Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2011) 12, 89–98

Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences

www.esentas.org

ORIGINAL ARTICLE

The use of the rib grafts in head and neck reconstruction

Alaa Kamel Abdel-Haleem a,*, Radwan Nouby b, Mohammed Taghian b

a ENT Department, Assiut University Hospital, Assiut, Egyptb Department of Neurosurgery, Assiut University Hospital, Assiut, Egypt

Received 5 June 2011; accepted 3 August 2011Available online 16 September 2011

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KEYWORDS

Rib;

Defects;

Reconstruction

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Abstract Background: Many grafting materials are available for reconstructing variable defects of

the head and neck.

Objective: The aim is to describe the advantages and disadvantages of the rib grafts in head and

neck reconstruction.

Patients and methods: The rib grafts were used to reconstruct variable deformities and/or defects in

the mandible (12 patients), nose (13 patients), skull and cranial base (six patients), maxilla (five

patients), trachea (three patients), and auricle (one patient).

Results: All patients showed good healing at the recipient site with successful reconstruction of the

structural deformity and accepted esthetic and functional results indicating survival and take of the

grafts except in one patient (2.5%) where graft necrosis occurred because of infection. Wound

dehiscence and graft exposure were not reported. At the donor site, mild wound infection occurred

in two patients (5%) which was controlled by conservative measures with no reports of dehiscence

or pneumothorax.

Conclusion: The rib provides reliable abundant grafting materials sufficient to successfully recon-

struct variable defects in the head and neck region.ª 2011 Egyptian Society of Ear, Nose, Throat and Allied Sciences.

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com (A. K. Abdel-Haleem).

1. Introduction

Reconstruction of different kinds of defects or deformities ofcongenital or acquired etiology is a fundamental and frequentpractice in head and neck surgery. The use of different types of

autogenous grafting and alloplastic materials has minimizedthe resultant functional and cosmetic problems associated withsuch defects and deformities.1 Alloplasts have the following

advantages: unlimited availability, lack of donor site morbid-ity, ease of contouring, maintenance of shape and volume overtime and relative simplicity of insertion. Although they have

achieved widespread success, alloplasts have potentiallyserious complications of infection, aggressive foreign body

90 A.K. Abdel-Haleem et al.

reaction, extrusion and damage to the soft tissue and skin cov-ering.2 Among sources of non-vascularized autografts, the ribis unique in providing cartilage, bone, and combination of

both. The use of different rib components in grafting is anestablished and basic modality in nasal,3,4 auricular,5,6 crico-tracheal,7,8 cranial9,10 and mandibular reconstruction.11

The aim of this study is to describe the advantages and dis-advantages of the rib grafts in head and neck reconstruction.

2. Patients and methods

The rib grafts were used in reconstructing deformities ordefects in the craniomaxillofacial skeleton and trachea in 40

consecutive patients in the departments of ENT and neurosur-gery, Assiut University Hospital during the period fromMarch1999 to December 2009. They were 21 female and 19 male,

with an age range of 8–61 years. According to the site neededto be reconstructed, they were categorized into patients indi-cated for mandibular, nasal, cranial, maxillary, tracheal, andauricular reconstruction (Tables 1 and 2).

The preoperative clinical data of concern included the etiol-ogy, duration, site, and description of the structural, func-tional, and esthetic consequences of the deformity or the

defect.The radiologic investigations included plain chest X-ray,

orthopandentogram (panorama) in patients with mandibular

deformities, and CT and occasionally MRI before and aftercontrast administration in patients with tracheal stenosis andcranial and maxillary tumors.

Flexible fiberoptic laryngoscopy and rigid bronchoscopy

were done in patients with tracheal stenosis.

