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Taking Calvarial Grafts-Tools and

Techniques: VI. The Splitting of a Parietal


Bone Flap
P. Tessier, M.D., H. Kawamoto, M.D., J. Posnick, M.D., Y. Raulo, M.D., J. F. Tulasne, M.D., and
S. A. Wolfe, M.D.

FIG. 1. Taking a bevelled, or chamfered, parietal bone


flap with a Gigli saw or a craniotome.
Miami, Fla.

FIG. 2. (Left) The pericranial flap is elevated. (Center) Burr holes are made with a Gigli saw, shown with the guide in place.
(Right) The parietal bone flap is removed and the dura exposed.

DOI: 10.1097/01.prs.0000177277.36391.28

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FIG. 3. (Left) The parietal bone is cut into several strips. (Center and right) Splitting of the strips with sharp bone splitters.

FIG. 4. (Left) All of the strips are split and (right) half of them are returned to the donor site.

FIG. 5. In the case of a bifrontal craniotomy, a biparietal flap is taken behind a posterior frontal bar.

FIG. 6. (Left) The biparietal flap is spit into two laminae. (Center) Bifrontal and biparietal craniotomies are closed; (right) they
are separated by a narrow bar that stabilizes both cranial flaps.

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FIG. 7. In the case of a unilateral frontal craniotomy and large requirements of bone for extensive facial repairs, several bone
flaps are taken from the frontal region to the lambdoidal suture. Narrow bars are preserved between the flaps.

FIG. 8. All four flaps are split into two.

FIG. 9. Half of the bone segments are returned to the donor area; the other half is used for facial repairs.

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FIG. 10. (Left, above and below) Patient with loss of frontal bone following a vehicular accident and three
previous failures: once with an iliac bone graft, once with a polyethylene implant, and once with irradiated
cadaver bone, using alloplastic materials. (Right, above and below) Views after reconstruction of the entire frontal
bone with the two parietal bones split back to the lamboidal suture, nasal bone graft, and transnasal medial
canthopexies.

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FIG. 11. Preoperative and postoperative radiographs.

FIG. 12. (Left) Preoperative view of patient with loss of the left frontal bone and orbital roof from ballistic
injury, as well as ptosis of the left upper eyelid. (Right) View after correction of all bone defects with split cranial
bone and correction of ptosis.

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FIG. 13. Preoperative defect and outline of parietal bone flap to be used as donor area; the inner table is placed
in the donor area, and the outer table is used anteriorly.

FIG. 14. Preoperative and postoperative three-dimensional computed tomography scans.

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FIG. 15. (Left) Patient with loss of the right frontal bone and enucleation following ballistic injury; (right)
postoperative appearance after correction with split cranial bone and ocular prosthesis.

FIG. 16. The right parietal bone is split in two halves, using
a very thin flexible saw blade, and thin curved osteotomes.
Again, the inner table is placed in the donor area, and the
outer table is placed anteriorly.

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FIG. 17. Preoperative and postoperative three-dimensional computed tomography scans.

FIG. 18. Three-year-old boy with enlarging mass in the


right frontal bone.

FIG. 19. Appearance of mass after reflection of the pericranium.

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FIG. 21. Appearance of patient 1 year postoperatively.


The mass was diagnosed as desmoid fibroplasia.

FIG. 20. (Above) Complete removal of the bony mass; (below) correction with a split cranial graft from the parietal area
behind the coronal suture (thicker bone).

FIG. 22. Three-dimensional computed tomography scans showing the graft and the donor area, both
well ossified. Age 3 is about the youngest that one can count on splitting a cranial bone flap.

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FIG. 23. Four-year-old boy with rapidly growing mass of the left zygoma.

FIG. 24. Preoperative three-dimensional computed tomography scans.

FIG. 25. The excised mass was diagnosed as a primary


hemangioma of bone.

FIG. 26. A soft metal template was used for precise sizing
of the split cranial grafts.

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FIG. 28. Postoperative appearance of the patient at age 5.

FIG. 27. Split cranial grafts were used to reconstruct the


zygoma, lateral orbital wall, and frontozygomatic area.

FIG. 29. Postoperative three-dimensional computed tomography scans show the reconstructed area and the parietal donor
area.

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FIG. 30. Fibrous dysplasia involving the entire left frontal bone and orbital roof and optic canal, with extension
to most of the right supraorbital ridge and frontal bone.

FIG. 31. Computed tomography scans of patient shown in Figure 30.

FIG. 32. (Left) Intraoperative view of involved bone outlined in methylene blue; (right) the frontal bone was more than
5 cm thick.

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FIG. 33. After resection, the defect was reconstructed with


split calvarial bone from both parietal areas.

FIG. 34. Appearance of the patient 2 years postoperatively.

FIG. 35. Computed tomography scans of patient shown in Figure 34, 2 years postoperatively.

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FIG. 36. Patient with shotgun injury through the mandible, maxilla, and nose at initial presentation.

FIG. 37. (Above) After stabilization of the maxillary and


mandibular segments with miniplates and macroplates. (Center) After bone grafting of mandible and maxilla with cranial
bone. (Below) With osseointegrated implants in mandibular
bone graft.

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FIG. 38. Final result after mandibular, maxillary, lip, and nose reconstruction; patient has functional dentures.

S. Anthony Wolfe, M.D.


Miami Childrens Hospital
3100 SW 62nd Street, Suite 120
Miami, Fla. 33155
awolfemd@bellsouth.net