Use of rib cartilage in revision rhinoplasty
There are three types of cartilage used in revision rhinoplasty. The first choice is always cartilage from the septum, as it is straight, firm cartilage which does not require harvesting from outside of the nose. In cases where septal cartilage has already been used during previous surgery, the next choices are ear and rib.
Ear cartilage can be excellent for certain smaller grafts but tends to be weaker than septal cartilage and may not be strong enough for reconstructing noses which require major support.
Rib cartilage can also safely and effectively be used in revision rhinoplasty. The cartilage can be autologous, which means that it comes from the patient, or irradiated, which is donated by an individual who is deceased. The harvest of rib cartilage is done through an inconspicuous 2-3 cm incision, which can be tucked under the right breast in women. The first risk related to harvesting this cartilage is injury to the underlying lung or tissue layer around the lung, called the pleura. This can result in air being introduced around the lung, what is known as a pneumothorax. This extremely uncommon complication can be managed by temporary placement of a chest tube for a few days following the procedure. Other risks related to rib cartilage include the grafts becoming visible under the skin, shifting of the grafts, and resorption, or dissolving of the grafts. This risk of resorption is thought to be greater when the cartilage is irradiated (cadaveric cartilage). In general, use of rib cartilage is extremely safe and for surgeons who specialize in revision rhinoplasty, the benefits of utilizing rib cartilage greatly outweigh these risks.
Rib Cartilage Grafting for Revision Rhinoplasty
In revision rhinoplasty, it is usually necessary to reconstruct and reshape the nasal framework using cartilage grafts. Because available septal cartilage has usually been removed during the first surgery, grafts must obtained from either another site - the ear or the rib.
Rib cartilage has many uses and advantages in revision rhinoplasty. It can be carved or shaped to the desired configuration. Its rigidity can provide support to a weakend nasal framewoek.
Drawbacks of Rib Cartilage Include:
- Rendency to warp (curve). This can make the result unpredictable.
- Nose may feel firm or inflexible.
Potential Risks of Rib Cartilage Harvest:
- Collapsed lung (pneumothorax)
- Chest wall deformity
However, in experienced hands, rib cartilage allows successful results in revision rhinoplasty.
Risks of revision rhinoplasty using rib (costal) cartilage
The risks are generally low when performed by an experienced surgeon but they can include (and are not limited to):
infection, bleeding, hematoma, wound breakdown, hyperftrophic or keloid scar formation, contour irregularity, hemo/pneumothorax, graft resorption or warping, overcorrection, undercorrection, graft rotation/extrusion/exposure, inability to acheive a specific funtional and/or cosmetic result.
A variety of choices are available when cartilage grafts are required.
Your question is stated without specifying the problem, or the region of the nose that a graft is being considered.
With that, a variety of choices exist as donor sites, Septal Cartilage, Conchal (Ear) Cartilage, and Rib Cartilage. Depending on the specifics of the need and history of prior procedure(s) I may choose any one of these. From experience of having used all of these choices in rhinoplasty procedures, each donor site has its own set of considerations, and benefits.
Sergio P. Maggi, MD, FACS
Austin Plastic Surgery Center
Risks of Rib Cartilage- Costal cartilage
Cartilage in rhinoplasty is used for support and structure to the nose. The three most commonly used donor areas in rhinoplasty are
- Septal cartilage (often missing in revision rhinoplasty) and made of fibroelastic cartilage
- Ear 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 cartilage
The 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 placement
- Scar- 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 scars
- Pneumothorax- 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 unlikely
Although 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 cartilage for rhinoplasty
Rib cartilage is a great option for revision rhinoplasties but for primary, or first time, rhinoplasties septal cartilage or ear cartilage are preferred. There are 2 ways to obtain rib cartilage:
1. Rib can be harvested from your own rib cage. This is your own tissue but there are several downsides which include a scar, the risk of lung injury, and pain that may require a prolonged hospital stay.
2. Irradiated rib can be obtained from a cartilage bank. There are about a half dozen in the US and the cost depends on the supply. These ribs are radiated so the chance of a contagious infection is almost non-existent. This avoids the scar, the risk of lung injury, but most importantly, the pain and hospital stay.
Rib cartilage, much like septal or ear cartilage, used to add height to the nose have similar side effects. The main one is migration of the cartilage even if stitched in place. If that happens, the surgeon may have to revisit the nose and reposition the graft.
Major Risks of Revision Rhinoplasty Using Rib Cartilage?
Rib cartilage is often the last resort for most of us. The cartilage harvested from the septum is the best graft for most indications. A rib graft is often used when there is need for support rather than volume, in the absence septum graft. Rib cartilage is not an ideal choice as the tip graft unless 1) the surface portion of the graft is used which softer, 2) the graft is made really thin or 3) it is used on patients with very thick skin since it has had tendency to thin the skin, which is the first hazard of the rib graft. Additionally, the rib cartage has a tendency to warp. We have developed many techniques to minimize the chance for warping. In some sites. like the tip the rib cartilage can be too stiff. For that reason my choice of tip graft is the ear cartilage or slightly softened septum cartilage.
Rib graft for rhinoplasty
Using the rib as a source of cartilage for rhinoplasty is a great option. It offers a large amount of cartilage that can be used to reconstruct the nose. The main risk if the risk of collapsed lung, which is a serious risk that may require a chest tube. However, the risk is very low (I have never see it happen in my practice and not even in my training during residency or fellowship). The other risk that sometimes worries people is pain. Rib grafting used to be associated with significant pain, but with some simple changes in technique, the pain can be quite minimal. Most patients tell us that the pain is not an issue at all.
major risks of rhinoplasty using rib cartilage
It is important to use patient's own nasal cartilage first for grafting purposes. If the nose has been depleted of cartilage, consideration for ear cartilage as the next best source. If the ears have been depleted or are not adequate, then consideration for using rib cartilage can be entertained. Rib cartilage can tend to warp years after it has been placed in the nose, the donor site usually can be quite tender for several months afterwards and patient's have a very small risk of pneumothorax during the procedure.
Revisions Rhinoplasty with Rib cartilage
Revision rhinoplasty presents many challenges, including where to find cartilage to rebuild important structures. Most surgeons use septal cartilage as a primary material. If not available ear cartilage is the next choice.
When a large amount of cartilage is needed, and the septum and/or ear are not sufficient, rib is the next logical material. Even then we have the choice of using a patients own rib, or obtaining cadaver rib instead. Both can be effective. Great care must be taken to carve the rib grafts, and to minimize the warping which can occur. When needed, this can be an excellent material.