Distraction Osteogenesis

The Scar Solution Book

Get Instant Access

Distraction osteogenesis is a process that results in the creation of new bone in an enlarging gap between two bone fragments caused by their gradual separation (59). Originally described by Codivilla (1904) for lengthening lower extremity bones, the process gained wider acceptance after Gavril Ilizarov, a Russian surgeon, studied the mechanics and physiology of limb lengthening in 1954. Dr. Ilizarov continued his work and has contributed much of the current clinical knowledge of the method and biology of distraction osteogenesis (60-62).

Three methods of distraction osteogenesis are described: monofocal, bifocal, and trifocal. Monofocal distraction is the separation of two fragments of bone with one focus of new bone formation between the fragments (e.g., limb lengthening). Bifocal distraction is the movement of a single bone fragment or what is termed a transport disk, cut from the remaining bone stump, across a gap to unite with the opposite native bone (Fig. 7). Trifocal distraction is the movement of two apposing disks across a gap (e.g., advancing osteotomized mandibular body segments for sym-physeal reconstruction. (63).

The method of distraction osteogenesis for maxillofacial application is extrapolated largely from the experiences with long bone distraction. First, division of the bone cortex (corticotomy) is required, preserving the medullary blood supply (e.g., inferior alveolar artery) and the periosteum. A latent period of up to 15 days (shorter for younger patients) is required for adequate callus formation and regeneration of central vessels and periosteal tissue. The external distraction device is connected to the underlying bones percutaneously via pins attached to a threaded bar for manual separation. Internalization of the distraction device to avoid cutaneous scarring has recently been studied (64). New bone formation occurs in -g the distracted mandible by intramembranous ossification. Distraction results in new bone formation induced by the combination of stretching and compressive forces by functional activity, referred to by Ilizarov as the tension-stress effect. The surrounding soft tissue envelope is concurrently expanded. The ideal rate of distraction was determined by Ilizarov in canines to be 1 mm/day in 0.25 mm incre- 3

ments. A slower rate of distraction resulted in premature union, and a faster rate resulted in delayed or nonunions. Osteogenic activity at the callous is greatest with continuous distraction; however, distracting in 0.25 mm increments results in satis- §

factory new bone formation.

Distraction Osteogenesis Mandible

Indications for distraction osteogenesis in the maxillofacial region include treatment of the following:

Transverse maxillary deficiency (65) and congenital mandibular hypoplasia

(e.g., hemifacial microsomia) (66) Treacher Collins syndrome for tracheotomy decannulation (67) Mandibular defects from tumor resection or trauma Sagittal maxillary deficiency secondary to cleft palate Craniosynostoses (59)

Potential complications using distraction in the facial region include premature union, nonunion, elongated cutaneous scars, and patient intolerance of the device. Even very minor movement, other than the controlled daily distractions, can lead to fibrous nonunion or cartilage formation. Although the effects of radiation on distraction require further study, Gantous et al. successfully distracted irradiated canine mandibles (68). Neurosensory disturbances in the cheek (infraorbital nerve) after maxillary distraction or in the chin (inferior alveolar nerve) after mandibular distraction can occur early in distraction, but resolve over time (69).

REFERENCES |

1. Dolan RW, Kerr DC, Arena S. Improved reflow and viability in reperfused ischemic rat >3 island groin flaps using dexamethasone. Microsurgery 1995; 16:86-89. ^

2. Angel MF, Ramasastry SS, Swartz WM, Narayanan K, Kuhns DB, Basford RE, et al. q The critical relationship between free radicals and degrees of ischemia: evidence for tissue intolerance of marginal perfusion. Plas Reconstr Surg 1988; 81:233-239. S

3. Manson PN, Anthenelli RM, Im MJ, Bulkley GB, Hoopes JE. The role of oxygen-free radicals in ischemic tissue injury in island skin flaps. Ann Surg 1983; 198:87-90.

