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Dorsal nasal reconstruction using bone harvested from the mandible
J Oral Maxillofac Surg 62:1082-1087, 2004
Dorsal Nasal Reconstruction Using Bone Harvested From the Mandible Alan S. Herford, DDS, MD* Purpose:
This article describes a technique for reconstructing nasal deformities resulting from trauma. Bone harvested from the lateral ramus/body of the mandible is used to provide nasal support for major nasal deformities. Patients and Methods: Ten patients underwent repair of their nasal deformities with an autogenous bone graft harvested from the mandible. Primary bone grafting was used to repair a nasal deformity associated with a naso-orbito-ethmoidal fracture in 8 patients. Secondarily, 2 patients underwent placement of a graft for correction of a saddle nose deformity. Results: All patients achieved aesthetic results. There was maintenance of nasal projection and symmetry without displacement of the graft. None of the patients complained of an unnatural hardness of the nasal tip or dorsum. All grafts healed without evidence of infection, dehiscence, or necrosis. Conclusion: The lateral ramus/body of the mandible provide an excellent donor site alternative for nasal reconstruction. © 2004 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 62:1082-1087, 2004 Traumatic nasal deformities can present challenges for the reconstructive surgeon. Primary grafting as a part of initial fracture management can prevent significant secondary nasal deformities (saddle nose), which can be difficult to reconstruct.1-5 Primary and secondary repair of extensive nasal defects relies on the use of grafts. Options for grafting include alloplastic augmentation and autogenous tissue such as bone or cartilage.6-14 Autogenous tissue is the preferred grafting material for nasal reconstruction.15-23 A number of authors have recommended cartilage rib grafts or composite rib grafts for reconstruction of nasal dorsal defects.24,25 However, these grafts are often associated with significant warping. Bone grafts have advantages over cartilage grafts, especially for severe nasal deformities. These grafts are typically harvested from the outer cranium, iliac crest, or rib. A disadvantage of
*Chairman and Program Director, Department of Oral & Maxillofacial Surgery, Loma Linda University Medical Center, Loma Linda, CA, and Director, Division of Oral & Maxillofacial Surgery, Department of Surgery, Arrowhead Regional Medical Center, Colton, CA. Address correspondence and reprint requests to Dr Herford: Department of Oral and Maxillofacial Surgery, Loma Linda University School of Dentistry, Room 3306, 11092 Anderson St, Loma Linda, CA 92350; e-mail: [email protected] © 2004 American Association of Oral and Maxillofacial Surgeons
0278-2391/04/6209-0007$30.00/0 doi:10.1016/j.joms.2004.01.023
cranial bone grafts is that the nasal tip becomes hard and immobile. The ascending ramus has been used for alveolar grafting before implant placement,26,27 maxillary sinus grafting,28 orbital floor reconstruction,29 and for primary mandibular reconstruction after resection of tumors.30 This article introduces the mandible as an alternative donor site for nasal reconstruction. The surgical technique is discussed along with patient examples.
Patients and Methods Ten consecutive patients with significant nasal defects that required grafting were included in this study. Seven patients underwent exposure of their naso-orbito-ethmoidal (NOE) fracture via a coronal flap, through existing lacerations in 1 patient, and through an open rhinoplasty approach in 2 patients. The donor site was evaluated postoperatively. Examination included a thorough neurosensory exam performed immediately postoperatively and at monthly intervals. The examination involving the inferior alveolar/mental nerve included soft touch, two-point discrimination, and hot and cold. The noses were photographed preoperatively and postoperatively. Postoperative photos were taken immediately after surgery and also at the latest follow-up. Nasal reconstructions were evaluated for symmetry, displacement, resorption, and aesthetic result. The aesthetic criteria was subjective and included balance, nasal projection, supratip break (if desired), and nasal rotation.
1082
1083
ALAN S. HERFORD
ing was not performed to assess graft integrity/resorption, clinically there was no evidence of resorption. An aesthetic result was achieved in all cases. Good nasal projection and symmetry was obtained. No displacement of the graft was observed during the follow-up period. None of the patients complained of hardness of the nasal tip or dorsum. There were no complications, and all grafts healed uneventfully without evidence of infection, dehiscence, or necrosis. No patient required further surgeries.
