Chin augmentation with nasal osteocartilaginous graft

The use of the nasal hump removed during rhinoplasty was described by Aufricht in 1934 and 1958. In the past 10 years, the author has been using a similar technique but with significant variations. Before beginning the rhinoplasty surgery, the author dissects, through a submental incision, a subperiosteal mental pocket. Then, the osteocartilaginous nasal hump is removed; once the mucoperiosteum/mucoperichondrium is meticulously dissected, the nasal hump is tailored to achieve a mental form and the removed alar cartilage, nasal spine, or septal cartilage is used to fill or supplement the concavities of the hump. This report includes a total of 36 cases, 10 of which were controlled after 3 to 8 years of implantation by tridimensional computed tomography, from which the author observed an osteointegration with the mandibular bone and no reabsorption of the grafts or alteration of the structure of this bone. The patients revealed a high degree of satisfaction, and during the clinical examination, the author could not observe or palpate any distortion of the shape or projection of the chin. None of the grafts needed review or removal. This simple, fast procedure is a very good alternative for patients with some form of microgenia or when patients and surgeons are not likely to use alloplastic implants.     

The Turkish delight: a pliable graft for rhinoplasty

In nose surgery, carved or crushed cartilage used as a graft has some disadvantages, chiefly that it may be perceptible through the nasal skin after tissue resolution is complete. To overcome these problems and to obtain a smoother surface, the authors initiated the use of Surgicel-wrapped diced cartilage. This innovative technique has been used by the authors on 2365 patients over the past 10 years: in 165 patients with traumatic nasal deformity, in 350 patients with postrhinoplasty deformity, and in 1850 patients during primary rhinoplasty. The highlights of the surgical procedure include harvested cartilage (septal, alar, conchal, and sometimes costal) cut in pieces of 0.5 to 1 mm using a no. 11 blade. The fine-textured cartilage mass is then wrapped in one layer of Surgicel and moistened with an antibiotic (rifamycin). The graft is then molded into a cylindrical form and inserted under the dorsal nasal skin. In the lateral wall and tip of the nose, some overcorrection is performed depending on the type of deformity. When the mucosal stitching is complete, this graft can be externally molded, like plasticine, under the dorsal skin. In cases of mild-to-moderate nasal depression, septal and conchal cartilages are used in the same manner to augment the nasal dorsum with consistently effective and durable results. In cases with more severe defects of the nose, costal cartilage is necessary to correct both the length of the nose and the projection of the columella. In patients with recurrent deviation of the nasal bridge, this technique provided a simple solution to the problem. After overexcision of the dorsal part of deviated septal cartilage and insertion of Surgicel-wrapped diced cartilage, a straight nose was obtained in all patients with no recurrence (follow-up of 1 to 10 years). The technique also proved to be highly effective in primary rhinoplasties to camouflage bone irregularities after hump removal in patients with thin nasal skin and/or in cases when excessive hump removal was performed. As a complication, in six patients early postoperative swelling was more than usual. In 16 patients, overcorrection was persistent owing to fibrosis, and in 11 patients resorption was excessive beyond the expected amount. A histologic evaluation was possible in 16 patients, 3, 6, and 12 months postoperatively, by removing thin slices of excess cartilage from the dorsum of the nose during touch-up surgery. This graft showed a mosaic-type alignment of graft cartilage with fibrous tissue connection among the fragments. In conclusion, this type of graft is very easy to apply, because a plasticine-like material is obtained that can be molded with the fingers, giving a smooth surface with desirable form and long-lasting results in all cases. The favorable results obtained by this technique have led the authors to use Surgicel-wrapped diced cartilage routinely in all types of rhinoplasty.     

Surgical correction of the severely deviated nose by extramucosal excision of the osseocartilaginous septum and replacement as a free graft

Twenty-five patients with severe internal and external deviation of the nose characterized by deviation of the septum in several planes and almost total obstruction of the airway on one or both sides were operated on. The entire bony and cartilaginous septum was removed in each of these patients, preserving the mucoperichondrial and mucoperiosteal flaps. The extramucosal technique of septal dissection was used. A support graft was fashioned from cartilaginous remnants of the septal cartilage and placed between the mucoperichondrial flaps as a free graft. All patients were followed for a minimum of 1 year. The longest follow-up is 15 years. Aesthetic improvement of the nose was obtained in all patients. All patients experienced varying degrees of improvement in nasal blockade.     