4. Vedder NB, Winn RK, Rice CL, Chi EY, Arfors KE, Harlan JM. A monoclonal antibody to the adherence-promoting leukocyte glycoprotein, CD18, reduces organ injury and improves survival from hemorrhagic shock and resuscitation in rabbits. J Clin Invest 1988; 81:939-944.

5. Dolan R, Hartshorn K, Andry C, McAvoy D. Systemic neutrophil intrinsic 5-lipoxygenase activity and CD18 receptor expression linked to reperfusion injury. Laryngoscope 1998; 108:1386-1389.

6. Dolan RW, Kerr D, Arena S. Reducing ischemia-reperfusion injury in rat island groin flaps by dexamethasone and BW755C. Laryngoscope 1995; 105:1322-1325.

7. Bonow RO, Lipson LC, Sheehan FH, Capurro NL, Isner JM, Roberts WC. Lack of effect of aspirin on myocardial infarct size in the dog. Am J Cardiol 1981; 47:258-264.

8. Simpson PJ. Arachidonic acid metabolites. In: Zelenock GB, ed. Clinical Ischemic Syndomes, St. Louis: CV Mosby Co, 1990:277-285.

9. Roberts AP, Cohen JI, Cook TA. The rat ventral island flap: a comparison of the effects of reduction in arterial inflow and venous outflow. Plast Reconstr Surg 1996; 97:610-615.

10. Reinisch JF. The pathophysiology of skin flap circulation. The delay phenomenon. Plast Reconstr Surg 1974; 54:585-598.

11. Kerrigan CL. Skin flap failure: pathophysiology. Plast Reconstr Surg 1983; 72:766-777.

12. Angel MF, Narayanan K, Swartz WM, Ramasastry SS, Basford RE, Kuhns DB, et al. The etiologic role of free radicals in hematoma-induced flap necrosis. Plast Reconstr Surg 1986; 77:795-803.

13. Goldminz D, Bennett RG. Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol 1991; 127:1012-1015.

14. Jensen JA, Goodson WH, Hopf HW, Hunt TK. Cigarette smoking decreases tissue oxygen. Arch Surg 1991; 126:1131-1134.

15. Daniel RK, Kerrigan CL. Skin flaps: an anatomical and hemodynamic approach. Clin Plast Surg 1979; 6:181-200.

16. Neligan P, Pang CY, Nakatsuka T, Lindsay WK, Thomson HG. Pharmacologic action of isoxsuprine in cutaneous and myocutaneous flaps. Plast Reconstr Surg 1985; 75:363-374.

17. Nichter LS, Sobieski MW. Efficacy of verapamil in the salvage of failing random skin flaps. Ann Plast Surg 1988; 21:242-245.

18. Nichter LS, Sobieski MW, Edgerton MT. Efficacy of topical nitroglycerin for random-pattern skin-flap salvage. Plas Reconstr Surg 1985; 75:847-852.

19. Dohar JE, Goding GSJ, Maisel RH. The effects of inhalation anesthetic agents on survival in a pig random skin flap model. Arch Otolaryngol Head Neck Surg 1992; 118:37-40.

20. Hom DB, Assefa G. Effects of endothelial cell growth factor on vascular compromised skin flaps. Arch Otolaryngol Head Neck Surg 1992; 118:624-628.

21. Pratt MF. Edmund Prince Fowler Award thesis. Evaluation of random skin flap survival in a porcine model. Laryngoscope 1996; 106:700-712. g

22. Ramasastry SS, Waterman P, Angel MF, Futrell JW. Effect of Fluosol-DA (20%) on | skin flap survival in rats. Ann Plast Surg 1985; 15:436-442. J

23. Nemiroff PM, Merwin GE, Brant T, Cassisi NJ. Effects of hyperbaric oxygen and irradiation on experimental skin flaps in rats. Otolaryngol Head Neck Surg 1985; ^

24. Goding GS, Hom DB. Skin flap physiology. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction, St. Louis: Cv Mosby, 1995:15-30.

