Rib Grafting
Christian P. Conderman
INTRODUCTION
Cartilage grafts are often required in head and neck surgery for nasal and auricular reconstruction, upper airway surgery, and primary and secondary rhinoplasty. For nasal reconstruction and rhinoplasty, septal cartilage is considered the ideal tissue for use in restoring or enhancing the structural framework of the nose. Auricular cartilage can serve as a secondary cartilage-grafting source that is readily accessed with modest donor site morbidity. Situations may arise, however, when these cartilage reservoirs do not provide a viable option, such as when larger cartilage grafts are required to provide adequate material for changes in the shape of the nose or for additional structural support. Similarly, prior surgery may have depleted an individual’s septal and auricular cartilages. In these cases, alternatives must be considered, and, historically, a number of different graft materials have been used, including alloplasts, homografts, and autologous bone and costal cartilage. Nonetheless, as more experience has been gained with the use of these grafting materials, autologous costal cartilage has shown itself to be a viable and long-lasting option for functional and structural grafting in nasal surgery. Osseous grafts, such as split calvarial and iliac crest bone, have certain limitations and should not be considered as first-line alternatives. These bone grafts are prone to fracture, may lead to excessive nasal stiffness, and may resorb to a variable degree. Allografts, such as silicone and polytetrafluoroethylene (PTFE) (Gore-Tex, WL Gore & Associates, Flagstaff, AZ), may be easier to use without the attendant morbidity of a donor site, yet are associated with extrusion, infection, and foreign body reactions. As a result of the aforementioned factors, autologous costal cartilage may be viewed as the preferred grafting material when the above demands must be met.
In the early 20th century, the initial enthusiasm that accompanied the implantation of costal cartilage in nasal reconstruction and rhinoplasty waned due to the tendency of these costal grafts to warp in unanticipated ways. The problems and complications associated with warping, however, have largely been overcome as the use of cartilage has become more widespread, and approaches for harvest, sectioning, and carving have become standardized. Gibson, in 1958, described the principle of balanced cross-sections to minimize distortion of the graft and warping, and this time-honored approach relies upon harvesting cartilage grafts from the central cross-section of a rib. Similarly, Gunter has shown that a K-wire placed within the graft can be an effective means of overcoming warping, although this approach has not been widely adopted.
A variety of techniques exist for costal cartilage harvest and most have shown a long record of safe use. Moreover, the ribs provide an ample reservoir of cartilage for harvest. While the complications of this technique are well known, if performed properly, procurement of costal cartilage is a safe procedure and provides adequate graft materials for aesthetic, functional, and reconstructive operations.
HISTORY
A thorough clinical history must be obtained including a complete review of medical illnesses, previous operations, tobacco and alcohol use, current and previous medications, drug allergies, and family history. Comorbidities
should also be identified at the time of the initial evaluation. During the consultation, an in-depth inquiry of any previous cardiopulmonary problems and surgery must be obtained. Patients should be queried regarding prescription and over-the-counter medications. Specifically, this should include not only prescribed anticoagulants but also herbals and over-the-counter products known to interfere with hemostatic pathways. This may include garlic, ginseng, ginkgo biloba, vitamin E, fish oil, and NSAIDs. Patients should be asked about participation in contact sports such as boxing, football, and the martial arts as thoracoabdominal trauma may lead to premature ossification of costal cartilages and may warrant a preoperative chest CT scan (Figs. 26.1 and 26.2). The operative reports of the patient’s prior nasal and auricular operations should be reviewed if available. Finally, the consultation should clearly define the patient’s functional (airway) and cosmetic concerns and desires.
should also be identified at the time of the initial evaluation. During the consultation, an in-depth inquiry of any previous cardiopulmonary problems and surgery must be obtained. Patients should be queried regarding prescription and over-the-counter medications. Specifically, this should include not only prescribed anticoagulants but also herbals and over-the-counter products known to interfere with hemostatic pathways. This may include garlic, ginseng, ginkgo biloba, vitamin E, fish oil, and NSAIDs. Patients should be asked about participation in contact sports such as boxing, football, and the martial arts as thoracoabdominal trauma may lead to premature ossification of costal cartilages and may warrant a preoperative chest CT scan (Figs. 26.1 and 26.2). The operative reports of the patient’s prior nasal and auricular operations should be reviewed if available. Finally, the consultation should clearly define the patient’s functional (airway) and cosmetic concerns and desires.
