Phẫu Thuật Tạo Hình (Tập 1): Nguyên Lý Cơ Bản – Neligan (Ấn bản 4)

312
CHAPTER 18 • Repair and grafting of bone
16th century), to Meekeren’s use of canine bone in a human
subject, the quest for a suitable nonautologous material
has been ever present.440 The ideal bone substitute has the
following characteristics: (1) chemically inert; (2) hypoal­
lergenic or incapable of inducing a foreign-body reaction;
(3) easily contoured; (4) stable and durable shape retention;
(5) noncarcinogenic; and (6) capable of incorporation into or
replacement with living tissue from the recipient. Although
this ideal has not been achieved, several products are avail­
able and are discussed below. The following discussion is
based upon the three broad categories of substitutes used in
clinical practice: (1) cement pastes; (2) biomaterials replaced
by bone; and (3) prefabricated polymers. Finally, we discuss
scaffold biomimicry used for the engineering of osseous
tissue.
Cement pastes
Calcium phosphates
Resembling the inorganic form of bone, hydroxyapatite and
related composites have been available for FDA-approved
clinical use since 1994. Calcium phosphate substitutes have
supplanted calcium sulfate variants due to their closer resem­
blance to bone, higher biocompatibility, and tendency to
undergo less resorption. Two main forms are available for use:
ceramic pastes and cement pastes. Ceramic hydroxyapatite
constructs (e.g., Interpore, Interpore International, Irvine,
CA), although difficult to mold, demonstrate less resorption
and better osteoconduction than their cement counterparts, as
demonstrated in a series of animal experimentation.300 These
authors were able to demonstrate that the higher the pore size,
the greater degree of osteoconduction and osteoinduction, as
substitutes composed of pure ceramic hydroxyapatite, or
cement forms of higher TCP (80% TCP/20% hydroxyapatite)
exhibited greater replacement by lamellar bone histologi­
cally.300 The latter formulation was osteoinductive by virtue of
the relatively high TCP content that yields to resorption and
replacement by macropores. The cement form of this material
has been quite popular, due to its biocompatibility, malleabil­
ity, and relative ease of handling. Due to the limited scope of
this chapter in this regard, only two major commercially avail­
able forms of bone cement will be discussed: BoneSource and
Norian. The reader interested in further review is directed
elsewhere.441,442
BoneSource
The first commercially available calcium phosphate cement,443
BoneSource (Stryker Leibinger, Inc.) is based on a mixture
of tetracalcium phosphate and dicalcium phosphate dehy­
drate and activated with water at a 4 : 1 ratio prior to use.
After an isothermic reaction, the resulting paste can be
contoured on the field, setting into pure hydroxyapatite
within 20–25 minutes. Final set time is 4–6 hours.444 A dry
operative field is mandatory for this biomaterial to reach
its final cured state. In this state, BoneSource achieves a
compressive strength of 50 MPa and a diametral strength
of 8 MPa.
BoneSource has been used over the years in numerous
applications on the craniofacial skeleton. Providing one of the
largest series to date, Burstein and colleagues445 reviewed
their
experience
with
this
product
in
61
patients
Risk of disease transmission
The risk of disease transmission from processed allografts
is minimal due to extensive donor screening and testing as
well as the acellular nature of the graft.432,433 The pathogens
of main concern are human immunodeficiency virus (HIV),
hepatitis B virus (HBV), and HCV. Using donor screening
recommendations, the transmission risk for HIV is estimated
to be one in 1.67 million.433 However, this risk is probably
lower with current screening and processing techniques.
Immunogenicity
Host immune reactions caused by allografts depend upon the
degree of antigen mismatch between donor and host and the
process of graft preparation. The immune system responds to
fresh allografts via humoral and cell-mediated mechanisms;
fresh frozen allografts, however, predominantly activate the
cell-mediated immune system. The cell-mediated response is
due to mismatch among cell surface major histocompatibility
class (MHC) I and II antigens. Interestingly, freeze-dried
allografts elicit only a minimal immune response.434 Signs of
graft rejection, which are not as apparent as in solid organ
rejection, include resorption and mechanical dysfunction.
Chronic rejection may cause impaired allograft remodeling
due to the sequestration of the implant in a fibrous capsule.
The rejection process can be diminished by cyclosporine
administration.435
Incorporation of allograft bone
The phases of allograft incorporation are similar to fracture
repair. They include an initial limited inflammatory response
with increased vascularity, followed by resorption, bone for­
mation and remodeling. Cancellous bone is incorporated
quicker than cortical grafts. The biomechanical strength of
allografts after incorporation is lower than that of autografts,
and this needs to be taken into consideration when recon­
structing weight-bearing bones.
Formulations of allogeneic bone grafts
There are several formulations of allograft bone available
including DBM, morselized cancellous chips, cortical and
corticocancellous grafts, and whole bone segments. Deminer­
alized bone preparations are not osteogenic, but they are
osteoinductive and provide scaffolding upon which new bone
can be formed.436–438
Xenogeneic bone grafts
Xenografts are taken from a genetically different species. They
undergo a high rate of resorption, and their immunogenicity,
specifically due to matrix and serum proteins, limits their clini­
cal utility. Deproteinated and defatted xenograft preparations
demonstrate decreased immune stimulation but also demon­
strate destruction of BMPs and other growth factors. Xenoge­
neic grafts are clearly inferior to autografts and allografts.439
Bone substitutes
Alloplastic cranioplasty is a concept as old as trephination.
From the Incan use of precious metals, to the first documented
use of a synthetic material to repair a cranial defect (Fallopius,

313
Clinical application of bone transfers
deionized water, ethanol, and ethyl ether. In contrast to bioac­
tive glass, DBM contains trace amounts of BMP, which makes
this biomaterial both osteoconductive and osteoinductive. At
baseline, however, DBM alone is hard to handle, making it
difficult to apply clinically. In order to improve handling
characteristics, manufacturers have added various types of
carriers to the formulation (e.g., glycerol, gelatin, calcium
sulfate). Therefore, not all preparations of DBM are the same.
To this end, Acarturk and Hollinger453 have performed com­
parative analysis of all the different DBM products. In an
athymic rat critical-sized calvarial defect model, they found
that there was indeed a differential bone-regenerative effect
among the different formulations. One unifying principle was
that those formulations that handled better (DBM + glycerol
(Grafton, Osteotech, Inc.), DBM + hyaluronan (DBX, Synthes
US)) demonstrated statistically significant higher bone forma­
tion than other groups, as assessed by histomorphometry.
Overall, however, the bone-regenerative capacity was not as
robust as the authors predicted, which could be related to not
achieving the threshold quantity of particulate DBM required
for complete ossification of the defect. There are numerous
formulations of DBM that have been utilized for a variety of
applications as reviewed by Gruskin and colleagues.454
Prefabricated polymers
Methylmethacrylate
An acrylic-based construct, methylmethacrylate455–457 forms
when a powdered mixture of methyl methacrylate polymer,
methyl methacrylate-styrene copolymer, and benzoyl perox­
ide monomer is combined. The reaction is caustic, leading to
an exothermia that approaches 85°C and pungent fumes that
are carcinogenic. In fact, the premixing recommendations of
this construct recommend use in an approved fume hood.
After mixing for 8–10 minutes, the polymerization process
yields a rigid, durable material that can be contoured, is
radiolucent, and can be fixed rigidly to the cranioplasty site.
Advantages of this material include a relatively low cost,
possibility of in situ contouring, and lack of biodegrada­
tion. A prefabricated, customized, modified version of this
material (Hard Tissue Replacement, Biomet Corporation,
Jacksonville, FL) is composed of polymethylmethacrylate-
polyhydroxyethyl methacrylate and available based on
preoperative computed tomography data.458 This hard tissue
replacement polymer has been utilized in cranial defect recon­
struction, chin and malar augmentation, and correction of the
temporal “hourglass” deformity.459 The major drawback to
acrylic-based resins, and in particular methylmethacrylate, is
the substantial exothermic reaction involved in curing, which
in situ can lead to severe thermal tissue injury. The cured,
rigid substance has a high bacterial adhesion profile, and thus
the high incidence of infected cranioplasties when using this
substance.
Medpor
A high-density, porous polyethylene construct (pore size
100–250 mm), Medpor has gained some popularity in the re­
construction of select sites of the craniofacial skeleton. Cur­
rent applications include nasal/malar augmentation, orbital
floor reconstruction, genioplasty, and cranial augmentation.
In this last application, Medpor has been found to augment
retrospectively (20-month mean follow-up). Inlay and onlay
grafting were performed over a 3-year period. Postoperative
complications were present in 11% of patients, mainly seromas.
Interestingly, the authors used slow-release antibiotic therapy
(1 g cephalosporin mixed with 10 g of cement prior to use).
In another large trial in cranioplasty patients (n = 103), an
overall infection rate of 5.8% was achieved.446
Norian SRS/CRS
Norian (Synthes, Inc.) is a unique carbonated calcium phos­
phate that mimics the inorganic phase of bone. Conferring
solubility at a low pH, Norian has the theoretical advantage
of resorption and replacement by true bone.447 This calcium
phosphate cement is produced intraoperatively by mixing
a base powder (monocalcium sulfate, monohydrate, α-TCP,
calcium carbonate) and a solvent containing sodium phos­
phate at room temperature.448 After a 5-minute interval, the
material becomes implantable, and continues to cure for
approximately 24 hours to become a microporous polycrystal­
line apatite with a maximum compressive strength of 50 MPa
and tensile strength of 2.1 MPa. For comparison, the compres­
sive and tensile properties of cancellous bone are 1.9 and
2.42 MPa, respectively.448 The commercial product is available
in regular and fast-setting formulations.
FDA-approved since 1998, Norian CRS has now been
subject to long-term clinical outcome analysis. Providing the
largest series specific to this bone cement in the context of
craniofacial surgery, Gilardino and colleagues449 report a
rather substantial complication rate (26% overall) when using
this product, regardless of the type of cranioplasty (onlay,
full-thickness inlay). The majority of complications were
infectious, attributable to the sheer amount of material used,
or its use in a contaminated field. Stratifying according to type
of cranioplasty (inlay versus onlay), the authors report the
following limitations with Norian: (1) increased trending
complication rate when >25 cm2 inlay defects are reconstructed
with this bone cement; (2) statistically significant increased
complication rate when onlay constructs were placed in areas
of high bacterial contamination (paranasal sinuses). Such
results indicate that this bone cement, not dissimilar to others,
is likely not osteoconductive, as supported by several experi­
mental studies.450
Osteoactive materials
Osteoactive materials include bioactive glass (NovaBone®,
Porex Surgical Inc.) and DBM. Composed of silica dioxide,
sodium dioxide, calcium dioxide and phosphate, bioactive
glass confers its osteogenic properties when these components
are mixed together to form an apatite surface layer. This layer
recruits and stimulates osteoprogenitor cells to produce
cytokines that have an autocrine and paracrine effect. Osteo­
blasts proliferate and differentiate on this surface, leading to
new bone formation. In turn, the particulate glass is resorbed
via osteoclastic activity.
The formulation that comprises DBM is based upon the
landmark work of Urist and Strates451 and Reddi and
Huggins.452 To date, manufacturers produce this bone substi­
tute with the standard methodology: human cadaver long
diaphyses are morselized to 250–600-mm particle sizes,
demineralized in 0.6 N hydrochloric acid, and washed with

314
CHAPTER 18 • Repair and grafting of bone
74. Deng ZL, Sharff KA, Tang N, et al. Regulation of osteogenic
differentiation during skeletal development. Front Biosci.
2008;13:2001–2021. This paper provides an important review of skeletal
development at molecular and genetic levels. Both the major signaling
pathways involved with and the transcriptional control of osteogenic
differentiation are detailed.
312. 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 Relat Res. 1989;238:249–281. This paper
describes a pioneer study on distraction osteogenesis. Among other
parameters, this study evaluated optimum conditions during limb
lengthening as well as examined changes that occur in soft tissues that
undergo elongation.
315. McCarthy JG, Schreiber J, Karp N, et al. Lengthening the human
mandible by gradual distraction. Plast Reconstr Surg. 1992;89:1–8,
discussion 9–10. This paper describes a pioneer study on distraction
osteogenesis of the craniofacial skeleton. Early evidence on the efficacy of
bilateral mandibular distraction is described in the context of clinical
experience.
323. 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 Relat Res. 1989;239:263–285.
358. Chamay A, Tschantz P. Mechanical influences in bone remodeling.
Experimental research on Wolff’s law. J Biomech. 1972;5:173–180.
368. Finkemeier CG. Bone-grafting and bone-graft substitutes. J Bone
Joint Surg Am. 2002;84-A:454–464. This paper reviews the concept of
bone grafting and bone graft substitutes. Various options for bone
grafting, including autologous bone grafts, allografts, and ceramic
composites, are discussed.
372. Tessier P, Kawamoto H, Matthews D, et al. Autogenous bone
grafts and bone substitutes–tools and techniques: I. A 20,000-case
experience in maxillofacial and craniofacial surgery. Plast Reconstr
Surg. 2005;116:6S–24S, discussion 92S–94S.
377. Tessier P, Kawamoto H, Matthews D, et al. Taking bone grafts
from the anterior and posterior ilium–tools and techniques: II. A
6800-case experience in maxillofacial and craniofacial surgery. Plast
Reconstr Surg. 2005;116:25S–37S, discussion 92S–94S. This paper
reviews the use of the ilium for bone grafts. Advantages, disadvantages,
and techniques regarding iliac graft use are discussed.
384. Marx RE. Clinical application of bone biology to mandibular and
maxillary reconstruction. Clin Plast Surg. 1994;21:377–392.
458. Ripamonti U, Petit JC, Moehl T, et al. Immediate reconstruction of
massive cranio-orbito-facial defects with allogeneic and alloplastic
matrices in baboons. J Craniomaxillofac Surg. 1993;21:302–308.
Access the complete reference list online at

successfully resorptive areas of the craniofacial skeleton (e.g.,
temporal fossa). Due to its porous nature, this implant per­
mits native tissue ingrowth and therefore may provide some
resistance to infection. Other advantages include the ability
for intraoperative contouring, and customized prefabrication
based on three-dimensional volumetric data (DICOM) from
computed tomography. Despite these benefits, there are clear
disadvantages to this material (risk of infection, exposure,
extrusion) that limit its use to well-vascularized recipient
sites. As with all alloplastic cranioplasties, an irradiated field
bears a relative contraindication from the use of this implant.
Recently, Medpor has been successfully used in conjunction
with 3D modeling for reconstruction of a suprastructure
maxillectomy defect.460 Indeed, the use of 3D modeling and
virtual surgical planning may improve surgical outcomes
and aesthetics when using alloplastic implants for complex
craniomaxillofacial defects.
Experimental scaffolds
Appreciation for the role and structure of native ECM as well
as pitfalls associated with current techniques for bone regen­
eration have prompted investigation of experimental scaffolds
to augment osseous engineering strategies. Biomimetic scaf­
folds can be used to improve delivery and containment
of progenitor cells and growth factors to the defect. These
complex 3D structures serve a role analogous to native ECM.461
Effective scaffolds are biocompatible, exhibit mechanical
properties similar to the surrounding tissue into which they
are implanted, and support cellular adhesion and prolifera­
tion. Additionally, scaffolds must allow for ingrowth of
autologous tissue (i.e., be biodegradable). Many experimental
scaffolds have been studied, including polymer-based, CaP-
based, and composite-based scaffolds. An in-depth review of
significant recent research can be found elsewhere.442

314.e1
References
References
1. Olsen BR, Reginato AM, Wang W. Bone development. Annu Rev
Cell Dev Biol. 2000;16:191–220.
2. Ducy P, Schinke T, Karsenty G. The osteoblast: a sophisticated
fibroblast under central surveillance. Science. 2000;289:1501–1504.
3. Reddi AH. Bone morphogenetic proteins: an unconventional
approach to isolation of first mammalian morphogens. Cytokine
Growth Factor Rev. 1997;8:11–20.
4. Karsenty G. The genetic transformation of bone biology. Genes
Dev. 1999;13:3037–3051.
5. Doty SB. Morphological evidence of gap junctions between bone
cells. Calcif Tissue Int. 1981;33:509–512.
6. Yellowley CE, Li Z, Zhou Z, et al. Functional gap junctions
between osteocytic and osteoblastic cells. J Bone Miner Res.
2000;15:209–217.
7. Morgan EF, Barnes GL, Einhorn TA. Osteoporosis. San Diego:
Academic Press; 2008.
8. Zhu W, Robey PG, Bosky AL. Osteoporosis. San Diego: Academic
Press; 2008.
9. Feng X. Chemical and biochemical basis of cell-bone matrix
interaction in health and disease. Curr Chem Biol. 2009;3:189–196.
10. Brommage R, Neuman WF. Passive accumulation of magnesium,
sodium, and potassium by chick calvaria. Calcif Tissue Int.
1979;28:57–63.
11. McConnell D, Foreman DW Jr, Drew I, et al. Texture and
composition of bone. Science. 1971;172:971–973.
12. McConnell D. Bone mineral. Science. 1964;145:1336.
13. Lian J, Stein GS. Osteoporosis. San Diego: Academic Press; 2008.
14. Ou-Yang H, Paschalis EP, Mayo WE, et al. Infrared microscopic
imaging of bone: spatial distribution of CO3(2. J Bone Miner Res.
2001;16:893–900.
15. Peng Y, Kang Q, Luo Q, et al. Inhibitor of DNA binding/
differentiation helix-loop-helix proteins mediate bone
morphogenetic protein-induced osteoblast differentiation of
mesenchymal stem cells. J Biol Chem. 2004;279:32941–32949.
16. Safadi FF, Barbe MF, Abdelmagid SM. Bone Pathology. New York:
Humana Press; 2009.
17. Landis WJ, Song MJ, Leith A, et al. Mineral and organic matrix
interaction in normally calcifying tendon visualized in three
dimensions by high-voltage electron microscopic tomography and
graphic image reconstruction. J Struct Biol. 1993;110:39–54.
18. Hohling HJ, Barckhaus RH, Krefting ER, et al. Quantitative
electron microscopy of the early stages of cartilage mineralization.
Metab Bone Diesease Res. 1978;1:109–114.
19. Luu HH, Song WX, Luo X, et al. Distinct roles of bone
morphogenetic proteins in osteogenic differentiation of
mesenchymal stem cells. J Orthop Res. 2007;25:665–677.
20. Lian JB, Stein GS, Stein JL, van Wijnen AJ. Transcriptional control
of osteoblast differentiation. Biochem Soc Trans. 1998;26:14–21.
21. Zhu J, Zhang Y, Nacksung K. Osteoblasts support early B
lymphoiesis as well as stem cell proliferation and myelopoiesis:
identification of the mammalian cellular analog of the bursa of
Fabricius. Blood. 2004;104:508.
22. Knothe Tate ML, Adamson JR, Tami AE, Bauer TW. The osteocyte.
Int J Biochem Cell Biol. 2004;36:1–8.
23. Bergwitz C, Wendlandt T, Kispert A, Brabant G. Wnts
differentially regulate colony growth and differentiation of
chondrogenic rat calvaria cells. Biochim Biophys Acta.
2001;1538:129–140.
24. Fischer L, Boland G, Tuan RS. Wnt signaling during BMP-2
stimulation of mesenchymal chondrogenesis. J Cell Biochem.
2002;84:816–831.
25. Wang J, Wynshaw-Boris A. The canonical Wnt pathway in early
mammalian embryogenesis and stem cell maintenance/
differentiation. Curr Opin Genet Dev. 2004;14:533–539.
26. Gregory CA, Gunn WG, Reyes E, et al. How Wnt signaling affects
bone repair by mesenchymal stem cells from the bone marrow.
Ann N Y Acad Sci. 2005;1049:97–106.
27. Luo J, Sun MH, Kang Q, et al. Gene therapy for bone regeneration.
Curr Gene Ther. 2005;5:167–179.
28. Kang Q, Sun MH, Cheng H, et al. Characterization of the distinct
orthotopic bone-forming activity of 14 BMPs using recombinant
adenovirus-mediated gene delivery. Gene Ther. 2004;11:1312–1320.
29. Cheng H, Jiang W, Phillips FM, et al. Osteogenic activity of the
fourteen types of human bone morphogenetic proteins (BMPs). J
Bone Joint Surg Am. 2003;85-A:1544–1552.
30. Tezuka K, Yasuda M, Watanabe N, et al. Stimulation of osteoblastic
cell differentiation by Notch. J Bone Miner Res. 2002;17:231–239.
31. Sciaudone M, Gazzerro E, Priest L, et al. Notch 1 impairs
osteoblastic cell differentiation. Endocrinology. 2003;144:5631–5639.
32. Schnabel M, Fichtel I, Gotzen L, Schlegel J. Differential expression
of Notch genes in human osteoblastic cells. Int J Mol Med.
2002;9:229–232.
33. Hooper JE, Scott MP. Communicating with Hedgehogs. Nat Rev
Mol Cell Biol. 2005;6:306–317.
34. Lum L, Beachy PA. The Hedgehog response network: sensors,
switches, and routers. Science. 2004;304:1755–1759.
35. Ehlen HW, Buelens LA, Vortkamp A. Hedgehog signaling in
skeletal development. Birth Defects Res C Embryo Today.
2006;78:267–279.
36. Lai LP, Mitchell J. Indian hedgehog: its roles and regulation in
endochondral bone development. J Cell Biochem. 2005;96:1163–1173.
37. Ornitz DM, Marie PJ. FGF signaling pathways in endochondral
and intramembranous bone development and human genetic
disease. Genes Dev. 2002;16:1446–1465.
38. Chen L, Deng CX. Roles of FGF signaling in skeletal development
and human genetic diseases. Front Biosci. 2005;10:1961–1976.
39. Ornitz DM. FGF signaling in the developing endochondral
skeleton. Cytokine Growth Factor Rev. 2005;16:205–213.
40. Jackson RA, Nurcombe V, Cool SM. Coordinated fibroblast growth
factor and heparan sulfate regulation of osteogenesis. Gene.
2006;379:79–91.
41. Holmen SL, Zylstra CR, Mukherjee A, et al. Essential role of
beta-catenin in postnatal bone acquisition. J Biol Chem.
2005;280:21162–21168.
42. Day TF, Guo X, Garrett-Beal L, Yang Y. Wnt/beta-catenin signaling
in mesenchymal progenitors controls osteoblast and chondrocyte
differentiation during vertebrate skeletogenesis. Dev Cell.
2005;8:739–750.
43. Hill TP, Spater D, Taketo MM, et al. Canonical Wnt/beta-catenin
signaling prevents osteoblasts from differentiating into
chondrocytes. Dev Cell. 2005;8:727–738.
44. Nobta M, Tsukazaki T, Shibata Y, et al. Critical regulation of bone
morphogenetic protein-induced osteoblastic differentiation by
Delta1/Jagged1-activated Notch1 signaling. J Biol Chem.
2005;280:15842–15848.
45. Engin F, Yao Z, Yang T, et al. Dimorphic effects of Notch signaling
in bone homeostasis. Nat Med. 2008;14:299–305.
46. Cohen MM Jr. The hedgehog signaling network. Am J Med Genet
A. 2003;123A:5–28.
47. McMahon AP, Ingham PW, Tabin CJ. Developmental roles and
clinical significance of hedgehog signaling. Curr Top Dev Biol.
2003;53:1–114.
48. Baron MH, Fraser ST. The specification of early hematopoiesis in
the mammal. Curr Opin Hematol. 2005;12:217–221.
49. Lupo G, Harris WA, Lewis KE. Mechanisms of ventral patterning
in the vertebrate nervous system. Nat Rev Neurosci. 2006;7:103–114.
50. St-Jacques B, Hammerschmidt M, McMahon AP. Indian hedgehog
signaling regulates proliferation and differentiation of
chondrocytes and is essential for bone formation. Genes Dev.
1999;13:2072–2086.
51. Chiang C, Litingtung Y, Lee E, et al. Cyclopia and defective axial
patterning in mice lacking Sonic hedgehog gene function. Nature.
1996;383:407–413.
52. Otto F, Thornell AP, Crompton T, et al. Cbfa1, a candidate gene for
cleidocranial dysplasia syndrome, is essential for osteoblast
differentiation and bone development. Cell. 1997;89:765–771.

314.e2
CHAPTER 18 • Repair and grafting of bone
53. Komori T, Yagi H, Nomura S, et al. Targeted disruption of Cbfa1
results in a complete lack of bone formation owing to maturational
arrest of osteoblasts. Cell. 1997;89:755–764.
54. Komori T. Regulation of bone development and extracellular
matrix protein genes by RUNX2. Cell Tissue Res. 2010;339:189–195.
55. Nakashima K, Zhou X, Kunkel G, et al. The novel zinc finger-
containing transcription factor osterix is required for osteoblast
differentiation and bone formation. Cell. 2002;108:17–29.
56. Kaback LA, Soung do Y, Naik A, et al. Osterix/Sp7 regulates
mesenchymal stem cell mediated endochondral ossification. J Cell
Physiol. 2008;214:173–182.
57. Tu Q, Valverde P, Li S, et al. Osterix overexpression in
mesenchymal stem cells stimulates healing of critical-sized defects
in murine calvarial bone. Tissue Eng. 2007;13:2431–2440.
58. Mundlos S, Otto F, Mundlos C, et al. Mutations involving the
transcription factor CBFA1 cause cleidocranial dysplasia. Cell.
1997;89:773–779.
59. Pelletier N, Champagne N, Stifani S, Yang XJ. MOZ and MORF
histone acetyltransferases interact with the Runt-domain
transcription factor Runx2. Oncogene. 2002;21:2729–2740.
60. Sierra J, Villagra A, Paredes R, et al. Regulation of the bone-
specific osteocalcin gene by p300 requires Runx2/Cbfa1 and the
vitamin D3 receptor but not p300 intrinsic histone
acetyltransferase activity. Mol Cell Biol. 2003;23:3339–3351.
61. Huang J, Zhao L, Xing L, Chen D. MicroRNA-204 regulates Runx2
protein expression and mesenchymal progenitor cell
differentiation. Stem Cells. 2010;28:357–364.
62. Gangaraju VK, Lin H. MicroRNAs: key regulators of stem cells.
Nat Rev Mol Cell Biol. 2009;10:116–125.
63. Lakshmipathy U, Hart RP. Concise review: MicroRNA expression
in multipotent mesenchymal stromal cells. Stem Cells.
2008;26:356–363.
64. Jensen ED, Schroeder TM, Bailey J, et al. Histone deacetylase 7
associates with Runx2 and represses its activity during osteoblast
maturation in a deacetylation-independent manner. J Bone Miner
Res. 2008;23:361–372.
65. Lamour V, Detry C, Sanchez C, et al. Runx2- and histone
deacetylase 3-mediated repression is relieved in differentiating
human osteoblast cells to allow high bone sialoprotein expression.
J Biol Chem. 2007;282:36240–36249.
66. Tintut Y, Parhami F, Le V, et al. Inhibition of osteoblast-specific
transcription factor Cbfa1 by the cAMP pathway in osteoblastic
cells. Ubiquitin/proteasome-dependent regulation. J Biol Chem.
1999;274:28875–28879.
67. Jones DC, Wein MN, Glimcher LH. Schnurri-3: a key regulator of
postnatal skeletal remodeling. Adv Exp Med Biol. 2007;602:1–13.
68. Glimcher LH, Jones DC, Wein MN. Control of postnatal bone mass
by the zinc finger adapter protein Schnurri-3. Ann N Y Acad Sci.
2007;1116:174–181.
69. Selvamurugan N, Pulumati MR, Tyson DR, Partridge NC.
Parathyroid hormone regulation of the rat collagenase-3 promoter
by protein kinase A-dependent transactivation of core binding
factor alpha1. J Biol Chem. 2000;275:5037–5042.
70. Selvamurugan N, Jefcoat SC, Kwok S, et al. Overexpression of
Runx2 directed by the matrix metalloproteinase-13 promoter
containing the AP-1 and Runx/RD/Cbfa sites alters bone
remodeling in vivo. J Cell Biochem. 2006;99:545–557.
71. Komori T. Regulation of osteoblast differentiation by transcription
factors. J Cell Biochem. 2006;99:1233–1239.
72. Inada M, Yasui T, Nomura S, et al. Maturational disturbance of
chondrocytes in Cbfa1-deficient mice. Dev Dyn. 1999;214:279–290.
73. Nishio Y, Dong Y, Paris M, et al. Runx2-mediated regulation of the
zinc finger Osterix/Sp7 gene. Gene. 2006;372:62–70.
74. Deng ZL, Sharff KA, Tang N, et al. Regulation of osteogenic
differentiation during skeletal development. Front Biosci.
2008;13:2001–2021.
75. Jensen ED, Gopalakrishnan R, Westendorf JJ. Regulation of gene
expression in osteoblasts. Biofactors. 2010;36:25–32.
76. Dudley HR, Spiro D. The fine structure of bone cells. J Biophys
Biochem Cytol. 1961;11:627–649.
77. Bonucci E. The osteocyte: the underestimated conductor of the
bone orchestra. Rend Eis Acc Lincei. 2009;20:237–254.
78. Banes AJ, Tsuzaki M, Yamamoto J, et al. Mechanoreception at the
cellular level: the detection, interpretation, and diversity of
responses to mechanical signals. Biochem Cell Biol. 1995;73:349–365.
79. Civitelli R. Cell-cell communication in the osteoblast/osteocyte
lineage. Arch Biochem Biophys. 2008;473:188–192.
80. Wang Y, McNamara LM, Schaffler MB, Weinbaum S. A model for
the role of integrins in flow induced mechanotransduction in
osteocytes. Proc Natl Acad Sci USA. 2007;104:15941–15946.
81. Inaoka T, Lean JM, Bessho T, et al. Sequential analysis of gene
expression after an osteogenic stimulus: c-fos expression is
induced in osteocytes. Biochem Biophys Res Commun.
1995;217:264–270.
82. Lean JM, Mackay AG, Chow JW, Chambers TJ. Osteocytic
expression of mRNA for c-fos and IGF-I: an immediate early gene
response to an osteogenic stimulus. Am J Physiol. 1996;270:E937–
E945.
83. Mullender M, El Haj AJ, Yang Y, et al. Mechanotransduction of
bone cells in vitro: mechanobiology of bone tissue. Med Biol Eng
Comput. 2004;42:14–21.
84. Robinson JA, Chatterjee-Kishore M, Yaworsky PJ, et al. Wnt/
beta-catenin signaling is a normal physiological response to
mechanical loading in bone. J Biol Chem. 2006;281:31720–31728.
85. Bonewald LF, Johnson ML. Osteocytes, mechanosensing and Wnt
signaling. Bone. 2008;42:606–615.
86. Tatsumi S, Ishii K, Amizuka N, et al. Targeted ablation of
osteocytes induces osteoporosis with defective
mechanotransduction. Cell Metab. 2007;5:464–475.
87. Bonucci E, Gherardi G. Osteocyte ultrastructure in renal
osteodystrophy. Virchows Arch A Pathol Anat Histol.
1977;373:213–231.
88. Krempen B, Ritz E. Effects of parathyroid hormone on osteocytes.
Ultrastructural evidence for anisotropic osteolysis and
involvement of the cytoskeleton. Metab Bone Disease Relat Res.
1978;1:55–65.
89. Baylink D, Sipe J, Wergedal J, Whittemore OJ. Vitamin D-enhanced
osteocytic and osteoclastic bone resorption. Am J Physiol.
1973;224:1345–1357.
90. Tazawa K, Hoshi K, Kawamoto S, et al. Osteocytic osteolysis
observed in rats to which parathyroid hormone was continuously
administered. J Bone Miner Metab. 2004;22:524–529.
91. Sbaihi M, Kacem A, Aroua S, et al. Thyroid hormone-induced
demineralisation of the vertebral skeleton of the eel, Anguilla
anguilla. Gen Comp Endocrinol. 2007;151:98–107.
92. Wysolmerski JJ. Osteocytes remove and replace perilacunar
mineral during reproductive cycles. Bone. 2013;54:230–236.
93. Boyde A, Ali NN, Jones SJ. Resorption of dentine by isolated
osteoclasts in vitro. Br Dent J. 1984;156:216–220.
94. Chambers TJ, Revell PA, Fuller K, Athanasou NA. Resorption of
bone by isolated rabbit osteoclasts. J Cell Sci. 1984;66:383–399.
95. Vaananen HK, Zhao H, Mulari M, Halleen JM. The cell biology of
osteoclast function. J Cell Sci. 2000;113:377–381.
96. Rodan GA, Martin TJ. Role of osteoblasts in hormonal control of
bone resorption–a hypothesis. Calcif Tissue Int. 1981;33:349–351.
97. Horton MA, Taylor ML, Arnett TR, Helfrich MH. Arg-Gly-Asp
(RGD) peptides and the anti-vitronectin receptor antibody 23C6
inhibit dentine resorption and cell spreading by osteoclasts. Exp
Cell Res. 1991;195:368–375.
98. Lakkakorpi PT, Horton MA, Helfrich MH, et al. Vitronectin
receptor has a role in bone resorption but does not mediate tight
sealing zone attachment of osteoclasts to the bone surface. J Cell
Biol. 1991;115:1179–1186.
99. Fisher JE, Caulfield MP, Sato M, et al. Inhibition of osteoclastic
bone resorption in vivo by echistatin, an “arginyl-glycyl-aspartyl”
(RGD)-containing protein. Endocrinology. 1993;132:1411–1413.
100. McMichael BK, Cheney RE, Lee BS. Myosin X regulates sealing
zone patterning in osteoclasts through linkage of podosomes and
microtubules. J Biol Chem. 2010;285:9506–9515.