Long-term use of polyurethane breast prostheses: a 14-year experience

I have used polyurethane prostheses for the past 14 years, implanting 220 implants into 130 patients who desired breast reconstruction after subcutaneous mastectomy or cancer ablation or simply breast augmentation. I theorize that a polyurethane-covered implant resists contracture, retaining its compressibility because the fibroblasts proliferate into the polyurethane in many different directions. When the fibrils contract, the forces of contracture counterbalance one another, resisting contracture. However, when smooth prostheses are implanted, fibrils are directed in a circular fashion around the implant and naturally contract, leading to firmer breasts. There were 115 prostheses inserted following subcutaneous mastectomy, and 22 percent developed contracted capsules. Seven implants became exposed because of skin necroses; one was removed because of a Staphylococcus infection; and two patients developed a combination of polyurethane and silicone granulomas. These developed only with the earlier implant, where there was shedding of the polyurethane sponge layer and silicone bled from the low-viscosity silicone used in the earlier implants. No granulomas were noted with the currently used Surgitek Replicon implant. Eighty-five breasts were reconstructed after cancer ablation with polyurethane implants, and the contracture rate was 2.3 percent. Other complications were minimal. A smaller group of patients had augmentation mammaplasty, and 20 prostheses were placed in 10 patients. A 15 percent contracture rate was noted in this group. In this study, 82 percent of patients were followed for up to 14 years. Capsular contractures occurred in 30 implants between 1 and 11 years, for an average recurrence at 6.3 years. The overall contracture rate was 13 percent. Other complications were minimal. All implants were placed subcutaneously or subglandularly, and all were drained.     

Reconstruction of the internal nasal valve with a splay conchal graft

The internal nasal valve is the narrowest point in the nasal airway and thus is the controlling point that regulates inspiration flow. The cross-sectional area of the internal nasal valve is approximately 40 to 55 mm, and 40 to 50 percent of inspiratory resistance is attributable to internal nasal valve function. Collapse of one or both internal nasal valves can be a consequence of previous surgery, trauma, aging, or primary weakness of the upper lateral cartilage. In this study, autologous conchal cartilage was used as a splay graft for opening and reconstructing the internal nasal valve. Over 3.5 years, 31 patients (18 female patients and 13 male patients) were operated on using the splay graft. Inclusion criteria were positive Cottle sign and modified Cottle sign. Cause of collapse was previous surgery in 12 patients (38.7 percent), primary weakness in 10 patients (32.3 percent), and nasal trauma in nine patients (29 percent). After 10 to 42 months of follow-up, 80.6 percent of patients had good to excellent (stable) subjective respiratory function. There was no major morbidity or complication after surgery. Six patients complained of broadening in the middle nasal vault.     

Proteochondroitin sulfate synthesized in cartilages induced in vivo and in vitro by bone matrix gelatin.

Implanted allogeneic demineralized bone matrix gelatin induced sequential development of cartilage and bone in the recipient rat muscle tissue. Proteoglycans of the implants labeled in vivo with [35S]sulfate at different stages of development were analyzed by sucrose density gradient centrifugation. The major proteoglycan synthesized in day-5 implant, just prior to onset of chondrogenesis, was a dermatan sulfate-containing proteoglycan with relatively slow sedimentation rate. Additionally, a small amount of a faster sedimenting component could be detected. The faster sedimenting proteoglycan, in which chondroitin 4-sulfate accounted for 85% of total radioactivity, became predominant in day-10 sample when cartilage formation was maximal. By day 30, when cartilage had been replaced by newly formed bone, the synthesis of this faster sedimenting component had ceased. A similar, if not identical, proteoglycan was found to be a major one synthesized by the in vitro-induced cartilage. This proteoglycan was smaller in overall size and shorter in length of its chondroitin sulfate chains than a major proteoglycan component obtained from neonatal rat epiphyseal cartilage. Concurrent with these changes in proteoglycan type, there appeared to be a change in collagen type, since type II collagen, in addition to type I collagen, was synthesized in day-10 implant. These results indicate that the proteoglycan can be used as a molecular marker for chondrogenesis by bone matrix gelatin.     

