Donor Site Morbidity of RibGraft Harvesting in PrimaryAlveolar Cleft Bone Grafting

Barry L. Eppley, MD, DMD

Indianapolis, Indiana

Abstract: The use of the rib for primary alveolar cleft bone graftingoffers one of the few donor sites for grafting under one year of age.Its use in 211 patients in an 11 year period revealed no morbidityother than a small donor scar. Rib grafting in infants differs sig-nificantly from that in teenagers and adults with minimal pain, norisk of pneumothorax when properly performed, and more thanan adequate stock of bone for the alveolar defect.

Key Words: Alveolar cleft grafting, rib harvest

Alveolar bone grafting is an important componentof surgical rehabilitation for all cleft deformities

that involve the alveolus. The establishment of abony bridge across the clefted maxilla at the alveolarlevel has well-recognized functional benefits. Theseinclude maxillary arch stability, obliteration of oro-nasal fistulae, and the creation of an osseous matrixthat is favorable to both the periodontal health ofteeth adjacent to the cleft and underlying odontogen-ic eruption. The timing of such alveolar osseous ismost commonly done as a secondary proceduresomewhere in the mixed dentition period, althoughthe use of graft placement in patients younger than 1year is the preferred initial approach in some centers.

Donor site options for secondary alveolar graft-ing are multiple and can include the ilium, calva-rium, tibia, and mandibular symphysis. The morbid-ity associated with harvesting of these donor sites iswell known and has been previously reported.1–4

However, donor site options in primary alveolar cleftgrafting are more limited because of the immatureskeletal development of the infant. These are re-stricted to the calvarium and rib, although the skullis not typically used because of the absence of adiploic layer in patients younger than 1 year. Cranialharvest in an infant may result in a permanent full-thickness defect because bony regeneration is not al-ways assured. Therefore, primary alveolar cleft bonegrafting usually is done using rib tissue.

The morbidity of infant rib harvesting has notbeen previously reported, presumably because of thelimited number of cleft centers that use this ap-proach. One parameter on which to judge the clinicalutility of any bone graft donor site is the morbidity ofthe harvest. From this perspective, the technique andresults in a large series of infant rib harvests for al-veolar cleft grafting is reviewed.

SURGICAL TECHNIQUE

After the induction of general anesthesia, the infantis positioned so that good exposure is obtained toeither anterior hemithorax. This is facilitated by theplacement of a rolled towel under the ipsilateralscapula. The rib chosen for harvest should lie severalcentimeters inferior to the nipple, especially in fe-male patients to avoid a potential scar over the de-velopment of the future breast mound. This can beassured if the level of the rib harvest lies below theinferior edge of the pectoralis major muscle (Fig 1).This is usually the sixth or seventh rib, but the actualrib number is unimportant as long as the harvest siteis low enough. A small 3-cm incision is marked withits most medial extent at or just behind the anterioraxillary line. This is important because access to thecostochondral junction for anterior disarticulation isneeded. The incision should parallel the posterolat-eral curve of the underlying rib. After infiltration oflocal anesthesia containing epinephrine, sharp dis-section is carried through skin and the underlyingserratus muscle to the desired rib. The periosteum isincised and elevated circumferentially with smallDoyan (pigtail) rib dissectors. The rib is then disar-ticulated from the costochondral junction anteriorlyand cut posteriorly with small bone cutters, usually

From the Department of Plastic Surgery, Indiana UniversitySchool of Medicine, Indianapolis, Indiana.

Address correspondence and reprint requests to Dr. Eppley,Associate Professor of Plastic Surgery, Indiana University Schoolof Medicine, 702 Barnhill Drive, #3540, Indianapolis, IN 46202;e-mail: beppley@iupui.edu

Fig 1 Outline of anatomic landmarks of chest donor site.The lateral chest incision should be placed inferior andlateral to the lower border of the pectoralis, which usuallyresults in harvest of a portion of the sixth or seventh rib.CCJ = costochondral junction; PM = lower border of pec-toralis major muscle.

