The human costal cartilage: Anatomical and radiological study of macro-vascularization and micro-vascularization and its clinical relevance regarding vascularized chondrocostal free flap surgery.

INTRODUCTION: Cartilage repair usually involves in non-vascularized osteochondral or chondral grafts with some drawbacks potentially linked to the lack of vascular supply in those grafts. The aim of this study was to describe a surgical approach for harvesting a vascularized chondrocostal graft, to study the vascular supply to the perichondrium and finally to describe the perichondrium micro-vascularization in order to know how such grafts could be used in cartilage repair surgery. MATERIALS AND METHODS: We harvested and studied 18 costal cartilages harvested from 12 fresh anatomical subjects. The anatomic pieces were injected with a radio-opaque tracer, analyzed macroscopically, then a plain X-rays and CT scan analysis with three-dimensional rendering was performed in order to evaluate the characteristics of the different patterns of their vascularization. RESULTS: The surgical approach to harvest a vascularized 5th chondrocostal graft is explained in detail. All of the cartilages were vascularized by the internal thoracic artery and harvested with a pedicle of an average length of 34mm and diameter of 2.14mm. In all specimens, perichondrium vascularization arises from both superior and inferior intercostal branches. Anastomoses between inferior and superior intercostal branches are always found in all specimens at the level of the epichondrium. CONCLUSIONS: The anatomic approach for harvesting a vascularized chondrocostal graft is simple and only slightly differs from the approach described for harvesting a non-vascularized chondrocostal graft. The vascular supply to the perichondrium of such a vascularized chondrocostal graft is sustained by the internal thoracic vessels which have a sufficient diameter and length to allow easy micro-anastomosis. The organization of the micro-vasculature within the perichondrium allows the graft to be tailored to a large cartilage defects and also to small bipolar cartilage defects.

Forensic age estimation based on the pigmentation in the costal cartilage from human mortal remains.

Age estimation is considered a crucial and challenging issue in forensic casework. Costal cartilage appears a potential mortal remain in age-at-death estimation attributable to its correlative alteration in color based on pigment accumulation with the advancing age. In this study, samples from the second costal cartilage were collected in a Chinese Han population, and the cross sections were subsequently scanned and digitalized in a standard way. Color change was quantified using mean gray value (MGV), which was measured by Photoshop CS5. After the exclusion of samples with factors which could impair the quality of images and the accuracy of values, a high correlation was demonstrated between age and MGV in samples. A linear regression model (AGE = 173.425-0.755*aveMGV) was established for age prediction, with its performance evaluated using both samples from the training set and the blind test set, in which a mean absolute deviation of 4.42 years and 3.57 years was obtained, respectively. Altogether, MGV could be reckoned as a precise quantification of pigmentation in costal cartilage and an excellent indicator of age prediction in the age interval from 20 to 60 years. Moreover, our strategy appears more user-friendly and accurate, thus exceedingly practical for age estimation in forensic anthropology.

Modified Methods of Fabricating Helix and Antihelix in Total Auricular Reconstruction Based on Different Length of Eighth Costal Cartilage.

BACKGROUND: Attaining an ideal appearance of the reconstructed ear depends primarily on the fabricated cartilaginous ear framework. Despite the role of eighth costal cartilage, the length of the eighth rib cartilage is difficult to anticipate, and growth of the eighth cartilage is variable. The authors discussed modified methods of fabricating helix and antihelix based on different length of eighth costal cartilage. METHODS: Based on the actual length of the eighth costal cartilage, patients were divided into group A and group B. In group A, the eighth costal cartilage was divided into 2 parts. Part I was used to fashion the helix, whereas part II was used to fabricate the antihelix and superior crus. In group B, the seventh costal cartilage was cut into 3 parts. Part I and part II were used to fashion the helix, antihelix, and superior crus as group A did. Part III was assembled to the lateral part of the framework to form the inferior crus. RESULTS: A total of 56 patients underwent auricular reconstruction adopting the modified techniques between 2015 and 2016. Three cases have been selected to illustrate the favorable result achieved. They revealed that the helix, antihelix, superior crus, and inferior crus all appeared distinct and presented a favorable result of the contour of the reconstructed auricle. CONCLUSIONS: Based on different length of eighth costal cartilage, modified methods of fabricating helix and antihelix make full use of the autogenous costal cartilage, elevate anatomical details, and enhance the overall aesthetics of reconstructed ear. The great majority of patients have satisfactory surgical outcomes, demonstrating that personalized treatment is necessary.

