Occipital calvarial bone graft in posterior occipitocervical fusion

STUDY DESIGN: Dorsal occipitocervical fusion is associated with a high rate of fusion failure and requires an additional surgical site for donor bone graft harvesting. In this series, an autologous occipital calvarial bone graft obtained from the same occipitocervical incision with contoured metal loops was used in 25 adults to achieve craniovertebral stabilization and fusion. OBJECTIVES: To study the use of autologous occipital calvarial bone grafts in occipitocervical fusion. SUMMARY OF BACKGROUND DATA: Cranial bone grafts have been used successfully in craniofacial reconstruction with good long-term results. In the plastic surgery literature, there are claims that membranous bone grafts are superior to endochondral bone grafts in fusions because of decreased resorption. In recent studies, results have shown successful use of calvarial bone in fusing the upper cervical spine in children. The use of autologous occipital bone in posterior occipitocervical fusions avoids many of the problems associated with traditional donor sites and provides a sufficient quantity of good quality bone for the fusion. This is especially true in the fragile rheumatoid arthritis patient with cranial cervical instability. METHOD: Split-thickness, autologous calvarial bone grafts with contoured loop and cable instrumentation were used for posterior occipitocervical stabilization and fusion in 25 patients, most of whom had rheumatoid arthritis. The calvarial bone graft was harvested from the occipital skull, using a microair impactor, and was secured next to the loop construct. After surgery, all patients were immobilized with external orthoses. RESULTS: None of the patients had hardware failure or complications from the occipital graft procurement. In 22 patients, good alignment, stability, and bony fusion were shown on radiographs. CONCLUSIONS: Occipital calvarial bone graft appears to work as well as other autologous corticocancellous bone grafts routinely used in posterior occipitocervical fusions.     

Autologous calvarial and iliac onlay bone grafts in miniature swine

Calvarial bone has been reported to be superior to iliac bone for onlay bone grafting due to decreased resorption. This study evaluated the physical, histologic, and radiographic characteristics of calvarial and corticocancellous iliac onlay bone grafts in nine Pitman-Moore miniature swine at 2 weeks, and at 1-, 2-, 4-, 6-, 7-, 8-, 10-, and 12-month intervals. Compared with iliac grafts, the calvarial onlay grafts had more than a twofold greater radiographic density. Statistical analysis of the mature grafts using the standard of estimated means of the bone graft volumes revealed 85% retention of the calvarial grafts compared with 34% retention of the grafted iliac bone. There was no subjective difference in the rate or degree of revascularization between the two grafted materials.     

Split calvarial graft cranioplasty for the prevention of headache after retrosigmoid resection of acoustic neuromas

OBJECTIVE: This study describes the technique and efficacy of split calvarial graft cranioplasty for the reconstruction of retrosigmoid/suboccipital defects following surgery for acoustic neuromas. STUDY DESIGN: A prospective study of the technique of split calvarial graft cranioplasty, its postoperative healing, and incidence of postoperative headache. METHODS: The technique requires splitting of the craniotomy bone flap into outer and inner table bone grafts. The combination of both bony grafts allows the coverage of a wider area of posterior fossa dura. This technique was used in 18 patients. All patients were followed for a minimum of 6 months. Eleven of 18 patients were followed for 1 year or longer. Four patients had three-dimensional computed tomography of their skull and area of split calvarial bone graft. RESULTS: One of 18 patients had a persistent disabling headache at 1 year postoperatively. A natural contour of the retrosigmoid area was achieved in all patients. Three-dimensional computed tomography scan, obtained 6 months postoperatively, showed total coverage of the retrosigmoid area and fusion of the bone flap to the surrounding skull. CONCLUSION: The technique of split calvarial grafting of posterior fossa defects is a feasible, safe, and effective way of separating the nuchal musculature and posterior fossa dura. The technique also allows the restoration of the contour and bony covering of the retrosigmoid area. The technique is a simple alternative to other types of cranioplasties aimed at reducing the incidence of postoperative headache in patients with acoustic neuromas.     

