Surgeon(s): ***

‍Assistant Surgeon(s):  ***

‍Preoperative Diagnosis: ***

‍Postoperative Diagnosis: Same

‍Procedure(s): ***

‍Anesthesia: General

‍Implants: None

‍Specimen:***

‍Drains: None

‍Fluids: See anesthesia record

‍EBL: Minimal

‍Complications: None

‍Counts:  Correct x2

‍Indications: ​***

‍Findings: As expected

‍Procedure in Detail:

‍The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail.  The patient was transferred to the operating room by the anesthesia team.  The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures.  A time-out was performed and the procedure began.

positioned to maximize access to the thoracic area, with the operative side slightly elevated. The selected rib, often the sixth or seventh for its curvature and size, was identified using preoperative imaging to guide the incision placement. A longitudinal incision was made over the rib, ensuring to stay parallel to the rib to avoid injury to the underlying structures. The skin and subcutaneous tissue were incised, followed by careful dissection through the muscle layers using electrocautery to minimize bleeding. Special attention was given to preserving the periosteum, which is crucial for rib regeneration and reducing postoperative pain.

The intercostal muscles attached to the superior and inferior borders of the rib were carefully detached. The periosteum was incised longitudinally along the rib, and a periosteal elevator was used to strip the periosteum from the bone, exposing the desired length of rib. Care was taken to protect the neurovascular bundle running along the inferior edge of the rib to prevent sensory deficits and chronic pain.

Once isolated, the segment of rib needed for the graft was measured and marked. A rib cutter was used to make precise cuts at the anterior and posterior limits of the harvested section, ensuring enough rib was left intact to maintain chest wall integrity and minimize the risk of pneumothorax. The harvested rib was then removed and immediately placed in a sterile saline solution to keep it viable until transplantation.

The rib bed was inspected for hemostasis, with particular attention paid to securing any bleeding from the periosteum and intercostal arteries. A chest drain may be placed if there is concern about potential space or risk of pneumothorax. The muscle layers and subcutaneous tissue were then reapproximated over the donor site, and the skin was closed with absorbable sutures. Postoperative chest X-rays were planned to confirm no intrathoracic complications.

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The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

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