If rib cartilage warps, then how can it possible be used as spreader grafts?

Question

Please give specifics and not the standard line "in the hands an experienced surgeon"

Mark Baldwin, MBBS · Answer

In the hands of an experienced concreter*, LVL (Laminated Veneered Lumber) beams are used to support the formwork for suspended slabs because they can tolerate major deforming forces whilst remaining straight and true. Despite the fact they are made from crappy thin bits of timber which wouldn't stay straight in a mild breeze. Spreader grafts are just like that, except not quite as good. 
* Actually a formwork carpenter technically. Always make sure your concreter is board certified and can show you examples of their work!

Thomas J. Walker, MD, FACS · Answer

Simple answer: two curved pieces with the concave sides facing each other and sutured to each other leads to a straight piece. Warping declares rather quickly in the OR and with a surgeon who understands that principle and waits until the direction of warping declares itself there won't be any trouble. There are very few grafts in the nose that should be perfectly straight and flat. Best,Thomas Walker, MD, FACS

James Murphy, FRCS(Plast) · Answer

This is a highly technical question which, whilst it might be interesting to rhinoplasty surgeons, is of little value to prospective patients. Rib cartilage is a very useful material for major reconstructive work or if septal cartilage is not available. If you cut a strip of it lengthways, it does have a tendency to bend (try doing the same with a carrot and you'll see what I mean). You can get round this by using cartilage from the centre, rather than the edge but, failing that, you can use to slightly warped pieces and have them facing each other as spread grafts so that they cancel each other out. This is a useful trick but is by no means a guarantee that late warping will not occur. Unfortunately for you, the best piece of advice I can give is to find "an experienced surgeon" who knows how to handle the cartilage, cut it up judiciously and select the right pieces. I hope that gives you some insight

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question.  Spreader grafts can be a very useful maneuver in the right patient.  I prefer to use to septal cartilage for spreader grafts which does not warp.  If septal cartilage is not available in a patient who previously had septoplasty, then I prefer to use MTF irradiated cadaveric cartilage.  MTF cartilage can be cut in a manner to ensure it is straight.  Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and not just a computer animation system.  You should be able to view numerous pictures of actual patients with noses similar to yours performed by your surgeon.  If you cannot find enough real before and after pictures, then consider continuing your search for a surgeon. 
 
 Best wishes and good luck.

Richard G. Reish, M.D. FACS

Harvard-trained plastic surgeon

Robert S. Schmidt, MD · Answer

Thanks for your question. You're right. Rib cartilage can warp. However, there are studies that show that quite a lot of the warping happens in the first 20-30 minutes after harvest and carving. My standard way of handling the cartilage is to harvest it, carve the grafts, and then let the grafts soak in antibiotic solution for 20-30 minutes while I close the chest and readdress the nose. If warping has occurred, you can still use the warped grafts for spreader grafts. You take two warped pieces and put one on each side of the septum like parenthesis around an I (I). When you suture the warped pieces to the septum, their curvature cancels out. This is how to prevent your grafts causing warping of the septum.

Anthony Bared, MD, FACS · Answer

Rib cartilage is a very useful material for spreader grafts in patients who have had previous septoplasty or have little septal cartilage.  Septal cartilage is the ideal autologous graft material but rib cartilage is very useful when septal cartilage is not an option in certain cases.  Rib cartilage is placed in an opposing fashion and sutured against the septum to prevent warping.  Rib cartilage warping is more of a risk when used on bridge as an onlay graft or in the tip as a strut graft, but the risk of warping as a spreader graft is minimal.

Jeffrey T. Steitz, MD · Answer

Rib cartilage warps to varying degrees primarily based on calcification of the rib which increases as you get older.  In younger patients there are very few calcifications so the rib warps a lot.  In contrast, older patients have more calcifications so it warps much less.  Irradiated rib still has some warping tendencies as well but usually is pretty minimal.
Rib cartilage can very safely be used for spreader grafts, you just have to harvest the rib early, carve it into the appropriate size grafts and watch for warping tendencies.  The grafts can then either be splinted or placed so that the warping of each spreader graft is opposite and equal to the other side.
Septal cartilage is wonderful but in revision surgeries and patients with severe deformities, sometimes there isn't enough for all the grafting that is necessary.
Hopefully that answers your question, good luck!

Richard W. Fleming, MD (retired) · Answer

I'm not aware of any spreader graft warping. The two grafts are secured to the septum which makes movement an warping almost impossible.

If rib cartilage warps, then how can it possible be used as spreader grafts?

Answers (8)

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