314.e3
References
101. Jurdic P, Saltel F, Chabadel A, Destaing O. Podosome and sealing
zone: specificity of the osteoclast model. Eur J Cell Biol.
2006;85:195–202.
102. Vaananen HK, Karhukorpi EK, Sundquist K, et al. Evidence for the
presence of a proton pump of the vacuolar H(+)-ATPase type in
the ruffled borders of osteoclasts. J Cell Biol. 1990;111:1305–1311.
103. Blair HC, Teitelbaum SL, Ghiselli R, Gluck S. Osteoclastic bone
resorption by a polarized vacuolar proton pump. Science.
1989;245:855–857.
104. Drake FH, Dodds RA, James IE, et al. Cathepsin K, but not
cathepsins B, L, or S, is abundantly expressed in human
osteoclasts. J Biol Chem. 1996;271:12511–12516.
105. Tezuka K, Nemoto K, Tezuka Y, et al. Identification of matrix
metalloproteinase 9 in rabbit osteoclasts. J Biol Chem.
1994;269:15006–15009.
106. Nesbitt SA, Horton MA. Trafficking of matrix collagens through
bone-resorbing osteoclasts. Science. 1997;276:266–269.
107. Salo J, Lehenkari P, Mulari M, et al. Removal of osteoclast bone
resorption products by transcytosis. Science. 1997;276:270–273.
108. Stenbeck G, Horton MA. Endocytic trafficking in actively
resorbing osteoclasts. J Cell Sci. 2004;117:827–836.
109. Halleen JM, Raisanen S, Salo JJ, et al. Intracellular fragmentation
of bone resorption products by reactive oxygen species generated
by osteoclastic tartrate-resistant acid phosphatase. J Biol Chem.
1999;274:22907–22910.
110. Wiktor-Jedrzejczak W, Bartocci A, Ferrante AW Jr, et al. Total
absence of colony-stimulating factor 1 in the macrophage-deficient
osteopetrotic (op/op) mouse. Proc Natl Acad Sci USA.
1990;87:4828–4832.
111. Yoshida H, Hayashi S, Kunisada T, et al. The murine mutation
osteopetrosis is in the coding region of the macrophage colony
stimulating factor gene. Nature.
1990;345:442–444.
112. Lagasse E, Weissman IL. Enforced expression of Bcl-2 in
monocytes rescues macrophages and partially reverses
osteopetrosis in op/op mice. Cell. 1997;89:1021–1031.
113. Dougall WC, Glaccum M, Charrier K, et al. RANK is essential for
osteoclast and lymph node development. Genes Dev.
1999;13:2412–2424.
114. Li J, Sarosi I, Yan XQ, et al. RANK is the intrinsic hematopoietic
cell surface receptor that controls osteoclastogenesis and regulation
of bone mass and calcium metabolism. Proc Natl Acad Sci USA.
2000;97:1566–1571.
115. Kong YY, Yoshida H, Sarosi I, et al. OPGL is a key regulator of
osteoclastogenesis, lymphocyte development and lymph-node
organogenesis. Nature. 1999;397:315–323.
116. Marks SC Jr, Seifert MF, McGuire JL. Congenitally osteopetrotic
(oplop) mice are not cured by transplants of spleen or bone
marrow cells from normal littermates. Metab Bone Dis Relat Res.
1984;5:183–186.
117. Marks SC Jr, Lane PW. Osteopetrosis, a new recessive skeletal
mutation on chromosome 12 of the mouse. J Hered. 1976;67:11–18.
118. Yasuda H, Shima N, Nakagawa N, et al. Identity of
osteoclastogenesis inhibitory factor (OCIF) and osteoprotegerin
(OPG): a mechanism by which OPG/OCIF inhibits
osteoclastogenesis in vitro. Endocrinology.
1998;139:1329–1337.
119. Yasuda H, Shima N, Nakagawa N, et al. Osteoclast differentiation
factor is a ligand for osteoprotegerin/osteoclastogenesis-inhibitory
factor and is identical to TRANCE/RANKL. Proc Natl Acad Sci
USA. 1998;95:3597–3602.
120. Lacey DL, Timms E, Tan HL, et al. Osteoprotegerin ligand is a
cytokine that regulates osteoclast differentiation and activation.
Cell. 1998;93:165–176.
121. Kong YY, Feige U, Sarosi I, et al. Activated T cells regulate bone
loss and joint destruction in adjuvant arthritis through
osteoprotegerin ligand. Nature. 1999;402:304–309.
122. Simonet WS, Lacey DL, Dunstan CR, et al. Osteoprotegerin: a
novel secreted protein involved in the regulation of bone density.
Cell. 1997;89:309–319.
123. Bucay N, Sarosi I, Dunstan CR, et al. osteoprotegerin-deficient
mice develop early onset osteoporosis and arterial calcification.
Genes Dev. 1998;12:1260–1268.
124. Mizuno A, Amizuka N, Irie K, et al. Severe osteoporosis in mice
lacking osteoclastogenesis inhibitory factor/osteoprotegerin.
Biochem Biophys Res Commun. 1998;247:610–615.
125. Darnay BG, Haridas V, Ni J, et al. Characterization of the
intracellular domain of receptor activator of NF-kappaB (RANK).
Interaction with tumor necrosis factor receptor-associated factors
and activation of NF-kappab and c-Jun N-terminal kinase. J Biol
Chem. 1998;273:20551–20555.
126. Wong BR, Besser D, Kim N, et al. TRANCE, a TNF family
member, activates Akt/PKB through a signaling complex
involving TRAF6 and c-Src. Mol Cell. 1999;4:1041–1049.
127. Wong BR, Josien R, Lee SY, et al. The TRAF family of signal
transducers mediates NF-kappaB activation by the TRANCE
receptor. J Biol Chem. 1998;273:28355–28359.
128. Gohda J, Akiyama T, Koga T, et al. RANK-mediated amplification
of TRAF6 signaling leads to NFATc1 induction during
osteoclastogenesis. EMBO J. 2005;24:790–799.
129. Kadono Y, Okada F, Perchonock C, et al. Strength of TRAF6
signalling determines osteoclastogenesis. EMBO Rep.
2005;6:171–176.
130. Kobayashi N, Kadono Y, Naito A, et al. Segregation of TRAF6-
mediated signaling pathways clarifies its role in osteoclastogenesis.
EMBO J. 2001;20:1271–1280.
131. Naito A, Azuma S, Tanaka S, et al. Severe osteopetrosis, defective
interleukin-1 signalling and lymph node organogenesis in
TRAF6-deficient mice. Genes Cells. 1999;4:353–362.
132. Lomaga MA, Yeh WC, Sarosi I, et al. TRAF6 deficiency results in
osteopetrosis and defective interleukin-1, CD40, and LPS signaling.
Genes Dev. 1999;13:1015–1024.
133. Iotsova V, Caamano J, Loy J, et al. Osteopetrosis in mice lacking
NF-kappaB1 and NF-kappaB2. Nat Med. 1997;3:1285–1289.
134. Franzoso G, Carlson L, Xing L, et al. Requirement for NF-kappaB
in osteoclast and B-cell development. Genes Dev. 1997;11:3482–
3496.
135. Asagiri M, Takayanagi H. The molecular understanding of
osteoclast differentiation. Bone. 2007;40:251–264.
136. Basel D, Steiner RD. Osteogenesis imperfecta: recent findings shed
new light on this once well-understood condition. Genet Med.
2009;11:375–385.
137. Denhardt DT, Guo X. Osteopontin: a protein with diverse
functions. FASEB J. 1993;7:1475–1482.
138. Denhardt DT, Noda M. Osteopontin expression and function: role
in bone remodeling. J Cell Biochem Suppl. 1998;30–31:92–102.
139. Sodek J, Ganss B, McKee MD. Osteopontin. Crit Rev Oral Biol Med.
2000;11:279–303.
140. Sodek J, Chen J, Kasugai S. Elucidating the Functions of Bone
Sialoprotein and Osteopontin in Bone Formation. New York: Elsevier
Science; 1992.
141. Glimcher MJ. Mechanism of calcification: role of collagen fibrils
and collagen-phosphoprotein complexes in vitro and in vivo. Anat
Rec. 1989;224:139–153.
142. Butler WT. The nature and significance of osteopontin. Connect
Tissue Res. 1989;23:123–136.
143. Kasugai S, Nagata T, Sodek J. Temporal studies on the tissue
compartmentalization of bone sialoprotein (BSP), osteopontin
(OPN), and SPARC protein during bone formation in vitro. J Cell
Physiol. 1992;152:467–477.
144. Reinholt FP, Hultenby K, Oldberg A, Heinegard D. Osteopontin–a
possible anchor of osteoclasts to bone. Proc Natl Acad Sci USA.
1990;87:4473–4475.
145. McKee MD, Farach-Carson MC, Butler WT, et al. Ultrastructural
immunolocalization of noncollagenous (osteopontin and
osteocalcin) and plasma (albumin and alpha 2HS-glycoprotein)
proteins in rat bone. J Bone Miner Res. 1993;8:485–496.
146. Guweidhi A, Kleeff J, Adwan H, et al. Osteonectin influences
growth and invasion of pancreatic cancer cells. Ann Surg.
2005;242:224–234.

314.e4
CHAPTER 18 • Repair and grafting of bone
147. Watkins G, Douglas-Jones A, Bryce R, et al. Increased levels of
SPARC (osteonectin) in human breast cancer tissues and its
association with clinical outcomes. Prostaglandins Leukot Essent
Fatty Acids. 2005;72:267–272.
148. Bianco P, Riminucci M, Silvestrini G, et al. Localization of bone
sialoprotein (BSP) to Golgi and post-Golgi secretory structures in
osteoblasts and to discrete sites in early bone matrix. J Histochem
Cytochem. 1993;41:193–203.
149. Baht GS, Hunter GK, Goldberg HA. Bone sialoprotein-collagen
interaction promotes hydroxyapatite nucleation. Matrix Biol.
2008;27:600–608.
150. Malaval L, Wade-Gueye NM, Boudiffa M, et al. Bone sialoprotein
plays a functional role in bone formation and osteoclastogenesis. J
Exp Med. 2008;205:1145–1153.
151. Polak-Jonkisz D, Zwolinska D. Osteocalcin as a biochemical
marker of bone turnover. Nephrology. 1998;4:339–346.
152. Ducy P, Desbois C, Boyce B, et al. Increased bone formation in
osteocalcin-deficient mice. Nature. 1996;382:448–452.
153. Boskey AL, Gadaleta S, Gundberg C, et al. Fourier transform
infrared microspectroscopic analysis of bones of osteocalcin-
deficient mice provides insight into the function of osteocalcin.
Bone. 1998;23:187–196.
154. Glowacki J, Rey C, Glimcher MJ, et al. A role for osteocalcin in
osteoclast differentiation. J Cell Biochem. 1991;45:292–302.
155. Lee NK, Sowa H, Hinoi E, et al. Endocrine regulation of energy
metabolism by the skeleton. Cell. 2007;130:456–469.
156. Reinehr T, Roth CL. A new link between skeleton, obesity and
insulin resistance: relationships between osteocalcin, leptin and
insulin resistance in obese children before and after weight loss.
Int J Obes (Lond). 2010;34:852–858.
157. Xu T, Bianco P, Fisher LW, et al. Targeted disruption of the
biglycan gene leads to an osteoporosis-like phenotype in mice. Nat
Genet. 1998;20:78–82.
158. Heegaard AM, Corsi A, Danielsen CC, et al. Biglycan deficiency
causes spontaneous aortic dissection and rupture in mice.
Circulation. 2007;115:2731–2738.
159. Young MF, Bi Y, Ameye L. Biglycan knockout mice: new models
for musculoskeletal diseases. Glycoconj J. 2002;19:257–262.
160. Delmas PD. Biochemical markers of bone turnover. Acta Orthop
Scand Suppl. 1995;266:176–182.
161. Raisz LG. Pathogenesis of osteoporosis: concepts, conflicts, and
prospects. J Clin Invest. 2005;115:3318–3325.
162. Stark Z, Savarirayan R. Osteopetrosis. Orphanet J Rare Dis. 2009;4:5.
163. Mashiba T, Hirano T, Turner CH, et al. Suppressed bone turnover
by bisphosphonates increases microdamage accumulation and
reduces some biomechanical properties in dog rib. J Bone Miner
Res. 2000;15:613–620.
164. Odvina CV, Zerwekh JE, Rao DS, et al. Severely suppressed bone
turnover: a potential complication of alendronate therapy. J Clin
Endocrinol Metab. 2005;90:1294–1301.
165. Burr DB, Martin RB. Calculating the probability that microcracks
initiate resorption spaces. J Biomech. 1993;26:613–616.
166. Burr DB, Martin RB, Schaffler MB, Radin EL. Bone remodeling in
response to in vivo fatigue microdamage. J Biomech.
1985;18:189–200.
167. Mori S, Burr DB. Increased intracortical remodeling following
fatigue damage. Bone. 1993;14:103–109.
168. Burr DB. Targeted and nontargeted remodeling. Bone. 2002;30:2–4.
169. Wolff J. Das Gesetz der Transformation der Knochen. Berlin:
Hirchwild; 1892.
170. Cowin SC. The False Premise of Wolff’s Law. Vol. 30. Boca Raton:
CRC Press; 2001.
171. Ruff C, Holt B, Trinkaus E. Who’s afraid of the big bad Wolff?:
“Wolff’s law” and bone functional adaptation. Am J Phys
Anthropol. 2006;129:484–498.
172. Santos A, Bakker AD, Klein-Nulend J. The role of osteocytes in
bone mechanotransduction. Osteoporos Int. 2009;20:1027–1031.
173. Chakkalakal DA. Mechanoelectric transduction in bone. J Mater
Res. 1989;4:1034–1036.
174. Pavalko FM, Norvell SM, Burr DB, et al. A model for
mechanotransduction in bone cells: the load-bearing
mechanosomes. J Cell Biochem. 2003;88:104–112.
175. Turner CH, Pavalko FM. Mechanotransduction and functional
response of the skeleton to physical stress: the mechanisms and
mechanics of bone adaptation. J Orthop Sci. 1998;3:346–355.
176. Cowin SC, Moss-Salentijn L, Moss ML. Candidates for the
mechanosensory system in bone. J Biomech Eng. 1991;113:191–197.
177. Klein-Nulend J, van der Plas A, Semeins CM, et al. Sensitivity of
osteocytes to biomechanical stress in vitro. FASEB J.
1995;9:441–445.
178. You J, Yellowley CE, Donahue HJ, et al. Substrate deformation
levels associated with routine physical activity are less stimulatory
to bone cells relative to loading-induced oscillatory fluid flow. J
Biomech Eng. 2000;122:387–393.
179. Cowin SC, Weinbaum S, Zeng Y. A case for bone canaliculi as the
anatomical site of strain generated potentials. J Biomech.
1995;28:1281–1297.
180. Hung CT, Pollack SR, Reilly TM, Brighton CT. Real-time calcium
response of cultured bone cells to fluid flow. Clin Orthop Relat Res.
1995;256–269.
181. Hung CT, Allen FD, Pollack SR, Brighton CT. What is the role of
the convective current density in the real-time calcium response of
cultured bone cells to fluid flow? J Biomech. 1996;29:1403–1409.
182. Klein-Nulend J, Semeins CM, Ajubi NE, et al. Pulsating fluid flow
increases nitric oxide (NO) synthesis by osteocytes but not
periosteal fibroblasts–correlation with prostaglandin upregulation.
Biochem Biophys Res Commun. 1995;217:640–648.
183. Pitsillides AA, Rawlinson SC, Suswillo RF, et al. Mechanical
strain-induced NO production by bone cells: a possible role in
adaptive bone (re)modeling? FASEB J. 1995;9:1614–1622.
184. Ajubi NE, Klein-Nulend J, Nijweide PJ, et al. Pulsating fluid flow
increases prostaglandin production by cultured chicken
osteocytes–a cytoskeleton-dependent process. Biochem Biophys Res
Commun. 1996;225:62–68.
185. Klein-Nulend J, Burger EH, Semeins CM, et al. Pulsating fluid
flow stimulates prostaglandin release and inducible prostaglandin
G/H synthase mRNA expression in primary mouse bone cells. J
Bone Miner Res. 1997;12:45–51.
186. Westbroek I, Ajubi NE, Alblas MJ, et al. Differential stimulation of
prostaglandin G/H synthase-2 in osteocytes and other osteogenic
cells by pulsating fluid flow. Biochem Biophys Res Commun.
2000;268:414–419.
187. Bakker AD, Klein-Nulend J, Burger EH. Mechanotransduction in
bone cells proceeds via activation of COX-2, but not COX-1.
Biochem Biophys Res Commun. 2003;305:677–683.
188. Forwood MR. Inducible cyclo-oxygenase (COX-2) mediates the
induction of bone formation by mechanical loading in vivo. J Bone
Miner Res. 1996;11:1688–1693.
189. Dominici M, Le Blanc K, Mueller I, et al. Minimal criteria for
defining multipotent mesenchymal stromal cells. The International
Society for Cellular Therapy position statement. Cytotherapy.
2006;8:315–317.
190. Williams JT, Southerland SS, Souza J, et al. Cells isolated from
adult human skeletal muscle capable of differentiating into
multiple mesodermal phenotypes. Am Surg. 1999;65:22–26.
191. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human
adipose tissue: implications for cell-based therapies. Tissue Eng.
2001;7:211–228.
192. Gronthos S, Mankani M, Brahim J, et al. Postnatal human dental
pulp stem cells (DPSCs) in vitro and in vivo. Proc Natl Acad Sci
USA. 2000;97:13625–13630.
193. Kuznetsov SA, Mankani MH, Gronthos S, et al. Circulating
skeletal stem cells. J Cell Biol. 2001;153:1133–1140.
194. De Bari C, Dell’Accio F, Tylzanowski P, Luyten FP. Multipotent
mesenchymal stem cells from adult human synovial membrane.
Arthritis Rheum. 2001;44:1928–1942.
195. In ‘t Anker PS, Scherjon SA, Kleijburg-van der Keur C, et al.
Amniotic fluid as a novel source of mesenchymal stem cells for
therapeutic transplantation. Blood. 2003;102:1548–1549.

314.e5
References
196. Bharadwaj S, Liu G, Shi Y, et al. Multipotential differentiation of
human urine-derived stem cells: potential for therapeutic
applications in urology. Stem Cells. 2013;31:1840–1856.
197. Erices A, Conget P, Minguell JJ. Mesenchymal progenitor cells in
human umbilical cord blood. Br J Haematol. 2000;109:235–242.
198. Campagnoli C, Roberts IA, Kumar S, et al. Identification of
mesenchymal stem/progenitor cells in human first-trimester fetal
blood, liver, and bone marrow. Blood. 2001;98:2396–2402.
199. Fan CG, Tang FW, Zhang QJ, et al. Characterization and neural
differentiation of fetal lung mesenchymal stem cells. Cell
Transplant. 2005;14:311–321.
200. Kraus KH, Kirker-Head C. Mesenchymal stem cells and bone
regeneration. Vet Surg. 2006;35:232–242.
201. Krampera M, Pizzolo G, Aprili G, Franchini M. Mesenchymal stem
cells for bone, cartilage, tendon and skeletal muscle repair. Bone.
2006;39:678–683.
202. Teven CM, Liu X, Hu N, et al. Epigenetic regulation of
mesenchymal stem cells: a focus on osteogenic and adipogenic
differentiation. Stem Cells Int. 2011;2011:201371.
203. Teven CM, Greives M, Natale RB, et al. Differentiation of
osteoprogenitor cells is induced by high-frequency pulsed
electromagnetic fields. J Craniofac Surg. 2012;23:586–593.
204. Horwitz EM, Gordon PL, Koo WK, et al. Isolated allogeneic bone
marrow-derived mesenchymal cells engraft and stimulate growth
in children with osteogenesis imperfecta: Implications for cell
therapy of bone. Proc Natl Acad Sci USA. 2002;99:8932–8937.
205. Iso Y, Spees JL, Serrano C, et al. Multipotent human stromal cells
improve cardiac function after myocardial infarction in mice
without long-term engraftment. Biochem Biophys Res Commun.
2007;354:700–706.
206. Fukuda K, Yuasa S. Stem cells as a source of regenerative
cardiomyocytes. Circ Res. 2006;98:1002–1013.
207. Prockop DJ. “Stemness” does not explain the repair of many
tissues by mesenchymal stem/multipotent stromal cells (MSCs).
Clin Pharmacol Ther. 2007;82:241–243.
208. Phinney DG, Prockop DJ. Concise review: mesenchymal stem/
multipotent stromal cells: the state of transdifferentiation and
modes of tissue repair–current views. Stem Cells.
2007;25:2896–2902.
209. Urist MR. Bone: formation by autoinduction. Science.
1965;150:893–899.
210. Adachi T, Takanaga H, Kunimoto M, Asou H. Influence of LIF and
BMP-2 on differentiation and development of glial cells in primary
cultures of embryonic rat cerebral hemisphere. J Neurosci Res.
2005;79:608–615.
211. Hogan BL. Bone morphogenetic proteins: multifunctional
regulators of vertebrate development. Genes Dev.
1996;10:1580–1594.
212. Zou H, Choe KM, Lu Y, et al. BMP signaling and vertebrate limb
development. Cold Spring Harb Symp Quant Biol.
1997;62:269–272.
213. Wagner ER, Luther G, Zhu G, et al. Defective osteogenic
differentiation in the development of osteosarcoma. Sarcoma.
2011;2011:325238.
214. Xiao YT, Xiang LX, Shao JZ. Bone morphogenetic protein. Biochem
Biophys Res Commun. 2007;362:550–553.
215. Heldin CH, Miyazono K, ten Dijke P. TGF-beta signalling from cell
membrane to nucleus through SMAD proteins. Nature.
1997;390:465–471.
216. Chenard KE, Teven CM, He TC, Reid RR. Bone morphogenetic
proteins in craniofacial surgery: current techniques, clinical
experiences, and the future of personalized stem cell therapy. J
Biomed Biotechnol. 2012;2012:601549.
217. Munoz-Sanjuan I, Brivanlou AH. Neural induction, the default
model and embryonic stem cells. Nat Rev Neurosci. 2002;3:271–280.
218. Christiansen JH, Coles EG, Wilkinson DG. Molecular control of
neural crest formation, migration and differentiation. Curr Opin
Cell Biol. 2000;12:719–724.
219. Chen D, Zhao M, Mundy GR. Bone morphogenetic proteins.
Growth Factors. 2004;22:233–241.
220. Luther G, Wagner ER, Zhu G, et al. BMP-9 induced osteogenic
differentiation of mesenchymal stem cells: molecular mechanism
and therapeutic potential. Curr Gene Ther. 2011;11:229–240.
221. Bae SC, Lee KS, Zhang YW, Ito Y. Intimate relationship between
TGF-beta/BMP signaling and runt domain transcription factor,
PEBP2/CBF. J Bone Joint Surg Am. 2001;83-A(suppl 1):S48–S55.
222. Mbalaviele G, Sheikh S, Stains JP, et al. Beta-catenin and BMP-2
synergize to promote osteoblast differentiation and new bone
formation. J Cell Biochem. 2005;94:403–418.
223. Bain G, Muller T, Wang X, Papkoff J. Activated beta-catenin
induces osteoblast differentiation of C3H10T1/2 cells and
participates in BMP2 mediated signal transduction. Biochem
Biophys Res Commun. 2003;301:84–91.
224. Mukherjee A, Wilson EM, Rotwein P. Selective signaling by Akt2
promotes bone morphogenetic protein 2-mediated osteoblast
differentiation. Mol Cell Biol. 2010;30:1018–1027.
225. Kawai M, Rosen CJ. Insulin-like growth factor-I and bone: lessons
from mice and men. Pediatr Nephrol. 2009;24:1277–1285.
226. Mukherjee A, Rotwein P. Insulin-like growth factor-binding
protein-5 inhibits osteoblast differentiation and skeletal growth by
blocking insulin-like growth factor actions. Mol Endocrinol.
2008;22:1238–1250.
227. Zhang M, Xuan S, Bouxsein ML, et al. Osteoblast-specific
knockout of the insulin-like growth factor (IGF) receptor gene
reveals an essential role of IGF signaling in bone matrix
mineralization. J Biol Chem. 2002;277:44005–44012.
228. Zhao G, Monier-Faugere MC, Langub MC, et al. Targeted
overexpression of insulin-like growth factor I to osteoblasts of
transgenic mice: increased trabecular bone volume without
increased osteoblast proliferation. Endocrinology.
2000;141:2674–2682.
229. Boyne PJ. Application of bone morphogenetic proteins in the
treatment of clinical oral and maxillofacial osseous defects. J Bone
Joint Surg Am. 2001;83-A(suppl 1):S146–S150.
230. Boyne PJ, Salina S, Nakamura A, et al. Bone regeneration using
rhBMP-2 induction in hemimandibulectomy type defects of elderly
sub-human primates. Cell Tissue Bank. 2006;7:1–10.
231. Yasko AW, Lane JM, Fellinger EJ, et al. The healing of segmental
bone defects, induced by recombinant human bone morphogenetic
protein (rhBMP-2). A radiographic, histological, and biomechanical
study in rats. J Bone Joint Surg Am. 1992;74:659–670.
232. Burkus JK, Gornet MF, Dickman CA, Zdeblick TA. Anterior
lumbar interbody fusion using rhBMP-2 with tapered interbody
cages. J Spinal Disord Tech. 2002;15:337–349.
233. Singh K, Smucker JD, Gill S, Boden SD. Use of recombinant
human bone morphogenetic protein-2 as an adjunct in
posterolateral lumbar spine fusion: a prospective CT-scan analysis
at one and two years. J Spinal Disord Tech. 2006;19:416–423.
234. Slosar PJ, Josey R, Reynolds J. Accelerating lumbar fusions by
combining rhBMP-2 with allograft bone: a prospective analysis of
interbody fusion rates and clinical outcomes. Spine J.
2007;7:301–307.
235. Shenaq DS, Teven CM, Seitz IA, et al. Characterization of
reversibly immortalized calvarial mesenchymal progenitor cells. J
Craniofac Surg. 2015;26:1207–1213.
236. Teven CM, Rossi M, Shenaq D, et al. Bone morphogenetic
protein-9 effectively induces osteogenic differentiation of
reversibly immortalized calvarial mesenchymal progenitor cells.
Genes Dis. 2015;2:268–275.
237. Vaccaro AR, Whang PG, Patel T, et al. The safety and efficacy of
OP-1 (rhBMP-7) as a replacement for iliac crest autograft for
posterolateral lumbar arthrodesis: minimum 4-year follow-up of a
pilot study. Spine J. 2008;8:457–465.
238. Ristiniemi J, Flinkkila T, Hyvonen P, et al. RhBMP-7 accelerates the
healing in distal tibial fractures treated by external fixation. J Bone
Joint Surg Br. 2007;89:265–272.
239. Barr T, McNamara AJ, Sandor GK, et al. Comparison of the
osteoinductivity of bioimplants containing recombinant human
bone morphogenetic proteins 2 (Infuse) and 7 (OP-1). Oral Surg
Oral Med Oral Pathol Oral Radiol Endod.
2010;109:531–540.