Costal and Auricular Cartilage Grafts for Nasal Reconstruction: An Anatomic Analysis.

OBJECTIVES: The aim of this study was to measure the length, width, and surface area of costal and auricular cartilage harvested for grafting in rhinoplasty and nasal reconstruction. We also compared the sizes of ear cartilage grafts harvested from the anterior and posterior approaches. METHODS: Fifty-eight nasal reconstructive surgeries requiring rib or ear cartilage were performed by 2 facial plastic surgeons from February 2015 through January 2016. Among the 57 cases that met inclusion criteria, they comprised of 33 costal cartilage grafts and 24 auricular cartilage grafts (17 via anterior approach and 7 via posterior approach). RESULTS: The mean length, width, and surface area for the auricular cartilage grafts were 3.39 cm, 1.22 cm, and 4.38 cm2, respectively. The mean length, width, and surface area of the costal cartilage grafts were 4.21 cm, 1.46 cm, and 17.87 cm2, respectively. The differences in length, width, and surface area between the anterior versus posterior approach groups were all statistically significant. CONCLUSIONS: In our study, ear cartilage grafts harvested from the posterior approach had significantly greater length, width, and surface area. While this analysis has several limitations, it sets quantitative norms for costal and auricular cartilage harvest that can aid in surgical planning.

Injerto costal en rinoplastia. Recaudos anatómicos para la recolección de cartílago costal / Costal graft in rhinoplasty. Anatomical collections for thecollection of costal cartilage / Enxerto costal na rinoplastia. Coleções anatômicas para a cartilagem colheitacostela

Introducción: la finalidad es ponderar el conocimiento anatómico indispensable de la pared torácica para la recolección segura de cartílago costal en rinoplastia. Materiales y métodos: Se dividió en dos fases. Esta presentación corresponde a la Fase I, de tipo descriptiva observacional. La Fase II (actualmente en curso) tiene un diseño prospectivo y experimental para una futura presentación. Primera instancia: recolección de información bibliográfica, de no más de 5 años de antigüedad en bases de datos médicos y textos específicos. Segunda instancia: representación del acto quirúrgico en 3 especímenes cadavéricos humanos. En cada espécimen se realizaron 4 abordajes (2 submamarios y 2 subcostales inferiores) se hizo hincapié en la descripción de aquellas estructuras anatómicas importantes para respetar en el abordaje de la pared torácica. Resultados: Fue posible recrear las diferentes técnicas de abordaje de la pared costal. Se pudo constatar que la ubicación del paquete vasculonervioso dentro del surco costal fue constante inter especímenes e intra espécimen. La relación entre el pericondrio interno, la fascia endotorácica y la hoja parietal de la pleura resultó ser un sistema fibroadhesivo complejo y variable. Coincidimos con la bibliografía acerca de que la técnica se dificulta cuando se realiza la recolección a nivel costal más proximal. Conclusiones: Creemos que el conocimiento de la anatomía torácica es indispensable para realizar una correcta técnica de disección y posterior recolección de cartílago costal; esto disminuiría las complicaciones y la morbilidad en el sitio dador. El neumotórax y el dolor neuropático provienen del daño de estructuras anatómicas constantes.

