PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 30 no. 1 January – June 2015
ORIGINAL ARTICLES
PhiliPPine Journal of otolaryngology-head and neck Surgery 29
ABSTRACT
Objective: To investigate the outcome and complications of augmentation rhinoplasty with rib
cartilage grafts.
Methods:
Design: Retrospective study
Setting: Tertiary Government Hospital
Subjects: Patients who underwent dorsal nasal augmentation with autologous rib
cartilage grafts between June 2008 and October 2012.
Results: A total of 12 patients (3 male, 9 female) were included in the study. Mean age was 29
years. Seven were cases of primary simple rhinoplasty with four cases of revision (previously using
alloplastic materials) and one case of trauma. Indications for the procedure were all cosmetic.
There was no incidence of infection, both in the donor and recipient sites, warping of the graft,
graft extrusion, resorption, pneumothorax, chest wall deformity or prolonged edema. Post-
operative pain in the donor site was relieved by oral pain medications. No revision surgery was
required.
Conclusion: Costal cartilage is a good option for structural support of the nose. In our experience
patients have become wary of the complication of allografts and have opted to use autografts.
The surgeon’s knowledge of the nasal anatomy as well as his or her experience with autologous
grafts plays a major role in avoiding post-operative morbidity.
Keywords: Rhinoplasty, rib graft, costal cartilage graft, Southeast Asian nose
The nose occupies a central position in the face. Any deformity of the nose can lead to
functional and psychological disability.1 Rhinoplasty aims to achieve nasal balance and establish
harmony with the face while preserving a functional nasal airway. Graft and implant materials
are used primarily to maintain or strengthen the structural framework to provide contour or
camouflage defects and to restore the nose to an aesthetic ideal.2
There are three broad categories of graft and implant materials currently available for
rhinoplasty: autografts from the patient’s own tissues; homografts from tissues obtained from
a different donor of the same species; and alloplasts.2 Autogenous cartilage has generally been
Augmentation Rhinoplasty with Rib
Cartilage Graft
Elaine Marie A. Lagura, MD
Eduardo C. Yap, MD
Anna Victoria G. Garcia, MD
Department of Otolaryngology Head and Neck Surgery
Ospital ng Makati
Correspondence: Dr. Eduardo C. Yap
Department of Otolaryngology Head and Neck Surgery
5th Floor, Ospital ng Makati
Sampaguita Street, Brgy. Pembo, Makati City 1208
Philippines
Phone: (632) 882 6316 local 309
Email: osmakenthns@yahoo.com
Reprints will not be available from the authors.
The authors declared that this represents original material
that is not being considered for publication or has not been
published or accepted for publication elsewhere, in full or in
part, in print or electronic media; that the manuscript has been
read and approved by all the authors, that the requirements
for authorship have been met by each author, and that each
author believes that the manuscript represents honest work.
Disclosures: The authors signed disclosures that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional affiliations
that might lead to a conflict of interest. Philipp J Otolaryngol Head Neck Surg 2015; 30 (1): 29-33 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 30 no. 1 January – June 2015
30 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
considered the gold standard grafting material in reconstructive
septorhinoplasty for volume filling and structural support. It can
be harvested from the nasal septum, the auricle or the rib but costal
cartilage is considered the best graft material in patients requiring
major reconstruction.3 Costal cartilage provides the advantages of a
large volume of graft material with excellent structural support and
low rate of complications such as resorption, infection and extrusion
compared to homografts and alloplastic implants. The disadvantages
observed include warping and potential donor site morbidities
including pneumothorax, scar visibility and chest wall deformity.2-3
METHODS
A retrospective analysis was done on patients who underwent
augmentation rhinoplasty with rib cartilage graft in a tertiary
government hospital from June 2008 to October 2012. The patients
were admitted with detailed history, clinical examination, routine
investigations and special investigations including photography.
Consent was obtained from each patient for surgical demonstration as
well as the possible public viewing of videos and pictures taken during
the procedure. (Appendix A) Additional consent was obtained for the
publication of pictures for this study.
All procedures were carried out under general anesthesia and were
covered by prophylactic intravenous antibiotics. The open rhinoplasty
was performed by the same senior surgeon on all patients.
Rib cartilage harvest
In male patients, the incision was made over the seventh costal
cartilage and in women under the breast crease to hide the scar.
Although either side may be utilized, all of our patients had their grafts
harvested from the right side. After the skin incision, the overlying
muscles were spread and retracted until the underlying costal cartilage
Figure 1. Harvest of 7th intercostal rib
Figure 2. Harvested 7thintercostals rib, with black arrow, part used for dorsal graft, white arrow used
for other enhancement grafts.
