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Cranial Bone Harvest, Grafting
AORN JOURNAL
JANUARY 1994, VOL 59, NO 1
Cranial Bone Harvest, Grafting A CHOICE FOR MAXILLOFACIAL RECONSTRUCTION
Barbara J. Bruno, RN; Patricia A. Gustafson, RN
M
ost perioperative nurses are familiar with the use of iliac and rib bone as graft material in facial reconstructive procedures. At William Beaumont Army Medical Center, El Paso, Tex, we harvest and graft cranial bone for reconstructing facial regions. We believe cranial bone offers a number of advantages and is a viable alternative to using iliac and rib bone as graft material.
Bone Grafting Process
A
graft is tissue that is transplanted and expected to become a part of the host.’ The healing of bone and bone grafts is
Barbara J. Bruno, RN, MS, CNOR, MAJ, US Army Nurse Corps, is director of the perioperutive nursing course at William Beaumont Army Medical Center, El Paso, Tex. She earned her bachelor of science degree in nursing from the Universit,y of Texas System School of Nursing, El Paso; her master of science degree in systems management from the University of Southern California, Los Angeles; and her master of science degree in nursing f r o m the University of Kansas, Kansas City. Patricia A . Gustafson, R N , M A , MAJ, US Army Nurse Corps, is a staff nurse at William Beaumont Army Medical Center, El Paso, Tex. She earned her bachelor of science degree in nursing from the University of Arkansas for Medical Science, Little Rock, and her master of 242
unique among connective tissues because new bone formation arises from tissue regeneration rather than from simple tissue repair with scar formation.2 After bone is grafted, osteogenesis (ie, the formation of bone) is thought to occur in two phases: cells in the graft proliferate and form new osteoid (ie, the newly formed organic bone matrix that precedes calcification); and then the graft is incorporated into the host bed with continued resorption (ie, loss of bone tissue secondary to biochemical changes), replacement, and rernodeling.3 The amount of new bone that is formed depends on the number of cells transplanted (ie, the greater
arts degree in human resources development from Webster University,St Louis. The opinions or assertions contained in this article are the private views of the authors and are not to be construed as official or as reflecting the views of the U S Army Medical Department or the Department of Defense. The authors wish to express appreciation to the staff members of the oral-maxillojacial surgery department at William Beaumont Army Medical Center, El Paso, Tex,for their support and to Michael G. Donovan, MD, COL, US Army Medical Corps, chief of the orul-maxillofacial surgery department at William Beaumont Army Medical Center, El Paso, Tex, ,for his assistance in preparing the manuscript.
AORN JOURNAL
JANUARY 1994, VOL 59, NO 1
the number of viable cells that can be transplanted with the graft, the more bone will form). Autogenous bone (ie, the patient’s own bone) makes ideal grafting material, because it is the only type of graft to supply the living, immunocompatible bone cells that are essential to the first phase of osteogenesis. (See “Types of Grafts.”)
Types of Grafts
History of Bone Grafting
H
istorically, xenografts or heterografts (ie, grafts taken from another species) were the first bone grafts reported. H. H. deBoer, MD, describes the history of bone grafts. The theoretical basis of bone grafting was laid in 1674 with Dutch scientist Antoni van Leeuwenhoek’s description of bone structure. . . . In the 1700s, Henri-Louis Duhamel du Monceau, a Dutch scientist, was credited with having conducted the first research on osteogenesis, although Dutch scientist Antonius de Heyde had described callus calcification 60 years earlier. . . . In 1820, the first clinical autograft was performed by Philips lion Walter, a German surgeon. In 1880, a Scottish surgical team successfully reconstructed a child‘s infected humerus with an allograf. . . . A . M . Phelps, M D , attempted to graft a piece of bone from a dog into the tibia1 defect of a boy in 1891; the boy and the dog were attached to each other for two weeks. Although the graft failed, the idea of transplanting living bone was born. . . . In 1915, F . H . Albee, MD, published a book on bone graft surgery in the United States, marking a new era in bone tran~plantation.~
Cruniofucial Anatomy ones of the skull have three layers or tables. The outer and inner tables are compact bone, and the middle layer is a spongy layer called diploe. Except for the mandible and the sphenoid, the bones of the skull are formed by ossification of the membranes and are called membranous bone. Long
0
Autogenous - tissue removed from one part of the body is grafted to another part; also called autograft. Allogeneic - tissue removed from a genetically nonidentical donor of the same species is grafted into the recipient; also called allograft. Heterologous - tissue taken from a different species is transplanted into the recipient; also called xenograft, heterograft.