A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects

PURPOSE: This study compared vascularized and nonvascularized bone grafts for the reconstruction of segmental defects of the mandible. PATIENTS AND METHODS: The results in 39 patients having vascularized bone grafts (38 fibulas and one iliac crest) and 29 patients having nonvascularized bone grafts (26 iliac crest [22 corticocancellous block grafts, four cancellous bone grafts in a tray] and three rib grafts) for segmental mandibular reconstruction were evaluated in terms of overall success rate, total number of surgeries performed, total blood loss, total number of hospital days, and total number of hours in the operating room. RESULTS: Of 39 vascularized bone grafts, two failed (95% success rate), whereas of 29 nonvascularized bone grafts, seven failed (76% success rate). Failure for the nonvascularized bone grafts was closely correlated to the length of the defect. Nonvascularized bone graft patients underwent an average of one more surgical procedure for total reconstruction than vascularized bone graft patients, including osseointegrated implants. However, vascularized bone graft patients spent a mean of over 14 additional days in the hospital for all of their reconstructive procedures and an additional 3 hours in the operating room as compared with nonvascularized bone graft patients. Blood loss was similar in both groups (1,100 mL). Only 20% to 24% of patients in each treatment group have completed reconstruction to include osseointegrated implants. CONCLUSIONS: The success rate for vascularized bone grafting is high and is the treatment of choice when primary reconstruction is required, when the patient has been previously irradiated, or when simultaneous replacement of soft tissue is required. Vascularized bone grafts are also the treatment of choice for mandibular replacements over 9 cm in length. Nonvascularized bone grafts create a better contour and bone volume for facial esthetics and subsequent implant insertion, and may be the treatment of choice for secondary reconstruction of defects less than 9 cm in length.     

Frontal sinus trauma: experimental reconstruction with proplast

Trauma has become the most common pathologic entity requiring operative intervention in the frontal sinus. Treatment has evolved from simple open drainage to ablation with reconstruction at a later date. Methyl-methacrylate, currently the most widely used alloplastic material, has inherent disadvantages such as two-stage reconstruction, difficulty in handling and molding, and susceptibility to trauma. The present investigation evaluates Proplast, a biocompatible Teflon fluorocarbon polymer implant, in one and two-stage frontal reconstruction following traumatic defects to the canine frontal sinus. Following the loss of anterior or posterior frontal bone, Proplast provided excellent cosmetic reconstruction over a period of one year. Resistance to infection was good, reaction with dura and brain was absent, and cerebrospinal fluid leaks sealed rapidly. In contrast to other alloplastic materials, rapid vascularization and collagen ingrowth lead to stabilization rather than sequestration. Several advantages over alloplastic and metallic implants may give Proplast a unique potential in operative cranioplasty.     

The choice of material for above-knee femoropopliteal bypass. A 20-year experience

OBJECTIVE: The choice of material for above-knee femoropopliteal bypass grafting is a matter of continuing controversy for various reasons. The most important argument in favor of alloplastic grafts is to preserve the autologous saphenous vein for a below-knee bypass, which might become indicated at a later date. DESIGN: A consecutive series of above-knee reconstructions were analyzed with regard to long-term behavior. Early graft occlusions were not included, and the median follow-up was 83 months. SETTING: A university hospital with a particular interest in vascular surgery. PATIENTS AND METHODS: Four hundred forty-two patients received either autologous saphenous vein (n = 310) or alloplastic graft (n = 132) material, and were analyzed in a univariate (Kaplan-Meier) and multivariate (Cox) manner. MAIN OUTCOME MEASURES: Analysis as to whether alloplastic graft material provides equal or less favorable results as compared with autologous saphenous vein material, in terms of primary and secondary patency, secondary below-knee bypass grafting, limb salvage, and survival. RESULTS: Although univariate analysis demonstrated a significantly better primary patency rate for autologous saphenous vein material, multivariate analysis did not show any effect of the material in terms of patency, limb salvage, and survival. The frequency of secondary below-knee repair was 7% (31 patients); 56% were performed in the first 2 years postoperatively. This amounted to an estimated probability of 4.4% and 12.3% at 18 years, respectively. CONCLUSION: The small probability of secondary below-knee repair in our series does not support the policy to use alloplastic grafts routinely for a primary above-knee bypass, to spare the saphenous vein. Therefore, patients should be offered the best material for the first operation even at the above-knee level.     

Spontaneous and induced minisatellite instability in the human genome

Two patients with recurrent parotid gland carcinoma required subtotal petrosectomy and infratemporal fossa type C approach. To achieve en bloc resection, the ascending mandibular ramus and the entire temporomandibular joint, including the adjacent temporal bone, were removed. An original technique for immediate reconstruction of the infratemporal region, including the glenoid fossa and the ramus of the mandible, is described. Rigid fixation, as well as good functional and aesthetic results, was achieved with autologous calvarial bone and full-thickness rib grafts, allowing the patients to mobilize their jaw very rapidly.     

