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Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 44-50

Split-rib graft cranioplasty: Our experience and tips to achieve optimum results

Department of Plastic and Reconstructive Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India

Date of Submission17-Dec-2018
Date of Acceptance03-May-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Sharad Kumar
Department of Plastic and Reconstructive Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_44_18

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Background: Calvarial defect reconstruction can be performed using a wide range of materials which can be divided into autologous and alloplastic options each with their own advantages and disadvantages. Limiting factors of available options include the risk of infection, absorption, cost, and damage to adjacent tissue. Here, we present our experience of calvarial reconstruction using autologous split-rib graft along with technical details of the surgical procedure.
Materials and Methods: Our retrospective study included 22 patients over 6 years. All the patients were operated by the same team, and records were maintained. Patients were followed up for at least 2 years.
Results: Results achieved were found to be excellent with no major postoperative complications. Patient satisfaction was motivating, and contour of the cranium was acceptable. There was negligible residual or recurrent deformity in our 2-year follow-up.
Conclusions: Calvarial reconstruction with autologous bone graft is superior compared to alloplastic materials. Reconstruction with the rib graft gives optimum results which can be used in most clinical scenarios, including pediatric patients.

Keywords: Calvarial defects, cranioplasty, split-rib graft

How to cite this article:
Goil P, Sharma A, Kumar S, Jain A. Split-rib graft cranioplasty: Our experience and tips to achieve optimum results. J Curr Res Sci Med 2019;5:44-50

How to cite this URL:
Goil P, Sharma A, Kumar S, Jain A. Split-rib graft cranioplasty: Our experience and tips to achieve optimum results. J Curr Res Sci Med [serial online] 2019 [cited 2022 Oct 2];5:44-50. Available from: https://www.jcrsmed.org/text.asp?2019/5/1/44/260640

  Introduction Top

Skull defects may result from congenital anomalies, infection, trauma, radiation necrosis, craniotomy, and surgical excision.[1],[2] Reconstruction is mandatory as such defect poses great threat to patient's psychological status along with number of symptoms together referred to as “syndrome of trephined."[1] Cranioplasty is the corrective procedure done to restore the function and the structural support of the lost cranium bone.[3]

A variety of materials have been described in the literature to restore the integrity of lost cranium. They can be autograft, allograft, xenograft, synthetic material, or a combination. Bone grafts have been used for years in various corrective and cosmetic procedures.[4],[5] With the better understanding of immunology (graft rejection and histocompatibility) and due to high risk of transmission of diseases, especially viral infections, xenografts, and allografts (from cadavers) are no longer used in calvarial reconstructive surgeries.[3] Currently, cranioplasty is done mainly using autologous tissue, alloplastic materials, or a combination of both.[1],[3]

An alloplast is an inert, avascular foreign body. Alloplastic materials widely used are polymethylmethacrylate (PMMA), ceramics, hydroxyapatite, polyether ether ketone, carbon fiber reinforced polymer, and titanium mesh.[1],[3],[4],[5],[6] Its use is not preferred in children as it cannot keep up with the dynamic contouring of the growing cranium. Furthermore, its use is discouraged in problem recipient beds with soft-tissues erosion or paranasal sinus exposure which may result in implant infection. Apart from this, there are reports of late exposure and failure of alloplastic cranioplasties.[7]

In view of the above facts, autologous bone grafts that had been relatively set aside due to new alloplastic materials have been re-established as the most suitable, safe, and natural material for cranial reconstruction.[8] Talking about autologous bone graft in cranial reconstruction, split calvarial bone (outer tabula of the calvarium) and split-rib graft are most frequently used techniques currently. Other options include the sternum, scapula, tibia, and iliac crest.[3],[4],[5]

Rib graft is one of the avascular osseous and osteochondral grafts that have numerous applications in reconstructive procedures. The purpose of this article is to assess the utility, technical details, outcome, and complications of the split-rib graft in calvarial defect reconstruction and share our experiences and technical nuances.

  Materials and Methods Top

This retrospective study was conducted in the Department of Plastic and Reconstructive Surgery, Sawai Man Singh Medical College, Jaipur, from 2012 to 2017. All patients reported to us in the Outpatient Department or were referred to us from the Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur.

Inclusion criteria

The inclusion criteria were as follows:

  1. Full-thickness cranial defect of any size
  2. No age bar was considered
  3. Minimum 3 months' postcraniotomy/trauma/burn
  4. No other associated medical/surgical illness
  5. All patients with Glasgow Coma Scale 15/15
  6. Motivated patients committed for treatment and follow-up.

In our study, we have included the patient only after complete treatment of the primary etiology of disease and clearance from the neurosurgery/oncosurgery department. All the patients were examined thoroughly, and general fitness was obtained before surgery. The medical and radiographic records of patients were reviewed. Operative records were inspected for intraoperative findings, surgical details, and transfusion data. Postoperational records were reviewed for complications related to the surgery as well as clinical outcome.

