2009 ghassemi-comparsion of donor beckjoms

BASIC AND PATIENT-ORIENTED RESEARCH
J Oral Maxillofac Surg
67:1589-1594, 2009
Comparison of Donor-Site Engraftment
After Harvesting Vascularized and
Nonvascularized Iliac Bone Grafts
Alireza Ghassemi, MD, DMD, PhD,*
Mehrangiz Ghassemi, DMD,† Dieter Riediger, MD, DMD, PhD,‡
Ralf-Dieter Hilgers, DSc, PhD,§ and
Marcus Gerressen, MD, DMD, PhDʈ
Purpose: The objective of this study is to characterize the donor-site morbidity after harvesting of
nonvascularized and vascularized iliac bone grafts.
Patients and Methods: Clinical data of 353 patients were collected for analysis. In addition, a
questionnaire was sent to all patients asking about their perceptions of different parameters. In an
individual age-matched layout, we compared 34 patients with nonvascularized iliac bone grafts with 34
patients with vascularized iliac bone grafts.
Results: Transplantation of vascularized bone grafts has been increasingly performed at our institution.
The mean age was 41.5 years in the nonvascularized group and 48.6 years in the vascularized group. The
main reason for the bony defect in the vascularized group was malignancy. The majority of postoperative
functional problems were observed in obese patients. No patient had serious or long-term complications
at the donor site. The amount of bone graft taken affected postoperative sensitivity disturbance and
caused postoperative functional problems and pain.
Conclusions: We conclude that the iliac crest is a suitable site for harvesting both vascularized and
nonvascularized bone grafts measuring up to 10 ϫ 3 cm. For larger defects that require a larger bone
graft, a vascularized bone graft is more suitable with a better predictable healing capability. No significant
differences in donor-site morbidity were found between the vascularized and nonvascularized bone
grafts if a similar amount of bone was taken for transplant.
© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:1589-1594, 2009
Trauma, congenital defects, infections, or neoplasms
can produce deformities of the face causing the most
disabling and socially isolating afflictions.1
Esthetic
and functional restoration remains problematic. The
contaminated nature of the oral, nasal, and sinus cav-
ities; the requirement for rigid 3-dimensional recon-
struction; and severe load-bearing stresses make re-
construction a challenging task.2
An unreconstructed
maxilla or mandible not only leads to profound esthetic
sequelae but is functionally crippling, producing difficul-
ties with oral nutrition, control of secretions, and swal-
lowing, as well as speech abnormalities.3,4
Nonvascularized bone grafts are useful for small
defects in non–load-bearing areas.5
Alloplastic and
Received from the University Hospital of the Aachen University,
Aachen, Germany.
*Assistant Professor, Department of Oral, Maxillofacial and Plastic
Facial Surgery.
†Fellow, Department of Orthodontics.
‡Professor and Chair, Department of Oral, Maxillofacial and Plas-
tic Facial Surgery.
§Professor and Chair, Institute of Medical Statistics.
ʈAssistant Professor, Department of Oral, Maxillofacial and Plastic
Facial Surgery.
Address correspondence and reprint requests to Dr Dr Ghas-
semi: Department of Oral, Maxillofacial and Plastic Facial Surgery,
University Hospital of the Aachen University, Pauwelsstrasse 30,
52074, Aachen, Germany; e-mail: aghassemi@ukaachen.de
© 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6708-0003$36.00/0
doi:10.1016/j.joms.2009.04.013
1589

implant materials have a less well-defined role in bony
reconstruction and are of a temporary nature.6,7
The
vascularized bone has an independent immediate
blood supply, which gives the transplant a better
chance for survival.8
The added complexity of radia-
tion therapy in malignancy has led to the acceptance
of vascularized bone transfer as the optimal type of
reconstruction.9
The iliac bone is one of many different donor sites
and is a suitable source of both free nonvascularized
and vascularized bone grafts.10-13
A large part of the
iliac bone, with adequate dimensions in terms of
height and width for the insertion of dental im-
plants,14
can be resected, leaving remnants of bone
posteriorly and distally for sufficient stability.12
There
is no doubt that vascularized bone grafts are indicated
for the treatment of large bone defects after cancer
surgery.15
However, there are also borderline situa-
tions where choosing between nonvascularized and
vascularized bone grafts is not easy. In some cases the
vascularized bone graft would be the best choice
from the point of view of healing and rehabilitation,
but concern regarding postoperative donor-site mor-
bidity limits its use.16
However, the high failure rate of
nonvascularized bone grafts frequently used to recon-
struct large bony defects15
motivated us to compare
postsurgical donor-site morbidity after harvesting iliac
bone grafts both in vascularized form and in nonvas-
cularized form.
