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Rhinoplasty is a common surgical procedure in medical cosmetology. From patients with saddle nose deformity to beauty seekers with low and short noses, this surgery is mainly sought to improve the nose's appearance. To investigate the effect of modified auricular cartilage scaffold combined with L-shaped prosthesis in rhinoplasty. This retrospective study included 54 patients who underwent auricular cartilage augmentation rhinoplasty with L-shaped implants in our hospital from July 2018 to July 2021. The function of nasal ventilation and olfaction was inspected. As a result, the degree of nasal tip protrusion and the changes in the superior lip angle of columella were improved. The patients' satisfaction was measured a year after the surgery. Patients who underwent auricular cartilage augmentation rhinoplasty with L-shaped prosthesis were satisfied with the surgery outcomes. Using a protective auricular cartilage scaffold combined with an L-shaped implant for augmentation rhinoplasty reduced the shortage of the application and reinforced the stability of the auricular cartilage augmentation rhinoplasty. At >12 months follow-up, there were no serious adverse effects on nasal ventilation and olfactory function in any of the patients. The presented method made full use of auricular cartilage so that it reduced the harvest of the cartilage. Besides, it achieved the remarkable lift of the nose tip, thus simulating the appearance of costal cartilage rhinoplasty. Furthermore, the risk of implant exposure was efficiently reduced, making it worthy of clinical application., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Purpose: A constricted ear is a deformity that is distinguished by curling of the upper portion of the ear, which includes the helix, scapha, and antihelix. The treatment for severely constricted ears seems to be quite invasive. To reduce invasiveness and fully utilize the folded cartilage, the authors used a helix costal cartilage scaffold combined with a single V-Y advanced flap in the correction of Tanzer type IIB constricted ear deformity to investigate the clinical effect., Materials and Methods: From 2020 to 2021, autologous costal cartilage helix stent combined with local V-Y advanced flap was applied to correct the constricted ear malformation in 18 patients admitted to the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences., Results: All patients were followed for a duration of 6 to 12 months (average 7 months). Reconstructed auricles were cosmetically satisfying, with a natural-looking helix and enlarged cavum conchae cavity, as well as auricle sizes that were close to normal and near symmetry between both ears., Conclusions: With satisfactory clinical results, our technique can be used to repair types IIB cup ear deformities. It has a broad range of practical applications., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Insufficient support of the nasal septum due to congenital or secondary deficiency leads to severe saddle nose deformity, which presents an unpleasant appearance., Objectives: The purpose of this study is to present our approach to constructing a costal cartilaginous framework with autologous costal cartilage for correction of severe saddle nose deformities., Methods: A retrospective analysis was conducted of patients who underwent correction of severe saddle nose deformity (type 2 to type 4) by a senior surgeon from January 2018 to January 2022. Preoperative and postoperative measurements were conducted to evaluate the surgical outcomes., Results: A total of 41 patients ages 15 to 50 years completed the study. The average follow-up time was 20.6 months. No short-term complications were observed. Revisional operations were performed on 3 patients. All patients were satisfied with the aesthetic results. Analysis of objective measurements showed that the nasofrontal angle, columellar-labial angle, and tip projection improved significantly in type 2 cases, the nasofrontal angle and tip projection improved significantly in type 3 cases, and tip projection improved significantly in type 4 cases., Conclusions: Application of this modified costal cartilaginous framework, which consists of a fairly stable foundation layer and an aesthetic contour layer of block costal cartilage, has achieved satisfactory results over the long term., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The costal cartilage is widely used in rhinoplasty. Although different surgical methods of costal cartilage harvest have been developed, few studies have reported the method of costal cartilage harvest for patients after breast augmentation. This study aims to provide our experience of costal cartilage harvest through a small incision approach., Methods: A retrospective review was performed for patients undergoing esthetic rhinoplasty with costal cartilage after breast augmentation between May 2019 and May 2021. Postoperative pain was evaluated with the Visual Analog Scale, and the scars at the donor site were assessed 1 year postoperatively with the Modified Vancouver Scar Scale., Results: A total of 23 female patients were included. The average follow-up time was 21.4 months. No complications of massive bleeding, pleural injury, or breast implant injury during the surgery, wound dehiscence, or wound infection in the harvested site were observed. No patients complained of changes in breast morphology or breast asymmetry after costal cartilage harvest. Results of Visual Analog Scale for donor-site pain indicated pain in donor-site peaked at 12 hours after surgery and gradually decreased. All patients were satisfied with the scarring of the donor sites after surgery., Conclusion: The better scar performance, low complication rates, and high satisfaction among patients suggest that this is a safe technique to harvest costal cartilage with a small incision in rhinoplasty for patients after breast augmentation., Competing Interests: The authors declare that they have no conflict of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Objective: In auricular reconstruction, the convex structures of the framework determine the esthetics, and young doctors often need sufficient training to determine the best carving techniques. This study aimed to recommend optimal carving methods and provide measured data of convex structures of the carved costal cartilage framework to prevent complications, improve esthetics, and reduce the learning curve., Methods: From 2018 to 2021, 406 patients with microtia who underwent costal cartilage carving were enrolled. The helix is formed by the eighth costal cartilage. The complex of the antihelix was fabricated from part of the eighth costal cartilage or the ninth costal cartilage. The tragus was constructed using residual cartilage pieces from the base frame. These components were measured, and those from the new ear graded "excellent" were used for data analysis. The statistical analysis was principally processed using Excel software., Results: A total of 112 ears were graded "excellent". The following are the mean and standard deviation of each group of data: antihelix thickness, 0.31 ± 0.06 cm; antihelix width, 0.40 ± 0.06 cm; superior crus thickness, 0.18 ± 0.04 cm; superior crus width, 0.38 ± 0.09 cm; inferior crus width, 0.22 ± 0.04 cm; inferior crus thickness, 0.28 ± 0.05 cm; helix thickness, 0.31 ± 0.04 cm; the four-point height of the helix, 0.52 ± 0.08 cm/0.51 ± 0.07 cm/0.46 ± 0.06 cm/0.41 ± 0.06 cm; and tragus height, 0.98 ± 0.15 cm., Conclusion: These data may help beginners in reducing the learning curve of ear reconstruction. Framework fabrication based on these data allows attaining a harmonious ear framework and satisfactory three-dimensional auricle outline, yielding acceptable results and few complications., Level of Evidence: 4 Laryngoscope, 133:569-575, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluate and compare the costal cartilage lateral crural strut graft's (LCSG) ability to support a weak lateral crus in patients with external nasal valve dysfunction (EVD) undergoing primary versus revision functional rhinoplasty., Methods: This is a prospective cohort study of 26 patients (mean [SD]: 40.23 [6.75] years of age; 10 [38%] females) with clinically diagnosed EVD, who underwent primary versus revision functional rhinoplasty with the use of a costal cartilage LCSG (10 [38%] primary functional rhinoplasty patients and the 16 [62%] revision patients). Preoperative and 12-month postoperative subjective and objective functional measurements along with statistical analysis were performed., Results: While all baseline demographic and preoperative functional measurement scores were similar between the 2 groups, the primary cohort's preoperative scores were higher overall. Follow-up was a mean of 14.58 months. The primary group demonstrated a greater difference in score improvement postoperatively in all categories. All patients had significantly improved visual analog scale (VAS), Nasal Obstruction Symptom Evaluation Scale, 22-Item Sinonasal Outcome Test, and nasal peak inspiratory flow (NPIF) scores. When comparing the overall score outcome and surgical efficacy of the LCSG, both groups had near equal final score outcomes with the exception of VAS L and NPIF., Conclusion: The LCSG is a viable and versatile option in the management of EVD for both primary and revision rhinoplasty patients.

