Pleurodesis is the obliteration of the pleural space, achieved by adhering the visceral pleura on the lung surface to the costal pleura of the chest wall. Adhesion is caused by  inflammation  and subsequent scarring of the pleural layers. Inflammation may be induced by either physical or chemical irritation. The former is commonly used in younger patients and involves surgical abrasion. The latter involves the instillation of chemical sclerosant, usually sterile  talc , via a chest tube. Other sclerosing agents include  tetracycline  and  bleomycin . [ 30 ]  After sclerosant instillation, the patient may be moved through various positions to ensure even distribution. [ 13 ]  Due to the pain of this operation, it is accompanied by  local anaesthesia . Pleurodesis is also used in recurrent  pleural effusion , a common result of lung cancer. [ 30 ]


Lung transplant  is defined as ‘an operation to remove and replace a diseased lung with a healthy human lung from a donor. A donor is most commonly known to be a deceased person, however, in very rare cases a section of the lung that is required for a patient can be transplanted from a living donor. Lung transplants are usually required when a patient has advanced lung disease whereby the disease is also unresponsive to other methods of treatment. Another significant reason for a lung transplant to be considered as a necessary option is if the patients’ life expectancy is predicted to be under three years without the lung transplant procedure taking place. Typical conditions that are treated with a lung transplant include COPD, cystic fibrosis, pulmonary hypertension and idiopathic pulmonary fibrosis. [ 31 ]


Methods for the preservation of donor lungs are imperative in order to increase availability of lungs for transplantation which therefore increases the efficacy of the treatment as more available lungs for transplantation leads to more people being applicable to undergo the treatment/transplantation. Before an organ is removed from the donor for transplantation, the donor organ is commonly flushed free of blood with a preservation solution that is prepared to be ice-cold which also contains essential elements such as electrolytes and nutrients. Furthermore, when the organ is removed from the donor, it is packaged in wet ice for preservation of the organ. [ 32 ]  A therapy called  ex-vivo lung perfusion  that is commonly used for the donor lung just before transplantation provides an enhancement of the quality of the organ and can potentially make previously unsuitable organs, safe for transplantation. [ 33 ]


All lung surgeries breach the pleural cavity, which disrupts the negative intrapleural pressure and prevents normal breathing. [ 34 ]  Surgical trauma may also lead to  pleural effusion , further disrupting intrapleural pressure. [ 35 ]  To counteract these disruptions, a  chest tube  which is attached to a drainage system consisting of a collection chamber, one-way water valve and suction chamber is inserted into the patient. This enables air and fluid to be unidirectionally extracted from the pleural cavity. [ 36 ]  Chest tubes are usually removed one week after surgery along with any stitches or staples in the incisions.


Patients experiencing shortness of breath will be guided through deep breathing or coughing exercises by a physician or respiratory therapist. In severe cases, the patient will also receive oxygen supplementation through a mask or nostril tube. [ 37 ]


A pneumonectomy comes with its own risks whereby the most common complications are  cardiac arrhythmia  as well as atrial fibrillation (or flutter), which commonly occurs in the first three days following the surgery. Furthermore, additional risks following this surgery include: cardiac herniation, pulmonary complications (e.g.  pneumonia ), bronchopleural fistula,  pulmonary oedema , multi-organ dysfunction, acute lung injury,  acute respiratory distress syndrome  (ARDS) and postoperative acute kidney injury. [ 38 ]


Lobectomies share many of the complications that come with a pneumonectomy. However, additional risks that can result from a lobectomy include  empyema , which is an area of pus in the chest cavity, as well as  pleural effusion , which occurs as a result of fluid in the space between the lung and inner chest wall. [ 39 ]


Similar to other anatomic resections, cardiac arrhythmia is a major complication for segmentectomy. Additionally,  hemorrhage  in the pleural cavity may occur due to injury to the pulmonary artery or its branches. Patients may also develop a  contralateral  pneumothorax, necessitating the placement of a chest tube to eliminate air within the pleural cavity. [ 40 ]


Wedge resections share the complications of anatomic resections. [ 41 ]  However, the former generally has lower patient mortality. [ 30 ]  The major complications of bleb resection are prolonged air leak and pneumothorax recurrence. [ 42 ]


Pleurodesis may lead to a fever due to the induced inflammatory response. [ 43 ]  Chemical pleurodesis, specifically that using talc, may also cause ARDS via the  systemic absorption  of sclerosant. [ 44 ]


Lung transplantation is an intricate treatment that can provide efficient results, however, there are risks that come with this procedure which include: bleeding, infection, blockage of the blood vessels to the new lungs, blockage of the airways, severe  pulmonary oedema  as well as potential blood clot formation. [ 45 ]


Lung surgeries can be perceived as invasive procedures that may cause side effects such as bruising, swelling, numbness, pain, scarring and infection. However, new methods such as  video-assisted thoracoscopic surgery  (VATS) provide a minimally invasive method which can eliminate diseased parts of the lungs and lymph nodes. A development of thoracoscopy, VATS utilizes small, high-resolution cameras which are inserted into the chest through small incisions. This grants surgeons a high degree of visibility into the pleural cavity despite making smaller incisions, resulting in quicker patient recovery. [ 46 ]


Moreover, treatment for lung cancer has been further developed with the use of  robotic surgery  as a method for treatment. This method involves the use of robotic arms which are manipulated by a surgeon at a console, enabling more precise movements and providing the surgeon with 3D vision of the surgical site. [ 47 ]  Similar to VATS, robotic surgery has also been found to be minimally invasive and is extremely useful for removing certain parts of lung tissue that are diseased as well as surrounding lymph nodes. [ 48 ]  However, comparisons of current robotic methods with VATS have shown no significant differences in patient outcome. [ 49 ]


Rib removal  is  surgery  to remove one or more  ribs .  Rib resection  is the removal of part of a rib. [ 1 ]  The procedures are done for various medical reasons. A number of celebrities have been falsely rumoured to have had ribs removed as a form of  body modification . [ 2 ]


Rib removal may be medically approved in several situations. If a rib is fractured in such a way that it might puncture a vital organ, it may be safer to remove it than wait for it to heal. [ 1 ]  A  cancerous rib  may be removed to stop the cancer from spreading. [ 1 ]  Rib bone material may be used for a  bone graft . [ 1 ]  The excess pressure of  thoracic outlet syndrome  may be reduced by rib removal. [ 1 ]  Major surgery to the thoracic cavity, such as  open heart surgery , may require removal of ribs to allow access to the organ being operated on. [ 1 ]


Victorian fashion  valued a  wasp waist  and  hourglass figure  for women. This was achieved through laced  corsets . Twentieth-century rumors hold that some women had their lower ribs removed to facilitate tighter lacing of the waist. In 1931, corset-maker Rosa Binner alleged that French actress  Polaire  had had her lowest rib removed in the 1890s. [ 3 ]   Germaine Greer 's  second-wave feminist  book  The Female Eunuch  gives the practice as an example of male-directed distortion of the female body. [ 4 ]  Valerie Steele's history of the corset finds no evidence of such a procedure, and with Lynne Kutsche argues the mortal danger of surgery of the era makes it extremely implausible. [ 5 ]


Barbara Mikkelson of  Snopes.com  suggests that  Florenz Ziegfeld  might have started such a rumor about his protégée  Anna Held  to publicize her career. [ 6 ]   Similar stories have been spread about later celebrities.  Cher  hired a physician in 1990 to confirm that she has a full set of ribs. [ 6 ]  It was rumored that  Marilyn Manson  had ribs removed to facilitate  autofellatio . [ 7 ]
Interviewed for a  Vogue  article in 2000, John E. Sherman of  Weill Cornell Medical College  said that while such a procedure was theoretically possible, there was no record of it in the medical literature. [ 8 ]


Amanda Lepore  claimed that she had skirted the law to obtain a similar surgery.  She was quoted saying "'I've had my boobs done, and my lips done, my bottom lip reduced, and my bottom rib broken and pushed in—I think  Raquel Welch  and  Cher  did that, too. It's illegal in the US, but I had it done in Mexico. They break the  floating rib  in the back and push it in, so there's no scar." in an interview. [ 9 ]


In October 2015, internet model and self-proclaimed "living doll"  Pixee Fox  documented the procedure to remove her six lower ribs on her  Tumblr  account. The procedure shortened rather than fully removed the ribs. [ 10 ]  In an interview with  Closer , she stated that it was difficult to find a doctor willing to perform the surgery. [ 11 ]


The Society of Thoracic Surgeons  is a Chicago, Illinois (US)-based  medical specialty   professional society  in the field of  cardiothoracic surgery . Membership worldwide includes more than 7,500 surgeons, researchers, and other health care professionals who are part of the cardiothoracic surgery team. The Society's official journal is  The Annals of Thoracic Surgery .


The STS National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. The Database has four components—the Adult Cardiac Surgery Database (ACSD), the General Thoracic Surgery Database (GTSD), the Congenital Heart Surgery Database (CHSD), and the Intermacs Database—and now houses more than 7.5 million surgical records. The STS National Database has grown to be the largest database of its kind in medicine and is one of the pioneers in the analysis and reporting of risk-adjusted outcomes in cardiothoracic surgery. [ 1 ]


In late 2010, the Society launched an initiative through which participants of the ACSD could voluntarily report their performance on coronary artery bypass grafting (CABG) surgeries. Since then, ACSD public reporting has evolved to include aortic valve replacement (AVR) surgery and CABG+AVR; outcomes for isolated mitral valve replacement or mitral valve repair (MVRR) and combined MVRR+CABG are planned to be reported in early 2019. Public reporting from the CHSD was added in 2015, and public reporting from the GTSD began in 2017.  Consumer Reports  and  U.S. News & World Report  have both relied upon STS Public Reporting Online data for their respective hospital ratings programs. [ 2 ] [ 3 ]


To meet the needs of an expanding specialty, a group of established young thoracic surgeons, led primarily by  Dr. R. Adams Cowley  of Baltimore, met in the late 1950s to exchange ideas concerning the feasibility of another thoracic surgical society. [ 4 ]


By April 1963, a committee comprising Dr. Cowley (Chairman), Dr. Francis X. Byron of Los Angeles, Dr. Clifford F. Storey of San Diego, Dr. J. Maxwell Chamberlain of New York, Dr. John D. Steele of San Fernando, Calif., Dr. Byron H. Evans of Fresno, Calif., Dr. Edgar P. Mannix of Manhasset, NY, Dr. Earle B. Kay of Cleveland, and Dr. John E. Miller of Baltimore, recommended that the a new society for thoracic and cardiovascular surgery be established. [ 5 ]  A planning committee was appointed, and an STS constitution was finalized in August 1963 at the home or Dr. Robert K. Brown in Denver. Officers and councilors were elected on October 31, 1963, and included Dr. Paul C. Samson as president, Dr. Thomas H. Burford as vice president, Dr. Byron as secretary, and Dr. John E. Steele as editor of  The Annals of Thoracic Surgery . [ 6 ]


The first STS Annual Meeting was held in St. Louis in January 1965.


