Advertisement

Rib Grafting In Rhinoplasty

  • Orhan Özturan
  • Berke Özücer
  • Wolfgang Gubish
Chapter

Abstract

Autologous costal cartilage grafting (ACCG) is the workhorse grafting material in rhinoplasty, especially in post-traumatic and cartilage-depleted revision cases. Although the donor- and recipent-site morbidities have been criticized extensively for many years, refined and improved surgical techniques, novel approaches, and updates in management lowered the complication rates. With careful preoperative planning and meticulous surgical techniques, ACCG will yield predictable and satisfying outcomes. ACCG is an outstanding grafting material for every rhinoplasty surgeon’s armamentarium. Its strength and abundance allows durable reconstruction of the nose with an appropriate structural support and versatility. Irradiated homologous costal cartilage (IHCC) graft also presents as a good alternative when donor-site morbidity has to be avoided. ACCG indications have a wide range: saddle nose deformity (SND) following trauma, revision, and ethnic (Asian) rhinoplasty cases; reconstructions following removal of neoplastic malignancies; and congenital deformities that require abundant augmentation and structural cartilage grafting. Alloplastic materials have been extensively studied in the literature, and ACCG is generally preferred over alloplastic materials mainly due to lower extrusion, displacement, and infection rates. Whenever this is the case––especially in secondary and tertiary cases––the costal cartilage offers ample material with strength that allows reconstruction with adequate structural support and versatility. Hence, the surgeons should have a low threshold for ACCG as the outstanding versatile grafting material of choice. This chapter summarizes all aspects of costal grafting from harvesting to associated possible complications and their management.

Keywords

Autologous costal cartilage grafting Rhinoplasty Trauma Revision Secondary Tertiary 