All the patients were operated with due consent by common team. The patients were operated under general anesthesia in the supine position. Preoperative, intraoperative, postoperative, and follow-up photographs were taken, and record of each patient was maintained [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11].
Figure 1: Preoperative view of deformity over frontoparietal region

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Figure 2: Preoperative view of defect, side view (patient 1)

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Figure 3: Intraoperative view of large calvarial defect (Patient 1)

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Figure 4: Harvested rib graft (Patient 1)

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Figure 5: Fixation of split-rib graft using fine stainless steel wires (Patient 1)

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Figure 6: Postoperative results at 3 weeks

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Figure 7: Postoperative view of donor site at 3 weeks (Patient 1)

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Figure 8: Preoperative view of frontal deformity (Patient 2)

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Figure 9: Postoperative results at 3 weeks (Patient 2)

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Figure 10: Preoperative view of frontonasal deformity (Patient 3)

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Figure 11: Postoperative view (Patient 3)

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For harvesting ribs, incision was given over the right lower chest centered over the 7th rib. Size of the incision depended on the size of defect and amount of rib required for reconstruction. In case of large defects, we place incision more laterally, thus allowing larger segment of the rib to be harvested with natural contour simulating the shape of the cranium. Furthermore, alternate ribs were harvested to prevent contour deformity and split to increase the surface area. Although we have routinely split ribs even in small defect, because we believe this not only increases surface area but also increases flexibility which helps in achieving better contour. Furthermore, splitting exposes the cancellous portion of rib which increases the chances of graft survival by promoting vascularity. We used subperichondral dissection to harvest rib which also minimized the incidence of damaging underlying pleura. After harvesting, hemostasis was achieved, perichondral layer was closed, and pleural integrity confirmed, followed by closure of incision in layers with vicryl 3-0 for muscle and subcutaneous layer and nylon 3-0 for the skin. Whenever possible, we used two-team approach in order to decrease the operative time.

For preparing the recipient site, the previous incision was used whenever possible. The defect was exposed from all the sides. Dura was carefully dissected off the margins of defect. Bone is nibbled until the healthy bone was encountered seen as bleeding from the edges. Margins of the defect were beveled so that graft can fit snugly. We used fine stainless steel wires for fixation of the rib graft. Scalp closed after achieving hemostasis. Dressing was done on the 2nd-postoperative day then biweekly. Patients were discharged on the 5th–7th-postoperative day.

  Results Top

A total of 22 patients were operated during the study period, which included 18 males and 4 females. Out of these, 14 patients were postcraniotomy following trauma, 5 were electric burn survivors, and 3 had tumor resection. Patient's age ranged between 11 and 49 years. The mean age was 23 years. The location of the defect is shown in [Table 1]. Seventeen patients had medium-sized defect (12–25 cm2), three had small-sized defect (<12 cm2), and two had large-sized defect (>25 cm2). The average operative time recorded was 2 h. Of the 22 patients, only one patient required blood transfusion. None of the patients developed major intraoperative or postoperative donor-site complications in terms of hemothorax, pneumothorax, loss of chest wall contouring, significant postoperative chest pain, and scarring. One patient had pain at donor site up to 13th-postoperative day which subsided spontaneously. No postoperative infections were encountered. All the cases showed excellent cranial contour, which was assessed clinically. Graft resorption was not recorded in any of our patient during follow-up. The mean duration of follow-up was 18 months (range: 6–36 months).
Table 1: Location of defect

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  Discussion Top

The main objective of cranial tissue reconstruction is to have a tension-free, durable, and esthetically acceptable cranium.[9] According to the literature, cranioplasty is indicated in the following conditions:[2],[7],[9]

  1. Neurological issues: severe headache, dizziness, irritability, discomfort, epilepsy, pulsatile defect, and pain at the site of the defect
  2. Feeling of apprehension and insecurity
  3. Depression
  4. Intolerance to noise and vibration
  5. Cosmetic/esthetic issues
  6. Fatigability
  7. When defect increases the risk of injury to underlying structures.

The decision regarding the type of graft in cranioplasty must be influenced by the patient's age, prognosis, activity level, the specific condition of the calvarium, size of the defect, and condition of the recipient bed. Inadequate choice of graft material can result in improper coverage, leading to defect exposure, wound breakdown, repeated surgeries, patient distress, and prolonged hospital stay.[10]

The ideal graft material should be biocompatible, osteoinductive, osteoconductive, readily available, ready to use, easily adaptable to the site in terms of size and shape, biodegradable, lightweight, rigid, replaceable by host bone, esthetically suitable, durable, protective, and should be resistant to heat and cold, sterile, radiotransparent, nonmagnetic, with the least possibility to cause a tissue rejection, does not result in allergic reaction and inexpensive.[2],[3],[4] However, till date, there is no material which has all these properties. This has given rise to a constant debate regarding the superiority of one over the other.