2.1. Graft harvesting, set, and fixation

The right sixth rib was harvested, osseous only or chondro-osseous (costochondral), for mandibular, maxillary and cra-nial reconstruction. An inframammary skin incision was done

down to the muscles that were split and retracted to expose therib. The periostium was sharply incised along the anterior sur-face of the rib and carefully dissected in a circumferential man-

ner from both surfaces by curved and Doyn elevators takingcare not to injure the underlying pleura. The bone was sharplyseparated from the chondral junction and cut posteriorly withbone cutting forceps. When a costochondral graft (CCG) was

desired for reconstructing the mandibular ramus, the perichon-drium on the anterior surface was preserved in continuity with

Table 1 Type of the rib grafts used in patients with mandibular, n

Diagnosis

Mandibular defects:

Unilateral temporomandibular joint ankylosis

Bilateral temporomandibular joint ankylosis

Flat body

Segmental post ablative defect

Nasal dorsal saddling

Tracheal stenosis

Cauliflower auricular deformity

a small strip of periostium. If another graft was desired thefourth one was harvested.

The right ninth costal cartilage was the source of cartilage

grafts used in reconstructing nasal dorsal saddling, trachealstenosis, and auricular deformities. A subcostal skin incisionwas used and dissection was continued as previously described

strictly in a circumferential subperichondrial fashion. Theanterior perichondrium was preserved in the cases of trachealreconstruction.

During harvesting, continuous palpation of the underlyingrib is essential to avoid pleural injury. Pneumothorax was ex-cluded by the absence of air leakage after filling the woundwith saline solution while the anesthetist was applying positive

pressure into the lungs. The wound was then infiltrated with5–10 ml of 2% xylocaine and closed in layers after applicationof a suction drain. The rib grafts used to reconstruct the man-

dible (split rib, onlay whole rib, CCGs) were fixed by 0.5 mmstainless steel wire or 13 mm long titanium self tabbing mini-screws preceded by maxillomandibular fixation that was re-

leased 1–3 weeks postoperatively (except in the patient wherethe rib was used as an onlay graft). For nasal reconstruction,an endonasal approach consisting of a transfixion septal inci-

sion and bilateral intercartilagenous incisions was used to cre-ate the dorsal and columellar pockets. The dorsal cartilagestrut was fixed to the upper lateral cartilage by a 4/0 polyglac-tin 910 transverse stitch on both sides. The columellar strut

was fixed to the anterior nasal spine and the medial crura ofthe lower lateral cartilage by 4/0 polyglactin 910 stitches. Incranioplasty, the rib bone was split, contoured by bone bend-

ing forceps, and fixed by stainless steel wires to the edges of theskull defect and by 2/0 polyglactin 910 stitches to the pericra-nium. The split ribs were fixed by 0.5 mm stainless steel wires

or to previously contoured titanium 2 mm thickness miniplatesthat were fixed to the remaining nasal, zygomatic and maxil-lary alveolar bones in mid face reconstruction. In tracheal

reconstruction, the trachea was exposed, tracheostome wasrefashioned, the stenotic area above the tracheostome was slitopened till the lumen was reached, a silicone tracheal T tubewas inserted and the rib cartilage was carved to reconstruct

the anterior tracheal wall with perichondrium facing mucosal.It was fixed to the trachea using 3/0 prolene stitches. The fol-lowing additive surgical procedures were done:

� Temporalis muscle flaps were used in patients with tempo-romandibular joint (TMJ) ankylosis (10 patients) and with

maxillary defects (five patients).

asal, tracheal, and auricular reconstruction.

Type of graft N

12

Unilateral costochondral graft 6

Bilateral costochondral graft 4

Onlay rib bone 1

Split rib bone 1

13

Dorsal and columellar cartilage struts 9

Dorsal cartilage strut 4

Costal cartilage 3

Costal cartilage 1

Table 2 The cause and the site of defects in patients subjected to cranioplasty and maxillary reconstruction.

