Rib graft concerns. What's the chance of trouble down the road?

Rib grafts vs. ear for revision is a frequent question. In 35 years of rhinoplasty I have never had to go to the rib which is painful and costly. Often there is enough cartilage in the septum and definitely in the ears. I do not. " use a cannon to kill a mosquito"!

 

Cartilage in rhinoplasty is used for support and structure to the nose. There is not a higher chance or ear cartilage infection vs rib cartilage.The three most commonly used donor areas in rhinoplasty areSeptal cartilage (often missing in revision rhinoplasty) and made of fibroelastic cartilageEar cartilage -softer cartilage and is elastic type of cartilage (hence softer and likely to bend)Rib or costal cartilage- firmer cartilage and similar in makeup as septal cartilageThe main risks of harvesting costal cartilage are as follows:Warping-This risk can be minimized with experience of carving rhinoplasty, patients with calcifications in the rib, and the location and type of graft placementScar- The scar size can be minimized based on the patient's body type (thinner patients can have a smaller scar) and surgeon's experience with more advanced surgeon's harvesting from 1-3 cm rib scarsPneumothorax- This is where a lung deflates since the surgeon is working around the rib site. This is rare but the surgeon must be able to handle this risk.Breast implant violation- Patients with breast implants may be at risk for a "popped" implant although this is unlikelyAlthough there are some risks with rib cartilage, the benefits can often outweigh the risks as it costal cartilage is strong and abundant in younger and middle aged patients. For revision rhinoplasty, patients should seek out surgeons with experience in using rib cartilage as results may be compromised without enough cartilage or the sole use of ear cartilage in certain circumstances.

Rib, either the patient's own or irradiated cadaver rib, can be excellent and sometimes the only option in revision rhinoplasty.  There is a chance of resorption, but this is no different than any other source of donor cartilage be it ear or nasal septum.  The main risk of rib, other than the harvesting risks, is warping.  With proper carving this risk can be minimized especially when used as a dorsal graft.  Having said that, I use rib, usually irradiated cadaver, when necessary, and only when necessary.  If I can get the job done with nasal septum or ear the that's the choice.  In many cases of revision rhinoplaty however, those sites are just not enough.  In those cases we don't hesitate to use rib.  It's not the tools in the chest that make a great craftman, it's how the craftsman uses the tools.