314.e6
CHAPTER 18 • Repair and grafting of bone
240. Li JZ, Li H, Sasaki T, et al. Osteogenic potential of five different
recombinant human bone morphogenetic protein adenoviral
vectors in the rat. Gene Ther. 2003;10:1735–1743.
241. Blobe GC, Schiemann WP, Lodish HF. Role of transforming growth
factor beta in human disease. N Engl J Med. 2000;342:1350–1358.
242. Massague J. TGF-beta signal transduction. Annu Rev Biochem.
1998;67:753–791.
243. Robey PG, Young MF, Flanders KC, et al. Osteoblasts synthesize
and respond to transforming growth factor-type beta (TGF-beta) in
vitro. J Cell Biol. 1987;105:457–463.
244. Centrella M, McCarthy TL, Canalis E. Transforming growth factor
beta is a bifunctional regulator of replication and collagen
synthesis in osteoblast-enriched cell cultures from fetal rat bone. J
Biol Chem. 1987;262:2869–2874.
245. Noda M, Yoon K, Prince CW, et al. Transcriptional regulation of
osteopontin production in rat osteosarcoma cells by type beta
transforming growth factor. J Biol Chem. 1988;263:13916–13921.
246. Noda M, Camilliere JJ. In vivo stimulation of bone formation by
transforming growth factor-beta. Endocrinology. 1989;124:2991
–2994.
247. Bismar H, Kloppinger T, Schuster EM, et al. Transforming growth
factor beta (TGF-beta) levels in the conditioned media of human
bone cells: relationship to donor age, bone volume, and
concentration of TGF-beta in human bone matrix in vivo. Bone.
1999;24:565–569.
248. Janssens K, ten Dijke P, Janssens S, Van Hul W. Transforming
growth factor-beta1 to the bone. Endocr Rev. 2005;26:743–774.
249. Alliston T, Choy L, Ducy P, et al. TGF-beta-induced repression of
CBFA1 by Smad3 decreases cbfa1 and osteocalcin expression and
inhibits osteoblast differentiation. EMBO J. 2001;20:2254–2272.
250. Tang Y, Wu X, Lei W, et al. TGF-beta1-induced migration of bone
mesenchymal stem cells couples bone resorption with formation.
Nat Med. 2009;15:757–765.
251. Cho TJ, Gerstenfeld LC, Einhorn TA. Differential temporal
expression of members of the transforming growth factor beta
superfamily during murine fracture healing. J Bone Miner Res.
2002;17:513–520.
252. Ripamonti U, Crooks J, Matsaba T, Tasker J. Induction of
endochondral bone formation by recombinant human
transforming growth factor-beta2 in the baboon (Papio ursinus).
Growth Factors. 2000;17:269–285.
253. Ripamonti U, Ferretti C, Teare J, Blann L. Transforming growth
factor-beta isoforms and the induction of bone formation:
implications for reconstructive craniofacial surgery. J Craniofac
Surg. 2009;20:1544–1555.
254. Shakir S, MacIsaac ZM, Naran S, et al. Transforming growth factor
beta 1 augments calvarial defect healing and promotes suture
regeneration. Tissue Eng Part A. 2015;21:939–947.
255. Ornitz DM, Itoh N. Fibroblast growth factors. Genome Biol.
2001;2:REVIEWS3005.
256. Teven CM, Farina EM, Rivas J, Reid RR. Fibroblast growth factor
(FGF) signaling in development and skeletal diseases. Genes Dis.
2014;1:199–213.
257. Eswarakumar VP, Lax I, Schlessinger J. Cellular signaling by
fibroblast growth factor receptors. Cytokine Growth Factor Rev.
2005;16:139–149.
258. Coffin JD, Florkiewicz RZ, Neumann J, et al. Abnormal bone
growth and selective translational regulation in basic fibroblast
growth factor (FGF-2) transgenic mice. Mol Biol Cell.
1995;6:1861–1873.
259. Radomsky ML, Thompson AY, Spiro RC, Poser JW. Potential role
of fibroblast growth factor in enhancement of fracture healing. Clin
Orthop Relat Res. 1998;355(suppl):S283–S293.
260. Maegawa N, Kawamura K, Hirose M, et al. Enhancement of
osteoblastic differentiation of mesenchymal stromal cells cultured
by selective combination of bone morphogenetic protein-2 (BMP-2)
and fibroblast growth factor-2 (FGF-2). J Tissue Eng Regen Med.
2007;1:306–313.
261. Sabbieti MG, Agas D, Xiao L, et al. Endogenous FGF-2 is critically
important in PTH anabolic effects on bone. J Cell Physiol.
2009;219:143–151.
262. Fredriksson L, Li H, Eriksson U. The PDGF family: four gene
products form five dimeric isoforms. Cytokine Growth Factor Rev.
2004;15:197–204.
263. Joukov V, Kaipainen A, Jeltsch M, et al. Vascular endothelial
growth factors VEGF-B and VEGF-C. J Cell Physiol.
1997;173:211–215.
264. Heldin CH, Westermark B. Mechanism of action and in vivo role
of platelet-derived growth factor. Physiol Rev. 1999;79:1283–1316.
265. Tallquist M, Kazlauskas A. PDGF signaling in cells and mice.
Cytokine Growth Factor Rev. 2004;15:205–213.
266. Hollinger JO, Hart CE, Hirsch SN, et al. Recombinant human
platelet-derived growth factor: biology and clinical applications. J
Bone Joint Surg Am. 2008;90:48–54.
267. Bouletreau PJ, Warren SM, Spector JA, et al. Factors in the fracture
microenvironment induce primary osteoblast angiogenic cytokine
production. Plast Reconstr Surg. 2002;110:139–148.
268. Levi B, James AW, Wan DC, et al. Regulation of human adipose-
derived stromal cell osteogenic differentiation by insulin-like
growth factor-1 and platelet-derived growth factor-alpha. Plast
Reconstr Surg. 2010;126:41–52.
269. Nevins M, Giannobile WV, McGuire MK, et al. Platelet-derived
growth factor stimulates bone fill and rate of attachment level
gain: results of a large multicenter randomized controlled trial. J
Periodontol. 2005;76:2205–2215.
270. Nevins M, Kao RT, McGuire MK, et al. Platelet-derived growth
factor promotes periodontal regeneration in localized osseous
defects: 36-month extension results from a randomized, controlled,
double-masked clinical trial. J Periodontol. 2013;84:456–464.
271. Lin S, DiGiovanni C, Baumhauer J. A prospective, randomized,
controlled multicenter human clinical feasibility trial to evaluate
the preliminary safety and efficacy of rhPDGF versus autologous
bone graft as a bone regenerative device. Read at the Annual
Summer Meeting of the American Orthopedic Foot and Ankle Society.
Toronto, Canada.2007.
272. McKibbin B. The biology of fracture healing in long bones. J Bone
Joint Surg Br. 1978;60-B:150–162.
273. Cawood JI. Small plate osteosynthesis of mandibular fractures. Br
J Oral Maxillofac Surg. 1985;23:77–91.
274. Raman J, Song DH, Bolotin G, Jeevanandam V. Sternal closure
with titanium plate fixation–a paradigm shift in preventing
mediastinitis. Interact Cardiovasc Thorac Surg. 2006;5:336–339.
275. Manson PN, Clark N, Robertson B, Crawley WA. Comprehensive
management of pan-facial fractures. J Craniomaxillofac Trauma.
1995;1:43–56.
276. Evans GR, Clark N, Manson PN, Leipziger LS. Role of mini- and
microplate fixation in fractures of the midface and mandible. Ann
Plast Surg. 1995;34:453–456.
277. Einhorn TA. The cell and molecular biology of fracture healing.
Clin Orthop Relat Res. 1998;355(suppl):S7–S21.
278. Sfeir C, Ho L, Doll BA. Fracture Repair. New Jersey: Humana Press;
2005.
279. Bolander ME. Regulation of fracture repair by growth factors. Proc
Soc Exp Biol Med. 1992;200:165–170.
280. Brookes M, Revell WJ. The Blood Supply of Bone: Scientific Aspects.
New York: Springer; 1998.
281. McCarthy I. The physiology of bone blood flow: a review. J Bone
Joint Surg Am. 2006;88:4–9.
282. Towler DA. The osteogenic-angiogenic interface: novel insights
into the biology of bone formation and fracture repair. Curr
Osteoporos Rep. 2008;6:67–71.
283. Wan C, Gilbert SR, Wang Y, et al. Activation of the hypoxia-
inducible factor-1alpha pathway accelerates bone regeneration.
Proc Natl Acad Sci USA. 2008;105:686–691.
284. Ferrara N, Carver-Moore K, Chen H, et al. Heterozygous
embryonic lethality induced by targeted inactivation of the VEGF
gene. Nature. 1996;380:439–442.

314.e7
References
285. Carlevaro MF, Cermelli S, Cancedda R, et al. Vascular endothelial
growth factor (VEGF) in cartilage neovascularization and
chondrocyte differentiation: auto-paracrine role during
endochondral bone formation. J Cell Sci. 2000;113:59–69.
286. Ryan AM, Eppler DB, Hagler KE, et al. Preclinical safety
evaluation of rhuMAbVEGF, an antiangiogenic humanized
monoclonal antibody. Toxicol Pathol. 1999;27:78–86.
287. Gerber HP, Vu TH, Ryan AM, et al. VEGF couples hypertrophic
cartilage remodeling, ossification and angiogenesis during
endochondral bone formation. Nat Med. 1999;5:623–628.
288. Yang YQ, Tan YY, Wong R, et al. The role of vascular endothelial
growth factor in ossification. Int J Oral Sci. 2012;4:64–68.
289. Luo T, Zhang W, Shi B, et al. Enhanced bone regeneration around
dental implant with bone morphogenetic protein 2 gene and
vascular endothelial growth factor protein delivery. Clin Oral
Implants Res. 2012;23:467–473.
290. Liu Y, Olsen BR. Distinct VEGF functions during bone
development and homeostasis. Arch Immunol Ther Exp (Warsz).
2014;62:363–368.
291. Kwong FN, Harris MB. Recent developments in the biology of
fracture repair. J Am Acad Orthop Surg. 2008;16:619–625.
292. Palomares KT, Gleason RE, Mason ZD, et al. Mechanical
stimulation alters tissue differentiation and molecular expression
during bone healing. J Orthop Res. 2009;27:1123–1132.
293. Desai BJ, Meyer MH, Porter S, et al. The effect of age on gene
expression in adult and juvenile rats following femoral fracture. J
Orthop Trauma. 2003;17:689–698.
294. Shimada T, Takeshita Y, Murohara T, et al. Angiogenesis and
vasculogenesis are impaired in the precocious-aging klotho mouse.
Circulation. 2004;110:1148–1155.
295. Lu C, Hansen E, Sapozhnikova A, et al. Effect of age on
vascularization during fracture repair. J Orthop Res.
2008;26:1384–1389.
296. Fan W, Crawford R, Xiao Y. Structural and cellular differences
between metaphyseal and diaphyseal periosteum in different aged
rats. Bone. 2008;42:81–89.
297. Meyer MH, Meyer RA Jr. Altered expression of mitochondrial
genes in response to fracture in old rats. Acta Orthop.
2006;77:944–951.
298. Albrektsson T, Johansson C. Osteoinduction, osteoconduction and
osseointegration. Eur Spine J. 2001;10:S96–S101.
299. Gosain AK. Bioactive glass for bone replacement in
craniomaxillofacial reconstruction. Plast Reconstr Surg.
2004;114:590–593.
300. Chim H, Gosain AK. Biomaterials in craniofacial surgery:
experimental studies and clinical application. J Craniofac Surg.
2009;20:29–33.
301. Caballero M, Reed CR, Madan G, van Aalst JA. Osteoinduction in
umbilical cord- and palate periosteum-derived mesenchymal stem
cells. Ann Plast Surg. 2010;64:605–609.
302. Polini A, Pisignano D, Parodi M, et al. Osteoinduction of human
mesenchymal stem cells by bioactive composite scaffolds without
supplemental osteogenic growth factors. PLoS ONE.
2011;6:e26211.
303. Miron RJ, Zhang YF. Osteoinduction: a review of old concepts
with new standards. J Dent Res. 2012;91:736–744.
304. Nazirkar G, Singh S, Dole V, Nikam A. Effortless effort in bone
regeneration: a review. J Int Oral Health. 2014;6:120–124.
305. Cornell CN. Osteoconductive materials and their role as
substitutes for autogenous bone grafts. Orthop Clin North Am.
1999;30:591–598.
306. De Long WG Jr, Einhorn TA, Koval K, et al. Bone grafts and bone
graft substitutes in orthopaedic trauma surgery. A critical analysis.
J Bone Joint Surg Am. 2007;89:649–658.
307. Schenk RK, Buser D. Osseointegration: a reality. Periodontol 2000.
1998;17:22–35.
308. Buser D, Schenk RK, Steinemann S, et al. Influence of surface
characteristics on bone integration of titanium implants. A
histomorphometric study in miniature pigs. J Biomed Mater Res.
1991;25:889–902.
309. Butz F, Aita H, Wang CJ, Ogawa T. Harder and stiffer bone
osseointegrated to roughened titanium. J Dent Res.
2006;85:560–565.
310. Shibli JA, Grassi S, de Figueiredo LC, et al. Influence of implant
surface topography on early osseointegration: a histological study
in human jaws. J Biomed Mater Res B Appl Biomater.
2007;80:377–385.
311. Codivilla A. On the means of lengthening in the lower limbs, the
muscles and tissues which are shortened through deformity. J Bone
Joint Surg Am. 1905;S2–S3:353–369.
312. 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 Relat Res. 1989;238:249–281.
313. Ilizarov GA. Clinical application of the tension-stress effect for
limb lengthening. Clin Orthop Relat Res. 1990;250:8–26.
314. Snyder CC, Levine GA, Swanson HM, Browne EZ Jr. Mandibular
lengthening by gradual distraction. Preliminary report. Plast
Reconstr Surg. 1973;51:506–508.
315. McCarthy JG, Schreiber J, Karp N, et al. Lengthening the human
mandible by gradual distraction. Plast Reconstr Surg. 1992;89:1–8,
discussion 9–10.
316. McCarthy JG. Distraction of the Craniofacial Skeleton. New York:
Springer-Verlag; 1999.
317. McCarthy JG, Stelnicki EJ, Mehrara BJ, Longaker MT. Distraction
osteogenesis of the craniofacial skeleton. Plast Reconstr Surg.
2001;107:1812–1827.
318. Verlinden CR, van de Vijfeijken SE, Jansma EP, et al. Complications
of mandibular distraction osteogenesis for congenital deformities:
a systematic review of the literature and proposal of a new
classification for complications. Int J Oral Maxillofac Surg.
2015;44:37–43.
319. Nagy K, Kuijpers-Jagtman AM, Mommaerts MY. No evidence for
long-term effectiveness of early osteodistraction in hemifacial
microsomia. Plast Reconstr Surg. 2009;124:2061–2071.
320. Mofid MM, Manson PN, Robertson BC, et al. Craniofacial
distraction osteogenesis: a review of 3278 cases. Plast Reconstr
Surg. 2001;108:1103–1114, discussion 1115–1107.
321. Davidson EH, Brown D, Shetye PR, et al. The evolution of
mandibular distraction: device selection. Plast Reconstr Surg.
2010;126:2061–2070.
322. Shetye PR, Warren SM, Brown D, et al. Documentation of the
incidents associated with mandibular distraction: introduction of a
new stratification system. Plast Reconstr Surg. 2009;123:627–634.
323. 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 Relat Res. 1989;239:263–285.
324. Karp NS, McCarthy JG, Schreiber JS, et al. Membranous bone
lengthening: a serial histological study. Ann Plast Surg. 1992;29:2–7.
325. Karaharju-Suvanto T, Karaharju EO, Ranta R. Mandibular
distraction. An experimental study on sheep. J Craniomaxillofac
Surg. 1990;18:280–283.
326. Karaharju EO, Aalto K, Kahri A, et al. Distraction bone healing.
Clin Orthop Relat Res. 1993;297:38–43.
327. Ganey TM, Klotch DW, Slater-Haase AS, Sasse J. Evaluation of
distraction osteogenesis by scanning electron microscopy.
Otolaryngol Head Neck Surg. 1994;111:265–272.
328. Cetrulo CL Jr, Knox KR, Brown DJ, et al. Stem cells and distraction
osteogenesis: endothelial progenitor cells home to the ischemic
generate in activation and consolidation. Plast Reconstr Surg.
2005;116:1053–1064, discussion 1065–1057.
329. Aronson J. The Biology of Distraction Osteogenesis. Philadelphia: JB
Lippincott; 1993.
330. Karp NS, Thorne CH, McCarthy JG, Sissons HA. Bone lengthening
in the craniofacial skeleton. Ann Plast Surg. 1990;24:231–237.
331. McCarthy JG, Staffenberg DA, Wood RJ, et al. Introduction of an
intraoral bone-lengthening device. Plast Reconstr Surg.
1995;96:978–981.
332. Rhee ST, El-Bassiony L, Buchman SR. Extracellular signal-related
kinase and bone morphogenetic protein expression during
distraction osteogenesis of the mandible: in vivo evidence of a

314.e8
CHAPTER 18 • Repair and grafting of bone
mechanotransduction mechanism for differentiation and
osteogenesis by mesenchymal precursor cells. Plast Reconstr Surg.
2006;117:2243–2249.
333. Aronson J, Good B, Stewart C, et al. Preliminary studies of
mineralization during distraction osteogenesis. Clin Orthop Relat
Res. 1990;250:43–49.
334. Luchs JS, Stelnicki EJ, Rowe NM, et al. Molding of the regenerate
in mandibular distraction: part 1: laboratory study. J Craniofac
Surg. 2002;13:205–211.
335. McCarthy JG, Hopper RA, Hollier LH Jr, et al. Molding of the
regenerate in mandibular distraction: clinical experience. Plast
Reconstr Surg. 2003;112:1239–1246.
336. Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Jt Dis
Orthop Inst. 1988;48:1–11.
337. Grundnes O, Reikeras O. The role of hematoma and periosteal
sealing for fracture healing in rats. Acta Orthop Scand.
1993;64:47–49.
338. Komuro Y, Takato T, Harii K, Yonemara Y. The histologic analysis
of distraction osteogenesis of the mandible in rabbits. Plast
Reconstr Surg. 1994;94:152–159.
339. Kojimoto H, Yasui N, Goto T, et al. Bone lengthening in rabbits by
callus distraction. The role of periosteum and endosteum. J Bone
Joint Surg Br. 1988;70:543–549.
340. Aronson J, Shen X. Experimental healing of distraction
osteogenesis comparing metaphyseal with diaphyseal sites. Clin
Orthop Relat Res. 1994;301:25–30.
341. Bab I, Passi-Even L, Gazit D, et al. Osteogenesis in in vivo
diffusion chamber cultures of human marrow cells. Bone Miner.
1988;4:373–386.
342. Hollier LH Jr, Higuera S, Stal S, Taylor TD. Distraction rate and
latency: factors in the outcome of pediatric mandibular distraction.
Plast Reconstr Surg. 2006;117:2333–2336.
343. Slack GC, Fan KL, Tabit C, et al. Necessity of latency period in
craniofacial distraction: investigations with in vitro microdistractor
and clinical outcomes. J Plast Reconstr Aesthet Surg.
2015;68:1206–1214.
344. Ham AW. Some histophysiological problems peculiar to calcified
tissues. J Bone Joint Surg Am. 1952;24A:701–728.
345. Ilizarov GA. Transosseous osteosynthesis. In: Theoretical and
Clinical Aspects of the Regeneration and Growth of Tissue. Berlin:
Springer-Verlag; 1992.
346. Yu JC, Fearon J, Havlik RJ, et al. Distraction osteogenesis of the
craniofacial skeleton. Plast Reconstr Surg. 2004;114:1E–20E.
347. Holmes SB, Lloyd T, Coghlan KM, Newman L. Distraction
osteogenesis of the mandible in the previously irradiated patient. J
Oral Maxillofac Surg. 2002;60:305–309.
348. Raghoebar GM, Jansma J, Vissink A, Roodenburg JL. Distraction
osteogenesis in the irradiated mandible. A case report. J
Craniomaxillofac Surg. 2005;33:246–250.
349. Sawaki Y, Hagino H, Yamamoto H, Ueda M. Trifocal distraction
osteogenesis for segmental mandibular defect: a technical
innovation. J Craniomaxillofac Surg. 1997;25:310–315.
350. Shao Z, Liu B, Liu Y, et al. Distraction osteogenesis in the
irradiated rabbit mandible. J Plast Reconstr Aesthet Surg.
2006;59:181–187.
351. Gantous A, Phillips JH, Catton P, Holmberg D. Distraction
osteogenesis in the irradiated canine mandible. Plast Reconstr Surg.
1994;93:164–168.
352. Muhonen A, Muhonen J, Lindholm TC, et al. Osteodistraction of a
previously irradiated mandible with or without adjunctive
hyperbaric oxygenation: an experimental study in rabbits. Int J
Oral Maxillofac Surg. 2002;31:519–524.
353. Clark CL, Strider J, Hall C, et al. Distraction osteogenesis in
irradiated rabbit mandibles with adjunctive hyperbaric oxygen
therapy. J Oral Maxillofac Surg. 2006;64:589–593.
354. Fregene A, Jing XL, Monson LA, Buchman SR. Alteration in
volumetric bone mineralization density gradation patterns in
mandibular distraction osteogenesis following radiation therapy.
Plast Reconstr Surg. 2009;124:1237–1244.
355. Monsell FP, Barnes JR, Bellemore MC, et al. Cytotoxic agents are
detrimental to bone formed by distraction osteogenesis. Strategies
Trauma Limb Reconstr. 2013;8:173–180.
356. Ehrhart N, Eurell JA, Tommasini M, et al. Effect of cisplatin on
bone transport osteogenesis in dogs. Am J Vet Res.
2002;63:703–711.
357. Barth H. Histologische untersuchungen uber knochen
transplantation. Beitr Pathol Anat Allg Pathol. 1895;17:65–142.
358. Chamay A, Tschantz P. Mechanical influences in bone remodeling.
Experimental research on Wolff’s law. J Biomech. 1972;5:173–180.
359. Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone
grafts in the reconstruction of segmental skeletal defects. J Bone
Joint Surg Am. 1980;62:1039–1058.
360. Claes L, Eckert-Hubner K, Augat P. The effect of mechanical
stability on local vascularization and tissue differentiation in callus
healing. J Orthop Res. 2002;20:1099–1105.
361. Thompson N, Casson JA. Experimental onlay bone grafts to the
jaws. A preliminary study in dogs. Plast Reconstr Surg.
1970;46:341–349.
362. LaTrenta GS, McCarthy JG, Breitbart AS, et al. The role of rigid
skeletal fixation in bone-graft augmentation of the craniofacial
skeleton. Plast Reconstr Surg. 1989;84:578–588.
363. LaTrenta GS, McCarthy JG, Epstein M, et al. Bone graft survival in
expanded skin. Plast Reconstr Surg. 1988;81:406–413.
364. Gray JC, Elves MW. Early osteogenesis in compact bone isografts:
a quantitative study of contributions of the different graft cells.
Calcif Tissue Int. 1979;29:225–237.
365. Heslop BF, Zeiss IM, Nisbet NW. Studies on transference of bone.
I. A comparison of autologous and homologous bone implants
with reference to osteocyte survival, osteogenesis and host
reaction. Br J Exp Pathol. 1960;41:269–287.
366. Williams RG. Comparison of living autogenous and homogenous
grafts of cancellous bone heterotopically placed in rabbits. Anat
Rec. 1962;143:93–105.
367. Burwell RG. Studies in the transplantation of bone. VII. The fresh
composite homograft-autograft of cancellous bone; an analysis of
factors leading to osteogenesis in marrow transplants and in
marrow-containing bone grafts. J Bone Joint Surg Br.
1964;46:110–140.
368. Finkemeier CG. Bone-grafting and bone-graft substitutes. J Bone
Joint Surg Am. 2002;84-A:454–464.
369. DeLacure MD. Physiology of bone healing and bone grafts.
Otolaryngol Clin North Am. 1994;27:859–874.
370. Burchardt H. The biology of bone graft repair. Clin Orthop Relat
Res. 1983;174:28–42.
371. Burchardt H. Biology of bone transplantation. Orthop Clin North
Am. 1987;18:187–196.
372. Tessier P, Kawamoto H, Matthews D, et al. Autogenous bone
grafts and bone substitutes–tools and techniques: I. A 20,000-case
experience in maxillofacial and craniofacial surgery. Plast Reconstr
Surg. 2005;116:6S–24S, discussion 92S–94S.
373. Bassett CA. Clinical implications of cell function in bone grafting.
Clin Orthop Relat Res. 1972;87:49–59.
374. Akahane M, Ono H, Ohgushi H, Takakura Y. Viability of
ischemia/reperfused bone determined at the gene expression
level. J Reconstr Microsurg. 2001;17:203–209.
375. Berggren A, Weiland AJ, Dorfman H. The effect of prolonged
ischemia time on osteocyte and osteoblast survival in composite
bone grafts revascularized by microvascular anastomoses. Plast
Reconstr Surg. 1982;69:290–298.
376. Kurz LT, Garfin SR, Booth RE Jr. Harvesting autogenous iliac bone
grafts. A review of complications and techniques. Spine.
1989;14:1324–1331.
377. Tessier P, Kawamoto H, Matthews D, et al. Taking bone grafts
from the anterior and posterior ilium–tools and techniques: II. A
6800-case experience in maxillofacial and craniofacial surgery. Plast
Reconstr Surg. 2005;116:25S–37S, discussion 92S–94S.
378. Jager M, Westhoff B, Wild A. Knochenspanentnahme am Becken.
Techniken und Probleme. Orthopäde. 2005;34:976–994.

