Cartilage is typically harvested (Fig. 2) from the eighth and ninth ribs or the confluence. If additional cartilage is required, the tenth rib also may be harvested. Bone may be harvested with the ninth rib if desired.
A 4-cm to 6-cm incision overlying the eighth rib allows adequate exposure. Dissection proceeds to and then through the rib perichondrium. The muscle fibers can be separated in-stead of cut to minimize postoperative pain. Dissection around the rib is undertaken subperichondrially; the pleura is typically closely adherent to the perichondrium. With the graft completely separated from surrounding soft tissue, the graft is incised and delivered under direct vision. The surgeon may elect to place a malleable retractor beneath the rib as it is incised. Saline is placed in the surgical site and Valsalva or positive pressure applied to check for a pleural leak. If a pleural tear is identified, a pursestring suture closure is un dertaken around a red-rubber suction catheter. The surgeon then requests a TM Valsalva" from the anesthesiologist. The red rubber is then removed and the suture tightened. Saline may be placed in the wound and another Valsalva undertaken while the surgeon carefully inspects for air bubbles. A standard, layered soft-tissue closure without a drain is accomplished. Skin edge eversion can be accomplished with everting subcutaneous sutures.
A chest radiograph is obtained in all patients after rib harvest. In the rare instance of a difficulty, the surgeon may wish to consult the appropriate surgical colleague.
Figure 2. Rib cartilage harvest. Cartilage is typically harvested from the eighth and ninth ribs. A 4 cm to 6 cm incision overlying the eighth rib allows adequate expo- sure (see also Chapter 11, Fig. 6). Dissection proceeds to and then through the rib perichondrium. Dissection around the rib is undertaken subperichondrially; the pleura is typically closely adherent to the perichondrium. With the donor rib completely separated from surround ing soft tissue, the graft is incised and delivered under di rect vision. The surgeon may place a malleable retractor beneath the rib as it is incised.