The initial management activities of STS were conducted from the office of Dr. J. Maxwell Chamberlain in New York. By 1969, when membership in the Society had grown to approximately 700, it was decided that management activities would be handled by a professional management organization. Smith, Bucklin and Associates (SBA) managed STS from 1969 to 2002, but in the later years of the SBA era, the Society's leadership felt the organization had grown so robust that it was time to hire a staff of dedicated STS employees.


The transition to self-management was successfully implemented under the direction of Mark B. Orringer, MD, who completed his term as STS President, and William A. Baumgartner, MD, his successor as President.


On June 1, 2002, STS opened its headquarters office in the American College of Surgeons building in Chicago with 9.5 full-time employee equivalents, including Executive Director & General Counsel Robert A. Wynbrandt, and a membership that had grown to more than 4,100. In 2004, a dedicated STS office in Washington, DC, was established; by 2018, the STS staff in Chicago and Washington had grown to approximately more than 65 full-time employees, and membership had grown to more than 7,500.


STS manages and provides staff support for five affiliate organizations, including its charitable arm, The Thoracic Surgery Foundation.


Oral and maxillofacial surgery  is a surgical specialty focusing on  reconstructive surgery  of the  face ,  facial trauma   surgery , the  mouth ,  head  and  neck , and  jaws , as well as facial  plastic surgery  including cleft lip and cleft palate surgery.


An oral and maxillofacial surgeon is a specialist  surgeon  who treats the entire  craniomaxillofacial complex :  anatomical  area of the  mouth ,  jaws ,  face , and  skull , head and neck as well as associated structures. Depending upon the national jurisdiction, oral and maxillofacial surgery may require a degree in  medicine ,  dentistry  or both.


In the U.S., oral and maxillofacial surgeons, whether possessing a single or dual degree, may further specialize after residency, undergoing additional one or two year sub-specialty oral and maxillofacial surgery fellowship training in the following areas:


In countries such as the UK and most of Europe, it is recognised as a  specialty of medicine  with a degree in medicine and an additional degree in dentistry being compulsory. [ 1 ]  The scope of practice is mainly  head and neck cancer ,  microvascular reconstruction ,  craniofacial surgery  and  cranio-maxillofacial trauma , skin cancer, facial deformity, cleft lip and palate, craniofacial surgery,  TMJ  surgery and  cosmetic facial surgery .


In the UK, Maxillofacial surgery is a specialty of the  Royal College of Surgeons of England ,  Royal College of Surgeons of Edinburgh . Intercollegiate Board Certification is provided through the JCIE, and is the same as Plastic Surgery, ENT, General Surgery, Orthopaedics, Paediatric Surgery, Neurosurgery and Cardiothoracic Surgery.


The FRCS (Fellowship of the Royal College of Surgeons) is the specialist exam at the end of surgical training, and is required to work as a Consultant Surgeon in Maxillofacial Surgery.


In the EU, OMFS is defined within Directive 2005/36 on professional qualifications (updated 2021). The two OMFS specialties are 'dual degree' dental, oral, and maxillofacial surgery (DOMFS) and 'single medical degree' maxillofacial surgery (MFS). In some cases a dental degree may be required to enter specialty training but in all cases the medical degree must be obtained before starting OMFS specialty training.  [ 2 ]


In Poland, Maxillofacial Surgery has always been dominated by dentists and still the majority of current OMFS trainees are dental graduates.


Since 2019, Norway switched from dual degree requirement for Maxillofacial Surgery to medical degree only. Similarly, Sweden has started several Maxillofacial Surgery training programs for medical graduates.
 [ 3 ]


In Asia, oral and maxillofacial surgery is also recognized as a dental specialty and requires a degree in dentistry prior to surgical residency training. The Canadian model is the same as the model used in the United States of America.


In Pakistan, OMFS is recognized as specialty of dentistry which requires FCPS from CPSP after 4 years BDS degree and a one-year housejob. The candidate has to pass FCPS-1 in order to commence his/her training followed by PGMI Exam(not in all cases). [ 4 ]


Oral and maxillofacial surgery, also known as OMFS, is a branch recognized by DCI (Dental Council of India) in countries such as India. In India, becoming a maxillofacial surgeon requires a five-year dental degree followed by three years of post-graduate specialisation. In India, oral and maxillofacial surgery includes the treatment of complex dental surgery, including wisdom tooth removal, dental implant, craniomaxillofacial trauma, Orofacial pain (trigeminal neuralgia) and jaw joint pain (Temporomandibular disorder(TMD) or TMJ Pain) management, jaw joint(TMJ) replacement for TMJ ankylosis and deformed jaw joint cases, Lefort-3 distraction for Craniosynostosis case, jaw tumor and cyst removal surgery, head and neck cancer, facial aesthetic like rhinoplasty, eye and ear plastic surgery, Facial cosmetic surgery, microvascular surgery, and cleft and craniomaxillofacial surgery. In India, a Maxillofacial surgeon is considered one of the required members of the emergency team. Almost 20-25% of trauma patients usually have sustained facial trauma, and that needs urgent opinion and primary management that can be better managed by Maxillofacial experts.


In Australia and New Zealand, oral and maxillofacial surgery is recognised as both a specialty of medicine and dentistry. Degrees in both medicine and dentistry are compulsory prior to being accepted for surgical training. The scope of practice is broad and there is the ability to undertake subspecialty fellowships in areas such as head and neck surgery and microvascular reconstruction.


In other countries, oral and maxillofacial surgery as a specialty exists but under different forms, as the work is sometimes performed by a single or dual qualified specialist depending on each country's regulations and training opportunities available. In several countries, oral and maxillofacial surgery is a specialty recognized by a professional association, as is the case with the Dental Council of India, American Dental Association,  Royal College of Surgeons of England ,  Royal College of Surgeons of Edinburgh , Royal College of Dentists of Canada,  Royal Australasian College of Surgeons  and Brazilian Federal Council of Odontology (CFO).


Oral and maxillofacial surgery is an internationally recognized surgical specialty. Oral and maxillofacial surgery is formally designated as either a medical, dental or dual (medical and dental) specialty.


In the United States, oral and maxillofacial surgery is a recognized  surgical specialty , formally designated as a dental specialty. A professional dental degree is required, [ 5 ]  a qualification in medicine may be undertaken optionally during residency training. In this respect, oral and maxillofacial surgery is  sui generis  among  surgical specialties . [ 6 ]  Oral and maxillofacial surgery requires an extensive 4-6 year surgical residency training covering the U.S. specialty's scope of practice: surgery of the oral cavity,  dental implant  surgery,  dentoalveolar  surgery, surgery of the  temporomandibular joint ,  general surgery ,  reconstructive surgery  of the  face ,  head and neck ,  mouth , and  jaws , facial  cosmetic surgery ,  facial deformity ,  craniofacial surgery , facial  skin cancer ,  head and neck cancer ,  microsurgery  free flap reconstruction,  facial trauma , facial  trauma surgery  and, uniquely, the administration of  general anesthesia  and deep  sedation . [ 7 ]  As is the norm among surgical specialists, oral and maxillofacial surgery residents typically serve as  Chief Resident  in their final year.


Following residency training, oral and maxillofacial surgeons, whether single or dual degree, have the option of undergoing 1-2 year surgical sub-specialty  fellowship  for further training in  head and neck cancer ,  microvascular reconstruction ,  cosmetic facial surgery ,  craniofacial surgery  and  cranio-maxillofacial trauma .


Board certification in the U.S. is governed by the American Board of Oral and Maxillofacial Surgery (ABOMS). [ 8 ]  Oral and maxillofacial surgery is among the fourteen  surgical specialties  recognized by the  American College of Surgeons . [ 9 ]  Oral and maxillofacial surgeons in the United States, whether single or dual degree, may become Fellows of the American College of Surgeons, "FACS" (Fellow, American College of Surgeons). [ 10 ]


The  American Association of Oral and Maxillofacial Surgeons  (AAOMS) is the chief professional organization representing the roughly 9,000 oral and maxillofacial surgeons in the United States. [ 11 ]  The American Association of Oral and Maxillofacial Surgeons publishes the peer-reviewed  Journal of Oral and Maxillofacial Surgery .


In the U.S., oral and maxillofacial surgeons are required to undergo five months of intensive general anesthesia training. An additional month of pediatric anesthesia training is also required. The  American Society of Anesthesiologists  published a  Statement on the Anesthesia Care Team  which specifies qualified anesthesia personnel and practitioners as anesthesiologists, anesthesiology fellows, anesthesiology residents, and oral and maxillofacial surgery residents. [ 12 ]


Unique among surgical specialists in the U.S., [ 13 ]  oral and maxillofacial surgeons are trained to administer  general anesthesia  and deep  sedation , and they are licensed to do so in both hospital and office settings. [ 14 ]


In the specialty's infancy, dental and oral surgeons were plenary in the introduction of  anesthesia  to modern  medicine  and the development of modern  surgery . In 1844, at  Harvard Medical School 's  Massachusetts General Hospital , dentist, Dr.  Horace Wells  was the first to use anesthesia, but with limited success. On 16 October 1846, Boston oral surgeon, Dr.  William Thomas Green Morton  gave a successful demonstration using  diethyl ether  to Harvard medical students at the same venue. In one of the most important and well documented events in American medical history, Morton was invited to Massachusetts General Hospital to demonstrate his technique for painless surgery. After Morton had induced anesthesia, Dr.  John Collins Warren , a founding member of Massachusetts General Hospital, the hospital's first surgeon, and the first Dean of Harvard Medical School, removed a  tumor  from the neck of patient,  Edward Gilbert Abbott . The demonstration was performed in the surgical amphitheater now called the  Ether Dome  at  Harvard . Massachusetts General Hospital views the demonstration as among the institution's most significant claims to fame. Upon the successful completion of Dr. Morton's demonstration, Dr. Warren famously proclaimed to the crowded, astonished and elated amphitheater, what would become likely the most famous words in modern medicine, "Gentlemen, this is no humbug." Indeed, the event marked the beginning of modern anesthesia and surgical practice.


