Risks of Using Rib Cartilage for Revision Rhinoplasty?

I prefer to use septal or ear cartilage for nasal grafting when possible. Rib cartilage is primarily used when larger quantities of material are needed. There are additional possible complications using the ribs, but if necessary, it is a good choice. Discuss the procedure with your surgeon. Your goal should be the best possible result, understanding all advantages and disadvantages of each procedure.

Optimally, one of the most important aspects in rhinoplasty, both primary and secondary, is to use autologous tissue if needed. These are the most challenging operative procedures that we do in aesthetic plastic surgery, therefore, it’s very important to choose an experienced rhinoplasty surgeon. Find someone that has significant expertise in secondary rhinoplasty surgery as this is a very challenging and difficult operative procedure. One can never totally restore one to a normal nose especially if you’ve had multiple operative procedures. The use of rib grafts are used if there is loss or collapse of the nose and/or tip. However, it is not without its problems including potential temporary chest wall pain and warping of the cartilage itself short or long term. I will use it in those patients where I can not use any other autologous material like septum or the ear and certainly in the dorsum if I need to augment it more than 4-6mm, I will definitely use rib.

In general the risks of rib cartilage grafting include:

• Graft asymmetry or warping. With an experienced surgeon this risk is lessened significantly.
• Injury to the underlying lung during graft harvest (also rare with an experienced surgeon)
• stiffer nose after surgery
• Poor healing of the chest incision. Ask your surgeon what length incision they use (this varies among surgeons). The chest incision typically heals very well.
• risks of surgery in general such as bleeding, infection, anesthesia, etc.

Depending on your anatomy, septal cartilage and/or ear cartilage may be used. Needing a large volume of cartilage for reconstructing your bridge is often best done with rib, though.

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 another site - either 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 framework.

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:

* Bleeding
* Prominent scar
* Pain
* Infection
* Collapsed lung (pneumothorax)
* Chest wall deformity

However, in experienced hands, rib cartilage allows successful results in revision rhinoplasty.

 Before attempting to use any rib cartilage, it's important to know whether or not there is any  Nasal/septal cartilage left in the nose. Nasal cartilage is always the best choice for reconstruction.  If you have a cartilage depleted nose, then ear cartilage could be considered. Rib cartilage is an alternative, but once the other 2 Options have been used. Rib cartilage when placed in the nose ,tends to ossify, warp, and the makes nose very hard.

Thank you for the great question. Using autologous (from you) rib in rhinoplasty is generally safe.  The long-term complication that is most feared with costal cartilage grafts is warping -- or shape change/curvature of the graft material over time. Certain techniques are used in surgery to limit this, but it is unfortunately not completely predictable. The other possibility is graft resorption (the grafts don't survive and the nose loses volume again).The alternatives in cases where a significant amount of grafts are needed are less appealing. With implants in the nose, there is a risk of infection and extrusion over time, in addition to the risks of settling or shifting. This is not an easy decision, but, in my opinion, using your own tissue is always better.
 

Rib cartilage's main advantage is its plentiful supply.  The main risks of rib cartilage are:

Risk of pneumothorax-  Pneumothorax is a "popped lung".  This can occur when harvesting rib from the chest area.  This is not common with an experienced rib revision surgery.

Risk of warping-  Warping can occur with rib cartilage.  Decreasing the incidence of warping significantly by experience in carving costal cartilage.  There are several techniques for doing this.

Scarring-  Rib rhinoplasty requires a scar on the chest.  Most patients can have a limited incision scar which can limit postoperative visbility of the area.

Overly stiff nose-  Rib cartilage is a stiffer material and can make the nose a stiffer feeling 

Overly wide nose- Rib cartilage can make the nose wider.  Ideally, it is carved into narrower portions to limit issues with width post procedure

Infection- Any graft has the risk of infection

Postoperative pain-  Rarely patients can experience pain in area where rib was harvested

When large quantities of cartilage are needed in revision rhinoplasty, rib cartilage can be the best solution. But, to avoid the scarring, pain, and possible lung puncture of harvesting your own cartilage, rib cartilage can be obtained from a tissue bank safely with no higher a complication rate than using your own cartilage and with the advantage of decreasing your operative and anesthesia time. Please look up this paper to see our experience with over 1000 such grafts with long term follow-up: Kridel RWH et al.: Long-term Use and Follow-up of Irradiated Homologous Costal Cartilage Grafts in the Nose in Arch Facial Plast Surg. 2009;11(6):378-394.

One of the most challenging aspects of revision Rhinoplasty is choosing material that will age in a predictable manner with the patient.  Tissue that warps, partially dissolves or in some other manner causes nasal irregularities should be avoided.  After more than 20 years using various materials for Rhinoplasty and Revision Rhinoplasty these are the ones I use.

1. For the nasal tip, ear conchal cartilage is the best.
2. For the nasal bridge, which is your particular case, I only use silastic dorsal implants.  Bone, rib cartilage, banked cartilage all have a tendency to partially dissolve over time creating nasal deformities.  Septal cartilage would work for a short dorsal indentation but rarely is long enough for a complete dorsal reconstruction...as is your case.  For these reasons, the silastic dorsal implant, IMHO, is vastly superior.  I have used it many times with very good results.

You have several good answers but you may consider use of bone from scalp which in my experience is less painful and with well hidden scar with no warpping and good long term survival. But, must be done by an experienced rhinoplastic surgeon. Other sources are cadaver cartialges as well as silicone implants that work well.