Purpose: Non/minimally irradiated Cadaveric Costal Cartilage (NCCC) is commonly used for grafts in nasal reconstruction; however, no information exists on its use in total ear reconstruction for type III microtia. In this case series we describe preliminary results from the novel use of NCCC for auricular framework construction in 7 ear reconstructions., Methods: Patients requiring total ear reconstruction from August 2020 to October 2021 were eligible and underwent ear reconstruction using NCCC from MTF Biologics (Edison, NJ). Patients were evaluated for surgical site infection, skin necrosis, cartilage exposure, warping, and resorption during regular follow up visits., Results: Seven ears were reconstructed using NCCC across 5 patients with type III microtia. Patients ranged from 5 to 51 years old at the time of surgery. Follow up time ranged from 12 to 78 weeks (mean: 46 wk). No patients experienced surgical site infections or significant cartilage resorption. All procedures were done outpatient, total time under anesthesia was <90 minutes in 5/7 cases and postoperative narcotics for pain management were not needed in 5/7 cases. Complications included minor skin necrosis that was repaired via primary closure, construct exposure in the immediate postoperative period, which was successfully salvaged with a local flap, and explantation of one construct after reconstruction for a complicated revision surgery involving a previous temporoparietal fascial flap., Conclusion: NCCC serves as an immediately available alternative to alloplastic and autologous materials for construction of auricular frameworks during ear reconstruction. Longer follow up times and a larger sample size will further elucidate long-term efficacy., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Secondary cleft rhinoplasty typically requires large amounts of cartilage grafts for augmentation. The purpose of this study was to present our short-term experience with alloplastic implants in cleft rhinoplasty. This was a retrospective cohort study of cleft lip and palate patients treated with secondary rhinoplasty at Hanoi Medical University Hospital and Ruby Hospital between 2017 and 2020. All rhinoplasty procedures consisted of lower lateral cartilage repositioning, a dorsal augmentation with silicone implant, columellar strut implant or graft, and onlay tip grafts. Cartilage was obtained from the septum and concha, and no cartilage was harvested from the rib. The study outcomes included the Rhinoplasty Outcome Evaluation (ROE) survey, a modified Mortier scoring scale, 8 intranasal measures of symmetry, and 4 nasofacial measures of tip projection and nasal length. Changes in patient satisfaction and nasal esthetics were compared before and after surgery. A total of 38 patients were included in the final study sample, of whom 65.79% had unilateral clefts. The overall complication rate was 7.89%, and there were 2 cases of infection and 1 case of dorsal implant displacement. Following rhinoplasty, ROE satisfaction scores significantly increased (+39.36, P <0.01) and Mortier severity scores decreased (-3.06, P <0.01). Nostril symmetry nearly normalized in width, height, and inclination. Mean columellar deviation decreased from 8.82 to 2.08 degrees, and nasal projection increased as assessed on multiple analyses. Patients with bilateral clefts had similar improvements in ROE and Mortier scores. In our experience, synthetic implants simplified the correction of cleft nasal deformity and eliminated the need for costal cartilage. We found that our protocol produced acceptable and stable short-term clinical results without increasing the complication rate above what has been reported with autologous grafts., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Revision operation of the unsatisfactory microtia reconstruction is 1 of the most difficult revision operations in plastic surgery. This study discussed the cases about revision operation of the unsatisfactory or failed ear reconstruction using autologous costal cartilage and residual., Methods: A prospectively maintained database of all consecutive patients who underwent secondary total ear reconstruction from 2013 to 2020 was reviewed. Demographic data and outcomes were assessed., Results: Thirty-six patients with microtia met the inclusion criteria. The age of the patients who underwent secondary reconstruction ranged 6 to 56 years. The follow-up duration was from 1 to 8 years. Primary reconstruction using costal cartilage was performed in 34 cases, and Medpor (porous high-density polyethylene) were used in 2 cases. All 36 cases were treated with costal cartilage as the revision. One-stage revision was performed in 27 cases, including scaffold covered by superficial temporal fascia flap in 9 cases, retroauricular fascia flap in 12 cases and superficial temporal plus retroauricular fascia flap in 5 cases. Nine cases were renovated with expanders by stages, of which 8 cases were covered by retroauricular fascia and 1 case was covered by expanded skin flap. Complications occurred in 2 cases, and 1 patient was not satisfied with the partial scaffold repair., Conclusions: The effect of revision operation of ear reconstruction with costal cartilage is satisfactory, and different methods of ear reconstruction are indicated in different operation conditions, and the revision surgery requires adequate preoperative evaluation.Level of Evidence: Level IV, therapeutic study., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: The manufacture of cartilage framework is a key element in the success of total ear reconstruction. Appropriate training can improve cartilage curving and fabricating skills, which is especially helpful for the novice clinicians. Based on threedimensional printing silicone model and porcine rib cartilage, the authors have designed a 2-stage training program to improve skills and cosmetic cognition for ear reconstruction., Methods: The training program includes 2 successive stages. In the first stage, trainees completed observation of framework fabrication, design and sculpturing practice on silicone rib models. Porcine costal cartilages are used for fabrication in the second stage. After that, the framework was put in a latex glove connected with a suction to simulate the skin cover procedure in operation., Results: At the end of the training program, all trainees could fabricate an ear-shaped cartilage framework successfully. Their cosmetic cognitions of the ear have also improved., Conclusions: Based on three-dimensional printing silicone model and porcine rib cartilage, the authors have designed a 2-stage training program to improve trainee's carving techniques and cosmetic cognition for ear reconstruction. The authors believe that this training program is helpful in training, practicing and teaching activities of framework fabrication in total ear reconstruction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Background: This study evaluated the incidence and clinical characteristics of postoperative infection following rhinoplasty., Methods: This article is a retrospective review of 2630 East Asian rhinoplasty cases performed by a single surgeon (Y.J.J.), from July of 2003 to June of 2018. There were 1595 male patients (69.9 percent) and 687 female patients (30.1 percent), and the median age was 31 years. The incidence of infection was compared between primary and revision cases and analyzed according to the materials used. The authors evaluated the organisms cultured and the timeframe of infection development and intervention., Results: There were 2134 primary and 496 revision cases. Materials included autologous costal cartilage (413 cases), conchal cartilage (572 cases), homologous fascia lata (829 cases), homologous costal cartilage (102 cases), Gore-Tex (373 cases), and silicone (32 cases). The authors identified 22 cases (0.84 percent) of postoperative infection, 18 of which were revision. Revision surgery had a 19-fold greater infection rate than primary surgery (3.63 percent versus 0.19 percent). Women were 3.6 times as likely to develop an infection ( p = 0.002). The infection rate using autologous costal cartilage was 3.39 percent, and that for simultaneous correction of a septal perforation was 8.57 percent. In 11 cases (50 percent), infection developed within 1 month after surgery (12 ± 7 days). Methicillin-resistant Staphylococcus aureus was cultured in eight cases. Infection manifested at the nasal tip in 45 percent and the caudal septum/columella in 32 percent of cases. Twenty cases (90.9 percent) underwent surgical débridement., Conclusion: Revision rhinoplasty in women, requiring the use of costal cartilage or simultaneous correction of septal perforation, showed a higher risk of postrhinoplasty infection, which usually manifested at the nasal tip and caudal septum/columella and needed to be managed by surgical débridement., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Our aim was to evaluate the efficacy and safety of multimodal cocktail intercostal injection for the relief of chest pain after costal cartilage harvest for rhinoplasty. Consecutive patients who underwent costal cartilage harvest during rhinoplasty were prospectively assigned as per patient preference to group A (injection containing ropivacaine, parecoxib sodium, epinephrine, and compound betamethasone), group B (intercostal nerve block (ICNB)), or group C (ICNB plus patient-controlled analgesia (PCA)). The outcomes were visual analogue scale (VAS) scores for chest pain after costal cartilage harvest, rescue analgesia, complications, and cost during the first two days. Of the 66 patients assessed, 63 (29 patients in group A, 13 in group B, and 21 in group C) were eligible and included. The VAS scores in group A were significantly lower than those in groups B and C (all p<0.001). Group A had a significantly lower rate of rescue analgesia due to a VAS score of more than 4 (3.45%, 1/29) compared with group B (46.15%, 6/13; p=0.001) and group C (28.57%, 6/21; p=0.012). Complications were observed only in group C (nausea/vomiting 28.57%; dizziness/headache 23.81%), which differed significantly from group A (p=0.002 and 0.006, respectively). The mean cost for group A (US $15 (0)) was significantly lower than it was for group C (US $113.1 (4.4), p<0.05), but higher than it was for group B (US $5.97 (0), p= -). Multimodal cocktail intercostal injection may be superior for chest pain relief after costal cartilage harvest for rhinoplasty compared with ICNB with or without PCA. Further study is warranted., (Copyright © 2021 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Summary: Costal cartilage is the ideal medium for auricular framework fabrication in auricular reconstruction surgery. Well-developed cartilage is closely associated with surgical outcomes; however, which costal cartilage is better developed and more suitable for framework fabrication is controversial. This study aimed to examine the laterality differences in costal cartilage development in pediatric patients who have undergone auricular reconstruction surgery for microtia. Preoperative thoracic computed tomography data of 101 microtia patients (age range, 6 to 10 years) were retrospectively analyzed. Computer software was used to create three-dimensional costal cartilage images. The length and volume of the costal cartilage of the sixth, seventh, and eighth ribs were measured from these images. Results indicate that the cartilage of the sixth rib on the left side was significantly longer and had a greater volume than that on the right side. Further, the cartilage of the seventh rib on the left side was significantly longer than that on the right side; however, there was no significant difference in volume. No significant differences were found between the cartilage of the eighth rib on the right and left sides. In general, the costal cartilage of ribs on the left side of the thorax was more developed than that on the right. These results may help clinicians in selecting appropriate donor sites before auricular reconstruction surgery in microtia patients., (Copyright © 2022 by the American Society of Plastic Surgeons.)