 FIGURE 26.1 Normal chest CT of a 48-year-old male with minimal calcification of costal cartilage. |
PHYSICAL EXAMINATION
A dedicated head and neck and full physical examination should be performed prior to harvesting rib grafts. Additionally, a detailed nasal examination must be performed and particular attention should be paid to the nasal septum. This is done to evaluate the amount and quality of septal cartilage that is present. A moistened cotton-tipped applicator may be used to gently palpate the nasal septum under direct visualization with a nasal speculum to aid in the evaluation of the amount of existing septal cartilage. The posterior nasal vault may also be further examined with an endoscope, which may reveal perforations, septal spurs, and deviations that may be encountered intraoperatively and may not be evident solely on anterior rhinoscopy alone. The pinnae and periauricular area should also be examined, and the surgeon should ascertain the relative amount of auricular cartilage that may be available. While auricular cartilage is more pliable than costal and septal cartilage, it
can serve as a useful adjunctive grafting material in a variety of situations. Auricular cartilage can serve as a replacement graft for the lower lateral cartilages, especially in cases of prior overresection, overaggressive cephalic trim, and retraction of the alar margin. A thorough examination of the chest wall should also be performed. In addition to pulmonary auscultation, chest wall abnormalities should be documented at the time of the preoperative examination. Prior breast augmentation and the type of implant used should also be clarified as this may require modification of the operative plan. Obese patients may be at an increased risk for the development of a postoperative seroma and hematoma, and this should be discussed with the patient preoperatively. Lastly, patients should be made aware of the position and length of any potential incisions used for rib harvest. Generally, however, inframammary incisions on females, incisions designed to lie directly over the 6th and 7th rib in males, and incisions placed more inferolaterally on the torso/flank when composite grafts are necessary will usually heal without significant residual deformity or morbidity.
can serve as a useful adjunctive grafting material in a variety of situations. Auricular cartilage can serve as a replacement graft for the lower lateral cartilages, especially in cases of prior overresection, overaggressive cephalic trim, and retraction of the alar margin. A thorough examination of the chest wall should also be performed. In addition to pulmonary auscultation, chest wall abnormalities should be documented at the time of the preoperative examination. Prior breast augmentation and the type of implant used should also be clarified as this may require modification of the operative plan. Obese patients may be at an increased risk for the development of a postoperative seroma and hematoma, and this should be discussed with the patient preoperatively. Lastly, patients should be made aware of the position and length of any potential incisions used for rib harvest. Generally, however, inframammary incisions on females, incisions designed to lie directly over the 6th and 7th rib in males, and incisions placed more inferolaterally on the torso/flank when composite grafts are necessary will usually heal without significant residual deformity or morbidity.
 FIGURE 26.2 Chest CT showing calcification of costal cartilage seen on coronal view of a 67-year-old female. |
INDICATIONS
Costal cartilage is a versatile graft material and may also be used for auricular reconstruction, for pediatric laryngotracheal reconstruction, and in reconstruction of the temporomandibular joint (TMJ). I will focus mostly on its use in nasal reconstruction and septorhinoplasty. Details regarding its other uses are well described elsewhere. The indications and contraindications for its use in these procedures are as follows:
Septorhinoplasty (SRP)
Cases requiring a significant increase in projection, reinforcement of tip support, or augmentation of the nasal dorsum
Ethnic rhinoplasty—correction of poor tip support and/or underprojection, dorsal augmentation, and pre-maxillary augmentation
Primary SRP with a need for extensive structural support with poor or limited native septal cartilage (e.g., caudal septal extension grafts, extended spreader grafts)
Secondary SRP
Cartilage-depleted individuals lacking adequate septal or conchal cartilage
Need for extensive structural grafting
Need for extensive dorsal augmentation
Nasal reconstruction
Posttraumatic nasal defects
Nasal defects associated with cocaine abuse
Saddle nose deformity due to trauma, infection, or systemic disease (e.g., Wegener’s granulomatosis)
Poor septal support and/or loss of cartilaginous L-strut
Rhinectomy defects requiring structural grafting
Septal perforation and septectomy defects
Total/subtotal nasal reconstruction
Congenital nasal deformities, for example, Binder syndrome (nasomaxillary dysplasia)
Laryngotracheal reconstruction
Auricular reconstruction
Temporomandibular joint reconstruction
CONTRAINDICATIONS
Older age group
Significant medical comorbidities
Extensive or diffuse cartilaginous ossification as evidenced on preoperative CT scan
History of restrictive lung disease or recent pulmonary infection
PREOPERATIVE PLANNING
The procedure should be thoroughly explained to the patient, and his/her expectations and desires should be understood prior to surgery. Complications, outcomes, risks, benefits, alternatives, and indications of the procedure should be discussed in detail with the patient. A formal surgical plan should be in place prior to proceeding to the operating room, including an estimation of the type of necessary grafts and their respective source, size, and shape. This will dictate the selection of septal, auricular, and/or costal cartilage harvest. Oftentimes, septal and auricular cartilage may adequately serve the patient’s needs for grafting material and may obviate the need for costal cartilage. Furthermore, a PDS plate (Ethicon, Somerville, NJ) can be used as an adjunct during surgery to expand and supplement the use of these local reservoirs.
