Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 17:
Rib Microvascular Transplantation
  The rib is an excellent source of vascularized bone when structural support is not needed.1 It has not held up well as a weight-bearing bone in the lower extremities,2 as we shall illustrate, but it is ideal as a segmental strut to reconstruct defects of the mandible and facial bones. It has also been used successfully to reconstruct upper extremity segmental defects. The fibula is a much stronger structural element but a more privileged donor area. The rib has survived well as a nonvascularized free graft, particularly when split, providing a wide area for graft-bed contact and rapid revascularization. This application has been used for skull defects. In many instances when segmental bone transplants are needed, however, the bed is scarred or irradiated. In such cases, vascularized grafts bring in their own blood supply and are better than nonvascularized free grafts that require nourishment from the bed to survive.3-5

Technical Considerations

The seventh, eighth, or ninth rib is usually chosen as the donor area. The intercostal arteries come off the thoracic aorta into the intercostal spaces about midway between the upper and lower ribs. The major branch rises to reach the intercostal groove lateral to the rib tubercle and can be identified deep to the external and internal intercostal muscles on the posterior intercostal membrane. Identifying the vessel in this deep posterior position is seldom necessary except when an extremely long segment of rib is needed. The intercostal neurovascular bundle, with the nerve most inferior, followed by the vein and artery, is more easily identified and removed in the lower ribs than in the upper ribs.


The intercostal blood supply runs along the lower border of the rib, and a long rib segment can be carried on the intercostal blood supply from either the anterior or posterior inflow. The rib has a nutrient vessel entering it at the tuberosity or posterior to it, but it will survive on either the anterior or posterior intercostal blood supply owing to the presence of multiple periosteal perforators.6-8 For this reason, a variable length of rib, involving a third, a half, or more, may easily be taken. For particularly long segments, the entire rib can be removed.

next page...

  2002 © This page, and all contents, are Copyright by The Buncke Clinic