Discussion
FIGURE 1. Harvest of a graft from the posterior mandible. Alan S. Herford. Nasal Reconstruction Using Mandibular Bone. J Oral Maxillofac Surg 2004.
Surgical Technique A template of the desired shape and length of the graft is useful to outline the desired bone graft. A cross-cut fissure bur (#701) is helpful to outline the bone graft by performing vertical and superior cuts. The inferior cut is accomplished using a 4 mm round carbide bur. A straight osteotome is then placed parallel to the outer cortex and used to gently outfracture the buccal plate in the ramus/body region (Fig 1). The bone graft is removed and the incision closed with 3.0 chromic gut suture. A recipient pocket for placing the graft is made with iris scissors through either an inferior or superior approach. A coronal approach is often used to provide wide surgical access for treating comminuted NOE fractures and provides excellent exposure for placing a dorsal nasal graft. Alternatively, a pocket can be created inferiorly through an open or closed rhinoplasty approach. The bone graft is inserted into the tunnel, taking care to place the caudal portion of the graft just beneath the lower lateral cartilages. The bone in the radix region is deepened with a chisel or rasp to obtain a raw surface for good bony union and the superior portion of the graft is secured with either screws alone or in conjunction with miniplates (Figs 2, 3).
Results Follow-up ranged from 6 to 18 months (average, 14 months). No evidence of altered sensation in any patients was observed. Although postoperative imag-
A goal of nasal reconstruction is to reconstruct a nose that is anatomically correct. The nasal tip should be soft and mobile. In defects involving missing or defective lower lateral cartilages, it may be necessary to combine a cartilage graft with the bone graft. By placing the caudal portion of the graft beneath the lower lateral nasal cartilages it provides optimal nasal tip support and also avoids the creation of a hard tip postoperatively. Isolated dorsal deformities can be approached through an endonasal or open approach. For extensive defects, it is preferable to use an open approach. Advantages of an open rhinoplasty incision for complex nasal deformities include maximum exposure and the scarred tissues are easily freed and mobilized. For NOE fractures with comminuted nasal bones, it is often preferable to place a bone graft primarily.1-5 This avoids or minimizes secondary nasal deformities, which are difficult to treat. NOE fractures are most commonly approached through a coronal incision. This approach provides excellent exposure for harvesting cranial bone grafts. Cranial bone is recommended over a corticocancellous iliac crest bone graft.19 Cranial bone has disadvantages including its brittleness and hardness. Some patients with associated skull fractures or underlying head injuries may not be candidates for cranial bone harvest. Saddle nose deformities are often caused by inadequate cartilage support.31-34 A bone graft that is rigidly fixed into place provides primary support for the reconstruction. Saddle nose deformities give the impression of a flat nose, and dorsal augmentation makes the nose look narrower. Fixation for the bone graft is accomplished by placing screws alone or combining them with plates.35 Small plates are used to avoid palpable hardware postoperatively. The screws are countersunk to allow a smooth contour of the graft and screws. We did not observe significant resorption in any patients in this study. Rigid fixation of the graft likely minimizes the degree of resorption.36 Cartilage is more pliable, easier to carve, and has a lower resorption rate than bone. However, septal
1084
NASAL RECONSTRUCTION USING MANDIBULAR BONE
FIGURE 2. A, A secondary (saddle nose) deformity resulting from loss of septal support. B, The graft contains adequate length for a nasal strut. C, The graft is thinned and contoured to the desired shape. D, The graft is placed through an open rhinoplasty incision. Note that the inferior end of the graft is beneath the lower lateral cartilages to avoid a hard nasal tip. E, Postoperative result showing good projection and support of the nose. Alan S. Herford. Nasal Reconstruction Using Mandibular Bone. J Oral Maxillofac Surg 2004.
FIGURE 3. A, A patient who sustained a NOE fracture with comminution of her nasal bones. The patient had associated cranium fractures. B, Significant nasal deformity. C, Postoperative result with restoration of the nasal support. D, The strut graft provides adequate dorsal nasal support. Alan S. Herford. Nasal Reconstruction Using Mandibular Bone. J Oral Maxillofac Surg 2004.