bones, the mandible, and the sphenoid are first modeled in cartilage before ossifying and are called endochondral bone.s
Calvariul Bone Grafts
B
one grafts are used to correct defects in size, shape, position, or amount of bony structure of the face. Traditionally, surgeons have preferred the iliac crest as the donor tissue for autogenous bone grafts in reconstructive maxillofacial surgery. The rib and tibia and allogeneic grafts also have been used to repair defects. Although rib and iliac bone are traditional donor sources for mandible, maxilla, and midface grafts, up to 80% resorption can be seen when using bone from these areas6 Another donor source for maxillofacial bone grafts is the calvaria, the dome-like portion of the skull, which is composed of the superior portions of the frontal, parietal, and occipital bones. The advantages of using calvarial bone include 0 marked reduction of donor site postoperative pain, 0 an inconspicuous scar, 0 rapid harvest time, sufficient amounts of donor bone, a single surgical field for both graft and donor site, and 0 decreased hospitalization time.’ Calvarial bone may undergo less resorption, most likely because of its dense blood supply. 243
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JANUARY 1994, VOL 59, NO 1
Calvarial bone grafts revascularize rapidly and display increased retention when grafted to the facial skeleton.8 The subtle curvature of the calvarial bone is ideal for grafting in the midface, maxilla, and mandible where there are few flat surfaces. Patients most often undergo cranial bone grafting to repair maxillofacial structures damaged by trauma or to correct congenital anomalies of the facial region. Cranial bone harvest with graft placement is a one-stage procedure. Although additional surgery may be required for completion of reconstruction, most patients are discharged within 24 hours after the cranial bone harvest and graft placement procedure. We present a pictorial essay of one patient’s cranial bone harvest and graft placement performed at our facility. This patient was a 22-year-old male who was injured in a blast during Operation Desert Storm. He sustained loss of the anterior maxilla and mandible, bums to the arm and hand, and blast and bum injuries to the chest, abdomen, and leg. He had marked soft tissue asymmetry, facial deformity, and limited ability to open his mouth (Figs 1 and 2). Dental stone models illustrate the loss of mandibular and maxillary support to his face and the associated loss of teeth, alveolus, and premaxilla area (Fig 3). Before undergoing cranial bone grafting to the
Fig 1. Soft tissue asymmetry is visible before cranial bone graft implantation.
maxilla and mandible, the patient was evaluated for staged reconstruction and underwent bilateral commissurotomies to increase flexibility of perioral tissues and increase the range of motion of the mandible.
Preoperative Care
T
he patient is counseled regarding risks, benefits, and alternatives of the planned procedure. Potential complications of cranial bone grafting include pain, infection, hemorrhage, partial or total loss of grafts, edema, cranial nerve dysfunction, permanent scars, need for follow-up surgery, involvement of intracranial structures, 0 stroke, 0 headaches, 0 subdural hematoma, numbness, 0 blindness, 0 seizures, postconcussion syndrome, and 0 death.
Fig 2. Patient has limited ability to open his mouth before reconstructive surgery. 245
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AORN JOURNAL
Fig 3. Dental model shows loss of bony support from maxilla and mandible and loss of teeth, alveolus, and premaxilla area.
Fig 4. Three-dimensional imaging helps the surgeons plan accurate reconstruction of the maxillofacial region.
The standard preoperative workup includes radiographic evaluation (ie, skull series), cephalometric (ie, head measurement) tracings, creation of plaster occlusion models that will ensure proper alignment of the teeth and jaws, three-dimensional imaging (Fig 4), construction of models or template patterns to approximate the size and shape of the calvaria1 bone graft, and a complete history and physical examination. The skull series is performed to rule out preexisting bony pathology and ensure there is adequate calvarial bone for grafting. The patient may have other studies determined by the type of reconstructive surgery planned. The patient may enter the hospital the day before the scheduled surgery or on the same day, depending on the diagnosis. Anesthesia personnel and the perioperative nurses evaluate the patient and provide standard preoperative instructions (eg, not wearing makeup, remaining NPO). The patient signs the operative permit and has standard laboratory work (eg, complete blood count, urinalysis, prothrombin time, partial thromboplastin time, blood chemistry panel). The perioperative nurse assesses the patient’s potential for infection, fear related to
the surgical experience, and altered nutritional status if oral surgery is planned. The nurse also determines the patient’s handedness to avoid harvesting bone from the skull over the dominant side of the brain. Based on these assessment data, the nurse constructs an individualized plan of care for the patient. The nurse assembles the supplies and equipment that will be needed for the cranial bone h a vest and grafting. These items are listed in Table 1 .