Of the various techniques mentioned in literature, autologous bone grafts remain the gold standard, but recent trend appears to be shifting toward alloplastic reconstruction.[4] The most important characteristic of fresh autogenous bone graft material is its potential to get incorporated as a living tissue. This aid cannot be matched by any existing alloplast.[7],[11] Other advantages of autologous bone graft are low risk of graft rejection, provision for replacing like with like, low risk of infection, and better osteointegration. Limitations include inadequate amount, difficulty in attaining proper shape and contouring, potential of resorption, donor-site morbidity, risk of inadvertent injury to nearby tissue during harvest, and increase in operative time.[12],[13]

We preferred autogenous split-rib bone in our study because of its beneficial properties such as improved healing in bacterially contaminated beds, minimal blood loss, and minimal donor-site morbidity.[14],[15] Other advantages of split costal graft are listed in [Table 2].
Table 2: Split-rib graft advantages

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Literature available on split-rib graft reconstruction is lacking when compared to enormous studies available on split cranium bone graft which is considered ideal by most neurosurgeons. In 1911, Dobrotworski used ribs for thefirst time in cranioplasty. Later, Longacre and Destefano modified the technique by splitting the ribs into two, which is popular worldwide.[2],[17]

Complication rate of cranioplasty depends on the graft used primarily and varies from 10% to 22%.[4],[12] Reported hazards of rib graft cranioplasty include pneumothorax, hemothorax, persistent pain, scarring at the donor site, extensive bone resorption, contour deformities, prolonged operative time, lack of protective effect during the healing period, and requirement of multiple ribs for large defects in staged reconstruction.[3],[13],[15],[16]

Adequate debridement of bone up to healthy margin, good vascular flap coverage, and tension-free wound closure are few tricks that helped us in avoiding complications and achieving good results. We did not encounter any major complications in terms of pneumothorax, hemothorax, infection, excessive scarring at donor site, contour deformities, and chronic chest pain. Similar results were also obtained by Sahoo et al.,[15] Taggard and Menezes. in pediatric patients,[16] and Mahrous et al.[17] However, Kawakami et al. reported a single case of hemothorax out of six cases operated by them.[18]

Most neurosurgeons prefer split cranial graft, but the literature suggests greater blood loss during harvest when compared with rib graft harvest which is associated with minimal blood loss as seen in our study and only one of our patients required blood transfusions. Although Tessier et al. reported two cases of secondary bleeding in their 2900 cases of rib harvest for craniofacial reconstruction.[19]

Another problem associated with autogenous bone graft is its limited availability. Many researchers believe that autografts are insufficient for covering large defects and should be preferred for small- and medium-sized defects only.[3],[7] However, we did not face this issue in both of our cases having large-sized defect of 80 cm2 and 110 cm2, respectively. Similar results were obtained by Haleem et al., wherein skull defects up to 180 cm2 were successfully covered using split-rib graft.[20] There are reports from other researchers as well, wherein successful results have been obtained in correcting large calvarial defect using split costa grafts.[8],[10] We suggest more studies assessing the use of splitrib graft in large defects reconstruction. This will further add to our knowledge.

Among alloplastic materials, PMMA is the most commonly used material along with titanium mesh. It is claimed to be very effective, alternative with few technical modifications by many surgeons.[4] With the advent of computer-aided design and manufacturing, both metal and acrylic cranial implants can now be designed and manufactured to precisely fit the patient's defect. However, the main limitations of these alloplasts include their cost, foreign body reaction, infection, exothermic reaction-related tissue damage resulting in graft exposure, and rejection.[4],[21] Furthermore, these materials are not ideal for developing cranial vault as they do not grow.[13]

We preferred stainless steel wires for graft fixation because titanium plate and screws would have increased the alloplastic content of reconstruction. Furthermore, plates and screw fixation lead to relatively rigid fixation which may affect the dynamic contouring of cranium, especially in pediatric patients. Furthermore, there are studies reporting infection rate up to 7.4% and exposure rate up to 3.3% and risk of plate migration as well.[13],[20],[21]

Limitations of the study

The present study could not provide the comparison of various autologous and alloplastic reconstructions. We were not able to compare the results of rib cranioplasty using various fixation techniques of graft, and our sample size was small.