314.e9
References
379. Johanson B, Ohlsson A. Bone grafting and dental orthopaedics in
primary and secondary cases of cleft lip and palate. Acta Chir
Scand. 1961;122:112–124.
380. Hughes CW, Revington PJ. The proximal tibia donor site in cleft
alveolar bone grafting: experience of 75 consecutive cases. J
Craniomaxillofac Surg. 2002;30:12–16, discussion 17.
381. Tessier P, Kawamoto H, Matthews D, et al. Taking tibial grafts in
the diaphysis and upper epiphysis–tools and techniques: IV. A
650-case experience in maxillofacial and craniofacial surgery. Plast
Reconstr Surg. 2005;116:47S–53S, discussion 92S-94S.
382. Tessier P, Kawamoto H, Matthews D, et al. Taking long rib grafts
for facial reconstruction–tools and techniques: III. A 2900-case
experience in maxillofacial and craniofacial surgery. Plast Reconstr
Surg. 2005;116:38S–46S, discussion 92S–94S.
383. Zins JE, Whitaker LA. Membranous versus endochondral bone:
implications for craniofacial reconstruction. Plast Reconstr Surg.
1983;72:778–785.
384. Marx RE. Clinical application of bone biology to mandibular and
maxillary reconstruction. Clin Plast Surg. 1994;21:377–392.
385. McCarthy JG, Zide BM. The spectrum of calvarial bone grafting:
introduction of the vascularized calvarial bone flap. Plast Reconstr
Surg. 1984;74:10–18.
386. Tessier P, Kawamoto H, Posnick J, et al. Taking calvarial grafts,
either split in situ or splitting of the parietal bone flap ex vivo–
tools and techniques: V. A 9650-case experience in craniofacial and
maxillofacial surgery. Plast Reconstr Surg. 2005;116:54S–71S,
discussion 92S–94S.
387. Berggren A, Weiland AJ, Dorfman H. Free vascularized bone
grafts: factors affecting their survival and ability to heal to
recipient bone defects. Plast Reconstr Surg. 1982;69:19–29.
388. Arai K, Toh S, Harata S. Experimental study on vascularized
island pedicle bone graft: bony fusion between the graft and the
recipient floor. Microsurgery. 1999;19:239–246.
389. Ostrup LT, Fredrickson JM. Distant transfer of a free, living bone
graft by microvascular anastomoses. An experimental study. Plast
Reconstr Surg. 1974;54:274–285.
390. Buncke HJ, Furnas DW, Gordon L, Achauer BM. Free
osteocutaneous flap from a rib to the tibia. Plast Reconstr Surg.
1977;59:799–804.
391. Cutting CB, McCarthy JG. Comparison of residual osseous mass
between vascularized and nonvascularized onlay bone transfers.
Plast Reconstr Surg. 1983;72:672–675.
392. Davis PK, Mazur JM, Coleman GN. A torsional strength
comparison of vascularized and nonvascularized bone grafts. J
Biomech. 1982;15:875–880.
393. Moore JB, Mazur JM, Zehr D, et al. A biomechanical comparison
of vascularized and conventional autogenous bone grafts. Plast
Reconstr Surg. 1984;73:382–386.
394. Weiland AJ, Phillips TW, Randolph MA. Bone grafts: a radiologic,
histologic, and biomechanical model comparing autografts,
allografts, and free vascularized bone grafts. Plast Reconstr Surg.
1984;74:368–379.
395. Nettelblad H, Randolph MA, Weiland AJ. Free microvascular
epiphyseal-plate transplantation. An experimental study in dogs. J
Bone Joint Surg Am. 1984;66:1421–1430.
396. Bowen V. Experimental free vascularized epiphyseal transplants.
Orthopedics. 1986;9:893–898.
397. Brown K, Marie P, Lyszakowski T, et al. Epiphysial growth after
free fibular transfer with and without microvascular anastomosis.
Experimental study in the dog. J Bone Joint Surg Br.
1983;65:493–501.
398. Donski PK, O’Brien BM. Free microvascular epiphyseal
transplantation: an experimental study in dogs. Br J Plast Surg.
1980;33:169–178.
399. Tsai TM, Ludwig L, Tonkin M. Vascularized fibular epiphyseal
transfer. A clinical study. Clin Orthop Relat Res. 1986;210:228–234.
400. Yoshizaki K. [Experimental study of vascularized fibular grafting
including the epiphyseal growth plate–autogenous orthotopic
grafting]. Nihon Seikeigeka Gakkai Zasshi. 1984;58:813–828.
401. Moran CG, Wood MB. Vascularized bone autografts. Orthop Rev.
1993;22:187–197.
402. Mathoulin C, Gilbert A, Azze RG. Congenital pseudarthrosis of
the forearm: treatment of six cases with vascularized fibular graft
and a review of the literature. Microsurgery. 1993;14:252–259.
403. Evans HB, Brown S, Hurst LN. The effects of early postoperative
radiation on vascularized bone grafts. Ann Plast Surg.
1991;26:505–510.
404. Weiland AJ, Moore JR, Daniel RK. Vascularized bone autografts.
Experience with 41 cases. Clin Orthop Relat Res. 1983;174:87–95.
405. Taylor GI, Townsend P, Corlett R. Superiority of the deep
circumflex iliac vessels as the supply for free groin flaps. Plast
Reconstr Surg. 1979;64:595–604.
406. Taylor GI, Townsend P, Corlett R. Superiority of the deep
circumflex iliac vessels as the supply for free groin flaps. Clinical
work. Plast Reconstr Surg. 1979;64:745–759.
407. Koshima I, Fukuda H, Soeda S. Free combined anterolateral thigh
flap and vascularized iliac bone graft with double vascular
pedicle. J Reconstr Microsurg. 1989;5:55–61.
408. Dorafshar AH, Seitz IA, DeWolfe M, et al. Split lateral iliac crest
chimera flap: utility of the ascending branch of the lateral femoral
circumflex vessels. Plast Reconstr Surg. 2010;125:574–581.
409. Chen ZW, Yan W. The study and clinical application of the
osteocutaneous flap of fibula. Microsurgery. 1983;4:11–16.
410. Arai K, Toh S, Tsubo K, et al. Complications of vascularized fibula
graft for reconstruction of long bones. Plast Reconstr Surg.
2002;109:2301–2306.
411. Friedrich JB, Moran SL, Bishop AT, et al. Free vascularized fibular
graft salvage of complications of long-bone allograft after tumor
reconstruction. J Bone Joint Surg Am. 2008;90:93–100.
412. Erdmann D, Garcia RM, Blueschke G, et al. Vascularized fibula-
based physis transfer for pediatric proximal humerus
reconstruction. Plast Reconstr Surg. 2013;132:281e–287e.
413. Fong AJ, Lemelman BT, Lam S, et al. Reconstructive approach to
hostile cranioplasty: a review of the University of Chicago
experience. J Plast Reconstr Aesthet Surg. 2015;68:1036–1043.
414. Lee JC, Kleiber GM, Pelletier AT, et al. Autologous immediate
cranioplasty with vascularized bone in high-risk composite cranial
defects. Plast Reconstr Surg. 2013;132:967–975.
415. Thoma A, Archibald S, Payk I, Young JE. The free medial scapular
osteofasciocutaneous flap for head and neck reconstruction. Br J
Plast Surg. 1991;44:477–482.
416. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous
scapular flap for mandibular and maxillary reconstruction. Plast
Reconstr Surg. 1986;77:530–545.
417. Teot L, Bosse JP, Moufarrege R. The scapular crest pedicled bone
graft. Int J Microsurg. 1981;3:257–263.
418. Deraemaecker R, Thienen CV, Lejour M. The serratus anterior-
scapular free flap: a new osteomuscular unit for reconstruction after head
and neck surgery. Paper presented at: Second International
Conference on Head and Neck Cancer. 1988; Boston, MA.
419. Wagner AJ, Bayles SW. The angular branch: maximizing the
scapular pedicle in head and neck reconstruction. Arch Otolaryngol
Head Neck Surg. 2008;134:1214–1217.
420. Urken ML, Bridger AG, Zur KB, Genden EM. The scapular
osteofasciocutaneous flap: a 12-year experience. Arch Otolaryngol
Head Neck Surg. 2001;127:862–869.
421. Papanastasiou VW, Lalonde DH, Williams HB. The vascular
pattern and viability of microvascularized rib grafts based on
periosteal circulation–an experimental study. Ann Plast Surg.
1984;13:375–382.
422. Schmidt DR, Robson MC. One-stage composite reconstruction
using the latissimus myoosteocutaneous free flap. Am J Surg.
1982;144:470–472.
423. Seitz IA, Adler N, Odessey E, et al. Latissimus dorsi/rib intercostal
perforator myo-osseocutaneous free flap reconstruction in
composite defects of the scalp: case series and review of literature.
J Reconstr Microsurg. 2009;25:559–567.

314.e10
CHAPTER 18 • Repair and grafting of bone
424. Davison SP, Mesbahi AN, Clemens MW, Picken CA. Vascularized
calvarial bone flaps and midface reconstruction. Plast Reconstr
Surg. 2008;122:10e–18e.
425. Wong TY, Chung CH, Huang JS, Chen HA. The inverted
temporalis muscle flap for intraoral reconstruction: its rationale
and the results of its application. J Oral Maxillofac Surg.
2004;62:667–675.
426. Habal MB. Bone grafting in craniofacial surgery. Clin Plast Surg.
1994;21:349–363.
427. Seitz IA, Gottlieb LJ. Reconstruction of scalp and forehead defects.
Clin Plast Surg. 2009;36:355–377.
428. Spin-Neto R, Stavropoulos A, Coletti FL, et al. Graft incorporation
and implant osseointegration following the use of autologous and
fresh-frozen allogeneic block bone grafts for lateral ridge
augmentation. Clin Oral Implants Res. 2014;25:226–233.
429. Fernandez-Bances I, Perez-Basterrechea M, Perez-Lopez S, et al.
Repair of long-bone pseudoarthrosis with autologous bone
marrow mononuclear cells combined with allogenic bone graft.
Cytotherapy. 2013;15:571–577.
430. Stevenson S. Biology of bone grafts. Orthop Clin North Am.
1999;30:543–552.
431. Kang JS, Kim NH. The biomechanical properties of deep freezing
and freeze drying bones and their biomechanical changes after
in-vivo allograft. Yonsei Med J. 1995;36:332–335.
432. Food and Drug Administration CfBEaR. Screening and testing of
donors of human tissue intended for transplantation. In: Services
UDoHaH, ed. Washington, DC; 1997.
433. Buck BE, Malinin TI, Brown MD. Bone transplantation and human
immunodeficiency virus. An estimate of risk of acquired
immunodeficiency syndrome (AIDS). Clin Orthop Relat Res.
1989;240:129–136.
434. Elves MW, Ford CHJ. A study of the humoral immune response to
massive osteoarticular allografts in sheep. Clin Exp Immunol.
1976;23:360–366.
435. Gornet MF, Randolph MA, Schofield BH, et al. Immunologic and
ultrastructural changes during early rejection of vascularized bone
allografts. Plast Reconstr Surg. 1991;88:860–868.
436. Urist MR, Iwata H, Ceccotti PL, et al. Bone morphogenesis in
implants of insoluble bone gelatin. Proc Natl Acad Sci USA.
1973;70:3511–3515.
437. Urist MR, Dawson E. Intertransverse process fusion with the aid
of chemosterilized autolyzed antigen-extracted allogeneic (AAA)
bone. Clin Orthop Relat Res. 1981;154:97–113.
438. Dahners LE, Jacobs RR. Long bone defects treated with
demineralized bone. South Med J. 1985;78:933–934.
439. Salama R. Xenogeneic bone grafting in humans. Clin Orthop Relat
Res. 1983;174:113–121.
440. Sanan A, Haines SJ. Repairing holes in the head: a history of
cranioplasty. Neurosurgery. 1997;40:588–603.
441. Bose S, Tarafder S. Calcium phosphate ceramic systems in growth
factor and drug delivery for bone tissue engineering: a review.
Acta Biomater. 2012;8:1401–1421.
442. Teven CM, Fisher S, Ameer GA, et al. Biomimetic approaches to
complex craniofacial defects. Ann Maxillofac Surg. 2015;5(1):4–13.
443. Brown W, Chow L. A New Calcium Phosphate, Water-Setting Cement.
Westerville: American Ceramic Society; 1986.
444. Fukase Y, Eanes ED, Takagi S, Chow LC, Brown WE. Setting
reactions and compressive strengths of calcium phosphate
cements. J Dent Res. 1990;69:1852–1856.
445. Burstein FD, Cohen SR, Hudgins R, et al. The use of
hydroxyapatite cement in secondary craniofacial reconstruction.
Plast Reconstr Surg. 1999;104:1270–1275.
446. Friedman CD, Costantino PD, Takagi S, Chow LC. BoneSource
hydroxyapatite cement: a novel biomaterial for craniofacial
skeletal tissue engineering and reconstruction. J Biomed Mater Res.
1998;43:428–432.
447. Baker SB, Weinzweig J, Kirschner RE, Bartlett SP. Applications of a
new carbonated calcium phosphate bone cement: early experience
in pediatric and adult craniofacial reconstruction. Plast Reconstr
Surg. 2002;109:1789–1796.
448. Rohl L, Larsen E, Linde F, et al. Tensile and compressive properties
of cancellous bone. J Biomech. 1991;24:1143–1149.
449. Gilardino MS, Cabiling DS, Bartlett SP. Long-term follow-up
experience with carbonated calcium phosphate cement (Norian)
for cranioplasty in children and adults. Plast Reconstr Surg.
2009;123:983–994.
450. Kirschner RE, Karmacharya J, Ong G, et al. Repair of the immature
craniofacial skeleton with a calcium phosphate cement:
quantitative assessment of craniofacial growth. Ann Plast Surg.
2002;49:33–38, discussion 38.
451. Urist MR, Strates BS. Bone formation in implants of partially and
wholly demineralized bone matrix. Including observations on
acetone-fixed intra and extracellular proteins. Clin Orthop Relat Res.
1970;71:271–278.
452. Reddi AH, Huggins CB. Formation of bone marrow in fibroblast-
transformation ossicles. Proc Natl Acad Sci USA. 1975;72:2212–2216.
453. Acarturk TO, Hollinger JO. Commercially available demineralized
bone matrix compositions to regenerate calvarial critical-sized
bone defects. Plast Reconstr Surg. 2006;118:862–873.
454. Gruskin E, Doll BA, Futrell FW, et al. Demineralized bone matrix
in bone repair: history and use. Adv Drug Deliv Rev.
2012;64:1063–1077.
455. Eppley BL. Alloplastic implantation. Plast Reconstr Surg.
1999;104:1761–1783, quiz 1784–1765.
456. Mason JM, Grande DA, Barcia M, et al. Expression of human bone
morphogenic protein 7 in primary rabbit periosteal cells: potential
utility in gene therapy for osteochondral repair. Gene Ther.
1998;5:1098–1104.
457. Ousterhout DK, Stelnicki EJ. Plastic surgery’s plastics. Clin Plast
Surg. 1996;23:183–190.
458. Ripamonti U, Petit JC, Moehl T, et al. Immediate reconstruction of
massive cranio-orbito-facial defects with allogeneic and alloplastic
matrices in baboons. J Craniomaxillofac Surg. 1993;21:302–308.
459. Eppley BL, Kilgo M, Coleman JJ 3rd. Cranial reconstruction with
computer-generated hard-tissue replacement patient-matched
implants: indications, surgical technique, and long-term follow-up.
Plast Reconstr Surg. 2002;109:864–871.
460. Echo A, Wolfswinkel EM, Weathers W, et al. Use of a three-
dimensional model to optimize a MEDPOR implant for delayed
reconstruction of a suprastructure maxillectomy defect.
Craniomaxillofac Trauma Reconstr. 2013;6:275–280.
461. Zaky SH, Hangadora CK, Tudares MA, et al. Poly (glycerol
sebacate) elastomer supports osteogenic phenotype for bone
engineering applications. Biomed Mater. 2014;9:025003.

19 
Repair and grafting of peripheral nerve
Kirsty Usher Boyd, Renata V. Weber, Andrew Yee, and Susan E. Mackinnon
SYNOPSIS
■ Primary neurorrhapy remains the gold standard in nerve repair; all
other methods of repair are judged in comparison to primary
neurorrhaphy.
■ Following any mechanism of repair, nerve regrowth occurs at a
maximum of 1 mm/day, making distance from end-target muscle the
most important prognosticator for recovery.
■ Excessive tension will inhibit nerve regeneration, however a small
amount of tension to achieve primary coaptation is acceptable.
■ In the event of a nerve gap, several options for repair exist including:
• Mobilization and primary coaptation
• Interpositional nerve autografting
• Interpositional nerve allograft (acellular or fresh cadaveric)
• Interpositional nerve conduit
• Distal nerve transfer.
■ Prognosis following nerve injury is impacted by several factors:
• Patient age and comorbidities
• Location of injury (proximal versus distal peripheral nerve)
• Mechanism of injury (crush versus avulsion versus transection)
• Timing of repair
• Method of repair (tension, alignment, scarring).
Introduction
Nerve injuries present a unique problem in patient manage­
ment due to the prolonged periods of recovery and the neces­
sity of having viable axons reach the end-motor target prior
to irreversible atrophy and fibrosis. These patients suffer sig­
nificant negative impacts including chronic pain, depression,
and considerable effect on daily life.1 In the setting of progno­
sis, time is muscle, with permanent muscle damage occurring
as early as one year after denervation. While primary nerve
repair and grafting have not changed significantly in the last
several decades, there have been several paradigm shifts as
understanding of the internal neural topography has improved
and new techniques and products have become available. The
gold standard in nerve repair remains primary neurorrhaphy,
however in the situation of a nerve gap, other alternatives are
necessary to avoid excessive tension, which causes permanent
scarring at the repair site. Autologous nerve grafting has been
the procedure of choice for addressing a nerve gap, however
donor sites are limited and leave deficits. While nerve auto­
grafts are considered the “gold standard” for a nerve gap
reconstruction, it should actually be considered a “bronze
standard” as results are never normal. Other alternatives
include acellular nerve allografts, conduits, and nerve trans­
fers. This chapter reviews the various methods of addressing
a nerve injury, with emphasis on surgical decision-making,
timing, and prognosis.
Access the Historical Perspective section online at

Basic science/disease process
Types of nerve injury
As seen in Table 19.1, nerve injuries can be classified based on
their degree of damage and the components of the nerve that
have been affected. While this method of classification is useful
for prognosis and surgical decision-making, the mechanism of
injury also provides a useful method of classification that
allows for an algorithmic approach to treatment. Nerve injuries
can therefore be classified as either open or closed, and then
subdivided by mechanism of injury as penetrating injuries,
avulsion or crush injuries, or stretch and avulsion injuries.
Penetrating injuries
Penetrating trauma can be a result of sharp or blunt penetra­
tion and will often have concomitant injuries to adjacent
structures such as blood vessel, tendon, and muscle. A sharp
  Access video lecture content for this chapter online at expertconsult.com

315.e1
Historical perspective
Historical perspective
The history of nerve injury
A peripheral nerve can be classified in several ways. Histori­
cally, the first classification system by Sir Herbert Seddon
(1943) was based on gross and histologic anatomical changes
rather than mechanism of injury.2 He described three types of
nerve injuries:
1. Neurapraxia: involves a local conduction block at a
discrete area along the course of a nerve.
2. Axonotmesis: implies direct axonal damage.
3. Neurotmesis: implies transection of the peripheral
nerve.
In neurapraxic injuries, Wallerian degeneration does not occur
and the prognosis is excellent with anticipated recovery of full
strength and function. In both axonotmetic and neurotmetic
injuries, Wallerian degeneration occurs distal to the site of
injury. Recovery is possible within an axonotmetic injury, but
Seddon described a degree of scarring and less complete
recovery within this type of nerve injury. In neurotmesis, there
will be no recovery. Sunderland expanded upon the earlier
Seddon classification and emphasized five degrees of nerve
injury.3 Mackinnon later went on to include a sixth degree (see
Table 19.1).4,5 Understanding the degree of injury is helpful to
predict recovery. It is anticipated that a first-degree neura­
praxic injury will make a full and speedy recovery. Second-
degree axonotmetic injuries will make a full recovery at the
classic rate of 1–1.5 mm/day.6 Fourth-degree axonotmetic
injuries, also known as a neuroma-in-continuity, and fifth-
degree neurotmetic injuries do not recover. Third-degree
axonotmetic and sixth-degree (multi-level) injuries recover
partially for different reasons. The difficulty with surgical
correction of a sixth-degree injury is limiting the repair to
fascicles affected by fourth- and fifth-degree damage, and not
damaging adjacent fascicles with potential for spontaneous
recovery.
The history of nerve grafts
Current practices that account for the success of nerve grafts
include the use of small, thin grafts that are cabled when
necessary. Historically, when nerve trunks were used as grafts,
poor results ensued.7 Small, thin grafts revascularize more
easily than larger nerves and this contributes to the success
of functional outcomes. The maximum length that may be
bridged by a nerve graft is controversial. In general, results
fall off and are less predictable at lengths greater than 6 cm.
However, 20 cm and longer nerve grafts have been used with
varying degrees of success.8,9 Taylor and Ham introduced free
vascularized nerve grafts in 1976 in order to treat these longer
gaps.10 For smaller defects, a vascularized graft and conven­
tional graft do not appear to differ in clinical outcome,
however Doi et al. recommend using free vascularized nerve
grafts when the gap distance is greater than 6 cm with associ­
ated soft-tissue loss over the repaired area.11 Currently, the
indication for a free vascularized nerve graft is for reconstruc­
tion larger-diameter nerve grafts, such as the ulnar nerve, in
brachial plexus avulsion injury.11–13
The history of conduits
Biological conduits, including bone, artery, collagen, vein,
muscle, and small-intestine submucosa have been used.14–17
Biodegradable synthetic conduits such as polyglycolic acid
are currently used, while nondegradable nerve guides made
from silicone have fallen out of favor.18 Their major disadvan­
tage is leaving foreign material that potentially causes a
chronic reaction with excessive scarring.

316
CHAPTER 19 • Repair and grafting of peripheral nerve
laceration, such as from a knife or a piece of glass, will almost
always necessitate exploration if a nerve deficit is present on
initial clinical examination. The likelihood that the nerve is
partially or completely transected is high. These injuries
should be explored within 72 hours if distal stimulation using
an intraoperative nerve stimulator is needed. In addition, the
further from the time of injury, the more difficult mobilization
of the proximal and distal ends to coapt primarily becomes.
In the event of a penetrating trauma associated with a vascular
injury, immediate exploration is warranted. Unfortunately, in
significant proximal injuries necessitating arterial reconstruc­
tion with or without underlying fractures, a nerve injury can
be overlooked due to the more urgent vascular and orthopedic
injuries. In these situations, when a nerve deficit is noticed
postoperatively, it is unclear if the nerve injury is from the
inciting event, iatrogenic during the repair of the other inju­
ries, or secondary to edema or hematoma. While a computed
tomography scan or magnetic resonance imaging may be
helpful to evaluate for the latter, internal scarring of the nerve
may not always be clearly determined.
Blunt penetrating and blast injuries, such as gunshot
wounds or injuries due to an incendiary device, are often
managed conservatively similar to closed crush and traction
injuries. There is potential for spontaneous recovery. Local
tissue edema often causes a neurapraxia, which should
resolve within 12 weeks. If recovery is not evident on serial
clinical examination and electrodiagnostic studies by four
months, the algorithm for a crush injury should be followed
(Fig. 19.1).
Crush injuries
Crush injuries are common peripheral nerve injuries to the
upper extremity. External crush may be complicated by
increased internal pressure from hematomas, fractures, and
local tissue edema. When minor, this may cause a temporary
neurapraxia, but with greater compression, the likelihood of
a permanent injury increases. The most severe consequence
of a soft tissue crush injury is the progression to compartment
syndrome, which is a surgical emergency. Often an early sign
of impending compartment syndrome is a decrease in vibra­
tion sensibility.19
While nerves are fairly resistant to injury given their elas­
ticity, a mixed nerve injury can often occur. A more extensive
crush injury can cause local tissue damage that contributes
more to the loss of function than the original nerve injury.
Muscle tissue is the most susceptible to external forces. Even
if the injury is not significant enough to cause a compartment
syndrome, the local destruction of muscle may lead to muscle
necrosis. Tendon and skin are more resistant and can
Hints and tips
Sharp penetrating injuries with an acute nerve deficit should
be explored early (within 72 hours) if stimulation of the distal
end is needed to perform a primary neurorrhaphy. Crush and
traction injuries should be treated conservatively with serial
examination and electrodiagnostic studies at regular intervals
based on expected recovery.
withstand higher compressive forces before irreversible
damage to the cells results.
The nerve portion of a crush injury is usually treated
conservatively. Exploration is warranted if nerve recovery
does not follow the anticipated pattern of recovery based
on distance from injury to end-target muscle. Along with
avulsion injuries, the treatment algorithm for a crush
injury involves serial clinical examination and electrodi­
agnostic studies as dictated by the anticipated recovery
(Fig. 19.2).
Stretch and avulsion injuries
When the strain on the nerve exceeds a certain limit, the
internal structure of the nerve becomes injured without any
appreciable external evidence of injury. Nerves that are
stretched to the point of avulsing from their proximal origin
suggest a high-velocity, or high-impact, injury that is often
associated with limb or life-threatening injuries that take
precedence over the repair of the nerve. The nerves tend to
be avulsed around areas of tethering, such as bony foramina
or the spinal cord. If the proximal nerve can be accessed,
grafting of the nerve may be possible. For areas such as the
cranial nerves or the spinal roots, where the portion proxi­
mal to the avulsion is not accessible, reconstruction is
typically done by either nerve or tendon transfers.20 The
algorithm for treatment of these injuries involves focusing
first on the nerve injury, with repair or reconstruction dic­
tated by degree of injury, followed by procedures to augment
recovery such as tendon transfers and joint arthrodesis
(see Fig. 19.2).21
In situations where no distal nerve is accessible, such as
avulsions from the neuromuscular junction, implantation of
the proximal nerve directly into the muscle to neurotize the
muscle is an alternative. Some studies show as good as MRC
4/5 motor recovery 1–2 years after direct nerve to muscle
neurotization, however experimental studies do not support
these findings; rather, recovery is much less than a nerve
coaptation would produce.22,23
Table 19.1  Classification of nerve injury
Seddon
Sunderland
Injury
Recovery
Neurapraxia
Degree I
Conduction block resolves spontaneously
Fast/excellent
Axonotmesis
Degree II
Axonal rupture without interruption of the basal lamina tubes
Slow/excellent
Degree III
Rupture of both axons and basal lamina tubes, some scar
Slow/incomplete
Degree IV
Complete scar block
None
Neurotmesis
Degree V
Complete transection
None
Degree VI (Mackinnon)
Combination of degree I–IV ± normal fascicles
Mixed

317
Diagnosis/patient presentation
The quick and easy “ten test” uses the patient’s own subjec­
tive perception to moving light touch to elicit differences
in sensation, using the contralateral digit as a reference point.24
This technique is particularly useful in young children, who
may have difficulty cooperating with two-point discrimina­
tion, or with rapid assessment of a patient being rushed to the
operating room for an associated vascular injury.
Motor deficits are recognized by focused examination of
all muscle groups in the upper extremity, with patterns
Diagnosis/patient presentation
A thorough history and physical examination remain the
mainstay of diagnosis for a peripheral nerve deficit. A com­
ponent of experience in recognizing common patterns of
nerve injury can facilitate this.
Sensation can be tested using Semmes–Weinstein filaments,
two-point static and moving discrimination, or the “ten test”.
Fig. 19.1  Algorithm for penetrating injury and lacerations.
Vascular compromise
Nerve injury
Yes
No
Yes
No
Immediate
exploration
Can it be primarily
repaired?
No nerve
intervention
Yes
No
Primary
repair
Nerve graft
+/- nerve transfer
Yes
No
Electrodiagnostic
studies at 3–4 weeks
No nerve
intervention
Studies confirm
nerve injury
Yes
No
Recovery evident
with time to reach
target by 12 months
Reassess
as required
Yes
No
No nerve
intervention
Plan for surgical
intervention
Yes
No
Primary repair
Nerve graft
Neuroma excised
Primary repair?
Yes
No
Explore nerve
within 72 hours
Serial clinical
examination
Neurologic
deficit identified?
Acute neurologic
deficit?

318
CHAPTER 19 • Repair and grafting of peripheral nerve
of weakness or inactivity being used to diagnose the involved
peripheral nerve.
In patients with an acute deficit, determination of whether
the nerve will recover spontaneously, or whether surgical
intervention is required, can often be difficult. The mechanism
of injury can assist in preoperative evaluation. Any sharp,
penetrating injury should be explored within 72 hours. Simi­
larly, any injury where there is a high index of suspicion
for nerve transection should be explored and repaired. The
Fig. 19.2  Algorithm for closed traction injury, stretch injury, or
avulsion injury.
Yes
No
Acute
decompression
Evidence of
neurologic deficit?
Yes
No
Serial clinical
examination
Improvement by
3–4 weeks?
No nerve
intervention
Yes
No
No nerve
intervention
Yes
No
Yes
No
Electrodiagnostic
studies
Motor unit potentials
Yes
Full recovery?
MUPs
No
Serial clinical
examination
Repeat electrodiagnostic
studies in 2 months
Compartment syndrome or
vascular compromise?
No nerve
intervention
MUP = Motor unit potentials
Consider
decompression/
neurolysis
Yes
No
Full recovery?
No nerve
intervention
Consider
decompression/neurolysis
Serial clinical
examination
Plan for surgical
intervention (grafting
or nerve transfer)
advantage to early repair, and specifically repair within two
weeks, is that the proximal and distal nerve ends have not
retracted and primary neurorrhaphy is often possible. Closed
traction injuries, partial avulsion injuries, and crush injuries
with an associated nerve palsy are more difficult to evaluate.
Waiting 3 to 4 months with serial clinical and electrodiagnostic
examination is advocated.
The electrodiagnostic signs of an axonotmetic injury,
particularly fibrillations and positive sharp waves, may not

319
Treatment/surgical repair
be present for at least three weeks from the time of injury,
once Wallerian degeneration has occurred. For this reason,
electrodiagnostic studies at the time of injury are not recom­
mended except to document any pre-injury pathology. Regular
electrodiagnostic testing, and specifically electromyography,
is advocated due to the fact that EMG changes precede clinical
recovery by months. In closed injuries, if there is no evidence
of recovery in the form of motor unit potentials (MUPs) by
3 to 4 months, surgical exploration and reconstruction are
warranted. The presence of MUPs by three months suggests
at worst a third-grade injury, which should recover spontane­
ously at the rate of 1 mm/day.
The role of imaging in the clinical investigation of nerve
injuries is more controversial. New ultrasound machines have
the resolution to detect digital nerve neuromas, however
these studies are still largely investigational and are highly
operator-dependent. There is some early evidence that ultra­
sound is more sensitive (93%) than MRI (67%) with similar
specificity (86%), however this is more typically in the setting
of nerve pathology.25
Hints and tips
Clinical evaluation at the earliest opportunity, followed by serial
clinical examination and electrodiagnostic studies, are critical
in the diagnosis and assessment of a nerve deficit.
Recognizing patterns of recovery or the lack thereof can
facilitate decision-making regarding timing an operative
intervention.
the correct end-target.27 Recent studies also show that
Schwann cell senescence occurs as graft length increases.
In the event that a primary repair is not possible, mobiliza­
tion of the proximal and/or distal nerve ends may overcome
a small, less than 5 mm, gap because of the elastic property of
the nerve.28 If, however, a repair is performed in the face of
tension and contamination, unfavorable scarring will occur. In
this situation, two neurorrhaphy sites are preferable to a single
neurorrhaphy under unfavorable conditions.29,30 If primary
repair by mobilization cannot be achieved, there are several
techniques to address the resultant nerve gap (Table 19.2).31,32
Conduits
The use of conduits to bridge major nerve gaps has been
described, but has largely fallen out of favor. For non-critical,
small diameter, sensory deficits less than 3 cm, conduits may
serve as a potential option. Biological and synthetic conduits
are available. Using this method, protective sensation, and in
some cases good sensation, have been restored.33 When using
a conduit, placing a small portion of the proximal nerve into
the conduit to serve as a source of Schwann cells is recom­
mended.34 More often, the conduits are now used as nerve
wraps for protection of a primary neurorrhaphy, however this
can be cost prohibitive. Seprafilm® adhesion barrier (Genzyme,
Cambridge, MA) has been used by the authors placing a small
piece above and/or below the repair.
Nerve grafting
Autologous nerve grafting
The most common technique for addressing a nerve graft is
interpositional nerve grafting. Autologous nerve grafts are the
gold standard or better termed bronze standard. The nerve
graft serves as a guide for the axon as it regrows towards the
distal stump (Fig. 19.3). Although the sural nerve is most
commonly used as a donor nerve, our algorithm for selecting
autograft donors has evolved away from this donor (Table
19.3).32,35–37 Wherever possible, donor nerves within the
affected extremity and available through the same surgical
incision are selected.38 Experimental studies comparing motor,
mixed, and sensory grafts support the idea that motor and
mixed nerve grafts achieve better regeneration across the
repair.39,40 Donor motor nerve grafts, however, are in more
limited supply, and in clinical practice, the branch from the
obturator to the gracilis and the distal anterior interosseous
nerve are the two motor grafts that cause the least morbidity.
The obvious downsides of autologous grafting are the limited
number of donor nerves available and the resulting donor site
morbidity.
Acellular nerve graft
Acellular human processed nerve allografts (ANA) have
been introduced as a method for spanning the nerve gap.
Initial clinical trials show that recovery for small sensory
gaps is better than that for conduits and more comparable to
autografts.41 This human tissue retains its three-dimensional
structure, including epineurium, fascicles, endoneural tubes
and laminin, and it is believed that the scaffold allows for
repopulation of the host cells, similar to autologous tissue
(Fig. 19.4).
Patient selection
Nerve injuries often occur in the setting of concomitant inju­
ries and sometimes multi-organ system trauma. Unlike in the
elective surgical patient, there is little ability to select an ideal
patient.
The importance of recognizing the impact of concomitant
injuries cannot be overstated. Patients should be stabilized,
with repair of life-threatening injuries (such as vascular lac­
eration) taking priority. Bony fixation and fracture immobili­
zation generally precede nerve repair, as the possibility of
iatrogenic injury to the microscopic nerve repair is high.
Wherever possible, nerve repair should be performed
during daytime hours, with proper operating equipment and
well-versed operating staff. An operating microscope and
loupe magnification should be used to explore and identify
cut nerve ends. Experienced surgeons will facilitate surgical
decision-making based on method and level of injury.
Treatment/surgical repair
Prompt, tension-free, primary neurorrhaphy is universally
held as the ideal repair, and multiple animal studies support
the idea that single nerve repair results in a better outcome
over a nerve graft.26 With each repair site, a percentage of
fibers are lost, therefore fewer neurorrhaphies ensures a
greater percentage of proximal nerve axons reaching the
target endplates. Some investigators believe that as many as
50% of regenerating sensory or motor axons may never reach