Immediately following the demonstration, in a congratulatory letter to Dr. William Thomas Green Morton,  polymath  and later Harvard Medical School Dean,  Oliver Wendell Holmes Sr. , father of Justice  Oliver Wendell Holmes Jr.  of the  Supreme Court of the United States , proposed naming the state produced "anesthesia", and the procedure an "anesthetic." [ 15 ]  Holmes wrote to Morton, "Everybody wants to have a hand in a great discovery. All I will do is to give a hint or two as to names—or the name—to be applied to the state produced and the agent. The state should, I think, be called 'Anaesthesia.' This signifies insensibility—more particularly ... to objects of touch." Holmes added poetically that the new term "will be repeated by the  tongues  of every civilized [member] of mankind." [ 16 ]


Dr. Ferdinand Hasbrouck, a New York oral surgeon and an 1870 graduate of the  University of Pennsylvania School of Dental Medicine  was among the first practitioners to succeed in the regular and commercial use of anesthesia in private surgical practice. [ 17 ]  In 1893, U.S.  President Grover Cleveland  was diagnosed with an intraoral tumor. The President chose Dr. Hasbrouck to serve among his team of surgeons and simultaneously as  the   anesthesiologist  for the procedure. For political reasons, Cleveland did not want the public to know about his condition. [ 18 ]  The operation was performed in secret on the yacht  Oneida  in the Long Island Sound, NY. Dr. Hasbrouck, induced President Cleveland with  nitrous oxide  and extracted teeth from the corpus of the tumor. As Cleveland recovered from nitrous oxide, Dr. Hasbrouck began the administration of ether for the remainder of the procedure as he and the team performed the tumor surgery. [ 19 ]  The procedure was a milestone for the practice of anesthesia. [ 20 ]  Ferdinand Hasbrouck's son, James F. Hasbrouck, discussed below, was among the founders of the  Columbia University  College of Dental and Oral Surgeons in 1916. [ 21 ]


In 1945, oral and maxillofacial surgeon, Dr. Niels Jorgensen was first to develop intravenous moderate  sedation . His technique, administering  pentobarbital ,  meperidine  and  scopolamine  intravenously, was widely accepted and first taught at  Loma Linda University School of Medicine , beginning in 1945.


In the United States, a close educational and professional relationship between oral and maxillofacial surgery and anesthesiology persists to the present day. [ 22 ] [ 15 ]


Oral and maxillofacial surgery stands as a pillar of the modern practice of  plastic surgery  and plastic surgery's recognition in 1941 [ 23 ]  as a surgical specialty in the United States. In the early 1900s, plastic surgery was founded by a professional organization of oral surgeons with elite training and an interest in plastic and reconstructive surgery, the American Association of Oral and Plastic Surgery. [ 24 ]  Over time, the exclusive organization began to elect a small number of non-oral surgeon members, the first of which was legendary general surgeon Dr. Vilray Blair of Washington University in St. Louis. The organization became the American Association of Plastic Surgeons in 1921. [ 25 ]  At  Harvard University , oral and maxillofacial surgeon, Dr.  Varaztad Kazanjian  pioneered plastic surgery and is considered to be a founder, if not,  the  founder of the modern practice of plastic surgery. He graduated from  Harvard School of Dental Medicine  in 1905. Dr. Kazanjian was Professor of Clinical Oral Surgery at Harvard from 1922 to 1941 when he was named Harvard's first Professor of Plastic Surgery. Dr. Kazanjian was instrumental in plastic surgery's formal recognition as an independent surgical specialty in 1941. Dr. Kazanjian joined the First Harvard Unit, serving with the British Forces in WWI, establishing the first dental and maxillofacial clinic in France, handling more than 3,000 cases of severe wounds to the face and jaws. He was honored for his surgical advances by British monarch  George V , who invested him Companion to the  Order of St Michael and St George . [ 26 ]  Kazanjian served as an early president of American Association of Plastic Surgeons.


Another founder and god-father of plastic surgery was  University of Pennsylvania  oral surgeon, Dr.  Robert H. Ivy , an 1898  University of Pennsylvania School of Dental Medicine  graduate, developed the surgical treatment of  cleft lip  and  cleft palate . The inter-maxillary fixation technique, the  Ivy Loop  is named after him. Ivy is considered a pioneer and father of the modern practice of plastic surgery. Ivy was influenced by Dr. Vilray Blair of  Washington University School of Medicine . [ 25 ]  Ivy founded the  Journal of Plastic and Reconstructive Surgery , plastic surgery's premier peer-reviewed academic journal and the American Association of Oral and Plastic Surgeons and served as its president. In 1919, New York City oral and maxillofacial surgeon, Dr. Armin Wald, an 1896 graduate of  New York University College of Dentistry , was among the first in the United States [ 27 ]  to successfully demonstrate and publish a procedure for alveolectomy and  alveoloplasty , the surgical resection and smoothing of the ridge of the mandible and maxilla for cosmetic and prosthetic purposes. [ 28 ]  Once mastered, the innovative procedure was remarkably simple; to the present, the procedure is commonplace among oral, plastic and ENT surgeons performing  alveolar ridge  reconstruction and  bone grafting . Wald was influenced by his father, Henry Wald, M.D., [ 29 ]  an 1872  University of Vienna Faculty of Medicine  graduate [ 30 ]  and preceptor in surgery at  Columbia College   School of Medicine ; [ 31 ]  their nephew,  Charles A. Reich , became a law professor at  Yale . Wald's partner, [ 32 ]   New York University  oral and maxillofacial surgeon, Dr. James F. Hasbrouck, [ 33 ]  interested in the development of the surgical specialty in New York, [ 34 ]  was among the founders of the Columbia University College of Dental and Oral Surgery in 1916. [ 21 ]  In keeping with the ideals of the American Association of Oral and Plastic Surgeons, the first two years of coursework at the new college were fully unified with Columbia's College of Physicians and Surgeons, [ 35 ]  of which Hasbrouck was an 1894 graduate. [ 36 ]  Students devoted their entire second two years to specialization in surgery at Columbia Presbyterian Hospital, which provided extraordinary preparation for the possibility of post-graduate residency training in oral surgery. [ 35 ]  Hasbrouck was notable in the specialty for having received both a dental and medical degree prior to 1895. His father, oral surgeon, Ferdinand Hasbrouck, discussed above, was a pioneer in  anesthesiology . Hasbrouck's and Wald's sons, Theodore F. Hasbrouck and Arthur H. Wald [ 37 ]  both graduated from Columbia's College of Dental and Oral Surgery in 1937. [ 38 ]  Arthur Wald made further advances in  grafting  in oral, plastic and reconstructive surgery [ 39 ]  with the early use of  fibrin  foam and  thrombin  in the resection of large and rare mandibular tumors. [ 40 ]  He served in the  United States Army Air Forces  during  World War II  and owned a cosmetic practice in midtown  Manhattan . Globally, the role of oral and maxillofacial surgery was also profound in the founding of plastic surgery: outside the United States, fathers of plastic surgery include London based  otolaryngologist  Sir  Harold Gillies [ 41 ]  and his French mentor, the  oral and maxillofacial surgeon  Dr.  Hippolyte Morestin .


Oral and maxillofacial surgery's stature and clout in university hospitals can be traced to its plenary role in the development of modern medicine and surgery.


While a professional dental degree,  i.e. , D.D.S. or D.M.D. is mandatory in the U.S., oral and maxillofacial surgeons may possess various doctoral degree combinations,  e.g. , D.D.S., D.M.D., D.D.S./M.D., D.M.D./M.D., D.M.D./Ph.D. or D.D.S./Ph.D. Still, it is the completion of an oral and maxillofacial residency training program and corresponding certificate of specialty training that confers surgical specialty status and board eligibility, [ 42 ]  not the surgeon's professional degree or degree combination. [ 43 ]  Analogously, it is a certificate of specialty training and board eligibility that satisfies state licensure requirements to administer  general anesthesia [ 44 ]  and deep  sedation , not the surgeon's professional degree or degree combination. [ 14 ]


D.D.S. (Doctor of Dental Surgery) and D.M.D. (Doctor of Medicine in Dentistry or Doctor of Dental Medicine) are the same degrees. D.M.D. and D.D.S. represent the same education. The letters used are a function of university discretion, both degrees represent an identical curriculum, set of educational requirements and level of educational attainment.


Oral and maxillofacial surgery [ 45 ]  is assigned Health Care Provider Taxonomy Code: 204E00000X  [ 46 ]


In the United States and globally, treatments may be performed on the  craniomaxillofacial complex : mouth, jaws, face, neck, and skull, and include:


Oral and maxillofacial surgery is intellectually and physically demanding and is among the most highly compensated  surgical specialties  in the United States [ 47 ]  with a 2008 average annual income of $568,968. [ 48 ]


The popularity of oral and maxillofacial surgery as a career for persons whose first degree was medicine, not dentistry, seems to be increasing. At least one program (University of Alabama at Birmingham) exists that allows highly qualified candidates whose first degree is in medicine, to earn the required dental degree, so as to qualify for entrance into oral and maxillofacial residency training programs and ultimately achieve board eligibility and certification in the surgical specialty. [ 49 ]


In the UK, Oral and maxillofacial surgery is one of the ten medical specialties, requiring MRCS and FRCS examinations.


In mainland Europe, its status, including whether or not oral surgery, maxillofacial surgery and stomatology are considered separate specialties, varies by country. The required qualifications (medical degree, dental degree, or both, as well as the required internship and residency programs) also vary.


In the US, Australia and South Africa, Oral and maxillofacial surgery is one of the ten dental specialties recognized by the  American Dental Association ,  Royal College of Dentists of Canada , and the  Royal Australasian College of Dental Surgeons . Oral and maxillofacial surgery requires four to six years of further formal university training after dental school ( i.e. , DDS, BDent, DMD or BDS).


Residency training programs are either four or six years in duration. In the  United States , four-year  residency  programs grant a certificate of specialty training in oral and maxillofacial surgery. Six year programs granting an optional  MD degree  emerged in the early 1990s in the United States. Typically, Six-year residency programs grant the specialty certificate and an additional degree such as a medical degree (e.g.,  MD , MBBS, MBChB) or research degree (e.g., MS, MSc, MPhil, MDS, MSD, MDSc, DClinDent, DSc, DMSc, PhD). Both four– and six–year graduates are designated US "Board Eligible" and those who earn "Board Certification" are Diplomats. Approximately 50% of the training programs in the US and 66% [ 50 ]  of Canadian training programs are "dual-degree." The typical total length of education and training, post-secondary school is 12 to 14 years. Beyond these years, some sub-specialize, adding an additional 1-2 year fellowship.