Proteochondroitin sulfate synthesized in cartilages induced in vivo and in vitro by bone matrix gelatin

Implanted allogeneic demineralized bone matrix gelatin induced sequential development of cartilage and bone in the recipient rat muscle tissue. Proteoglycans of the implants labeled in vivo with [³⁵S]sulfate at different stages of development were analyzed by sucrose density gradient centrifugation. The major proteoglycan synthesized in day-5 implant, just prior to onset of chondrogenesis, was a dermatan sulfate-containing proteoglycan with relatively slow sedimentation rate. Additionally, a small amount of a faster sedimenting component could be detected. The faster sedimenting proteoglycan, in which chondroitin 4-sulfate accounted for 85% of total radioactivity, became predominant in day-10 sample when cartilage formation was maximal. By day 30, when cartilage had been replaced by newly formed bone, the synthesis of this faster sedimenting component had ceased. A similar, if not identical, proteoglycan was found to be a major one synthesized by the in vitro-induced cartilage. This proteoglycan was smaller in overall size and shorter in length of its chondroitin sulfate chains than a major proteoglycan component obtained from neonatal rat epiphyseal cartilage. Concurrent with these changes in proteoglycan type, there appeared to be a change in collagen type, since type II collagen, in addition to type I collagen, was synthesized in day-10 implant. These results indicate that the proteoglycan can be used as a molecular marker for chondrogenesis by bone matrix gelatin.     

Long-term results of MISTI gold breast implants: a retrospective study

MISTI Gold breast implants (Bioplasty, St. Paul, Minn.) filled with polyvinylpyrrolidone-hydrogel were developed as a promising alternative to silicone-filled implants. Some studies have reported on the positive effects of the implant, such as improved radiolucency and biocompatibility of the gel; however, there are also reports that such implants increased in volume and were subject to capsular contracture in the human body, resulting in demands for their removal. The purpose of this retrospective study was to analyze the long-term results of a series of patients with MISTI Gold breast implants. Between 1991 and 1993, the authors inserted 83 MISTI Gold implants in 61 patients with an average age of 46 years (range, 16 to 69). The authors were able to follow up 48 patients with 71 MISTI Gold implants. The average follow-up was 68 months (range, 10 to 108 months). The retrospective study found that 59 percent of all MISTI Gold implants were removed after an average period of 4.14 years. The main reason for implant removal was an increase in volume of 38 percent, followed by capsular contracture in 14 percent of all 71 MISTI Gold implants. The average increase in volume of all removed MISTI Gold implants was 43 percent. Capsular contracture was graded as Baker I and II in 63 percent and as Baker III and IV in 37 percent. In conclusion, the authors believe that MISTI Gold implants do not fulfill the criteria of safe breast implants, and they agree with the December of 2000 opinion of the Medical Devices Agency of the Department of Health in London that the hydrogel-filled breast implants should not be used until more information about the filler material and its metabolic fate is available.     

Capsule injection for the prevention of contracture

From 1990 through 1999, 164 patients with prior augmentation mammaplasty underwent implant removal by the author, and 128 of the patients had the implants replaced. Of that group, 86 were noted on preoperative examination to have capsule contracture of grade III or IV. Patients with preoperative capsule contracture were offered the option of a postoperative injection of triamcinolone intended to prevent recurrent contracture. Patients who elected to have replacement with gel-filled implants were excluded. A total of 48 patients underwent injection of triamcinolone 4 to 6 weeks after surgery. Of the remaining 38 patients, 12 were not offered injection because they selected gel-filled implants and 26 declined injection. Follow-up ranged from 8 months to 10 years (mean, 46 months), and no patient was followed up for less than 8 months. Of the 48 patients who received injections, two developed recurrent contracture, one at 3 years and one at 4.5 years. Of the 26 patients who declined injection, eight had recurrent contracture (three bilateral) within 12 months. These data suggest that in this high-risk group of patients, a postoperative injection of triamcinolone can reduce the risk of recurrent contracture.     

Infectious complications following breast reconstruction with expanders and implants