320
CHAPTER 19 • Repair and grafting of peripheral nerve
Table 19.2  Options for management of the nerve gap
Advantages
Disadvantages
Nerve autograft
Gold standard for reconstruction
Schwann cells in extracellular matrix
Second operative site
Results in donor sensory loss
Potential for neuroma formation/pain
Sensory nerve autografts do not support motor regeneration
as well as motor or mixed sensorimotor nerves
Limited available length
Allograft
Can potentially allow functional recovery
equivalent to autograft
No donor site morbidity
Requires patient systemic immunosuppression (~18 months)
Patients vulnerable to opportunistic infections
Conduits
Circumvents adverse effects of autografts
and allografts
Guides regenerating nerve to intended target
Length limitation (<3 cm)
Only for small-diameter sensory nerves
No Schwann cells
No matrix
Expensive
Acellularized graft
Retains scaffolding matrix of nerve tissue
Nonimmunogenic and inert
Biological substrate for nerve regeneration
without need for immunosuppression
Length limitation (<5 cm)
No Schwann cells
Only for small-diameter nerves
Very expensive
End-to-side
No length limitation
Poor sensory results
Motor requires donor neurectomy
Reverse end-to-side
Augment partial motor/sensory nerve injury
Requires knowledge of topography
Requires knowledge of expendable donors
May need nerve autograft or acellular graft
Nerve transfer
Earlier motor/sensory target recovery
Requires expendable donor
Requires motor (sensory) re-education
Requires knowledge of nerve topography
These grafts shorten operative time and eliminate donor
deficit, however they are expensive. The ANA handles simi­
larly to an autologous graft, and may be secured via suture
or sealant. ANAs have been shown to be superior to an empty
conduit, however they are inferior to autograft.42
In the authors’ practices, ANAs have largely replaced
the use of conduits, and are appropriate for small-diameter,
noncritical short (less than or equal to 3 cm) nerve gaps.
These grafts are never used for large-diameter gaps, motor
defects, or used to bridge a long gap. ANAs are dependent
on proliferating Schwann cells from the host tissue. Axonal
regeneration and functional recovery have been demonstrated
to decrease with graft length and are inferior to autograft at
all lengths.43 The mechanism appears to be in part Schwann
cell senescence induced by ischemia and cellular proliferation.
Transplanting Schwann cells into ANA has been shown to
improve functional regeneration closer to isograft levels in a
laboratory setting.44
ANAs undergo differing processing methods and there is
some evidence that this may impact functional outcome.
Three models of acellular nerve allografts were examined in
a rat model, and the differential processing for removal of
cellular constituents in preparing the ANAs were found to
affect recovery in vivo.45
Nerve transfers
Over the past decade, there has been a paradigm shift towards
the use of nerve transfers in the restoration of function
following nerve injury. In 2011, Garg et al. performed a sys­
tematic analysis that demonstrated that when international
data were pooled, nerve transfers were strongly superior to
nerve grafting in upper brachial plexus injuries.46
The principles of nerve transfer are to use expendable, pure
donor fascicles. Nerves with redundant fascicles or branches
make excellent donor nerves. Because the nerve transfer does
not rely on the amplitude and excursion of the tendon muscle
unit, unlike tendon transfers, and is not limited to one func­
tion, nor a straight line of pull, the muscle–tendon balance can
be maintained. The major advantages of a nerve transfer over
that of a tendon transfer are that: (1) nerve transfers can
restore sensibility in addition to motor function; (2) a nerve
that innervates multiple muscle groups can be restored with
a single nerve transfer; and (3) the insertion and attachments
of the muscle are not disrupted, thus the original muscle
function and tension are maintained. Synergistic nerve trans­
fers are preferred because of the ease of rehabilitation.
Nerve transfers are advantageous compared to long nerve
grafts because they have the ability to convert a proximal,
high-level nerve injury into a low-level nerve. This is particu­
larly important in high median and ulnar nerve injuries to
achieve restoration of hand function. Nerve transfers facilitate
operating outside the zone of injury and have the advantage
of a single neurorrhaphy.
Nerve transfers are possible because of the redundancy
existing in proximal, mixed nerve fibers. Knowledge of the
internal topography facilitates the separation of fascicular
groups even in the proximal extremity; fascicular groups run

321
Treatment/surgical repair
A
B
Fig. 19.3  Nerve autograft. A patient presenting with (A) a neuroma-in-continuity of
the median nerve at the level of the carpal tunnel. The neuroma (B) was resected
and treated with (C) cable grafting using medial antebrachial cutaneous nerve
(MABC) as a donor.
C
adjacent to each other in a consistent pattern within the larger
nerve itself.47 Intraoperative electrical stimulation with a
hand-held device (Vari-Stim®, Bio-Medicine) can be used to
identify and confirm specific function.
Bioengineering
The need for a bridge or scaffold that successfully allows
regenerating axons to reach the end-target muscle in the
A
Fig. 19.4  The nerve allograft (A) can be chosen to match the width of the injured
nerve. Here are two different size grafts that were sutured in place with 9-0 nylon
sutures after resection of two digital neuromas (B).
B
setting of a nerve gap has been long recognized. While mul­
tiple bioengineering projects have started investigating a
solution to this challenge, none so far has succeeded.48–51
Johnson et al. have recently described the characteristics of
an ideal tissue-engineered construct, including the goals of
creation.52
Method of repair
Timing of repair
Patients with an index of suspicion for potential nerve tran­
section are taken to the operating room within 72 hours for
exploration and primary repair. Nerves repaired within 48
hours are considered repaired primarily. Delayed repair
occurs between 2 and 7 days, and requires freshening of the
distal and proximal ends prior to coaptation. Nerves repaired
after the first week are considered to be secondarily repaired.
While these times are arbitrary, it is clear that the longer the

322
CHAPTER 19 • Repair and grafting of peripheral nerve
Table 19.3  Characteristics of nerve autograft donors based on published literature
Donor
nerve
Harvestable length
Fascicle
count
Cross-
sectional area
Disadvantage
Advantage
MABC
Up to 28 cm
7–10
2–3.15 mm2
• Medial arm scar
• Long length and larger caliber
nerve suitable for larger nerve gaps
and/or multiple cables required
• Can minimize donor morbidity with
end-to-side repair of distal end
MABC to median nerve
LABC
5–8 cm
4–9
1.3–1.8 mm2
• Visible forearm scar
• Good for short gaps
5–18
• Good size match with digital nerve
6–15
• Usually injured with SBR and
therefore good nerve graft for SBR
injuries
5–7
• Dermatome overlap with SBR
reduces donor morbidity
TWMa
24.5 cm
2–13
4.43 mm2
• Sensory loss in hand
(non-critical)
• Easy access through volar distal
forearm incisions
PCMa
Mean length 5.24 cm
• Sensory loss in palm
• Easy access through volar forearm
incisions
DCUa
Up to 26 cm
2.4 mm2 at
origin
• Sensory loss to
dorsal-ulnar hand
and digits
• Useful if ulnar nerve already injured
and working in same operative site
• Dorsal-ulnar hand
divisions, 5–6 cm
AINa
3–5
0.6–0.7 mm2
• Deep dissection into
pronator quadratus
• No sensory loss
• Short segment
available
• Good size match with digital
nerves
PINb
2.5 cm
2
0.5–0.8 mm2
• Visible dorsal incision
• No cutaneous sensory loss
• Small diameter graft
SBRa
• Potential for
hypersensitivity in
donor territory
• Consider if radial nerve already
injured
Sural
30–50 cm
9–14
2.5–4 mm
• Positioning difficult
• Long length
MSC 1–3
MSC 1.5
• Requires second
extremity
LSC 5–7
LSC 1.5
Obturator
9.9–13.6 cm
2–4
• Loss of gracilis as
possible future free
functional flap
• No sensory loss
11.5 cm average
• Expendable motor nerve graft
AIN, anterior interosseous nerve; DCU, dorsal cutaneous branch of ulnar nerve; LABC, lateral antebrachial cutaneous nerve; LSC, lateral sural cutaneous; MABC, medial
antebrachial cutaneous nerve; MSC, medial sural cutaneous; PCM, palmar cutaneous branch of median nerve; PIN, posterior interosseous nerve; SBR, radial sensory
nerve; TWM, third webspace branch of median nerve
aUsed as non-critical portion of injured nerve
bTerminal branch
(From Poppler LH, Davidge K, Lu JC, et al. Alternatives to sural nerve grafts in the upper extremity. Hand (N Y). 2015;10:68–75.)
time from injury, the less likely that a primary neurorrhaphy
can be achieved, even with significant mobilization of the
proximal and distal nerve ends.
Tension
Excessive tension across a nerve repair is known to increase
the scarring at the coaptation site, thereby impairing axonal
regeneration. In an uninjured nerve, a 15% strain of the
nerve causes a reduction in microvascular flow and a delay
of peak velocity.53 Clinically, the tension across a repair is
never measured, however insetting with any tension is
meticulously avoided. The authors also denounce postural
manipulation of the extremity to facilitate tension-free repair,
as this increases the likelihood of dehiscence and stiffness
due to immobilization.29
Type of repair
The suture diameter is clinically selected based on the size of
the nerve. Giddins et al. demonstrated in a cadaveric study
that 9-0 nylon was the optimal suture to acutely repair the
median nerve.54 At a lower tension, 10-0 nylon sutures
snapped and 8-0 nylon sutures pulled out of the nerve tissue.

323
Treatment/surgical repair
Several surgeons advocate for the use of fibrin glue, in
place of sutures, especially when there is no tension. Laser
energy for epineurial coaptation has been investigated, but
causes heat damage and decreased tensile strength. The gold
standard remains microsuture under the operating micro­
scope. The authors routinely use a combination of suture and
fibrin glue.
Epineurial repair is the preferred method of coaptation
once the severed ends are surgically freshened. External
markers such as a vessel on the surface and matching the
fascicular patterns are used to align the fascicles without
overlapping (Fig. 19.5). For major peripheral nerves, an argu­
ment for perineurial repair can be made to improve alignment
of the larger fascicular groups individually, however clinical
studies support both techniques as equally effective as long
as the fascicles were not overlapped (Fig. 19.6).55 The disad­
vantage of perineurial repair is that the extensive dissection
and the permanent intraneural stitches can lead to increased
fibrosis.56 In practice, it is often difficult to align the fascicles
accurately, as trauma, edema, and scarring can distort the
normal topography.
Fig. 19.5  Schematic depicting an epineurial (B) versus perineurial (C) repair after
transection of the nerve (A). The native artery and the fascicular pattern are used to
align the neurorrhaphy properly. The least number of epineurial sutures using 9-0
nylon is used.
A
B
C
Fig. 19.6  Good alignment of the fascicles (A) is crucial to optimal outcome,
whereas bunching and overlap (B) produces an inferior result.
A
B
Hints and tips
Using topical landmarks such as longitudinal vessels or
fascicular groups for orientation, and the least number of
sutures possible to achieve tension-free epineurial repair
through gentle, full range of motion, is the optimum method of
neurorrhaphy.
Orientation of repair
The majority of nerve repairs are performed in the classic end-
to-end fashion. This is irrespective of primary neurorrhaphy
or nerve grafting. The role of end-to-side repair continues to
be debated. Certainly, end-to-end repair continues to be rec­
ommended for all motor, mixed nerves, and sensory nerves
in critical distributions. End-to-side repairs for noncritical
sensory deficits are acceptable given spontaneous sprouting
of sensory nerves. Motor nerves, however, do not sponta­
neously collaterally sprout; instead, regenerative sprouting
occurs following axonal injury proximal to the repair.57
The supercharge end-to-side (SETS) technique is used to
facilitate early motor axons reaching the target endplates
while awaiting proximal regrowth from a high-level injury.
This is particularly useful in proximal Sunderland second-
degree and third-degree injuries, where long regeneration
distance yields prolonged time to muscle reinnervation and
suboptimal functional recovery.58 The validity of this method
of transfer has been confirmed in an animal model.59 The
classic example would be to perform an anterior interosse­
ous SETS procedure to the ulnar motor branch in the setting
of a high ulnar nerve injury, where some recovery is
anticipated.
Intraoperative nerve stimulation
A hand-held disposable nerve stimulator may be used to facili­
tate intraoperative decision-making. While uncomplicated,

324
CHAPTER 19 • Repair and grafting of peripheral nerve
Patient-related factors
The age of the patient seems to be the most predominant
patient-related factor. We know from historical data that nerve
repairs in children and young adults, both sensory and motor,
yield better results that in adults. In part, this is due to the
fact that children are smaller, and thus the nerve regeneration
rate of 1 mm/day allows axons to hit the motor endplates in
a shorter period of time. Children also demonstrated faster
and more adaptable brain plasticity, making recovery from
injury significantly faster.
Injury-related factors
The degree and type of injury affect prognosis and outcome.
Proximal injuries, which often involve mixed nerves contain­
ing both motor and sensory, are more difficult to reconstruct
and are located further away from target endplates. Crush
and avulsion injuries are more likely to have associated soft-
tissue injuries and thus tend to be worse than sharp injuries
occurring at the same level. The internal damage of a nerve is
often underestimated acutely and poor recovery is usually a
result of repair within the zone of injury when re-explored.
Repair-related factors
The timing of repair historically revealed that earlier repair
led to better prognosis, most likely because a primary neuror­
rhaphy was possible. Good prognosis is expected if the repair
occurs within six months and the best results occur if the
repair is performed within three weeks. In general, functional
recovery (FR) is inversely proportional to the time of denerva­
tion and directly proportional to the number of motor axons
reaching the target endplate. “Time is muscle.”
FR
Number of motor axons reaching target endplate
Time of D
α
enervation
clean transections may be equally able to be aligned using
topical surface landmarks, in closed traction injuries, especially
of the brachial plexus or injuries to larger mixed peripheral
nerves, formal intraoperative stimulation may help to identify
distal segments. This is also useful if the nerve is injured at
several segments along its length, or in the case of partial bra­
chial plexus injury.
When preoperative electrodiagnostic studies have been
equivocal, or to ensure that additional recovery has not
occurred between testing and surgical repair, the results of
intraoperative stimulation may affect the surgical plan.
The hand-held nerve stimulator will provide information
about distal motor fascicles, but will not be useful for sensory
deficits. The stimulator can also be useful to confirm the iden­
tity of redundant nerve fascicles for potential nerve transfer.
Postoperative care
After tension-free primary neurorrhaphy or grafting, no
immobilization is theoretically required because the extremity
has been taken through full range in the operating room prior
to closure. Immobilization for up to 7 days protects the coap­
tation as the proximal axons grow across the repair site, and
the authors use this strategy. Early, protected range of motion,
however, is critical for neural gliding and decreased scar­
ring.60 Protected range of motion is started within 72 hours for
most patients.
In patients with concomitant injuries, the postoperative
protocol is guided by the injury and is often difficult to reha­
bilitate. For example, in a zone 2 volar finger injury where
both nerves and tendons are transected, the flexor tendon
rehabilitation protocol takes precedence over the nerve reha­
bilitation, as the nerves can be readdressed at a later time if
necessary. In the case of fractures in addition to nerve or
soft-tissue injury, the bony fixation takes precedence.
Postoperative pain management is a critical part of the
broader treatment of a patient with a nerve injury, and can
dramatically affect outcome. Many patients complain in the
postoperative period of paresthesia, burning, or electrical
shocks. These symptoms can extend beyond the zone of
injury. Most of these symptoms can be controlled with neuro­
tropic medications such as nortriptyline, or pregabalin. In
some patients, the recovering nerve pain is so severe that they
require significant narcotic and neuroleptic medications and
the involvement of a pain specialist becomes paramount to
managing the associated chronic pain these patients experi­
ence. Anxiety and depression should also be addressed and
treated.
Physical therapy and occupational therapy continue for an
extended rehabilitation period to prevent joint contracture, to
provide sensory and motor re-education, to fabricate and
adjust splints, and to monitor progress.
Prognosis and outcomes
Prognosis
Several factors will affect the success of a nerve repair. These
factors can be further subdivided into patient-related factors,
injury-related factors, and repair-related factors.
Hints and tips
There are a number of factors affecting prognosis following
nerve injury. In general, the most important factor is getting as
many motor axons to the target endplate in the shortest period
of time as possible.
Outcomes
The outcomes achieved with peripheral nerve repair are
largely related to the prognostic factors discussed above.
Sharply transected isolated distal injuries to isolated motor or
sensory nerves do significantly better than more complicated
injuries.
Several methods to potentially improve outcomes have
been investigated. Recent interest in pharmacological thera­
pies to augment axonal regeneration and overcome inhibitory
signals has led to basic science investigation in this area.61 The
role of senescent Schwann cells is another potential area to
target.61

325
Summary
Secondary procedures
Nerve repair, either primarily or with nerve grafting or trans­
fer, often obtains good surgical outcomes when the damage
is isolated to the nerve and the injury is a clean transection.
In other settings, however, a wide zone of injury or concomi­
tant injuries make outcomes less satisfactory.
There are a number of potential secondary procedures that
may improve function and can be performed at a later date.
Decompression at known tight spots along the length of
a recovering nerve can improve axonal regeneration, espe­
cially if re-growth has stalled. Distal nerve transfers can be
performed simultaneously to supercharge or “babysit” the
recovering muscles, or can be performed at a later date if
grafting has failed, assuming that the nerve will reach end-
target origin by approximately 12 months (Fig. 19.7).
Tendon transfers are an extremely useful adjunct to the
management of significant nerve injuries, and their impor­
tance should not be overlooked. In patients who are not good
candidates for lengthy nerve grafting procedures or who will
not be compliant with, nor able to cooperate with, post-nerve-
transfer rehabilitation, tendon transfers remain the standard
of care. Certain tendon transfers, such as radial nerve trans­
fers, are typically more successful than nerve transfers and
return to activity is much faster following a period of immo­
bilization for tendon healing.
Summary
Primary neurorrhaphy remains the gold standard for all nerve
repair techniques, with autologous nerve grafting being the
gold standard for bridging a nerve gap. Since the implementa­
tion of a nerve allograft in 1870 by Philipeaux and Vulpian,
significant contributions regarding suturing technique, neural
topography, and the biology of nerve reconstruction have
transformed the way we approach nerve reconstruction.
While primary neurorrhaphy and autografts are the most
common methods for repair, several newer options are at our
disposal. Nerve transfers have revolutionized our approach
Fig. 19.7  Algorithm for incorporating nerve transfers into the management of a
nerve injury. SETS, supercharge end-to-side.
Significant
neurologic injury
Is the nerve
avulsed?
Primary repair
or nerve graft
Is the injury proximal?
Yes
No
Distal nerve
transfers
Is grafting
feasible?
Yes
No
Will axons reach
target muscle within
12 months?
Distal nerve
transfers
Yes
No
No additional
nerve procedure
Add SETS
nerve transfer
Yes
No
1. Wojtkiewicz DM, Saunders J, Domeshek L, et al. Social impact of
peripheral nerve injuries. Hand. 2015;10:161–167.
2. Seddon HJ. Three types of nerve injury. Brain. 1943;66:237–288.
3. Sunderland S. Nerves and Nerve Injuries. 2nd ed. Edinburgh:
Churchill Livingstone; 1978. An excellent summary of addressing nerve
injuries, this review explores some of the recent literature, specifically
addressing recent basic science advances in end-to-side and reverse
end-to-side recovery, Schwann cell migration, and neuropathic pain. The
management of nerve gaps, including the use of nerve conduits and
acellularized nerve allografts, is examined. Current commonly performed
nerve transfers are detailed with focus on both motor and sensory nerve
transfers, their indications, and a basic overview of selected surgical
techniques.
4. Mackinnon SE. Double and multiple “crush” syndromes. Double
and multiple entrapment neuropathies. Hand Clin. 1992;8:369. This
study reviews 86 patients receiving 109 nerve grafts over an 11 year
period. Outcomes from alternate donor nerves to the sural nerve are
comparable with the added benefit of restricting surgical intervention to a
single limb. An algorithm for selecting nerve graft material that has
evolved with growing understanding of nerve internal topography and the
drive to minimize additional incisions, maximize ease of harvest, and limit
donor morbidity is presented.
5. Mackinnon SE. New directions in peripheral nerve surgery. Ann
Plast Surg. 1989;22:257–273. This important meta-analysis pooled the
international data for the treatment of C5/C6 nerve injuries and looked at
recovery of elbow flexion and shoulder function assessed by MRC grade.
The data strongly favored dual nerve transfers over traditional nerve
grafting for restoration of both shoulder and elbow flexion. This paper has
both highlighted and validated the paradigm shift away from nerve
grafting in favor of distal nerve transfers and may be helpful to surgeons
considering intraoperative options, particularly in cases where grafting
may be suboptimal such as root avulsion, long gaps, and traumatized soft
tissue.
Access the complete reference list online at

for treating devastating brachial plexus and high-level
peripheral nerve injuries, converting them to lower-level
injuries and allowing us to operate outside the zone of trauma.
Bioengineering continues to be a long-term goal, however this
is not currently an option.

326
CHAPTER 19 • Repair and grafting of peripheral nerve
6. Seddon HJ, Medawar PB, Smith J. Rate of regeneration of
peripheral nerves in man. J Physiol. 1943;102:191–215.
7. Brunnell S. Nerve grafts. Am J Surg. 1939;44–64. This basic science
paper performed in a rat model studied the potential for reverse end-to-side
coaptation (now known as supercharge end-to-side (SETS)) to reinnervate
distal motor endplates. Compared to negative controls, muscle-mass
preservation was improved with both end-to-end and reverse-end-to-side
coaptation and nerve generation across the RETS coaptation was robust.
Translating this paper to the clinical setting suggests that SETS is a
viable option in the treatment of nerve injury, and one that would also
allow for spontaneous recovery while functioning as a babysitting
procedure to keep motor endplates viable while waiting for axonal
regrowth from proximal injuries.
8. Lenoble E, Sokolow C, Ebelin M, et al. [Results of the primary
repair of 28 isolated median nerve injuries in the wrist]. Ann Chir
Main. 1989;8:347–351. This basic science paper compared conduits,
isografts, and several processed allografts using measurement of muscle
force as an outcome. The findings that detergent-processed allografts
promoted isograft-equivalent levels of motor recovery and were superior to
AxoGen-processed and cold-preserved allografts suggest that the
differential processing for removal of cellular constituents in preparing
acellular nerve allografts does affect in vivo recovery. In addition, all
acellular allografts promoted better motor recovery than silicone conduits.
This may influence surgeons in the selection of materials to address a
nerve gap.
9. Millesi H. Indication, technique, and results of nerve grafting.
Handchirurgie. 1977;2(suppl):1–24.
10. Taylor GI, Ham FJ. The free vascularized nerve graft. A further
experimental and clinical application of microvascular techniques.
Plast Reconstr Surg. 1976;57:413–426.

326.e1
References
References
1. Wojtkiewicz DM, Saunders J, Domeshek L, et al. Social impact of
peripheral nerve injuries. Hand. 2015;10:161–167.
2. Seddon HJ. Three types of nerve injury. Brain. 1943;66:237–288.
3. Sunderland S. Nerves and Nerve Injuries. 2nd ed. Edinburgh:
Churchill Livingstone; 1978. An excellent summary of addressing nerve
injuries, this review explores some of the recent literature, specifically
addressing recent basic science advances in end-to-side and reverse
end-to-side recovery, Schwann cell migration, and neuropathic pain. The
management of nerve gaps, including the use of nerve conduits and
acellularized nerve allografts, is examined. Current commonly performed
nerve transfers are detailed with focus on both motor and sensory nerve
transfers, their indications, and a basic overview of selected surgical
techniques.
4. Mackinnon SE. Double and multiple “crush” syndromes. Double
and multiple entrapment neuropathies. Hand Clin. 1992;8:369. This
study reviews 86 patients receiving 109 nerve grafts over an 11 year
period. Outcomes from alternate donor nerves to the sural nerve are
comparable with the added benefit of restricting surgical intervention to a
single limb. An algorithm for selecting nerve graft material that has
evolved with growing understanding of nerve internal topography and the
drive to minimize additional incisions, maximize ease of harvest, and limit
donor morbidity is presented.
5. Mackinnon SE. New directions in peripheral nerve surgery. Ann
Plast Surg. 1989;22:257–273. This important meta-analysis pooled the
international data for the treatment of C5/C6 nerve injuries and looked at
recovery of elbow flexion and shoulder function assessed by MRC grade.
The data strongly favored dual nerve transfers over traditional nerve
grafting for restoration of both shoulder and elbow flexion. This paper has
both highlighted and validated the paradigm shift away from nerve
grafting in favor of distal nerve transfers and may be helpful to surgeons
considering intraoperative options, particularly in cases where grafting
may be suboptimal such as root avulsion, long gaps, and traumatized soft
tissue.
6. Seddon HJ, Medawar PB, Smith J. Rate of regeneration of
peripheral nerves in man. J Physiol. 1943;102:191–215.
7. Brunnell S. Nerve grafts. Am J Surg. 1939;44–64. This basic science
paper performed in a rat model studied the potential for reverse end-to-side
coaptation (now known as supercharge end-to-side (SETS)) to reinnervate
distal motor endplates. Compared to negative controls, muscle-mass
preservation was improved with both end-to-end and reverse-end-to-side
coaptation and nerve generation across the RETS coaptation was robust.
Translating this paper to the clinical setting suggests that SETS is a
viable option in the treatment of nerve injury, and one that would also
allow for spontaneous recovery while functioning as a babysitting
procedure to keep motor endplates viable while waiting for axonal
regrowth from proximal injuries.
8. Lenoble E, Sokolow C, Ebelin M, et al. [Results of the primary
repair of 28 isolated median nerve injuries in the wrist]. Ann Chir
Main. 1989;8:347–351. This basic science paper compared conduits,
isografts, and several processed allografts using measurement of muscle
force as an outcome. The findings that detergent-processed allografts
promoted isograft-equivalent levels of motor recovery and were superior to
AxoGen-processed and cold-preserved allografts suggest that the
differential processing for removal of cellular constituents in preparing
acellular nerve allografts does affect in vivo recovery. In addition, all
acellular allografts promoted better motor recovery than silicone conduits.
This may influence surgeons in the selection of materials to address a
nerve gap.
9. Millesi H. Indication, technique, and results of nerve grafting.
Handchirurgie. 1977;2(suppl):1–24.
10. Taylor GI, Ham FJ. The free vascularized nerve graft. A further
experimental and clinical application of microvascular techniques.
Plast Reconstr Surg. 1976;57:413–426.
11. Doi K, Tamaru K, Sakai K, et al. A comparison of vascularized and
conventional sural nerve grafts. J Hand Surg Am. 1992;17:670–676.
12. Doi K, Kuwata N, Kawakami F, et al. The free vascularized sural
nerve graft. Microsurgery. 1984;5:175–184.
13. Hasegawa T, Nakamura S, Manabe T, Mikawa Y. Vascularized
nerve grafts for the treatment of large nerve gap after severe
trauma to an upper extremity. Arch Orthop Trauma Surg.
2004;124:209–213.
14. Kim DH, Connolly SE, Zhao S, et al. Comparison of macropore,
semipermeable, and nonpermeable collagen conduits in nerve
repair. J Reconst Microsurg. 1993;9:415–420.
15. Chen LE, Seaber AV, Urbaniak JR, Murrell GA. Denatured
muscle as a nerve conduit: a functional, morphologic, and
electrophysiologic evaluation. J Reconstr Microsurg. 1994;10:
137–144.
16. Chiu DT, Strauch B. A prospective clinical evaluation of autogenous
vein grafts used as a nerve conduit for distal sensory nerve defects
of 3 cm or less. Plast Reconst Surg. 1990;86:928–934.
17. Smith RM, Wiedl C, Chubb P, Greene CH. Role of small intestine
submucosa (SIS) as a nerve conduit: preliminary report. J Invest
Surg. 2004;17:339–344.
18. Meek MF, Coert JH. Clinical use of nerve conduits in peripheral-
nerve repair; review of the literature. J Reconstr Microsurg.
2002;18:97–109.
19. Phillips JH, Mackinnon SE, Beatty SE, et al. Vibratory sensory
testing in acute compartment syndromes: a clinical and
experimental study. Plast Reconstr Surg. 1987;79:796–801.
20. Weber RV, Mackinnon SE. Nerve transfers in the upper extremity.
J Am Soc Surg Hand. 2004;4:200–213.
21. Rostoucher P, Alnot JY, Touam C, Oberlin C. Tendon transfers to
restore elbow flexion after traumatic paralysis of the brachial plexus
in adults. Int Orthop. 1998;22:255–262.
22. Becker M, Lassner F, Fansa H, et al. Refinements in nerve to muscle
neurotization. Muscle Nerve. 2002;26:362–366.
23. Bielecki M, Skowronski R, Skowronski J. A comparative
morphological study of direct nerve implantation and
neuromuscular pedicle methods in cross reinnervation of the rat
skeletal muscle. Rocz Akad Med Bialymst. 2004;49:10–17.
24. Strauch B, Lang A, Ferder M, et al. The ten test. Plast Reconstr Surg.
1997;99:1074–1078.
25. Zaidman CM, Seelig MJ, Baker JC, et al. Detection of peripheral
nerve pathology: comparison of ultrasound and MRI. Neurology.
2013;80:1634–1640.
26. Myckatyn TM, Mackinnon SE. A review of research endeavors to
optimize peripheral nerve reconstruction. Neurol Res.
2004;26:124–138.
27. Trumble TE, Archibald S, Allan CH. Bioengineering for nerve repair
in the future. J Am Soc Surg Hand. 2004;4:134–142.
28. Millesi H. The nerve gap. Theory and clinical practice. Hand Clin.
1986;2:651–663.
29. Millesi H. Microsurgery of peripheral nerves. Ann Chir Gynaecol.
1982;71:56–64.
30. Seddon HJ. Surgical Disorders of Peripheral Nerves. Edinburgh:
Churchill Livingstone; 1975.
31. Ray WZ, Mackinnon SE. Management of nerve gaps: autografts,
allografts, nerve transfers, and end-to-side neurorrhaphy. Exp
Neurol. 2010;223:77–85.
32. Boyd KU, Nimigan AS, Mackinnon SE. Nerve reconstruction in the
hand and upper extremity. Clin Plast Surg. 2011;38:643–660.
33. Weber RA, Breidenbach WC, Brown RE, et al. A randomized
prospective study of polyglycolic acid conduits for digital
nerve reconstruction in humans. Plast Reconstr Surg.
2000;106:1036–1045.
34. Saito I, Oka Y, Odaka M. Promoting nerve regeneration through
long gaps using a small nerve tissue graft. Surg Neurol.
2003;59:148–154.
35. Dvali L, Mackinnon S. Nerve repair, grafting, and nerve transfers.
Clin Plast Surg. 2003;30:203–221.
36. Myckatyn TM, Mackinnon SE. Surgical techniques of nerve grafting
(standard/vascularized/allograft). Oper Tech Orthop.
2004;14:171–178.
37. Novak CB, Mackinnon SE. Distal anterior interosseous nerve
transfer to the deep motor branch of the ulnar nerve for
reconstruction of high ulnar nerve injuries. J Reconstr Microsurg.
2002;18:459–464.