246
Intraoperative Phase
T
he circulating nurse greets the patient, verifies the patient’s identification, and assists him or her into the supine position on the OR bed. Nasal intubation is indicated for patients having jaw surgery, and oral intubation is used for other craniofacial procedures. Anesthesia personnel use a long anesthesia circuit and position all monitoring devices within easy access. The nurse positions and pads the patient carefully, flexing the patient’s knees slightly, placing foam padding at all bony prominences, and tucking one arm before the bed is turned 90 degrees. The nurse ensures that the
JANUARY 1994, VOL 59, NO I
patient’s body is properly aligned to avoid postoperative musculoskeletal discomfort. He or she positions the patient’s head to expose the selected donor site. Depending on the length of the entire surgical procedure (eg, one and one-half hours for harvest, one to two hours for graft placement), the patient may require a Foley catheter. The nurse applies antiembolism stockings and the electrosurgical unit grounding pad. Hair prep. The hair prep for this procedure differs from the usual neurosurgical prep. It is neither necessary nor indicated to cut or shave any hair for cranial bone grafts: leaving the hair intact does not increase the risk of infection or other postoperative compli~ations.~ The circulating nurse washes the patient’s hair with povidone-iodine scrub and uses a sterile comb to part the hair at the surgical incision line (Fig 5). The nurse then uses sterile rubber bands to secure the hair in a neat and fixed position, makes small pony tails, and gathers up any loose ends with the rubber bands. If the patient has short hair, the nurse applies antibiotic ointment to “style” the hair out of the way. Skin prep, eyelear protection. The circulating nurse applies a nonwater-soluble ophthalmic ointment to the patient’s eyes and places cotton balls in the ear canals before prepping the face. The nurse then performs a standard povidone-iodine prep if the patient has no history of iodine allergy and sets up an additional prep for the surgeon to paint the patient’s face. After completing the prep, the nurse irrigates the patient’s eyes with balanced salt solution to remove any povidone-iodine solution that may have flowed into the eyes and reapplies ophthalmic ointment to protect the eyes during surgery. Small, sterile barriers are placed over the eyes to prevent chemical or mechanical abrasions. Draping. When the prep is completed, the surgery team drapes the patient according to the surgeon’s preference. In most cases, a standard craniotomy drape and otolaryngology drapes are used. Harvest procedure. The surgeon injects the incision line with a solution containing 1:100,000
AORN JOURNAL
Table 1
Cranial Bone Harvest Supplies
0
0
Raney scalp clips, appliers high-speed hand piece (eg, Stryker) with burrs osteotomes chisels rigid fixation system bone wax drains
epinephrine to promote hemostasis. He or she uses a #10 blade to make an incision that begins at the midline and extends laterally. The surgeon undermines the margins, applies Raney scalp clips, and undermines the scalp superiorly and inferiorly in the plane just superficial to the paracranium. The surgeon identifies the sagittal suture to avoid harvesting bone over the sagittal sinus, because accidental entry into this sinus can cause excessive bleeding and even death. The surgeon calculates the amount of bone needed for the implant preoperative1y to ensure the harvest of an adequate amount. Frequently, the surgeon has prepared a template or pattern of the desired graft before surgery (Fig 6). This template helps in graft shaping and reduces the risk of making graft cuts that are too small, too large, or curved the wrong direction. Using a high-speed handpiece and burr, the surgeon cuts through the outer cortical layer of bone, avoiding the medullary space. After the surgeon completes the outline, he or she cuts several strips, one of which is an access strip. The access strip (Fig 7) is only half the width of the other strips, or it can be a totally different shape. This difference in width or shape facilitates removal of the actual graft strips. Even if the access strip is damaged, it may be used for filler material at the graft site. The surgeon then bevels the superior and lateral margins to allow a more favorable approach and uses a burr to separate the outer and inner cortex. This step is repeated for each strip before it is removed. The medullary space 241
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JANUARY 1994, VOL 59, NO 1
Fig 6. The template is used to ensure the correctly-sized graft.
Fig 5 . The shampooed hair is parted at the incision line.
Fig 7. The access strip (seen on the extreme right) is carefully removed. 248
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Fig 8. Surgeon reapproximates and sutures bone graft tissue.
Fig 10. Patient wears device to decrease scar formation and contractions.
Fig 9. Radiologic view illustrates reconstructed maxilla and mandible. 249
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is smoothed after each strip is removed. The harvested bone is approximately 4 mm thick, leaving the brain protected by the remaining bone. If a thicker graft is needed for the implant site, several layers of cranial bone can be used. The surgeon bevels the edges of the donor site to lessen the visibility of the defect and then begins closure. He or she may place oxidized cellulose (eg, Surgicel) over the donor site to promote hemostasis before reapproximating and closing the paracranium. Bone wax is used on bone edges to prevent injury to brain tissue, but it is used sparingly because of its nonresorbable characteristics. The surgeon uses interrupted horizontal or vertical mattress sutures to close the subcutaneous tissues. Raney scalp clips are removed as the tissues are closed to minimize blood loss. The surgeon uses skin staples to close the skin, and then the surgery team applies a bulky, pressure head dressing made of fluffs, Kerlix, and Elastoplast. Bone graft implantation. The surgeon prepares the maxillary bed for placement of the bone graft and then places the calvarial bone strips on the maxilla and nasal floor (Fig 8). Titanium osseointegration fixtures secure the grafts in place. If the procedure requires other fixation, the surgeon may use wires or plates to secure the grafts.