The incidence of infection following breast reconstruction with expanders and implants ranges from 1 to 24 percent. Numerous factors associated with infection have been described; however, a one-variable at time setting and multifactorial analysis have not been performed. The purpose of this study was to analyze a set of factors that may predispose women to infection of the expander or implant. Between 1997 and 2000, a total of 168 implant reconstructions were performed in 130 women at a single institution. The mean age for all women was 48.2 years (range, 25 to 77 years). The factors that were analyzed included axillary lymph node dissection, chemotherapy, radiation therapy, tumor stage, timing of implant insertion, number of sides (unilateral versus bilateral), tobacco use, and presence or absence of diabetes mellitus. Statistical analysis was performed with stepwise logistic regression. Mean time to follow-up for all patients was 29 months (range, 12 to 47 months). Infectious complications occurred in 10 women (7.7 percent) and in 10 expanders or implants (5.9 percent). Infected implants were removed an average of 116 days following insertion (range, 14 to 333 days). Cultured bacteria included Staphylococcus aureus and Serratia marcescens. A significant association (p < 0.04) was detected between implant infection and radiation therapy. The chance for implant infection was 4.88 times greater for implants that were exposed to radiation therapy compared with those that were not. In addition, there was suggestive (p < 0.09) evidence that the chance of implant infection following lymph node dissection was 6.29 times higher than when no lymph nodes were removed. No significant association between implant infection and age, diabetes, tobacco use, tumor stage, timing of implant insertion, or chemotherapy was found.     

Anatomy of the external nasal nerve

After rhinoplasty, many patients report numbness of the nasal tip. This is primarily because of injury to the external nasal nerve. It is imperative that surgeons performing rhinoplasty be familiar with the anatomy and the common variations of this nerve. Therefore, the purpose of this study was to present an anatomical study of the external nasal nerve. Twenty external nasal nerves were examined by dissecting 10 fresh cadaver noses within 48 hours of death. On dissection, the exit of the nerve between the nasal bone and upper lateral cartilage was identified. The distance from the point of exit to the midline of the nose and the size of the nerve were measured. The course and the running plane of the nerve were investigated. The nerve branchings were also classified into three types: type I, only one nerve without any branch; type II, one nerve proximally and then splitting into two main branches at the intercartilaginous junction; and type III, two main branches from the point of exit. The point of exit of the external nasal nerve from the distal nasal bone was located 6.5 to 8.5 mm (7.3 +/- 0.6 mm) lateral to the nasal midline. The average diameter of the nerve at the point of exit was 0.35 +/- 0.036 mm. Most of the nerves (95 percent) passed through the deep fatty layer directly under the nasal superficial musculoaponeurotic layer, all the way down to the alar cartilages. In terms of the branching type, type I was observed in 10 of 20 nerves (50 percent), type II was observed in six of 20 (30 percent), and type III was seen in four of 20 (20 percent). On the basis of the results of this study, the following precautions are suggested during a rhinoplasty to minimize the chance of injury to this nerve. First, it is best to avoid deep intercartilaginous or intracartilaginous incisions so that the deep fatty layer is not invaded and the dissection is maintained directly on the surface of the cartilage (deep to the nasal superficial musculoaponeurotic layer). Second, dissection at the junction of the nasal bone and upper lateral cartilage area of one side should be limited to within 6.5 mm from the midline. Lastly, when the nasal dorsum is augmented by an onlay graft, implants or grafts less than 13 mm wide at the rhinion level should be used.     

Long-term comparison of a newly designed gold implant with the conventional implant in facial nerve paralysis.

Patients with complete facial nerve palsy are at risk for eye complications resulting from exposure of the cornea and loss of the blinking reflex. Failure of protection predisposes the patient to exposure keratitis, corneal abrasion and, in rare cases, blindness. The mainstays of non-surgical therapy are cumbersome, obscure vision, and are mostly helpful in patients with acute facial paralysis in whom recovery of orbicularis oculi function is expected. Methods of lid-loading using metal implants and gold eyelid weights have been reported in the literature. Between October of 1988 and March of 1995, 32 patients with lagophthalmos due to facial nerve palsy underwent a total of 34 procedures for the insertion of a gold eyelid weight. Each patient had a gold weight inserted into a small pocket between the orbicularis oculi and the tarsal plate of the upper eyelid. The gold implant is curved to fit the curvature of the eye and contains holes for fixation to the tarsus with sutures. Ingrowth of fibrous tissue through the holes may also help fix the weight in position. Between 1988 and 1991, 10 patients received 10 commercially available rectangular gold implants with 2 holes; these implants resulted in adverse effects, such as infection and exposure in up to 30 percent of the cases. Because of the high complication rate with the rectangular gold implant, the authors began using a new, elliptical gold implant with 3 holes, which is longer, thinner, wider in the center, and narrower in the peripheral portion. This new elliptical implant was used on 22 patients (24 implants) from December of 1991 through March of 1995. The mean follow-up time for the 32 patients in the study was 41.3 months (range, 6 to 63 months), 49.8 months for patients with rectangular implants and 32.8 months for patients with elliptical implants. The elliptical gold implant resulted in dynamic closure of the eyelid and in excellent protection and cosmesis. Lagophthalmos and exposure keratitis resolved, visual acuity significantly improved without complications, and most patients could dispense with eyedrops and salves. A lower eyelid supporting procedure (conchal cartilage graft) should be performed simultaneously in patients with lagophthalmos of a moderate or severe degree to achieve complete closure of the eyelid. Use of a tall pillow decreased the incidence of eyelid opening during sleep. Double eyelid fold operations'were performed on the contralateral eyelid after 6 months, resulting in a symmetrical and beautiful eyelid.     