326.e2
CHAPTER 19 • Repair and grafting of peripheral nerve
38. Poppler LH, Davidge K, Lu JC, et al. Alternatives to sural nerve
grafts in the upper extremity. Hand. 2015;10:68–75.
39. Brushart TM. Preferential reinnervation of motor nerves by
regenerating motor axons. J Neurosci. 1988;8:1026–1031.
40. Moradzadeh A, Borschel GH, Luciano JP, et al. The impack of
motor and sensory nerve architecture on nerve regeneration. Exp
Neurol. 2008;212:370–376.
41. Karabekmez FE, Duymaz A, Moran SL. Early clinical outcomes
with the use of decellularized nerve allograft for repair of sensory
defects within the hand. Hand. 2009;4:245–249.
42. Whitlock EL, Tuffaha SH, Luciano JP, et al. Processed allografts and
type I collagen conduits for repair of peripheral nerve gaps. Muscle
Nerve. 2009;39:787–799.
43. Saheb-Al-Zamani M, Yan Y, Farber SJ, et al. Limited regeneration in
long acellular nerve allografts is associated with increased Schwann
cell senescence. Exp Neurol. 2013;247:165–177.
44. Jesurai NJ, Santosa KB, Macewan MR, et al. Schwann cells seeded
in acellular nerve grafts improve functional recovery. Muscle Nerve.
2014;49:267–276.
45. Moore AM, MacEwan M, Santosa KB, et al. Acellular nerve
allografts in peripheral nerve regeneration: a comparative study.
Muscle Nerve. 2011;44:221–234.
46. Garg R, Merrell GA, Hillstrom JH, Wolfe SW. Comparison of nerve
transfers and nerve grafting for traumatic upper plexus palsy: a
systematic review and analysis. J Bone Joint Surg Am.
2011;93:819–829.
47. Brandt KE, Mackinnon SE. Microsurgical repair of peripheral
nerves and nerve grafts. In: Aston SJ, Beasley RW, Thorne DHM,
eds. Grabb and Smiths’ Plastic Surgery. New York: Lippincott-Raven;
1997:79–90.
48. McCallister WV, Tang P, Smith J, Trumble TE. Axonal regeneration
stimulated by the combination of nerve growth factor and ciliary
neurotrophic factor in an end-to-side model. J Hand Surg Am.
2001;26:478–488.
49. Bothwell M. Functional interactions of neurotrophins and
neurotrophin receptors. Annu Rev Neurosci. 1995;18:223–253.
50. Fansa H, Schneider W, Wolf G, Keilhoff G. Influence of insulin-like
growth factor-I (IGF-1) on nerve autografts and tissue-engineered
nerve grafts. Muscle Nerve. 2002;26:87–93.
51. Santos X, Rodrigo J, Hontanilla B, Bilbao G. Local administration of
neurotrophic growth factor in subcutaneous silicon chambers
enhances the regeneration of the sensory component of the rat
sciatic nerve. Microsurgery. 1999;19:275–280.
52. Johnson PJ, Wood MD, Moore AM, Mackinnon SE. Tissue
engineered constructs for peripheral nerve surgery. Eur Surg.
2013;45(3).
53. Driscoll PJ, Glasby MA, Lawson GM. An in vivo study of
peripheral nerves in continuity: biomechanical and physiological
responses to elongation. J Orthop Res. 2002;20:370–375.
54. Giddins GE, Wade PJ, Amis AA. Primary nerve repair: strength of
repair with different gauges of nylon suture material. J Hand Surg
[Br]. 1989;14:301–302.
55. Cabaud HE, Rodkey WF, McCarroll HR Jr, et al. Epineurial and
perineurial fascicular nerve repairs: a critical comparison. J Hand
Surg Am. 1976;1:131–137.
56. Zhao Q, Dahlin LB, Kanje M, Lundborg G. Specificity of muscle
reinnervation following repair of the transected sciatic nerve. A
comparative study of different repair techniques in the rat. J Hand
Surg [Br]. 1992;17:257–261.
57. Hayashi A, Pannucci C, Moradzadeh A, et al. Axotomy or
compression is required for axonal sprouting following end-to-side
neurorraphy. Exp Neurol. 2008;211:539–550.
58. Farber SJ, Glaus SW, Moore AM, et al. Supercharge nerve transfer
to enhance motor recovery: a laboratory study. J Hand Surg Am.
2013;38:466–477.
59. Kale SS, Glaus SW, Yee A, et al. Reverse end-to-side nerve transfer:
from animal model to clinical use. J Hand Surg Am.
2011;36:1631–1639.
60. Yu RS, Catalano LW 3rd, Barron OA, et al. Limited, protected
postsurgical motion does not affect the results of digital nerve
repair. J Hand Surg Am. 2004;29:302–306.
61. Wood MD, Mackinnon SE. Pathways regulating modality-specific
axonal regeneration in peripheral nerve. Exp Neurol.
2015;265:171–175.

20 
Reconstructive fat grafting
Wesley N. Sivak and J. Peter Rubin
SYNOPSIS
■ Fat grafting is an important technique for tissue repair and/or
augmentation in both reconstructive and aesthetic plastic surgery.
■ Fat grafting can be used as a minimally invasive adjunct to restore
volume and rejuvenate tissues lost secondary to aging, trauma, or
disease.
■ The biology and principal components of adipose tissue are reviewed
with specific focus on adipose-derived stem cells.
■ The safety of fat grafting – with specific focus on oncologic
implications – is reviewed from both a basic science and clinical
standpoint.
■ Numerous aesthetic and reconstructive problems can be addressed
with fat grafting, and patient selection remains vitally important.
Introduction
Autologous fat grafting has become a common technique for
addressing volume and contour abnormalities in plastic
surgery, demonstrating efficacy in both aesthetic and recon­
structive procedures. Although early use of fat grafting was
largely an aesthetic adjunct, recent advancements have made
fat grafting an attractive alternative for many reconstructive
challenges. A survey conducted in 2013 showed that approxi­
mately 70% of plastic surgeons have incorporated fat grafting
into their clinical breast practice.1 Fat grafting has been used
successfully for facial rejuvenation, breast augmentation,
mitigating radiation damage, breast capsular contracture,
post-traumatic deformities, congenital anomalies, and burn
injuries;2–8 the techniques continually evolve and novel appli­
cations rapidly emerge. Autologous fat grafts have numerous
beneficial characteristics for reconstruction including: low
donor site morbidity, simplicity of procedure, low cost, and
resultant living autologous tissue at the site of treatment.
Additionally, grafted fat has appealing bioactive factors.
Cannula adipose tissue particles include adipose stem cells
(ASCs) or preadipocytes, fibroblasts, vascular endothelial
cells, and a variety of immune cells.9 It has become apparent
through extensive research in the past decade that stromal
vascular fraction cells and the adipose stem cells within can
improve fat graft survival, largely through their angiogenic
properties.10,11 Applications for cell isolates from adipose
tissue are also finding applications in the fields of tissue
engineering and regenerative medicine. Basic science research
continues to uncover cellular elements critical for inclusion in
fat grafts, which will ultimately lead to modifications and
enhancement of existing techniques for improved long-term
outcomes.
Access the Historical Perspective section online at

Basic science
Adipose tissue: structure and physiology
Adipose tissue is primarily comprised of large lipid-laden
adipocytes, which are surrounded by various stromal vascular
cells, each with a unique role. Stromal vascular cells include
fibroblasts, immune cells, pericytes, and endothelial cells. The
extracellular matrix that interconnects adipocytes and forms
the fat lobules within adipose tissue provides the structural
framework of adipose tissue. There are two general types of
adipose tissue: brown fat and white fat. In humans, brown
adipose tissue is predominantly found during the neonatal
period and is responsible for generating thermogenesis from
triglycerides. Brown fat deposits do not appear to play a
significant role in human adult metabolism, although recent
research has begun to emerge on the importance of brown
fat.30,31 The discussion here will be limited to the role of white
fat, as it is used exclusively for fat grafting procedures.
White fat is involved in a variety of physiologic
roles including the storage of energy-rich triglycerides,
  Access video lecture content for this chapter online at expertconsult.com

327.e1
Historical perspective
Historical perspective
The first clinical report of fat grafting was in 1893 by German
surgeon Gustav Neuber when he harvested adipose tissue
from the arm and corrected a depressed facial scar resulting
from osteomyelitis.12 This was quickly followed by a report 2
years later by Vincenz Czerny, who transferred a lipoma from
the buttock to correct a post-surgical breast deformity.13
Though state of the art for that time, fat grafting was ulti­
mately considered difficult and too time consuming with
unpredictable results.
Looking for a solution to these problems, Eugene Holländer
first injected fat through a small diameter cannula.14,15
However, considerable reabsorption of the fat resulted. Later,
in 1919, Erich Lexer published a two-volume book dedicated
to the technique of fat grafting.16 In this book, he presented a
wide variety of conditions such as depressed scars, breast
asymmetry, knee ankylosis, tendon adhesions, and microgna­
thia that he successfully treated with fat grafting. Charles
Miller in 1926 described the injection of autologous fat for the
correction of facial folds and wrinkles.17 Despite some early
favorable results, fat grafting on the whole remained unpre­
dictable and again fell out of favor.
It was not until the 1950s, when Lyndon Peer systemati­
cally studied the gross and histologic appearance of trans­
planted fat, that an understanding and improved predictability
of fat grafting began to emerge.18 He demonstrated adipose
grafts lose about 45% of their weight and volume at one year.
Fat cells that survive transfer appeared to maintain their
native volume. Improper handling of the fat prior to and
during transplantation decreased survival of the graft. He also
demonstrated that graft size plays a role in overall survival.
A graft the size of a walnut was found to lose volume more
rapidly than multiple smaller grafts of similar weight, due to
increased surface area of the smaller grafts. Revascularization,
seen microscopically, was noted by Peer to be essential for fat
achieving graft survival.
With the advent of liposuction in the 1980s by Fournier and
Illouz, there was a renewed interest in fat grafting.19,20 Fat was
now a byproduct of a popular procedure and stood in the
ready, just waiting for clinical application. Early results of
grafting lipoaspirate were only partially successful; the
thought at the time was that still better preparation of the
fat was needed for survival. Chajchir and Benzaquen made
some initial recommendations based on their own favorable
results.21 There was still great confusion as to what really
worked until the 1990s, when Coleman perfected his standard
technique. This technique, called structural fat grafting,
emphasizes gentle extraction of fat, centrifugation, and serial
small volume injections in multiple tissue planes. Coleman
has used this technique for almost 30 years and has repeatedly
documented durability of fat grafting performed with his
method.22–25 Numerous researchers have since built upon the
work of Coleman and begun to lay the scientific foundation
for emerging adipose technologies in the fields of tissue
engineering and regenerative medicine.
Although, early reports of fat grafting by Neuber, Czerny,
and Holländer as far back as the 19th century demonstrated
the potential results achievable with fat grafting for facial and
breast reconstruction,12–14 fat grafting was not widely accepted
until the 1990s. Despite early successes, subsequent reports
were met with varying levels of failure, often associated with
unpredictable fat resorption.26,27 Beginning in the early 1980s,
several successful reports of fat grafting were published, and
fat grafting increased in popularity once again.20,28,29 Plastic
surgeons began to recognize the importance of the technical
aspects used in harvesting, processing, and injecting fat in
order to achieve successful outcomes. Coleman substantiated
these claims with his introduction of structural fat grafting in
the 1990s, and others have since begun to lay the scientific
framework and principles underlying successful fat grafting.

328
CHAPTER 20 • Reconstructive fat grafting
fatty acid-binding proteins (FABP) known as adipocyte lipid
binding protein (aP2) and keratinocyte lipid-binding protein.
As preadipocytes differentiate into adipocytes, they lose their
morphologic similarities to fibroblasts via decreased expres­
sion of collagen types I and III and increased production of
collagen type IV, laminin, entactin, and glycosaminoglycans.
In fact, inhibition of collagen synthesis during this phase
actually blocks preadipocyte differentiation.43
Biology of ASCs
Preadipocytes were first described in 1976 by Dardick in a rat
model;44 similar cells were later isolated from human adipose
tissues.45–47 Isolated preadipocytes were initially used to probe
adipocyte biology in vitro, leading to the recognition that dif­
ferent anatomic locations and adipose depots express different
biological characteristics, such as adipocyte size and lipolytic
potential. In 2001, Zuk48 first discussed the differentiation
plasticity of preadipocytes and eventually the term adipose-
derived stem cell (ASC) was adopted to encompass the
characteristics of self-renewal, asymmetric division, and
multi-lineage potency. Although ASCs proliferate and rapidly
expand in culture, exogenous growth factors are required
to induce lineage-specific differentiation.49 Differentiation of
ASCs to other mesenchymal phenotypes has been well estab­
lished both in vitro and in vivo. ASC differentiation to cell
lineages of the ectodermal and endodermal germ layers has
also been successful in several studies.50–68
Adipose-derived stem cells (ASCs) are prevalent within
human adipose tissue, surrounding blood vessels and resid­
ing within the connective tissue framework. These non-
lipid-laden stromal cells are easily isolated from either
suction-aspirated adipose tissue or excised human fat via
enzymatic collagenase digestion. Numerous descriptions for
cell isolation methods appear in the literature.69–71 The resul­
tant freshly isolated cell pellet is highly heterogeneous and is
named the stromal vascular fraction (SVF). When SVF cells
are placed in culture, the ASCs adhere to the surface of
an untreated tissue culture flask after 6–8 hours’ incubation
at 37°C and 5% CO2. Once ASCs have adhered to the
culture flask surface, non-adherent populations, representing
approximately 7–15% of the SVF and consisting of mainly
hematopoietic origin cells, are washed away with sterile
phosphate buffered solution and/or fresh culture media. A
commonly used ASC expansion medium consists of a Dul­
becco’s Modified Eagle Medium (DMEM) and DMEM/F12
media combination, with 10% serum, antibiotic (e.g., penicil­
lin, streptomycin), and a small amount of dexamethasone to
halt differentiation to another mesenchymal lineage. Once in
culture, specific growth factors or other additives can be
applied to direct the differentiation to a specific phenotype,
such as adipose, bone, cartilage, or muscle.
SVF is attractive therapeutically because it may be obtained
from tissue within 60–90 minutes, and the isolation can be
performed in a clean room near an operating room, or even
within an operating room using available automated devices.
Collagenase digestion results in approximately 2–5 × 105
nucleated SVF cells per gram of adipose tissue. However,
complete ASC isolation takes 24 hours and requires access to
cell culture facilities. Benefits of cell culture also include the
ability to differentially expand the cell number, select for
specific subpopulations, or control the microenvironment for
cushioning of vital structures and organs, maintenance of
metabolic homeostasis, immune regulation, reproduction,
and angiogenesis.32–35 The imbalance of adipose tissue result­
ing in either too much fat, such as in generalized obesity, or
too little fat, such as in genetic or acquired lipodystrophies
and aging, is an increasingly prevalent problem worldwide.
Associated disorders are generally linked with physiologic
derangements in insulin metabolism, triglyceride and choles­
terol stores, as well as generalized insults to end organs
involved in these pathways. The increased recognition of
these problems has highlighted the need for a more complete
understanding of adipose biology.
Adipose tissue influences metabolic homeostasis through
production of assorted hormones, cytokines, growth factors,
and other peptides. Factors secreted by adipose tissue are
involved in a broad spectrum of physiological processes and
molecular pathways including: lipid and steroid metabolism,
growth factor signaling, protein binding, cytokine signal trans­
duction, vasoactivity, eicosanoid activity, alternative comple­
ment system activation, and extracellular matrix deposition.
These effector molecules, termed adipokines, exert their influ­
ences in endocrine, paracrine, and autocrine manners. Major
adipokines leptin and adiponectin are implicated in obesity
and function by regulating appetite and energy expenditure.32–35
Tumor necrosis factor–alpha (TNF-α), interleukin-8 (IL-8), and
interleukin-6 (IL-6) are all increased in obesity; they function as
proinflammatory cytokines promoting increased insulin resis­
tance. In addition, type 1 plasminogen activator inhibitor
(PAI-1) is also increased in obesity and functions to promote
thrombosis by inhibiting fibrinolysis, acting as a main endog­
enous regulator of the coagulation system.36
Adipocyte differentiation begins with the transformation
of mesenchymal stem cells into adipoblasts, preadipocytes
and, finally, mature lipid-synthesizing, lipid-storing adipo­
cytes. Preadipocytes bear striking resemblance to early
fibroblasts in terms of their cellular architecture and cytoskel­
etal arrangement. Differentiation involves the coordinated
expression of specific genes involved in producing the adipo­
cyte phenotype.37 Transcriptional regulation of adipocyte
differentiation during development is largely controlled by
peroxisome proliferator-activated receptor-γ (PPAR-γ). PPAR-
γ is the factor demonstrated to be the most specific to adipo­
genic differentiation. When its receptor becomes activated by
its agonist ligand in a target cell, a process of differentiation
into an adipocyte begins via morphologic changes, lipid
accumulation, and activation of genes distinctively expressed
by the mature adipocyte. Additional support during differen­
tiation comes from CCAAT/enhancer-binding proteins (C/
EBPs), with C/EBP-β and C/EBP-α specifically stimulating
PPAR-γ expression during early differentiation and C/EBP-α
having a similar role later in the pathway. Recently, lipopro­
tein lipase (LPL), specific Krüppel-like factors (KLF5, KLF15,
and KLF2), early growth response 2 (Krox20), and early B-cell
(O/E-1) factors have also been implicated in adipocyte
differentiation.38–42 Both insulin and insulin-like growth
factor-1 (IGF-1) are known to be required for adipocyte dif­
ferentiation. Simultaneously, preadipocyte factor–1 (pref-1),
whose role is in the maintenance of the preadipocyte pheno­
type, is decreased during adipocyte differentiation. Late
markers of differentiation, which are factors produced once
adipocytes mature, include adipsin, angiotensinogen II, acyl-
coenzyme A (Co-A)-binding protein (ACBP), leptin, and two

329
Basic science
Common approaches to fat harvesting include syringe
aspiration and liposuction.25,74,75 The primary concerns during
tissue harvest are minimizing the level of invasiveness (i.e.,
patient safety) and maximizing tissue viability (i.e., efficacy).
The ASPS Fat Graft Task Force in its 2009 report suggested
that tissue harvest be performed using a 3- to 4-mm blunt
cannula, while utilizing minimal amounts of suction required
for tissue extraction.76 However, a 2013 report by Lee showed
no statistically significant differences in parcel size or histo­
logic architecture when fat was harvested with suction pres­
sures up to −0.83 atm through a standard 4-mm cannula.77
Additionally, the utilization of ultrasound-assisted liposuc­
tion also appears to have minimal effect on cellular viability
and overall graft survival rates, with similar amounts of SVF
cell populations present irrespective of the harvest technique
utilized.78
Once the fat has been harvested, it can be prepared for
injection via one of several methods, which can include
washing with physiologic buffers, centrifugation (for separa­
tion of cells from debris), decantation, or concentration (i.e.,
rolling across an absorbent medium).28,79–83 To avoid contami­
nation and maximize tissue viability, exposure to air and
mechanical damage should again be minimized. The ASPS
Fat Graft Task Force in its 2009 report suggested that viable
adipocytes be separated from blood, serum, and damaged
adipocytes via centrifugation (3000 rpm for 3 minutes) while
remaining within the harvest syringe to limit exposures.76
However, Fisher et al. demonstrated superior graft retention
rates with gauze-rolled fat, attributed in part to greater reten­
tion of the SVF components.78 In a 2012 review of fat grafting
techniques, Gir and colleagues concluded the body of evi­
dence to date does not support one processing technique
above another.6 They do, however, caution that when centrifu­
gation is used, several studies suggest that forces greater than
3000 rpm (1200 g) can inflict greater levels of cellular damage
that can negatively impact overall graft retention rates.
Once refined, fat is subsequently injected subcutaneously
with an assortment of delivery methods using blunt-tipped
needles. To optimize fat graft viability, mechanical damage of
the tissue must be minimized during the injection process.
The ASPS Fat Graft Task Force 2009 report suggests that injec­
tion be performed using a 2- to 2.5-mm blunt-tipped infusion
cannula (or a similar blunt needle); small aliquots of fat should
be deposited serially, with multiple injections occurring in
multiple tissue planes within the area of augmentation.76
Ozsoy et al. compared three different diameters of injection
Coleman-type cannulas and found that adipocyte viability
was significantly greater with 2.5-mm-diameter injection can­
nulas compared with smaller diameter cannulas (1.6 or
2 mm).84 Adipocytes have been shown to be highly susceptible
to the effects of shear stress, which is proportional to flow rate
during injection. Lee et al. demonstrated that slow injections
(0.5–1 cc/second) resulted in a 38% improvement in fat graft
survival over fast injections (3–5 cc/second) through similar
sized cannulas.77 Special consideration should be made to
minimize the factors that increase shear stress upon the graft.
Variables such as viscosity, concentration, cannula length,
cannula diameter, and flow rate play a significant role and can
negatively impact fat graft survival to a high degree when
proper technique is not utilized.
Another variable to consider in the overall technique of fat
grafting is the ideal donor site. When harvests from four
directed differentiation, or seeding of a scaffold material. Flow
cytometry characterization of the surface markers on freshly
isolated and cultured adipose-derived cells can be performed,
and shows the presence of early progenitor markers such as
CD34 and CD90.49,72
Freshly isolated SVF obtained directly from harvested
adipose tissue has diverse patterns of cell surface markers as
identified by flow cytometry.50,72 Zimmerlin and colleagues
identified several similar cell surface markers in ASCs com­
pared with bone marrow-derived stem cells (BMSCs).72,73 Li
and colleagues reported four subpopulations of interest that
can be isolated and cultured.70 The first subpopulation is
CD31+/CD34− and is classified as “mature endothelial” as it
expresses the endothelial marker of CD31 but lacks the pro­
genitor marker CD34. The second subpopulation is classified
as “endothelial stem” and is CD31+/CD34+, expressing both
endothelial and progenitor markers. A third subpopulation,
CD31−/CD34+ is classified as “adipose stem” (i.e., ASC),
displaying just progenitor markers. The fourth subpopulation
represents a “pericyte group” characterized by surface
markers CD146+/CD90+/CD31−/CD34−. Pericytes function
as contractile cells that regulate blood flow and reside adjacent
to the blood vessel walls as shown by immunostaining.51
Similar to BMSCs, ASCs do not express major histocompatibil­
ity complex (MHC)-II and inhibit proliferation of activated
peripheral blood mononuclear cells, suggesting a role for
modulating the immune system in inflammatory disorders or
allogeneic transplantation.50 In fact, ASCs are an active target
of much research in the area of vascularized composite tissue
transplantation, hoping to aid in the induction of tolerance to
transplanted allograft tissues.
Nonenzymatic isolation of ASCs and SVF has been a topic
of recent interest, driven by a potentially less restrictive regu­
latory pathway. Strategies have focused on mechanical forces
such as ultrasound, but there is no evidence to suggest
equivalence to enzymatic digestion. There has also been inter­
est in whether there are viable ASCs in the aqueous portion
of the lipoaspirate, obviating the need to expose tissue grafts
to digestive enzymes. Although some cells are present, the
quantity is insufficient for clinical use. Because the ASCs are
firmly embedded within the connective tissue, enzymatic
digestion is currently necessary to release them in significant
quantity for use in clinical applications.
Fat harvesting, preparation and
grafting techniques
Over the last 30 years, numerous fat grafting techniques have
been described with each iteration promising improved con­
sistency and more reliable outcomes. To date, a standard has
yet to be universally adopted by all authorities. Most variables
that remain in question relate to three major steps in fat graft­
ing: (1) harvesting from the donor site, (2) processing the fat
ex vivo, and (3) reintroduction to the recipient site. Investiga­
tors refining the techniques of fat harvesting, preparation, and
grafting have relied upon clinical outcomes in addition to
utilizing both in vitro and in vivo models of adipogenesis. Lack
of consensus thus far has resulted from numerous studies
showing equivocal results when various methodologies are
compared. In 2009, the ASPS Fat Graft Task Force published
its evidence-based guidelines for autologous fat grafting
based upon a thorough review of the existing literature.