Figure 3. Shaping of the dorsal graft
Figure 4. Exposure using open technique
Figure 5. positioning of rib graft
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 30 no. 1 January – June 2015
ORIGINAL ARTICLES
PhiliPPine Journal of otolaryngology-head and neck Surgery 31
Figure 7. Pre-operative and 6 months post operative picture. Photos printed in full with permission.
Figure 6. Immediate pre operative and post operative
was exposed. The perichondrium was cut and subperichondrial
dissection was done using a periosteal elevator. The cartilaginous
rib was separated from its medial attachment near the sternum and
laterally from the bony rib. A partial-thickness incision was made
perpendicular to the long axis of the rib. The cartilaginous incision
was then completed with the sharp end of a Freer elevator. (Figure 1)
Once the cartilage segment was released both medially and laterally,
the graft was easily removed from the wound and placed in sterile
saline with gentamicin until the surgeon was ready for shaping. Water
leak test was performed to make sure there was no tear in the pleura.
The longer end of the cartilage was used for dorsal augmentation
while the shorter segment could be utilized for support or contour
grafts. (Figure 2) In shaping of the dorsal graft, cross-hatching of the
cartilage was done to prevent warping. (Figure 3)
Rhinoplasty
An open approach was utilized. (Figure 4) The columellar flap was
freed with scissors dissecting up to expose the dome of the lower
lateral cartilage. Soft tissue dissection was continued in the superficial
muscular aponeurotic system plane and in the subperiostal plane over
the bony vault for adequate access to the nasal dorsum. (Figure 5)
Septoplasty was done in cases where there was septal deviation leaving
a 10 mm L-strut. The shorter limb of the harvested costal cartilage was
fashioned into 2 mm sheets for use as septal extension graft, spreader
graft and tip grafts. Depending on the vector of the new tip, the septal
extension graft was sutured to the caudal end of the septum using
PDS 5-0. The lower lateral cartilage was fixed to the caudal end of the
septal extension graft. Further enhancement of the tip was done using
various tip grafts e.g. Shield and onlay graft. (Figure 6) Alar lift procedure
via sail excision and alar base plasty were done when needed.
All of the patients were discharged one day post operatively with
continuation of antibiotics for one week and adequate analgesics.
Follow-up was done 5-7 days post operatively for the removal of splint
and sutures, then again at one month, 3 months, six months, 12 months
and yearly thereafter with photo documentation. (Figures 7, 8)
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 30 no. 1 January – June 2015
32 PhiliPPine Journal of otolaryngology-head and neck Surgery
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RESULTS
A total of 12 patients (3 male and 9 female) were included in the
study. Age ranged from 23 to 54 years old with a mean age of 29 years.
There were four cases of revision rhinoplasty previously using alloplastic
materials and one case of trauma. The rest of the cases were primary
simple rhinoplasty. Indications for the procedure were all cosmetic.
There was no incidence of infection, both in the donor and recipient
sites, warping of the graft, graft extrusion, resorption, pneumothorax,
chest wall deformity or prolonged edema. Patients complained of
minimal post-operative pain in the donor site relieved by oral pain
medication. Patients usually noted the pain to be maximal at 3 to 5 days
and tolerable at 7 to 10 days. No revision surgery was required.
DISCUSSION
The goal of septorhinoplasty is reconstruction of the nasal skeleton
to provide adequate structural support allowing optimum functioning
of the nasal airway while achieving an aesthetically pleasing result
with the rest of the face. To obtain aesthetically pleasing results, ensure
patient satisfaction and minimize complications, the rhinoplasty
surgeon must possess a thorough knowledge of nasal anatomy and
ideal facial aesthetic proportions. The surgeon must be familiar with
all types of graft material and the current methods to correct nasal
deformities.1,4 Understanding the use of autologous, homologous and
alloplastic materials for grafting and implantation purposes has become
a necessity in the armamentarium of the rhinoplasty surgeon.2
Graft and implant materials are used primarily to maintain or
strengthen the structural framework to provide contour or camouflage
defects and to restore the nose to an aesthetic ideal. The ideal graft or
implant material is biocompatible and possesses physical properties
and long-term stability devoid of complications. Cartilage is nearly the
ideal implantation material by its excellent biotolerance having low
infection and extrusion rates. Cartilage possesses excellent elasticity,
resistance, is easy to shape, has good vitality even with poor blood
supply and a minimal resorption rate.2
The rib offers an abundant supply of cartilage for use in virtually
every aspect of rhinoplasty and is the preferred donor site when rigid
support is necessary. The most significant advantage of rib cartilage is
that grafts can be produced with considerable versatility with respect
to shape, length and width. This facilitates reconstruction of the nasal
framework in patients with virtually all types of functional and aesthetic
requirements.5,6
Uppal et al. did a retrospective study on 42 patients who underwent
coastal cartilage harvest for ear reconstruction. They noted that donor
site pain and clicking sound were the most common complaints. Donor
site scarring and deformity were acceptable for most patients but five Figure 8. Pre operative and 2 years post operative picture. Photos printed in full with permission.