The typical training program for an oral and maxillofacial surgeon is:


In addition, single and dual qualified graduates of oral and maxillofacial surgery training programs can pursue post-residency sub-specialty fellowships, typically 1–2 years in length, in the following areas:


A number of notable philanthropic organizations provide humanitarian oral and maxillofacial surgery around the globe.  Smile Train  was created in 1998 by  Charles Wang  focusing on childhood facial deformity.  Operation Smile  focuses on correcting cleft lips and palates in children.  AboutFace , created by  Paul Stanley , of the rock band KISS, who was born with a facial deformity, focuses on  craniofacial  disfiguration.


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Alveolar cleft grafting  is a surgical procedure, used to repair the defect in the  upper jaw  that is associated with  cleft lip and palate , where the bone defect is filled with bone or bone substitute, and any holes between the mouth and the nose are closed. [ 1 ]


An alveolar cleft is a failure of the  premaxilla  to fuse with the  upper jaw  leaving a defect in the bone. It is common in people with  cleft palate  and is also associated with  holes  between the mouth and the nose that affects speech, and allows fluid to move into the nose when eating and drinking. [ citation needed ]


Surgeries on the  roof of the mouth  early in life typically close the larger hole between the mouth and the nose (caused by the cleft in the palate) but  do not repair the defect in the bone, or any holes further  forward  between the  palate  and the upper lip.  About the age of 8, just before the  eye teeth  are about to erupt into the bone defect (the cleft),  braces  are used to first widen the upper jaw,  and position the premaxilla. Then, a surgery places bone or a bone substitute in the defect to allow the premaxilla to fuse to the rest of the maxilla, provide  bone  for eruption of the  canine , and  close  any remaining holes between the mouth and nose.  If completed early, the canine teeth will erupt into the mouth with good bone support and remain healthy.


Alveolar cleft grafting is used primarily to allow the eruption of the  maxillary canines  into the mouth between the ages of 8 and 13 years old.  It is also used to close oranasal  fistulas , stop fluid reflux into the nose, improve speech, support the  maxillary lateral  teeth, and stabilize the jaw for  orthodontics  or  orthognathic surgery . [ citation needed ]


In cleft palate patients bone grafting during the mixed dentition has been widely accepted since the mid-1960s.  The goals of surgery are to stabilize the  maxilla , facilitate the healthy eruption of teeth that are adjacent the cleft, improving the esthetics of the base of the nose, create a bone base for  dental implants , and to close any oro-nasal  fistulas . [ 2 ]


One of the most controversial topics in alveolar cleft grafting is the timing of treatment, however, most centres recommend grafting around the ages of 6–8 years old as the  lateral incisor  and  maxillary canine  near the cleft site. [ 3 ]   This is referred to as secondary grafting during  mixed dentition  (after eruption of the maxillary central incisors but before the eruption of the canine). [ 4 ]   A smaller proportion recommend primary grafting around the age of 2, but success rates are lower, and fewer patients are good candidates.  Late secondary grafting (after eruption of the canine) has also been advocated but has been largely abandoned due to the loss of tooth support. [ 4 ]


In secondary grafting, the dental age of the patient needs to be closely monitored for the eruption of the first maxillary molars in unilateral cases around the age of 6, and in bilateral cases the eruption of central incisors about the age of 8.  This timing is used because there is minimal growth of the upper jaw after ages 6–7, the patient is more compliant with orthodontics that is required prior to surgery for expansion, the donor site is better developed, and the grafting precedes the eruption of teeth into the site. [ 4 ]


In cases with a single cleft, 35-60% of  lateral incisors  are congenitally missing, [ 4 ]  and cannot be relied on for timing.  Instead, the eruption of the incisors and first molars is used as a queue to begin assessments.   With bilateral cases, the premaxilla must be repositioned before grafting and special consideration must be given.  During this time, the orthodontist must be wary of rotating teeth into the cleft site.  Last, the size of the patient, defect, and social issues must all be taken into consideration and is best assessed with a   CBCT  scan as the patient enters the  mixed dentition  phase of dental development. [ 5 ]


In cleft lip and palate cases, the  maxilla  is typically narrow compared to the lower jaw and must be expanded outward.  An expansion appliance is placed in the maxilla 6–9 months prior to correct any  crossbite  or upper arch constriction. [ 3 ]    This will widen the cleft size, and so that parents and patients need to be warned the symptoms such as fluid reflux may worsen, although some centres will expand the jaw after surgery is complete.  In the case of double clefts, expansion is typically before surgery because the  premaxilla  needs to be repositioned forward, which cannot occur until the upper jaw is widened to allow room. [ 4 ]


The goals of the surgery are to: [ 4 ]


At surgery, the gingiva is incised along the cleft margin to allow creation of pocket of tissue up towards the nose (recreating a nasal floor), and down towards the mouth (recreating a palate, and closing the palatal opening). The bony edges of the cleft are cleaned, and any extra teeth in the cleft are removed.  The gingiva along the  outside  part of the  upper jaw  is raised, so that it can be drawn forward to close the cleft.  [ citation needed ]


After creation of the pocket, but before suturing closed the gingiva a  bone graft  is placed into the bony defect.  This is most commonly harvested from the  anterior   hip  but can also be obtained from other sites, donor bone, or bioactive materials such as  bone morphogenic proteins .  Once packed the cleft is filled with bone material the gingiva is sutured closed to create a water tight closure between the mouth and the nose.   [ 4 ]


The most common source of the bone graft is from the  iliac crest , [ 6 ]  harvested at the time of the cleft closure. Other sources such as the chin, and posterior iliac crest, or  skull  can also be used.  Artificial grafts such as  demineralized bone ,  recombinent bone morphogenic protein  or a mix of harvested bone and artificial grafts have also been used.   Insufficient data exists to show that one is beneficial over the other. [ 1 ]


The mouth wounds recover in 7–10 days with precautions for fluid only diet for 5 days, and not to increase pressure in the nose or sinuses for 2–3 weeks.  Evidence that the bone graft is forming will be seen on x-ray at about 8 weeks.  Movement of teeth into the graft can begin at 3 months once bone graft consolidation is seen on xray. [ 4 ]   Recovery from the bone harvest will vary depending on the site (if harvested) with the anterior iliac crest being sore for 2–3 weeks. [ citation needed ]


Success of the bone graft with the first surgery are approximately 85% [ 7 ]  but may vary with technique and bone grafting material. [ 1 ]


Orthodontics after surgery can close the space between the  central incisor  and  maxillary canine  in 50-75% of cases, and for those who can't have the space closed the gap can be filled with a dental implant once growth has finished. [ 8 ]


The first attempts at bone grafting cleft patients were made by Lexer (1908) and Drachter (1914).  Between 1921 and 1952 various attempts were made to graft patients using the  turbinate ,  rib  and other harvest sites.  Schmid (1954) at meetings in 1951 and 1952 reported on the treatment of patients using iliac crest bone grafts but stated, "The procedure has merely been presented for discussion".  By 1964 the iliac crest bone graft had gained popularity and was presented at multiple meetings. [ 9 ]


Bioceramics  and  bioglasses  are  ceramic  materials that are  biocompatible . [ 1 ]  Bioceramics are an important subset of  biomaterials . [ 2 ] [ 3 ]  Bioceramics range in biocompatibility from the ceramic  oxides , which are inert in the body, to the other extreme of resorbable materials, which are eventually replaced by the body after they have assisted repair. Bioceramics are used in many types of medical procedures. Bioceramics are typically used as rigid materials in  surgical implants , though some bioceramics are flexible. The ceramic materials used are not the same as  porcelain  type ceramic materials. Rather, bioceramics are closely related to either the body's own materials or are extremely durable  metal oxides .


Prior to 1925, the materials used in implant surgery were primarily relatively pure metals. The success of these materials was surprising considering the relatively primitive surgical techniques. The 1930s marked the beginning of the era of better surgical techniques as well as the first use of alloys such as  vitallium .


In 1969, L. L. Hench and others discovered that various kinds of glasses and ceramics could bond to living bone. [ 4 ] [ 5 ]  Hench was inspired by the idea on his way to a conference on materials. He was seated next to a colonel who had just returned from the Vietnam War. The colonel shared that after an injury the bodies of soldiers would often reject the implant. Hench was intrigued and began to investigate materials that would be biocompatible. The final product was a new material which he called  bioglass . This work inspired a new field called bioceramics. [ 6 ]  With the discovery of bioglass, interest in bioceramics grew rapidly.


On April 26, 1988, the first international symposium on bioceramics was held in Kyoto, Japan. [ 7 ]


Ceramics are now commonly used as  dental  and  bone   implants . [ 8 ] [ 9 ]  Surgical  cermets  are used regularly. Joint replacements are commonly coated with bioceramic materials to reduce wear and inflammatory response. Other examples of medical uses for bioceramics are in  pacemakers , kidney dialysis machines, and respirators. [ 6 ]


Bioceramics are meant [ clarification needed ]  to be used in extracorporeal circulation systems ( kidney dialysis , for example) or engineered bioreactors; however, they are most common as  implants . [ 10 ]  Ceramics show numerous applications as biomaterials due to their physico-chemical properties. They have the advantage of being inert in the human body, and their hardness and resistance to abrasion makes them useful for bone and tooth replacement. Some ceramics also have excellent resistance to friction, making them useful as replacement materials for malfunctioning  joints . Properties such as appearance and electrical insulation are also a concern for specific biomedical applications.


Some bioceramics incorporate  alumina  (Al 2 O 3 ) as their lifespan is longer than that of the patient's. The material can be used in middle  ear ossicles , ocular prostheses, electrical insulation for pacemakers, catheter orifices and in numerous prototypes of implantable systems such as cardiac pumps. [ 11 ]


Aluminosilicates  are commonly used in dental prostheses, pure or in ceramic-polymer  composites . The ceramic-polymer composites are a potential way to fill cavities, replacing amalgams suspected to have toxic effects. The aluminosilicates also have a glassy structure. Unlike artificial teeth in resin, the colour of tooth ceramic remains stable. [ 10 ] [ 12 ]  Zirconia  doped  with  yttrium oxide  has been proposed as a substitute for alumina for osteoarticular prostheses. The main advantages are a greater failure strength, and a good resistance to fatigue.