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removing a 2.0-cm piece for unilateral cleft defectsand a 3.0-cm piece for bilateral cleft defects (Fig 2).The harvest site is then filled with saline and checkedfor a pleural leak by positive pressure ventilation to30 cm of water. Multiple layer closure is done, in-cluding the periosteum, muscle, dermis, and skin.Final skin closure is done with a running 5-0 plainsuture and an occlusive skin glue (Dermabond, Ethi-con, Somerville, NJ).

The rib is split by an osteotome and placed as abuccal onlay between the cleft maxillary edges over aminimally dissected pocket through a triangular buc-cal mucosal flap technique.

RESULTS

A total of 211 patients during an 11-year period weretreated with primary alveolar cleft bone grafts. Allpatients were between the ages of 8 and 14 months ofage. Most of the clefts treated were unilateral (175;83%), with a preponderance of male patients (124;59%). The typical time required for harvest from skinincision to skin closure was less than 30 minutes.

No patient experienced a pleural violation andthe introduction of intrathoracic air that required in-traoperative repair. Postoperative chest films, whichwere routinely taken in the recovery room, demon-strated no pneumothorax. As of 1999, after the 108thpatient in this series, the use of routine postoperativechest films was discontinued.

No postoperative infections requiring drainageof the chest donor site occurred. Cellulitis presentedin one patient, which required intravenous antibiot-ics for resolution (1/211; 0.5%). No patient experi-enced any postoperative pulmonary complicationssuch as atelectasis or pneumonia. All incisions pro-ceeded to complete healing without hypertrophicscarring (Fig 3). No patient required any form of scartreatments or surgical revision.

DISCUSSION

Numerous articles have appeared in the literaturepertaining to the multiple uses of autogenous ribgrafts; however, few report the incidence of donorsite morbidity associated with their harvesting.When rib graft harvests are considered, most sur-geons typically have concerns about intraoperativepneumothorax and postoperative intercostal neural-gia5,6 in addition to its structural quality, moldabil-ity, and volume preservation.

Donor site morbidity is one of several importantfactors that must be considered when choosing abone graft. Other equally important factors to con-sider are the quantity of bone required, the type (cor-tical and/or cancellous) of bone needed, location ofthe recipient site, age of the patient, and the expectedbiologic behavior, mainly neovascularization andbone resorption, as well as experience of the surgeon.

Skouteris and Sotereanos7 presented a retro-spective study evaluating 28 patients in whom a totalof 31 rib resections had been performed. They noteda pleural tear in one patient during the harvesting ofa costochondral rib graft, with the tear being re-paired without resultant pneumothorax. No inci-dence of pneumothorax, postoperative pulmonarycomplications, or wound infection or breakdownwas reported. Long-term follow-up showed that nopatient experienced any chronic donor site discomfort,and all patients found their scars to be esthetically ac-ceptable.

Whitaker et al8,9 published three articles inwhich the incidence of pneumothorax was reportedafter rib graft harvesting for craniofacial procedures.In two of these reports,8,9 the first of which involved149 patients and the second 151 patients, the inci-dence of pneumothorax was 5.3%, and 18%, respec-tively. In these two groups of patients, autogenousgrafts were obtained from the calvarium, ribs, andiliac crest; however, the number of patients who hadrib grafts taken was not recorded. In their third re-

Fig 2 Rib bone graft harvested through a similarly sizedincision.

Fig 3 Chest wall donor scar.

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port, Whitaker et al5 recorded an incidence of pneu-mothorax as high as 20% to 30% in a group of 793patients who underwent craniofacial operations.