A paradigm of experimentally induced mild hyperthyroidism: effects on nitrogen balance, body composition, and energy expenditure in healthy young men

OBJECTIVE: To conceptualize, with fine needle aspiration cytology (FNAC), the early cellular events occurring in and around fresh autogenous and allogenic bone grafts during the first 40 postimplantation days. STUDY DESIGN: Forty-eight cases of bone grafts were studied by FNAC at serial intervals of 10, 20, 30 and 40 postimplantation days. Twenty patients were recipients of autogenous grafts, 16 received 0.6N HCI partially decalcified allogenic bone implants, and 4 received combined autogenous and allogenic bone grafts (included in the allograft group). There were eight control cases of closed fracture shaft femur, which were managed conservatively. RESULTS: The initial cellular responses in autogenous grafts, allografts and controls appear to be a part of the nonspecific reparative process followed by a more specific phase, with a steady increase in relative lymphocyte count from the 20th day onwards. Osteogenesis, as judged by osteoblasts and osteoclasts, was also comparable. CONCLUSION: Partially decalcified allografts appear to be a good substitute for autogenous bone grafts in clinical practice when adequate autogenous material is not available. FNAC is a good technique for studying bone graft responses without interfering with graft uptake. It is helpful in the early detection of subclinical infection or any other pathology at the graft site.     

The fate of preserved autogenous bone graft

Certain clinical conditions exist in which a section of cranial bone is removed but not immediately replaced at the initial procedure. Preservation of this bone can provide a valuable autogenous donor source for a future reconstructive procedure. The purpose of our study was to compare the volume retention of fresh autogenous bone with that of preserved autogenous bone as inlay and onlay cranial grafts. Two bone grafts were harvested from the skull of 15 adult New Zealand White rabbits. The graft volumes were calculated, and the graft were preserved in a normal saline-antibiotic solution at -20 degrees C. Three months later, during the second procedure, a fresh graft was harvested and then placed in the preexisting occipital defect as an inlay graft. Also at this time, the preserved grafts were placed, one as an inlay graft in the fresh occipital defect and the other as an onlay graft in the frontal region. The animals were sacrificed 3 months later, and the percentage of graft volume retention was determined. The fresh inlay grafts had a mean volume retention of 85.1 percent, while the preserved inlay nad onlay grafts had 61.8 and 75.9 percent mean volume retention, respectively. It is concluded that while fresh cranial autograft remains the "gold standard" for craniofacial reconstruction, preserved autogenous cranial bone is a viable alternative for inlay and onlay grafting of the craniofacial region.     

Complex injuries of the dorsum of the hand. Therapeutic reflections apropos of 2 cases

We report 2 similar cases of severe injury of the dorsum of the hand, both treated in emergency. FIRST CASE: A 37-year-old right handed male truck driver was admitted with a complex severe injury of the dorsum of his right hand following a traffic accident. He had a combined large defect involving skin, tendons and bone. A complex reconstruction was performed using a massive iliac crest allograft, a tendon graft and a free serratus anterior flap in a one stage procedure, eight hours after the injury. A skin graft was done later. Two years later the functional and esthetic results are good. SECOND CASE: A 37-year-old woman was admitted with a severe injury of the dorsum of her right hand following a traffic accident. She had a large combined defect involving skin, tendon and bone. A complex reconstruction was carried out using a large iliac crest autograft, a multiple tendon graft and a free latissimus dorsi flap, in one stage 6 hours after the trauma. Eight months later the functional result is partial but useful for the daily activities of the patient.     

The viability of cryopreserved onlay cranial bone allografts: a comparative experimental study versus fresh autografts

It is well known that calvarial bone autografts are the bone grafts that are the least reabsorbent and have the best long-term evolution in craniofacial surgery. However, they do have certain limitations: (1) reabsorption results in repeated surgery and the need for new donor areas, (2) a limited amount of autogenous cranial bone is available (due to avoiding areas close to cranial sutures and venous sinuses, and because the temporal bone is very fragile and the cranium has not fully developed in children), and (3) graft extraction increases surgical time and morbidity. Because of this, we present an alternative to calvarial bone autografts: cryopreserved allografts. This paper is an experimental prospective study carried out on sheep with the following goals: (1) to assess the behavior of calvarial onlay bone grafts cryopreserved at -80 degrees C, using fresh autografts implanted under the same conditions as controls; (2) to compare reabsorption percentages statistically over time; and (3) to study qualitatively any histological variations. The results obtained are (1) more reabsorption of allografts when compared to autografts (at 90 days, 21.97% versus 20.21% of grafted volume), although this difference is not statistically significant; (2) a reduction in height in all onlay grafts as a consequence of the loss of the dipl?e; (3) the absence of any type of inflammation caused by a reaction to cryopreserved allografts; and (4) bone substitution performed using frozen allografts is histologically similar to that using fresh autografts.     