Postoperative Cure
T
he circulating nurse and anesthesia personnel transport the patient to the postanesthesia care unit. After the patient recovers from anesthesia, he or she returns to the surgical nursing unit. Much of the nursing care at this point is specific to the type of reconstructive surgery performed. General care includes offering the patient clear liquids and discontinuing the IV line and Foley catheter after the patient is able to take and retain adequate fluids.
Patient Outcome
A
radiologic view of the patient’s reconstructed maxilla and mandible appears in Fig 9. The patient wore a device (Fig lo), which was wired to the maxilla, for six months following surgery to decrease scar formation and contractions. A later photograph (Fig 11) shows the patient with healed commissurotomies and an established frontal maxilla, The patient will undergo further surgery to correct the nasal deformity and revise scars. Of the 80 patients who have undergone cranial bone harvest at our institution, none have had any postoperative complications related to the calvarial bone harvest. Only one of the 40 patients needed a drain placed in the harvest site, and this was removed within the first 24 hours after surgery. There have been no instances of infection even though hair is not removed from the donor site. No cases of graft failure have occurred.
Conclusion
P
Fig 11. Reconstructed frontal maxilla and healed commissurotomies. 250
erioperative nurses who care for patients undergoing facial reconstructive surgery must appreciate the complexity of these patients’ situations. Some patients, such as the young man presented in this article, undergo maxillofacial reconstructive surgery primarily for aesthetic reasons. Many patients, however, seek reconstructive surgery to regain function
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JANUARY 1994, VOL 59, NO 1
(eg, eating) and the ability to go out in public. Calvarial bone harvest and grafting offer these patients the advantages of less pain, no visible donor site scarring, shortened surgical times, quicker recovery periods, and excellent reconstructive results. This relatively new procedure presents perioperative nurses with new opportunities and challenges, which will increase as the use of cranial bone expands to other surgical specialties. 0 Notes 1. E Ellis 111, “Surgical reconstruction of defects of the jaws,” in Contemporary Oral and Maxillofacial Surgery, ed L J Peterson (St Louis: The C V Mosby Co, 1988) 651-655. 2. Ibid. 3. Ibid. 4. H H deBoer, “The history of bone grafts,” Clinical Orthopaedics and Related Research 226
Delegates Vote for National Officers Delegates representing AORN members at Congress are responsible for casting ballots to elect officers, Board members, and Nominating Committee members. This important activity is scheduled for Thursday, March 17, from 6:45to 8:15 AM in Meeting Rooms 26 and 28, on the second level of the Convention Center. This year, delegate status will be coded on the Galaxy Expocards, and delegates must insert their Expocards into automated readers to gain access to the polling area. Delegate changes must be completed by 5:30PM on Wednesday, March 16. Delegates and alternates involved in changes must have their Expocards recoded and new badges printed. Delegates must bring delegate badges and Expocards on Thursday morning to be eligible to vote. Candidate presentations and interview opportunities are important in preparing to vote. Delegates may bring notes to the polling area.
(January 1988) 292-298. 5. W F Ganong, Review of Medical Physiology, 14th ed (Norwalk, Conn: Appleton & Lange, 1989) 329. 6. J D Smith, M Abramson, “Membranous vs endochondrial bone autografts,” Archives of Otolaryngology 99 (March 1974) 203-205. 7. S A Wolfe, S Berkowitz, “The use of cranial bone grafts in the closure of alveolar and anterior palatal clefts,” Plastic and Reconstructive Surgery 72 (November 1983) 659-671. 8. J E Zins, L A Whitaker, “Membranous versus endochondral bone: Implication for craniofacial reconstruction,” Plastic and Reconstructive Surgery 72 (December 1983) 778-785; M A Petroff et al, “Cranial bone grafts for post-traumatic facial defects,” Laryngoscope 97 (November 1987) 12491253. 9. N B Powell, R W Riley, “Cranial bone grafting in facial aesthetic and reconstructive contouring,” Archives of Otolaryngology Head and Neck Surgery 113 (July 1987) 713-719.
Congress News Location in New Orleans The Congress News will be published daily during Congress week beginning Sunday, March 13, and ending Friday, March 18. Congress attendees can pick up copies in Lobbies A and F of the Ernest N. Morial Convention Center, New Orleans. The Congress News contains reports of selected pre-Congress seminars, the House of Delegates meetings, Forums, selected education sessions, and announcements. Election results will be published in the Friday edition of the Congress News. All additions, corrections, updates, and other information submitted for publication must be in the Congress News office, Meeting Room 16 on the second level of the Convention Center, by 2 PM the day before they are to be published.
