J Oral Maxillofac
Surg
49:105.1991
N. ROBERTMARKOWITZ,DMD Oklahoma City, Oklahoma
AVOIDING THE SAGITTAL SINUS DURING CALVARIAL BONE HARVEST To the Editor:--1 would like to compliment Doctors Cannella and Hopkins for reporting their involvement with a autogenous calvarial bone graft harvest in which the superior sag&al sinus was lacerated, causing severe hemorrhage (J Oral Maxillofac Surg 48:741, 1990). Having previously published a modified technique of harvesting cranial bone grafts in the Journal of Oral and Muxillofucial Surgery, ’ I would like to emphasize their point that surgeons who harvest cranial bone grafts should be familiar with cranial surgical technique. I am not sure of their last statement, however, in which they state that surgeons should be capable of managing intraoperative complications at the donor site. If this were the case, then only neurosurgeons would be allowed to harvest cranial bone grafts. I would hope that the authors’ intention, as Ian Jackson has pointed out, was that surgeons who harvest cranial bone must have a neurosurgeon available for immediate consultation if intracranial complications occur. The authors also state that no article has specifically addressed the possible risks that may be associated with the technique of harvesting cranial bone grafts. Both Jackson’ and Harsha et al3 have listed possible neurosurgical complications that can occur in articles published in the Journal of
References 1. Markowitz NR, Allan PG: Cranial bone graft harvesting: A modified technique. J Oral Maxillofac Sura 47:1113. 1989 2. Jackson IT, Helden G, Marx R: Skull bone grafts in maxillofacial and craniofacial surgerv. J Oral Maxi.llofac Surg 44:949, 1986 3. Harsha BC, Turvey TA, Powers SK: Use of autogenous cranial bone grafts in maxillofacial surgery: A preliminary report. J Oral Maxillofac Surg 44: 11, 1986 SLEEPING OR WORKING DURING RESIDENCY EDUCATION? To rhe Editor:-1 would like to offer my perspective regarding your editorial about the long hours spent in resident training. I recently completed a residency in oral and maxillofacial surgery at a level I trauma center, which included 1 year of general surgery. The call schedules for both aspects of the program were essentially every other night in the hospital, with limited opportunity for sleep when on call. As a chief resident, I was allowed to take call from home, which had its problems as well. I never made an error in patient management because of lack of sleep. Any errors that I did make were when I was well-rested and overestimated my ability to handle a given situation. When I was going through my residency experience, I moaned and complained as much as the next person. Now that I have had a chance to put it all in a better perspective, I feel that the time that I spent involved in education and patient care, albeit sleep-deprived, was well worth it. Certainly, improvements can be made. Residents should have a safe, quiet, clean, and private place to sleep and keep their belongings. Adequate meal allowances, as well as access to healthy and palatable food, should be offered to all residents on call. Students and residents should not be required to do tasks of little or no educational benefit to save the hospital from having to pay additional nurses or technicians. These are not fundamental problems in the residency system, but rather an indication of the lack of respect for residents by teaching hospitals. We must not let those with an incomplete perspective change a system of great tradition that has served our profession and our patients so well. To loosely paraphrase our First Lady, when I walk into the operating room and put a knife in my hand I don’t regret the time not spent sleeping, not reading fiction, or not spent with my family. I regret the experience lost from the patients on whom I didn’t operate because I was not on call.
Oral and Maxillofacial Surgery.
I have harvested over 350 split thickness cranial bone grafts with virtually no morbidity using my modified technique in the last 4 years, and one of the points that I stress is to never attempt to cross the midline of the calvarium while harvesting cranial bone in the parietal region, staying at least 2 cm lateral to the midline suture to avoid the sinus. If the oral and maxillofacial surgeon needs a long piece of cranial bone, two or more parietal strips can be mortised together with a mini bone plate instead of attempting to harvest a longer graft across the midline and risking entering the sag&al sinus with its ensuring complications. The authors also note in their article that an oscillating saw blade was used, which does not give the surgeon a tactual sense of how deep the blade is in the calvarium. Using a rotating, low-speed bone drill (Stryker) gives the surgeon better control during bone scoring, particularly in determining proper depth.