Biomechanical and histologic alteration of facial recipient bone after reconstruction with autogenous bone grafts and alloplastic implants: a 1-year study

Potential alteration of the underlying recipient bone resulting from a graft or implant has significant clinical relevance. The present study was designed to evaluate the biomechanical and histologic alteration of facial recipient bone with autogenous bone graft and alloplastic implants over a 1-year period. The bilateral arches of 15 rabbits were randomized between four groups: (1) control (n = 6), subperiosteal exposure of the zygomatic arch was made; (2) onlay (n = 12), bone graft was placed as an onlay to the zygomatic arch; (3) inlay (n = 6), bone graft was placed as an inlay within the zygomatic arch; (4) implant (n = 6), a stainless steel plate was placed as an onlay to the zygomatic arch. Animals were killed 1 year after grafting. In the onlay groups, all steel implants and half of the onlay bone grafts (n = 6) were separated from the zygomatic arch; the remaining onlay bone grafts (n = 6) were left on the zygomatic arch. Three-point breaking strength was measured through the center of the graft/implant site on the zygomatic arch, followed by histologic evaluation and histometric assessment of residual bone density. The findings demonstrated no difference in the breaking strength per unit bone area between the control zygomatic arch group and the onlay group in which the bone graft was left in place. Breaking strength of the zygomatic arch in the former two groups was significantly greater than that in either group in which the onlay bone graft or implant had been removed, and was also greater than the breaking strength in that group in which inlay bone had been placed (p < 0.05). Histologic assessment showed full-thickness conversion in architecture of the zygomatic arch from compact to woven bone beneath onlays of either autogenous bone graft or steel implant; histometric assessment demonstrated an accompanying decrease in bone density in the latter groups relative to the control zygoma (p < 0.05). We conclude that onlay autogenous bone graft and alloplastic implants to the facial skeleton induce transformation of both graft and recipient bone from compact to woven architecture, accompanied by a reduction in bone density. The biomechanical strength of recipient facial bone is significantly weakened if an onlay bone graft or implant is removed. Weakening occurs per unit area of remaining bone, and is therefore independent of any thinning that may occur within the recipient bone because of graft/implant placement. These findings may impact upon decisions to augment stress-bearing regions of the facial skeleton with bone graft or implants, particularly if the graft/implant may eventually require removal.     

Acetabular reconstruction with impacted morselized cancellous allografts in cemented hip arthroplasty: a histological and biomechanical study on the goat

Bone defects in total hip arthroplasty revision surgery can be restored with different types of bone graft. The use of impacted morselized allograft chips in combination with cement is the treatment of our choice. To establish the incorporation capacity of the grafts and mechanical stability of the implant, an animal model in the goat was developed. An acetabular defect was created and restored with morselized grafts and a cemented cup. Postoperative performance of the reconstruction was followed both histologically and biomechanically. Histology showed that consolidation of the graft with the host bone bed had occurred within 3 weeks. In the following period a front of vascular sprouts infiltrated the graft. Graft resorption, woven bone deposition, and subsequent remodeling resulted in a new trabecular structure. This structure contained only scarce remnants of the original dead graft material. At the graft-cement interface, graft resorption and new bone formation had resulted in areas of direct vital bone-cement contact. Locally, a soft tissue interface was present. After longer follow-up periods, progressive interface formation and loosening of the cups were found in most animals. Mechanical testing showed that the stability of the reconstruction increased during the first 12 postoperative weeks. Thereafter, the stability decreased, probably by soft-tissue interface formation at the graft cement interface. We conclude that cemented morselized allografts have a high capacity to incorporate. Initial cup stability is adequate to provoke graft incorporation with decreasing stability after the incorporation process has been completed.     