Vitreous carbon  is also used as it is light, resistant to wear, and compatible with blood. It is mostly used in cardiac valve replacement. Diamond can be used for the same application, but in coating form. [ 11 ]


Calcium phosphate -based ceramics constitute, at present, the preferred bone substitute material in orthopaedic and maxillofacial applications, as they are similar to the main mineral phase of bone in structure and chemical composition. Such synthetic bone substitute or scaffold materials are typically porous, which provides an increased surface area that encourages osseointegration, involving cell colonisation and revascularisation. However, such porous materials generally exhibit lower mechanical strength compared to bone, making highly porous implants very delicate. Since the  elastic modulus  values of ceramic materials are generally higher than that of the surrounding bone tissue, the implant can cause mechanical stresses at the bone interface. [ 10 ]  Calcium phosphates usually found in bioceramics include hydroxyapatite (HAP) Ca 10 (PO 4 ) 6 (OH) 2 ; tricalcium phosphate β (β TCP): Ca 3  (PO 4 ) 2 ; and mixtures of HAP and β TCP.


A number of implanted ceramics have not actually been designed for specific biomedical applications. However, they manage to find their way into different implantable systems because of their properties and their good biocompatibility. Among these ceramics, we can cite  silicon carbide ,  titanium nitrides  and  carbides , and  boron nitride . TiN has been suggested as the friction surface in hip prostheses. While cell culture tests show a good biocompatibility, the analysis of implants shows significant  wear , related to a delaminating of the TiN layer. Silicon carbide is another modern-day ceramic which seems to provide good biocompatibility and can be used in bone implants. [ 10 ]


In addition to being used for their traditional properties, bioactive ceramics have seen specific use for due to their  biological activity . Calcium phosphates,  oxides , and  hydroxides  are common examples. Other natural materials — generally of animal origin — such as bioglass and other composites feature a combination of mineral-organic composite materials such as HAP, alumina, or titanium dioxide with the biocompatible polymers (polymethylmethacrylate): PMMA, poly(L-lactic) acid: PLLA, poly(ethylene). Composites can be differentiated as bioresorbable or non-bioresorbable, with the latter being the result of the combination of a bioresorbable calcium phosphate (HAP) with a non-bioresorbable  polymer  (PMMA, PE). These materials may become more widespread in the future, on account of the many combination possibilities and their aptitude at combining a biological activity with mechanical properties similar to those of the bone. [ 11 ]


Bioceramics' properties of being anticorrosive, biocompatible, and aesthetic make them quite suitable for medical usage.  Zirconia  ceramic has bioinertness and noncytotoxicity. Carbon is another alternative with similar mechanical properties to bone, and it also features blood compatibility, no tissue reaction, and non-toxicity to cells. Bioinert ceramics do not exhibit bonding with the bone, known as osseointegration. However, bioactivity of bioinert ceramics can be achieved by forming composites with bioactive ceramics. Bioactive ceramics, including bioglasses must be non-toxic, and form a bond with bone. In bone repair applications, i.e. scaffolds for bone regeneration, the solubility of bioceramics is an important parameter, and the slow dissolution rate of most bioceramics relative to bone growth rates remains a challenge in their remedial usage. Unsurprisingly, much focus is placed on improving dissolution characteristics of bioceramics while maintaining or improving their mechanical properties. Glass ceramics elicit  osteoinductive  properties, with higher dissolution rates relative to crystalline materials, while crystalline calcium phosphate ceramics also exhibit non-toxicity to tissues and bioresorption. The ceramic particulate reinforcement has led to the choice of more materials for implant applications that include ceramic/ceramic, ceramic/polymer, and ceramic/metal composites. Among these composites ceramic/polymer composites have been found to release toxic elements into the surrounding tissues.  Metals  face corrosion related problems, and ceramic coatings on metallic implants degrade over time during lengthy applications. Ceramic/ceramic composites enjoy superiority due to similarity to bone minerals, exhibiting biocompatibility and a readiness to be shaped. The biological activity of bioceramics has to be considered under various  in vitro  and  in vivo  studies. Performance needs must be considered in accordance with the particular site of implantation. [ 11 ]


Technically, ceramics are composed of raw materials such as powders and natural or synthetic  chemical additives , favouring either compaction (hot, cold or isostatic), setting (hydraulic or chemical), or accelerating  sintering  processes. According to the formulation and shaping process used, bioceramics can vary in density and porosity as  cements , ceramic depositions, or ceramic composites. Porosity is often desired in bioceramics including bioglasses. Towards improving the performance of transplanted porous bioceramics, numerous processing techniques are available for the control of  porosity , pore size distribution and pore alignment. For crystalline materials, grain size and crystalline defects provide further pathways to enhance biodegradation and osseointegration, which are key for effective bone graft and bone transplant materials. [ 10 ]  This can be achieved by the inclusion of grain refining dopants and by imparting defects in the crystalline structure through various physical means.


A developing material processing technique based on the biomimetic processes aims to imitate natural and biological processes and offer the possibility of making bioceramics at ambient temperature rather than through conventional or hydrothermal processes [GRO 96]. The prospect of using these relatively low processing temperatures opens up possibilities for mineral organic combinations with improved biological properties through the addition of proteins and biologically active molecules (growth factors, antibiotics, anti-tumor agents, etc.). However, these materials have poor mechanical properties which can be improved, partially, by combining them with bonding proteins. [ 10 ]


Common bioactive materials available commercially for clinical use include 45S5 bioactive glass, A/W bioactive glass ceramic, dense synthetic HA, and bioactive composites such as a  polyethylene –HA mixture. All these materials form an interfacial bond with adjacent tissue. [ 12 ]


High-purity alumina bioceramics are currently commercially available from various producers. U.K. manufacturer Morgan Advanced Ceramics (MAC) began manufacturing orthopaedic devices in 1985 and quickly became a recognised supplier of ceramic femoral heads for hip replacements. MAC Bioceramics has the longest clinical history for alumina ceramic materials, manufacturing HIP Vitox® alumina since 1985. [ 13 ]  Some calcium-deficient phosphates with an apatite structure were thus commercialised as "tricalcium phosphate" even though they did not exhibit the expected crystalline structure of tricalcium phosphate. [ 13 ]


Currently, numerous commercial products described as HA are available in various physical forms (e.g. granules, specially designed blocks for specific applications). HA/polymer composite (HA/polyethyelene, HAPEXTM) is also commercially available for ear implants, abrasives, and plasma-sprayed coating for orthopedic and dental implants. [ 13 ]


Bioceramics are also been used in cannabis or delta 8 devices as wicks for the vaporization of such extracts. [ 14 ]


Bioceramics have been proposed as a possible treatment for  cancer . Two methods of treatment have been proposed:  hyperthermia  and  radiotherapy .  Hyperthermia treatment  involves implanting a bioceramic material that contains a ferrite or other magnetic material. [ 15 ]  The area is then exposed to an alternating magnetic field, which causes the implant and surrounding area to heat up. Alternatively, the bioceramic materials can be doped with β-emitting materials and implanted into the cancerous area. [ 2 ]


Other trends include engineering bioceramics for specific tasks. Ongoing research involves the chemistry, composition, and micro- and nanostructures of the materials to improve their biocompatibility. [ 16 ] [ 17 ] [ 18 ]


Bone grafting  is a surgical procedure that replaces missing bone in order to repair  bone fractures  that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some small or acute fractures can be cured without bone grafting, but the risk is greater for large fractures like compound fractures.


Bone generally has the ability to regenerate completely but requires a very small fracture space or some sort of scaffold to do so. Bone grafts may be autologous (bone harvested from the patient's own body, often from the  iliac crest ), allograft (cadaveric bone usually obtained from a bone bank), or synthetic (often made of  hydroxyapatite  or other naturally occurring and  biocompatible  substances) with similar mechanical properties to bone. Most bone grafts are expected to be resorbed and replaced as the natural bone heals over a few months' time.


The principles involved in successful bone grafts include osteoconduction (guiding the reparative growth of the natural bone), osteoinduction (encouraging undifferentiated cells to become active osteoblasts), and osteogenesis (living bone cells in the graft material contribute to bone remodeling). Osteogenesis only occurs with autograft tissue and allograft cellular bone matrices.


Bone grafting is possible because bone tissue, unlike most other tissues, has the ability to regenerate completely if provided the space into which to grow. As native bone grows, it will generally replace the graft material completely, resulting in a fully integrated region of new bone. The biologic mechanisms that provide a rationale for bone grafting are osteoconduction, osteoinduction and osteogenesis. [ 1 ]


Osteoconduction is termed as "the property of a material to support tissue ingrowth, osteoprogenitor cell growth, and development for bone formation to occur". [ 2 ]  In the context of bone grafting it occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone.  Osteoblasts  from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone. [ 1 ]  Osteoblasts do not originate from the donor tissue, but through the internal ingrowing of the host's cells. [ 3 ]  The proper bonding of bioactive chemicals (Beta-Tricalcium Phosphate) in implants used in bone grafting surgery allow the promotion of  osteoconductivity  in the area of a defect. [ 2 ]  In the very least, a bone graft material should be osteoconductive by being made up of these bioactive chemicals.


Osteoinduction involves the stimulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators is  bone morphogenetic proteins  (BMPs). [ 1 ]  A bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger the formation of new osteoblasts, theoretically promoting faster integration of the graft. [ citation needed ]


Osteopromotion involves the enhancement of osteoinduction without the possession of osteoinductive properties. For example,  enamel matrix derivative  has been shown to enhance the osteoinductive effect of  demineralized freeze dried bone allograft  (DFDBA), but will not stimulate new bone growth alone. [ 4 ]


Osteogenesis occurs when vital osteoblasts originating from the bone graft material contribute to new bone growth along with bone growth generated via the other two mechanisms. [ 1 ]


Depending on where the bone graft is needed, a different doctor may be requested to do the surgery. Doctors and physicians that perform bone graft procedures are commonly  orthopedic surgeons ,  otolaryngology head and neck surgeon ,  neurosurgeons ,  craniofacial surgeons ,  oral and maxillofacial surgeons ,  podiatric surgeons  and  periodontists ,  dental surgeons ,  oral surgeons  and  implantologists . [ 5 ]


Autologous  (or autogenous) bone grafting involves utilizing bone obtained from the same individual receiving the graft. Bone can be harvested from non-essential bones, such as from the  iliac crest , or more commonly in oral and maxillofacial surgery, from the mandibular symphysis (chin area) or anterior mandibular ramus (the  coronoid process ); this is particularly true for  block grafts , in which a small block of bone is placed whole in the area being grafted. When a block graft will be performed, autogenous bone is the most preferred because there is less risk of the graft rejection because the graft originated from the patient's own body. [ 6 ]  As indicated in the chart above, such a graft would be osteoinductive and osteogenic, as well as osteoconductive. A negative aspect of autologous grafts is that an additional surgical site is required, in effect adding another potential location for post-operative pain and complications. [ 7 ]