Microbial growth in saline breast implants and saline tissue expanders

The subject of microbial growth within the saline medium of prosthetic breast implants has been one of great controversy in recent years. Although several articles have described microbial growth within the tissue surrounding implanted breast prostheses, few have attempted to determine the possibility of such contamination of the luminal saline. The authors studied the intraluminal saline medium of a series of explanted breast prostheses with the objective of identifying any microbial contamination. Over a 6-month period, a consecutive series of saline-filled breast implants and tissue expanders were removed from 37 patients. Under the supervision of a microbiologist, saline extracted from each implant was subjected to bacterial and fungal cultures, Gram staining, and acid-fast staining. A total of 24 saline-filled breast implants were removed from 15 patients, and 32 saline-filled tissue expanders were removed from 22 patients. The average length of implantation was 28.1 months for the implants and 7.1 months for the expanders. None of the saline within the implants or expanders within our series displayed any evidence of microbial contamination. These results suggest that microbial contamination of the luminal saline of prosthetic breast implants is an extremely unlikely event.     

Temporoparietal free fascia grafts in rhinoplasty

The temporoparietal fascial graft provides adequate coverage, contour, and bulk on the cartilage dorsum of the nose, as well as an inconspicuous donor site. In my opinion, this technique not only prevents the occurrence of noticeable sharp edges of the cartilage graft, but also adds to the smooth contour of the reconstructed nasal dorsum. The improved results either in primary and secondary rhinoplasty would seem to justify this technique. Some variations in fascia grafts are presented with clinical examples.     

Kinetics of chondrocyte growth in cell-polymer implants

In vitro cultivation of cartilage cells (chondrocytes) on biodegradable polyglycolic acid (PGA) scaffolds resulted in implants which could potentially be used to repair damaged joint cartilage or for reconstructive surgery. Cell growth kinetics were studied to define conditions under which the cellularity of implants made from isolated calf chondrocytes reached that of the parent calf cartilage. In static cultures, condrocyte growth rates decreased as either implant thickness or implant cell density increased. Over 4 weeks of cultivation, implant permeability to glucose decreased to 3% that of the plain polymer scaffold; this effect was attributed to the decrease in effective implant porosity associated with cartilage tissue regeneration.In a well-mixed culture, implants 1 cm in diameter by 0.3 cm thick maintained high cell growth rates over 7 weeks and hard normal cell densities. Regenerated cartilage with these dimensions is large enough to resurface small joints such as the trapezium bone at the base of the human thumb. Such implants could not be grown statically, since cell growth stopped at 3-4 weeks and cell densities remained below normal. Optimization of the tissue culture environment is thus essential in order to cultivate clinically useful cartilage implants in vitro. (c) 1994 John Wiley & Sons, Inc.     

In vitro redifferentiation of culture-expanded rabbit and human auricular chondrocytes for cartilage reconstruction

To construct an autologous cartilage graft using tissue engineering, cells must be multiplied in vitro; they then lose their cartilage-specific phenotype. The objective of this study was to assess the capacity of multiplied ear chondrocytes to re-express their cartilage phenotype using various culture conditions. Cells were isolated from the cartilage of the ears of three young and three adult rabbits and, after multiplication in monolayer culture, they were seeded in alginate and cultured for 3 weeks in serum-free medium with insulin-like growth factor 1 (IGF-1) and transforming growth factor-beta2 (TGF-beta2) in three different dose combinations. As a control, cells were cultured in 10% fetal calf serum, which was demonstrated in previous experiments to be unable to induce redifferentiation. Chondrocytes from the ears of young, but not adult, rabbits, synthesized significantly more glycosaminoglycan when serum was replaced by insulin-like growth factor-1 and transforming growth factor-beta2. The number of collagen type II-positive cells was increased from 10 percent to 97 percent in young cells and to 33 percent in adult cells. Using human ear cells from 12 patients (aged 7 to 60 years), glycosaminoglycan synthesis could also be stimulated by replacing serum with insulin-like growth factor and transforming growth factor-beta. Although the number of collagen type II-positive cells could be increased under these conditions, it never reached above 10 percent. Data from five patients showed that further optimization of the culture conditions by adding ITS+ and cortisol significantly increased (doubled or tripled) both glycosaminoglycan synthesis and collagen type II expression. In conclusion, this study demonstrates a method to regain cartilage phenotype in multiplied ear cartilage cells. This improves the chances of generating human cartilage grafts for the reconstruction of external ears or the repair of defects of the nasal septum.     