Introduction: the purpose is to weight the anatomical knowl edge essential to the chestwall for the safe collection of costal cartilage in rhinoplasty. Materials and methods: It is divided in to two phases. This presentation corresponds to Phase I, of an observational descriptive type. Phase II (currently underway) has a prospective and experimental design for future presentation. First instance: collection of bibliographic information, not more than 5 years old in medical databases and specific texts. Second instance: representation of the surgical act in 3 human cadaveric specimens. In each specimen, 4 approaches (2 sub mamarios and 2 lower subcostals) were performed, emphasizing the description of those anatomical structures important to respect in the thoracic wall approach. Results: It was possible to recreate the different techniques of approaching the costal wall. It was observed that the location of the vasculo nervioso package with in the costal groove was constant between specimens and intra specimen. The relationship between the internal perichondrium, the endothoracic fascia and the parietal leaf of the pleura turned out to be a complex and variable fibro adhesive system. We agree with the bibliography that the technique is difficult twhen the collection is carried out at the most proximal costal level. Conclusions: We believe that knowl edge of the thoracic anatomy is essential to perform a correct technique of dissection and later collection of costal cartilage, this would reduce complications and morbidity in the donor site. Pneumothorax and neuropathic painarise from the damage of constant anatomical structures.

Introdução: o objetivo é avaliar o conhecimento anatômico essencial da parede torácica para a recolha de cartilagem costal em rinoplastia. Materiais e métodos: dividido em duas fases. Esta apresentação corresponde à Fase I, observacional descritivo. Fase II (em curso) tem um desenho prospectivo e experimental para uma apresentação futuro. Primeira instância: recolha de informação bibliográfica, não mais de 5 anos de idade em bancos de dados médicos e textos específicos. Segunda instância: a representação da cirurgia em 3 espécimes de cadá- veres humanos. Em cada espécime 4 abordagens (2 submamária e 2 inferior subcostal) enfatizou a descrição dessas estruturas anatômicas importantes a respeitar no tratamento da parede torácica foram realizadas. Resultados: Foi possível recriar as diferentes técnicas de abordagem parede torácica. Verificou-se que a localização do feixe neurovascular no sulco costal foi constante espécimes inter e intra espécime. A relação entre o pericôndrio interno, a fáscia e a folha intratorácica pleura parietal provou ser um sistema de fibro adhesive complexa e variável. Estamos de acordó com a literatura que a técnica é difícil quando a coleção é composta nível costal mais proximal. Conclusão: Acreditamos que o conhecimento da anatomia torácica é essencial para uma correta técnica de dissecção e subsequenterecolha de cartilagem costal, este iria diminuir as complicações e morbidade no sítiodoador. Pneumotórax e dorneuropática vem de danos causados por estrutura sanatômicas constantes.

Effect of anisotropy and drying of costal cartilage on its optical transmittance in laser reshaping of implants with 1, 2, and 3 mm in thickness.

BACKGROUND AND OBJECTIVE: Laser reshaping of cartilage is a prospective technique which can be applied for manufacturing the natural implants for otolaryngology and reconstructive surgery. Optical properties and optimal laser settings for laser reshaping of costal cartilage depend on its thickness, water content, and structural anisotropy of the tissue, in particular, the distinct orientation of collagen packing. The aim of the work is to study the effect of different collagen orientation, thickness, and drying of costal cartilage on its interaction with laser radiation. MATERIALS AND METHODS: Costal cartilage was cut along and crosswise the distinct collagen orientation. The dried and normal cartilage was used for the comparative analysis. The collagen package was studied using atomic force microscopy. The dried tissue was analyzed with thermogravimetry-differential scanning calorimetry (TG-DSC) analysis to reveal the residual water content. The optical transmittance was measured for two wavelengths λ: 1,560 and 532 nm. The reshaping of cartilage of 1-3 mm in thickness was performed with infrared laser with λ = 1560 nm while, the radiation with λ = 532 nm was used to determine the location of the IR beam. RESULTS: The transmittance of 532 nm radiation does not depend on collagen orientation and tissue drying. The IR radiation transmits better along the distinct collagen direction in dried cartilage while in normal cartilage the intensity of transmitted IR radiation increases intermittently passing crosswise and does not change dramatically with time along the collagen orientation. CONCLUSIONS: The effect of structural anisotropy of costal cartilage reveals itself in the increasing scattering of IR radiation with λ = 1,560 nm passing crosswise the collagen orientation when tissue water content is decreased. The radiation with λ = 1,560 nm is effective to perform the reshaping for cartilage of 1-3 mm in thickness; however, for 3 mm, the residual mechanical stress should be taken into account. Lasers Surg. Med. 48:887-892, 2016. © 2016 Wiley Periodicals, Inc.