To investigate donor-site morbidity after harvesting
bone graft from the iliac crest with 2 different meth-
ods—nonvascularized versus vascularized—we con-
ducted a matched-pair comparison study.
Patients and Methods
We conducted an age-matched comparison study
based on our retrospective database of all 353 pa-
tients who were operated on from January 1994 to
December 2004.
Originally, 319 of the 353 patients belonged to the
nonvascularized group and 34 to the vascularized
group. Our age matching resulted in 2 groups with 34
patients each, with both groups having almost the
same amount of bone harvested.
Further matching criteria could not be used be-
cause of the small sample size in the vascularized
group. We compared these 2 groups regarding leg
pain, function disturbance, and sensibility distur-
bance.
Demographic and clinical data were divided into 5
categories:
1. Demographics—age and gender
2. Clinical—weight, height, and medical history
3. Surgical—donor site, amount of bone harvested,
bone type (cancellous, cortical, or combined),
method of harvesting (nonvascularized or vascu-
larized), and length of incision
4. Postoperative—wound healing, pain, functional
problems, sensitivity impairment, and length of
hospital stay
5. Quality of life—gait disability and sensitivity
impairment
QUESTIONNAIRE
A detailed functional outcome questionnaire com-
posed of 10 questions pertaining to the level and
duration of postoperative pain, residual pain, sensory
disturbance, functional limitations, cosmetic appear-
ance, and overall satisfaction with the result of the
bone graft procedure was mailed to all study partici-
pants. Patients graded the severity of postoperative
pain retrospectively on a scale from 0 to 10, with 0
corresponding to no pain and 10 to very severe pain.
There were specific questions concerning the loca-
tion of both temporary and residual sensory distur-
bances. Functional disturbances were evaluated with
questions pertaining to gait and difficulties with walk-
ing. Patients were asked whether they were satisfied
or dissatisfied with the cosmetic appearance of the
scar and with the overall result of the reconstruction
procedure.
STATISTICAL METHODS
The McNemar test was used to compare the
matched sample according to the type of vasculariza-
tion. We used the following age classes: less than 20
years, 20 to 30 years, 30 to 40 years, and greater than
40 years.
Statistical computation was performed with SPSS
software, version 12.00 (SPSS, Chicago, IL), by use of
Windows XP (Microsoft, Redmond, WA).
Results
This study included 34 patients who received vas-
cularized iliac bone grafts and 319 patients who re-
ceived nonvascularized iliac bone grafts. All harvest-
ing procedures were done to reconstruct the missing
part of the mandible or maxilla. Patients who were
lost to follow-up were excluded from the study. We
could specify 4 larger diagnosis groups:
1. Atrophic maxilla and mandible (n ϭ 141, 39.9%)
2. Cleft alveolus and palate (n ϭ 60, 17%)
3. Bone resection because of ablative surgery (n ϭ
56, 15.9%)
4. Others (n ϭ 96, 27.2%)
1590 DONOR-SITE ENGRAFTMENT AND ILIAC BONE GRAFTS

Of a total of 19 women, 8 (42.1%) underwent
reconstruction with nonvascularized bone grafts from
the iliac crest and 11 with vascularized bone grafts. Of
a total of 49 men, 26 (53%) underwent reconstruction
with nonvascularized bone grafts and 23 (46%) with
vascularized bone grafts (P ϭ .02, McNemar test) (Fig 1).