The slipping rib syndrome is characterized by burning pain in the lower thorax and upper abdomen, often disabling, caused by hypermobility of the costal cartilage with entrapment of the intercostal nerve. The syndrome is often underdiagnosed. The diagnosis is clinical and the definitive treatment is surgical, with an excellent result for pain relief. Based on the observation of 4 cases undergoing rib resection for SRS, we noticed a new possible sign of the disease. Our patients showed less thickness of the ipsilateral rectus abdominis muscle on ultrasound of the abdomen. The aim of this study is to demonstrate this sign in the diagnosis of SRS, to make this disease more recognizable and treatable., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Slipping rib syndrome (SRS) is a painful condition of hypermobile, detached lower costal cartilages impinging the intercostal nerves. While surgical resection of the cartilaginous rib is reported as definitive treatment, recurrent symptoms are common. We describe the addition of vertical bioabsorbable rib plating to decrease recurrence., Methods: An IRB-approved (#17-098), single institution, retrospective chart review was performed for patients who presented with SRS from 2009 to 2019 at a single institution. Descriptive statistics were used to compare patients with and without bioabsorbable vertical plating., Results: A total of 85 patients (71.8% female, mean age 17.7 years) underwent evaluation for SRS. Of the 70 who underwent surgery solely for SRS, 29 (41%) underwent vertical rib plating at initial surgery while 41 (58.6%) did not. Recurrent symptoms developed in 7 (17.1%) unplated patients, while only 1 (3.4%) plated patient had recurrent SRS (which occurred after a motor vehicle crash) (p = 0.0116). Of the 8 with recurrent symptoms, 3 underwent vertical plating at a subsequent operation., Conclusion: Rate of recurrent symptoms after cartilage resection alone for SRS was 17.1%. The addition of vertical rib plating with bioabsorbable plates decreased recurrent symptoms and improved outcomes., Level of Evidence: II., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The base frame provides a stable support for the helix, antihelix, and tragus-antitragus complex in microtia reconstruction, and this support is vital to attain a highly defined outline for a reconstructed auricle. The success of base frame sculpting depends on appropriate treatment of the cartilage, mainly the sixth and seventh costal cartilages, which may have different characteristics. The aim of this study was to demonstrate the relevant details for base frame fabrication under various scenarios. Between 2016 and 2019, a total of 352 patients with microtia underwent autologous auricular reconstruction. Concerning the different sizes and characteristics of the costal cartilage used for the base frame reconstruction, we describe the related methods for fabrication and introduce corresponding strategies for proper management. We found that 90% of the patients responded at follow-up, and 76% of them were satisfied with the cosmetically refined auricle with harmonious integrity. The elaborate design and appropriate utilization of costal cartilage for base frame sculpting is one of the most significant and fundamental processes in microtia reconstruction. It contributes to achieving a clearly defined outline of the auricle with harmonious integrity, which is as important as the other projected subunits., (© 2021. The Author(s).)

