10 Graft Harvest Techniques
Summary
This chapter focuses on the surgical principles involved with harvest of grafting material for reconstruction principles discussed in previous chapters. We provide specific techniques for septal cartilage and perpendicular bone harvest for reconstruction of nasal defects. When such sources are deemed to be insufficient, the surgeon may consider auricular or costal cartilage harvesting. Lastly, we discuss techniques for harvesting split calvarial bone graft.
Keywords: costal cartilage, auricular cartilage, calvarial bone graft, septal cartilage, graft harvest, autologous
Introduction
Certain autogenous grafts are commonly used in conjunction with the reconstructive techniques presented in this book (Fig. 10.1). The most common grafts harvested are septal cartilage and bone, conchal cartilage, costal cartilage and/or rib bone, and calvarial bone. The harvest techniques presented are not exhaustive, but they will provide reliable materials for the surgeon. The authors advocate the use of autogenous materials, in conjunction with maxillofacial plating where necessary, over the use of nonautogenous materials in most cases.
Septal Cartilage and Bone
Septal cartilage grafts can be harvested from the quadrangular cartilage, with care to preserve the 1 cm caudal and dorsal strut that is necessary for nasal tip support (Fig. 10.2). Additionally, the perpendicular plate of the ethmoid bone and the vomer can also be used for grafting materials. These grafts are especially useful for nasal reconstruction where they are commonly used for nasal tip, nasal dorsum, nasal sidewall, and caudal septal reconstruction. The materials are very pliable, and holes can be drilled into the thin bone with an 18-gauge needle or septal auger for suture fixation. The grafts are harvested with standard septoplasty techniques.
Fig. 10.2 Parasagittal section of the nasal septum viewed from the left side. The left lateral wall of the nasal cavity has been removed with the adjacent bones. The nasal septum consists of an anterior cartilaginous part, the septal cartilage, and a posterior bony part. The posterior process of the cartilaginous septum extends deep into the bony septum. Reproduced with permission from Schuenke M, et al. Thieme Atlas of Anatomy: Head and Neuroanatomy. New York: Thieme; 2007. Illustration by Karl Wesker.
Ear Cartilage
Cartilage grafts are usually harvested from the concha cymba and/or the concha cavum. These grafts are useful in nasal and eyelid reconstruction. By restricting the harvest to these sites, the shape of the ear will not be distorted. The cartilage can be harvested from either an anterior incision following the antihelical fold boundary with the conchal cartilage or a posterior incision over the site to be harvested (Fig. 10.3 and Fig. 10.4). The perichondrium can be left intact on the cartilage or in situ. In older patients, it is best to harvest the perichondrium with the cartilage, as the cartilage tends to slightly ossify with age and become brittle. The wound can be closed with 5–0 fast-absorbing suture and a tie-over bolster to prevent hematoma formation. A simple bolster can be fashioned from dental rolls (one on the back and one on the front) affi xed with a 3–0 suture on Keith needles that pass through the site of graft harvest. The bolster is usually left in place 3 to 5 days.