  Conclusions Top

The use of autologous rib graft for cranioplasty, particularly in young age group, was found to be cost-effective, easily harvested with minimum blood loss, molded to the skull shape well, and osteointegrated adequately with the surrounding bone, thus offering good brain protection and is associated with low complication rate in relation to other techniques. However, prospective studies comparing autologous rib grafts with alloplastic materials need to be done.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rangan NM, Sahoo NK, Tomar K, Chattopadhyay PK. Efficacy of autogenous split thickness calvarial graft in the management of residual cranial defect. J Maxillofac Oral Surg 2015;14:754-60.  Back to cited text no. 1
Grant FC, Norcross NC. Repair of cranial defects by cranioplasty. Ann Surg 1939;110:488-512.  Back to cited text no. 2
Koksal V, Kayaci S, Bedir R. Split rib cranioplasty for frontal osteoma: A case report and review of the literature. Iran Red Crescent Med J 2016;18:e29541.  Back to cited text no. 3
Kumar NG, Sudeep S, Balwan R. Cranioplasty of hemispherical defects using calcium phosphate cements along with titanium mesh: Our experience. J Maxillofac Oral Surg 2015;14:920-4.  Back to cited text no. 4
Ooi AS, Kanapathy M, Ong YS, Tan KC, Tan BK. Optimising aesthetic reconstruction of scalp soft tissue by an algorithm based on defect size and location. Ann Acad Med Singapore 2015;44:535-41.  Back to cited text no. 5
Arun Kumar KV, Singla NK, Gowda ME, Kumar D, Legha VS. Current concepts in restoring acquired cranial defects. J Indian Prosthodont Soc 2014;14:14-7.  Back to cited text no. 6
Lee C, Antonyshyn OM, Forrest CR. Cranioplasty: Indications, technique, and early results of autogenous split skull cranial vault reconstruction. J Craniomaxillofac Surg 1995;23:133-42.  Back to cited text no. 7
Artico M, Ferrante L, Pastore FS, Ramundo EO, Cantarelli D, Scopelliti D, et al. Bone autografting of the calvaria and craniofacial skeleton: Historical background, surgical results in a series of 15 patients, and review of the literature. Surg Neurol 2003;60:71-9.  Back to cited text no. 8
Goldstein JA, Paliga JT, Bartlett SP. Cranioplasty: Indications and advances. Curr Opin Otolaryngol Head Neck Surg 2013;21:400-9.  Back to cited text no. 9
Beekmans SJ, Don Griot JP, Mulder JW. Split rib cranioplasty for aplasia cutis congenita and traumatic skull defects: More than 30 years of follow-up. J Craniofac Surg 2007;18:594-7.  Back to cited text no. 10
Guyuron M, Shafron M, Columbi B. Management of extensive and difficult cranial defects. J Neurosurg 1988;69:210-21.  Back to cited text no. 11
Moreira-Gonzalez A, Jackson IT, Miyawaki T, Barakat K, DiNick V. Clinical outcome in cranioplasty: Critical review in long-term follow-up. J Craniofac Surg 2003;14:144-53.  Back to cited text no. 12
Shah AM, Jung H, Skirboll S. Materials used in cranioplasty: A history and analysis. Neurosurg Focus 2014;36:E19.  Back to cited text no. 13
Yano H, Tanaka K, Matsuo T, Tsuda M, Akita S, Hirano A. Cranioplasty with auto-purified bone flap after infection. J Craniofac Surg 2006;17:1076-9.  Back to cited text no. 14
Sahoo NK, Roy ID, Rangarajan H. Cranioplasty in children with split rib graft. Med J Armed Forces India 2011;67:83-5.  Back to cited text no. 15
Taggard DA, Menezes AH. Successful use of rib grafts for cranioplasty in children. Pediatr Neurosurg 2001;34:149-55.  Back to cited text no. 16
Mahrous A, Darwish A, Salama H. Cranioplasty: Successful use of rib grafts. Egypt J Plast Reconstr Surg 2008;32:13-22.  Back to cited text no. 17
Kawakami K, Takahara N, Yamanouchi Y, Suwa J, Matsumura K, Ikeda Y, et al. Split rib cranioplasty. No Shinkei Geka 1989;17:1023-7.  Back to cited text no. 18
Tessier P, Kawamoto H, Matthews D, Posnick J, Raulo Y, Tulasne JF, et al. Taking long rib grafts for facial reconstruction – Tools and techniques: III. A 2900-case experience in maxillofacial and craniofacial surgery. Plast Reconstr Surg 2005;116:38S-46S.  Back to cited text no. 19
Haleem AK, Nouby R, Taghian M. The use of the rib grafts in head and neck reconstruction. Egypt J Ear Nose Throat Allied Sci 2011;12:89-98.  Back to cited text no. 20
Zins JE, Langevin CJ, Nasir S. Controversies in skull reconstruction. J Craniofac Surg 2010;21:1755-60.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

  [Table 1], [Table 2]

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