Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 17:
Rib Microvascular Transplantation
  If an island of skin is taken with the underlying rib, it should be seated over the lateral central third of the rib segment so that the lateral intercostal neurovascular pedicle can be incorporated. Because this intercostal perforator is usually the largest perforator, it must be included in the skin island. This maneuver also converts the osteocutaneous transplant into a sensory transplant. In mobilizing the skin island, one must be careful not to shear off the mesenteric-like connection of the skin island to the underlying rib. The farther back the island is positioned, the more muscle must be carried with the island to preserve blood supply.

The rib can also be carried on the blood supply that enters it through the serratus anterior muscle after supplying the latissimus muscle. The subscapular artery continues distally to supply the lower digitations of the serratus anterior muscle. A close relationship exists between the blood supply to the serratus anterior, particularly to the lower three slips, 9-11 and the underlying ribs. Rib segments can be carried on an intact vascular pedicle and transferred as far as the jaw by mobilizing the blood supply coming through the serratus anterior muscle and separating it from the latissimus dorsi muscle up into the axilla. This same pedicle can be used to carry a segment of the seventh, eighth, or ninth rib, plus a variable amount of serratus muscle as a free transplant.12 As mentioned earlier, an island of skin can also be included when additional cover is needed. For complex wound problems, both the thoracodorsal and intercostal blood supplies can be used, adding a portion of the latissimus muscle and scapular skin flap as additional paddles of tissue. 13


PLATE XVII-1. Anatomy

A. The conFIGuration of the rib at levels 7, 8, and 9 shows the gentle curve of the anterior two thirds, compared with the sharper curve of the posterior third.

The arterial branch to the spinal cord and the posterior cutaneous arterial perforator are shown posterior to the tuberosity of the rib. The blood and nerve supplies to the rib are shown arising posteriorly and reaching the subcostal groove in the region of the tuberosity. The nutrient vessel is seen entering the inner cortex in the region of the tuberosity. The largest perforators to muscle and skin arise laterally at about the anterior axillary line and supply the overlying skin insland.


A. The rib section to be removed is marked out with the dotted lines. No attempt is now made to begin this dissection at the spinous process because the nutrient vessel is not needed.

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