13.  You want to bone graft a nose.  Should you use endochondral or membranous bone.  Should you fix it?  Strip the periosteum?  How should you orient it?

Answer:
In studies, the majority of endochondral bone (arises from cartilage, i.e. most of axillary skeleton) is resorbed, while membranous bone (arises directly from prexisting mesenchymal tissue, i.e. facial bones and cranial vault) survives.

One should fix the bone to prevent movement and scar interfering with graft take. Peer, Thompson and Casson demonstrated that grafts with retained periosteum have a faster rate of consolidation and a longer length of survival.  In fact the outer layer of periosteum may be responsible for early graft vascularization through the process of inosculation.

Periosteal surface should be in contact with soft tissue and cancellous surface should be in contact with host bone for best volume maintenance.
 

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