title: Split cranial bone grafting in children younger than 3 years old: debunking a surgical myth.
abstract: BACKGROUND
  In cranioplasty patients split cranial bone provides excellent structural support and fundamentally "replaces like with like." However, traditional teaching in craniofacial surgery is that cranial bone cannot be split before the age of 3 years because of the lack of diploic space. The authors have found this not to be the case and describe their experience with splitting cranial bone in children with craniosynostosis younger than 3 years.
  
  
  METHODS
  The authors completed a retrospective review of 418 cranioplasties performed between 1997 and 2013 by a single surgeon on patients younger than 3 years with syndromic and nonsyndromic craniosynostosis. Average patient age at the time of the procedure was 328 days. The youngest patient was 58 days old.
  
  
  RESULTS
  Of the 418 cranial procedures performed in this study, cranial bone could be split and used as bone graft in every case. Although the presence of Lückenschädel prevented a complete split of the inner table from the outer table of the bone flap, split cranial bone grafting could still be performed, providing significant grafting material to foster reconstruction. No complications from split cranial harvest were observed.
  
  
  CONCLUSIONS
  Contrary to popular belief and the misconception perpetuated by the Plastic Surgery In-Service Examination, the cranium of children younger than 3 years can indeed be safely and predictably split between the inner and outer cortex. This important finding provides the craniofacial surgeon with a valuable, expanded source of rigid bone for cranial vault remodeling in the pediatric patient population.
  
  
  METHODS
  Therapeutic, IV.
authors.affiliation: Ann Arbor, Mich. From the Section of Plastic Surgery, University of Michigan; the University of Michigan Medical School; and the Craniofacial Anomalies Program, C.S. Mott Children's Hospital.
authors.forename: Christian J
authors.initials: CJ
authors.lastname: Vercler
authors.forename: Kristoffer B
authors.initials: KB
authors.lastname: Sugg
authors.forename: Steven R
authors.initials: SR
authors.lastname: Buchman
mesh_terms: D064592:Autografts; D016025:Bone Transplantation / Q000379:methods*; D002675:Child, Preschool; D003398:Craniosynostoses / Q000601:surgery*; D005260:Female; D005624:Frontal Bone / Q000601:surgery; D006801:Humans; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D012886:Skull / Q000601:surgery* / Q000637:transplantation