Brian W. Kelley1 and Christopher J. Haggerty2
1Private Practice, Carolinas Center for Oral and Facial Surgery, Charlotte, North Carolina; and Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
2Private Practice, Lakewood Oral and Maxillofacial Surgery Specialists, Lees Summit; and Department of Oral and Maxillofacial Surgery, University of Missouri–Kansas City, Kansas City, Missouri, USA
A means of obtaining autogenous, nonvascularized bone for the reconstruction of hard tissue defects and for the replacement of mandibular condyles. A means of obtaining a hyaline cartilage graft for the reconstruction of cartilaginous maxillofacial defects.
- Temporomandibular joint (TMJ) replacements in pediatric patients with active growth centers to reconstruct condylar processes defects caused by trauma, neoplasms, infections, congenital dysplasias, growth abnormalities, ankyloses, and rheumatoid arthritis
- TMJ reconstruction in adult patients due to idiopathic condylar resorption, osteoarthritis, and rheumatoid arthritis when other methods (alloplastic joint replacement) are contraindicated
- Reconstruction of craniomaxillofacial defects caused by loss of hard tissue
- Reconstruction of skull defects or cranioplasty
- Reconstruction of nasal dorsum defects or saddle nose deformities (costochondral cartilage)
- Reconstruction of the helical framework of the ear (costochondral cartilage)
- History of restrictive lung disease
- History of recent pulmonary infection
- History of cardiopulmonary instability
Hyaline cartilage can withstand the stresses of the TMJ and also has an active growth center, allowing for spontaneous growth in the pediatric patient.
The first seven vertebrosternal ribs (true ribs) are attached to the sternum and the manubrium directly by means of costal cartilage.
Vertebrochondral ribs 8,9, and 10 (false ribs) are attached to the vertebrosternal ribs above by means of costal cartilage.
Vertebral ribs 11 and 12 (floating ribs) have no attachment to the sternum.
- The anterior chest wall is prepped and draped, allowing for visualization of the sternum, clavicle, nipple, and umbilicus.
- The ribs are counted and marked with a marking pen.
- A sterile marking pen is used to outline a 6–8 cm line within the inframammary crease of female patients (Figure 57.1) or at the level of the sixth or seventh rib in male patients. In pediatric female patients, the incision is placed in the anticipated future location of the inframammary crease.
- Local anesthetic containing a vasoconstrictor is used to infiltrate the subcutaneous tissue overlying the rib to be harvested.
- Digital pressure is used to identify the fifth, sixth, or seventh rib and the costochondral spaces. A 6–8 cm skin incision is made with a #15 blade directly over the superior aspect of the rib to be harvested. The incision transverses skin, subcutaneous tissue, and pectoralis muscle (Figure 57.2) down to the periosteum directly overlying the rib.
- A #9 periosteal elevator is used to dissect circumferentially around the rib. A tissue plane is developed between the rib’s periosteum–perichondrium and the thin parietal pleura (Figure 57.3). The subperiosteal dissection continues laterally as far as is needed and medially until the costochondral junction is reached. It is important to stay subperiosteal in order to avoid injury to the vascular bundle on the inferior portion of the rib.
- At the costochondral junction, dissection proceeds in a supraperichondrial plane so as not to detach the hyaline cartilaginous cap from the medial aspect of the rib.
- A guillotine rib cutter is used to transect the lateral portion of the r/>