Background: 3D computer-simulated technology is becoming popular in China. Rhinoplasty with costal cartilage is a good option for Asians. However, the application of 3D imaging in Asian rhinoplasty with costal cartilage has not been systematically assessed., Objective: To analyze the effect of 3D imaging in Asian rhinoplasty with costal cartilage., Methods: In this study, 44 patients were included and randomly divided into 3D and non-3D imaging groups. We performed a prospective survey on the aesthetic scores for preoperative, simulated, and postoperative images and calculated the relative nasal index scores of patients in both groups. Additionally, surveys on satisfactions with surgical outcomes and doctor-patient communication in both groups were conducted., Results: The actual postoperative result was well consistent with the preoperative simulation result. The 3D computer simulation did not impact the satisfaction with surgical outcomes but increased that with doctor-patient communication. The 3D computer-simulated technology was an effective tool for doctor-patient communication and surgery planning in Asian rhinoplasty with costal cartilage., Level of Evidence Ii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 ., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

The correction of severe asymmetric pectus excavatum is still challenging, especially for adults with a rigid thorax. For the repair of asymmetric cases, we introduce our surgical techniques added to the Nuss procedure. Chondrotomy of the depressed and deformed costal cartilage to elevate the depressed side was performed in a 42-year-old female patient. The depressed chest wall was directly elevated using pectus bars. Her sternal rotation angle improved from 27° to 15° after bar removal. In a 26-year-old male patient, oblique sternotomy and chondrotomy were performed. The sternal rotation angle improved from 26° to 9° postoperatively. These techniques were effective for correcting severe asymmetric pectus excavatum in adults.

