**7. Harvesting of cranial bone graft**

Cranial bone grafts can be harvested as split-thickness or full-thickness bone grafts according to the condition of the recipient area. In the case of full-thickness cranial bone graft harvesting, a neurosurgeon should be involved in the surgery team. The desired shape and size of the bone graft are drawn on the skull after the scalp is subperiosteally dissected. Then the neurosurgeon opens burr holes at the planned areas. The burr holes are connected by cutting the cranium with an electrical craniotome. The dura is dissected carefully, releasing the cranial bone from the brain. In most conditions, harvested full-thickness cranial bone is split from diploe obtaining pieces of split-thickness cranial bone grafts.

Usually, the outer table of the cranium is used to reconstruct the donor site, which is fixated without any step to protect the cranium against undesired irregularities (**Illustration 1**). In children up to 10 years old, the diploe does not exist. The diploe may not exist in women and men who had a poor diet during their period of growth. In those with syndromic cranial anomalies, an undesired forehead shape may be corrected by transferring a nice part of the cranium to the forehead (**Photo 4**). In the case of split-thickness cranial bone graft harvesting, the desired shape is drawn on the temporoparietal skull with a pencil. Then, the graft area is cut down to the diploe with a special electrical osteotome. One of the edges of the bone graft is exposed, and a tiny wedge of bone is removed.

Then, a curved, tiny chisel or specially designed, L-shaped electrical osteotome is used to release the outer table of the cranium. Cranial bone graft-donor sites are reconstructed with tiny bone chip lamellae that are harvested from the area that is adjacent to the donor area (**Illustration 2**). This procedure is associated with a low incidence of patient complaints, thereby suggesting higher patient satisfaction [8]. This approach to cranial bone grafting appears to have a high patient acceptance [8].

Cranial bone grafts can also be harvested as bone chips, especially in patients who undergo alveolar cleft repair [9].

**7.1. Cranium reconstruction using cranial bone graft**

**Illustration 2.** Cranial bone graft donor site reconstruction.

**Photo 4.** Temporoparietal bone block transferred to the forehead.

(**Photo 5**).

Cranial defects must be reconstructed with cranial bone grafts. All alloplastics have different

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Split-thickness, outer table cranial defects may not be reconstructed, but we described a technique in which cranial bone chips were used to reconstruct the outer table of the cranium [8]

side effects and complications, while cranial bone grafts are durable and strong.

**Illustration 1.** Full-thickness cranial bone graft harvesting.

**Photo 4.** Temporoparietal bone block transferred to the forehead.

Usually, the outer table of the cranium is used to reconstruct the donor site, which is fixated without any step to protect the cranium against undesired irregularities (**Illustration 1**). In children up to 10 years old, the diploe does not exist. The diploe may not exist in women and men who had a poor diet during their period of growth. In those with syndromic cranial anomalies, an undesired forehead shape may be corrected by transferring a nice part of the cranium to the forehead (**Photo 4**). In the case of split-thickness cranial bone graft harvesting, the desired shape is drawn on the temporoparietal skull with a pencil. Then, the graft area is cut down to the diploe with a special electrical osteotome. One of the edges of the bone graft

Then, a curved, tiny chisel or specially designed, L-shaped electrical osteotome is used to release the outer table of the cranium. Cranial bone graft-donor sites are reconstructed with tiny bone chip lamellae that are harvested from the area that is adjacent to the donor area (**Illustration 2**). This procedure is associated with a low incidence of patient complaints, thereby suggesting higher patient satisfaction [8]. This approach to cranial bone grafting

Cranial bone grafts can also be harvested as bone chips, especially in patients who undergo

is exposed, and a tiny wedge of bone is removed.

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

appears to have a high patient acceptance [8].

**Illustration 1.** Full-thickness cranial bone graft harvesting.

alveolar cleft repair [9].

**Illustration 2.** Cranial bone graft donor site reconstruction.

#### **7.1. Cranium reconstruction using cranial bone graft**

Cranial defects must be reconstructed with cranial bone grafts. All alloplastics have different side effects and complications, while cranial bone grafts are durable and strong.