In the vascularized group, 30 of 34 patients had
bone resections because of underlying malignancies.
In 3 patients the reason for bone resection was osteo-
myelitis, and in 1 patient it was an extremely atrophic
mandible (Fig 2). There was a signiﬁcant relationship
between obesity and postoperative functional distur-
bance (Table 1). The postoperative stay in the hospi-
tal ranged from 2 to 54 days. The mean hospital stay
was 24.5 days in the vascularized group and 14 days in
the nonvascularized group (SE, 0.64). Thus the overall
hospital stay in the vascularized group was 10 days
longer than in the nonvascularized group. It needs to
be emphasized that in the vascularized group, pa-
tients had pre-existing comorbidities apart from the
malignancy (Fig 2). All vascularized bone grafts healed
well without any complications. In 2 patients (5.9%)
in the nonvascularized group the transplant had to be
removed completely because of infection or other rea-
FIGURE 2. Relationship of diagnosis with type of removed iliac bone graft. NV, nonvascularized; V, vascularized; TMJ, temporomandibular
joint.
Ghassemi et al. Donor-Site Engraftment and Iliac Bone Grafts. J Oral Maxillofac Surg 2009.
Table 1. BROCA INDEX AND FUNCTIONAL
DISTURBANCES*
Broca Index
Functional Disturbances
(%)
TotalYes No
Ͻ0.8 8 (17.4) 38 (82.6) 46
0.8-1.2 15 (11.8) 112 (88.2) 127
Ͼ1.2 5 (16.1) 26 (83.9) 31
Total 44 (16.9) 216 (83.1) 260
*P ϭ .05.
Ghassemi et al. Donor-Site Engraftment and Iliac Bone Grafts.
J Oral Maxillofac Surg 2009.
FIGURE 1. Relationship of gender with type of removed iliac bone
graft. NV, nonvascularized; V, vascularized.
GHASSEMI ET AL 1591

sons (Table 2). We used a vascularized bone graft for
reconstruction for the repeat procedure. Of 21 unsatis-
ﬁed patients, 15 were in the nonvascularized group,
mostly with persistent postoperative pain, and 6 were in
the vascularized group, mainly complaining about some
degree of discomfort (P ϭ .025, McNemar test).
Sensibility of the lateral part of the upper thigh was
affected in 16.7% of patients in the vascularized group
and 6.1% in the nonvascularized group (P Ͻ .001,
McNemar test) (Table 3).
Two patients in the nonvascularized group and 9
patients in the vascularized group complained about
some pain in the leg or hip (P Ͻ .001, McNemar test)
(Table 4). In the vascularized group 8 patients had
more than 10 cm2
of bone taken. In addition, the
patients in the nonvascularized group with pain had
at least 8 cm2
of bone taken.
Walking disturbances were seen in 3 patients in the
nonvascularized group and 9 patients in the vascular-
ized group (P Ͻ .001, McNemar test) (Table 5). In the
nonvascularized group these disturbances increased
with the amount of bone removed. In the nonvascu-
larized group both patients with gait disturbances had
more than 10 cm2
of bone removed. In the vascular-
ized group 8 patients with gait disturbances had more
than 10 cm2
of bone removed.
Two patients in the nonvascularized group and 1 in
the vascularized group had a revision or repeat oper-
ation (Table 2).