25. Marks MW, Burney RE, Mackenzie JR, Knight PR. Enhanced capillary blood flow in rapidly expanded random pattern flaps. J Trauma 1986; 26:913-915. S

26. Kroll SS, Goepfert H, Jones M, Guillamondegui O, Schusterman M. Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 1990; 25:93-97.

27. Mehta S, Sarkar S, Kavarana N, Bhathena H, Mehta A. Complications of the pectoralis major myocutaneous flap in the oral cavity: a prospective evaluation of 220 cases. Plast Reconstr Surg 1996; 98:31-37.

28. Kerrigan CL, Wizman P, Hjortdal VE, Sampalis J. Global flap ischemia: a comparison of arterial versus venous etiology. Plas Reconstr Surg 1994; 93:1485-1495.

29. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40:113-141.

30. Weinzweig N, Gonzalez M. Free tissue failure is not an all-or-none phenomenon. Plast Reconstr Surg 1995; 96:648-660.

31. Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, Ingram D, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102:711-721.

32. Bodin IKH, Lind MG, Arnander C. Free radial forearm reconstruction in surgery of the oral cavity and pharynx: surgical complications, impairment in speech and swallowing. Clin Otolaryngol 1994; 19:28-34.

33. Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98:1230-1233.

34. Salemark L. International survey of current microvascular practices in free tissue transfer and replantation surgery. Microsurgery 1991; 12:308-311.

35. Sloan GM, Sasaki GH. Noninvasive monitoring of tissue viability. [Review]. Clin Plast Surg 1985; 12:185-195.

36. Gross JE, Friedman JD. Soft tissue reconstruction. Monitoring. [Review]. Orthop Clin North Am 1993; 24:531-536.

37. McCraw JB, Myers B, Shanklin KD. The value of fluorescein in predicting the viability of arterialized flaps. Plast Reconstr Surg 1977; 60:710-719.

38. Silverman DG, LaRossa DD, Barlow CH, Bering TG, Popky LM, Smith TC. Quantification of tissue fluorescein delivery and prediction of flap viability with the fiberoptic dermofluorometer. Plast Reconstr Surg 1980; 66:545-553.

39. Hayden RE, Phillips JG, McLear PW. Leeches. Objective monitoring of altered perfusion in congested flaps. Arch Otolaryngol Head Neck Surg 1988; 114:1395-1399.

40. de Chalain TM. Exploring the use of the medicinal leech: a clinical risk-benefit analysis. J Reconstr Microsurg 1996; 12:165-172.

41. Utley DS, Koch RJ, Goode RL. The failing flap in facial plastic and reconstructive surgery: role of the medicinal leech. Laryngoscope 1998; 108:1129-1135.

42. Grabb WC, Smith JW. Basic techniques in plastic surgery. In: Grabb WC, Smith JW, eds. Plastic Surgery, London: J. & A. Churchill Ltd, 1968:54-57.

43. Norberg KA, Palmer B. Improvement of blood circulation in experimental skin flaps by phentolamine. Eur J Pharmacol 1969; 8:36-38.

44. Morris SF, Taylor GI. The time sequence of the delay phenomenon: when is a surgical g delay effective? An experimental study. Plast Reconstr Surg 1995; 95:526-533. g

45. Swenson RW. Tissue Expansion. In: Papel ID, Nachlas NE, eds. Facial Plastic and J

Reconstructive Surger, St. Louis: CV Mosby, 1992:56-67. «

46. Radovan, C. Adjacent flap development using expandable silastic implants. Presented at ^ the annual meeting of the American Society of Plastic and Reconstructive Surgeons. 1976. >3

47. Austad ED, Pasyk KA, McClatchey KD, Cherry GW. Histomorphologic evaluation of | guinea pig skin and soft tissue after controlled tissue expansion. Plast Reconstr Surg

48. Baker SR, Swanson NA. Tissue expansion of the head and neck. Indications, technique, and complications. Arch Otolaryngol Head Neck Surg 1990; 116:1147-1153.

