a single 5-0 nylon or polypropylene suture.

Dressing
None required.

Postoperative Care and Instructions

Normal activity is allowed, and there is no need for ice or supportive medica-
tion because little if any edema occurs. Patients should be instructed to inform
the surgeon if unexpected swelling, bruising, or gait disturbance occurs.

Complications
Complications are extremely rare. However, malpositioning of the trocar can
theoretically injure a nerve or blood vessel and could separate a small piece of
bone from the cortex. Therefore, potential complications include paresthesia,
pain, hematoma, ecchymosis, excessive swelling, and a slight disturbance in
ambulation.

149
 Index

fuformation in figures is denoted byf anterior tubercle of ilium, 2 lf, 41/

anticoagulant citrate dextroSc·A (ACD-A), 144
anticoagulation, in bone marrow aspiration, 144
A apical dental infections, 102
ACD-A. &e anticoagulant citrate dextrose-A articulation replacement, costochondral, 62
{ACD-A) aspiration, of bone marrow
acetabulum, 21f, 4Jf anatomy in, 143
acute bleeding, in posterior iliwn harr-esting, 36 anticoagulation in, 144
alopecia, 97, 97f approach, 143- 149
alveolar artery cautions with, 142
inferior, 103 complications in, 149
posterior superior, 125, 131-132 contraindications for, 142
alveolar cleft graft, adult, 8, 40, 80 indications for, 142
alveolar nerve limitations of, 142
inferior, 120 patient positioning for, 143
posterior superior, 125 postoperative care, 149
alveolar neurovascular bundle volume in, 143
inferior, 113f, 114, 115f auricular artery, posterior, 82, 83/
posterior superior, 125/
alveolar ridge augmentation
horizontal, 8,40,80,102, 112 B
vt:rtical,8,40,80, 102, 112 bilateral trap door approach, for anterior ilium
alveolar ridge preservation, 8, 124, 134 harvest, 56, 56/
ankle swelling, after tibia harvesting, 17, 17/ bisphosphonate, 124
anterior gluteal line, 23 bleeding, in posterior ilium harv-esting, 36
anterior ilium harv-esting site BMP-2 g=e, 135
anatomy in, 41-47 bone, harvested, care of, 3-4
bilateral, 40 bone cement, 92-93
for bone marrow aspiration, 143, 144 bone gouge, 3'lf
cautions with, 41 bone grafting, history of, 2- 3
in children, 60, 60/ bone marrow aspiration
clamshell approach for, 52-53, 52.£ 53/ anatomy in, 143
contraindications for, 40 anticoagulation in, 144
dressing of, 60 approach, 143-149
indications for, 40 cautions with, 142
lateral corticocancellous harvest in, 59, 59/ complications in, 149
left hip for, 48 contraindications for, 142
limitations of, 40 indications for, 142
medial corticocanccllous harvest in, 56-59 limitations of, 142
medial trap door approach for, 54, 54{, 55/ patient positioning for, 143
nerves in, 46-47, 46/ postoperative care, 149
patient positioning in, 48, 4!if volume in, 143
surgical approach for, 48-6 0 bone marrov: dysplasia, 142
tibia vs, 40 bone marrow malignancy, 142
anterior inferior spine of ilium, 21f, 41.£ 45f buccal artery, 114, 115f
anterior superior spine of ilium, 21.£ 41/ buccal fat pad, 13Q(
anterior superior spine of ilium fracture, 45, 45/ buccal nerve, 114, 115f