Diagnosis and treatment of osteogenic sarcomas, techniques of reconstructions. Future prospects

PATIENTS AND METHODS: We have performed 34 massive bone-cartilage grafts with a follow-up of 2 to 7 years (1988-1993) including 5 complete joint grafts of the knee. Between 1988 and 1993, 8 massive diaphyso-metaphyseal bone grafts were performed. Joint reconstructions using massive bone-cartilage allografts are increasingly used in routine oncology surgery. Long-term rehabilitation and possibilities of immediate anatomic reconstruction of the articular surface, together with mid-term results suggest that the functional results are promising compared with major reconstruction prostheses. Indications for operations are being increasingly widened to younger subjects who have undergone partial or total joint exeresis for tumour. Sleeved prostheses were used for 12 reconstructions (1988-1993) for sarcoma of the knee. RESULTS The risk of sepsis are comparable for the different groups and are mainly related to the quality of the skin repair during chemotherapy. Fractures of the graft occur when the fixation is insufficient or when rehabilitation exercises were too aggressive. Non-consolidation was exceptional when the junction between the allograft and the receiver bone is not surrounded with autologous spongious autografts. Joint instability and arthrosis depend on the stability of the ligament reconstruction. To this day, no Charcot type joint disease has been demonstrated, periarticular innervation has maintained joint trophism. DISCUSSION: There are still some incompletely resolved problems concerning the revascularization of the graft, its integration into the skeleton, the outcome of the grafted cartilage and that of the ligament formations attached to the graft or used as allografts. These massive grafts must be studied over a longer period of time but the early results are encouraging. Sleeved grafts using bone-bank specimens could be an intermediary solution which appears to be indicated in cases where the tumoural resection was particularly large removing bone, cartilage, ligaments and muscles. With these sleeved prostheses, the muscles can be refixed onto the graft thus reducing the risk of shank fracture and loosening. The use of a tibial graft with the patellar tendon is helpful in reconstructing the extensor apparatus. However, if rehabilitation is not undertaken rapidly and followed regularly for several months, the graft favours the development of muscular adherances which can be a major limitation to joint mobility.     

Changes in the aortic endothelium and plasma von Willebrand factor levels during the onset and progression of insulin-dependent diabetes in BB rats

The superior volume maintenance of membranous over endochondral bone has been shown in several studies and provides the basis for its preferred clinical use as an onlay grafting material in the craniofacial skeleton. The scientific rationale for this seeming embryologic advantage, however, has never been proven. Our hypothesis is that the pattern of onlay bone graft resorption is primarily determined by a graft's micro-architecture (relative cortical and cancellous composition) rather than its embryologic origin (membranous versus endochondral). Twenty-five adult New Zealand, White rabbits were used for this study. Eight animals were killed at 3 weeks, eight animals at 8 weeks, and nine animals at 16 weeks. Three graft types were placed onto each rabbit cranium: cortical bone graft of membranous origin and cortical and cancellous bone graft of endochondral origin. Fluorochrome markers were injected into all living rabbits at 1, 6, and 14 weeks. Microcomputed tomography scanning was performed on all of the bone grafts to determine postsacrifice volumes and to obtain detailed information regarding the bone graft's trabecular architecture. In addition, specimens were examined histologically. Volume analysis showed a statistically greater resorption rate in the cancellous endochondral bone graft than in either the endochondral or membranous cortical bone grafts (p < 0.05) for all time points. In addition there was no significant difference in the resorption rates between the endochondral and membranous cortical bone grafts. A post-test power analysis (alpha = 5 percent) of the volume data comparing the two types of cortical bone grafts showed that a difference in resorption of 8.9 percent would be detected with a 90-percent probability. Previous studies, which have shown a seeming superiority of membranous over endochondral bone grafts, used composite grafts composed of both cortical and cancellous portions. By separating these components, we have shown that cortical bone grafts maintain their volumes significantly better than cancellous bone grafts. In addition, we found no statistical difference in the resorption rates between the two cortical onlay bone grafts of different embryologic origins, a finding that has never been previously published. From our results, we believe cortical bone to be a superior onlay grafting material, independent of its embryologic origin. We believe these results challenge the currently accepted theories of bone graft dynamics and may lead to a change in the way clinicians approach bone graft selections for craniofacial surgery.     