1086 cartilage is insufficient for severe deformities. For dorsal nasal reconstruction, rib cartilage provides adequate grafting material. A disadvantage of cartilage is its susceptibility to warp in an unpredictable way. Potential donor site complications include deformities and pneumothorax. In elderly patients, the cartilage is often calcified and makes carving difficult. Split calvarial grafts have a resorption rate of 20% to 30% and have been associated with up to 20% donor site morbidity.12 Cranial bone is brittle and susceptible to fracture.37 Potential complications include intracranial penetration, subdural hematoma, and brain injury. Bone harvested from the mandible closely resembles nasal bone in regard to texture and is far less brittle than cranial bone. The graft is strong and can be reduced to a dimension of 2.0 mm and is therefore less susceptible to fracture. This reduces the need for excessive removal of radix bone, which is required with thicker grafts. Rib grafts are softer and may bend when split. The bone harvested from the lateral ramus/body is slightly convex, with a thickness up to 4 mm. A length of up to 5 cm and diameter of 1 to 2 cm can be harvested. Membranous bone grafts resorb to a lesser degree compared with endochondral bone.38 Advantages of this donor site include the convenient surgical access and proximity of the donor and recipient sites. The lateral ramus offers advantages over other intraoral harvest sites.26 The graft is of the desired size and contour, and the postoperative course is associated with minimal discomfort. There is no residual functional deformity at the donor site, the periosteum remains intact, and the harvest site will repair itself without the need for grafting. The mandibular ramus/body graft has a low incidence of complications compared with other harvest sites.27 Harvest of bone from this region requires knowledge of the location of the mandibular canal to prevent injury to the inferior alveolar neurovascular bundle. Vertical cuts are progressively deepened until bleeding cancellous bone is encountered. The risk of damage to the inferior alveolar nerve can be minimized with correct orientation of the chisel and also by performing adequate inferior and vertical bone cuts. Autogenous tissue is the preferred grafting material for reconstruction of both primary and secondary major nasal deformities. Bone grafts have advantages over cartilage and alloplastic materials. Bone grafts harvested from the lateral ramus/body of the mandible provide a viable alternative for nasal reconstruction.
References 1. Markowitz BL, Manson PN, Sargent L, et al: Management of the medial canthal tendon in nasoethmoid orbital fractures: The
NASAL RECONSTRUCTION USING MANDIBULAR BONE
2. 3.
4. 5.
6. 7. 8. 9. 10.
11. 12.
13.
14. 15. 16. 17. 18. 19. 20.
21. 22. 23.
24. 25.
26.
27.
28.
29.
30.
importance of the central fragment in classification and treatment. Plast Reconstr Surg 87:843, 1991 Ellis E III: Sequencing treatment for naso-orbito-ethmoid fractures. J Oral Maxillofac Surg 51:543, 1993 Vora NM, Fedok FG: Management of the central nasal support complex in naso-orbital ethmoid fractures. Facial Plast Surg 16:181, 2000 Gruss JS: Naso-orbital-ethmoid fractures: classification and role of primary bone grafting. Plast Reconstr Surg 75:303, 1985 Frodel JL Jr: Management of the nasal dorsum in central facial injuries: Indications for calvarial bone grafting. Arch Otolaryngol Head Neck Surg 121:307, 1995 Neu BR: Segmental bone and cartilage reconstruction of major nasal dorsal defects. Plast Reconstr Surg 106:160, 2000 Mass CS, Monhian N, Shah SB: Implants in rhinoplasty. Facial Plast Surg 13:279, 1997 Karacaoglan N, Uysal OA: Use of iliac bone graft for saddle nose deformity. Auris Nasus Larynx 25:49, 1998 Jackson IT, Smith J, Mixter RC: Nasal bone grafting using split skull grafts. Ann Plast Surg 11:533, 1983 Niechajev I: Porous polyethylene implants for nasal reconstruction: Clinical and histologic studies. Aesthetic Plast Surg 23: 395, 1999 Romo T III, Sclafani AP, Jacono AA: Nasal reconstruction using porous pol12. yethylene implants. Facial Plast Surg 16:55, 2000 Romo T III, McLaughlin LA, Levine JM, et al: Nasal implants: Autogenous, semisynthetic, and synthetic. Facial Plast Surg 10:155, 2002 Lovice DB, Mingrone MD, Toriumi DM: Grafts and implants in rhinoplasty and nasal reconstruction. Otolaryngol Clin N Am 32:113, 1999 Silver WE, Goldberg J: Nasal grafts and implants. Facial Plast Surg 7:43, 1994 Kinnebrew M: Augmentation rhinoplasty. Atlas Oral Maxillofac Surg Clin North Am 3:39, 1995 Park SS, Cook TA: Reconstructive rhinoplasty. Facial Plast Surg 13:309, 1997 Romo T, Jablonski RD: Nasal reconstruction using split calvarial grafts. Otolaryngol Head Neck Surg 107:622, 1992 Flowers RS: Nasal augmentation. Facial Plast Surg Clin N Am 2:339, 1994 Tessier P: Autogenous bone grafts taken from the calvarium for facial and cranial applications. Clin Plast Surg 9:531, 1982 Posnick JC, Seagle MB, Armstrong D: Nasal reconstruction with full-thickness cranial bone grafts and rigid internal fixation through a coronal incision. Plast Reconstr Surg 86:894, 1990 Wheeler ES, Kawamato HK, Zarem HA: Bone grafts for nasal reconstruction. Plast Reconstr Surg 69:9, 1982 Sheen JH: The ideal dorsal graft: A continuing quest. Plast Reconstr Surg 102:2490, 1998 Jackson IT, Choi HY, Clay R, et al: Long term follow-up of cranial bone graft in dorsal nasal augmentation. Plast Reconstr Surg 102:1869, 1998 Daniel RK: Rhinoplasty and rib grafts: Evolving a flexible operative technique. Plast Reconstr Surg 94:597, 1994 Gibson T, Davis WB: The distortion of autogenous cartilage grafts: Its cause and prevention. Br J Plast Surg 10:257, 1958 Misch CM: Ridge augmentation using mandibular ramus bone grafts for the placement of dental implants: Presentation of a technique. Prac Periodont Aesth Dent 8:127, 1996 Misch CM: Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 12:767, 1997 Wood RM, Moore DL: Grafting of the maxillary sinus with intraorally harvested autogenous bone prior to implant placement. Int J Oral Maxillofac Implants 3:209, 1988 Girdler NM, Hosseini M: Orbital floor reconstruction with bone harvested from the mandibular lingual cortex. Br J Oral Maxillofac Surg 30:36, 1992 Muto T, Kanazawa M: Mandibular reconstruction using the
ALAN S. HERFORD
31. 32. 33. 34.
anterior part of ascending ramus: Report of two cases. J Oral Maxillofac Surg 55:1152, 1997 Tardy ME Jr, Schwartz M, Parras G: Saddle nose deformity: autogenous graft repair. Facial Plast Surg 6:121, 1989 Andrade M, Fernandes VS: Saddle nose: Our approach to the problem. Aesthetic Plast Surg 23:403, 1999 Aiach G, Monaghan P: Treatment of over-reduction of the nose and subsequent deformities. Br J Oral Maxillofac Surg 33:250, 1995 Dyer WK II, Beaty MM, Prabhat A: Architectural deficiencies of the nose: Treatment of the saddle nose and short nose deformities. Otolaryngol Clin North Am 32:89, 1999
1087 35. David DJ, Moore MH: Cantilever nasal bone grafting with miniscrew fixation. Plast Reconstr Surg 83:728, 1989 36. Phillips JH, Rahn BA: Fixation effects on membranous and endochondral onlay bone-graft resorption. Plast Reconstr Surg 82:872, 1988 37. Sullivan PK, Varma M, Rozzelle A: Optimizing bone-graft nasal reconstruction: A study of nasal bone shape and thickness. Plast Reconstr Surg 97:327, 1996 38. Ozaki W, Buchman SR: Volume maintenance of onlay bone grafts in the craniofacial skeleton: Micro-architecture versus embryologic origin. Plast Reconstr Surg 102:291, 1998
Dorsal Nasal Reconstruction Using Bone Harvested From the Mandible Alan S. Herford, DDS, MD* Purpose:
This article describes a technique for reconstructing nasal deformities resulting from trauma. Bone harvested from the lateral ramus/body of the mandible is used to provide nasal support for major nasal deformities. Patients and Methods: Ten patients underwent repair of their nasal deformities with an autogenous bone graft harvested from the mandible. Primary bone grafting was used to repair a nasal deformity associated with a naso-orbito-ethmoidal fracture in 8 patients. Secondarily, 2 patients underwent placement of a graft for correction of a saddle nose deformity. Results: All patients achieved aesthetic results. There was maintenance of nasal projection and symmetry without displacement of the graft. None of the patients complained of an unnatural hardness of the nasal tip or dorsum. All grafts healed without evidence of infection, dehiscence, or necrosis. Conclusion: The lateral ramus/body of the mandible provide an excellent donor site alternative for nasal reconstruction. © 2004 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 62:1082-1087, 2004 Traumatic nasal deformities can present challenges for the reconstructive surgeon. Primary grafting as a part of initial fracture management can prevent significant secondary nasal deformities (saddle nose), which can be difficult to reconstruct.1-5 Primary and secondary repair of extensive nasal defects relies on the use of grafts. Options for grafting include alloplastic augmentation and autogenous tissue such as bone or cartilage.6-14 Autogenous tissue is the preferred grafting material for nasal reconstruction.15-23 A number of authors have recommended cartilage rib grafts or composite rib grafts for reconstruction of nasal dorsal defects.24,25 However, these grafts are often associated with significant warping. Bone grafts have advantages over cartilage grafts, especially for severe nasal deformities. These grafts are typically harvested from the outer cranium, iliac crest, or rib. A disadvantage of
*Chairman and Program Director, Department of Oral & Maxillofacial Surgery, Loma Linda University Medical Center, Loma Linda, CA, and Director, Division of Oral & Maxillofacial Surgery, Department of Surgery, Arrowhead Regional Medical Center, Colton, CA. Address correspondence and reprint requests to Dr Herford: Department of Oral and Maxillofacial Surgery, Loma Linda University School of Dentistry, Room 3306, 11092 Anderson St, Loma Linda, CA 92350; e-mail: [email protected] © 2004 American Association of Oral and Maxillofacial Surgeons
0278-2391/04/6209-0007$30.00/0 doi:10.1016/j.joms.2004.01.023
cranial bone grafts is that the nasal tip becomes hard and immobile. The ascending ramus has been used for alveolar grafting before implant placement,26,27 maxillary sinus grafting,28 orbital floor reconstruction,29 and for primary mandibular reconstruction after resection of tumors.30 This article introduces the mandible as an alternative donor site for nasal reconstruction. The surgical technique is discussed along with patient examples.
Patients and Methods Ten consecutive patients with significant nasal defects that required grafting were included in this study. Seven patients underwent exposure of their naso-orbito-ethmoidal (NOE) fracture via a coronal flap, through existing lacerations in 1 patient, and through an open rhinoplasty approach in 2 patients. The donor site was evaluated postoperatively. Examination included a thorough neurosensory exam performed immediately postoperatively and at monthly intervals. The examination involving the inferior alveolar/mental nerve included soft touch, two-point discrimination, and hot and cold. The noses were photographed preoperatively and postoperatively. Postoperative photos were taken immediately after surgery and also at the latest follow-up. Nasal reconstructions were evaluated for symmetry, displacement, resorption, and aesthetic result. The aesthetic criteria was subjective and included balance, nasal projection, supratip break (if desired), and nasal rotation.
1082
1083
ALAN S. HERFORD
ing was not performed to assess graft integrity/resorption, clinically there was no evidence of resorption. An aesthetic result was achieved in all cases. Good nasal projection and symmetry was obtained. No displacement of the graft was observed during the follow-up period. None of the patients complained of hardness of the nasal tip or dorsum. There were no complications, and all grafts healed uneventfully without evidence of infection, dehiscence, or necrosis. No patient required further surgeries.