Discussion
Vascularized bone grafts play an important role in
the reconstruction of facial bony defects with the
potential for good functional and esthetic out-
comes.17-19
This graft is the preferred transplant for
primary or secondary reconstruction after segmental
mandibulectomy or extensive maxillectomy, espe-
cially if optimal rehabilitation regarding esthetic and
function by use of endosseous implants and pros-
thetic integration is of concern.20,21
Many different
sites for vascularized bone grafting have been evalu-
ated and used for reconstruction.10,22
The selection of
vascularized or nonvascularized bone grafts de-
pends on the extent of the hard tissue defect,
rehabilitation expectations of the patient, condi-
tion of the recipient’s tissue bed, surgical capabil-
ity, availability of equipment, and expertise of the
surgeon.15
The minor donor-site morbidity seems to
be one of the primary reasons for selecting nonva-
scularized bone grafts instead of vascularized bone
grafts from the iliac crest. Despite a large number of
studies regarding the iliac bone graft,23-29
none has
compared postoperative donor-site morbidity after
harvesting of vascularized and nonvascularized bone
grafts.
The aim of this observational and retrospective
study was to investigate donor-site morbidity after
harvesting iliac bone grafts according to 2 different
Table 2. REVISION AND BONE TRANSPLANT*
Revision
Bone Transplant
TotalNonvascularized Vascularized
No (%) 32 (94.1) 33 (97.1) 65
Yes (%) 2 (5.9) 1 (2.9) 3
Total 34 34 68
*P Ͻ .001.
Table 4. PAIN AND BONE TRANSPLANT*
Leg Pain
Bone Transplant
No (%) 28 (93.3) 21 (70.0) 49
Yes (%) 2 (6.7) 9 (30.0) 11
Total 30 30 60
*P Ͻ .001.
Table 5. FUNCTIONAL DISTURBANCES AND BONE
TRANSPLANT*
Functional
Disturbance
Bone Transplant
No (%) 29 (90.6) 21 (70.0) 50
Yes (%) 3 (9.4) 9 (30.0) 12
Total 32 30 62
*P Ͻ .001.
Table 3. SENSIBILITY DISTURBANCE AND BONE
TRANSPLANT*
Sensibility
Disturbance
Bone Transplant
No (%) 31 (93.9) 25 (83.3) 56
Yes (%) 2 (6.1) 5 (16.7) 7
Total 33 30 63
*P Ͻ .001.

methods. Our quantitative analysis shows an in-
creased number of postoperative complications with
increasing amounts of harvested bone independent of
the harvesting method used. This information can
assist us in making the appropriate decision regarding
the correct graft harvesting method. Subjective do-
nor-site morbidity, as assessed with our evaluation
system, was generally low. Only 2 patients showed
significant morbidity, whereas the majority of the
examined patients had no significant problems. This
finding is consistent with other reports on vascular-
ized iliac bone grafts.30
Pain and functional distur-
bances were the most frequently reported complaints
in our study and were mainly described as an infre-
quent aching at the donor site. Besides pain and gait
problems, other complaints mentioned were sensory
disturbances.
A more detailed examination shows that most vas-
cularized bone transfers are performed in elderly pa-
tients with malignancy and significant comorbidities.
They often have accompanying conditions such as
cardiovascular disease, diabetes mellitus, obesity, al-
cohol dependence, and smoking habits, which could
explain the longer hospital stays according to more
severe cardiopulmonary problems. Functional distur-
bances were mostly observed in obese patients with
clustering of comorbidities. With increased amounts
of removed bone, an increasing rate of functional
disturbances and pain was observed, which were
independent of the harvesting method. One of the
other feared donor-site morbidities is damage to the
lateral cutaneous femoral nerve,31,32
which causes
sensibility impairment of the upper lateral part of the
thigh. Furthermore, it is obvious that in the vascular-
ized group, the incision is usually longer, more than
10 cm on average, whereas in the nonvascularized
group it usually measures less than 10 cm. Sensory
deficits are not frequent and disappear after 1 year.
During dissection, care should be taken to preserve
the lateral cutaneous nerve of the thigh. All vascular-
ized bone grafts were harvested by an experienced
surgeon. This may be the reason for fewer complica-
tions, such as infections and wound dehiscence, im-
mediately postoperatively, as well as the lower rate of
long-term complications such as hernia, arterio-
venous fistula, ureteral injury, and walking prob-
lems.33,34
Our analysis of subjective donor-site morbidity after
harvesting of bone grafts from the iliac crest showed
that the majority of patients expressed similar minor
complaints independent of harvesting method.
