Calvarial bone grafting techniques as an adjunct to rhinoplasty

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Principles and techniques for augmentation rhino­ plasty arc well established. However, the use of calvarial bone for nasal dorsal augmentation has only recently be­ come accepted as a standard technique in rhinoplasty. Not only is the use of this material often useful in recon­ structive situations such as in the treatment of the sequel­ ae secondary to severe nasoethmoid injuries, but calvarial bone is also occasionally indicated in rhinoplasty when significant augmentation is necessary. While options also include other autogenous materials such as conchal cartilage, homologous materials such as irradiated carti­ lage and demineralized bone, and alloplastic materials such as Silastic, Proplast, and mersiline mesh, the rhino­ plastic surgeon should be familiar with at least one tech­ nique of harvesting calvarial bone . Accordingly, a sim­ plified approach to harvesting outer cortex calvarial bone will be presented. PROCEDURE The surgeon should select a site in the parietal region greater than 2 em from the midline in order to avoid potential penetration of the sagittal sinus. The orienta­ tion of the proposed graft should be anteroposteriorly, as this allows for a graft with the flattest profile (Fig 1). An incision is made through the scalp and underlying periosteum directly overlying the proposed graft. Mini­ mal or no hair is shaved. The scalp is retracted and peri­ osteum elevated in a standard fashion . At this point, it is important to determine the proper length and width of the graft that will be used for the augmentation rhino­ plasty. The proposed graft size is then outlined on the calvarium. Using a drill or osteotome, a wide groove is created in the outer cortex around the graft site. When the diploic space is reached, noted by slight increase in bleeding bone, the proper depth has been attained. Several tech­ niques can then be used to elevate the graft. The first