Diagnosis Reconstructed defect N

Frontal osteoma Frontal bone 4–5 · 10 cm 2

Frontoethmoidal fibrous dysplasia Anterior cranial base: 2 · 5 cm 1

Medial wall of the orbit

Nasomaxillary buttress

Bifrontal interosseous meningioma Anterior cranial base: 4 · 10 cm 1

Bifrontal 9 · 20 cm

Frontal mucocoele Anterior cranial base 4 · 5 cm 1

Squamous cell carcinoma of the temporal bone Temporal bone 4 · 8 cm 1

Pleomorphic adenoma of palate Bilateral pterygomaxillary buttresses 2

Recurrent maxillary myxoma Pterygomaxillary buttress 1

Zygomaticomaxillary buttress

Orbital floor

Recurrent adenoid cystic carcinoma of the maxilla Pterygomaxillary buttress 1

Zygomaticomaxillary buttress

Osteomyelitis of the maxilla Pterygomaxillary buttress 1

Zygomaticomaxillary buttress

The use of the rib grafts in head and neck reconstruction 91

� Nasal osteotomies were done in three patients with saddlingand significant septal deviations were corrected in anotherthree patients.

� The pericranium was used to reconstruct the anterior cra-nial base with the split rib bone grafts in three patients.

Patients were followed up during a period that ranged fromsix months to six years.

3. Results

3.1. Patients with mandibular defects or deformities (Table 1)

All the patients with TMJ ankylosis (10 subjects) were suffer-ing from limitation of mouth opening, chewing difficulties,

multiple caries, and dental malocclusions following traumain the form of a fall on the chin dating back to a period of4–20 years. When such trauma was in the childhood period,the patients acquire facial deformity in the form of retrogna-

thia with symmetric face in bilateral ankylosis and asymmetryin the form of deviation of the chin to the affected side in uni-lateral cases. Such patients suffer from snoring and possible

sleep apnea.In these 10 patients the CCGs were used to reconstruct the

ramus after condylectomy and coronoidectomy. This was fol-

lowed by restoration of mouth opening as measured by a max-imal interincisal distance of more than 35 mm maintained bymouth training exercises for a period not less than 6 months.

Improvement of the esthetic deformity (retrognathia and facialasymmetry) was noted in all patients especially in youngpatients with unilateral ankylosis in the form of correction ofretrognathia and chin deviation except in a single patient (with

unilateral TMJ ankylosis) because of infection of the graft.Another patient needed to trim a projecting edge of the appliedCCG that was causing a prominent angle.

In another patient the use of the rib bone as an onlay graftwas followed by a satisfactory esthetic result in camouflagingthe post traumatic flattened right mandibular body deformity

(Fig. 1).The split rib bones were used to successfully reconstruct a

segmental mandibular body defect of 5 cm length followingexcision of an adenocarcinoma of the submandibular gland

with good healing and prevention of the post mandibulectomy

esthetic deformity.

3.2. Patients with nasal dorsal saddling (Table 1)

The cause of saddling in these patients was a neglected facialtrauma (10 patients) and previous submucous resection ofthe nasal septum (three patients). None had previous attempts

of surgical correction of saddling. Preoperatively, all thepatients were found to have variable degrees of broadeningand saddling of the nasal dorsum, shortening of the columella,rounded nostrils and tip deformity in the form of low projec-

tion and downward rotation (Fig. 2a). Three patients sufferedfrom nasal obstruction due to significantly deviated septum.Postoperatively all the patients reported satisfactory esthetic

results (Fig. 2b). None of the grafts was extruded. Woundshealed without reported infections. Minor degree of dorsalgraft wrapping was noted in a single patient.

3.3. Patients with cranial and skull base defects

The split rib bone grafts were used to primarily reconstruct

defects in the frontal (Figs. 3 and 4a) and temporal bones ofa size that ranges from 32 cm2 to 180 cm2 and in the anteriorcranial base with a size of 10–40 cm2 (Table 2). The ribs werecompletely filling the whole defect with rib to rib contact in all

the cranial defects except in the patient with the interosseousmeningioma where the defect consisted of both frontal bones(Fig. 4a). In all patients wound healing was reported without

infection, dehiscence or graft exposure. Good esthetic resultwas obtained in these patients with prevention of the sinkingskin flap syndrome with no reports of pulsating exophthalmos

or enophthalmos. A less satisfactory result, albeit accepted bythe patient, was noted in the patient with the bifrontal menin-gioma. CSF leaks were not reported.