Split-thickness, outer table cranial defects may not be reconstructed, but we described a technique in which cranial bone chips were used to reconstruct the outer table of the cranium [8] (**Photo 5**).

**Photo 5.** Orbital floor and medial orbital wall reconstructed using split cranial bone grafts.

Full-thickness cranium defects must be reconstructed because of the possible risk of brain injury. For this purpose, the shape of the defect is drawn on the donor area, and a full-thickness graft is harvested and split into two pieces.

The outer table is used to reconstruct the donor site, avoiding any step deformity. The inner table is used to reconstruct the defect.

#### **7.2. Orbital floor reconstruction with cranial bone**

In the case of blow-out fracture of the orbit with a tiny bone defect on the floor, the size of the defect is drawn on the donor area, and the periosteum must be kept on the cranial bone. Then, the area around the graft is outlined with a tiny curved chisel. Finally, the graft that is 3 mm in thickness is harvested. This curved graft with a few fractures is inserted into the orbital floor through transconjunctival incision and is not fixed. The periosteum keeps the fractured, small cranial bones in one piece.

Large orbital defects are reconstructed with split-thickness cranial bone grafts. The shape of the defect is drawn on the temporoparietal cranium. After harvesting the desired graft, the surgeon fixes a miniplate to the harvested bone graft (**Illustration 3a** and **Photo 6**). Then, the graft is placed on the orbital floor and fixed to the anteroinferior part of the orbit (**Illustration 3b**).

of cranial bone grafts in other areas of the face. Cranial bone grafts are composed of membranous bone, and it is felt that they retain their bulk better than other types of bone grafts do. In patients with cranial bone grafts on the nose, these grafts should be examined more effectively than grafts that are placed on other areas of the face because the grafts are in such an

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According to Jackson et al.'s technique, the cranial bone from the radix to the tip of the nose is used. However, this technique has two disadvantages: it causes the nasal tip to become rigid and the nose is rendered because of traumatic forces. Therefore, we described a modified technique for dorsal nasal reconstruction with the cranial bone [7]. We believe that the bony segment of the nose must be reconstructed with bone and cartilage segment and a cartilage

obvious and easily examined area and are covered with thin skin.

**Photo 6.** Malar augmentation with cranial bone graft.

**Illustration 3.** Orbital floor reconstruction using split cranial bone graft.

#### **7.3. Dorsal nasal reconstruction with cranial bone**

According to my 22 years of experience, a cranial bone graft is the best choice for dorsal nasal reconstruction. Jackson et al. described the cranial bone grafting for nasal reconstruction in 1983 [2].

They published a long-term follow-up paper about the use of cranial bone grafts in dorsal nasal augmentation [6]. They mentioned that they formed various impressions about the use

**Illustration 3.** Orbital floor reconstruction using split cranial bone graft.

**Photo 6.** Malar augmentation with cranial bone graft.

Full-thickness cranium defects must be reconstructed because of the possible risk of brain injury. For this purpose, the shape of the defect is drawn on the donor area, and a full-thick-

**Photo 5.** Orbital floor and medial orbital wall reconstructed using split cranial bone grafts.

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

The outer table is used to reconstruct the donor site, avoiding any step deformity. The inner

In the case of blow-out fracture of the orbit with a tiny bone defect on the floor, the size of the defect is drawn on the donor area, and the periosteum must be kept on the cranial bone. Then, the area around the graft is outlined with a tiny curved chisel. Finally, the graft that is 3 mm in thickness is harvested. This curved graft with a few fractures is inserted into the orbital floor through transconjunctival incision and is not fixed. The periosteum keeps the fractured, small

Large orbital defects are reconstructed with split-thickness cranial bone grafts. The shape of the defect is drawn on the temporoparietal cranium. After harvesting the desired graft, the surgeon fixes a miniplate to the harvested bone graft (**Illustration 3a** and **Photo 6**). Then, the graft is placed on the orbital floor and fixed to the anteroinferior part of the orbit (**Illustration 3b**).