NICOLASS. VEACO, DDS, MD Los Angeles, California
105
Surg
49:105.1991
N. ROBERTMARKOWITZ,DMD Oklahoma City, Oklahoma
AVOIDING THE SAGITTAL SINUS DURING CALVARIAL BONE HARVEST To the Editor:--1 would like to compliment Doctors Cannella and Hopkins for reporting their involvement with a autogenous calvarial bone graft harvest in which the superior sag&al sinus was lacerated, causing severe hemorrhage (J Oral Maxillofac Surg 48:741, 1990). Having previously published a modified technique of harvesting cranial bone grafts in the Journal of Oral and Muxillofucial Surgery, ’ I would like to emphasize their point that surgeons who harvest cranial bone grafts should be familiar with cranial surgical technique. I am not sure of their last statement, however, in which they state that surgeons should be capable of managing intraoperative complications at the donor site. If this were the case, then only neurosurgeons would be allowed to harvest cranial bone grafts. I would hope that the authors’ intention, as Ian Jackson has pointed out, was that surgeons who harvest cranial bone must have a neurosurgeon available for immediate consultation if intracranial complications occur. The authors also state that no article has specifically addressed the possible risks that may be associated with the technique of harvesting cranial bone grafts. Both Jackson’ and Harsha et al3 have listed possible neurosurgical complications that can occur in articles published in the Journal of
References 1. Markowitz NR, Allan PG: Cranial bone graft harvesting: A modified technique. J Oral Maxillofac Sura 47:1113. 1989 2. Jackson IT, Helden G, Marx R: Skull bone grafts in maxillofacial and craniofacial surgerv. J Oral Maxi.llofac Surg 44:949, 1986 3. Harsha BC, Turvey TA, Powers SK: Use of autogenous cranial bone grafts in maxillofacial surgery: A preliminary report. J Oral Maxillofac Surg 44: 11, 1986 SLEEPING OR WORKING DURING RESIDENCY EDUCATION? To rhe Editor:-1 would like to offer my perspective regarding your editorial about the long hours spent in resident training. I recently completed a residency in oral and maxillofacial surgery at a level I trauma center, which included 1 year of general surgery. The call schedules for both aspects of the program were essentially every other night in the hospital, with limited opportunity for sleep when on call. As a chief resident, I was allowed to take call from home, which had its problems as well. I never made an error in patient management because of lack of sleep. Any errors that I did make were when I was well-rested and overestimated my ability to handle a given situation. When I was going through my residency experience, I moaned and complained as much as the next person. Now that I have had a chance to put it all in a better perspective, I feel that the time that I spent involved in education and patient care, albeit sleep-deprived, was well worth it. Certainly, improvements can be made. Residents should have a safe, quiet, clean, and private place to sleep and keep their belongings. Adequate meal allowances, as well as access to healthy and palatable food, should be offered to all residents on call. Students and residents should not be required to do tasks of little or no educational benefit to save the hospital from having to pay additional nurses or technicians. These are not fundamental problems in the residency system, but rather an indication of the lack of respect for residents by teaching hospitals. We must not let those with an incomplete perspective change a system of great tradition that has served our profession and our patients so well. To loosely paraphrase our First Lady, when I walk into the operating room and put a knife in my hand I don’t regret the time not spent sleeping, not reading fiction, or not spent with my family. I regret the experience lost from the patients on whom I didn’t operate because I was not on call.
Oral and Maxillofacial Surgery.
I have harvested over 350 split thickness cranial bone grafts with virtually no morbidity using my modified technique in the last 4 years, and one of the points that I stress is to never attempt to cross the midline of the calvarium while harvesting cranial bone in the parietal region, staying at least 2 cm lateral to the midline suture to avoid the sinus. If the oral and maxillofacial surgeon needs a long piece of cranial bone, two or more parietal strips can be mortised together with a mini bone plate instead of attempting to harvest a longer graft across the midline and risking entering the sag&al sinus with its ensuring complications. The authors also note in their article that an oscillating saw blade was used, which does not give the surgeon a tactual sense of how deep the blade is in the calvarium. Using a rotating, low-speed bone drill (Stryker) gives the surgeon better control during bone scoring, particularly in determining proper depth.
NICOLASS. VEACO, DDS, MD Los Angeles, California
105
