A. A stainless steel metal spacer has been used in this patient, who has undergone a hemimandibulectomy. This situation is ideal for a segmental rib graft because there is no need for lining or external cover. The anterior facial vessels have been found to be intact by Doppler probe and are depicted here as the recipient vessels. A short vascular pedicle will be needed. Had these vessels been absent or had branches of the external carotid been needed at a greater distance, the vascular pedicle on the rib could have been mobilized for a greater distance. If necessary, interpositional segmental vein grafts can be added.

B. The submandibular incision has been reopened and a large cervical skin flap folded upward.

C. The rib segment and mandibular stumps have been freshened to provide raw bony contact.

D. The rib is positioned, drill holes made, and stainless steel wires used for secure fixation, taking care to protect the vascular pedicle from being caught in revolving drills or wire loops.

E. A viable spacer has replaced the foreign-body metal object, reconstituting mandibular integrity and contour.

CASE 1

A child had undergone nine unsuccessful bone graftings.

FIG. 17-01. These x rays demonstrate the use of a vascularized rib graft to correct congenital pseudarthrosis of the tibia and fibula. A vascularized rib segment was inserted, hypertrophied slowly at 2 years, and needed additional grafts to consolidate, as seen in the final x ray at 5 years. The rib is not a good weight-bearing structure in the lower extremity. It either fractures or bows. For this reason, the vascularized fibula is the bone of choice. (From Taylor, G.I., Buncke, H.J., Watson, N., and Murray, W.: Vascularized osseous transplantation for reconstruction of the tibia. In Microsurgical Composite Tissue Transplantation. Edited by Dr. Serafin and H.J. Buncke, St. Louis, C.V. Mosby, 1979.)

CASE 2

The patient sustained a traumatic defect of the central third of his left tibia, and had multiple previous failures at soft-tissue cover. (From Buncke, H.J., Furnas, D.W., Gordon, and Achauer, B.M.: Free osteocutaneous flap from a rib to the tibia. Plast. Reconstr. Surg. 59:799, 1977.)

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