CCG

1. Costochondral graft in
maxillofacial surgery
Dr Jameel kifayatullah
Khyber college of dentistry Peshawar
Islamic republic of pakistan

3. Anatomical landmarks
• Anatomical landmarks considered for the
incision are medial axillary line,
• midclavicular line, and the
• relief of the 6th or 7th costal arch

4. Surgical installation and landmarks: (a)
installation and (B) skin markers.

5. Rib cartilages are identified on supine position. The clavicle
and xyphoid process is a key landmark and the first rib below
the clavicle is the second rib

6. Costochondral Graft (CCG) Harvest
Technique
1. The anterior chest wall is prepped and draped,
allowing for visualization of the sternum, clavicle,
nipple, and umbilicus
2.The ribs are counted and marked with a marking pen.
3. A sterile marking pen is used to outline a 6–8
cm line within the inframammary crease of
female patients or at the level of the sixth or
seventh rib in male patients. In pediatric
female patients, the incision is placed in the
anticipated future location of the
inframammary crease.

7. A 6 cm incision is marked corresponding to the anticipated
location of the inframammary crease, which corresponds
to rib #6.

8. Costochondral Graft (CCG) Harvest
Technique
4.Local anesthetic containing a vasoconstrictor is used to
infiltrate the subcutaneous tissue overlying the rib to be
harvested.
5. Digital pressure is used to identify the fifth,
sixth, or seventh rib and the costochondral
spaces. A 6–8 cm skin incision is made with a
#15 blade directly over the superior aspect of
the rib to be harvested. The incision transverses
skin, subcutaneous tissue, and pectoralis
muscle down to the perios- teum directly
overlying the rib.

9. Dissection directly over the superior aspect of the rib to be harvested.
The incision transverses skin, subcutaneous tissue, and pectoralis
muscle.

10. Costochondral Graft (CCG) Harvest
Technique
6. A #9 periosteal elevator is used to dissect circumfer-
entially around the rib. A tissue plane is developed
between the rib’s periosteum–perichondrium and
the thin parietal pleura . The subperiosteal dissection
continues laterally as far as is needed and medially
until the costochondral junction is reached. It is
important to stay subperiosteal in order to avoid
injury to the vascular bundle on the inferior portion
of the rib.

11. A #9 periosteal elevator is used to dissect circumferen- tially around the
rib. A tissue plane is developed between the rib's periosteum
perichondrium and the thin parietal pleura.

12. Costochondral Graft (CCG) Harvest
Technique
7)At the costochondral junction, dissection proceeds
in a supraperichondrial plane so as not to detach the
hyaline cartilaginous cap from the medial aspect of
the rib.
8)A guillotine rib cutter is used to transect the lateral
portion of the rib.

13. Costochondral Graft (CCG) Harvest
Technique
9) Either a Doyen retractor or a silk suture is used to elevate
the rib and to check the deep mar- gin for tissue–muscle
adherence.

14. A silk suture is used to elevate the rib and to check the deep
margin for tissue–muscle adherence after osteotomy of the
lateral margin.

15. Costochondral Graft (CCG) Harvest
Technique
10. A malleable retractor is placed deep to the medial
aspect of the rib. A #10 blade is used to cut the
medial aspect of the rib preserving a 5–10 mm
cartilaginous cap. The malleable retractor will
prevent the #10 blade from cutting into the
underlying parietal pleura.

16. Costochondral Graft (CCG) Harvest
Technique
11. The harvested costochondral graft is placed within a
sterile, saline‐soaked gauze until the recipient site is
prepared.

17. Costochondral Graft (CCG) Harvest
Technique
12. Once the rib or ribs are removed, sterile
water is placed over the anterior chest wall
defect, and the anesthesiologist is asked to
provide positive pressure in order to inspect
the harvest site for pleural perforations. If no
air bubbles are present, then the harvest site
is closed in layers. If minor air bubbles are
present, pleural tears can be closed primarily
with interrupted sutures. If large air bubbles
are present, then a thoracotomy tube is
placed

18. Once the rib is removed, the anterior chest wall cavity is inspected for
any bleeding or signs of pneumothorax. Sterile water can be placed over
the anterior chest wall defect, and positive pressure is provided in order
to inspect for pleural perforations.

19. Costochondral Graft (CCG) Harvest
Technique
13. After closure of the surgical site in a layered
fashion, steri-strips are applied to provide
additional skin ten- sion. Generally, a drain is not
required.

20. Indications of costochondral graft
1)Temporomandibular joint (TMJ) replacements in pediatric patients
with active growth centers to reconstruct condylar processes defects
caused by trauma, neoplasms, infections, congenital dysplasias,
growth abnormalities, ankyloses, and rheumatoid arthritis
2. TMJ reconstruction in adult patients due to idiopathic condylar
resorption, osteoarthritis, and rheumatoid arthritis when other
methods (alloplastic joint replacement) are contraindicated
3. Reconstruction of craniomaxillofacial defects caused by loss of hard
tissue
4. Reconstruction of skull defects or cranioplasty
5. Reconstruction of nasal dorsum defects or saddle nose deformities
(costochondral cartilage)
6. Reconstruction of the helical framework of the ear (costochondral
cartilage)

21. Contraindications
• History of restrictive lung disease
• History of recent pulmonary infection
• History of cardiopulmonary instability

22. Advantages
• biological compatibility
• workability
• functional adaptability
• minimal additional detriment to the patient
• The growth potential of the costochondral
graft makes it an ideal choice in children

23. Disadvantages/problems/drawbacks
• fracture
• further ankylosis
• increased operating time
• additional surgical site
• donor site morbidity
• variable growth behavior of the graft

24. Complications
• Immediate or Early Complications
1) Pleural tears, pneumothorax, and pleuritis
2) Infection
3) Hematoma or seroma formation
4) Injury to the intercostal neurovascular
5) Fracture at the bone–cartilage interface of the
CCG

25. Late Complications
• Chest concavity: Occurs when multiple, adjacent
ribs are harvested.
• Scar formation over the breast in female
patients: Incisions in female patients should be
placed in either the inframammary crease or in
the area of the antici- pated future
inframammary crease. At no point should the
incision be placed over the developing breast
mound or near the areolas.
• Areola retraction: Occurs when the incision is
placed near the areolas.