References

  1. 1.
    Defatta RJ, Williams EF. The decision process in choosing costal cartilage for use in revision rhinoplasty. Facial Plast Surg. 2008;24(3):365–71.  https://doi.org/10.1055/s-0028-1083090.CrossRefPubMedGoogle Scholar
  2. 2.
    Cakmak O, Ergin T. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch Facial Plast Surg. 2002;4(3):172–6. http://www.ncbi.nlm.nih.gov/pubmed/12167075. Accessed 18 Nov 18 2015.CrossRefGoogle Scholar
  3. 3.
    Bozzato A, Bumm K, Hertel V, Wurm J. Ultrasonographic evaluation of calcification patterns in costal cartilage: implications for rib graft harvesting. JAMA Facial Plast Surg. 2013;15(6):457–60.  https://doi.org/10.1001/jamafacial.2013.128.CrossRefPubMedGoogle Scholar
  4. 4.
    Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg. 2010;37(2):335–52.  https://doi.org/10.1016/j.cps.2009.12.008.CrossRefPubMedGoogle Scholar
  5. 5.
    Windfuhr JP, Chen Y-S, Güldner C, Neukirch D. Rib cartilage harvesting in rhinoplasty procedures based on CT radiological data. Acta Otolaryngol. 2011;131(1):67–71.  https://doi.org/10.3109/00016489.2010.502185.CrossRefPubMedGoogle Scholar
  6. 6.
    Jung D-H, Choi S-H, Moon H-J, Chung I-H, Im J-H, Lam SM. A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty. Plast Reconstr Surg. 2004;114(2):545–50. http://www.ncbi.nlm.nih.gov/pubmed/15277829. Accessed 8 Nov 2015CrossRefGoogle Scholar
  7. 7.
    Marin VP, Landecker A, Gunter JP. Harvesting rib cartilage grafts for secondary rhinoplasty. Plast Reconstr Surg. 2008;121(4):1442–8.  https://doi.org/10.1097/01.prs.0000302467.24489.42.CrossRefPubMedGoogle Scholar
  8. 8.
    Toriumi DM, Patel AB, DeRosa J. Correcting the short nose in revision rhinoplasty. Facial Plast Surg Clin North Am. 2006;14(4):343–55, vi.  https://doi.org/10.1016/j.fsc.2006.06.004.CrossRefPubMedGoogle Scholar
  9. 9.
    Fedok FG. Costal cartilage grafts in rhinoplasty. Clin Plast Surg. 2016;43(1):201–12.  https://doi.org/10.1016/j.cps.2015.08.002.CrossRefPubMedGoogle Scholar
  10. 10.
    Berke O, Paltura C, Dinc ME, et al. Comparison of postoperative donor-site pain following rib harvesting: muscle-sparing versus muscle-cutting technique. JAMA Facial Plast Surg. 2018;20(2):136–40.CrossRefGoogle Scholar
  11. 11.
    Lee LN, Boahene KD. A novel technique for sculpting costal cartilage in microtia repair and rhinoplasty. JAMA Facial Plast Surg. 2013;15(5):349–51.  https://doi.org/10.1001/jamafacial.2013.1307.CrossRefPubMedGoogle Scholar
  12. 12.
    Foulad A, Hamamoto A, Manuel C, Wong BJ. Precise and rapid costal cartilage graft sectioning using a novel device: clinical application. JAMA Facial Plast Surg. 2014;16(2):107–12.  https://doi.org/10.1001/jamafacial.2013.2040.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Taştan E, Yücel ÖT, Aydin E, Aydoğan F, Beriat K, Ulusoy MG. The oblique split method: a novel technique for carving costal cartilage grafts. JAMA Facial Plast Surg. 2013;15(3):198–203.  https://doi.org/10.1001/jamafacial.2013.671.CrossRefPubMedGoogle Scholar
  14. 14.
    Wilson GC, Dias L, Faris C. A comparison of costal cartilage warping using oblique split vs concentric carving methods. JAMA Facial Plast Surg. 2017;19(6):484–9.  https://doi.org/10.1001/jamafacial.2017.0163.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Apaydin F. The “Chef’s Knife” in oblique split technique for rhinoplasty. JAMA Facial Plast Surg. 2015;17(5):382–3.  https://doi.org/10.1001/jamafacial.2015.0332.CrossRefPubMedGoogle Scholar
  16. 16.
    Wee JH, Park M-H, Oh S, Jin H-R. Complications associated with autologous rib cartilage use in rhinoplasty: a meta-analysis. JAMA Facial Plast Surg. 2015;17(1):49–55.  https://doi.org/10.1001/jamafacial.2014.914.CrossRefPubMedGoogle Scholar
  17. 17.
    Varadharajan K, Sethukumar P, Anwar M, Patel K. Complications associated with the use of autologous costal cartilage in rhinoplasty: a systematic review. Aesthet Surg J. 2015;35(6):644–52.  https://doi.org/10.1093/asj/sju117.CrossRefPubMedGoogle Scholar
  18. 18.
    Boyaci Z, Çelik Ö, Ateşpare A, Koca Ö. Conservative costal cartilage harvest for revision septorhinoplasty. J Craniofac Surg. 2013;24(3):975–7.  https://doi.org/10.1097/SCS.0b013e318280254a.CrossRefPubMedGoogle Scholar
  19. 19.
    Ağaoğlu G, Erol OO. In situ split costal cartilage graft harvesting through a small incision using a gouge. Plast Reconstr Surg. 2000;106(4):932–5-7. http://www.ncbi.nlm.nih.gov/pubmed/11007411. Accessed 8 Nov 2015CrossRefGoogle Scholar