Objective: This study aimed to investigate the clinical effect of diced cartilage on correcting nasal alar base depression in Asian cleft rhinoplasty., Methods: A retrospective study was conducted on 25 patients with nasal deformity, who underwent the second cleft rhinoplasty between January 2018 and January 2020. Autologous costal cartilage was harvested in all the patients to reconstruct the contour of the nose, while the remaining cartilage from the surgery was cut into 1.0×1.0 mm pieces and filled into the nasal alar base. The preoperative and postoperative effects of visual images were compared and analyzed using Adobe Photoshop CS6 software. The patients were followed up for 8-18 months (mean 12 months) to investigate the satisfaction and complication rate., Results: The nasal alar base depression was corrected, and the profile of malformed noses was significantly improved in 25 patients after the surgery. The postoperative effect was satisfactory, and no obvious graft shift or other complications were observed in the follow-up., Conclusions: The application of diced cartilage to correct nasal alar base depression after cleft lip surgery is a feasible method. Its advantages include mainly the crafty use of the remaining cartilage and the presentation of a more natural appearance than mass cartilage., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Although costal cartilage has many uses and is a reliable source of cartilage for rhinoplasty procedures, donor-site complications may arise with conventional harvesting techniques. The present report reports a novel technique of harvesting costal cartilage using a specially designed scalpel and studies the use of the harvested cartilage in the reconstruction of secondary nasal deformities in patients with cleft lips., Methods: Ten patients (7 females and 3 males) with nasal deformities secondary to cleft lip underwent rhinoplasty using this new technique at the Department of Oral and Maxillofacial Surgery, Second Hospital of Hebei Medical University, China, between May 2011 and December 2013. Clinical outcomes were evaluated with a follow-up period of 6 to 30 months., Results: The new technique successfully corrected primary nasal deformities, including flat nasal tip, short columella, flaring alae, and asymmetrical nostrils. Surgeons and patients assessed the outcome to be either good or satisfactory. Patients experienced transient discomfort at the wound site but there were no major complications (such as wound infection, dehiscence, exposure, graft extrusion, and pulmonary involvement)., Conclusions: The novel technique can harvest a lateral segment of costal cartilage for use in the reconstruction of nasal deformities secondary to cleft lip in a one-stage procedure, with minimal donor-site morbidity., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Background and Aims: We performed thoracoscopic costal cartilage excision (TCCE) combined with the Nuss procedure to correct asymmetrical pectus excavatum (PE). We reviewed the efficacy of combined TCCE and Nuss procedure for asymmetric PE. Patients and Methods: Overall, 8 patients with asymmetrical PE underwent TCCE with the Nuss procedure. The Haller index, asymmetry index, and angle of sternal rotation were calculated using preoperative computed tomography. The procedure was performed using bilateral 2.5-cm incisions at the same level of the deepest chest wall depression. The most depressed three to four costal cartilages were partially resected through a right mini-thoracotomy. Subsequently, one or two titanium bars were implanted and secured with stabilizers. The cosmetic outcome was evaluated on the following four ratings: excellent, good, fair, and failure ( = recurrence). Results: The median age at surgery was 14.5 years (8-20 years). The number of bars was one in 3 cases and two in 5 cases. The preoperative Haller index, asymmetry index, and angle of sternal rotation were 4.3 (3.5-5.9), 1.15 (1.04-1.26), and 21.5° (15°-31°), respectively; 2 patients had scoliosis before the Nuss procedure. Complications included surgical site infection and hemothorax. Median follow-up time was 25.5 months (3-63). Bars were removed in 3 patients, 3 years postoperatively. Cosmetic results were excellent, 4; good, 2; fair, 1; failure, 1. Both patients with scoliosis had poor outcomes (fair, 1; failure, 1). Conclusions: Combined TCCE with Nuss procedure is considered safe and effective for patients with asymmetrical PE. Careful long-term follow-up is required, especially in cases with scoliosis.

Background: Nasal dorsal augmentation is one of the most commonly performed rhinoplasty procedures in Asia. We describe our experience with multilayered costal cartilage grafting (MCG) for dorsal augmentation in Asian patients. We aimed to evaluate the aesthetic outcomes and complications of MCG in comparison with those of one-block concentric carving costal cartilage graft (OCG) using objective and subjective assessment criteria., Methods: Eighty-two consecutive patients who underwent dorsal augmentation with OCG (n = 39) or MCG (n = 43) by a single surgeon between November 2010 and September 2018 with > 12 months of follow-up were included in this retrospective cohort study. The aesthetic outcomes, which were determined by both anthropometric analysis and consensus decision, were compared. Patients' satisfaction and postoperative complications were also analyzed., Results: Dorsal height ratios and radix height ratios increased significantly by 14.0% and 19.4%, respectively, after the OCG technique (p < 0.001) and by 13.5% and 19.0%, respectively, after the MCG technique (p < 0.001). Anthropometric comparison revealed that OCG did not show any significant differences in dorsal height ratio (p = 0.707) and radix height ratio (p = 0.856) postoperatively when compared with MCG. However, the warping rate was higher in the OCG (15.4%) than in the MCG (4.7%) group, although not significantly. There were no differences in overall patient satisfaction between the two groups., Conclusions: Dorsal augmentation with MCG produces similar aesthetic outcomes but a lower warping rate than that with OCG. The MCG technique may minimize graft warping and thus might be an effective alternative for nasal dorsal augmentation, particularly in Asian rhinoplasty., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Various techniques for the aesthetic correction of short noses have been described, but the selection of the adequate graft material remains controversial. Previous reports have mainly focused on the application of septal cartilage or alloplastic materials for short nose elongation, but the lengthening effect is often unsatisfactory for severe short noses. We propose costal cartilage as an alternative treatment for short noses, describe the technique, and discuss outcomes, patient selection, and complications based on our 15-year experience., Methods: From February 2004 to December 2018, 611 patients with varying degrees of short noses were included in this retrospective study. All patients underwent nose elongation surgery using a costal cartilage graft. Nasal length before and after surgery was measured based on a 3-dimensional simulation technology. Outcomes and complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey., Results: Nasal elongation using costal cartilage was successfully achieved, with a mean increase in nasal length of 4.06 ±0.79 mm. Patients were followed up for a period of 8.5 months on average, ranging from 6 months to 8 years. Follow-up examinations demonstrated stable results. The overall complication rate was 3.8%. Complications included infection, implant extrusion, migration, deviation, visibility, prominence, and reddening of the nasal skin. Most patients (95.2%) rated their outcome as improved and much improved., Conclusion: Nasal elongation using costal cartilage grafting is an effective therapeutic approach for patients with severe short noses. Reliable outcomes and the use of autologous tissue along with minimal donor site morbidity contribute to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

Background: Resorption of the cartilage framework results from hematoma or infection, deteriorating outcomes in microtia reconstruction. Delayed resorption still occurs for unclear reasons in patients without adverse events. The risk factors for delayed framework resorption were explored in this 20-year microtia cohort. Methods: Patients who underwent auricular elevation >5 years ago were reviewed from January 2001 to March 2019. Bilateral microtia, infection, and hematoma cases were excluded. Framework resorption was graded on the last photographs as none to minimal (grade 1), blunted but all components present (grade 2), loss of either the helical or antihelical component (grade 3), and loss of all components (grade 4). Logistic regression was used to evaluate independent risk factors for grade 3 and 4 resorption. Results: Of the 367 patients, 132 revisited our institution with a mean postoperative duration of 8.0 years. Grade 1 resorption was seen in 37.1%, 2 in 31.8%, 3 in 24.2%, and 4 in 6.8%. Canalplasty increased the risk of resorption regardless of timing (before auricular elevation, p  = 0.017; after auricular elevation, p  = 0.011). Body mass index at the time of cartilage harvest lowered the risk of resorption ( p  = 0.057) with clinical significance. Conclusions: Canalplasty may be avoided given the risk of framework resorption or may be performed with antiresorption strategies if the expected hearing outcome is superior. Our timing of harvest at the age of 10 years may have ensured cartilage maturation, both in terms of size and biomechanics, resulting in the resistance to resorption.