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 30 no. 1 January – June 2015
ORIGINAL ARTICLES
PhiliPPine Journal of otolaryngology-head and neck Surgery 33
REFERENCES
1. Tahir M, Abir S, Ullah F. Rib Graft Rhinoplasty for the depressed dorsum of the nose. JPMI. 2006;
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2. Lin G, Lawson W. Complications using grafts and implants in rhinoplasty, Operative Techniques
in Otolaryngology. 2007; 18: 315-323
3. Morrieti A, Scuito S. Rib grafts in septorhinoplasty. Acta Otorhinolaryngol Ital. 2013 Jun;33(3):190-
195.
4. Saeed M. Costal cartilage graft in augmentation rhinoplasty. APMC.2012 Jul-Dec; 6(2): 166-
170.
5. Gunter JP, Cochran CS, Marin VP. Dorsal augmentation with autogenous rib cartilage. Semin
Plast Surg. 2008 May; 22( 2): 74-89.
6. Marin VP, Landecker A, Gunter JP. Harvesting rib cartilage grafts for secondary rhinoplasty.
PlastReconstrSurg. 2008 Apr; 121(4): 1442-8.
7. Baladiang DEA, Olveda MB, Yap EC. The “sail” excision technique: A modified alar lift procedure
for Southeast Asian noses. Philipp J Otolaryngol Head Neck Surg. 2010 Jan-Jun; 25( 1): 31-37.
8. Lee M, Inman J, Ducic Y. Central segment harvest of costal cartilage in rhinoplasty. Laryngoscope.
2011 Oct; 121(10):2155–2158.
9. Al-Aziz A, AhmadH, Al-Leithy I. Autogenous Cartilage Grafts in Primary Rhinoplasty in the Non-
Caucasian Population , Egypt. J Plast Reconstr Surg. 2005 Jan; 29(1): 67-72.
10. Cakmak O, Ergin T. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch
Facial Plast Surg. 2002 Jul-Sep;4(3):172-6.
11. Uppal RS, Sabbagh W, Chana J, Gault DT. Donor-site morbidity after autologous costal cartilage
harvest in ear reconstruction and approaches to reducing donor-site contour deformity. Plast
Reconstr Surg. 2008 Jun; 121(6):1949-55.
12. Park JH, Jin HR. Use of autologous costal cartilage in Asian rhinoplasty. Plast Reconstr Surg. 2012
Dec; 130(6):1338-48.
13. Yap EC. Improving the hanging ala. Facial Plast Surg. 2012; 28(02): 213-217.
underwent reconstruction to correct the deformity.
In a study by Cakmak et al. 20 patients with severe nasal deformity,
19 of which were revision cases received autogenous costal cartilage
grafts. They had one patient with early wound infection and three cases
of minor warping. They did not observe graft extrusion or resorption.
Other than temporary pain, there were no donor site morbidities
encountered.
Saeed likewise did a retrospective study of 60 patients who
underwent augmentation rhinoplasty with rib cartilage harvest
for patients with saddle nose deformity with no incidence of graft
resorption, infection and extrusion as with our study. They had one
patient with pneumothorax (2%), another with marginal show (2%) and
five patients with keloid formation (8%).
Another study by Park et al. noted a complication rate of 12%: of
the 83 patients included in the study, five developed post-operative
infection controlled by intravenous antibiotics and five had a warped
graft.
In our study, there were no incidence of post-operative infection in
both donor and recipient sites, warping of the graft, graft resorption,
graft extrusion, pneumothorax, chest wall deformity or prolonged
edema. The only donor site morbidity we encountered was pain that
was adequately managed with oral analgesics.
We conclude that costal cartilage is a good option for structural
support of the nose especially in patients with previous allografts. In
our experience patients have become wary of the complications of
allografts and have opted to use autografts. The surgeon’s knowledge
of nasal anatomy as well as his or her experience with autologous grafts
plays a major role in avoiding post-operative morbidity.