Discussion
FIGURE 1. Harvest of a graft from the posterior mandible. Alan S. Herford. Nasal Reconstruction Using Mandibular Bone. J Oral Maxillofac Surg 2004.
Surgical Technique A template of the desired shape and length of the graft is useful to outline the desired bone graft. A cross-cut fissure bur (#701) is helpful to outline the bone graft by performing vertical and superior cuts. The inferior cut is accomplished using a 4 mm round carbide bur. A straight osteotome is then placed parallel to the outer cortex and used to gently outfracture the buccal plate in the ramus/body region (Fig 1). The bone graft is removed and the incision closed with 3.0 chromic gut suture. A recipient pocket for placing the graft is made with iris scissors through either an inferior or superior approach. A coronal approach is often used to provide wide surgical access for treating comminuted NOE fractures and provides excellent exposure for placing a dorsal nasal graft. Alternatively, a pocket can be created inferiorly through an open or closed rhinoplasty approach. The bone graft is inserted into the tunnel, taking care to place the caudal portion of the graft just beneath the lower lateral cartilages. The bone in the radix region is deepened with a chisel or rasp to obtain a raw surface for good bony union and the superior portion of the graft is secured with either screws alone or in conjunction with miniplates (Figs 2, 3).
Results Follow-up ranged from 6 to 18 months (average, 14 months). No evidence of altered sensation in any patients was observed. Although postoperative imag-
A goal of nasal reconstruction is to reconstruct a nose that is anatomically correct. The nasal tip should be soft and mobile. In defects involving missing or defective lower lateral cartilages, it may be necessary to combine a cartilage graft with the bone graft. By placing the caudal portion of the graft beneath the lower lateral nasal cartilages it provides optimal nasal tip support and also avoids the creation of a hard tip postoperatively. Isolated dorsal deformities can be approached through an endonasal or open approach. For extensive defects, it is preferable to use an open approach. Advantages of an open rhinoplasty incision for complex nasal deformities include maximum exposure and the scarred tissues are easily freed and mobilized. For NOE fractures with comminuted nasal bones, it is often preferable to place a bone graft primarily.1-5 This avoids or minimizes secondary nasal deformities, which are difficult to treat. NOE fractures are most commonly approached through a coronal incision. This approach provides excellent exposure for harvesting cranial bone grafts. Cranial bone is recommended over a corticocancellous iliac crest bone graft.19 Cranial bone has disadvantages including its brittleness and hardness. Some patients with associated skull fractures or underlying head injuries may not be candidates for cranial bone harvest. Saddle nose deformities are often caused by inadequate cartilage support.31-34 A bone graft that is rigidly fixed into place provides primary support for the reconstruction. Saddle nose deformities give the impression of a flat nose, and dorsal augmentation makes the nose look narrower. Fixation for the bone graft is accomplished by placing screws alone or combining them with plates.35 Small plates are used to avoid palpable hardware postoperatively. The screws are countersunk to allow a smooth contour of the graft and screws. We did not observe significant resorption in any patients in this study. Rigid fixation of the graft likely minimizes the degree of resorption.36 Cartilage is more pliable, easier to carve, and has a lower resorption rate than bone. However, septal
1084
NASAL RECONSTRUCTION USING MANDIBULAR BONE
FIGURE 2. A, A secondary (saddle nose) deformity resulting from loss of septal support. B, The graft contains adequate length for a nasal strut. C, The graft is thinned and contoured to the desired shape. D, The graft is placed through an open rhinoplasty incision. Note that the inferior end of the graft is beneath the lower lateral cartilages to avoid a hard nasal tip. E, Postoperative result showing good projection and support of the nose. Alan S. Herford. Nasal Reconstruction Using Mandibular Bone. J Oral Maxillofac Surg 2004.
FIGURE 3. A, A patient who sustained a NOE fracture with comminution of her nasal bones. The patient had associated cranium fractures. B, Significant nasal deformity. C, Postoperative result with restoration of the nasal support. D, The strut graft provides adequate dorsal nasal support. Alan S. Herford. Nasal Reconstruction Using Mandibular Bone. J Oral Maxillofac Surg 2004.