151
 Index

c contraindications for, 80
dressings in, 96
canine roots, 103f dural tear after, 97, 98f
cement, 92-93 with Gigli wire saw, 94-95
chemotaxis, in rhBMP-2/ACS, 134, 134:f hair in, 85-86
chest trauma, 62 indications for, 80
children inner table grafts in, 98- 100
anterior ilium harvesting in, 60, 60f inner table perforations after, 97
posterior ilium harvesting in, 37 limitations of, 85
rib articulation in, 66, 66f outer table grafts in, 86-93
rib harvesting in, 73-74, 74:f patient instructions after, 96
Chinese hamster ovary (CHO) cells, 135 patient positioning for, 85- 86
chin harvesting site postoperative care for, 96
anatomy in, 103-104 surgical approach in, 86-95
bleeding in, 109 vasculature in, 82-84
cautions for, 102 cranial sutures, 81-82, 8 if
complications v:ith, 109-110 cranial thickness, 82
contraindications for, 102 crib containment support, 62
dressing of, 108 crushing chest iajury, 62
ecch}JDOsis in, 109 cyst, odontogenic, 102, 112
indications for, 102 cystic fibrosis, 62
limitations of, 102
mandibular fracture in, 109, lO!if
patient instructions after, 108 D
patient positioning for, 104 DCIA. &e deep circumflex iliac artery (DCIA)
postoperative care for, 108 decompression, ofintraoperative pneumothorax,
surgical approach for, 104-108 76-77, 76f
wound dehiscence after, 109 deep circumflex iliac artery (DCIA), 23 , 23.£ 47
chondritis, 78 dehiscence
circulation, plasmatic, 4 after chin harvesting, 109
circumflex iliac artery after rhBMP-2 sponge, 140
deep, 23, 23.£ 47 after tibia harvesting, 17-18
superficial, 47 dental implant salvage, 8
clamshcll approach, in anterior ilium harvest, dental infections, apical, 102
52-53, 52.£ 53f diploC, 82, 82f
clavicle, 64:f diploetic marrow space, 82f
cluneal nexves, 24 diploetic vasculature, 82f
coccyx, 22 Doyen nb stripper, 68, 69f
complications drain, in posterior ilium harvesting site, 35
in bone marrow aspiration, 149 dressing
in chin harvesting, 109-110 of anterior ilium harvesting, 60
in cranial bone harvesting, 97-98 of chin harvesting, 108
in mandibular ramus harvesting, 120- 122 of cranial harvesting, 96
in maxillary tuberosity harvesting, 128-132 of mandibular ramus harvesting, 120
in posterior ilium harvesting, 35-36 of posterior ilium harvesting, 35
in rhBMP-2 sponge, 140 of rib harvesting, 74, 74:f
in rib harvesting, 75-78 of tibia harvesting, 17
in tibia harvesting, 17-18 dural tear, 97, 91if
continuity defects, 142 dura mater, Bif, 84(
coronal suture, 81, 84:f
coronoid process, 113f
oorticocancellous block graft, from posterior E
iliwn, 20 Eb);Joseph D, 2
costochondral articulation replacement, 62 ecchymosis, 17, 109
costochondral growth grafts, 62 edema, with rhBMP-2 sponge, 140, 14-0f
cranial bone harvesting enzymes, restricted fragment, 135
alopecia after, 97, 97f epidural hem.atom.a, 84
anatomy in, 81-84 epineural nerv.: repair, 120, 12lf
cautions with, 80 external abdominal oblique muscle, 22.£ 42, 42.£
closure of, 94 5if
complications in, 97-98

152
 Index

extcmal abdominal oblique muscle attachment, humerus, 64{

43/ hyperpneUIIllltizedsinus, 124
extcmal iliac artery, 23/
external intercostal muscles, 65j, 66
cxtcmal oblique ridge, 113, 113j, 114{ I
iliac artery
deep circumflex, 23, 23j, 47
F cxtcmal, 23/
femoral artery, 23/ superficial circumflex, 47
femoral cutaneous nerve, lateral, 46-47, 4ef iliacus muscle, 44, 44j, 46, 47
abCITant course of, 47, 47.f iliohypogastric nerve, 46, 41if, 47.f
femur iliopsoas tendon, 44, 44f
greater trochanter of, 44/ iliotibial tract, 9.£ 42/
lesser trochanter of, 44, 44/ ilium, muscle origins of, 22, 22/
fibula, in obia anatomy, 9f ilium harvesting site
fracture anterior
of anterior superior iliac spine, 45, 45/ anatomy in, 41-47
in chin harvesting, 109, 109/ bilateral, 40
in mandibular ramus harvesting, 122 for bone marrow aspiration, 143, 144
in posterior ilium harvesting, 36 cautions with, 41
frontal bone, 81 in children, 60, 6Qf
clal'.l'.lllhell approach for, 52-53, 5if, 5'if
contraindications for, 40
G dressing of, 60
gait, posterior ilium harvesting and, 22-23, 36 indications for, 40
genial tubercles, 103 lateral corticocancellous harvest in, 59,
genicular artery 59/
lateral inferior, 1Qf left hip for, 48
lateral superior, lQf limitations of, 40
Gcrdy's tubercle, 8, 9j, 10, 42, 4if medial corticocancellous harvest in,
Gigii wire saw, 94-95 56-59
gluteus maxim.us muscle, 21, 22, 22j,23, 43/ medial trap door approach for, 54, 54,f,
gluteus medius muscle, 21, 22j,23, 43/ 55f
gluteus minimus muscle, 22.£ 43, 43/ nerves in, 46-47, 46/
grafting patient positioning in, 48, 48/
cleanliness and, 5 surgical approach for, 48-60
history of, 2-3 tibia vs, 40
onlay, 80 posterior
principles of, 4-5 acute bleeding in, 36
rbBMP-2 sponge as supplement for, 136 anatomy of, 21-24
stability in, 5 bone gouge use in, 32f
greater sciatic notch, 21f,23 for bone marrov.r aspiration, 143, 144
greater trochantcr of femur, 44/ cautions with, 20
growth grafts, costochondral, 62 in children, 37
closure in, 34, 34{
complications in, 35-36
H contraindications for, 20
hamular notch, 125/ drain in, 35
han·ested bone, care of, 3-4 dressing of, 35
harvest site morbidity, 4 fracture after use of, 3 6
head trauma, 80 fracture in ostc:ctomy with, 29/
hcmatoma gait disturbance with, 22-23, 36
in chin harvesting, 109 hematoma in, 36
in iliacus muscle, 47 indications for, 20
in mandibular ramus harvesting, 120-122 marrow harvest in, 33/
in posterior ilium harvesting, 36 nc:rves in, 24, 25/
hemothorax, 77, 77J, 78f ostectomy in, 28/
heparin, 144 patient instructions after, 35
history, of bone grafting, 2-3 patient positioning for, 24, 25f
horizontal ridge augmentation, 8, 40, 80, 102, postoperative care, 35
112 saw cut order in, 3Qf