Autologous bone is typically harvested from intra-oral sources as the chin or extra-oral sources as the  iliac crest , the  fibula , the  ribs , the  mandible  and even parts of the  skull . [ citation needed ]


All bone requires a blood supply in the transplanted site. Depending on where the transplant site is and the size of the graft, an additional blood supply may be required. For these types of grafts, extraction of the part of the  periosteum  and accompanying blood vessels along with donor bone is required. This kind of graft is known as a  vital bone graft . [ citation needed ]


An autograft may also be performed without a solid bony structure, for example, using bone reamed from the  anterior superior iliac spine . In this case, there is an osteoinductive and osteogenic action, however, there is no osteoconductive action, as there is no solid bony structure. [ citation needed ]


Chin offers a large amount of cortico-cancellous autograft and easy access among all the intraoral sites. It can be easily harvested in the office settings under local anaesthesia on an outpatient basis. Proximity of the donor and recipient sites reduce operative time and cost. Convenient surgical access, low morbidity, elimination of hospital stay, minimal donor site discomfort and avoidance of cutaneous scars are the added advantages. [ citation needed ]


Dentin  bone, made from extracted teeth, [ 8 ]  comprises more than 85% of tooth structure, the enamel consists of HA mineral and comprises 10% of tooth structure. Dentin is similar to bone in its chemical composition, by volume 70–75% is HA mineral and 20% organic matrix, mostly fibrous type I collagen. [ 9 ]  Dentin, like bone, may release growth and differentiating factors while being resorbed by osteoclasts. In order to make the dentin graft usable and bacteria-free, some companies have developed clinical procedures which include grinding, sorting and cleaning of the teeth for immediate or future use. In Korea, the Korea Tooth Bank performed bio-recycling of 38 000 patients' own teeth from January 2009 until October 2012. [ citation needed ]


Allograft  bone, like autogenous bone, is derived from humans; the difference is that allograft is harvested from an individual other than the one receiving the graft. Allograft bone can be taken from  cadavers  that have donated their bone so that it can be used for living people who are in need of it; it is typically sourced from a  bone bank . Bone banks also supply allograft bone sourced from  living  human bone donors (usually hospital inpatients) who are undergoing elective total hip arthroplasty (total hip replacement surgery). During total hip replacement, the orthopaedic surgeon removes the patient's femoral head, as a necessary part of the process of inserting the artificial hip prosthesis. The femoral head is a roughly spherical area of bone, located at the proximal end of the femur, with a diameter of 45 mm to 56 mm in adult humans. The patient's femoral head is most frequently discarded to hospital waste at the end of the surgical procedure. However, if a patient satisfies a number of stringent regulatory, medical and social history criteria, and provides informed consent, their femoral head may be deposited in the hospital's bone bank.


There are three types of bone allograft available: [ 10 ]


Alloplastic grafts may be made from  hydroxyapatite , a naturally occurring mineral that is also the main mineral component of bone. They may be made from  bioactive glass . Hydroxylapatite is a synthetic bone graft, which is the most used now among other synthetic due to its osteoconduction, hardness and acceptability by bone. Tricalcium phosphate which is now used in combination with hydroxylapatite thus give both effect osteoconduction and resorbability. Polymers such as some  microporous  grades of  PMMA  and various other acrylates (such as polyhydroxylethylmethacrylate aka PHEMA), coated with calcium hydroxide for adhesion, are also used as alloplastic grafts for their inhibition of infection and their mechanical resilience and biocompatibility. [ 11 ]  Calcifying marine algae such as  Corallina officinalis  have a fluorohydroxyapatitic composition whose structure is similar to human bone and offers gradual resorption, thus it is treated and standardized as "FHA (Fluoro-hydroxy-apatitic) biomaterial" alloplastic bone grafts. [ 12 ]


Artificial bone  can be created from ceramics such as calcium phosphates (e.g.  hydroxyapatite  and  tricalcium phosphate ),  Bioglass  and  calcium sulfate ; all of which are biologically active to different degrees depending on solubility in the physiological environment. [ 13 ]  These materials can be doped with  growth factors , ions such as  strontium [ 14 ]  or mixed with  bone marrow  aspirate to increase biological activity. Some authors believe this method is inferior to autogenous bone grafting; [ 6 ]  however, infection and rejection of the graft is much less of a risk, and the mechanical properties such as  Young's modulus  are comparable to bone. The presence of elements such as  strontium  can result in higher  bone mineral density  and enhanced  osteoblast  proliferation  in vivo . [ citation needed ]


A synthetic material may be used as a temporary antibiotic spacer before being replaced by a more permanent material. For example, the  Masquelet procedure  consists of initially using PMMA mixed with an  antibiotic  ( vancomycin  or  gentamicin ) for 4–12 weeks, and then replacing the space with an autologous bone graft. [ 15 ]  It can be used to treat posttraumatic bone defects. [ 15 ]


Bone xenografts are an alternative form of bone grafts that involve transplanting different animal species cells into humans. This graft can range from orthopedic to dental uses. Most xenografts are derived from bovine sources such as cows or pigs and are sterilized and processed for safe implantation into human tissue. They can be  freeze dried  or demineralized and deproteinized. Xenografts are usually only distributed as a calcified matrix. Madrepore and or millepore type of  corals  are harvested and treated to become 'coral derived granules' (CDG) [ 16 ]  and other types of coralline xenografts. [ 17 ]  Coral based xenografts are mainly  calcium carbonate  (and an important proportion of fluorides, useful in the context of grafting to promote bone development) while natural human bone is made of hydroxyapatite along with calcium phosphate and carbonate: the coral material is thus either transformed industrially into hydroxyapatite through a  hydrothermal  process, yielding a non-resorbable xenograft, or simply the process is omitted and the coralline material remains in its calcium carbonate state for better resorption of the graft by the natural bone. The coral xenograft is then saturated with growth-enhancing gels and solutions. [ 18 ]


Studies show that xenografts can be used, however they are closely monitored due to their risk of rejection.  Zoonoses , which are diseases that arise from the crossing of animal and human tissue, pose a threat to the success of xenograft implantation. Specifically, these diseases are referenced as "xenozoonoses". They can be categorized in 3 different groups: viral infection, prion-mediated infection, and bacterial infection. They have the potential to create a public health risk if they are not closely monitored, as they can cause diseases to be more easily transmissible through different species. [ citation needed ]


Growth Factor  enhanced grafts are produced using recombinant DNA technology. They consist of either Human Growth Factors or Morphogens ( Bone Morphogenic Proteins  in conjunction with a carrier medium, such as collagen).


The time it takes for an individual to recover depends on the severity of the injury being treated and lasts anywhere from two weeks to two months, with a possibility of vigorous exercise being barred for up to six months. Distal femoral bone graft takes up to six months to heal. [ 19 ]


The most common use of bone grafting is in the application of  dental implants  to restore the  edentulous  area of a missing tooth. Dental implants require bones underneath them for support and  proper integration  into the mouth. As mentioned earlier bone grafts come in various forms such as autologous (from the same person), Allograft, Xenograft (mainly bovine bone), and Alloplastic materials. Bone grafts can be used prior to implant placement or simultaneously. [ 20 ]  People who have been edentulous (without teeth) for a prolonged period may not have enough bone left in the necessary locations. In this case, autologous bone can be taken from the chin, from the pilot holes for the implants, or even from the iliac crest of the pelvis and inserted into the mouth underneath the new implant. Alternatively, exogenous bone can be used: xenograft is the most commonly used, because it offers the advantage of exceptional volume stability over time. Allograft offers the best regeneration quality but has lower volume stability. Often a mix of different kinds of bone grafts is used. [ citation needed ]


In general, bone graft is either used en bloc (such as from the chin or the ascending ramus area of the lower jaw) or particulated, in order to be able to adapt it better to a defect.


Dental bone grafting is a specialized oral surgical procedure that has been developed to reestablish lost jawbone. This loss can be a result of  dental infection of abscess ,  periodontal disease , trauma, or the natural process of aging. There are various reasons for replacing lost bone tissue and encouraging natural bone growth, and each technique tackles jawbone defects differently. Reasons that bone grafting might be needed include  sinus augmentation ,  socket preservation , ridge augmentation, or regeneration. There is currently some evidence supporting the use of autologous platelet concentrates (cell fragments containing growth factors to promote tissue regeneration) when bone grafting is used to treat gum disease. [ 21 ]


Another common bone graft, which is more substantial than those used for dental implants, is of the fibular shaft. After the segment of the fibular shaft has been removed normal activities such as running and jumping are permitted on the leg with the bone deficit. The grafted, vascularized fibulas have been used to restore skeletal integrity to long bones of limbs in which congenital bone defects exist and to replace segments of bone after trauma or malignant tumor invasion. The periosteum and nutrient artery are generally removed with the piece of bone so that the graft will remain alive and grow when transplanted into the new host site. Once the transplanted bone is secured into its new location it generally restores blood supply to the bone in which it has been attached. [ citation needed ]


Bone grafts are used in hopes that the defective bone will be healed or will regrow with little to no  graft rejection . [ 19 ]  Besides the main use of bone grafting – dental implants – this procedure is used to fuse joints to prevent movement, repair broken bones that have bone loss, and repair broken bone that has not yet healed. [ 19 ]  Furthermore, bone grafts or substitutes are widely used for augmentation of spinal fusion procedures. [ 22 ]


As with any procedure, there are risks involved; these include reactions to medicine, problems breathing,  bleeding , and  infection . [ 19 ]  Infection is reported to occur in less than 1% of cases and is curable with antibiotics. Overall, patients with a preexisting illness are at a higher risk of getting an infection as opposed to those who are overall healthy. [ 23 ]


Some of the potential risks and complications of bone grafts employing the  iliac crest  as a donor site include: [ 23 ] [ 24 ] [ 25 ]


Bone grafts harvested from the posterior iliac crest in general have less morbidity, but depending on the type of surgery, may require a flip while the patient is under general anesthesia. [ 31 ] [ 32 ]


Bone graft procedures consist of more than just the surgery itself. The complete three-month total cost of a complex posterolateral lumbar spine fusion bone graft supplemented with graft extenders ranges from a mean of approximately US$33,860 to US$37,227. [ 33 ]  This price includes all visits in and out of the hospital for three months. Besides the cost of the bone graft itself (ranging from US$250 to US$900) other expenses for the procedure include: outpatient rehabilitation fees (US$5,000 to US$7,000), screws and rods (US$7,500), room and board (US$5,000), operating room (US$3,500), sterile supplies (US$1,100), physical therapy (US$1,000), surgeon's fees (average US$3,500),  anesthesiologist  fees (approximately US$350 to US$400 per hour), medication charges (US$1,000), and additional fees for services such as medical supplies, diagnostic procedures, equipment use fees, etc. [ 34 ]


Bone segment navigation  is a surgical method used to find the anatomical position of displaced bone fragments in  fractures , or to position surgically created fragments in  craniofacial surgery .  Such fragments are later fixed in position by  osteosynthesis . It has been developed for use in craniofacial and  oral and maxillofacial surgery .


