Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 17:
Rib Microvascular Transplantation
  Although the rib can often be removed by extrapleural dissection, dissecting the pleura from the periosteum anteriorly where it becomes extremely adherent is sometimes difficult, particularly in older people, those with lung disease, or heavy smokers. The simplest method of dissection is to enter the pleura directly and remove the segment of pleura on the undersurface of the rib with the transplant. Closure of the donor defect is greatly simplified by opening the chest. Heavy circumferential sutures should then be placed around the rib above and below the donor area and a rib approximator used to close the defect as these heavy sutures are tied. An airtight closure can be performed over an intrathoracic tube brought out posteriorly where there are many layers of muscle for closure. The lung can be expanded at the completion of the procedure and the tube removed, completing the airtight closure.

Depending on the amount of room needed, the dissection can be done posteriorly all the way to the tubercle of the rib, if necessary. It is unwise to carry the dissection further posteriorly because branches from the intercostal vessel turn back into the spinal canal to nourish the spinal cord. If one stays anterior to the tubercle for the major portion of the dissection, compromise of this segmental blood supply to the cord is not a danger.

The dissection of the intercostal vessels from the inferior groove can be performed on the back table under magnification, discarding part of the bone and using the posterior dissected segment as the vascular pedicle.


If a greater curve is needed, the more posterior portion of the rib should be taken. To accommodate the donor-site requirements, the rib can be scored subperiosteally on its inner surface with multiple cuts. It can then be bent or straightened as necessary, producing a greenstick fracture of the cortex on the anterior surface. This scoring can be accomplished without disrupting the periosteum or its blood supply.

The intercostal nerves send out posterior, lateral, and anterior cutaneous branches. The lateral branches are often large and accompanied by branches of the intercostal artery and vein. This triad can be used to tease out the intercostal neurovascular bundle from its extraperiosteal position in the grooves. The branches should be noted in every dissection as they anastomose and communicate freely with branches to the serratus anterior muscle, the latissimus muscle, and the overlying skin island. The serratus anterior, latissimus dorsi, and sometimes the trapezius muscles have to be transected to mobilize the entire rib segments. When an overlying skin island is taken with the rib, these lateral branches become critically important.

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