In conclusion, donor-site morbidity, as perceived
subjectively, and the objectively noticeable distur-
bances are rare after free vascularized iliac bone trans-
fer, and donor-site morbidity is similar to that after
harvesting of a comparable amount of nonvascular-
ized bone. This unintentional finding led us to focus
on postoperative complaints by looking at the amount
of bone harvested for grafting. It might help in the
decision-making process in patients with poor prereq-
uisites for bony reconstruction. Such information is
useful when the healing of the nonvascularized bone
is not predictable and when the decision to harvest
nonvascularized bone versus vascularized bone for
grafting could be influenced by the considerations of
donor-site morbidity. We are aware that a prospective
study would be of interest, but it would be very
difficult to perform because of small sample sizes. In
our department we favor the bone graft from the iliac
crest in both forms—vascularized and nonvascular-
ized. The morbidity associated with harvesting of this
transplant is relatively minor postoperatively and al-
most absent after 1 year. Our experience with vascu-
larized bone graft has shown good outcomes in terms
of function and esthetics and is well accepted for
insertion of dental implants,10
especially in cases of
larger defects where functional rehabilitation plays an
important role (Fig 3). Nevertheless, the longer oper-
ating time with more difficult harvesting techniques
and longer hospital stay should be considered.
References
1. Wilson KM, Rizk NM, Armstrong SL, et al: Effects of hemiman-
dibulectomy on quality of life. Laryngoscope 108:1574, 1998
2. Egyedi P: Wound infection after mandibular reconstruction
with autogenous graft. Ann Acad Med Singapore 15:340, 1986
3. Schmelzeisen R, Neukam F, Shirota T, et al: Postoperative
function after implant insertion in vascularized bone grafts in
the maxilla and mandible. Plast Reconstr Surg 97:719, 1996
4. Urken ML, Buchbinder D, Weinberg H, et al: Functional eval-
uation following microvascular oromandibular reconstruction
of the oral cancer patient: A comparative study of recon-
structed and nonreconstructed patients. Laryngoscope 101:
933, 1991
FIGURE 3. Harvested vascularized iliac crest for hemimandibular
reconstruction.
GHASSEMI ET AL 1593

5. Kortebein MJ, Nelson CL, Sadove AM: Retrospective analysis of
135 secondary alveolar cleft grafts using iliac or calvarial bone.
J Oral Maxillofac Surg 49:493, 1991
6. Byars LT: Subperiosteal mandibular resection with internal bar
fixation. Plast Reconstr Surg 1:236, 1946
7. Freeman BS: The use of vitallium plates to maintain function
following resection of the mandible. Plast Reconstr Surg 3:73,
1948
8. Bitter K: Bone transplants from the iliac crest to the maxillo-
facial region by the microsurgical technique. J Maxillofac Surg
8:210, 1980
9. Hamaker RC: Irradiation autogenous mandibular grafts in pri-
mary reconstructions. Laryngoscope 91:1031, 1981
10. Moscoso JF, Keller J, Genden E, et al: Vascularized bone flaps in
oromandibular reconstruction: A comparative anatomic study
of bone stock from various donor sites to assess suitability for
endosseous dental implants. Arch Otolaryngol Head Neck Surg
120:36, 1994
11. Taylor GJ, Daniel EK: The anatomy of several free flap donor
sites. Plast Reconstr Surg 56:533, 1975
12. Taylor GJ, Miller GDH, Ham FJ: The free vascularized bone
graft. A clinical extension of microvascular techniques. Plast
Reconstr Surg 55:533, 1975
13. David D, Tan E, Katsaros J, et al: Mandibular reconstruction