3.4. Patients with maxillary defects

Together with the temporalis myofascial flaps, the split ribbone grafts fixed by plates and screws or wires were used in pri-

mary (four patients) (Fig. 4b) and secondary (one patient)

Figure 1 The patient with flattening of the right mandibular body: (a) preoperative view, (b) postoperative view after the use of an onlay

rib bone graft.

Figure 2 A patient with nasal dorsal saddling: (a) preoperative view, (b) postoperative view after the use of dorsal and columellar costal

cartilage struts.

92 A.K. Abdel-Haleem et al.

reconstruction of post maxillectomy defects. Reconstruction ofthe whole alveolar arch was done in two patients with pleo-

morphic adeoma necessitating total palatal resection. Thegrafts were applied according to the defects needed to bereconstructed that differ from a patient to another (Table 2).

Patients were satisfied by the cosmetic result (Fig. 4c) and goodchewing and speech abilities. Wound dehiscence, infection, andgraft exposure did not occur. One patient (with the recurrent

myxoma) suffered from persistent lower eyelid chymosis withepiphora.

3.5. Patients with tracheal stenosis: (Fig. 5)

These patients developed tracheal stenosis after prolongedendotracheal intubation for a period that ranged from 21 to

40 days. The causes of admission to the intensive care unit(ICU) were motor car accident in two patients and suicidal in-take of organophosphorus material in the third patient. All of

them had an already done tracheostomy. They presented afterone month to two years following ICU discharge. Resection

Figure 3 The patient with the interosseous meningioma: (a) preoperative profile with frontal bulging, (b) postoperative profile with no

skin flap sinking, (c) preoperative axial and coronal CT scan showing extension of the lesion, (d) preoperative sagittal and coronal MRI.

The use of the rib grafts in head and neck reconstruction 93

anastmosis was done in one of them with recurrence of stenosisone year after the operation. Preoperative endoscopic and

radiologic evaluation revealed the presence of tracheal narrow-ing without subglottic affection. Vocal cords were freely mo-bile. Operatively, the length of stenotic segment was foundto be 4–6 cm. Postoperatively, the silicone tracheal T tube

was removed after 4–6 months. All the patients did not devel-op post extubation stridor during a follow up period not lessthan 16 months. Two of them had postoperative harsh voice.

The single patient with the auricular cauliflower deformitypresented five years following perichondritis of the auricle.He did not attend regular follow up and did not complete fur-

ther adjustment procedures (Fig. 6).As regarding the donor site, control of the postoperative

pain was achieved in most patients with 75 mg diclofenac

intramuscular injection once or twice daily for 3–5 days fol-lowed by the oral intake of 50 mg diclofenac thee times dailytill the end of the week. Minor wound infection was reportedin two patients (5%) which was controlled without sequels.

Wound dehiscence or pneumothorax was not reported.

4. Discussion

The surgeons’ preference for different grafting procedures inreconstructing many head and neck defects and deformitiesof variable etiology depends on many factors such as the age

of the patient, nature of the defects; with their consequent

structural, functional, and cosmetic effects; available resources,and personal experience and training. Despite significant ad-

vances in biomedical engineering, the perfect graft materialhas to be attained. The rib grafts are among the sources of freenon-vascularised bone and cartilage grafting materials thathave versatility in craniomaxillofacial reconstruction.

In mandibular defects and deformities, the modality ofreconstruction chosen includes the use of simple bone graftwith or without a myocutaneous flap, pedicled osteomyocuta-

neous flap and the complex vascularised free flap.12,13 Vascu-larised free flaps are now the state of the art forreconstructing mandibular defects especially of composite nat-

ure as they are reliable, resistant to radiation and infection,provide soft tissue and bone components and allow the place-ment of dental implants.14 Despite the great progress in the

transfer of microsurgically anastmosed free flaps, such tech-niques are limited by their high financial cost, prolonged surgi-cal time, need for two teams with increased technical expertise,significant donor site morbidity and the inability of use in

young patients.15 As alternatives to vascularised free flaps,autologous bone grafts in the form of free rib and iliac bonegrafts have been wildly used for reconstructing large mandib-

ular defects due to their resistance to infection and the largevolume of bone they provide with possible dental implanta-tion.16 The CCG have been widely used for replacement of

mandibular condyle in various clinical situations and recently,it is still the best option in the growing children and adults.17–19