Reconstruction of residual alveolar cleft defects with one-stage mandibular bone grafts and osseointegrated implants

PURPOSE: This study evaluates a treatment regimen for reconstruction of residual maxillary alveolar cleft defects consisting of mandibular bone grafting and immediate implant installation. PATIENTS AND METHODS: Sixteen cleft patients (five female and 11 male) had residual cleft defects of the alveolar ridge reconstructed with bone grafts from the mandibular symphyseal region. The bone graft was pretapped at the donor site before fixation in the residual ridge with Br?nemark implants. Twenty implants were installed according to this concept. The period of observation ranged from 36 to 69 months, with a mean of 48 months after implant installation. RESULTS: Five patients developed wound dehiscenses that resulted in total or partial bone graft sequestration. Two implants were lost, one due to sequestration and the other due to mobility at the abutment procedure; 18 implants were still well functioning at the end of the observation period. However, all patients showed significant periimplant bone resorption after this one-stage treatment. CONCLUSION: Because of the observed complication rate, the one-stage procedure may not be optimal for reconstructing residual cleft defects.     

Iatrogenic arachnoid cyst with distinct clinical picture as a result of bone defect in the floor of the middle cranial fossa: case report

OBJECTIVE AND IMPORTANCE: This kind of arachnoid cyst has not previously been described as a complication of a cranial base bone defect. Recognition of this rare complication may be delayed, because clinicians are unaware of its possibility. CLINICAL PRESENTATION: A 22-year-old man presented with severe headache and increasing difficulty in breathing and swallowing. A physical examination revealed a pulsatile mass in the oral cavity, arising from the parapharyngeal area. A cystic mass that protruded into the oral cavity, through a dural and bony defect in the left middle fossa, was detected on neuroimages. INTERVENTION: A left frontotemporal craniotomy was made, and the cyst was decompressed. Duraplasty was performed with lyophilized dura. The bone defect was managed with a calvarial free bone graft and a pedicled myofacial flap. Serial neuroimaging studies performed postoperatively showed that the cyst had decreased in size. CONCLUSION: This report describes an unusual complication of a cranial base bone defect. Although not all bone defects in the cranial base require reconstruction, management of the large bone defect, particularly in the middle fossa, should preferably be accomplished with the help of a bone graft to support the dural graft.     

Value of scaphal graft in secondary rhinoplasties

The scaphal cartilaginous area is a most suitable anatomic site for cartilaginous graft harvesting. These grafts allow reconstruction of a flat dorsum, or a rounded dome, or alar cartilages or can be used for an extended tip graft. In some cases, both scaphes may be harvested. Raising of the grafts does not leave any sequelae when performed correctly. We have an experience of 20 cases. The main advantage of this graft is its flatness, which makes it ideal for the nasal dorsum. It has to be tailored, moderately crushed and included in a collagen "surgicel" in order to break the shape memory, slightly curved at its borders. We have used scaphal autografts in 15 cases of secondary rhinoplasties, 2 cases of cleft lip repair and in 3 cases of tertiary rhinoplasties. They solved most problems of missing cartilage, when minor defects had to be treated. These grafts will not solve major tissue defects which must be repaired by bone autografts, mostly iliac bone harvesting in our experience. The results of scaphal autografts are stable after 5 years. Resorption is moderate when the graft is correctly inserted, in an extramucosal pocket. The aesthetic result is maintained with a mean follow up of 2 years for 15 cases. The scaphal area of the ear therefore appears to be a favorable donor site for secondary, nose repair; it is easy to harvest, with inconspicuous morbidity and allows the raising of a good, flat and sculpturable material for cartilaginous nose replacement. Achieves the objectives of ore informed patients asking for artistic perfection.     

Oncogenes and tumor suppressor genes in photocarcinogenesis

A case of coup de sabre, a linear form of scleroderma, is presented. Treatment consisted of soft-tissue expansion and autologous bone grafting to the forehead, a composite graft for alar reconstruction, and a scalp graft for eyebrow reconstruction. None of the linear scleroderma cases reported in the literature consisted of bony reconstruction.     

Reconstruction of a short nose by full-thickness tissue transfer with osteotomy

A severely shortened nose secondary to fracture of the middle third of the face was reconstructed by full-thickness tissue transfer with osteotomy. A nasalis musculocutaneous island flap, including the scar located in the nasal dorsum, was harvested for the lining. It was elevated based on the lateral nasal artery. The donor site defect of the flap and the covering defect were reconstructed with a forehead flap. The platform and framework of the nose were corrected with an en bloc osteotomy of the nasal bone, including the piriform aperture with a vascularized calvarial bone graft. Satisfactory and stable results were obtained in one stage along with the restoration of the relationships between the nose and the surrounding structures.