Anatomy of the tenth costal cartilage for a columella strut in an Asian rhinoplasty.

The aim of this study was to elucidate the precise radiological and surface anatomy of the 10th costal cartilage for the usage of a columella strut in an Asian rhinoplasty.Three hundred abdominal computed tomography scans were reviewed and measured (166 males, 134 females), and the location of the 10th costochondral junction (CCJ) was measured in reference to the anterior superior iliac spine (ASIS) and umbilicus. Sixteen 10th costal cartilages were harvested from 10 Korean adult cadavers (7 males, 3 females), and the length, width, and thickness of each cartilage were measured.Distance from the anterior ASIS to the umbilicus was 155.4 ± 15.1 mm (male: 157.9 ± 15.5 mm, female: 152.2 ± 14.1 mm). Distance from the umbilicus to the 10th CCJ was 170.7 ± 23.0 mm (male: 179.2 ± 22.8 mm, female: 160.3 ± 18.7 mm). Distance from the ASIS to the 10th CSJ angle was 181.8 ± 21.8 mm (male: 184.7 ± 21.3 mm, female: 178.2 ± 22.1 mm). The ASIS-umbilicus-10th CSJ angle was 56.3 ± 5.6 degrees (male: 55.1 ± 5.5 degrees, female: 57.8 ± 5.3 degrees). The average length of the cartilage was 64.1 ± 19.7 mm. The average curved length of the cartilage was 69.6 ± 21.0 mm. The average greatest width was 11.0 ± 2.1 mm, and the width at its mid-length was 8.3 ± 1.7 mm. The average thickness of the cartilage was 5.7 ± 0.9 mm. In a 33-year-old woman, the 10th costal cartilage was used for columella strut.It is thought that the 10th costal cartilage can provide a sufficient amount and shape for a columella strut and tip in an onlay graft.

The importance of costal cartilage framework stabilization in microtia reconstruction: anthropometric comparison based on 216 cases.

This study explored anthropometric changes in the reconstructed auricle and the contralateral normal ear in a series of 216 microtia patients using different stabilization methods. Our main personal modifications concerning the preparation of the framework were the following: 1. The individualized framework grafting was based on patients with different ages and different degrees of the strength and thickness of the rib cartilage. 2. The framework was stabilized as a "C" shape by using a piece of cartilage or suture to reinforce the two end points of the "C". In group A (the thickness of cartilage was more than 5 mm), a block of residual cartilage fixed by wire was added between the tragus and the base frame of the inferior crus by the modified method but was not applied in the original method. In group B (the thickness of cartilage was less than 5 mm), a 4-0 braided suture was used to reinforce the two structures but was not used in the original method. No significant differences were found in the height or width measurements of the cartilage framework and the contralateral normal side in either group at the time of implantation. At the follow-up, the height and width measurements were obviously increased in both groups operated on by the original method compared with the initial implanted or contralateral normal measurements. There were no significant differences in the height or width measurements by the modified method in either group. The authors' techniques produced acceptable results and generated some useful parameters for the growth study of the reconstructed auricle and the contralateral normal ear. The modifications in framework stabilization allow a harmonious outline of the reconstructed auricle to be attained, which is almost symmetrical to the contralateral normal auricle.

Does patient sex affect the anatomic relationships between the sternoclavicular joint and posterior vascular structures?