153
 Index

seroma in, 36 mandibular nonunion, 8

surgical approach for, 24-35 mandibular ramus harvesting site
vasculature in, 23, '23f anatomy in, 113-114, 113.f 114(
impacted molar, third, 124 cautions with, 113
implant salvage, 8, 142 complications in, 120-122
incisor roots, 103f contraindications for, 112
infection dressing for, 120
after mandibular ramus harvesting, 122 hematoma in, 120-122
tissue bed and, 5 indications for, 112
inferior alveolar artery, 103 limitations of, 112
inferior alveolar nerve, 120 patient instructions after, 120
inferior alveolar neurovascular bundle, 113.f patient positioning for, 116
114, 115f postoperative care for, 120
inframamm~· crease incision, 67f surgical approach in, 116-119
inguinal ligament, 42.f 45 manubrium of sternum, 63f
inner cortex, 82f marrow aspiration
inner table grafts, 98-100 anatomy in, 143
inner table perforations, 97 anticoagulation in, 144
intercostal artery, 64, 65f approach, 143-149
interc0stal muscles cautions with, 142
external, 65.f 66 complications in, 149
intcmal, 65f contraindications for, 142
intercostal nerve, 65f indications for, 142
intercostal vein, 65f limitations of, 142
internal abdominal oblique muscle, 42 patient positioning for, 143
internal intercostal muscles, 65.f 66 postoperative care, 149
internal oblique ridge, 113, 113.f 114j volume in, 143
Ivy, Robert H, 2 marrow dysplasia, 142
marrow m.alignancy, 142
maxilla, corticocancellous block graft to, 20, 80
J maxillary sinus, l25j
hyperpneurnatized, 124
j ' graft, 112
maxillary sinus entry, 128, 121if-13JJ, 130
maxillary tuberosity harvesting site
L anatomy in, 125, 125f
bleeding in, 131-132
lambdoid suture, 81 cautions with, 124
lateral femoral cutaneous nerve, 46-47, 4:6j complications in, 128-132
aberrant course of, 47, 47f contraindications for, 124
lateral pterygoid plate, 125f indications for, 124
latissirnus donii muscle, 22f limitations of, 124
lesser trochanter, of femur, 44, 4ff oroantral communication in, 128, 12~13lj,'
lingual nerve, 114, UV, 120 130
local radiotherapy, as contraindication for patient instructions after, 128
harvesting site, 20, 112
patient positioning for, 125
long buccal artery, 114, 115f
periostitis after, 132
long buccal nerve, 114, 115f
postoperative care for, 128
lumbar spinal fusions, 134
surgical approach for, 126-127
medial ptcrygoid muscle, 115f
M medial trap door approach, to anterior ilium
harvest, 54, 54£ 55f
malunion, of mandible, 8 meningeal arteries, middle, 82, 84(
mandible mental foramina, 103, 103.f 104(
corticocancellous block graft to, 20 mentalis fossa, 103f
vertical resorption of anterior, 102 mentalis muscle, 104
mandibular condyle, l 13f mental nerve, 104, 104(
mandibular continuity defect, 8, 20, 4-0 mental tubercles, 103, 103f
mandibular fracture meralgia paresthetica, 47
in chin harvesting, 109, lO!if lllCSh,titanium,93,93f
in mandibular ramus harvesting, 122 methotrexate, 124
mandibular nerve, 114, 115j