1086 cartilage is insufficient for severe deformities. For dorsal nasal reconstruction, rib cartilage provides adequate grafting material. A disadvantage of cartilage is its susceptibility to warp in an unpredictable way. Potential donor site complications include deformities and pneumothorax. In elderly patients, the cartilage is often calcified and makes carving difficult. Split calvarial grafts have a resorption rate of 20% to 30% and have been associated with up to 20% donor site morbidity.12 Cranial bone is brittle and susceptible to fracture.37 Potential complications include intracranial penetration, subdural hematoma, and brain injury. Bone harvested from the mandible closely resembles nasal bone in regard to texture and is far less brittle than cranial bone. The graft is strong and can be reduced to a dimension of 2.0 mm and is therefore less susceptible to fracture. This reduces the need for excessive removal of radix bone, which is required with thicker grafts. Rib grafts are softer and may bend when split. The bone harvested from the lateral ramus/body is slightly convex, with a thickness up to 4 mm. A length of up to 5 cm and diameter of 1 to 2 cm can be harvested. Membranous bone grafts resorb to a lesser degree compared with endochondral bone.38 Advantages of this donor site include the convenient surgical access and proximity of the donor and recipient sites. The lateral ramus offers advantages over other intraoral harvest sites.26 The graft is of the desired size and contour, and the postoperative course is associated with minimal discomfort. There is no residual functional deformity at the donor site, the periosteum remains intact, and the harvest site will repair itself without the need for grafting. The mandibular ramus/body graft has a low incidence of complications compared with other harvest sites.27 Harvest of bone from this region requires knowledge of the location of the mandibular canal to prevent injury to the inferior alveolar neurovascular bundle. Vertical cuts are progressively deepened until bleeding cancellous bone is encountered. The risk of damage to the inferior alveolar nerve can be minimized with correct orientation of the chisel and also by performing adequate inferior and vertical bone cuts. Autogenous tissue is the preferred grafting material for reconstruction of both primary and secondary major nasal deformities. Bone grafts have advantages over cartilage and alloplastic materials. Bone grafts harvested from the lateral ramus/body of the mandible provide a viable alternative for nasal reconstruction.
References 1. Markowitz BL, Manson PN, Sargent L, et al: Management of the medial canthal tendon in nasoethmoid orbital fractures: The
NASAL RECONSTRUCTION USING MANDIBULAR BONE
2. 3.
4. 5.
6. 7. 8. 9. 10.
11. 12.
13.
14. 15. 16. 17. 18. 19. 20.
21. 22. 23.
24. 25.
26.
27.
28.
29.
30.
importance of the central fragment in classification and treatment. Plast Reconstr Surg 87:843, 1991 Ellis E III: Sequencing treatment for naso-orbito-ethmoid fractures. J Oral Maxillofac Surg 51:543, 1993 Vora NM, Fedok FG: Management of the central nasal support complex in naso-orbital ethmoid fractures. Facial Plast Surg 16:181, 2000 Gruss JS: Naso-orbital-ethmoid fractures: classification and role of primary bone grafting. Plast Reconstr Surg 75:303, 1985 Frodel JL Jr: Management of the nasal dorsum in central facial injuries: Indications for calvarial bone grafting. Arch Otolaryngol Head Neck Surg 121:307, 1995 Neu BR: Segmental bone and cartilage reconstruction of major nasal dorsal defects. Plast Reconstr Surg 106:160, 2000 Mass CS, Monhian N, Shah SB: Implants in rhinoplasty. Facial Plast Surg 13:279, 1997 Karacaoglan N, Uysal OA: Use of iliac bone graft for saddle nose deformity. Auris Nasus Larynx 