Figure 4 (a) Operative view showing the split rib grafts reconstructing the bifrontal defect in the patient with the interosseous

meningioma; (b) operative view of the split rib graft reconstructing the zygomaticomaxillary and pterygomaxillary buttresses; (c)

postoperative view of a patient after maxillary reconstruction with an accepted esthetic appearance; (d) postoperative 3DCT scan of the

patient in (c) showing the survived bone grafts.

94 A.K. Abdel-Haleem et al.

In this study 14 CCGs were used to reconstruct the mandibularramus after condylectomy in 10 patients with TMJ ankylosis

(four bilateral and six unilateral). In such cases the graft wasproved to have the advantages of restoring the shortened pos-terior face height, correcting the facial disfigurement in the

form of symmetric and non-symmetric retrognathia, prevent-ing recurrence of the ankylosis, and providing a potential forgrowth in children.20 Graft loss because of infection seems tobe the major disadvantage of the use of CCG. The periopera-

tive administration of systemic antibiotics and the temporarystorage of the graft in an antibiotic/saline solution are consid-ered to limit the incidence of such infection.18 This complica-

tion was reported in a single out of 10 patients with relapseof retrognathia that is planned to be corrected by mandibularadvancement using distraction osteogenesis. Although there

are reports of CCG overgrowth,21 such phenomenon was notreported in this study possibly because of the limited numberof patients. Based on a histological study, the asymmetric mas-ticatory movement and the uneven loading of the recon-

structed condyle were suggested to interpret overgrowth ofCCG.22

In the remaining two patients, where the significant bone

defect or deformity requires large volume of bone, the prefer-able grafting material would be either the rib or the ilium asalternatives to the vasularized bone transfer. Although the iliac

bone graft is preferred by some authors in reconstructing seg-mental mandibular defects because of providing bone of favor-

able thickness in accepting implants and restoring alveolarcrest,16 it was not used in the patient with the postablative de-

fect because of her refusal. In the patient with flattening of themandibular body, the rib was a more favorable choice becauseof its shape similarity, suitable thickness and pliability in con-

touring than the iliac bone. Still the problem of resorption islimiting the use of autologous bone grafting. Recently, theaddition of bone inducing factors as Recombinant Bone Mor-phogenetic Proteins as an osteoinductive material to the con-

ventional osteoconductive graft scaffolds, was tried withsuccessful results in achieving predictable reconstruction andpreventing graft resorption.13 Another point of importance

in preventing graft resorption, is stabilization of the graftedbone by maxillomandibular fixation and proper rigid fixationof the graft to the recipient site allowing bone to bone

contact.12,18,23

Several grafting and alloplastic materials are described incorrection and augmentation of the nasal saddling deformitythat results from reduced structural support secondary to sur-

gery, trauma or infection.2 Although alloplasts have multipleadvantages, many experts believe that they should not be thefirst choice particularly in rhinoplastic procedures as they have

increased risk of extrusion because of three reasons; first, thenose being of prominent location is commonly traumatizedwith an increased risk of trauma-associated displacement and

extrusion, second, the thin skin soft tissue envelope providinglittle cushioning for the alloplast, and third, mobility of the

Figure 5 A patient with tracheal stenosis: (a) preoperative CT scan, (b) operative view of costal cartilage tracheosoplasty.

Figure 6 The patient subjected to reconstruction of auricular

deformity: (a) preoperative view showing the cauliflower defor-

mity, (b) postoperative view.

