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. 

Rib cartilage can be an excellent source of cartilage for rhinoplasty grafting. Using rib cartilage successfully can be technique (surgeon) sensitive, though. There are several methods that can be used to prevent warping.

In my experience (and in various studies published in the facial plastic surgery literature) rib cartilage doesn't have clinically significant absorption issues.

That being said if the indentation that is being treated isn't very big you may be able to use ear or septum cartilage (if they is some still available). Your surgeon can discuss your options best since that's who has actually examined your nose.

      If you have ear cartilage available and you have a small defect, you can certainly consider grafting with the ear cartilage.  Find a plastic surgeon with ELITE credentials who performs hundreds of rhinoplasties and rhinoplasty revisions each year.  Then look at the plastic surgeon's website before and after photo galleries to get a sense of who can deliver the results.

Kenneth Hughes, MD Los Angeles, CA

You have valid concerns. I imagine several doctors have recommended rib graft. This is an option we consider only after we have exhausted septal and ear cartilage, or if the patient needs a lot of cartilage. Although I cannot comment on whether you need a rib graft without an exam, I can validate your concerns. Absorption and warping are possible, but not very like if the procedure is done by an experienced board certified surgeon. Make sure you get at least 2 opinions before you decide to have this done.

Rib graft can warp that is a known fact but it is good graft material.  Yes it can resorb a bit and can warp but it most cases it provides a long term satisfactory result.

 Rib grafting his only used when there are multiple grafts required  to be used in a revision rhinoplasty AND  there has been a cartilage depleted from the nose and  the ear.  A small cartilage graft  for a mid vault indentation can be harvested from the nose or ear  in most cases.

 I have performed Rhinoplasty and Revision Rhinoplasty for over 25 years and will not use rib cartilage in the nose as it does absorb unevenly over the years making the nose appear distorted.  You can do a medical literature search under "rib graft absorption in Rhinoplasty" as I'm certain that numerous papers have been written on the subject.  FYI, radiated cartilage seems to dissolve even quicker and to a greater extent.

Rib cartilage is an excellent choice for large bridge (dorsum) defects.  If your own rib is used, the resorption is usually small and warping is usually not seen.  I have not seen any infections in rib grafts.  That said, it sounds like your "dent" is small and it is very unlikely that rib would be needed.  Seek out an experienced board-certified Facial Plastic Surgeon.  Best wishes.