  20. 20.
    Lee M, Inman J, Ducic Y. Central segment harvest of costal cartilage in rhinoplasty. Laryngoscope. 2011;121(10):2155–8.  https://doi.org/10.1002/lary.22139.CrossRefPubMedGoogle Scholar
  21. 21.
    Kobayashi S, Yoza S, Takada H, Nagase T, Ohmori K. Endoscope-assisted rib cartilage harvesting. Ann Plast Surg. 1995;35(6):571–5. http://www.ncbi.nlm.nih.gov/pubmed/8748336. Accessed 18 Nov 2015CrossRefGoogle Scholar
  22. 22.
    Ching W-C, Hsiao Y-C. Transumbilical endoscopic costal cartilage harvesting: a new technique. Ann Plast Surg. 2014;72(4):423–7.  https://doi.org/10.1097/SAP.0b013e318264fcf1.CrossRefPubMedGoogle Scholar
  23. 23.
    Al-Qattan MM. Augmentation of the nasal dorsum with autogenous costal cartilage using the “edge-on” technique. Ann Plast Surg. 2007;59(6):642–4.  https://doi.org/10.1097/01.sap.0000258952.61173.12.CrossRefPubMedGoogle Scholar
  24. 24.
    Moon BJ, Lee HJ, Jang YJ. Outcomes following rhinoplasty using autologous costal cartilage. Arch Facial Plast Surg. 2012;14(3):175–80.  https://doi.org/10.1001/archfacial.2012.138.CrossRefPubMedGoogle Scholar
  25. 25.
    Park JH, Jin HR. Use of autologous costal cartilage in Asian rhinoplasty. Plast Reconstr Surg. 2012;130(6):1338–48.  https://doi.org/10.1097/PRS.0b013e31826d9f03.CrossRefPubMedGoogle Scholar
  26. 26.
    Ozturan O, Aksoy F, Veyseller B, Apuhan T, Yıldırım YS. Severe saddle nose: choices for augmentation and application of accordion technique against warping. Aesthet Plast Surg. 2013;37(1):106–16.  https://doi.org/10.1007/s00266-012-0038-4.CrossRefGoogle Scholar
  27. 27.
    Miranda N, Larocca CG, Aponte C. Rhinoplasty using autologous costal cartilage. Facial Plast Surg. 2013;29(3):184–92.  https://doi.org/10.1055/s-0033-1346999.CrossRefPubMedGoogle Scholar
  28. 28.
    Nelson M, Gaball C. Technique to reduce time, pain, and risk in costal cartilage harvest. JAMA Facial Plast Surg. March 2017;19(4):333–4.  https://doi.org/10.1001/jamafacial.2016.2144.CrossRefPubMedGoogle Scholar
  29. 29.
    Fedok FG. Costal cartilage grafts in rhinoplasty. Clin Plast Surg. 2016;43(1):201–12.  https://doi.org/10.1016/j.cps.2015.08.002.CrossRefPubMedGoogle Scholar
  30. 30.
    Gibson T, Davis WB. The distortion of autogenous cartilage grafts: its cause and prevention. Br J Plast Surg. 1957;10:257–74.  https://doi.org/10.1016/S0007-1226(57)80042-3.CrossRefGoogle Scholar
  31. 31.
    Balaji SM. Costal cartilage nasal augmentation rhinoplasty: study on warping. Ann Maxillofac Surg. 2013;3(1):20–4.  https://doi.org/10.4103/2231-0746.110070.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Harris S, Pan Y, Peterson R, Stal S, Spira M. Cartilage warping: an experimental model. Plast Reconstr Surg. 1993;92(5):912–5. http://www.ncbi.nlm.nih.gov/pubmed/8415973. Accessed 18 Nov 2015CrossRefGoogle Scholar
  33. 33.
    Kim DW, Shah AR, Toriumi DM. Concentric and eccentric carved costal cartilage: a comparison of warping. Arch Facial Plast Surg. 2006;8(1):42–6.  https://doi.org/10.1001/archfaci.8.1.42.CrossRefPubMedGoogle Scholar
  34. 34.
    Farkas JP, Lee MR, Lakianhi C, Rohrich RJ. Effects of carving plane, level of harvest, and oppositional suturing techniques on costal cartilage warping. Plast Reconstr Surg. 2013;132(2):319–25.  https://doi.org/10.1097/PRS.0b013e3182958aef.CrossRefPubMedGoogle Scholar
  35. 35.
    Lopez MA, Shah AR, Westine JG, O’Grady K, Toriumi DM. Analysis of the physical properties of costal cartilage in a porcine model. Arch Facial Plast Surg. 2007;9(1):35–9.  https://doi.org/10.1001/archfaci.9.1.35.CrossRefPubMedGoogle Scholar
  36. 36.
    Swanepoel PF, Fysh R. Laminated dorsal beam graft to eliminate postoperative twisting complications. Arch Facial Plast Surg. 2007;9(4):285–9.  https://doi.org/10.1001/archfaci.9.4.285.CrossRefPubMedGoogle Scholar
  37. 37.
    Hoehne J, Gubisch W, Kreutzer C, Haack S. Refining the nasal dorsum with free diced cartilage. Facial Plast Surg. 2016;32(4):345–50.  https://doi.org/10.1055/s-0036-1585572.CrossRefPubMedGoogle Scholar
  38. 38.
    Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137(1):43–51.  https://doi.org/10.1097/PRS.0000000000001876.CrossRefPubMedGoogle Scholar
  39. 39.