BACKGROUND: Despite increased concern for injury during surgical reconstruction of the sternoclavicular joint, to our knowledge there are few studies detailing the vascular relationships adjacent to the joint. QUESTIONS/PURPOSES: We investigated sex differences in the following relationships for sternoclavicular joint reconstruction: (1) safe distance from the posterior surface of the medial clavicle's medial and lateral segments to the major vessels, (2) length of the first costal cartilage and safe distance from the first rib to the internal mammary artery, (3) minimum distance medial to the sternoclavicular joint for optimal hole placement, and (4) safe distance from the manubrium to the great vessels. METHODS: Fifty normal postcontrast CT scans of the chest were reviewed. Means, standard deviations, and 95% CI were calculated for each aforementioned measurement. A t-test was used to determine if a sex difference exists (p≤0.05). RESULTS: At the medial end of the clavicle, the safe distance from the medial segment (first 10 mm) to the major vessels was greater in males than in females (3.5 mm versus 2.4 mm, respectively; 95% CI, 3 mm-4 mm versus 1.7 mm-3 mm, respectively; p=0.014). For the lateral segment (next 10 mm), the distance also was safer in males than in females (3.3 mm versus 1.7 mm, respectively; 95% CI, 2.7 mm-4 mm versus 1.1 mm-2.3 mm, respectively; p<0.001). The mean length of the first costal cartilage also was greater in males (35.8 mm versus 30.1 mm, respectively; 95% CI, 33.8 mm-37.8 mm versus 28.5 mm-31.9 mm, respectively; p<0.001); the distance from the first costochondral joint to the internal mammary artery was safer in males than in females (19.1 mm versus 15.4 mm, respectively; 95% CI, 16.5 mm-21.8 mm versus 13 mm-17.9 mm, respectively; p=0.05). The minimum distance to avoid inadvertent penetration of the sternoclavicular joint was greater in males than in females (16 mm versus 12.3 mm, respectively; 95% CI, 14.6 mm-17.5 mm versus 11 mm-13.6 mm, respectively; p<0.001). The distance to vessels after penetration of the manubrium was not different between males and females (5.6 mm versus 3.9, respectively; 95% CI, 4.4 mm-6.8 mm versus 2.6 mm-5.2 mm, respectively; p=0.06). CONCLUSIONS: This study makes apparent the intimate relationships between vessels and the musculoskeletal structures associated with sternoclavicular reconstruction. Based on our findings, we recommend considering the sex of the patient, using caution when drilling, and protecting essential structures posterior to the joint.

[Evaluation of multi-slice spiral ct scan and image reconstruction technology in estimating costal cartilage volume].

OBJECTIVE: To investigate the accuracy of multi-slice spiral CT (MSCT) scan and image reconstruction technology for measuring morphological parameters of costal cartilages and to evaluate the volume of costal cartilages. METHODS: Between March and August 2013, 75 patients with congenital microtia and scheduled for auricle reconstruction were included in the study. Of 75 patients, there were 49 males and 26 females with a mean age of 8 years and 5 months (range, 5 years and 7 months to 32 years and 7 months) and a mean weight of 29.5 kg (range, 21-82 kg). A Philips Brilliance 64 MSCT machine was used to scan 1st-12th costal cartilages with the parameters based on the age and weight of the patients. All the data were transported to the workstation for reconstructing the image of the costal cartilages with the technique of maximum intensity projection (MIP) and volume rendering technique (VRT). Then the morphologies of costal cartilages were observed through the images on VRT; the width of the costal cartilaginous ends close to ribs (W) and the length of thetotal cartilage (L) were measured and compared with their counterparts (W' and L') after the costal cartilages were harvested during the processes of auricle reconstructions to analyze consistency between these two sets of data. RESULTS: The morphologies of ribs and costal cartilages shown on VRT image got fine sharpness, verisimilitude, and stereoscopic impressions. A total of 192 costal cartilages were examined. The results showed that the widths of the costal cartilaginous ends close to ribs (W) was (9.69 ± 1.67) mm, and W' was (9.73 ± 1.64) mm, showing no significant difference between W and W' (t = -1.800, P = 0.073), and interclass correlation coefficient (ICC) test showed Cronbach's α = 0.993. The length of the total cartilage (L) was (83.03 ± 23.86) mm, and L' was (81.83 ± 16.43) mm, showing no significant difference between L and L' (t = -1.367, P = 0.173), and ICC test showed Cronbach's α = 0.904. Linear-regression analysis showed L = 1.28 x L' - 21.93 (R2 = 0.780, F = 673.427, P = 0.000). The results suggested there was a good consistency between these two sets of data. CONCLUSION: Scanning costal cartilages with appropriate parameters and reconstructing the cartilaginous image with MIP is an effective method to measure the width and length of costal cartilage and to estimate costal cartilage volume, which can provide accurate reference for plastic surgery together with reading the morphology from the image on VRT.