According to my 22 years of experience, a cranial bone graft is the best choice for dorsal nasal reconstruction. Jackson et al. described the cranial bone grafting for nasal reconstruction in 1983 [2]. They published a long-term follow-up paper about the use of cranial bone grafts in dorsal nasal augmentation [6]. They mentioned that they formed various impressions about the use

ness graft is harvested and split into two pieces.

**7.2. Orbital floor reconstruction with cranial bone**

**7.3. Dorsal nasal reconstruction with cranial bone**

table is used to reconstruct the defect.

cranial bones in one piece.

of cranial bone grafts in other areas of the face. Cranial bone grafts are composed of membranous bone, and it is felt that they retain their bulk better than other types of bone grafts do.

In patients with cranial bone grafts on the nose, these grafts should be examined more effectively than grafts that are placed on other areas of the face because the grafts are in such an obvious and easily examined area and are covered with thin skin.

According to Jackson et al.'s technique, the cranial bone from the radix to the tip of the nose is used. However, this technique has two disadvantages: it causes the nasal tip to become rigid and the nose is rendered because of traumatic forces. Therefore, we described a modified technique for dorsal nasal reconstruction with the cranial bone [7]. We believe that the bony segment of the nose must be reconstructed with bone and cartilage segment and a cartilage graft when performing anatomic nasal reconstruction. The idea for our technique arises from the principles of anatomic reconstruction, which means that the bony part of the nose is reconstructed with cranial bone and the cartilage part is reconstructed with cartilage (**Illustration 4**).

inserted in to the nose through an open approach incision, and the bony segment is fixated to

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Cranial bone graft is the first and best choice for malar augmentation in our practice. First, the malar area is exposed with subperiosteal dissection. Then, the augmentation thickness and size of the malar area are. The donor site is selected according to the size and shape of the required bone graft. Usually, a short, running Z incision is used for harvesting (**Illustration 2**). The desired graft is harvested and shaped using a contouring drill. When the graft is ready to be inserted, the best location is selected according to its esthetic appearance during a visual examination. Two screws are used for fixing the cranial bone graft to the underlying malar bones.

If maxillary osteotomies are performed to elongate or advance the maxillae, there is a significant risk of the relapse, even fixation with a plate and screw. When we examine the maxillae of patients with a cleft palate, there is retrusion and hypoplasia. In patients with these condi-

the radix with a screw through a vertical glabellar incision.

**7.5. Cranial bone grafting for fixation during the maxillary osteotomy**

tions, the maxillae should be advanced and elongated.

**Photo 7.** Reconstruction of the donor site of cranial bone graft.

**7.4. Malar augmentation with cranial bone graft**

According to our technique, the surgery is planned after the nose is examined. Nasal reconstruction is planned using cranial bone for the bony part of the nose and a double layer of ear cartilage for the distal part. The dimensions of the graft are measured on the nose and drawn on the skull with a marking pen. Then, the margins of the graft are cut down to the diploe with a special electrical osteotome. On one side of the margins, a wedge-shaped bone is removed to expose the diploe. Then, the bone graft is elevated using a tiny, curved chisel or an L-shaped electrical osteotome. After harvesting the bone and cartilage grafts, dorsally at the caudal end of the bone graft, the surgeon burrs away that is two millimeter in thickness. This burred area is deepened to create a space at the proximal end of the upper layer of the cartilage block. On the burred area, six small holes are opened using a tiny drill.

The cranial bone graft is shaped as desired with a contouring drill. The upper layer of the cartilage is fixed to the bone through these holes using 5-0 nylon sutures.

Then, another layer of cartilage graft is sutured posteriorly to the first layer, which is adapted to the bone graft that was created at the beginning of this step. The bone-cartilage block is

**Illustration 4.** Nasal reconstruction using both cranial bone and ear cartilage.

inserted in to the nose through an open approach incision, and the bony segment is fixated to the radix with a screw through a vertical glabellar incision.