330
CHAPTER 20 • Reconstructive fat grafting
been significant advances in cancer screening technologies
through the development of advanced mammography, MRI,
and ultrasound techniques. Given the lack of quality data
implicating autologous fat transfer, it is surprising that con­
cerns continue to persist.
Concerns regarding oncologic risk of fat grafting are pri­
marily four-fold: (1) interference with cancer surveillance, (2)
growth factor release, (3) stem cell malignant transformation,
and (4) enhanced migration and metastases of cancer cells.
Despite these concerns, fat grafting has become routine in
breast cancer reconstruction. This is due to the ability to reli­
ably transfer autologous tissues without the need for micro­
surgery, simple outpatient-based procedures, and abundance
of donor sites with minimal morbidity. Despite the aforemen­
tioned concerns, the number of articles in the literature
examining fat grafting has steadily risen since the early 1990s
as practitioners continually refine and expand upon the
technique and its indications.1
The concerns related to interference with cancer surveil­
lance have by and large been resolved in the literature, with
no studies demonstrating evidence of impediment to breast
cancer screening or surveillance in patients undergoing fat
grafting procedures. A matched cohort analysis of patients
undergoing post-mastectomy breast reconstruction with and
without fat grafting as a secondary procedure found the
incidence of breast biopsy to clarify abnormal imaging was
not significantly higher in the fat-grafted group (17.6% versus
7.8%, p=0.14).89 In fact, fewer than 10% of imaging studies in
the fat-grafted cohort were performed to investigate a clinical
or radiographic abnormality occupying the same breast
quadrant as prior fat injection. Another study by Rubin et al.
examined mammograms from patients undergoing either
breast fat grafting or breast reduction procedures and found
scarring (p<0.001) and masses requiring biopsy (p<0.001)
were significantly higher in the breast reduction cohort.90 In
addition, BI-RADS scores were noted to be significantly higher
for breast reduction patients (p<0.001). Finally, a 2015 system­
atic review of fat grafting to the breast that included 35 studies
with 3624 patients found fat necrosis was the most common
complication (4.4%), biopsy of a subsequent breast lump was
required in 2.7% and an interval mammogram in 11.5% of
patients.91 Meta-analysis of comparative studies showed no
significant difference in oncological event rates between fat-
grafted and non-fat-grafted groups (p=0.10).
Currently, a discrepancy exists in the literature surround­
ing fat grafting and breast cancer. Basic science studies repeat­
edly demonstrate a strong interplay between ASCs and cancer
cells. However, clinical studies fail to demonstrate any signifi­
cant detrimental effect with one lone exception. In vitro
experimental models show ASCs can create an enhanced
environment promoting tumorigenesis. And yet recurrence
rates amongst patients who have had fat grafting after cancer
treatment parallel those who have not. This discrepancy exists
in large part due to the use of immortalized breast cancer cell
lines (BCCs) used to represent primary or recurrent breast
cancer in laboratory studies.
Immortalized cell lines are routinely used as surrogates in
the laboratory to probe the biologic behavior of various tissue
types. One must recall that BCCs utilized today were isolated
decades ago from distant metastases and remain phenotypi­
cally different from primary cancer cell lines. Great caution
must be exercised when interpreting studies utilizing them as
commonly used donor sites (abdominal fat, thigh fat, flank
fat, or knee fat) from five subjects were evaluated, no immedi­
ate differences in adipocyte viability were observed.85 These
results were corroborated by another study in which no dif­
ferences in fat viability were observed when fat was harvested
from three donor sites from one subject (thigh, abdomen, and
breast) and injected into a nude mouse model.86 However,
these results were challenged by Schipper et al., showing there
is variability in physiologic function of ASCs that have been
harvested from different subcutaneous depots, with the
superficial abdominal depot being most resilient and provid­
ing superior graft retention rates.87 Additionally, the authors
demonstrated age-related changes in ASC function that may
impact overall graft survival irrespective of depot used,
stressing the importance of appropriate patient selection.
Furthermore, ASC counts in harvested tissues are observed to
vary widely from patient to patient and not only from depot
to depot.
Published data thus far have failed to produce an agreed-
upon algorithm of the required components for successful,
consistent, and durable autologous fat transplantation. There
is a modest preference in favor of the following approach:
harvesting abdominal fat with a blunt-tip cannula technique,
centrifugation without washing or other manipulation, and
immediate injection of small aliquots of fat by means of
multiple passes.7 After almost 30 years of varying applications
of fat transfer, surgeons and scientists alike are attempting to
provide insights into fat grafting techniques so that patients
are provided with optimized clinical outcomes. Large, well-
designed prospective randomized clinical trials are needed
but remain elusive given the sheer number of variables
in question and difficulty with appropriately blinding
surgeons.
Safety concerns
The overall safety of fat grafting procedures is well estab­
lished, with low morbidity and relatively few perioperative
complications. Overall, patients tolerate the procedure exceed­
ingly well. However, when questions regarding the safety of
fat grafting arise, they are generally related to oncologic
matters. The presumed interactions of fat grafts with the
recipient tissues are of primary concern – either the ability to
scar and distort cellular architecture or the ability of progeni­
tor cells to push and/or accelerate aberrant processes. Breast
cancer-related defects remain by far the most common onco­
logic defects reconstructed with autologous fat.88 With breast
cancer being the most common cancer in females and the
leading cause of cancer-related death in females, in 1987 the
ASPS banned fat grafting to the breast primarily due to con­
cerns regarding ongoing cancer surveillance. This was pre­
sumed to be due to low graft retention rates and high rates of
fat necrosis that were believed to interfere with routine cancer
surveillance. Concerns were later raised about the interaction
of ASCs within the fat graft and residual microscopic disease
that may remain following extirpation.
In 2007, the ASPS established its Fat Graft Task Force to
re-examine the potential hazards and numerous benefits of fat
grafting to the breast. During the 1990s, Coleman had intro­
duced and refined the concept of structural fat grafting,
leading to increased retention rates and better understanding
of graft predictability. In the decades since, there had also

331
Patient selection
with intraepithelial neoplasia compared to 118 matched con­
trols, showed the 5-year local recurrence was 18% versus 3%
for fat grafting and controls, respectively (p=0.02).103
Many systematic reviews/meta-analyses demonstrate
similar loco-regional recurrence rates for breast cancer patients
who underwent fat grafting relative to control subjects. Yet
one case series and one clinical study (both from the same
group of authors) point to higher local breast cancer recur­
rence after fat grafting in patients with intraepithelial neopla­
sia. In a 2015 review, the authors of the two studies in question
showing increased rates of recurrence state that definitive
conclusions require large series, controls with matching cancer
criteria, and minimum 5-year follow-up.104 However, the
oncologic safety of fat grafting has already been proven in the
literature and overwhelmingly demonstrates the overall
safety of fat grafting procedures in breast cancer patients.
Diagnosis/patient presentation
While the aesthetic applications of fat grafting have long been
described, this technique has numerous reconstructive appli­
cations. These include congenital deformities such as hemifa­
cial microsomia and Treacher Collins syndrome. In addition,
patients who have sustained previous trauma resulting in
significant scarring or tissue loss can often benefit from fat
grafting.105 Patients who have undergone previous cosmetic
surgery can also present with iatrogenic deformities such as
hollowed upper eyelids, flattening of the posterior jaw line,
or contour deformities resulting from liposuction. These areas
can be restored to a more youthful and natural appearance
with thoughtful and sensible applications of fat grafting.
A newer use of fat appears to come from its regenerative
properties on damaged tissues. Rigotti has grafted fat beneath
tissue ulcerations in the breast that occurred after radiation
therapy, and has noted remarkable restoration and healing of
the involved tissues.106 Irradiated tissue that is stiff and non­
compliant can be restored to a more normal consistency and
texture and allows filling of contour deformities. In addition,
anecdotal reports have been made regarding the improve­
ment of the appearance of scars and skin quality after fat
grafting.5,105 Amputees with poorly fitting prosthetics also
appear to gain benefit from remodeling of the stump at the
prosthetic interface, providing more robust tissue coverage
and a better, more durable fit.107
Patient selection
Patient selection must begin with a detailed history, noting
pertinent medical comorbidities that may limit therapeutic
potential. Candidates must be able to withstand the anesthetic
requirements of the procedure, and as a result it may not
always be prudent to offer fat grafting to those with profound
systemic ailments. Fat grafting to small areas can certainly be
performed under local anesthesia, but anything involving
more than a few milliliters will generally require sedation at
a minimum. Physical examination entails a thorough assess­
ment of the defect in question in addition to assessment of
potential donor sites. This allows the physician to formulate
a plan for correction of the defect in question. Patients with
unrealistic expectations are not good candidates for this or
representatives of primary cancer. However, multiple studies
do demonstrate strong interactions between BCCs and ASCs.
In a study assessing the role of the PDGF-β signaling pathway
in cancer metastasis, conditioned medium from MDA-MB-
231 and 4T1 BCCs was shown to serve as an attractant via
chemotaxis for ASCs.92 In another study, in vitro migration of
triple-negative MD-MB-231 was enhanced by ASC co-culture;
similar results were also achieved with ASC conditioned
media.93 In the study, increased metastases were also seen in
the liver, lung and spleen in a murine xenograft model, sug­
gesting a role for ASCs in angiogenesis and overall increase
in metastatic potential of BCCs. In yet another study, intercel­
lular contact between ASCs and BCCs led to increased expres­
sion of malignancy markers in BCCs.94 Specifically, ASCs with
higher basal levels of hepatocyte growth factor led BCCs in
co-culture to increase expression of c-Met, suggesting a role
for ASCs in enhancing tumorigenesis. When co-injected with
BCCs into nude mice, ASCs were found to differentiate into
endothelial-like cells and supported development of larger
primary tumors.95 CD34+ progenitor cells from fat have been
shown to differentiate in endothelial cells and form capillaries
that supported tumor growth and metastasis.96 Interestingly,
ASCs can also promote progression and penetration of the
invasive BCC line T4-2, but not its pre-invasive variant HMT-
3522-S3, suggesting pre-invasive lesions may not be as sensi­
tive to the local effects of ASCs.97 Experimental results like
those above should be interpreted with great caution – as the
experimental scenarios are highly idealized and do not repre­
sent any realistic clinical setting. BCCs again are not represen­
tative of clinical malignancies and ASC doses used in the
experiments are orders of magnitude higher than could ever
be obtained in clinical situations. Nonetheless, caution with
cell-enriched therapies is certainly warranted in high-risk
patients with breast cancer.
So what exactly is the clinical risk of fat grafting to the
breast? Breast cancer recurrence rates are in the range of
5.2–10.6% in patients who have not undergone fat grafting
after breast cancer surgery.98,99 A systematic review examining
the oncologic safety of breast fat grafting reviewed 16 clinical
studies including 2100 patients and found a local recurrence
rate of 2.2% following fat grafting procedures.100 A case–control
study assessing the oncologic safety of fat grafting reported
no significant excess oncologic events in patients after fat
grafting with respect to local recurrence (0.95% vs 1.90%,
p=0.33), regional recurrence (0.95% vs 0%, p=0.16), and distant
recurrence (3.32% vs 2.61%, p=0.65).101 A concurrent system­
atic review of the literature in the same study identified 1573
women who had fat grafting after oncologic breast surgery
and found a loco-regional relapse rate of 2.92% (or 0.95% per
year). Another systematic review of the literature included 35
studies and 3624 patients and found a 4.4% weighted mean
recurrence rate at 24.6 months amongst patients who under­
went autologous fat grafting of the breast.91 Meta-analysis in
that same study showed no significant difference in oncologic
event rate between fat-grafted and non-fat-grafted groups. A
matched-cohort study assessing loco-regional risk after fat
grafting in 321 breast cancer patients and 642 matched controls
found no difference in recurrence between fat grafting and
control groups (p=0.792).102 However, when cases were limited
to intraepithelial neoplasia (n=37), fat grafting may have
caused 4 recurrence events (p<0.001). A subsequent study by
the same authors, which looked specifically at 59 patients

332
CHAPTER 20 • Reconstructive fat grafting
gauze (Telfa rolling) can result in even higher rates of reten­
tion of injected fat. However, this method lacks efficiency. In
the case of large volume fat injection, the principles of harvest
and injection must be adapted to enable greater volumes of
fat to be handled efficiently in the operating room (Figs.
20.1–20.6).
Harvesting
As no conclusive differences in viability or graft take have
been demonstrated from one site to another in scientific
studies, the choice of donor site for fat grafting is dependent
on the desires of the patient and accessibility of the fat. In
general, the abdomen, “love handle”, posterior hip, back, and
lateral thighs are useful sites. In thinner patients, especially
males, the medial thighs are an often overlooked but fruitful
depot. Incisions should be hidden in creases, scars, stretch
marks, or hair-bearing areas, if at all possible. Through these
incisions, local anesthetic solution is infiltrated using a blunt
any other procedure. Patients must be informed that several
rounds of fat grafting may be needed to achieve the desired
results.
A relative contraindication is the thin patient who does not
have sufficient fat stores from which to harvest fat. Since large
volumes of fat are generally not needed for the face, enough
fat can usually be harvested for these procedures. For fat
grafting to the breasts or body, significantly more fat is gener­
ally required; often there is a limit to the correction that can
be made given the paucity of fat in some patients. Asking the
patient to gain weight prior to the procedure is feasible only
if the patient is willing and able to maintain that weight
afterwards. Weight loss following fat grafting can lead to loss
of volume and failure to maintain adequate correction.
Treatment/surgical technique
The surgeon must be familiar with the potential levels of
placement (e.g., subdermal, intramuscular, and supraperios­
teal) and the amounts necessary at each level to accomplish a
desirable change. These amounts will vary across regions of
body as well as from patient to patient. Determining the
amounts of fat to place and the levels in which to place the
fat in order to create subtle, lasting contour changes requires
a sophisticated surgical plan.
The Coleman method of fat grafting remains essentially
unchanged since the original inception almost three decades
ago.24 The process relies upon harvesting the fat gently to
preserve its architecture, refining the fat with centrifugation
to remove nonviable components and provide a predictable
volume, and placement of the fat in small aliquots to increase
the surface area and ensure a robust blood supply to the
grafted tissue.23 When these principles are adhered to, fat
grafting can be a reproducible and safe procedure. Histologic
studies have shown that this method of harvesting and refine­
ment with centrifugation yields fat with a high percentage of
survival and near-normal adipose cellular enzyme activity108
and, for small volume grafting, filtering the fat on sterile
Fig. 20.1  Large volume fat harvest and processing represents a logistical challenge in the operating room. A simple apparatus consists of a sterile collection chamber set
up in-line on the sterile field. Machine-generated suction from a standard liposuction aspirator is applied through the system, and a standard liposuction cannula of 3 or
4 mm diameter used to harvest fat into the vessel (A). The aspirate is allowed to decant until the fat separates from the aqueous layer. The aqueous layer is then removed
by aspiration with a suction cannula (B,C). Commercially available vessels for large-volume fat collection are also constructed with spigots at the base to drain the aqueous
layer.
A
B
C
Fig. 20.2  An alternative to decanting the fat is to filter the fat in a medical grade
sterile sieve.

333
Treatment/surgical technique
Fig. 20.3  The sterile graft material can be handled by placing it in a vessel with a pour-spout (A), and
then filling capped 30-cc syringe barrels from the back (B,C).
A
B
C
Fig. 20.4  For large-volume fat grafting, a 16-gauge blunt-tipped cannula can be used with the 30-cc syringes (A), and the fat should be easily flowable (B).
A
B
infiltration cannula. The local anesthetic mixture should
consist of 0.2% lidocaine with 1 : 200 000 epinephrine. In
general, the amount of solution infiltrated is equal to the
amount of fat removed (1 : 1 ratio, superwet technique).
After waiting approximately 10 minutes for the local anes­
thetic solution to take effect, fat is then harvested using a
bucket-handle harvesting cannula. This harvesting cannula is
designed to harvest intact fatty tissue parcels that are large
enough to survive, but small enough to pass through the
standard 17-gauge infiltration cannula used for grafting. The
cannula may be utilized with any vacuum- or power-assisted
liposuction equipment or simply attached to 10-ml syringes.
If 10-ml syringes are used, the plunger is pulled back only a
few milliliters so as not to create too much negative pressure
and traumatize the aspirate. Incisions are closed with inter­
rupted 5-0 fast-absorbing sutures.

334
CHAPTER 20 • Reconstructive fat grafting
sterility during the centrifugation process – a centrifuge
with a sterile central rotor and/or sterile sleeves is essential.
Centrifugation at 3000 rpm (1200 g) for 3 min concentrates
the fat so that the aqueous components (the local anesthetic
and blood) can be removed and discarded by releasing the
Luer-Lok™ plug. In addition, any oil can be decanted off the
top and/or wicked away with gauze pads. The processed fat
is then transferred to a 1-cc syringe for placement into the
defect.
Placement
Planned incision sites are anesthetized with 0.5% lidocaine
with 1 : 200 000 epinephrine and small stab incisions are made
for the placement of fat through 17-gauge Coleman injection
cannulas. This not only helps to reduce bruising, but also
decreases the chance of accidental intravascular embolization
of the fat. The success of the fat grafting procedure depends
not only on the harvesting and refinement, but also on the
placement of the fat in a manner that increases its chance for
optimal survival. This means maximizing the contact surface
area of the fatty parcel with the surrounding tissue, such that
a blood supply can be conferred to the newly grafted fat.
Transferring large globules of fat can result in central necrosis
of the mass with subsequent resorption and loss of volume,
or possibly even cyst formation.
The fat is gently placed during the withdrawal of a blunt
Coleman infiltration cannula. Recall fat can be placed at dif­
ferent levels to accomplish different effects – determining
where and at what level to place fat relies upon the skill
and experience of the surgeon. For instance, grafting fat
Refinement
As fat is harvested, the first few passes of the cannula will
retrieve more local anesthetic than subsequent passes. As suc­
tioning continues, the later passes may contain less aspirate
and more blood. After harvest, lipoaspirate is transferred to
10-ml syringes; a Luer-Lok™ plug is used to cap the syringe.
Using 10-ml syringes for aspiration avoids the need to
transfer. The plunger is removed, and the syringe is placed
into a sterile centrifuge. It is vitally important to maintain
Fig. 20.5  For small-volume fat grafting, the Coleman processing method is highly efficient and reproducible. A tabletop centrifuge (A) with a sterile rotor and tubes, holds
10-cc syringes (B) and generates 1200 G-force at 3000 rpm. The fat is centrifuged for three minutes to separate the oil, fat, and aqueous layers. After draining the aqueous
layer and wicking the oil with cotton gauze, the fat can be filled into 1-cc syringes (C), using a Luer connector or by filling the syringe from the back. Blunt-tipped cannulas
with a very small aperture and diameter are fitted to the 1-cc syringes for precise placement of fat in the regions such as the face or hand (D,E). These blunt-tipped
cannulas also come in curved shapes for accessing tight spaces.
A
B
C
D
E
Fig. 20.6  For processing very small volumes for grafting, an easy method is
filtering the fat graft on Telfa non-adherent gauze. This method yields a high
retention rate, but lacks efficiency.

335
Treatment/surgical technique
Fig. 20.7  Head and neck cancer reconstruction using fat graft. This 57-year-old woman was treated for an aggressive squamous cell carcinoma with full-thickness cheek
resection and reconstruction with a radial forearm free flap and subsequent radiation therapy. She presented three years after her cancer reconstruction, disease free, desiring
further reconstruction, this time with fat grafting.
A
B
C
Fig. 20.8  Intraoperative markings.
A
B
C
immediately beneath the dermis can improve the quality of
the skin, decrease wrinkling, decrease pore size, and may
even reduce scarring. Special care must be taken, however,
when placing fat superficially, as surface irregularities are
more apt to be apparent. This is especially true in areas that
have thin skin, such as the lower eyelid. To make changes in
the shape of the body that relate to the underlying bony
skeleton, fat can be placed above the periosteum. To build
bulk, the fat can be placed intramuscularly. The structure
should be purposefully built up with tiny aliquots of fat rather
than attempting to insert larger aliquots and then mold the
tissue after it is placed. Molding may displace the fat or cause
necrosis of some or all of the fat in an area, decreasing predict­
ability and increasing uneven contours. The only time molding
should be considered is if an irregularity is noted at the time
of placement, as the surface must be smooth before leaving
the operating room. The stab incisions used for placement of
the fat can be closed with single interrupted 5-0 fast-absorbing
sutures. An example of small volume grafting to the face for
reconstruction is shown in Figs. 20.7–20.10. Large-volume
Fig. 20.9  Postoperative results six months after first-stage treatment.
A
B
C

336
CHAPTER 20 • Reconstructive fat grafting
areas should remain elevated above the level of the heart for
72 hours following the procedure. Direct pressure upon the
grafted area should be avoided for one week. Sutures in
the face are removed in 4–5 days, and resorbable sutures
at other sites can be removed in one week or left to
dissolve away on their own. Donor sites may be dressed with
compression garments or an abdominal binder if large
volumes are harvested. Deep massage is avoided for one
month postoperatively. Preoperative antibiotics will suffice
for most patients, while those patients that are at high risk for
surgical site infection can be given 3–5 days of antibiotics
postoperatively.
Outcomes, prognosis, and
complications
Fat grafting procedures by and large are deemed to be low
risk and are associated with low perioperative morbidity
rates given proper patient selection. Soreness and swelling
are common, but not every patient will experience them.
The most significant risk remains the unpredictable nature of
the graft, where the recipient site may simply reabsorb most
of the transferred fat. The extent of resorption at this time
cannot be predicted for a given individual, but some degree
of resorption will happen in every patient. Rare but possible
fat transfer risks and complications include: allergic reaction
to the local anesthetic, permanent discoloration caused by a
ruptured blood vessel, fat necrosis, oil cyst formation, calcifica­
tion, overcorrection, perioperative bleeding, a blood clot at the
treatment or donor site, a blood-borne infection (more likely if
combined with another cosmetic procedure), scarring, and a
fat embolism from direct fat injection into a blood vessel. Most
problematic is the high potential for contour irregularities
visible through the skin, which can occur in both the recipient
and donor sites. In the recipient sites, excess grafted fat will
appear as lumps beneath the skin, and is generally the result
of placement of a volume that was too large just beneath thin
skin. Unwanted parcels of fat can be difficult to remove at
a later time, therefore prudence should be exercised when
placing grafts. Potential remedies for irregularities caused
by excess fat include liposuctioning of the fat, direct exci­
sion, lipodissolve products (not approved by the FDA in the
United States), and potentially off-label use of the deoxy­
cholic acid derivative ATX-101 (known as Kybella®).109–111
fat grafting to the breast is shown for lumpectomy defects
(Fig. 20.11), replacement of implants (Figs. 20.12–20.14), and
total breast reconstruction (Fig. 20.15).
Postoperative care
Care of the patient after fat grafting remains relatively simple.
Grafted areas are not routinely dressed, and patients may
shower 48 hours following the procedure. If possible, grafted
Fig. 20.10  Results eight months after second round of fat grafting. All fat grafting procedures were done on an outpatient basis.
A
B
C
Fig. 20.11  54-year-old woman three years status post left breast quadrantectomy
and radiation therapy for invasive breast carcinoma (A). Patient shown five months
status post fat grafting with scar release of the left breast, and concurrent reduction
of right breast for symmetry (B).
A
B

337
Outcomes, prognosis, and complications
Fig. 20.12  Removal of breast implants and replacement with fat graft in the same
procedure. This 48-year-old woman had severe right breast capsular contracture
with pain. This was a recurrent problem for this patient. She presented for
explantation of the implants.
A
B
C
Fig. 20.13  Patient six months after removal of 350-cc smooth round saline
implants and simultaneous grafting of 380 cc of fat per breast.
A
B
C

338
CHAPTER 20 • Reconstructive fat grafting
Fig. 20.14  The same patient shown 18 months after single-stage fat grafting.
A
B
C
Fig. 20.15  (A) 45-year-old woman status post
bilateral mastectomies. She has not been treated with
radiation. (B) Patient is shown three years after breast
reconstruction with external expansion (BRAVA), and
three fat grafting treatments. (Case courtesy of Dr.
Roger Khouri.)
A
B

339
Secondary procedures
Irregularities in the donor sites can be pronounced, particu­
larly if too much fat is removed from a single area. Significant
changes in weight can also result in related changes in the
size of the area grafted, therefore patients are encouraged
to have fat grafting procedures performed when they are
at their ideal body weight and to maintain that weight
indefinitely.
Secondary procedures
With fat grafting, secondary procedures, or touch-up proce­
dures, are possible if an incorrect volume of fat was placed
initially. Infiltration and swelling at the time of surgery,
in addition to the unpredictable resorption of fat, make
achieving perfection in a single stage difficult. Patients
should be instructed that multiple rounds of grafting might
be required to achieve the desired end. In reconstructive
cases, the soft tissue envelope often limits the surgeon, and
as tissue quality improves after initial fat grafting, the area
may become more receptive to larger subsequent volumes. It
is far better to under-correct a deficient area and return to
the operating room for a second stage, if necessary, at a later
date. In complicated liposuction cases, a second stage is
often part of the original plan, as it can be very difficult to
make an area perfect in one procedure. Generally, the goal of
the first procedure is to fill in large defects with significant
amounts of fat and later to come back and refine the area
with additional grafts.
1. Kling RE, Mehrara BJ, Pusic AL, et al. Trends in autologous fat
grafting to the breast: a national survey of the American Society of
Plastic Surgeons. Plast Reconstr Surg. 2013;132:35–46. This article
presents survey data that highlights the common use of breast fat
grafting in plastic surgery practice. The survey of board-certified plastic
surgeons revealed a 70% incidence of breast fat grafting, with twice as
many surgeons using fat grafting for reconstructive applications than
cosmetic applications.
9. Bourin P, Bunnell BA, Casteilla L, et al. Stromal cells from the
adipose tissue-derived stromal vascular fraction and culture
expanded adipose tissue-derived stromal/stem cells: a joint
statement of the International Federation for Adipose Therapeutics
and Science (IFATS) and the International Society for Cellular
Therapy (ISCT). Cytotherapy. 2013;15:641–648.
11. Philips BJ, Grahovac TL, Valentin JE, et al. Prevalence of
endogenous CD34+ adipose stem cells predicts human fat graft
retention in a xenograft model. Plast Reconstr Surg. 2013;132:845.
12. Neuber F. Fettransplantation. Verh Dtsch Ges Chir. 1893;22:66.
23. Coleman S. Structural Fat Grafting. St Louis: Quality Medical
Publishing; 2004. This work describes the Coleman fat grafting
technique, which has evolved as a widely used method across the globe.
The reproducibility and simplicity of the methodology has led to the
broad adoption of fat grafting in plastic surgery practice.
48. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human
adipose tissue: implications for cell-based therapies. Tissue Eng.
2001;7:211–228. One of the landmark articles describing adult stem cells
within adipose tissue. While “preadipocytes” had been described as the
precursors for mature adipocytes, the stromal cells within adipose
tissue were now shown to have plasticity and properties of adult stem
cells.
76. Gutowski KA, ASPS Fat Graft Task Force. Current applications
and safety of autologous fat grafts: a report of the ASPS fat graft
task force. Plast Reconstr Surg. 2009;124:272–280.
90. Rubin JP, Coon D, Zuley M, et al. Mammographic changes
after fat transfer to the breast compared with changes after
breast reduction: a blinded study. Plast Reconstr Surg. 2012;129:
1029–1038. A major concern with fat grafting to the breast has been the
risk that fat necrosis and calcifications can obscure cancer detection and/
or result in false positive imaging results and increased biopsy rates. This
study compared mammographic changes after fat grafting with changes
after reduction mammoplasty, and found that breast reduction patients
have more pronounced mammographic changes and a higher BI-RADS
score than fat grafting patients.
100. Charvet HJ, Orbay H, Wong MS, Sahar DE. The oncologic safety
of breast fat grafting and contradictions between basic science and
clinical studies: a systematic review of the recent literature. Ann
Plast Surg. 2015;75:471–479. This paper highlights the fact that basic
science studies suggest that bioactive components of fat grafts can induce
tumor growth. However, available clinical studies are suggesting that fat
grafting to the breast is a safe approach. More strong clinical data is
needed to further support this position.
101. Gale KL, Rakha EA, Ball G, et al. A case-controlled study of the
oncologic safety of fat grafting. Plast Reconstr Surg.
2015;135:1263–1275.
Access the complete reference list online at

339.e1
References
References
1. Kling RE, Mehrara BJ, Pusic AL, et al. Trends in autologous fat
grafting to the breast: a national survey of the American Society of
Plastic Surgeons. Plast Reconstr Surg. 2013;132:35–46. This article
presents survey data that highlights the common use of breast fat
grafting in plastic surgery practice. The survey of board-certified plastic
surgeons revealed a 70% incidence of breast fat grafting, with twice as
many surgeons using fat grafting for reconstructive applications than
cosmetic applications.
2. Choi M, Small K, Levovitz C, et al. The volumetric analysis of fat
graft survival in breast reconstruction. Plast Reconstr Surg.
2013;131:185–191.
3. Clauser LC, Tieghi R, Galiè M, Carinci F. Structural fat grafting:
facial volumetric restoration in complex reconstructive surgery. J
Craniofac Surg. 2011;22:1695–1701.
4. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg.
2001;28:111–119.
5. Coleman SR. Structural fat grafting: more than a permanent filler.
Plast Reconstr Surg. 2006;118:108S–120S.
6. Gir P, Brown SA, Oni G, et al. Fat grafting: evidence-based review
on autologous fat harvesting, processing, reinjection, and storage.
Plast Reconstr Surg. 2012;130:249–258.
7. Kaufman MR, Miller TA, Huang C, et al. Autologous fat transfer
for facial recontouring: is there science behind the art? Plast
Reconstr Surg. 2007;119:2287–2296.
8. Wetterau M, Szpalski C, Hazen A, Warren SM. Autologous fat
grafting and facial reconstruction. J Craniofac Surg.
2012;23:315–318.
9. Bourin P, Bunnell BA, Casteilla L, et al. Stromal cells from the
adipose tissue-derived stromal vascular fraction and culture
expanded adipose tissue-derived stromal/stem cells: a joint
statement of the International Federation for Adipose Therapeutics
and Science (IFATS) and the International Society for Cellular
Therapy (ISCT). Cytotherapy. 2013;15:641–648.
10. Condé-Green A, Wu I, Graham I, et al. Comparison of 3
techniques of fat grafting and cell-supplemented lipotransfer in
athymic rats. Aesthet Surg J. 2013;33:713–721.
11. Philips BJ, Grahovac TL, Valentin JE, et al. Prevalence of
endogenous CD34+ adipose stem cells predicts human fat graft
retention in a xenograft model. Plast Reconstr Surg. 2013;132:845.
12. Neuber F. Fettransplantation. Verh Dtsch Ges Chir. 1893;22:66.
13. Czerny V. Drie plastische operationen III. Plastischer Ersatz der
Brustdrüse durch ein Lipom. Verhandlungen der Deutschen
Gesellschaft für Chirurgie. 1895;II:216–217.
14. Holländer E. Die kosmetische Chirurgie. Leipzig: Veit; 1912.
15. Posner C, Kohn H. Berliner Klinische Wochenschrift. Vol. 45, No. 3. 1908.
16. Lexer E. Die freien Transplantationen. Vol. 25. Stuttgart: Enke; 1917.
17. Miller CC. Cannula Implants and Review of Implantation Technics in
Esthetic Surgery: In Two Parts. Chicago: Oak Press; 1926.
18. Peer LA. The neglected “free fat graft,” its behavior and clinical
use. Am J Surg. 1956;92:40–47.
19. Fournier P. Reduction syringe liposculpturing. Dermatol Clin.
1990;8:539–551.
20. Illouz Y-G. The fat cell “graft”: a new technique to fill depressions.
Plast Reconstr Surg. 1986;78:122.
21. Chajchir A, Benzaquen I. Fat-grafting injection for soft-tissue
augmentation. Plast Reconstr Surg. 1989;84:921–934.
22. Coleman S. Lipoinfiltration of the upper lip white roll. Aesthet Surg
J. 1994;14:231–234.
23. Coleman S. Structural Fat Grafting. St Louis: Quality Medical
Publishing; 2004. This work describes the Coleman fat grafting
technique, which has evolved as a widely used method across the globe.
The reproducibility and simplicity of the methodology has led to the
broad adoption of fat grafting in plastic surgery practice.
24. Coleman SR. The technique of periorbital lipoinfiltration. Oper Tech
Plast Reconstr Surg. 1994;1:120–126.
25. Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesthetic Plast Surg. 1995;19:421–425.
26. Ersek RA. Transplantation of purified autologous fat: a 3-year
follow-up is disappointing. Plast Reconstr Surg. 1991;87:219–227.
27. Peer LA. Loss of weight and volume in human fat grafts: with
postulation of a “cell survival theory”. Plast Reconstr Surg.
1950;5:217–230.
28. Coleman SR. Facial recontouring with lipostructure. Clin Plast
Surg. 1997;24:347–367.
29. Ellenbogen R. Free autogenous pearl fat grafts in the face-a
preliminary report of a rediscovered technique. Ann Plast Surg.
1986;16:179–194.
30. Kajimura S, Saito M. A new era in brown adipose tissue biology:
molecular control of brown fat development and energy
homeostasis. Annu Rev Physiol. 2014;76:225.
31. Kajimura S, Spiegelman BM, Seale P. Brown and beige fat:
physiological roles beyond heat generation. Cell Metab.
2015;22:546–559.
32. Haque WA, Garg A. Adipocyte biology and adipocytokines. Clin
Lab Med. 2004;24:217–234.
33. Niemelä S-M, Miettinen S, Konttinen Y, et al. Fat tissue: views on
reconstruction and exploitation. J Craniofac Surg. 2007;18:325–335.
34. Rosen ED, Spiegelman BM. Adipocytes as regulators of energy
balance and glucose homeostasis. Nature. 2006;444:847–853.
35. Sethi JK, Vidal-Puig AJ. Thematic review series: adipocyte biology.
Adipose tissue function and plasticity orchestrate nutritional
adaptation. J Lipid Res. 2007;48:1253–1262.
36. Landin K, Stigendal L, Eriksson E, et al. Abdominal obesity is
associated with an impaired fibrinolytic activity and elevated
plasminogen activator inhibitor-1. Metabolism. 1990;39:1044–1048.
37. Gregoire FM, Smas CM, Sul HS. Understanding adipocyte
differentiation. Physiol Rev. 1998;78:783–809.
38. Akerblad P, Lind U, Liberg D, et al. Early B-cell factor (O/E-1) is a
promoter of adipogenesis and involved in control of genes
important for terminal adipocyte differentiation. Mol Cell Biol.
2002;22:8015–8025.
39. Banerjee SS, Feinberg MW, Watanabe M, et al. The Krüppel-like
factor KLF2 inhibits peroxisome proliferator-activated receptor-γ
expression and adipogenesis. J Biol Chem. 2003;278:2581–2584.
40. Chen Z, Torrens JI, Anand A, et al. Krox20 stimulates adipogenesis
via C/EBPβ-dependent and-independent mechanisms. Cell Metab.
2005;1:93–106.
41. Mori T, Sakaue H, Iguchi H, et al. Role of Krüppel-like factor 15
(KLF15) in transcriptional regulation of adipogenesis. J Biol Chem.
2005;280:12867–12875.
42. Oishi Y, Manabe I, Tobe K, et al. Krüppel-like transcription factor
KLF5 is a key regulator of adipocyte differentiation. Cell Metab.
2005;1:27–39.
43. Ibrahimi A, Bonino F, Bardon S, et al. Essential role of collagens
for terminal differentiation of preadipocytes. Biochem Biophys Res
Commun. 1992;187:1314–1322.
44. Dardick I, Poznanski WJ, Waheed I, Setterfield G. Ultrastructural
observations on differentiating human preadipocytes cultured in
vitro. Tissue Cell. 1976;8:561–571.
45. Aksu AE, Rubin JP, Dudas JR, Marra KG. Role of gender and
anatomical region on induction of osteogenic differentiation of
human adipose-derived stem cells. Ann Plast Surg.
2008;60:306–322.
46. Green H, Kehinde O. An established preadipose cell line and its
differentiation in culture II. Factors affecting the adipose
conversion. Cell. 1975;5:19–27.
47. Hollenberg C, Vost A. Regulation of DNA synthesis in fat cells and
stromal elements from rat adipose tissue. J Clin Invest.
1968;47:2485.
48. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human
adipose tissue: implications for cell-based therapies. Tissue Eng.
2001;7:211–228. One of the landmark articles describing adult stem cells
within adipose tissue. While “preadipocytes” had been described as the
precursors for mature adipocytes, the stromal cells within adipose tissue
were now shown to have plasticity and properties of adult stem cells.
49. Rubin JP, Marra KG. Soft tissue reconstruction. Methods Mol Biol.
2011;702:395–400.