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., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

Background: Slipped rib syndrome (SRS) is a painful disorder caused when 1 or more of the 8th-10th false ribs become abnormally mobile. Established treatment modalities include analgesia, intercostal nerve injection, and costal cartilage excision. No definitive surgical correction of SRS without cartilage excision has been previously described. We aimed to determine whether a nonexcisional repair technique in affected adults could demonstrate significant relief from SRS using standardized outcome measures., Methods: We performed a retrospective review of cases of SRS treated at our institution in 2019. We obtained data by survey before and after sutured 10th rib fixation, using a self-reported rating scale from 0-10 at defined intervals. Surveyed outcome measures were compared pre- and postoperatively using the Wilcoxon signed rank sum test. The use of neural modulating, narcotic, and nonsteroidal antiinflammatory drug medications was also compared pre- and postoperatively using McNemar's test where applicable., Results: SRS was diagnosed using clinical examination alone in 42 adults and repaired in 29 patients. Median postoperative improvement in pain at 1 and 6 months was 75% (P < .001) and 80% (P < .001), respectively. Improvements in other outcome measures were similar. In patients who took pain medications preoperatively, narcotics were discontinued at 1 month by 100%, neural modulators by 86%, and nonsteroidal antiinflammatory drugs by 92% (all P values < .001). Pain medication use remained minimal at 6 months in 23 (79%) of patients completing follow-up., Conclusions: Minimally invasive slipped rib repair in adults provides significant relief of SRS, offering a useful alternative to costal cartilage excision. It is well tolerated and effective., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To evaluate the validity of a live porcine model for surgical training in tracheostomy and open-airway surgery., Study Design: Prospective observational study., Methods: Eleven expert otolaryngologists-head and neck surgeons rated a live porcine model's realism/anatomical accuracy (face validity) and perceived effectiveness as a training tool (content validity) for tracheostomy and laryngotracheoplasty using anterior costal cartilage and thyroid ala cartilage grafts using a 53-item post-trial questionnaire with a five-point Likert scale., Results: Experts rated the face validity of the live porcine model a median (interquartile range [IQR]) of 4/5 (4-5) and the content validity a median (IQR) of 5/5 (4-5) for each surgical procedure. Overall, 91% strongly agreed or agreed that the simulator would increase trainee competency for tracheostomy and laryngotracheoplasty using costal cartilage graft, and 82% strongly agreed or agreed that it would increase trainee competency for laryngotracheoplasty using thyroid ala cartilage graft., Conclusions: The live porcine model has high face and content validity as a training tool for tracheostomy and laryngotracheoplasty using costal cartilage and thyroid ala cartilage grafts. This training model can help surgical trainees practice these complex, low-frequency procedures., Level of Evidence: NA Laryngoscope, 130: 2063-2068, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Autologous ear construction for microtia creates an auricle using a costal cartilage framework. To separate the construct from the mastoid, the most common methods incorporate the use of fascial flaps or skin grafting. The authors describe a V-Y skin and subcutaneous scalp advancement flap for ear elevation as part of autologous ear construction for microtia. The method is simple and reliable and offers advantages compared to other techniques.

Background: Autogenous costal cartilage grafts (ACCG) are frequently used in secondary rhinoplasty; however, these grafts tend to warp. The objective of this study is to systematically evaluate current interventions to prevent warping of ACCGs and to assess long-term outcomes with their use., Methods: A systematic review was undertaken using a computerized search. Eligible articles assessed adult patients undergoing secondary rhinoplasty with ACCGs. Interventions to reduce warping were examined. Publication descriptors were extracted, heterogeneity was examined, and methodological quality of articles was assessed., Results: Eighteen studies were included. Most studies were published after 2010 (83.3%), assessed a single intervention (83.3%), and were of levels of evidence III and IV. Mean patient age was 30 (range 5-95 years) and studies included a mean of 64 cases (range 9-357). Nine of the 15 non-comparative studies were considered of high methodological quality, while all 3 comparative studies were considered high quality. Secondary rhinoplasties which did not describe a method to address warping showed increased rates of warping compared to counter balancing techniques, chimeric grafts, titanium microplating, Kirschner wire and suture usage, irradiation, and various carving techniques. Rates of warping remained low with no major complications with the use of a variety of approaches., Conclusions: ACCG warping during secondary rhinoplasty can be alleviated with a variety of techniques with no clear difference in outcomes between approaches. Plastic surgeons may consider adopting one of the various techniques described in order to reduce warping, maximize aesthetic outcomes and patient satisfaction.

Background: Repair of the septal perforation is a challenging procedure and there are many different surgical techniques. In this study, the authors present a novel method which the authors use costal cartilage and costal perichondrium sandwich graft as an interposition graft with bilateral opposing mucoperichondrial flaps., Patients and Methods: Fourteen patients (5 females, 9 males) underwent septal perforation repair. All surgeries were performed through an open approach septoplasty technique. The edges of the perforation were incised to excise the mucosa with a thickness of 2 mm. Bilateral mucoperichondrial flaps were raised. Then costal cartilage and costal perichondrium were harvested from the rib. The cartilage was divided into a smaller piece which is 2 mm thick and 1 cm wider than perforation size. The prepared cartilage was wrapped with perichondrium to obtain a sandwich graft. This sandwich graft was placed between the mucoperichondrial flaps, corresponding to the perforation., Results: After 9 months of follow-up, 11 (78%) of the 14 perforations were completely closed. Failure of the repair was observed in 3 patients; 2 of the perforations were medium size and one perforation was large size. No complications occurred., Conclusion: Using costal cartilage and costal perichondrium sandwich graft is a novel and useful technique especially in large septal perforations. Considering that septum surgery has an important role in the etiology of septum perforation, this method provides a good graft source for both perforation closure and simultaneous rhinoplasty surgery.