49. Sasaki GH. Intraoperative sustained limited expansion (ISLE) as an immediate reconstructive technique. Clin Plast Surg 1987; 14:563-573.

50. Austad ED, Rose GL. A self-inflating tissue expander. Plast Reconstr Surg 1982; 70:588-594.

51. Hallock GG. Maximum overinflation of tissue expanders. Plast Reconstr Surge 1987; 80:567-569.

52. Gibson T. The physical properties of skin. In: Converse JM, ed. Reconstructive Plastic Surgery, Philadelphia: WB Saunders, 1977.

53. Pasyk KA, Argenta LC, Hassett C. Quantitative analysis of the thickness of human skin and subcutaneous tissue following controlled expansion with a silicone implant. Plas Reconstr Surg 1988; 81:516-523.

54. van Rappard JH, Grubben MJ, Jerusalem C. Histological changes in expanded soft tissue. In: van Rappard JH, ed. Controlled Tissue Expansion of Reconstructive Surgery, Nijmegen, Netherlands, 1988.

55. Hall GD, Van Way CW, Kung FT, Compton-Allen M. Peripheral nerve elongation with tissue expansion techniques. J Trauma 1993; 34:401-405.

56. Morris SF, Pang CY, Mahoney J, Lofchy N, Kaddoura IL, Patterson R. Effect of capsulectomy on the hemodynamics and viability of random-pattern skin flaps raised on expanded skin in the pig. Plast Reconstr Surg 1989; 84:314-322.

57. Antonyshyn O, Gruss JS, Zuker R, Mackinnon SE. Tissue expansion in head and neck reconstruction. Plast Reconstr Surg 1988; 82:58-68.

58. Friedman RM, Ingram AEJ, Rohrich RJ, Byrd HS, Hodges PL, Burns AJ. Risk factors for complications in pediatric tissue expansion. Plast Reconstr Surg 1996; 98:1242-1246.

59. Tavakoli K, Stewart KJ, Poole MD. Distraction osteogenesis in craniofacial surgery: a review. [Review]. Ann Plast Surg 1998; 40:88-99.

60. Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. [Review]. Clin Orthop Rel Res 1990; 8-26.

61. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Rel Res 1989; 249-281.

62. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop Rel Res 1989; 263-285.

63. Annino DJJ, Goguen LA, Karmody CS. Distraction osteogenesis for reconstruction of mandibular symphyseal defects. Arch Otolaryngol Head Neck Surg 1994; 120:911-916.

64. Altuna G, Walker DA, Freeman E. Rapid orthopedic lengthening of the mandible in primates by sagittal split osteotomy and distraction osteogenesis: a pilot study. Int J Adult Orthodont Orthognath Surg 1995; 10:59-64.

65. Basdra EK, Zoller JE, Komposch G. Surgically assisted rapid palatal expansion. J Clin Orthodont 1995; 29:762-766.

66. McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992; 89:1-8. g

67. Moore MH, Guzman-Stein G, Proudman TW, Abbott AH, Netherway DJ, David.

Mandibular lengthening by distraction for airway obstruction in Treacher-Collins syndrome. J Craniofac Surg 1994; 5:22-25. ^

68. Gantous A, Phillips JH, Catton P, Holmberg D. Distraction osteogenesis in the irradiated canine mandible. Plast Reconstr Surg 1994; 93:164-168. ^

69. Karas ND, Boyd SB, Sinn DP. Recovery of neurosensory function following q orthognathic surgery. J Oral Maxillofac Surg 1990; 48:124-134. |

Copyright © Marcel Dekker, Inc. All rights reserved.

Was this article helpful?

0 0
Nicotine Support Superstar

Nicotine Support Superstar

Stop Nicotine Addiction Is Not Easy, But You Can Do It. Discover How To Have The Best Chance Of Quitting Nicotine And Dramatically Improve Your Quality Of Your Life Today. Finally You Can Fully Equip Yourself With These Must know Blue Print To Stop Nicotine Addiction And Live An Exciting Life You Deserve!

Get My Free Ebook


Post a comment