The use of the rib grafts in head and neck reconstruction 95

lower third of the nose.2 There are five potential donor sites forautogenous dorsal onlay grafts in rhinoplasty: septal, auricu-

lar, and rib cartilages and iliac and calvarial bones.2,24 In thisstudy, the costal cartilage was used with a successful outcome

in correcting the structural, esthetic and functional compo-nents of the saddling deformity with the advantages of provid-ing sufficient cartilage material with a reliable skeletal support,

flexibility, easy shaping, carving, fixation, and sculpturing, anda stable consistent result along six years of follow up in somepatients with no extrusion, infection, or resorption. In these

patients the amount of septal cartilage was insufficient to com-pensate for the structural defect because of either previous re-moval or concomitant deformity adding to the advantages of

costal cartilage. Among different literature the rib cartilagestands as the primary choice for dorsal augmentation when:the septal or auricular cartilages are insufficient, a largeamount of cartilage material is needed for correcting severe

saddling, or there is poor preoperative recipient site conditionscaused by previous surgeries.2,24,25 In addition to donor sitemorbidity, graft wrapping is a frequently mentioned drawback

for the use of costal cartilage in rhinoplasty. Such disadvan-tage, that was reported with a minimal degree in a single outof 13 patients in this study, can be minimized by the central

placement of stabilizing K-wire in the graft and performingcross sectional carving.24,26 Apart from appropriate graft fixa-tion, certain surgical technical considerations are controversialin augmentation rhinoplasty e.g. whether the open or closed

approach is selected, or whether to fix the dorsal to the colu-mellar strut or not.24,25,27 These issues are out of the scopeof this study.

96 A.K. Abdel-Haleem et al.

The surgical repair of large skull defects is still a challengefor the craniofacial surgeon. In addition to the cosmetic consid-erations, these defects when large leave a significant area of the

brain unprotected and are known to be associated with chronicheadache, developmental delay in young children, and the syn-drome termed sinking-skin-flap syndrome.10,28,29 Alloplasts

and autologous grafts are the options for cranioplasty. Amongalloplasts titanium has been used extensively in the last 20 yearsdue to its malleability, lightweight, and bioinert and non-mag-

netic properties.10,30 Others include polymethylmethacrylate,31

hydroxyapatite32 and more recently bioceramics.33 Because ofthe increased rate of infection, extrusion, and intense foreignbody reaction associated with the use of alloplasts, cranioplasty

using autologous split rib and calvarium has been universallyaccepted as the preferred option in adults and pediatric pa-tients.33–35 In this study the split rib was preferred than the split

calvarium although the latter is easier to harvest during crani-oplasty without the need for an extracranial operation. Splitcalvarium is harder, stiffer, and difficult to shape and bend than

the rib graft. Moreover, it is limited by the individually variableskull thickness and cannot provide large amount of bone toreconstruct big cranial defects. Follow up of the patients in this

study proved the ability of the rib graft to not only preventproblems of cranial defects but also successfully reconstructskull base defects avoiding their drastic complications. Theuse of split rib grafts placed across each other arranged in a

fashion mimicking the baseball catcher’s mask is a recentlyintroduced novel surgical solution to solve the problem of hugedefects with minimal grafting material.36,37

Different techniques are readily available to reconstruct par-tial maxillectomy defects with a considerable success. A pros-thetic obturator is a simple solution for a small defect after

inferior maxillectomy.38 A clasp retained obturator can laterbe substituted by a more stable one based on bone anchored im-plants. In edentulous patients with poor prosthetic stability or

in large inferior maxillectomy defects, the temporalis muscleflap is an easy, simple, and reliable method of reconstruction.39

However, reconstruction of extensive post maxillectomy de-fects is among the most difficult surgical tasks because of their

complex nature involving soft tissue and bone components, theresultant esthetic grotesque deformity and the associated func-tional disability in eating, and speaking. With the development

of vascularized composite tissue transfer using microsurgicaltechniques, reconstruction of such maxillary defects has beenachieved to a high level of functional and esthetic results.40