154
 Index

microneural rcanastomosis, 120, 12Jf anterior ilium harvesting in, 60, 60/
middle clwieal nerves, 2Sf posterior ilium harvesting in, 37
middle meningeal arteries, 82, 84[ rib articulation in, 66, 6fif
midface onlay graft, 80 rib harvesting in, 73-74, 74[
midline raphe, 42f pericoroniris, 112
molar, impacted third, 124 peri-implant bony defect, 124
muccr.iscidosis, 62 periodontal bony defect, 124
multiple myeloma, 142 periodontitis, 112
muscle origins, of right iliwn, 22, 22f periostiris, 132
perom:al artery, 10/
peroneal nerve, 10/
N piriformis muscle, 43/
nasal !:lone onlay graft, 80 plasmatic circulation, 4
nerves platelet-rich plasma (PRP)
in anterior iliwn, 46-47, 46f in care of harvested bone, 3
in posterior ilium, 24, 25f with rhBMP-2 sponge, 136
in ribs, 64, 65f pleuritis, 78
nonunion, of mandtble, 8 pnewnothorax, 62, 69f, 75-77
posterior auricular artery, 82, 83f
posterior ilium harvesting site
0 acute bleeding in, 3 6
occipital artery, 82, 83f anatomy of, 21-24
occipital bone, 81 bone gouge use in, 32f
odontogeni.c cyst, 102, 112 for bone marrow aspiration, 143, 144
odontogenic tumor, 102, 112 cautions with, 20
onlay graft, 80 in children, 37
open reduction and internal fixation, of closure in, 34, 34[
mandibular fracture, 122, 122f complications in, 35-36
orbital onlay graft, 80 contraindications for, 20
oroantral communication, 124, 128, 128..f13lf, drain in, 35
130 dressing of, 35
osteoblasts, 134, 134[ fracture after use of, 36
osteoid, 134, 134[ fracture in ostectomy with, 29/
osteoprogenitor cells, 134, 134[ gait disturbance with, 22-23, 36
osteotomy gap filling, 80, 102 hematoma in, 36
osteotomy separations, 112 indications for, 20
outer cortex, 82f marrow harvest in, 33f
outer table grafts, 86-93 nerves in, 24, 25f
ostectomy in, 28/
patient instructions after, 35
p patient positioning for, 24, 25/
paresthesia postoperative can:, 35
from anterior ilium harvesting, 46, 47 saw cut order in, 30/
in chin harvesting, 109 seroma in, 36
parietal bone, 81, 84f surgical approach for, 24-35
parietal pleura, 68 vasculature in, 23, 23f
patella, 9J, 42/ posterior tubercle of iliwn, 21f, 41f
patellar tendon, 9f posterior superior alveolar artery, 125, 131-132
patient positioning posterior superior alveolar nerve, 125
for anterior ilium harvesting, 48, 4!if posterior superior alveolar neurovascular bun-
for bone marrow aspiration, 143 dle, 125f
for chin harvesting, 104 postoperative carefmstructions
for cranial bone harvesting, 85- 86 for bone marrow aspiration, 149
for mandibular ramus harvesting, 116 for chin harvesting, 108
for maxillary tuberosity harvesting, 125 for cranial bone harvesting, 96
for posterior ilium harvesting, 24, 25f for mandibular ramus harvesting, 120
for rib harvesting, 66 for maxillary tuberosity harvesting, 128
for nbia harvesting, 11 for posterior ilium harvesting, 35
pectoralis major muscle, 64, 64f for rhBMP-2 sponge, 140
pediatric patients for rib harvesting, 75
for tibia harvesting, 17