#### **7.4. Malar augmentation with cranial bone graft**

graft when performing anatomic nasal reconstruction. The idea for our technique arises from the principles of anatomic reconstruction, which means that the bony part of the nose is reconstructed with cranial bone and the cartilage part is reconstructed with cartilage (**Illustration 4**). According to our technique, the surgery is planned after the nose is examined. Nasal reconstruction is planned using cranial bone for the bony part of the nose and a double layer of ear cartilage for the distal part. The dimensions of the graft are measured on the nose and drawn on the skull with a marking pen. Then, the margins of the graft are cut down to the diploe with a special electrical osteotome. On one side of the margins, a wedge-shaped bone is removed to expose the diploe. Then, the bone graft is elevated using a tiny, curved chisel or an L-shaped electrical osteotome. After harvesting the bone and cartilage grafts, dorsally at the caudal end of the bone graft, the surgeon burrs away that is two millimeter in thickness. This burred area is deepened to create a space at the proximal end of the upper layer of the

cartilage block. On the burred area, six small holes are opened using a tiny drill.

cartilage is fixed to the bone through these holes using 5-0 nylon sutures.

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

**Illustration 4.** Nasal reconstruction using both cranial bone and ear cartilage.

The cranial bone graft is shaped as desired with a contouring drill. The upper layer of the

Then, another layer of cartilage graft is sutured posteriorly to the first layer, which is adapted to the bone graft that was created at the beginning of this step. The bone-cartilage block is Cranial bone graft is the first and best choice for malar augmentation in our practice. First, the malar area is exposed with subperiosteal dissection. Then, the augmentation thickness and size of the malar area are. The donor site is selected according to the size and shape of the required bone graft. Usually, a short, running Z incision is used for harvesting (**Illustration 2**). The desired graft is harvested and shaped using a contouring drill. When the graft is ready to be inserted, the best location is selected according to its esthetic appearance during a visual examination. Two screws are used for fixing the cranial bone graft to the underlying malar bones.

#### **7.5. Cranial bone grafting for fixation during the maxillary osteotomy**

If maxillary osteotomies are performed to elongate or advance the maxillae, there is a significant risk of the relapse, even fixation with a plate and screw. When we examine the maxillae of patients with a cleft palate, there is retrusion and hypoplasia. In patients with these conditions, the maxillae should be advanced and elongated.

**Photo 7.** Reconstruction of the donor site of cranial bone graft.

Elongation and advancement are performed using Le Fort I osteotomy, and there is no bony contact between the advanced part and the maxillae.

is placed over the bone grafts to avoid displacement during the operation. The procedure is

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Among the patients we have treated, the reconstructed defects initially appeared to be undercorrected, which prompted us to modify our procedure by overfilling the cavity with cranial

As a craniofacial surgeon, I observed my mentors Henry Kawamoto and Ian Jackson perform cranial bone graft harvesting. My main concern was that patients might not accept the appearance of the donor site defect, especially when the procedure was performed for esthetic reasons. I described a technique of nasal bony reconstruction and performed it in a large number of patients. My initial experience with this procedure demonstrated that there was poor patient acceptance of the cranial bone grafting procedure owing to the presence of a defect at the donor site. Therefore, I reconstructed the donor site defect using tiny bone chips that are harvested from the cranial bone that is adjacent to the donor site. After the procedure was introduced, a higher proportion of my patients accepted the use of cranial bone grafts. The bone dust and small bone chips that are obtained during harvesting are also collected and placed in the donor site cavity, along with the tiny harvested bone chips. Overcorrection is advised to account for the potential dead spaces between the bone chips. Several reports have described reconstructing the donor site following full-thickness cranial bone grafting by

In our experience, reconstructing split-thickness and full-thickness donor sites with cranial bone chips is a simple, safe, and satisfying procedure. This technique is useful to fill the donor

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 experi-

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

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,

completed by closing the periosteum and skin in separate layers.

splitting another full-thickness bone graft or using a split graft.

site during cranial bone grafting, which is a concern for esthetic surgeons.

fibula grafts for dental restoration because of their spongy structures.

bone chips.

**10. Discussion**

ence contrasts with these studies.

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

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 deformities (**Photo 7**).
