The ''Eve'' procedure: The transfer of vascularized seventh rib, fascia, cartilage, and serratus muscle to reconstruct difficult defects

Very few microvascular units entertain the possibility of simultaneous vascularized transfer of bone, cartilage, muscle, and gliding fascia. In exceptionally complex conditions with loss of an essential joint, adjacent bone and functional muscle, reconstruction of all these structures at once may be necessary. At the same time, gliding tissue is often required to cover tendons. Reconstruction in one sitting prevents formation of dense scar tissue due to multiple interventions. Additionally, less bone resorption is seen if vascularized bone is used. Therefore, a more undisturbed tissue composition at the end is guaranteed. Moreover, rapid rehabilitation of moving function is possible with improvement in the final result. Finally, morbidity is lowered by using a single donor site, and costs are minimalized. We present four unique cases in which the seventh rib including the costochondral junction with overlying serratus muscle, branches of the thoracicus longus nerve, and adjacent fascia have been transferred as a microvascular unit to reconstruct two severely damaged hands and two other complex injuries. In analogy with the Bible story of the creation of ''the woman,'' it is called the ''Eve'' procedure. The vascularized rib was used to reconstruct a first and fourth metacarpal bone, the ascending ramus of the mandible, and the clavicle. The rib cartilage was sculptured in four cases to reconstruct an articular surface. The serratus muscle served as coverage and filling for lost tissues. It also was used as a soft bed for facial nerve repair. In two cases muscle reinnervation was performed. The fascia provided gliding tissue surrounding reconstructed tendons or articular surfaces. In all cases a high degree of function was obtained with a good cosmesis. Rehabilitation was uneventful, and no reinterventions have been necessary. Donor-site morbidity was low. Therefore, this flap proved to be successful in complex injuries where bone, cartilage, muscle, and gliding tissue were needed simultaneously. Dynamic reconstruction was attempted in two cases and was successful in one.