25:49, 1998 Jackson IT, Smith J, Mixter RC: Nasal bone grafting using split skull grafts. Ann Plast Surg 11:533, 1983 Niechajev I: Porous polyethylene implants for nasal reconstruction: Clinical and histologic studies. Aesthetic Plast Surg 23: 395, 1999 Romo T III, Sclafani AP, Jacono AA: Nasal reconstruction using porous pol12. yethylene implants. Facial Plast Surg 16:55, 2000 Romo T III, McLaughlin LA, Levine JM, et al: Nasal implants: Autogenous, semisynthetic, and synthetic. Facial Plast Surg 10:155, 2002 Lovice DB, Mingrone MD, Toriumi DM: Grafts and implants in rhinoplasty and nasal reconstruction. Otolaryngol Clin N Am 32:113, 1999 Silver WE, Goldberg J: Nasal grafts and implants. Facial Plast Surg 7:43, 1994 Kinnebrew M: Augmentation rhinoplasty. Atlas Oral Maxillofac Surg Clin North Am 3:39, 1995 Park SS, Cook TA: Reconstructive rhinoplasty. Facial Plast Surg 13:309, 1997 Romo T, Jablonski RD: Nasal reconstruction using split calvarial grafts. Otolaryngol Head Neck Surg 107:622, 1992 Flowers RS: Nasal augmentation. Facial Plast Surg Clin N Am 2:339, 1994 Tessier P: Autogenous bone grafts taken from the calvarium for facial and cranial applications. Clin Plast Surg 9:531, 1982 Posnick JC, Seagle MB, Armstrong D: Nasal reconstruction with full-thickness cranial bone grafts and rigid internal fixation through a coronal incision. Plast Reconstr Surg 86:894, 1990 Wheeler ES, Kawamato HK, Zarem HA: Bone grafts for nasal reconstruction. Plast Reconstr Surg 69:9, 1982 Sheen JH: The ideal dorsal graft: A continuing quest. Plast Reconstr Surg 102:2490, 1998 Jackson IT, Choi HY, Clay R, et al: Long term follow-up of cranial bone graft in dorsal nasal augmentation. Plast Reconstr Surg 102:1869, 1998 Daniel RK: Rhinoplasty and rib grafts: Evolving a flexible operative technique. Plast Reconstr Surg 94:597, 1994 Gibson T, Davis WB: The distortion of autogenous cartilage grafts: Its cause and prevention. Br J Plast Surg 10:257, 1958 Misch CM: Ridge augmentation using mandibular ramus bone grafts for the placement of dental implants: Presentation of a technique. Prac Periodont Aesth Dent 8:127, 1996 Misch CM: Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 12:767, 1997 Wood RM, Moore DL: Grafting of the maxillary sinus with intraorally harvested autogenous bone prior to implant placement. Int J Oral Maxillofac Implants 3:209, 1988 Girdler NM, Hosseini M: Orbital floor reconstruction with bone harvested from the mandibular lingual cortex. Br J Oral Maxillofac Surg 30:36, 1992 Muto T, Kanazawa M: Mandibular reconstruction using the
ALAN S. HERFORD
31. 32. 33. 34.
anterior part of ascending ramus: Report of two cases. J Oral Maxillofac Surg 55:1152, 1997 Tardy ME Jr, Schwartz M, Parras G: Saddle nose deformity: autogenous graft repair. Facial Plast Surg 6:121, 1989 Andrade M, Fernandes VS: Saddle nose: Our approach to the problem. Aesthetic Plast Surg 23:403, 1999 Aiach G, Monaghan P: Treatment of over-reduction of the nose and subsequent deformities. Br J Oral Maxillofac Surg 33:250, 1995 Dyer WK II, Beaty MM, Prabhat A: Architectural deficiencies of the nose: Treatment of the saddle nose and short nose deformities. Otolaryngol Clin North Am 32:89, 1999
1087 35. David DJ, Moore MH: Cantilever nasal bone grafting with miniscrew fixation. Plast Reconstr Surg 83:728, 1989 36. Phillips JH, Rahn BA: Fixation effects on membranous and endochondral onlay bone-graft resorption. Plast Reconstr Surg 82:872, 1988 37. Sullivan PK, Varma M, Rozzelle A: Optimizing bone-graft nasal reconstruction: A study of nasal bone shape and thickness. Plast Reconstr Surg 97:327, 1996 38. Ozaki W, Buchman SR: Volume maintenance of onlay bone grafts in the craniofacial skeleton: Micro-architecture versus embryologic origin. Plast Reconstr Surg 102:291, 1998