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Unusual complications of autogenous rib grafts
Unusual complications grafts
of autogenous rib
Cohn Hopper, MBBS, BDS, FRCS(Ed), FDS, London, England JOINT
DEPARTMENT
COLLEGE
OF
ORAL
AND
MAXILLOFACIAL
SURGERY.
THE
EASTMAN
DENTAL
AND
UNIVERSITY
HOSPITALS
A
utogenous rib grafts have an established place in maxillofacial surgery, the split rib graft being of particular value in difficult maxillary osteotomies such as cases of cleft palate.’ Complications of this procedure have been described in the literature and include postoperative chest infection, pneumothorax, and wound breakdown.2-5 Many of the patients undergoing major maxillofacial surgery requiring rib grafting have a generalized skeletal abnormality that may lead to other complications in the harvesting of ribs. Three such cases are described. OPERATIVE
TECHNIQUE
All three patients underwent harvesting of rib via the short submammary approach.3 One rib or two alternate ribs were harvested and onlaid for maxillary osteotomies. Pleural continuity was confirmed, the wound closed in layers, and a postoperative chest radiograph taken to exclude a pneumothorax. CASE REPORTS CASE 1 A 17-year-old girl with first arch syndrome, cleft lip and palate, and Klippel-Feil syndrome underwent a Le Fort 1 maxillary advancement osteotomy. It was planned to harvest one rib of approximately 12 cm in length. However, on exploration of the eighth rib, it was found to be small and round in cross section. It was almost impossible to split the bone longitudinally (because of the close approximation of the cortices), resulting in an inadequate harvest. The sixth rib also proved to be thin and round. The full length of both ribs, which were split with extreme difficulty, was just sufficient for the procedure. The preoperative chest radiograph (Fig. 1) had not indicated any significant rib abnormality, though it did show the characteristics of the Klippel-Feil syndrome, namely fused vertebrae or hemivertebrae, atlanto-occipital fusion, and failure of migration of the scapula (Sprengel’s deformity); sixth rib fusion was not a feature in this case.
7/12/11579
28
Fig. 1. ‘Chest radiograph of patient in case 1, KlippelFeil syndrome, showing gross abnormalities of cervical spine and ribs that are small in cross section. CASE 2 An 18-year-old girl with frontonasal dysplasia and right craniofacial microsomia underwent a Le Fort 1 maxillary
osteotomy, right mandibular costochondral graft, and left inverted-L osteotomy. The sixth and eighth ribs were harvested from the right side of the chest without difficulty. Subsequently, she underwent a left zygomatic advancement osteotomy with onlay grafting of cranial bone. The same ribs were again harvested through the same submam-
mary incision. However, although they appeared radiographically normal (Fig. 2), the ribs were composed of two thin cortical plates with no marrow spaces and were difficult to strip from the pleura. It was impossible to split them, though they were adequate for restoring the skull continuity after the cranial bone harvest.
Unusual complications
Volume 69 Number 1
of autogenous rib grafts
29
Fig. 2. Chest radiograph of patient in case 2, patient who had previously had rib graft taken from right side. It is difficult to identify the previous donor site.
Fig. 3. Chest radiograph of patient in case 2, cleidocranial dysostosis, showing absent clavicles and radiolucent ribs anteriorly.
CASE 3
A retrospective review of the chest radiographs was undertaken by a radiologist. It was thought that it might have been possible with careful examination to have forewarned the surgeons of the difficulties encountered. However, the importance of providing the radiologist with all the relevant proposed surgical details was stressed. It was thought that it would not have been possible to identify preoperatively the problems encountered in the second case except by referring to notes of the previous operation. It is stated in the literature that ribs may be reharvested,3 but this case shows the difficulties one may encounter.
A 21-year-old woman with cleidocranial dysostosis (Fig. 3) underwent a Le Fort 1 osteotomy to advance and lengthen the maxilla. The sixth rib was harvested, but this was cartilaginous as far posteriorly as the midaxillary line. This necessitated extensive dissection to harvest 5 cm of rib posterior to the midaxillary line. This was split and onlaid onto the maxillary osteotomy site. DISCUSSION Gross abnormalities
of ribs are uncommon,
though
there are several well-described syndromes affecting them.6 These include: l Achondrogenesis. l Focal dermal hypoplasia. l Median cleft lip-palate and short rib polydactyly syndrome. l Mucopolysaccharidosis (oar-shaped ribs). l Melnick-Needles syndrome (ribbonlike ribs with cortical irregularities). l Basal cell nevus syndrome (splaying or bifurcation of ribs). l Various chromosomal abnormalities (trisomy 4,7,8, and deletion of 18). Though some of these are lethal conditions, others are compatible with a reasonable life expectancy and persons with them may have surgery requiring rib grafting.