339.e2
CHAPTER 20 • Reconstructive fat grafting
50. Brayfield C, Marra K, Rubin J. Adipose stem cells for soft
tissue regeneration. Handchir Mikrochir Plast Chir. 2010;42:
124–128.
51. Bunnell BA, Estes BT, Guilak F, Gimble JM. Differentiation of
adipose stem cells. Methods Mol Biol. 2008;456:155–171.
52. Choi YS, Cha SM, Lee YY, et al. Adipogenic differentiation of
adipose tissue derived adult stem cells in nude mouse. Biochem
Biophys Res Commun. 2006;345:631–637.
53. Frye CA, Patrick CW Jr. Three-dimensional adipose tissue model
using low shear bioreactors. In Vitro Cell Dev Biol Anim.
2006;42:109–114.
54. Gaustad KG, Boquest AC, Anderson BE, et al. Differentiation of
human adipose tissue stem cells using extracts of rat
cardiomyocytes. Biochem Biophys Res Commun. 2004;314:420–427.
55. Gerlach JC, Lin YC, Brayfield CA, et al. Adipogenesis of human
adipose-derived stem cells within three-dimensional hollow
fiber-based bioreactors. Tissue Eng Part C Methods. 2011;18:54–61.
56. Kang SK, Lee DH, Bae YC, et al. Improvement of neurological
deficits by intracerebral transplantation of human adipose
tissue-derived stromal cells after cerebral ischemia in rats. Exp
Neurol. 2003;183:355–366.
57. Kimura Y, Ozeki M, Inamoto T, Tabata Y. Adipose tissue
engineering based on human preadipocytes combined with gelatin
microspheres containing basic fibroblast growth factor. Biomaterials.
2003;24:2513–2521.
58. Lee J-H, Kemp DM. Human adipose-derived stem cells display
myogenic potential and perturbed function in hypoxic conditions.
Biochem Biophys Res Commun. 2006;341:882–888.
59. Lin Y, Chen X, Yan Z, et al. Multilineage differentiation of
adipose-derived stromal cells from GFP transgenic mice. Mol Cell
Biochem. 2006;285:69–78.
60. Mehlhorn A, Niemeyer P, Kaiser S, et al. Differential expression
pattern of extracellular matrix molecules during chondrogenesis of
mesenchymal stem cells from bone marrow and adipose tissue.
Tissue Eng. 2006;12:2853–2862.
61. Miranville A, Heeschen C, Sengenès C, et al. Improvement of
postnatal neovascularization by human adipose tissue-derived
stem cells. Circulation. 2004;110:349–355.
62. Miyahara Y, Nagaya N, Kataoka M, et al. Monolayered
mesenchymal stem cells repair scarred myocardium after
myocardial infarction. Nat Med. 2006;12:459–465.
63. Ning H, Lin G, Lue TF, Lin CS. Neuron-like differentiation of
adipose tissue-derived stromal cells and vascular smooth muscle
cells. Differentiation. 2006;74:510–518.
64. Planat-Benard V, Menard C, André M, et al. Spontaneous
cardiomyocyte differentiation from adipose tissue stroma cells.
Circ Res. 2004;94:223–229.
65. Rodríguez LV, Alfonso Z, Zhang R, et al. Clonogenic multipotent
stem cells in human adipose tissue differentiate into functional
smooth muscle cells. Proc Natl Acad Sci USA.
2006;103:12167–12172.
66. Stiles J, Francendese A, Masoro E. Influence of age on size and
number of fat cells in the epididymal depot. Am J Physiol.
1975;229:1561–1568.
67. Strem BM, Hicok KC, Zhu M, et al. Multipotential differentiation
of adipose tissue-derived stem cells. Keio J Med. 2005;54:132–141.
68. Zuk PA, Zhu M, Ashjian P, et al. Human adipose tissue is a source
of multipotent stem cells. Mol Biol Cell. 2002;13:4279–4295.
69. Ando H, Yanagihara H, Hayashi Y, et al. Rhythmic messenger
ribonucleic acid expression of clock genes and adipocytokines in
mouse visceral adipose tissue. Endocrinology. 2005;146:5631–5636.
70. Li H, Zimmerlin L, Marra KG, et al. Adipogenic potential of
adipose stem cell subpopulations. Plast Reconstr Surg. 2011;
128:663.
71. Minteer D, Marra KG, Rubin JP. Adipose-derived mesenchymal
stem cells: biology and potential applications. Adv Biochem Eng
Biotechnol. 2013;129:59–71.
72. Zimmerlin L, Donnenberg VS, Pfeifer ME, et al. Stromal vascular
progenitors in adult human adipose tissue. Cytometry A.
2010;77:22–30.
73. Minteer DM, Marra KG, Rubin JP. Adipose stem cells: biology,
safety, regulation, and regenerative potential. Clin Plast Surg.
2015;42:169–179.
74. Nguyen A, Pasyk KA, Bouvier TN, et al. Comparative
study of survival of autologous adipose tissue taken and
transplanted by different techniques. Plast Reconstr Surg.
1990;85:378–386.
75. Shiffman MA, Mirrafati S. Fat transfer techniques: the effect of
harvest and transfer methods on adipocyte viability and review of
the literature. Dermatol Surg. 2001;27:819–826.
76. Gutowski KA, ASPS Fat Graft Task Force. Current applications
and safety of autologous fat grafts: a report of the ASPS fat graft
task force. Plast Reconstr Surg. 2009;124:272–280.
77. Lee JH, Kirkham JC, McCormack MC, et al. The effect of pressure
and shear on autologous fat grafting. Plast Reconstr Surg.
2013;131:1125–1136.
78. Fisher C, Grahovac TL, Schafer ME, et al. Comparison of harvest
and processing techniques for fat grafting and adipose stem cell
isolation. Plast Reconstr Surg. 2013;132:351–361.
79. Boschert MT, Beckert BW, Puckett CL, Concannon MJ. Analysis of
lipocyte viability after liposuction. Plast Reconstr Surg.
2002;109:761–765.
80. Carraway JH, Mellow CG. Syringe aspiration and fat
concentration: a simple technique for autologous fat injection. Ann
Plast Surg. 1990;24:293–297.
81. Ersek RA, Chang P, Salisbury M. Lipo layering of autologous fat:
an improved technique with promising results. Plast Reconstr Surg.
1998;101:820–826.
82. Hörl H, Feller A-M, Biemer E. Technique for liposuction fat
reimplantation and long-term volume evaluation by magnetic
resonance imaging. Ann Plast Surg. 1991;26:248–258.
83. Kononas TC, Bucky LP, Hurley C, May JW Jr. The fate of suctioned
and surgically removed fat after reimplantation for soft-tissue
augmentation: a volumetric and histologic study in the rabbit.
Plast Reconstr Surg. 1993;91:763–768.
84. Özsoy Z, Kul Z, Bilir A. The role of cannula diameter in improved
adipocyte viability: a quantitative analysis. Aesthet Surg J.
2006;26:287–289.
85. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat
transfer viability: a quantitative analysis of the role of
centrifugation and harvest site. Plast Reconstr Surg.
2004;113:391–395.
86. Ullmann Y, Shoshani O, Fodor A, et al. Searching for the favorable
donor site for fat injection: in vivo study using the nude mice
model. Dermatol Surg. 2005;31:1304–1307.
87. Schipper BM, Marra KG, Zhang W, et al. Regional anatomic and
age effects on cell function of human adipose-derived stem cells.
Ann Plast Surg. 2008;60:538.
88. Kohler BA, Sherman RL, Howlader N, et al. Annual Report to the
Nation on the Status of Cancer, 1975-2011, Featuring Incidence of
Breast Cancer Subtypes by Race/Ethnicity, Poverty, and State. J
Natl Cancer Inst. 2015;107:djv048.
89. Pinell-White XA, Etra J, Newell M, et al. Radiographic
implications of fat grafting to the reconstructed breast. Breast J.
2015;21:520–525.
90. Rubin JP, Coon D, Zuley M, et al. Mammographic changes
after fat transfer to the breast compared with changes after
breast reduction: a blinded study. Plast Reconstr Surg. 2012;129:
1029–1038. A major concern with fat grafting to the breast has been the
risk that fat necrosis and calcifications can obscure cancer detection and/
or result in false positive imaging results and increased biopsy rates. This
study compared mammographic changes after fat grafting with changes
after reduction mammoplasty, and found that breast reduction patients
have more pronounced mammographic changes and a higher BI-RADS
score than fat grafting patients.
91. Agha RA, Fowler AJ, Herlin C, et al. Use of autologous fat grafting
for breast reconstruction: A systematic review with meta-analysis
of oncological outcomes. J Plast Reconstr Aesthet Surg.
2015;68:143–161.
92. Gehmert S, Prantl L, Vykoukal J, et al. Breast cancer cells attract
the migration of adipose tissue-derived stem cells via the

339.e3
References
PDGF-BB/PDGFR-β signaling pathway. Biochem Biophys Res
Commun. 2010;398:601–605.
93. Rowan BG, Gimble JM, Sheng M, et al. Human adipose tissue-
derived stromal/stem cells promote migration and early
metastasis of triple negative breast cancer xenografts. PLoS ONE.
2014;9:e89595.
94. Eterno V, Zambelli A, Pavesi L, et al. Adipose-derived
mesenchymal stem cells (ASCs) may favour breast cancer
recurrence via HGF/c-Met signaling. Oncotarget. 2014;5:613–633.
95. Muehlberg FL, Song YH, Krohn A, et al. Tissue-resident stem cells
promote breast cancer growth and metastasis. Carcinogenesis.
2009;30:589–597.
96. Orecchioni S, Gregato G, Martin-Padura I, et al. Complementary
populations of human adipose CD34+ progenitor cells promote
growth, angiogenesis, and metastasis of breast cancer. Cancer Res.
2013;73:5880–5891.
97. Zhao M, Sachs PC, Wang X, et al. Mesenchymal stem cells in
mammary adipose tissue stimulate progression of breast cancer
resembling the basal-type. Cancer Biol Ther. 2012;13:782–792.
98. Brewster AM, Hortobagyi GN, Broglio KR, et al. Residual risk of
breast cancer recurrence 5 years after adjuvant therapy. J Natl
Cancer Inst. 2008;100:1179–1183.
99. Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of
differences in the extent of surgery for early breast cancer on local
recurrence and 15-year survival: an overview of the randomised
trials. Lancet. 2006;366:2087–2106.
100. Charvet HJ, Orbay H, Wong MS, Sahar DE. The oncologic safety
of breast fat grafting and contradictions between basic science and
clinical studies: a systematic review of the recent literature. Ann
Plast Surg. 2015;75:471–479. This paper highlights the fact that basic
science studies suggest that bioactive components of fat grafts can induce
tumor growth. However, available clinical studies are suggesting that fat
grafting to the breast is a safe approach. More strong clinical data is
needed to further support this position.
101. Gale KL, Rakha EA, Ball G, et al. A case-controlled study of the
oncologic safety of fat grafting. Plast Reconstr Surg.
2015;135:1263–1275.
102. Petit J, Botteri E, Lohsiriwat V, et al. Locoregional recurrence risk
after lipofilling in breast cancer patients. Ann Oncol.
2012;23:582–588.
103. Petit J, Rietjens M, Botteri E, et al. Evaluation of fat grafting safety
in patients with intra epithelial neoplasia: a matched-cohort study.
Ann Oncol. 2013;24:1479–1484.
104. Petit JY, Maisonneuve P, Rotmensz N, et al. Safety of lipofilling in
patients with breast cancer. Clin Plast Surg. 2015;42:339–344.
105. Mojallal A, Lequeux C, Shipkov C, et al. Improvement of skin
quality after fat grafting: clinical observation and an animal study.
Plast Reconstr Surg. 2009;124:765–774.
106. Rigotti G, Marchi A, Galiè M, et al. Clinical treatment of
radiotherapy tissue damage by lipoaspirate transplant: a healing
process mediated by adipose-derived adult stem cells. Plast
Reconstr Surg. 2007;119:1409–1422.
107. Bavikatte G, Kulkarni J, Choukairi F, Lees V. Use of lipomodeling
to forearm residuum to assist fitting of below-elbow prosthesis.
J Prosthet Orthot. 2012;24:50–51.
108. Pu LL, Coleman SR, Cui X, et al. Autologous fat grafts harvested
and refined by the Coleman technique: a comparative study. Plast
Reconstr Surg. 2008;122:932–937.
109. Coleman SR. Lower lid deformity secondary to autogenous fat
transfer: A cautionary tale. Aesthetic Plast Surg. 2008;32:415–417.
110. Duncan DI, Chubaty R. Clinical safety data and standards of
practice for injection lipolysis: a retrospective study. Aesthet Surg J.
2006;26:575–585.
111. Spector JA, Draper L, Aston SJ. Lower lid deformity secondary to
autogenous fat transfer: a cautionary tale. Aesthetic Plast Surg.
2008;32:411–414.

21 
Vascular territories
Steven F. Morris and G. Ian Taylor
SYNOPSIS
■ This chapter provides an overview of the angiosome concept and
reviews the vascular anatomy of the body. The historical perspective
summarizes the major progress in understanding the vascular basis
and clinical applications of flaps in reconstructive surgery.
■ The anatomical basis of angiosomes, choke anastomotic vessels,
arterial territories, and venous drainage of the human body are
summarized. The neurovascular territories of skin and muscle are
described. Comparisons with other species highlights the consistent
features of vascular anatomy of the human body and illustrates the
need to be aware of the vascular anatomy of animal flap models.
■ The vascular anatomy of skin, muscle, and bone of each region of
the body is discussed with an emphasis on flap design, avoiding
surgical complications and providing an overview of angiosomes of
the body.
■ The general concepts of the vascular supply to tissues of the body
are reviewed. The importance of these concepts to flap design is
highlighted with clinical examples. These concepts also provide the
basis for interpreting physiologic and pathologic events in skin
flaps.
■ The overall architecture of the vasculature of the human body is
consistent but there is significant variability in individual perforator
anatomy. Therefore, a versatile operative plan is needed for successful
flap design.
■ Methods of preoperative assessment of vascular anatomy and types of
flaps, including skin, fasciocutaneous, musculocutaneous and
perforator flaps, are reviewed.
■ The anatomic basis of the delay phenomenon and procedure is
explored.
Introduction
The angiosome theory has become well accepted in the field
of plastic and reconstructive surgery and allows the concep­
tualization of the vascular supply to all tissues of the human
body. An angiosome is a composite block of tissue supplied
by a main source vessel. The adjacent angiosomes are linked
either by reduced-caliber choke anastomotic vessels or vessels
without reduction in caliber – the true anastomoses of adjacent
arterioles. The latter are seen in many muscles or in the skin,
especially where vessels accompany cutaneous nerves. Flaps
designed along an axis of vessels linked by true anastomoses
have a longer survival length similar to a flap that has been
delayed. The anastomotic arteries are matched by veins
devoid of valves that allow bidirectional flow. The entire
human body consists of innumerable arcades of interconnect­
ing vessels which supply all tissues.
In 1977, Converse1 stated that “there is no simple and
all-encompassing system which is suitable for classifying
skin flaps”. It is now generally agreed that the anatomical
vascular basis of the flap provides the most accurate approach
for classification. Specific, anatomically based nomenclature
simplifies communication between surgeons and allows
for the advancement of the field of plastic and reconstruc­
tive surgery. The main named source vessels throughout
the body provide a useful road map for the description
of flaps.
The vascular architecture of the body is arranged anatomi­
cally as a continuous series of vascular loops, like the tiers of
a Roman aqueduct, that increase in number while their size
and caliber decrease as they approach the capillary bed (Fig.
21.1). The reverse situation occurs on the venous side. This
anatomic arrangement of the vascular “skeleton” is shown
beautifully in the corrosion cast studies of newborn babies
performed by Tompsett2 that reside in the Hunterian Museum
at the Royal College of Surgeons in London (Fig. 21.2). Note
how the main arterial loops hug the bony framework and the
secondary arcades follow the intermuscular and intramuscu­
lar connective tissue framework. The “keystones” of these
arcades are represented usually by reduced-caliber (choke
anastomotic) arteries and arterioles, matched on the venous
side by avalvular (oscillating) veins that permit bidirectional
flow. Choke arteries and avalvular veins have an essential role
in controlling this pressure gradient across the capillary bed
(see Fig. 21.1).
  Access video lecture content for this chapter online at expertconsult.com

341
Vascular anatomical research
latex and ink. Depending on the specific study, the area of
tissue of interest was then dissected and radiographed. As the
radiographic film quality improved, the quality of the image
of the small blood vessels improved. However, studies using
simple radiographs have largely been replaced by CT tech­
niques.43,45,46 These investigations were conducted in fresh
cadavers. In the majority of studies, the anatomical question
was problem-oriented in a desire to provide a surgical solu­
tion to the individual patient’s needs. We have performed a
large number of fresh cadaver studies, investigating various
regions, tissues, and combinations of tissues. This has included
an investigation of the entire integument and underlying
deep structures in a series of total body studies of the arter­
ies,47 which led to the angiosome concept, discussed in detail
in a later section. This was followed by studies of the veins48
and the neurovascular territories of the body49 and detailed
studies of the angiosomes of the forearm,50 the leg,51 and the
head and neck,52 as well as a comparative study of a series of
mammals.53 As well, we have performed detailed analyses of
numerous muscle flaps including sartorius,54 rectus femoris,55
gracilis,56 pectoralis major,57 and skin flaps, including the
reversed sural artery flap,58 thoracodorsal artery perforator
Fig. 21.1  Schematic representation of the arterial supply and venous drainage of
the capillary bed. Note the choke arteries (small black arrows) and bidirectional
avalvular veins (small shaded arrows) that allow equilibration of flow and pressure
to the capillary bed from arterioles (red arrows) and from the capillary bed through
venules (blue arrows).
32 mmHg
Arterial
Capillary
Venous
15 mmHg
Fig. 21.2  Tompsett’s arterial skeleton of the body. This corrosion cast of the
newborn body shows the arterial architecture of the body. (From Taylor GI, Palmer
JH. The vascular territories [angiosomes] of the body: experimental study and
clinical applications. Br J Plast Surg. 1987;40:113.)
Access the Historical Perspective section, including
Figs. 21.3 and 21.4, online at

Vascular anatomical research
Angiosome
The angiosome (from the Greek angeion, meaning vessel, and
somite, meaning segment or sector of the body derived from
soma, body) is defined as a composite block of tissue sup­
plied by a main source artery. The source arteries (segmental
or distributing arteries) that supply these blocks of tissue are
responsible for the supply of the skin and the underlying
deep structures. When pieced together like a jigsaw puzzle,
they constitute the three-dimensional vascular territories of
the body. In this section we present the basis of the anatomi­
cal studies which are the foundation of the angiosome
concept.
The angiographic studies produced by Salmon using lead
oxide, gelatin, and water were exceptional; however, modi­
fications of the technique have further improved results.41,42
In particular, reducing the concentration of lead oxide has
improved computed tomographic (CT) angiographic anatomic
studies.43 A review of vascular injection techniques reveals the
wide array of techniques available for investigation.44
Initially, cadaver injection studies to study the vascular
anatomy of the human integument and other structures uti­
lized intra-arterial injections of radiopaque substances such
as barium sulfate or lead oxide or visible substances such as

341.e1
Historical perspective
Historical perspective
Plastic surgery evolved as a specialty in Europe and North
America to restore the mutilated victims of the two World
Wars. With artistic flair and geometric precision, tissues were
advanced and rotated. These random flaps were transposed
locally and dispatched to distant sites on limb carriers, only
to be rebuffed on occasion by necrosis. Gillies often lamented
that “plastic surgery is a constant battle between blood supply
and beauty”.3 Gradually, rigid length-to-breadth flap ratios
were calculated for different regions of the body because most
of the flaps were designed without a precise knowledge or
appreciation of the vascular supply of flaps. The flaps designed
were “random” since it was not appreciated that the vascular
supply was crucial to flap survival and there was little under­
standing of the anatomy of the underlying vasculature.
Unfortunately, this anatomic information was available but
overlooked. In 1889, Manchot4 performed the first examina­
tion of the vascular supply of the human integument. His
treatise, Die Hautarterien des menschlichen Körpers [The Cutane­
ous Arteries of the Human Body], was initially published in
German and later translated to English.5 Manchot identified
the cutaneous perforators, assigned them to their underlying
source vessels, and charted the cutaneous vascular territories
of the body (Fig. 21.3). He did not have the advantage of
radiography since Röentgen was not to make his discovery
until several years later. Nevertheless, the accuracy of Man­
chot’s work has mostly stood the test of time.
In 1893, Spalteholz6 published an important paper on the
origin, course, and distribution of the cutaneous perforators
in adult and neonatal cadavers. He performed arterial injec­
tions of gelatin and various pigments. The soft tissues were
fixed in alcohol and subtracted in xylol, and the resulting
vascular network was embedded in Canada Balsam. Spalte­
holz’s main study concentrated on the detailed circulation
of the skin. He made an important distinction between
direct cutaneous vessels, which supply the skin, and indirect
cutaneous vessels, which are terminal branches of vessels
supplying the deeper organs, especially the muscles. A
detailed account of this work was published by Timmons7 in
a review of the landmarks in the anatomic study of the skin’s
blood supply.
The next major study was performed by Salmon,8,9 a French
anatomist and surgeon in the 1930s. Manchot had defined
approximately 40 cutaneous territories that excluded the
head, neck, hands, and feet. Salmon knew of Manchot’s
studies and set out to reappraise his work. Aided by radiog­
raphy, he was able to delineate the smaller vessels of the
cutaneous circulation and charted more than 80 territories
encompassing the entire body (Fig. 21.4). Salmon noted the
interconnections that exist between perforators, and his obser­
vation of the density and size of the vessels in different regions
of the body led him to define what he called the hypervascular
and hypovascular zones. His work has become available in
English.10 Ironically, in the preface to Michel Salmon’s book
on the cutaneous vascular anatomy published originally in
1936,8 Raymond Grégoire stated: “This new work by Michel
Salmon is a painstaking study that no surgeon from now on
can ignore and few anatomists would have had the courage
to undertake.” Indeed, if we had heeded this advice, plastic
surgery would have evolved much earlier!
In 1975, Schafer11 published an important study on the
arterial and venous anatomy of the lower extremity. Scribtol
and an ink–serum mixture were injected into the lower limbs
of adults and into the entire circulation of fetal and neonatal
cadavers. Schafer concluded that most cutaneous arteries
emerge in rows from the intermuscular septa or occasionally
from the intramuscular septa. In addition, he highlighted the
two systems of perforating veins: the venae communicantes,
large veins that pierce the deep fascia and connect the super­
ficial venous plexus to the deep venous system; and the venae
comitantes, small, usually paired veins that accompany the
cutaneous arterial perforators.
Early last century, advances on the clinical front gave sig­
nificance to the work of these great anatomists. In 1906,
Tansini12 reported a latissimus dorsi flap supplied by the
thoracodorsal artery. In 1919, Davis13 published Plastic Surgery
and introduced many of the chapters with illustrations from
Manchot’s book. In 1921, Blair14 described a forehead flap
based on the superficial temporal vessels, and in 1929, Esser
published Artery Flaps.15 In 1937, Webster16 again cited the
work of Manchot when he described a long, bipedicled tho­
racoepigastric flap based on named arteries that extended
from the groin to the axilla. Shaw and Payne17 used the clinical
information available in wartime to provide one-stage direct
flaps for hand reconstruction. In 1965, Bakamjian18 drew
attention to the long paramedian perforators of the internal
thoracic system.
The 1970s witnessed the beginning of the “anatomic revo­
lution”. McGregor and Morgan19 differentiated between large
flaps based on a known axial blood supply and those based
on random vessels. Daniel and Williams20 reappraised the
work of Manchot and others and classified the cutaneous
arteries into direct cutaneous and musculocutaneous vessels.
Studies on the free flap by Taylor and Daniel21,22 were
published in 1973, and a few years later the musculocutane­
ous flap was revived by McCraw23–25 and Mathes and Nahai.26
Both procedures demanded a precise knowledge of the vas­
cular supply of the tissue transfers. In the search for new
donor sites for tissue transfer, surgeons returned to the dis­
section room. In the 1980s the pedicled musculocutaneous
flap and the free microvascular transfer gained popularity
and their use became common. However, on occasion there
was a tendency for the techniques to neglect the aesthetic side
of plastic surgery. The results could sometimes be what
McDowell27 described as “globs and blobs”.
To escape from the hamburger of muscle and skin, surgeons
soon rediscovered that blood vessels follow fascial planes
and, starting in the 1980s, there was a much greater awareness
of the fasciocutaneous flap.28 With this development, there has
been an explosion of new terms and new classifications of the
cutaneous circulation. The thesaurus of flaps now includes a
bewildering array of terms including axial, random, direct
cutaneous, musculocutaneous, fasciocutaneous, supercutane­
ous, septocutaneous, chimeric, retrograde, antegrade, and
perforator. Indeed, there has been an attempt to classify flaps
into no less than 10 types and subtypes on the basis of the
origin of the cutaneous perforators.29 In many ways, these flap
classification terms are simply different expressions of the
basic cutaneous architecture that Manchot published in 18894
and Salmon reported in 1936.8 In an effort to standardize the
literature and add clarity to descriptions of flaps, we have
previously suggested using the name of the main source

341.e2
CHAPTER 21 • Vascular territories
Fig. 21.3  Carl Manchot’s vascular territories of the human integument. (A) Cutaneous vascular territories, ventral surface. (B) Cutaneous vascular territories, dorsal surface.
(From Manchot C. Die Hautarterien des menschlichen Körpers. Leipzig: FCW Vogel, 1889.)
A
B