Bone segment navigation is a patented  [ 1 ] [ 2 ]  surgical procedure, using a frameless and markerless registration technique. It uses for the first time natural registration surfaces instead of single artificial x-ray visible markers, in order to achieve a higher precision (1 mm and better). [ 3 ]  Previous methods of Cutting and Watzinger do not meet the criteria of bone segment navigation. [ 4 ]


After an accident or injury, a fracture can be produced and the resulting bony fragments can be displaced. In the oral and maxillofacial area, such a displacement could have a major effect both on facial aesthetics and organ function: a fracture occurring in a bone that delimits the  orbit  can lead to  diplopia ; a  mandibular  fracture can induce significant modifications of the  dental occlusion ; in the same manner, a skull ( neurocranium ) fracture can produce an increased  intracranial pressure . [ citation needed ]


In severe congenital malformations of the facial skeleton surgical creation of usually multiple [ 5 ] [ 6 ]  bone segments is required with precise movement of these segments to produce a more normal face.


An  osteotomy  is a surgical intervention that consists of cutting through bone and repositioning the resulting fragments in the correct anatomical place. To insure optimal repositioning of the bony structures by  osteotomy , the intervention can be planned in advance and simulated.  The surgical simulation is a key factor in reducing the actual operating time. Often, during this kind of operation, the surgical access to the bone segments is very limited by the presence of the soft tissues: muscles, fat tissue and skin - thus, the correct anatomical repositioning is very difficult to assess, or even impossible. Preoperative planning and simulation on models of the bare bony structures can be done.  An alternate strategy is to plan the procedure entirely on a CT scan generated model and output the movement specifications purely numerically. [ 7 ]


The osteotomies performed in  orthognathic surgery  are classically planned on cast models of the tooth-bearing jaws, fixed in an  articulator . For  edentulous  patients, the surgical planning may be made by using  stereolithographic models . These tridimensional models are then cut along the planned osteotomy line, slid and fixed in the new position.
Since the 1990s, modern techniques of presurgical planning were developed – allowing the surgeon to plan and simulate the osteotomy in a virtual environment, based on a preoperative  CT  or  MRI ; this procedure reduces the costs and the duration of creating, positioning, cutting, repositioning and refixing the cast models for each patient.


The usefulness of the preoperative planning, no matter how accurate, depends on the accuracy of the reproduction of the simulated  osteotomy  in the surgical field. The transfer of the planning was mainly based on the surgeon's visual skills. Different guiding headframes were further developed to mechanically guide bone fragment repositioning.  [ citation needed ]


Such a headframe is attached to the patient's head, during CT or MRI, and surgery. There are certain difficulties in using this device. First, exact reproducibility of the headframe position on the patient's head is needed, both during CT or MRI registration, and during surgery. The headframe is relatively uncomfortable to wear, and very difficult or even impossible to use on small children, who can be uncooperative during medical procedures.  For this reason headframes have been abandoned in favor of frameless stereotaxy of the mobilized segments with respect to the skull base.  Intraoperative registration of the patient's anatomy with the computer model is done such that pre-CT placement of fiducial points is not necessary. [ citation needed ]


Initial bone fragment positioning efforts using an electro-magnetic system were abandoned due to the need for an environment without ferrous metals. [ 8 ]   In 1991 Taylor at IBM working in collaboration with the craniofacial surgery team at New York University developed a bone fragment tracking system based on an  infrared (IR)  camera and IR  transmitters  attached to the skull. [ 9 ] [ 10 ]   This system was patented by IBM in 1994. [ 11 ]   At least three IR transmitters are attached in the  neurocranium  area to compensate the movements of the patient's head. There are three or more IR transmitters are attached to the bones where the osteotomy and bone repositioning is about to be performed onto. The  3D  position of each transmitter is measured by the IR camera, using the same principle as in  satellite navigation . A computer workstation is constantly visualizing the actual position of the bone fragments, compared with the predetermined position, and also makes real-time spatial determinations of the free-moving bony segments resulting from the osteotomy.
Thus, fragments can be very accurately positioned into the target position, predetermined by surgical simulation.  More recently a similar system, the  Surgical Segment Navigator  (SSN), was developed in 1997 at the   University of Regensburg, Germany , with the support of the  Carl Zeiss Company . [ 12 ]


The  Bonwill Triangle  is a triangle formed by the contact point of the  mandibular central incisors  and the right and left  mandibular condyles . [ 1 ] [ 2 ]


The distance between those points is equal in most humans and amounts on average to about 10 cm. [ 2 ]  The triangle is therefore an  equilateral triangle  in those cases.  William Gibson Arlington Bonwill  (1833–1899) was the first to describe this. [ 2 ]


Two variants of the Bonwill Triangle have been described that differ in the exact location of the points on the condyles. In one the points are located on the articulating surfaces of the condyles whilst in the other they are located centrally within the heads of the mandible. [ 1 ]


In terms of practical application, the Bonwill Triangle is utilized in the construction and correct application of fixed  articulators , which (in contrast to fully- and semi-adjustable articulators) are a type of articulator that does not allow for adjustments to imitate the specific movements of an individual's jaw. Instead, these articulators are designed to replicate the average movements of the jaw, and among others the Bonwill Triangle relationship is used to achieve this result. [ 3 ]


Cheek augmentation  is a   cosmetic surgical procedure  that is intended to emphasize the  cheeks  on a person's face. To augment the cheeks, a plastic surgeon may place a solid implant over the  cheekbone . Injections with the patients' own fat or a soft tissue filler, like  Restylane , are also popular. Rarely, various  cuts  to the  zygomatic bone  (cheekbone) may be performed. Cheek augmentation is commonly combined with other procedures, such as a  face lift  or  chin augmentation .


Cheek implants can be made of a variety of materials. The most common material is solid  silicone . In addition, two popular options are high-density porous  polyethylene , marketed as  Medpor , and ePTFE (expanded  polytetrafluoroethylene ), better known as  Gore-Tex . Both Medpor and ePTFE are  inert  substances, providing better integration with the underlying tissue and bone than solid silicone. However, in the case of Medpor, the implants' integration and ingrowth with the underlying tissue causes difficulty removing the implant if revisions are needed. [ 1 ] [ 2 ]


There are three general shapes to cheek implants:  malar ,  submalar , or  combined . Malar implants, the most common shape, are placed directly on the cheekbones. The result is more projection to the cheekbones, providing a "higher" contour to the side of the face. In contrast, submalar implants are not placed on the cheekbones. They are intended to augment the midface, especially if the person has a gaunt or "sunken" appearance to this area. Combined implants or  malar/submalar combination , are an extended implant intended to augment both the midface and the cheekbones. [ 3 ]


A surgeon will usually make an incision in the upper mouth near the top of the gum line and slide the implants into place.  Another method is to make an external incision near the eye,  but most patients do not choose this method since it can create a visible scar.  However, the intraoral (inside the mouth) approach carries a higher risk of infection since the mouth contains more  bacteria . Cheek implant surgery is usually performed under sedation or  general anesthesia  and take about one to two hours.  Recovery from this surgery usually takes about ten days. [ 4 ]


As with any surgery there is a risk of  infection , postoperative bleeding, formation of a  blood clot , and severe swelling. Asymmetry is a risk with all forms of cheek augmentation. This can occur due to uneven resorption, implant  displacement , or shifting. This shift can happen due to swelling, trauma or scarring. Although a temporary  loss of sensation  is common, an extended loss of sensation can occur with any surgery, especially cosmetic plastic surgery. [ 3 ]


Injections to the cheekbones to provide a less invasive and less expensive approach to cheek augmentation. A  hyaluronic acid , such as  Restylane  or  Juvederm , can be injected to the cheek area.  Autologous  fat is considered a "more permanent" option, but all are eventually completely resorbed. [ 5 ]


A zygomatic "sandwich" osteotomy is far less common. The procedure is often indicated during reconstructive surgery for  birth defects  or traumatic  injury . During this procedure, the zygoma, or cheekbone, is separated by bone cuts near the  orbital rim  and  maxilla . The bone is then moved outward and a solid material, such as  hydroxylapatite , is wedged in place to hold the new position of the zygoma. [ 6 ]


The cheek  constitutes the facial periphery and plays a key role in the maintenance of oral competence and mastication. It is also involved in the facial manifestation of human emotion and supports neighboring primary structures.


The most common causes of acquired cheek defects are  tumors , burns, and trauma. Congenital abnormalities in cheek contour may be due to facial clefts, vascular anomalies, or facial wasting syndromes. The repair of these defects seeks to achieve aesthetic and functional ends that must be carefully considered by the reconstructive surgeon.


The face can be divided into six  facial aesthetic units , with unique anatomic and aesthetic features. There are three central and three peripheral aesthetic units: eyelids, nose and lips; and forehead, cheek and chin, respectively. The aesthetic surface anatomy characteristics of the cheek have been described by Menick:


"The face can be divided into adjacent topographic areas of characteristic skin quality (color, texture, hair bearing), outline, and contour that define its regional units. The skin quality of the cheek matches the face in color and texture. The peripheral outline of the cheek unit is formed by the contours of the bordering units (forehead, eyelids, nose, lips, neck, and ear). Its outline follows the pre-auricular contours of the tragus and helix; goes around the sideburn, across the zygomatic arch, and into the lower eyelid-cheek junction; and then passes inferiorly along the nasal sidewall into the nasolabial fold and marionette line, around the chin and toward the submental crease. It then extends laterally along the jawline, passing superiorly up the angle of the jaw and back to the ear. In contour, the cheek is a relatively flat, expensive surface, except for the soft roundness of the nasolabial folds and cheek prominences." [ 1 ]


The  external carotid artery  (ECA), with contributions from the  internal carotid artery  (ICA) system, is the predominant arterial blood supply to the skin and muscles of the cheek. The greatest contribution is from the  facial artery  which traverses the face obliquely and terminates in the angular artery. The dorsal nasal artery runs along the nose and is the terminal branch of the  ophthalmic artery , which is a terminal branch of the ICA. Many smaller branches and communications also exist. [ citation needed ]


The venous drainage system of the cheek is predominantly formed by the  anterior facial vein , which subsequently communicates with the  internal jugular vein . However, substantial drainage via the ophthalmic, infraorbital, and deep facial veins communicates with the cavernous sinus  [ citation needed ]


The most important lymph nodes in the area are the intraparotid, submandibular and the submental lymph nodes. The inferior and medial parts usually drain to the submandibular nodes while the lateral and upper parts to the parotid nodes. Other lymphatic nodes include buccal nodes and submental nodes. [ citation needed ]


The nerve supply of the cheek can be divided into sensory and motor systems. Sensation to the cheek is carried primarily by the second (maxillary) and third (mandibular) divisions of the trigeminal nerve (cranial nerve V). The facial nerve (cranial nerve VII) provides motor innervation to the muscles of facial expression. [ 2 ]


The primary goals of cheek reconstruction include the restoration of native function, maximization of aesthetic outcome, and limitation of repair related morbidity. Implicit in this statement is the intent to re-established both internal and external coverage, expressivity, masticatory function and aesthetic contour and quality.