CONCLUSIONS Gross rib defects
may be expected
in patients
with
skeletal abnormalities requiring maxillary surgery. These should be anticipated by a careful preoperative assessment of the patient, and chest radiographs are essential. It is also important to provide the radiologist with as much information about the patient and the proposed operation as possible. Previous donor sites should not be reused until alternative sites have been exhausted because new rib may not have fully regenerated. Despite the aforementioned difficulties, none of the patients had significant complications and the graft was usable in all three cases.
30
Hopper
ORALSURG
I thank Mr. D. R. James and Professor M. Harris for permission to report on their cases, Dr. P. Woodhead for her radiologic advice, and Ms. G. Walker for her secretarial help. REFERENCES I. Goode RL. Bone and cartilage grafts: current concepts. Otolaryngol Clin North Am 1972;5:447-55. 2. Longacre JJ, De Stefano GA. Further observations of the behaviour of autogenous split-rib grafts in reconstruction of extensive defects of the cranium and face. Plast Reconstr Surg 1957;20:281-96. 3. James DR, Irvine GH. Autogenous rib grafts in maxillofacial surgery. J Maxillofac Surg 1983;I 1:201-3. 4. Whitaker LA, Munro IR, Jackson IT, Salyer KE. Problems in craniofacial surgery. J Maxillofac Surg 1976;4: 13 l-6.
BOUND
VOLUMES
AVAILABLE
ORAL
MEDORALPATHOL January 1990
Whitaker LA, Munro IR, Salyer KE, Jackson IT, OrtizMonasterio F, Marchac D. Combined reports of problems and complications in 793 craniofacial operations. Plast Reconstr Surg 1979;64: 198-203. Gorlin RJ, Pindborg JJ, Cohen MM. Syndromes of the head and neck. 2nd ed. New York: McGraw-Hill, 1976:9-l 1, 86-100, 310-4, 476-94, 473-S. Reprint requests to: Mr. C. Hopper Department of Oral and Maxillofacial Surgery University College and Middlesex School of Dentistry London WC1 6JD England
TO SUBSCRIBERS
Bound volumes of ORAL SURGERY, ORAL MEDICINE and ORAL PATHOLOGY are available to subscribers (only) for the 1990 issues from the Publisher, at a cost of $42.00 ($54.00 international) for Vol. 69 (January-June) and Vol. 70 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name votllmp number and vcar stamped in cold on the spine. Payment must accompanv all orders. Contact The C.V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
of autogenous rib
Cohn Hopper, MBBS, BDS, FRCS(Ed), FDS, London, England JOINT
DEPARTMENT
COLLEGE
OF
ORAL
AND
MAXILLOFACIAL
SURGERY.
THE
EASTMAN
DENTAL
AND
UNIVERSITY
HOSPITALS
A
utogenous rib grafts have an established place in maxillofacial surgery, the split rib graft being of particular value in difficult maxillary osteotomies such as cases of cleft palate.’ Complications of this procedure have been described in the literature and include postoperative chest infection, pneumothorax, and wound breakdown.2-5 Many of the patients undergoing major maxillofacial surgery requiring rib grafting have a generalized skeletal abnormality that may lead to other complications in the harvesting of ribs. Three such cases are described. OPERATIVE
TECHNIQUE
All three patients underwent harvesting of rib via the short submammary approach.3 One rib or two alternate ribs were harvested and onlaid for maxillary osteotomies. Pleural continuity was confirmed, the wound closed in layers, and a postoperative chest radiograph taken to exclude a pneumothorax. CASE REPORTS CASE 1 A 17-year-old girl with first arch syndrome, cleft lip and palate, and Klippel-Feil syndrome underwent a Le Fort 1 maxillary advancement osteotomy. It was planned to harvest one rib of approximately 12 cm in length. However, on exploration of the eighth rib, it was found to be small and round in cross section. It was almost impossible to split the bone longitudinally (because of the close approximation of the cortices), resulting in an inadequate harvest. The sixth rib also proved to be thin and round. The full length of both ribs, which were split with extreme difficulty, was just sufficient for the procedure. The preoperative chest radiograph (Fig. 1) had not indicated any significant rib abnormality, though it did show the characteristics of the Klippel-Feil syndrome, namely fused vertebrae or hemivertebrae, atlanto-occipital fusion, and failure of migration of the scapula (Sprengel’s deformity); sixth rib fusion was not a feature in this case.