251
JANUARY 1994, VOL 59, NO 1
Cranial Bone Harvest, Grafting A CHOICE FOR MAXILLOFACIAL RECONSTRUCTION
Barbara J. Bruno, RN; Patricia A. Gustafson, RN
M
ost perioperative nurses are familiar with the use of iliac and rib bone as graft material in facial reconstructive procedures. At William Beaumont Army Medical Center, El Paso, Tex, we harvest and graft cranial bone for reconstructing facial regions. We believe cranial bone offers a number of advantages and is a viable alternative to using iliac and rib bone as graft material.
Bone Grafting Process
A
graft is tissue that is transplanted and expected to become a part of the host.’ The healing of bone and bone grafts is
Barbara J. Bruno, RN, MS, CNOR, MAJ, US Army Nurse Corps, is director of the perioperutive nursing course at William Beaumont Army Medical Center, El Paso, Tex. She earned her bachelor of science degree in nursing from the Universit,y of Texas System School of Nursing, El Paso; her master of science degree in systems management from the University of Southern California, Los Angeles; and her master of science degree in nursing f r o m the University of Kansas, Kansas City. Patricia A . Gustafson, R N , M A , MAJ, US Army Nurse Corps, is a staff nurse at William Beaumont Army Medical Center, El Paso, Tex. She earned her bachelor of science degree in nursing from the University of Arkansas for Medical Science, Little Rock, and her master of 242
unique among connective tissues because new bone formation arises from tissue regeneration rather than from simple tissue repair with scar formation.2 After bone is grafted, osteogenesis (ie, the formation of bone) is thought to occur in two phases: cells in the graft proliferate and form new osteoid (ie, the newly formed organic bone matrix that precedes calcification); and then the graft is incorporated into the host bed with continued resorption (ie, loss of bone tissue secondary to biochemical changes), replacement, and rernodeling.3 The amount of new bone that is formed depends on the number of cells transplanted (ie, the greater
arts degree in human resources development from Webster University,St Louis. The opinions or assertions contained in this article are the private views of the authors and are not to be construed as official or as reflecting the views of the U S Army Medical Department or the Department of Defense. The authors wish to express appreciation to the staff members of the oral-maxillojacial surgery department at William Beaumont Army Medical Center, El Paso, Tex,for their support and to Michael G. Donovan, MD, COL, US Army Medical Corps, chief of the orul-maxillofacial surgery department at William Beaumont Army Medical Center, El Paso, Tex, ,for his assistance in preparing the manuscript.
AORN JOURNAL
JANUARY 1994, VOL 59, NO 1
the number of viable cells that can be transplanted with the graft, the more bone will form). Autogenous bone (ie, the patient’s own bone) makes ideal grafting material, because it is the only type of graft to supply the living, immunocompatible bone cells that are essential to the first phase of osteogenesis. (See “Types of Grafts.”)
Types of Grafts
History of Bone Grafting
H
istorically, xenografts or heterografts (ie, grafts taken from another species) were the first bone grafts reported. H. H. deBoer, MD, describes the history of bone grafts. The theoretical basis of bone grafting was laid in 1674 with Dutch scientist Antoni van Leeuwenhoek’s description of bone structure. . . . In the 1700s, Henri-Louis Duhamel du Monceau, a Dutch scientist, was credited with having conducted the first research on osteogenesis, although Dutch scientist Antonius de Heyde had described callus calcification 60 years earlier. . . . In 1820, the first clinical autograft was performed by Philips lion Walter, a German surgeon. In 1880, a Scottish surgical team successfully reconstructed a child‘s infected humerus with an allograf. . . . A . M . Phelps, M D , attempted to graft a piece of bone from a dog into the tibia1 defect of a boy in 1891; the boy and the dog were attached to each other for two weeks. Although the graft failed, the idea of transplanting living bone was born. . . . In 1915, F . H . Albee, MD, published a book on bone graft surgery in the United States, marking a new era in bone tran~plantation.~
Cruniofucial Anatomy ones of the skull have three layers or tables. The outer and inner tables are compact bone, and the middle layer is a spongy layer called diploe. Except for the mandible and the sphenoid, the bones of the skull are formed by ossification of the membranes and are called membranous bone. Long
0
Autogenous - tissue removed from one part of the body is grafted to another part; also called autograft. Allogeneic - tissue removed from a genetically nonidentical donor of the same species is grafted into the recipient; also called allograft. Heterologous - tissue taken from a different species is transplanted into the recipient; also called xenograft, heterograft.