The advantages of this flap is that there is no need to skin graft the donor site and scars are placed at the natural skin folds. This flap is used for posterior and moderate-sized anterior cheek defects. Lower eyelid  ectropion  should be prevented, by minimizing tension and by overcorrection and suspension of the cheek flap to the lateral orbital rim. This anterior-based flap is supplied by the facial and submental arteries and advances upward from the cervical area and rotates forward.


A posterior-based cervicofacial cheek flap is used for small and moderate-sized anterior cheek defects. This flap is used for reconstruction of small medial cheek defects next to the nose or lips. The flap is supplied by the superficial temporal artery and vessels in the pre-auriculair region. [ 3 ]


Larger posterior or lower cheek defects up to 10 cm can be closed if the incision of an anterior-based cervicofacial flap is extended, converting it into a cervicopectoral flap, which moves neck and chest skin to the face. This flap is vascularized by the internal mammary perforators. Advantages of this flap are its good skin color, texture, hair-bearing match and the location of the scars at natural folds.


For larger anterior cheek defects, the posterior-based cervicofacial flap is continued inferiorly along the sternum, then laterally down across the chest, above the nipple and toward the axilla. This flap is supplied by the superficial temporal artery and vessels, the vertebral and occipital arteries and the perforators of the trapezius muscle. [ 3 ]


This flap can be used for various defects in the head and neck area. Based on the dominant blood supply there are three different variations of the PMF: superior, posterior or inferior based. Only the superior and posterior based PMF is suitable for oral and facial reconstruction. The thin, quadrangular shaped, and paired platysma muscles lie in the superficial fascia of the neck.


The dominant blood supply is from the submental branch of the facial artery and the venous drainage of the v. submentalis. The arc of rotation is suitable for reconstruction of the anterior and lateral  floor of mouth , buccal mucosa, retromolar trigone, and skin of the lower cheek and parotid region.


This flap receives its blood supply primarily from branches of the a. occipitalis. Venous drainage is the v. jugularis interna.


The arc of rotation is suitable for reconstruction of the lower lip, floor of mouth, ventral tongue, and lower one third of the face. For the proper arc of rotation an adequate exposure of the muscle is necessary.


Advantages of the PMF is that the platysma flap has an appropriate thickness, minimal donor- site morbidity, acceptable scar and colour match and it is easy and faster to harvest. During the procedure the neck is in a hyperextended position. [ 3 ]


An adjunct to the utilization of local and locoregional flaps is the option of tissue expanders. They effectively increase the net skin surface area and provide skin that has the same texture, colour, and hair bearing qualities as the recipient site. [ 3 ]


Pedicled flaps are used when regional tissue is not available, for example because of burns or radiation. There are two pedicled flaps that are sometimes used for reconstruction of cheek defects with or without pre-expansion:


The supraclavicular flap, also known as the "epaulette" flap is vascularized by the supraclavicular artery, which branches off the transverse cervical artery. The vessels can be found using a hand held doppler in the triangle between the dorsal edge of the sternocleidomastoid muscle, the external jugular vein, and the medial part of the clavicle. The flap can be raised as an island flap as well as a pedicled flap.


The deltopectoral flap is beneficial for reconstruction of significant cheek defects, offering up to 250 cm2  of transferable cutaneous tissue to allow reconstruction of the entire cheek. The deltopectoral flap tolerates folding very well and allows movement in wide directions. [ 3 ]


Thanks to further refinements of microvascular techniques in the past three decades, transfer of a free flap is now a routine procedure. Free flaps are the first choice in case of complex, composite, and through-through cheek defects with exposed bone, sinuses, orbit or dura. Advantages of free flaps are their reliable blood supply and freedom of planning. Potential disadvantages are the mismatch of colour, texture, facial shape and thickness.


Whereas a multitude of free flaps are available, the radial forearm, anterolateral thigh, scapular, and lateral arm flap are most useful in cheek reconstruction. [ 3 ]


Prefabrication of flaps opens interesting new possibilities. It is primarily used for reconstruction of complex defects where conventional techniques are not available (in burn patients where common donor sites may have been damaged or destroyed). Flap prefabrication starts with introduction of a vascular pedicle to a desired donor tissue that on its own does not possess an axial blood supply. After a period of neovascularization of at least 8 weeks, this donor tissue can then be transferred to the recipient defect based on the newly acquired axial vasculature. This process can be combined with the use of tissue expanders. [ 3 ]


Careful patient selection is essential for a successful outcome. Donor site morbidity, patient characteristics such as skin laxity, age, tobacco use and sun exposure, potential radiotherapy, planned lymph node dissection, the size of the defect, structural involvement (skin, muscle, nerves, bone), functional concerns like maintaining  oral hygiene , swallowing, mouth opening, aesthetic concerns, experience of the surgeon are all factors that influence the kind of reconstructive technique that should be chosen.


Cordectomy  is the surgical removal of a cord. It usually refers to removal of one or both  vocal cords , often for the purpose of treating  laryngeal cancer . [ 1 ] [ 2 ]  The word is derived from the  Greek , combining  chorde  and  ektome  meaning excision. It can be carried out by traditional surgical techniques or, increasingly, by  carbon dioxide laser . [ 3 ]  CO 2  laser cordectomy has allowed the treatment of glottic carcinoma as a day case procedure. [ 4 ]  The procedure has also been carried out by veterinarians to reduce the volume of incessant barking by  dogs , where it is called  debarking . [ 5 ]  In humans, this type of operation is usually done by  otolaryngologists .


Prior to surgery, the patient must be informed of serious, debilitating, and permanent consequences of surgery, most notably the loss of speaking capacity with severity correlating to the portion of vocal cords removed. A patient will be incapable of producing most vocal sounds following total cordectomy, although deep guttural screams may still be produced, and with the patient almost always retaining the ability to speak in whispers. There is little to no chance of a patient recovering their voice following a complete or near-complete cordectomy as the procedure literally removes the organs responsible for vocal utterances, and patients with a less-than-entire cordectomy will always lose some or most of their vocal range (again corresponding to the section and amount of removed vocal cords). Doctors are encouraged to explore alternative communication technologies with patients (such as  electrolarynxes , whisper-amplifying devices, and  text-to-speech  software) prior to determining the acceptability of the procedure. Patients should be made to understand that the procedure is absolutely permanent and their vocal capacity (with current technology) will never recover to its range prior to the surgery, and patients with small percentages of cord removals will experience disproportionately severe loss of vocal range compared to the loss suffered by patients who have undergone a near-entire cordectomy procedure.


The indications being Carcinoma of Vocal cords and Early Glottic Carcinoma etc.


According to the European Laryngeal Society, Cordectomy is classified into the following types:


Craniofacial prostheses  are  prostheses  made by individuals trained in  anaplastology  or  maxillofacial prosthodontics  who medically help rehabilitate those with facial defects caused by  disease  (mostly progressed forms of  skin cancer , and  head and neck cancer ), trauma ( outer ear trauma ,  eye trauma ) or  birth defects  ( microtia ,  anophthalmia ).  They have the ability to replace almost any part of the face, but most commonly the  ear ,  nose  or  eye / eyelids .  An  ocular prosthesis  and  hair prosthesis  can also be classified as craniofacial prostheses.  Prostheses are held in place either by biocompatible drying  adhesives ,  osseointegrated implants ,  magnets , or another mechanical means (although rare) such as glasses or straps. Prostheses are designed to be as similar as possible to the natural anatomy of each individual.  Their purpose is to cover, protect, and disguise facial disfigurements or underdevelopments.


When surgical reconstruction is not ideal, craniofacial prosthetics are favored when they can better restore the form and function of the absent facial feature.  Craniofacial prosthetics are not wholly considered  cosmetic [ 1 ] [ 2 ]  because they replace the physical  form  and  functional  mechanics  of the absent anatomy and serve a significant role in the emotional stability and rehabilitation of those with facial defects.


Cranioplasty  is a  surgical operation  on the repairing of  cranial  defects caused by previous  injuries  or operations, such as  decompressive craniectomy . It is performed by filling the defective area with a range of materials, usually a bone piece from the patient or a synthetic material. Cranioplasty is carried out by incision and reflection of the  scalp  after applying anaesthetics and antibiotics to the patient. The  temporalis muscle  is reflected, and all surrounding  soft tissues  are removed, thus completely exposing the cranial defect. The cranioplasty flap is placed and secured on the cranial defect. The wound is then sealed. [ 1 ]


Cranioplasty was closely related to  trephination , and the earliest operation is dated to 3000 BC. [ 2 ]  Currently, the procedure is performed for both cosmetic and functional purposes. Cranioplasty can restore the normal shape of the  skull  and prevent other complications caused by a sunken scalp, such as the "syndrome of the trephined". [ 3 ]  Cranioplasty is a risky operation, with potential risks such as  bacterial infection  and  bone flap resorption . [ 4 ]


The word  cranioplasty  can be broken down into two parts: cranio- and -plasty. Cranio- originates from the Ancient  Greek  word κρανίον, meaning " cranium ", while -plasty comes from the Ancient  Greek  word πλαστός, meaning "moulded" or "fashioned". [ 5 ]


The operation has its cosmetic value as the normal shape of the cranium of patients is restored instead of the presence of a sunken skin flap, which may affect the confidence of patients. [ 1 ] [ 6 ]


It also has its therapeutic value as the operation provides structure to the skull and protection to the brain from physical damage. [ 1 ] [ 6 ]  The surgery restores regular  cerebrospinal fluid (CSF)  and  cerebral  blood flow dynamics, along with normal  intracranial pressure . [ 1 ] [ 3 ]  Cranioplasty may improve  neurological  function in some individuals. Furthermore, it can reduce the occurrence of  headaches  caused by injury or previous surgery. [ 6 ]