One of the most important components of an attractive nasal tip is the cephalocaudally conical form of the dome at the sagittal plane. With respect to this fact, the author tried to design a new forceps which holds the dome in a convex shape on a transverse plane and cephalocaudally conical in shape on the sagittal plane. Before grasping the dome in the desired position with Anais Cerci forceps, some degree of lateral steal is suggested and can be performed to increase the tip rotation and projection. With the help of its specific shape and template forming function, this novel instrument may also help to prevent the excess strain of transdomal suture which is crucially important to prevent the formation of pinching. This newly designed forceps can also help to provide the opportunity of the required acute angle between two domes. Slight oblique grasping of the dome reciprocally provides nice acute angle between 2 domes. Additionally, this forceps may also help to provide formation of symmetrically and reciprocally designed dome curvatures. In several secondary rhinoplasty cases with highly destroyed lower lateral cartilages, septal, auricular or costal cartilages are used for alar reconstruction. Mimicking the lower lateral cartilage anatomy from a straight cartilage graft piece is not an easy way of restoration. In such cases, Anais Cerci forceps may facilitate reshaping of the dome from an amorphous cartilage graft.

Although costal cartilage autograft has versatile usage, harvesting the graft is an invasive procedure with potential risks for complications. Therefore, it is important to make every effort to minimize these risks. Moreover, sculpting costal cartilage to the desired shape is challenging and time-consuming because of the natural rigidity. This study aimed to evaluate cases of costal cartilage harvest in terms of the most important donor site complications and to present a novel, practical and inexpensive technique to overcome the challenges in costal cartilage harvesting and contouring. A retrospective review of patient records was made of 103 patients who underwent costal cartilage harvest by the senior author. Costal cartilage harvest was applied using either the thermal chondroplasty technique or the conventional technique on patients undergoing revision rhinoplasty surgery. The number of complications and operation times were compared between the 2 techniques.A cohort of 47 patients (30 males, 17 females; mean age 34.5 years [range, 28-48 years]) underwent costal cartilage harvest using the thermal chondroplasty technique and a cohort of 56 patients (31 males, 25 females; mean age 36 years [range, 28-52 years]) underwent costal cartilage harvest with the conventional technique. The mean operation time for the costal cartilage harvest decreased by 7.5 minutes and the total operation time decreased by 17 minutes with the use of the thermal chondroplasty technique compared to the conventional technique (P < 0.05). Complications of 2 pneumothorax and 1 hematoma developed in the conventional technique group, and no complications were seen in the thermal chondroplasty group. The results of this study suggest that the thermal chondroplasty technique is safer and time-saving compared to the conventional technique.

The block of the lateral branches of the intercostal nerves in the middle axillary line (BRILMA) is an interfascial ultrasound-guided block for analgesia in thoracic wall and upper abdominal surgery, presenting as an adequate alternative to neuraxial techniques. We present the case of a 49-year-old female scheduled for idiopathic subglottic stenosis repair with a costal cartilage graft from the 10 th rib and tracheotomy. At the end of the surgery, unilateral ultrasound-guided BRILMA block with 20ml of ropivacaine 0.2% was performed at the level of the 6 th rib, uneventfully. Postoperatively, the patient referred a maximum level of pain of 3/10. There was no opioid consumption after the 2 nd postoperative day, although a subcostal incision may produce considerable pain. BRILMA is a superficial block, easily reproducible in most patients. It diminishes the number of punctures needed in the thoracic wall, as well as the risk for pneumothorax and local anesthetic toxicity., (Copyright © 2020 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Autologous costal cartilage graft is optimal for augmentation rhinoplasty but with complications including markedly visible graft margins and dorsal contour irregularities. Therefore, the authors introduced the diced costal cartilage graft to smoothen the margins of bilateral spreader graft for nasal dorsum augmentation. A total of 6 patients were recruited for this augmentation rhinoplasty. The pre- and postoperative photographs were taken for improvement evaluation. During a mean follow-up of 15 months, none of the patients developed major complications that may require removal or revision of the costal cartilage grafts. Five patients (80%) were very satisfied with the aesthetic outcome. This simple algorithm facilitates the substantial augmentation and removes the visibility of dorsal graft in the costal cartilage rhinoplasty for the East Asian population.

Autologous costal cartilage graft is an important material in orthopedic surgery. However, postoperative deformity of costal cartilage in donors is also a matter of concern. In our clinical experience, the preservation of the intercostal perichondrium, the replantation of part of the costal cartilage, and wearing an elastic chest strap for half a year are all ways to avoid thoracic deformity. Methods by which to avoid thoracic deformity is still the focus of our efforts.

Background: Slipping rib syndrome (SRS) is an often underdiagnosed cause of lower chest wall and abdominal pain. The diagnosis of SRS is established by physical examination with or without dynamic ultrasound. The pain can be debilitating and surgical excision of the nonattached, subluxing cartilages is curative for most patients, but frustratingly, up to a quarter of patients have transient or limited relief and require reoperation. Some of these patients were found to have subluxation of the remaining bony ribs, suggesting that excision of rib cartilage alone may not be curative in a subset of patients. Materials and Methods: A retrospective review was performed of 3 patients with recurrent slipping rib pain and hypermobile bony ribs on reoperation. In an effort to stabilize the hypermobile ribs, vertical bioabsorbable plating across their ribs was performed. The plates secure the ribs apart from each other, preventing the movement of ribs against each other and therefore the pain. Results: All patients tolerated the procedure well. Mean length of stay was 2.6 days. Mean follow-up is 7 months and all report significant improvement in pain. Conclusions: Rib plating allows stabilization of hypermobile ribs, while preserving the patient's anatomical rib cage, and is a safe treatment for recurrent pain after the initial procedure. This is a novel approach in patients with recurrent slipping rib symptoms.

