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Page 6 of 8 Göksel et al. Plast Aesthet Res 2019;6:17 I http://dx.doi.org/10.20517/2347-9264.2019.12

Figure 9. Insufflation test - filling the wound with saline solution

Figure 10. Closed wound. Separate skin sutures using 5.0 prolene

proven to be very helpful in contouring areas of calcification. In this situation, we prefer to enlarge the
incision and use piezo electric instrument under direct vision because it’s not easy to use piezo device with
endoscopic view. As the Piezo electric device does not harm any soft tissue, one can be safely cut out the
[7]
calcified area without injuring the perichondrium .
Small calcifications may also be found within the body of the rib cartilage itself. This fact should be drawn
to surgeon’s attention as it can impair the preparation of individual grafts and act as a site of weakness,
often having a tendency to fracture.

Safety check
After cartilage removal it’s important to make sure that pleura is left intact. We perform insufflation test -
filling the wound with saline solution and using positive thoracic pressure . If no bubbles observed- one is
[6]
safe and pleura is intact. After the test we wash the cavity with rifampicin solution [Figure 9].

Wound closure
We close the wound layer by layer for faster healing and avoiding tension. Closure is initiated from
perichondral layer by putting 2-3 stitches with 4.0 rapid vicryl. Then the subcutaneous layer is closed with
4.0 vicril.

Skin is closed with separate sutures using 5.0 prolene. We haven’t used any drain application on any of our
cases [Figure 10].

Graft fabrication
We suggest to use the rib according to the oblique split method, described by Dr. Eren Tastan [Figure 11].
As warping has been the main problem by costal cartilage grafting, oblique split method provides straight
costal cartilage grafts of varying thicknesses without the risk of warping.