with vascularized iliac crest: A 10-year experience. Plast Re-
constr Surg 82:792, 1988
14. Frodel JL, Funk GF, Capper DT: Osseointegrated Implants in
Vascularized Bone Flaps: A Comparison of Bone Thickness in Four
Flap Types Used in Mandibular Reconstruction. Presented at the
Annual Meeting of the American Academy of Facial Plastic and
Reconstructive Surgery, Kansas City, MO, September 1991
15. Pogrel MA, Podlesh S, Anthony JP, et al: Comparison of vascu-
larized and nonvascularized bone grafts for reconstruction of
mandibular continuity defects. J Oral Maxillofac Surg 55:1200,
1997
16. Adamo AK, Szal RL: Timing, results, and complications of
mandibular reconstructive surgery: Report of 32 cases. J Oral
Surg 37:755, 1979
17. Cordeiro PG, Disa JJ, Hidalgo DA, et al: Reconstruction of the
mandible with osseous free flaps: A 10-year experience with
150 consecutive patients. Plast Reconstr Surg 104:1314, 1999
18. Snyder CC, Mateman JM, Davis CW, et al: Mandibulo-facial
restoration with live osteocutaneous flaps. Plast Reconstr Surg
45:14, 1970
19. Disa JJ, Cordeiro PG: Mandible reconstruction with microvas-
cular surgery. Semin Surg Oncol 19:226, 2000
20. Dalkiz M, Beydemir B, Gunaydin Y: Treatment of a microvas-
cular reconstructed mandible using an implant-supported fixed
partial denture: Case report. Implant Dent 10:121, 2001
21. Nagy K, Borbely L, Kovacs A, et al: Implant-prosthetic rehabil-
itation after segmental mandibulectomy and bone grafting. J
Long Term Eff Med Implants 9:185, 1999
22. Chen YB, Chen HC, Hahn LH: Major mandibular reconstruction
with vascularized bone grafts: Indications and selection of
donor tissue. Microsurgery 15:227, 1994
23. Kurz LT, Grafin SR, Booth RE: Harvesting autogenous iliac bone
grafts: A review of complications and techniques. Spine 14:
1324, 1989
24. Marx RE, Morales MJ: Morbidity from bone harvest in major jaw
reconstruction: A randomized trial comparing the lateral ante-
rior and posterior approaches to the ilium. J Oral Maxillofac
Surg 48:196, 1988
25. Laurie SWS, Kaban LB, Mulliken JB, et al: Donor site morbidity
after harvesting rib and iliac bone. Plast Reconstr Surg 73:933,
1984
26. Tayapongsak P, Wimstatt JA, LaBanc JP, et al: Morbidity from
anterior ilium bone harvest: A comparative study of lateral
versus medial surgical approach. Oral Surg Oral Med Oral
Pathol 78:296, 1994
27. Joshi A, Kostakis GC: An investigation of post-operative mor-
bidity following iliac crest graft harvesting. Br Dent J 196:167,
2004
28. Arrington ED, Smith WJ, Chambers HG, et al: Complications of
iliac crest bone graft harvesting. Clin Orthop Relat Res 300,
1996
29. Shpitzer T, Neligan PC, Gullane PJ, et al: The free iliac crest and
fibula flaps in vascularized oromandibular reconstruction:
Comparison and long-term evaluation. Head Neck 21:639,
1999
30. Stoll P, Schilli W: Long-term follow-up of donor and recipient
sites after autologous bone grafts for reconstruction of the
facial skeleton. J Oral Surg 39:676, 1981
31. Mischkowski RA, Selbach I, Neugebauer J, et al: Lateral femoral
cutaneous nerve and iliac crest bone grafts—Anatomical and
clinical considerations. Int J Oral Maxillofac Surg 35:366, 2006
32. Dawson KH, Egbert MA, Myall RWT: Pain following iliac crest
bone grafting of alveolar clefts. J Craniomaxillofacial Surg 24:
151, 1996
33. Reid RL: Hernia through an iliac bone-graft donor site. J Bone
Joint Surg Am 50:757, 1968
34. Escalas F, DeWald RL: Combined traumatic arteriovenous fis-
tula and ureteral injury: A complication of iliac bone-grafting.
J Bone Joint Surg Am 59:270, 1977

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