155
 Index

pregnancy, 137 ridge augmentation

PRP. & platelet-rich plasma (PRP) horizontal, 8,40, 80, 102, 112
psoas major muscle, 44, 44/, 46 vertical,8,40,80, 102, 112
pterygoid muscle, medial, 115/ ridge preservation, 8, 124, 134
ptcrygoid plate, lateral, 12lf
ptcrygomaxillary fissure, 125/
pubic bone, 45 s
pulmonary fibrosis, 62 sacrotuberous ligmnent, 22
sacrum,2if,22,2if,43/
sagittal suture, 81, 8if, 8lf
R sagittal venous sinus, 82, 82.f 83/
radiotherapy, local, as contraindication for har- saline, in care of harvested bone, 3
vest site, 20, 112 sartorius muscle, 45
recombinant human bone morphogenetic pro- sartorius muscle attachment, 45/
tein-2/acellular collagen sponge scalp, 82/
(rhBMP-2/ACS) sciatic notch, greater, 2if, 4lj
cautions with, 138 scroma, in posterior ilium harvesting, 36
complications with, 140 sinus,hyperpneUJll3.tized, 124
contraindications for, 137 sinus augmentation, 40, 80, 102, 124, 134, 135
cost of, 137 sinus elevation graft, B
indications for, 134 skull thickness, 82
limitations of, 136-137 socket graft, 8, 124
mechanisms of action in, 134, 134( soft tissue matrix expansion grafts, 40
off-label applications of, 136 sphenoid bone, 81
platelet-rich plasma with, 136 sphenopalatine artery, 131-132
postoperative care for, 140 squamoparietalsuture,81,84/,98
preparation of, 138 squamotemporal bone, 84/
production of, 135, 135/ stability, of graft, 5
as supplement to grafting, 136 sternum
surgical approach for, 139, 139/ body of, 63/
rectus abdominis muscle, 64, 64( manubrium of, 63/
recurrent anterior tibial artery, 1Of xiphoid process of, 63/
restricted fragment enzymes, 135 subcostal muscles, 66
restrictive pulmonary disease, 62 subcostal nerve, 46, 4lf, 47/
rhBMP-2/ACS. See recombinant hum.an bone subgluteal artery, 23, 23/
morphogenetic protein-2/acellular superficial ciraunflex iliac artery, 47
collagen sponge (rhBMP-2/ACSJ superficial temporal artery, 82, 83/
nb fractures, 62 superior cluneal nerves, 25/
rib harvesting site superior sagittal venous sinus, 82, 82.f 83/
anatomy in, 63-66 supraorbital artery, 82, 83/
in children, 73-74, 74( supratrochlear artery, 82, 83/
chondritis with, 78 sutures, cranial, 81-82, 8lj
closure in, 71, 72/
complications in, 75-78
contraindications for, 62 T
dressing of, 74, 74( temporal artery, superficial, 82, 83/
hcmothorax in, 77, 77f temporal bone, 81, 84
indications for, 62 t.emporalis muscle, 115/
limitations of, 62 temporalis muscle attachment, llt, 114(
nerves in, 64, 65/ temporalis tendon, 114
parietal pleura in, 68 temporomandihular joint, 62
patient instructions for, 75 tensor fascia lata band, 42/
patient positioning in, 66 tensor fascia lata muscle. '¥,2if, 41-42, 42/
pleuritis with, 78 tensor fascia lata tendon, 9J
pneumothorax in, 62, 69.f 75-77 tent pole procedure, 40
postoperative care in, 75 third molar, impacted, 124
surgical approach in, 66-71 thoracoabdominal fascia, 2if, 4if
vasculature in, 65/ tibia harvesting site
ribs anatomy, 8-11
articulation of, 66, 66/ ankle swelling after, 17, 17/
true, 63-64, 63/ anterior iliwn vs, 40

156
 Index
for bone marrow aspiration, 143
complications with, 17-18
dressing in, 17
indications for use of, 8
neural anat.omy, lQf
patient positioning for, 11
postoperative instructions, 17
surgical approach in, 11-16
vascular anatomy, IQ!
wound dehiscence after, 17-18
tibial artery, anterior, 1 Qf
tibialis muscle, 9/
tibial shaft, 9/
tissue bed
importance of clean, 5
vascular, 4
titaIJium mesh, 93, 93/
transversus abdominis muscle, 42
true ribs, 63-64, 63/
tubercle of ilium
anterior, 2lf, 41/
posterior, 2lf, 4if
tumor, odontogenic, 102, 112
157
v
vascular tissue bed, importance of, 4
vertical :resorption of anterior mandible, 102
vertical ridge augmentation, 8, 40, 80, 102, 112
w
wanned saline, 4
water, distilled, harvested bone and, 3-4
wound dehiscence
after chin harvesting, 109
after rhBMP-2 sponge, 140
after tibia harvesting, 17- 18
wound infection, after mandibular ramus har-
vesting, 122
x
xiphoid process of sternum, 63/
z
zygomatic onlay graft, 80