Management of the chest-wall deformity in male patients with Poland's syndrome

The chest-wall deformity associated with Poland's syndrome was reconstructed in eight male patients 16 to 38 years old (average age 20 years). Follow-up ranged from 1 to 10 years. Two patients had custom silicone implants placed subcutaneously. In one of these patients, the edge of the implant could be seen. Three patients had transfer of an ipsilateral pedicled latissimus dorsi muscle flap with intact thoracodorsal nerve. All these patients had noticeable atrophy of the flap, and one underwent subsequent implantation of a custom silicone implant beneath the flap. Three other patients had a custom silicone implant covered immediately by a latissimus dorsi muscle flap. All four patients who had a combination of silicone implant and latissimus dorsi muscle flap had satisfactory correction of their deformity.     

Segmental bone and cartilage reconstruction of major nasal dorsal defects

This article describes the results of segmental bone and cartilage reconstruction of significant nasal dorsal defects. Solid bone graft reconstructions frequently lead to an unnatural hardness of the nasal tip. Rib cartilage reconstructions are pliable and soft but are a problem because they easily undergo warpage. The operation is performed using the open approach. Outer cranial bone graft is used for the bone component and extends at least two-thirds of the length of the dorsum. It is secured in place with a compression screw and a Kirschner wire. The cartilage component consists of an abbreviated L strut constructed of septal or conchal cartilage. It is slotted into the cranial bone in a tongue-in-groove manner and is sutured to it through a drill hole in the bone. The dorsal profile is completed with a single cartilage onlay graft or multiple sagittal cartilage grafts secured to the sides of the L strut. Twelve patients underwent segmental reconstruction of nasal deformities. Within this group, five patients underwent secondary rhinoplasty, five underwent posttraumatic rhinoplasty, and two underwent nose augmentation for Oriental features. There were seven men and five women. In all cases, good nasal tip mobility was maintained, and the nasal tips were soft. The interface between the bone graft and cartilage graftwas well camouflaged. The two did not separate. This procedure follows the principle of replacing lost tissue with like materials.     

Repairing defects of the lower eyelid with a free chondromucosal graft.

A method is presented for the repair of full-thickness defects of the eyelid. The lining and tarsal plate are replaced by a free chondromucosal graft from the nasal septum, in which the cartilage is thinned and perforated. Cover is provided by a compound, bipedicled flap of skin and muscle from the opposite lid.     

Long-term clinical experience with fresh osteochondral allografts for articular knee defects in high demand patients

Fresh osteochondral allografts are used to repair osteoarticular defects of the knee. For post-traumatic defects recent advances in other techniques for cartilage repair and resurfacing have reduced the role of allograft tissue transplantation to defects larger than 3 cm in diameter and 1 cm in depth. A fresh osteochondral allograft that has been harvested from a donor within 24 h from death and preserved in 4°C for up to 4 days shows 100% viability of the cartilage. The avascular bone remains structurally intact and mechanically strong until it is replaced by host bone or until it is weakened or absorbed. The indications for fresh osteochondral allografts for reconstructive surgery of the articular surface of the knee do not justify the use of immunosuppressive drugs and we therefore believe that surgical vascularization of the grafts should not be carried out. This clinical approach can provide a reconstructive solution for younger higher demand patients where implants are not desirable and arthrodesis is not acceptable. A clinical follow-up study as early as 1975 showed successful early outcomes. More recently, survival analysis found 95% survival at 5 years, 71% at 10 years, and 66% at 20 years. It was learned that older patients, bipolar transplants, improper loading of the graft, and grafts for osteoarthritis and steroid-induced avascular necrosis do not lead to good long-term outcomes. We would like to describe here some of our long-term clinical experience concerning this surgery. This revised version was published online in July 2006 with corrections to the Cover Date.