|| FIG. 17-02. The tibial defect can be seen bridged by a tube of skin and bordered by previous delayed flaps.
FIG. 17-03. A skin pattern of the soft-tissue defect is made, which also represents the bony defect of the tibia.
FIG. 17-04. The pattern is transferred to the lateral aspect of the chest over the middle third of the ninth rib. The skin island is outlined.
FIG. 17-05. The flap is elevated, preserving the cutaneous perforations to the overlying skin paddle.
FIG. 17-06. The rib is isolated and transected.
FIG. 17-07. The rib segment is seen with the overlying skin island. The intercostal pedicle is relatively short.
FIG. 17-08. The cutaneous flap has been sutured in place after completion of the microvascular repairs and pinning of the underlying rib segment. The capillary flush from the blade handle can be seen in the center of the flap.
FIG. 17-09. This case demonstrates one of the weaknesses of the rib graft used in long-bone defects, particularly of the lower extremity. The rib is not strong enough to survive as a supporting vascularized graft. The graft fractured at 6 months and additional bone grafts were needed. The fibula, a stronger bone, is the bone of choice for such defects.
A 53-year-old woman required excision of a right mandibular malignant tumor, managed originally with a metal spacer.
FIG. 17-10. Panorex of bony defect.
FIG. 17-11. After radiation therapy, bony contour was restored by transplantation of vascularized rib. Preoperatively, surface Doppler confirmed patent recipient anterior facial vessels.
FIG. 17-12. The plate was exposed, using the previous transverse incision.
FIG. 17-13. The spacer was removed and the bony defect recreated.
FIG. 17-14. A 15 cm segment of the seventh rib was harvested. Chest wound is shown.
FIG. 17-15. The intercostal neurovascular pedicle is demonstrated.
FIG. 17-16. The rib was scored and fixed in place with intraosseous wires.
FIG. 17-17. The intercostal vessels were anastomosed to the anterior facial vessels.