bones, the mandible, and the sphenoid are first modeled in cartilage before ossifying and are called endochondral bone.s
Calvariul Bone Grafts
B
one grafts are used to correct defects in size, shape, position, or amount of bony structure of the face. Traditionally, surgeons have preferred the iliac crest as the donor tissue for autogenous bone grafts in reconstructive maxillofacial surgery. The rib and tibia and allogeneic grafts also have been used to repair defects. Although rib and iliac bone are traditional donor sources for mandible, maxilla, and midface grafts, up to 80% resorption can be seen when using bone from these areas6 Another donor source for maxillofacial bone grafts is the calvaria, the dome-like portion of the skull, which is composed of the superior portions of the frontal, parietal, and occipital bones. The advantages of using calvarial bone include 0 marked reduction of donor site postoperative pain, 0 an inconspicuous scar, 0 rapid harvest time, sufficient amounts of donor bone, a single surgical field for both graft and donor site, and 0 decreased hospitalization time.’ Calvarial bone may undergo less resorption, most likely because of its dense blood supply. 243
AORN JOURNAL
JANUARY 1994, VOL 59, NO 1
Calvarial bone grafts revascularize rapidly and display increased retention when grafted to the facial skeleton.8 The subtle curvature of the calvarial bone is ideal for grafting in the midface, maxilla, and mandible where there are few flat surfaces. Patients most often undergo cranial bone grafting to repair maxillofacial structures damaged by trauma or to correct congenital anomalies of the facial region. Cranial bone harvest with graft placement is a one-stage procedure. Although additional surgery may be required for completion of reconstruction, most patients are discharged within 24 hours after the cranial bone harvest and graft placement procedure. We present a pictorial essay of one patient’s cranial bone harvest and graft placement performed at our facility. This patient was a 22-year-old male who was injured in a blast during Operation Desert Storm. He sustained loss of the anterior maxilla and mandible, bums to the arm and hand, and blast and bum injuries to the chest, abdomen, and leg. He had marked soft tissue asymmetry, facial deformity, and limited ability to open his mouth (Figs 1 and 2). Dental stone models illustrate the loss of mandibular and maxillary support to his face and the associated loss of teeth, alveolus, and premaxilla area (Fig 3). Before undergoing cranial bone grafting to the
Fig 1. Soft tissue asymmetry is visible before cranial bone graft implantation.
maxilla and mandible, the patient was evaluated for staged reconstruction and underwent bilateral commissurotomies to increase flexibility of perioral tissues and increase the range of motion of the mandible.
Preoperative Care
T
he patient is counseled regarding risks, benefits, and alternatives of the planned procedure. Potential complications of cranial bone grafting include pain, infection, hemorrhage, partial or total loss of grafts, edema, cranial nerve dysfunction, permanent scars, need for follow-up surgery, involvement of intracranial structures, 0 stroke, 0 headaches, 0 subdural hematoma, numbness, 0 blindness, 0 seizures, postconcussion syndrome, and 0 death.
Fig 2. Patient has limited ability to open his mouth before reconstructive surgery. 245
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Fig 3. Dental model shows loss of bony support from maxilla and mandible and loss of teeth, alveolus, and premaxilla area.
Fig 4. Three-dimensional imaging helps the surgeons plan accurate reconstruction of the maxillofacial region.
The standard preoperative workup includes radiographic evaluation (ie, skull series), cephalometric (ie, head measurement) tracings, creation of plaster occlusion models that will ensure proper alignment of the teeth and jaws, three-dimensional imaging (Fig 4), construction of models or template patterns to approximate the size and shape of the calvaria1 bone graft, and a complete history and physical examination. The skull series is performed to rule out preexisting bony pathology and ensure there is adequate calvarial bone for grafting. The patient may have other studies determined by the type of reconstructive surgery planned. The patient may enter the hospital the day before the scheduled surgery or on the same day, depending on the diagnosis. Anesthesia personnel and the perioperative nurses evaluate the patient and provide standard preoperative instructions (eg, not wearing makeup, remaining NPO). The patient signs the operative permit and has standard laboratory work (eg, complete blood count, urinalysis, prothrombin time, partial thromboplastin time, blood chemistry panel). The perioperative nurse assesses the patient’s potential for infection, fear related to
the surgical experience, and altered nutritional status if oral surgery is planned. The nurse also determines the patient’s handedness to avoid harvesting bone from the skull over the dominant side of the brain. Based on these assessment data, the nurse constructs an individualized plan of care for the patient. The nurse assembles the supplies and equipment that will be needed for the cranial bone h a vest and grafting. These items are listed in Table 1 .