 FIGURE 26.3 A: Calcifications seen within the central segment of harvested costal cartilage after preparation with a precision cartilage cutter. B: Another example of calcification seen after harvest of costal cartilage from a 67-year-old female. |
A preoperative chest CT may be considered for some patients and provides information about the degree of costal cartilage calcification, and in fact, some authors advocate the routine use of preoperative CT scanning prior to costal cartilage harvest. CT imaging is of greater value in older patients or those with a history of thoracoabdominal trauma. Calcifications or mineralized costal cartilage may be more difficult to section and carve for use in structural grafting and may have a higher tendency to resorb (Fig. 26.3).
SURGICAL TECHNIQUE
Several techniques have been described to obtain costal cartilage grafts, and a number of factors must be considered prior to graft harvest. The surgeon must estimate the amount of cartilage that is required to serve a patient’s functional and cosmetic needs. Additionally, the surgeon must also consider whether a cartilage-only or osseocartilaginous composite graft is desired. These decisions can dictate which rib or ribs will be selected and may dictate the use of an inframammary approach to the 5th, 6th, and 7th rib, or a subcostal/lateral approach to the 8th, 9th, and 10th ribs.
A number of factors regarding costal anatomy should be considered prior to harvesting the graft. The abdomen and thorax contain an array of muscles and fascia that are encountered during the dissection in the approach to the ribs for cartilage and/or bone harvesting. Figure 26.4 is a schematic representation of the muscular and fascial anatomy of the trunk as it pertains to this dissection. Once the soft tissue dissection has taken place and the ribs are exposed, it must be kept in mind that ribs 6 and 7 have a natural synchondrosis (Fig. 26.5) as they approach the sternum and rib. This may limit the amount of cartilage that is available for grafting purposes from these ribs. In addition, the 8th rib may become part of the synchondrosis as its cartilage approaches the costosternal junction. The 9th rib is the first floating rib and can be useful when a combined bone-cartilage graft is desired for use as a cantilevered graft for dorsal reconstruction or augmentation.
As noted above, grafting requirements will dictate which rib and approach is used for harvest. An inframammary approach to the 6th rib is oftentimes preferable as this provides a direct route to the cartilage and in most cases provides an adequate piece of straight cartilage that can then be tailored to the clinical requirements. Moreover, if additional grafting material is necessary, the rib above or below the harvested rib can be readily accessed via the existing incision. Laterality is another important consideration when performing costal graft harvesting. If a two-team approach is used, an approach to the left rib(s) may be preferable as this allows concomitant harvest of the graft while the surgeon is performing nasal surgery. Nonetheless, the differences in right and left-sided anatomy must be recognized as the pericardium lies in close proximity to the overlying synchondrosis and inadvertent entry into the pericardial space is a possible complication of left-sided harvest. Additionally, postoperative pain may mimic cardiac pain and needs to be evaluated thoroughly, especially in patients with a history of or predisposition to cardiac disease.
A number of other techniques have been described to approach rib harvest including the transumbilical approach and endoscopic harvest of the rib via a smaller incision. While these approaches may yield smaller incisions, they may add to the duration and technical difficulty of the operation and will not be elaborated upon in this text. Furthermore, microtia repair may require harvesting of a larger piece of cartilage from the synchondrosis to allow recreation of the natural shape of the pinna. This is described extensively by Brent and other authors and will not be covered in this chapter.
In females, an incision placed 1 to 2 mm above the inframammary crease is generally well concealed. In the presence of prior breast augmentation, the dissection and approach to the underlying rib must be performed in a meticulous fashion to avoid violation of the capsule surrounding the implant. While rare, rupture
of the implant can occur, and in cases of prior breast augmentation, patients should be advised of this possible complication during the preoperative informed consent process. In males, the incision is generally planned to lie either directly above the rib to be harvested or above an intercostal space if more than one rib harvest is anticipated.
of the implant can occur, and in cases of prior breast augmentation, patients should be advised of this possible complication during the preoperative informed consent process. In males, the incision is generally planned to lie either directly above the rib to be harvested or above an intercostal space if more than one rib harvest is anticipated.
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