Another potential risk when harvesting rib isthat of a superficial donor site infection. One suchcase of infection was reported by Woods et al10 in agroup of nine patients in whom rib grafts were usedfor simultaneous fracture repair and augmentationof the atrophic edentulous mandible. James and Irv-ine11 reported on the complications of autogenousrib graft harvesting in a group of 41 patients whounderwent 52 partial rib resections. The rib graftswere used in Le Fort I, II, and III osteotomies, tem-poromandibular joint reconstruction, an inverted Losteotomy, and as onlay grafts for the maxilla andmandible. The authors reported only one case ofpneumothorax, which was unrelated to the removalof the costochondral graft. Donor site wound break-down occurred in two patients as a result of woundinfection and from development of a hematoma. Theincidence of postoperative chest infection, the exactnature of which was not mentioned in the article,was high (14.6%; 5 patients). In four of these patientsthe chest infection was attributed to the late initiationof effective postoperative respiratory physiotherapy.

Laurie et al6 retrospectively and prospectivelyexamined 104 donor sites in 72 patients; 44 of thesites were the chest. The mean age of this study was14 years. A record was made of the incidence of pleu-ral laceration and other early chest complications (eg,pneumonia and hemothorax; severity and durationof early postoperative pain; incidence of delayedwound healing; state of the mature scar, includinglength, width, and contour; incidence and severity oflate pain; and final contour of the underlying ribs).Four (9%) patients had pleural lacerations that re-quired chest tube drainage during the postoperativeperiod. All four of these patients had more than onerib harvested. All chest wounds healed primarily,and no patients had chest infection or excessive hem-orrhage. All patients had postoperative pain of amoderate degree lasting from 1 to 8 weeks (mean, 2weeks). All chest scars were located in the inframam-mary crease. The average length of the mature chestscar was 7.5 cm; the average width was 0.3 cm. Threepatients (6.8%) had persistent chest pain, pleuritic aswell as constant, after 2 years.

On inspection, Laurie et al found most patientshad a mild chest-wall contour defect. No patient hada palpable contour deficit of the underlying rib, al-though fenestrations in regenerated ribs usuallywere obvious during repeat harvesting procedures.In fact, it was found that regenerated ribs were notgenerally suitable for grafts, which is contradictory

to what has been written in the literature. Accordingto the follow-up study of Psillakis and Woisky12 of 18rib grafts, patients younger than 30 years showedcomplete regeneration of donor areas of bone grafts,and these areas may be reused in young patients andwith complete assurance in those younger than 20years. The removal of rib grafts is easy in children,and the morbidity is low, with only minor com-plaints about the donor site.4

Rib grafts have been used in many parts of thebody, not just in craniofacial reconstruction. Sawin etal13 analyzed the postoperative morbidity of usingautogenic rib bone grafts in posterior cervical fu-sions. Graft-related morbidity was observed in 11(3.7%) of 300 patients who underwent rib harvesting.Pneumonia was the most common postoperativecomplication; it was encountered in eight patients.Persistent atelectasis occurred in two patients. Nocases of pneumothorax, intercostal neuralgia, orchronic chest wall pain were encountered.

This clinical series demonstrates that rib har-vesting in the infant is associated with essentially nomorbidity. This is different from most previously re-ported series, attributable principally to the age ofthe patient. The small size of the infant chest, thepliability of the thin cortical bone, and the limitedmanipulation of the tissues makes rib graft harvest-ing uncomplicated. In addition, avoiding the costo-chondral junction and requiring only a small amountof bone contributes to the safety and ease of the pro-cedure.

The infant offers few options for autogenousbone. Fortunately, the need for bone grafts in theinfant is uncommon, with the exception of early al-veolar cleft grafting, for which small struts of corticalbone are useful. When this procedure is undertaken,the donor chest site results in a small scar but noother significant morbidity.

REFERENCES

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5. Whitaker LA, Munro IR, Salyer KE, et al. Combined report ofproblems and complications in 793 craniofacial operations.Plast Reconstr Surg 1979;64:198

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10. Woods WR, Hiatt RW, Brooks RL. A technique for simulta-neous fracture repair and augmentation of the atrophic eden-tulous mandible. J Oral Surg 1979;37:131

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13. Sawin PD, Traynelis VC, Menezes AH. A comparative analy-sis of fusion rates and donor-site morbidity for autogeneic riband iliac crest bone grafts in posterior cervical fusions. J Neu-rosurg 1998;88:255

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