Limitations to such techniques were previously mentioned.As an alternative to the vascularised composite flaps the splitrib grafts fixed to previously contoured miniplates supportedby the temporalis myofascial flap were used in reconstructing

partial as well as total maxillary defects in the patients of thepresent study whether primary or secondary. Following thistechnique, considerably accepted esthetic and functional results

were obtained with a clinical and radiological evidence of a reli-able skeletal support without noticeable resorption for at leasttwo years (Fig. 4c and d). The important role of buttress recon-

struction in the surgical management of maxillary skeletal de-fects has been addressed.41 The split rib grafts were fixed byinterosseous wires or miniplates in a manner affording restora-

tion of the pterygomaxillary and/or the zygomaticomaxillarybuttresses which is an important approach to obtain the mosteffective reconstruction of complex maxillectomy defects.40

Several therapeutic procedures are described for managingtracheal stenosis including observation, tracheostomy, balloondilatation, laser and a variety of open surgical procedures.42

Laser vaporization proved disappointing results in circumfer-ential scarring of segments more than 1 cm.43 Various stentsto enlarge the stenotic part of the trachea have been used,

but the indications for their use are not clear. The choice ofthe open surgical procedures depends on the length of the ste-notic segment. Segmental tracheal resection with an end to end

anastmosis became the best method but only for short stenoticsegment without involvement of the upper part of the subglot-tis. For patients with medium length stenosis, the slide trache-oplasty has become a preferred method that doubles the

circumference of the trachea. In long segment tracheal steno-sis, tracheal reconstruction with a variety of grafting materialshas been the surgical treatment of choice.42 The costal cartilage

has been useful in this study as a grafting material in tracheo-plasty as preferred by many studies.44,45 The abundance of car-tilage material sufficient to reconstruct long tracheal segment,

stability, strength, absence of resorption and ease of shapingand fixation resemble the advantages of the costal cartilagein tracheoplasty. In general tracheoplasty is considered suc-

cessful if the patient is decannulated with an adequate com-fortable breathing without the need for reintubation over along period of follow up. The three patients suffering frompostintubtion tracheal stenosis presented in this study were

successfully decannulated and practiced a normal physicalactivity without respiratory difficulty along a period of followup not less than 16 months.

Although used in a single patient, the use of rib graft is anestablished modality in auricular reconstruction.46 Because ofthe complexity of the auricular structure, the tedious process

of harvesting rib cartilage, the difficulty of achieving an esthet-ically satisfactory result, the multiplicity of the surgical stagestill an end result is obtained with the possible need for revision

and skin expansion, some prefer the use of other reconstructivemethods as the porous polyethylene implants or osseointegrat-ed prosthesis.46,47 From the result shown in the single patientof this study, advantages of the costal cartilage grafts in auric-

ular reconstruction could not be stated with the need of morepatients compliant for follow up.

The post operative pain and the threat of pneumothorax

present the major rib graft donor site morbidities. The formerwas reduced by performing muscle ‘‘split’’ rather than ‘‘cut’’during flap harvest, infiltration of the wound with xylocaine

at the end of the procedure, and the use of post operative anal-gesia. Pneumothorax was prevented by strict preservation ofthe posterior periosteum.

In this study, the rib showed the potential to supply the

reconstructive surgeon with cartilage and/or bone of abundantamount that provide suitable grafting materials in many headand neck defects and/or deformities that are easily shaped,

bent, sculptured, and fixed with bone of good osteoconductiveproperty and a fair degree of resorption resistance. The ampleblood supply of the head and neck region which is assumed to

inhibit bone graft resorption36 may explain the high rate of ribgraft take in this study with a single case of graft loss (2.5%)because of infection. The good osteoconductivity of the split

rib graft refers to its high content of progenitor cells which willinitiate the bone formation at a short span of time13. However,stating particular advantages of the rib grafts in each defect

The use of the rib grafts in head and neck reconstruction 97

requires further studies including large number of patientsamong each category of defects with a longer follow up.

5. Conclusions

� The rib provides reliable abundant grafting materials suffi-cient to successfully reconstruct variable defects in the headand neck region.

� The best use of the rib cartilage is in dorsal augmentation ofthe nasal saddling deformity and in tracheoplasty.� The costochondral graft is the modality of choice in recon-

structing the mandibular ramus.� The split rib bones are reliable grafts in cranioplasty.� The rib bone can be an alternative to composite vascular-

ised flaps in maxillary and mandibular reconstruction.

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