Seeking more information on "Counterbalancing" rib graft technique for significantly building up the nasal dorsum.

I consulted with a surgeon who mentioned he uses a counterbalancing rib graft technique, where a single piece of rib cartilage is split into two pieces which deform in opposite directions, and are sutured together using permanent stitches. The theory is that the two opposing forces of deformation balance each other out. I have not been able to find any information on this technique except for one Indian study, so I was wondering if there was more information on this technique and its efficacy.

Doctor Answers 6

Rib graft rhinoplasty

Warping can occur with rib cartilage grafts even when the outmost care is taken to avoid it. In reality this is not as common as it once was when the cartilage is properly prepared. When the "inside section" of the cartilage is used there tends to be less chance of warping. Techniques such as the "oblique cut" are popular and have advantages and are popular these days. I tend to carve out single pieces from the graft for dorsal augmentation and have done hundreds of these with excellent long term results. You have to see the results that your surgeon obtains and feel comfortable with what he'she is offering.


Toronto Facial Plastic Surgeon
4.8 out of 5 stars 19 reviews

May work

There are many ways to do such surgeries and you should not get involved in how the surgery is done, but rather make sure to review the before/after photos of the surgeon you are choosing and see if you like their results.  See if there are photos that look similar to your nose.  Make sure they show you at least three views from each patient - front, quarter turn and profile.  Also, ask to see if you may speak to a patient or two who have had surgery recently with the doctor.

Andre Aboolian, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 56 reviews

Rib Cartilage Graft

Dear HH49,

If you were to search for a baker to make a "delicious" birthday cake, you would find many different types of cakes and many different techniques.  The important thing is for the baker to understand what "delicious" is to you.  Likewise, there are many techniques in grafting and many different types of grafts a surgeon can use.  I suggest that you get another opinion in order to find the surgeon who explains her plan and technique in a way that is easy-to-understand and that meets your aesthetic goals. 

On a separate and more literal note, if you search GoogleScholar, you can see if there are any published articles on this technique that your doctor proposes.

All the best,

Dr. Michelle Yagoda

Michelle R. Yagoda, MD
New York Facial Plastic Surgeon
5.0 out of 5 stars 5 reviews

Rib cartilage

There are many ways to skin a cat.  That is one way, and there are many other ways including shaving the graft, stitching it, some put a k-wire down it, etc..

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Nasal dorsum

Hello and thank you for your question. There are many techniques for dorsal augmentation, including rib grafting and cartilage grafting.  The best advice you can receive is from an in-person consultation.  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. The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation with a qualified board-certified plastic surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Richard G. Reish, MD
New York Plastic Surgeon
5.0 out of 5 stars 79 reviews

Rib grafts

I can understand what your surgeon is describing though I do not have any experience with that specific technique (though I have used rib grafts many times). Today, my preferred technique for dorsal augmentation is to use diced cartilage wrapped in fascia. The cartilage can be obtained from septum, ear or rib, all of which have been shown to work extremely well when diced and wrapped. The benefit is that warping, especially of rib, is less of a concern. You could certainly discuss this with your surgeon and get his/her opinion. Good luck.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.