246
Intraoperative Phase
T
he circulating nurse greets the patient, verifies the patient’s identification, and assists him or her into the supine position on the OR bed. Nasal intubation is indicated for patients having jaw surgery, and oral intubation is used for other craniofacial procedures. Anesthesia personnel use a long anesthesia circuit and position all monitoring devices within easy access. The nurse positions and pads the patient carefully, flexing the patient’s knees slightly, placing foam padding at all bony prominences, and tucking one arm before the bed is turned 90 degrees. The nurse ensures that the
JANUARY 1994, VOL 59, NO I
patient’s body is properly aligned to avoid postoperative musculoskeletal discomfort. He or she positions the patient’s head to expose the selected donor site. Depending on the length of the entire surgical procedure (eg, one and one-half hours for harvest, one to two hours for graft placement), the patient may require a Foley catheter. The nurse applies antiembolism stockings and the electrosurgical unit grounding pad. Hair prep. The hair prep for this procedure differs from the usual neurosurgical prep. It is neither necessary nor indicated to cut or shave any hair for cranial bone grafts: leaving the hair intact does not increase the risk of infection or other postoperative compli~ations.~ The circulating nurse washes the patient’s hair with povidone-iodine scrub and uses a sterile comb to part the hair at the surgical incision line (Fig 5). The nurse then uses sterile rubber bands to secure the hair in a neat and fixed position, makes small pony tails, and gathers up any loose ends with the rubber bands. If the patient has short hair, the nurse applies antibiotic ointment to “style” the hair out of the way. Skin prep, eyelear protection. The circulating nurse applies a nonwater-soluble ophthalmic ointment to the patient’s eyes and places cotton balls in the ear canals before prepping the face. The nurse then performs a standard povidone-iodine prep if the patient has no history of iodine allergy and sets up an additional prep for the surgeon to paint the patient’s face. After completing the prep, the nurse irrigates the patient’s eyes with balanced salt solution to remove any povidone-iodine solution that may have flowed into the eyes and reapplies ophthalmic ointment to protect the eyes during surgery. Small, sterile barriers are placed over the eyes to prevent chemical or mechanical abrasions. Draping. When the prep is completed, the surgery team drapes the patient according to the surgeon’s preference. In most cases, a standard craniotomy drape and otolaryngology drapes are used. Harvest procedure. The surgeon injects the incision line with a solution containing 1:100,000
AORN JOURNAL
Table 1
Cranial Bone Harvest Supplies
0
0
Raney scalp clips, appliers high-speed hand piece (eg, Stryker) with burrs osteotomes chisels rigid fixation system bone wax drains
epinephrine to promote hemostasis. He or she uses a #10 blade to make an incision that begins at the midline and extends laterally. The surgeon undermines the margins, applies Raney scalp clips, and undermines the scalp superiorly and inferiorly in the plane just superficial to the paracranium. The surgeon identifies the sagittal suture to avoid harvesting bone over the sagittal sinus, because accidental entry into this sinus can cause excessive bleeding and even death. The surgeon calculates the amount of bone needed for the implant preoperative1y to ensure the harvest of an adequate amount. Frequently, the surgeon has prepared a template or pattern of the desired graft before surgery (Fig 6). This template helps in graft shaping and reduces the risk of making graft cuts that are too small, too large, or curved the wrong direction. Using a high-speed handpiece and burr, the surgeon cuts through the outer cortical layer of bone, avoiding the medullary space. After the surgeon completes the outline, he or she cuts several strips, one of which is an access strip. The access strip (Fig 7) is only half the width of the other strips, or it can be a totally different shape. This difference in width or shape facilitates removal of the actual graft strips. Even if the access strip is damaged, it may be used for filler material at the graft site. The surgeon then bevels the superior and lateral margins to allow a more favorable approach and uses a burr to separate the outer and inner cortex. This step is repeated for each strip before it is removed. The medullary space 241
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Fig 6. The template is used to ensure the correctly-sized graft.
Fig 5 . The shampooed hair is parted at the incision line.
Fig 7. The access strip (seen on the extreme right) is carefully removed. 248
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Fig 8. Surgeon reapproximates and sutures bone graft tissue.
Fig 10. Patient wears device to decrease scar formation and contractions.
Fig 9. Radiologic view illustrates reconstructed maxilla and mandible. 249
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is smoothed after each strip is removed. The harvested bone is approximately 4 mm thick, leaving the brain protected by the remaining bone. If a thicker graft is needed for the implant site, several layers of cranial bone can be used. The surgeon bevels the edges of the donor site to lessen the visibility of the defect and then begins closure. He or she may place oxidized cellulose (eg, Surgicel) over the donor site to promote hemostasis before reapproximating and closing the paracranium. Bone wax is used on bone edges to prevent injury to brain tissue, but it is used sparingly because of its nonresorbable characteristics. The surgeon uses interrupted horizontal or vertical mattress sutures to close the subcutaneous tissues. Raney scalp clips are removed as the tissues are closed to minimize blood loss. The surgeon uses skin staples to close the skin, and then the surgery team applies a bulky, pressure head dressing made of fluffs, Kerlix, and Elastoplast. Bone graft implantation. The surgeon prepares the maxillary bed for placement of the bone graft and then places the calvarial bone strips on the maxilla and nasal floor (Fig 8). Titanium osseointegration fixtures secure the grafts in place. If the procedure requires other fixation, the surgeon may use wires or plates to secure the grafts.
