| |
The patient is placed in the full lateral position, with the upper arm abducted. The entire arm, shoulder, and axilla are included in the operative field, prepared, and draped. The position of the arm and scapula can therefore be moved during the dissection, and one can constantly observe the arm for pressure points and prevent brachial plexus stretch injury during these long procedures. A well-padded Mayo stand or a pillow strategically placed under the drapes serves well for this purpose.
 B. An incision is made over the ninth rib from the costochondral junction to the paravertebral area. The length varies according to the amount of rib needed. Removal of the entire rib makes later closure easier. Dissection of the rib becomes more difficult as one proceeds posteriorly into the paraspinous muscles. As mentioned previously, one should go only as far as the tubercle of the rib when unusual lengths are needed because the latissimus and lower fibers of the trapezius will have to be transected.
 C. Incisions are made through the intercostal muscles and the parietal pleura above and below the rib. These incisions can be close to the rib if no soft tissue is needed or in the mid-intercostal space if a cuff of muscle is to be transplanted with the rib for use in the recipient area. The rib has been isolated circumferentially. In young people, this isolation can be accomplished extrapleurally. In older individuals, however, this extrapleural plane is extremely difficult to preserve and closure is much simpler if the pleura is entered.
|
|
 D. A rib cutter is used to transect the anterior segment first.
PLATE XVII-3
 A. The freed anterior end is rotated so that the subcostal groove containing the vessels and nerves can be visualized. These structures can then be teased out of the groove, and the neurovascular pedicle can be mobilized in a posterior direction.
 B. Once the neurovascular bundle has been isolated for a centimeter or two, the rib cutter can be inserted above these structures and the rib cut free posteriorly.
 C. The neurovascular bundle is then ligated and divided. Further length of the pedicle may be obtained by mobilization posteriorly or dissection anteriorly along the lower border of the freed rib.
D,E,F. The necessary length and curvature of rib are carefully estimated, leaving adequate length for bony overlap and contact at each end. The periosteum is elevated from the surface of the rib that will oppose the mandible.
PLATE XVII-4
next page... |