7/12/11579
28
Fig. 1. ‘Chest radiograph of patient in case 1, KlippelFeil syndrome, showing gross abnormalities of cervical spine and ribs that are small in cross section. CASE 2 An 18-year-old girl with frontonasal dysplasia and right craniofacial microsomia underwent a Le Fort 1 maxillary
osteotomy, right mandibular costochondral graft, and left inverted-L osteotomy. The sixth and eighth ribs were harvested from the right side of the chest without difficulty. Subsequently, she underwent a left zygomatic advancement osteotomy with onlay grafting of cranial bone. The same ribs were again harvested through the same submam-
mary incision. However, although they appeared radiographically normal (Fig. 2), the ribs were composed of two thin cortical plates with no marrow spaces and were difficult to strip from the pleura. It was impossible to split them, though they were adequate for restoring the skull continuity after the cranial bone harvest.
Unusual complications
Volume 69 Number 1
of autogenous rib grafts
29
Fig. 2. Chest radiograph of patient in case 2, patient who had previously had rib graft taken from right side. It is difficult to identify the previous donor site.
Fig. 3. Chest radiograph of patient in case 2, cleidocranial dysostosis, showing absent clavicles and radiolucent ribs anteriorly.
CASE 3
A retrospective review of the chest radiographs was undertaken by a radiologist. It was thought that it might have been possible with careful examination to have forewarned the surgeons of the difficulties encountered. However, the importance of providing the radiologist with all the relevant proposed surgical details was stressed. It was thought that it would not have been possible to identify preoperatively the problems encountered in the second case except by referring to notes of the previous operation. It is stated in the literature that ribs may be reharvested,3 but this case shows the difficulties one may encounter.
A 21-year-old woman with cleidocranial dysostosis (Fig. 3) underwent a Le Fort 1 osteotomy to advance and lengthen the maxilla. The sixth rib was harvested, but this was cartilaginous as far posteriorly as the midaxillary line. This necessitated extensive dissection to harvest 5 cm of rib posterior to the midaxillary line. This was split and onlaid onto the maxillary osteotomy site. DISCUSSION Gross abnormalities
of ribs are uncommon,
though
there are several well-described syndromes affecting them.6 These include: l Achondrogenesis. l Focal dermal hypoplasia. l Median cleft lip-palate and short rib polydactyly syndrome. l Mucopolysaccharidosis (oar-shaped ribs). l Melnick-Needles syndrome (ribbonlike ribs with cortical irregularities). l Basal cell nevus syndrome (splaying or bifurcation of ribs). l Various chromosomal abnormalities (trisomy 4,7,8, and deletion of 18). Though some of these are lethal conditions, others are compatible with a reasonable life expectancy and persons with them may have surgery requiring rib grafting.
CONCLUSIONS Gross rib defects
may be expected
in patients
with
skeletal abnormalities requiring maxillary surgery. These should be anticipated by a careful preoperative assessment of the patient, and chest radiographs are essential. It is also important to provide the radiologist with as much information about the patient and the proposed operation as possible. Previous donor sites should not be reused until alternative sites have been exhausted because new rib may not have fully regenerated. Despite the aforementioned difficulties, none of the patients had significant complications and the graft was usable in all three cases.
30
Hopper
ORALSURG
I thank Mr. D. R. James and Professor M. Harris for permission to report on their cases, Dr. P. Woodhead for her radiologic advice, and Ms. G. Walker for her secretarial help. REFERENCES I. Goode RL. Bone and cartilage grafts: current concepts. Otolaryngol Clin North Am 1972;5:447-55. 2. Longacre JJ, De Stefano GA. Further observations of the behaviour of autogenous split-rib grafts in reconstruction of extensive defects of the cranium and face. Plast Reconstr Surg 1957;20:281-96. 3. James DR, Irvine GH. Autogenous rib grafts in maxillofacial surgery. J Maxillofac Surg 1983;I 1:201-3. 4. Whitaker LA, Munro IR, Jackson IT, Salyer KE. Problems in craniofacial surgery. J Maxillofac Surg 1976;4: 13 l-6.
BOUND
VOLUMES
AVAILABLE
ORAL
MEDORALPATHOL January 1990
Whitaker LA, Munro IR, Salyer KE, Jackson IT, OrtizMonasterio F, Marchac D. Combined reports of problems and complications in 793 craniofacial operations. Plast Reconstr Surg 1979;64: 198-203. Gorlin RJ, Pindborg JJ, Cohen MM. Syndromes of the head and neck. 2nd ed. New York: McGraw-Hill, 1976:9-l 1, 86-100, 310-4, 476-94, 473-S. Reprint requests to: Mr. C. Hopper Department of Oral and Maxillofacial Surgery University College and Middlesex School of Dentistry London WC1 6JD England
TO SUBSCRIBERS
Bound volumes of ORAL SURGERY, ORAL MEDICINE and ORAL PATHOLOGY are available to subscribers (only) for the 1990 issues from the Publisher, at a cost of $42.00 ($54.00 international) for Vol. 69 (January-June) and Vol. 70 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name votllmp number and vcar stamped in cold on the spine. Payment must accompanv all orders. Contact The C.V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.