Background: The full creation of an ear requires 2 reconstruction stages. In the second stage of reconstruction, the cartilaginous framework placed at first stage is separated from the head creating an auriculocephalic sulcus. Then a piece of rib cartilage is placed in the sulcus to maintain this separation and is covered with tissue that allows the integration of a full-thickness skin graft., Methods: A descriptive study based on the pre and postoperative medical records and photographic archives of patients diagnosed with microtia who underwent separation of the cartilaginous framework from February 2010 to July 2015 in the Plastic and Reconstructive Surgery Department at Hospital General Dr. Manuel Gea González., Results: Fifty-four patients met the selection criteria. The temporoparietal fascial flap was performed on 85% (n = 46), and 8 cases with random occipito-temporal fascial flap in association to a dermal regeneration template. The average time at the operating room was 177 minutes in patients with temporoparietal fascial flap versus 84.5 minutes in dermal regeneration template. The complication rate was 25.9% (n = 14), being similar rate with both techniques., Conclusions: Coverage with dermal regeneration template and random occipito-temporal fascia flap as an alternative use instead of temporoparietal fascial flaps, offers good postoperative results, lower operating times, and similar rate of complications, with the advantage of producing no visible scars and reserve the temporoparietal fascial flap for possible exposure of the cartilaginous framework.

At our department, the authors performed a periareolar mastopexy and harvested costal cartilage for use in a rhinoplasty through the same periareolar incision. This technique has several advantages compared to the traditional method, including less invasion, minimal chance of a hypertrophic scar and easier postoperative care. However, the location of the incision determines that the fifth costal cartilage is the lowest one accessible. Thus, calcification of the implant material poses a challenge to surgeons.In this case report, the authors present a 25-year-old female with a low-profile nose and mild breast ptosis who received a periareolar mastopexy and a dorsal and nasal tip augmentation simultaneously. The operation method, outcomes, advantages and potential risks are included.

Despite the improvement of primary repair of nasal deformities during the management of cleft lip in infancy, this does not exclude the need for revision rhinoplasty in adulthood for complete patients' rehabilitation. The purpose of this study was to evaluate the aesthetic outcome of secondary rhinoplasty using costal cartilage grafts in patients with unilateral cleft lip nasal deformity. Twenty patients who were operated at earlier ages for correction of cleft lip and had a residual unilateral cleft lip nasal deformity were included in this study. Costal cartilage rib grafts were harvested; carved and used for maxillary augmentation, columellar strut graft, and lateral crural strut graft. Five anthropometric measurements (nostril height, width and gap area, columellar axis deviation angle and nasal base inclination angle) were used for evaluation of aesthetic results. The ratio of nostril width, height and gap area between the cleft side and the non-cleft side showed significant improvement (P <0.05). The columellar axis deviation showed significant improvement towards the midline (P = 0.004), and the alar base inclination showed improvement towards the horizontal line (P = 0.0045). In conclusion, the aesthetic outcomes of secondary cleft lip rhinoplasty using the costal cartilage are satisfactory. The costal cartilage has the required strength, is easily carved and maintains shape for considerable time.

Total ear reconstruction for microtia is usually accomplished in 2 stages which is known as Nagata technique. After framework fabrication and implantation, the elevation procedure is required as a second step surgery. The authors are introducing a novel material for augmenting projection of rib cartilage framework in microtia treatment.

Objective: Thymectomy considered as a standard procedure in treatment of all the steps of myasthenia gravis. Video-assisted thoracoscopic surgery (VATS) thymectomy is one of the minimally invasive procedures that because of the short duration of hospitalization, less postoperative pain, and scar after surgery, nowadays it is replaced the traditional methods of surgery for patients with myasthenia gravis, but there are still differences and concerns. The aim of this study was to compare outcomes of two different techniques of surgery, VATS versus transsternal (TS) in the treatment of myasthenia gravis., Methods: In this pilot study, 42 patients with myasthenia gravis and without a thymus tumor were evaluated based on Myasthenia Gravis Foundation of America classification and drug consumption. Then, they randomly underwent two different techniques of surgery: VATS versus TS. Patients were evaluated based on preoperative and postoperative variables., Results: Duration of intensive care unit stay and hospitalization has been reduced in patients who underwent VATS thymectomy operation technique. In addition, duration of surgical procedure has been reduced significantly in these patients. These patients have less blood loss during surgery compared with TS group. The Myasthenia Gravis Foundation of America postoperative status in VATS thymectomy revealed that the number of patients with complete stable remission was higher and number of persons remained unchanged was lower in this group., Conclusions: VATS thymectomy is a safe and appropriate approach comparing with traditional methods such as TS thymectomy for patients with myasthenia gravis. This method has better results after surgery and can be used as a minimally invasive alternative method instead of TS thymectomy.

Purpose: Classical slipping rib syndrome (SRS) can be subclassified based on anatomical location. We describe our experience with three patients suffering from symptomatic sternocostal slipping rib syndrome (SCSRS), a much less common variant of SRS., Methods: This was a retrospective review of patients with SRS from 1988 to 2016. Described is our experience., Results: Of 44 patients identified with SRS, three patients underwent operations for SCSRS variant. All three had significant pain and point tenderness at the sternocostal junction, and all experienced a popping sensation localized to this area. The mean age at onset was 14.3 years and mean time to diagnosis was 1.3 years. All patients experienced total resolution of symptoms following localized excision of the offending cartilage., Conclusions: A high index of suspicion based on history and physical examination are key to the early diagnosis of SCSRS. Excision of the symptomatic cartilage is effective for treatment.