Postoperative Cure
T
he circulating nurse and anesthesia personnel transport the patient to the postanesthesia care unit. After the patient recovers from anesthesia, he or she returns to the surgical nursing unit. Much of the nursing care at this point is specific to the type of reconstructive surgery performed. General care includes offering the patient clear liquids and discontinuing the IV line and Foley catheter after the patient is able to take and retain adequate fluids.
Patient Outcome
A
radiologic view of the patient’s reconstructed maxilla and mandible appears in Fig 9. The patient wore a device (Fig lo), which was wired to the maxilla, for six months following surgery to decrease scar formation and contractions. A later photograph (Fig 11) shows the patient with healed commissurotomies and an established frontal maxilla, The patient will undergo further surgery to correct the nasal deformity and revise scars. Of the 80 patients who have undergone cranial bone harvest at our institution, none have had any postoperative complications related to the calvarial bone harvest. Only one of the 40 patients needed a drain placed in the harvest site, and this was removed within the first 24 hours after surgery. There have been no instances of infection even though hair is not removed from the donor site. No cases of graft failure have occurred.
Conclusion
P
Fig 11. Reconstructed frontal maxilla and healed commissurotomies. 250
erioperative nurses who care for patients undergoing facial reconstructive surgery must appreciate the complexity of these patients’ situations. Some patients, such as the young man presented in this article, undergo maxillofacial reconstructive surgery primarily for aesthetic reasons. Many patients, however, seek reconstructive surgery to regain function
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(eg, eating) and the ability to go out in public. Calvarial bone harvest and grafting offer these patients the advantages of less pain, no visible donor site scarring, shortened surgical times, quicker recovery periods, and excellent reconstructive results. This relatively new procedure presents perioperative nurses with new opportunities and challenges, which will increase as the use of cranial bone expands to other surgical specialties. 0 Notes 1. E Ellis 111, “Surgical reconstruction of defects of the jaws,” in Contemporary Oral and Maxillofacial Surgery, ed L J Peterson (St Louis: The C V Mosby Co, 1988) 651-655. 2. Ibid. 3. Ibid. 4. H H deBoer, “The history of bone grafts,” Clinical Orthopaedics and Related Research 226
Delegates Vote for National Officers Delegates representing AORN members at Congress are responsible for casting ballots to elect officers, Board members, and Nominating Committee members. This important activity is scheduled for Thursday, March 17, from 6:45to 8:15 AM in Meeting Rooms 26 and 28, on the second level of the Convention Center. This year, delegate status will be coded on the Galaxy Expocards, and delegates must insert their Expocards into automated readers to gain access to the polling area. Delegate changes must be completed by 5:30PM on Wednesday, March 16. Delegates and alternates involved in changes must have their Expocards recoded and new badges printed. Delegates must bring delegate badges and Expocards on Thursday morning to be eligible to vote. Candidate presentations and interview opportunities are important in preparing to vote. Delegates may bring notes to the polling area.
(January 1988) 292-298. 5. W F Ganong, Review of Medical Physiology, 14th ed (Norwalk, Conn: Appleton & Lange, 1989) 329. 6. J D Smith, M Abramson, “Membranous vs endochondrial bone autografts,” Archives of Otolaryngology 99 (March 1974) 203-205. 7. S A Wolfe, S Berkowitz, “The use of cranial bone grafts in the closure of alveolar and anterior palatal clefts,” Plastic and Reconstructive Surgery 72 (November 1983) 659-671. 8. J E Zins, L A Whitaker, “Membranous versus endochondral bone: Implication for craniofacial reconstruction,” Plastic and Reconstructive Surgery 72 (December 1983) 778-785; M A Petroff et al, “Cranial bone grafts for post-traumatic facial defects,” Laryngoscope 97 (November 1987) 12491253. 9. N B Powell, R W Riley, “Cranial bone grafting in facial aesthetic and reconstructive contouring,” Archives of Otolaryngology Head and Neck Surgery 113 (July 1987) 713-719.
Congress News Location in New Orleans The Congress News will be published daily during Congress week beginning Sunday, March 13, and ending Friday, March 18. Congress attendees can pick up copies in Lobbies A and F of the Ernest N. Morial Convention Center, New Orleans. The Congress News contains reports of selected pre-Congress seminars, the House of Delegates meetings, Forums, selected education sessions, and announcements. Election results will be published in the Friday edition of the Congress News. All additions, corrections, updates, and other information submitted for publication must be in the Congress News office, Meeting Room 16 on the second level of the Convention Center, by 2 PM the day before they are to be published.
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