    Calvert J, Kwon E. Techniques for diced cartilage with deep temporalis fascia graft. Facial Plast Surg Clin North Am. 2015;23(1):73–80.  https://doi.org/10.1016/j.fsc.2014.09.005.CrossRefPubMedGoogle Scholar
  40. 40.
    As K, Salehi SH. Rib diced cartilage – fascia grafting in dorsal nasal reconstruction: a randomized clinical trial of wrapping with rectus muscle fascia vs deep temporal fascia. Aesthet Surg J. 2014;34(6):NP21–31.  https://doi.org/10.1177/1090820X14535078.CrossRefGoogle Scholar
  41. 41.
    Kemaloğlu CA, Tekin Y. A comparison of diced cartilage grafts wrapped in perichondrium versus fascia. Aesthet Plast Surg. 2014;38(6):1164–8.  https://doi.org/10.1007/s00266-014-0403-6.CrossRefGoogle Scholar
  42. 42.
    Gunter JP, Cochran CS, Marin VP. Dorsal augmentation with autogenous rib cartilage. Semin Plast Surg. 2008;22(2):74–89.  https://doi.org/10.1055/s-2008-1063567.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Gunter JP, Clark CP, Friedman RM. Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping. Plast Reconstr Surg. 1997;100(1):161–9. http://www.ncbi.nlm.nih.gov/pubmed/9207674. Accessed 30 Nov 2015CrossRefGoogle Scholar
  44. 44.
    Daniel RK. Rhinoplasty and rib grafts: evolving a flexible operative technique. Plast Reconstr Surg. 1994;94(5):597–609-1. http://www.ncbi.nlm.nih.gov/pubmed/7938282. Accessed 30 Nov 2015CrossRefGoogle Scholar
  45. 45.
    Sheen JH, Sheen AP. Aesthetic rhinoplasty. 2nd ed. St. Louis, MO: Mosby; 1987.Google Scholar
  46. 46.
    Gunter JP. Secondary rhinoplasty: the open approach. In: Daniel RK, editor. Aesthetic plastic surgery: rhinoplasty. Boston, MA: Little, Brown; 1993. p. 833–47.Google Scholar
  47. 47.
    Toriumi D. Dorsal augmentation using autologous costal cartilage or microfat-infused soft tissue augmentation. Facial Plast Surg. 2017;33(2):162–78.  https://doi.org/10.1055/s-0037-159914.CrossRefPubMedGoogle Scholar
  48. 48.
    Moon DJ, Hunt J, Gianoutsos MP. The rib graft rhinoplasty: anchoring the extended columellar strut. Plast Reconstr Surg. 2015;135(6):1072e–3e.  https://doi.org/10.1097/PRS.0000000000001231.CrossRefPubMedGoogle Scholar
  49. 49.
    Kridel RWH, Ashoori F, Liu ES, Hart CG. Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose. Arch Facial Plast Surg. 2009;11(6):378–94.  https://doi.org/10.1001/archfacial.2009.91.CrossRefPubMedGoogle Scholar
  50. 50.
    Demirkan F, Arslan E, Unal S, Aksoy A. Irradiated homologous costal cartilage: versatile grafting material for rhinoplasty. Aesthet Plast Surg. 2003;27(3):213–20.  https://doi.org/10.1007/s00266-003-0118-6.CrossRefGoogle Scholar
  51. 51.
    Tosun Z, Karabekmez FE, Keskin M, Duymaz A, Savaci N. Allogenous cartilage graft versus autogenous cartilage graft in augmentation rhinoplasty: a decade of clinical experience. Aesthet Plast Surg. 2008;32(2):252–60.; discussion 261.  https://doi.org/10.1007/s00266-007-9044-3.CrossRefGoogle Scholar
  52. 52.
    Song HM, Lee B-J, Jang YJ. Processed costal cartilage homograft in rhinoplasty: the Asan Medical Center experience. Arch Otolaryngol Head Neck Surg. 2008;134(5):485–9.  https://doi.org/10.1001/archotol.134.5.485.CrossRefPubMedGoogle Scholar
  53. 53.
    Wee JH, Mun SJ, Na WS, et al. Autologous vs irradiated homologous costal cartilage as graft material in rhinoplasty. JAMA Facial Plast Surg. 2017;19(3):183.  https://doi.org/10.1001/jamafacial.2016.1776.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Humphrey CD, Arkins JP, Dayan SH. Soft tissue fillers in the nose. Aesthetic Surg J. 2009;29(6):477–84.  https://doi.org/10.1016/j.asj.2009.09.002.CrossRefGoogle Scholar
  55. 55.
    Adams WP, Rohrich RJ, Gunter JP, Clark CP, Robinson JB. The rate of warping in irradiated and nonirradiated homograft rib cartilage: a controlled comparison and clinical implications. Plast Reconstr Surg. 1999;103(1):265–70. http://www.ncbi.nlm.nih.gov/pubmed/9915191. Accessed 8 Nov 2015CrossRefGoogle Scholar
  56. 56.
    Cochran CS. Harvesting rib cartilage in primary and secondary rhinoplasty. Clin Plast Surg. 2016;43(1):195–200.  https://doi.org/10.1016/j.cps.2015.09.018.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Orhan Özturan
    • 1
  • Berke Özücer
    • 2
  • Wolfgang Gubish
    • 3
  1. 1.Department of OtorhinolaryngologyBezmiâlem Vakif UniversityIstanbulTurkey
  2. 2.ENT DepartmentIstanbul Hospital, Başkent UniversityIstanbulTurkey
  3. 3.Facial Plastic Surgery DepartmentMarien HospitalStutgartGermany

Personalised recommendations