**10. Discussion**

Elongation and advancement are performed using Le Fort I osteotomy, and there is no bony

However, this condition is subject to the relapse because of advancement and elongation. In most patients with midface retrusion, when the maxillae are advanced, malar retrusion becomes more prominent. Therefore, a cranial bone graft is used to both provide strong fixation of the Le Fort I osteotomy and augment malar retrusion. Usually, a preplanned, large

Cranial bone grafts are used for all types of upper face bone defects and chin defects, mandibular contour augmentation, periapertural augmentation, and augmentation of asymmetric

The most important concern, in my entire experience with cranial bone grafting procedures, is managing the donor site of the bone graft, such as the donor site cavity through harvesting and weakening of the cranium. The most frequent patient complaint, following cranial bone grafting for esthetic indications, is the presence of a cavity at the donor site. I previously described a technique for cranial bone graft donor site reconstruction. The cranial bone graft donor site is reconstructed with tiny bone chip lamellae that are harvested from the area that is adjacent to the donor site. This approach to cranial bone grafting appears to have high patient acceptance. Our 15-year experience with donor site reconstruction following cranial bone grafting has demonstrated that the procedure is simple, safe, and satisfying. Herein, we

As mentioned before, donor site reconstruction following cranial bone grafting involves the use of thin bone chip lamellae that are harvested from the cranial bone that is adjacent to the

We have successfully performed this procedure in more than 200 patients in a 15-year period. This reconstruction technique is applicable to mild-to-moderate donor site defects, and is

An initial Z-type scalp incision is made, followed by subperiosteal dissection to create a periosteal cover for the grafted bone chips. The galea over the periosteum is preserved to ensure that the periosteal blood supply is adequate. The use of subperiosteal dissection is essential in order to close the reconstructed donor site. Following graft harvesting of the cranial bone, thin cranial bone lamellae are harvested from the adjacent cranial bone by using a curved chisel (**Illustration 2** and **Photo 5**). The bone dust and small bone chips that are obtained during harvesting are collected and also used for reconstruction. The thin harvested bone chips are placed in the donor site cavity to over-correct the defect. Then, a block of gelatin sponge

split-thickness cranial bone graft can solve both problems on one side of the face.

provide a detailed description of our technique for donor site reconstruction.

useful for treating in both, split- and full-thickness donor site defects.

contact between the advanced part and the maxillae.

22 Bone Grafting - Recent Advances with Special References to Cranio-Maxillofacial Surgery

**8. Cranial bone graft donor site reconstruction**

deformities (**Photo 7**).

**9. Surgical technique**

donor site.

Overall, scientific studies have shown that bony defects of the craniofacial structures must be reconstructed with autogenous bone grafts. Although some studies have found that irradiated bone or autoclaved homografts are useful for bony reconstruction, our clinical experience contrasts with these studies.

Alloplastic materials such as medpor, silicon, and hydroxyapatite are not useful for bony reconstruction of the craniofacial skeleton. For defects of the mandible that are up to 10 cm in size, drilled, nonvascularized iliac bone grafting is an easy and suitable reconstruction method. The donor site of nonvascularized iliac grafts must be harvested at the midportion of the iliac bone instead of at the edge of the anterior part. For large or total reconstruction of the mandible, free iliac or fibula bone grafts are preferred. Free iliac grafts are superior to free fibula grafts for dental restoration because of their spongy structures.

As I mentioned before, cranial bone grafts are the best choice to reconstruct the upper face and cranium. Some research studies investigated resorption of cranial bone grafts on the craniofacial skeleton, and they showed minimal rates of resorption [5, 6]. According to my 23-year experience with cranial bone grafts, these grafts have minimal or no resorption. In the past, surgeons used materials from other sites for dorsal nasal augmentation: the rib, iliac crest, olecranon, mandible, or cartilage. It was reported that a cranial bone graft can be harvested by a surgeon who has had proper training, with an extremely low incidence of serious complications [10–13].

[7] Celik M, Tuncer S. Nasal reconstruction using both cranial bone and ear cartilage. Plastic

Craniofacial Bone Grafting

25

http://dx.doi.org/10.5772/intechopen.78787

[8] Celik M. Cranial bone graft donor site reconstruction. The Journal of Craniofacial Sur-

[9] Celik M. A simple method for cranial bone chips harvesting. Annals of Plastic Surgery.

[10] Kline RM Jr, Wolfe SA. Complications associated with harvesting of cranial bone grafts.

[11] Celik M, Tuncer S, Emekli U, Kesim SN. Histologic analysis of prefabricated, vascularized bone grafts: An experimental study in rabbits. Journal of Oral and Maxillofacial

[12] Oppenheimer AJ et al. Craniofacial bone grafting: Wollf's law revisited. Cranioma-

[13] Elsalanty ME et al. Bone grafts in caraniofacial surgery. Craniomaxillofacial Trauma &

and Reconstructive Surgery. 2000;**105**:1624

Plastic and Reconstructive Surgery. 1995;**95**:5

xillofacial Trauma & Reconstruction. 2008;**1**:49

gery. 2017;**28**:180

Surgery. 2000;**58**(3):292

Reconstruction. 2009;**2**:125

2004;**51**:434

Cranial bone resorbs less than other bone does, does not warp, has a hidden donor site, and has an excellent shape [5]. Solid silicone, silicone sponges, medpor, and proplast are easy to use but lead to a high rate of complications in Caucasian patients. This does not occur in Asian people.

Nasal reconstruction with a calvarial bone graft from the radix to the tip of the nose may cause problems such as pain in the nose, graft fracture, graft displacement, and an immobile nasal tip [6].

We believe that the bony segment of the nose must be reconstructed with bone and the cartilage segment should be reconstructed with a cartilage graft when anatomic nasal reconstruction is performed.

In conclusion, nasal reconstruction with a cranial bone-ear cartilage complex facilitates anatomic reconstruction, creating a flexible nasal tip that benefits from the use of autogenous materials.
