Posts Tagged ‘rib graft rhinoplasty’
Tuesday, January 17th, 2012
Q: Dr. Eppley, Many years ago I had an absessed septum in my nose and had to have emergency surgery. The doctor wanted to do plastic surgery after the procedure due to the excessive loss of cartilage in the nose, but because of the trauma of the initial surgery, I did not want it. After many years, I wish I had done the corrective surgery. Is there a chance that insurance might cover some of a corrective nose surgery for me after so long?
A: Loss of portions of the septum due to infection or hematomas creates, sooner or later, collapse of the overlying nose. This creates what is known as a saddle nose deformity with collapse or inward deviation of the dorsal line of the nose. With the sinking in of the middle vault, the tip of the nose will turn upward with excessive nostril show. With loss of portions of the septum there may also be a hole or perforation of varying sizes between the two sides of the nasal airway inside.
Reconstruction of a saddle nose almost always requires a rib graft to rebuild the dorsal line of the nose. The septum usually is not and cannot be rebuilt due to loss of lining nor would it have any influence on the appearance of the outer nose. Such rhinoplasty procedures would most certainly have some coverage under one’s health insurance due to the medical basis (infection, loss of septum) for the cause of the problem. This would be ascertained before surgery through an insurance predetermination process.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, rhinoplasty for saddle nose, rib graft rhinoplasty
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Wednesday, December 28th, 2011
Q: Dr. Eppley, I have questions about using rib grafts for rhinoplasty. How would the surgeon even determine if the rib graft he is going to take would be straight ‘enough’ for it to be placed directly to augment the bridge? What if the carving of the graft isn’t successful? Would you diced it instead and continue the surgery when the patient requested not to have the diced method done? After reading what you have written, a diced cartilage method is obviously better than a ‘single rib’ method right? But one question is that why many patients and surgeons are choosing the ‘single rib’ method instead of the diced method? Can I also know how much does a rib graft rhinoplasty cost? Does it include tiplasty and alarplasty too? Thanks Dr!
A: The quality and straightness of the rib graft is determined by the skill and experience of the surgeon taking it. There are a lot of rib choices on the lower end of the costal margin from the free floating #9 to the fixed ribs #s 6, 7 and 8. Usually a straight piece can be obtained as the longest rib graft that is needed does not usually exceed 4 cms.
If the patient does not want a diced graft method and does not consent to that option, then only the single piece method would be used.
The question of whether a diced vs a solid rib graft is better is a controversial one and every surgeon will have their own opinion on that matter. The answer would also depend on what the nose anatomy is and what one is trying to achieve. It is never that one method is always better than the other, it must be taken on an individual case basis.
A rib graft rhinoplasty can or cannot include tip and other work depending upon what needs to be done. I would view it as a comprehensive rhinoplasty with one fixed cost, no matter what needs to be done.
As a ball park figure, all costs included, the cost is in the range of $8,500 to $9,500.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, rib graft rhinoplasty
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Sunday, December 25th, 2011
Q: Dear Dr. Eppley, Do you mind sharing some advises of yours regarding to diced cartilage for nose jobs? What is the main difference between a piece of rib cartilage being place directly to augment the bridge and injecting fine diced rib cartilage into the bridge as well? Are the side effects of using this ‘diced cartilage’ technique be higher too? Lastly, are there any limitations pertaining to nasal bone narrowing procedures and tiplasty?
A: Rib grafting of the nose is most commonly done for significant dorsal augmentation. Rib grafts offer the most volume to do the procedure and can be done either as an en bloc or a diced technique. There are advantages and disadvantages to either approach. If one can get a nice straight piece of rib cartilage, in which carving and shaping it will not induce warping, then a single en bloc graft method should be done. The problem is that often a good perfectly straight rib graft can be hard to obtain or carving it straight may not make it stay that way. Also, the tunnel or tissue pathway into which the graft is placed must be very tight so the solid one-piece graft does not slip from a straight midline position When the rib graft is not straight and/or there are concerns about midline graft security/fixation, then a diced cartilage approach is the solution. While this takes intraoperative time to do, the risks of graft warping, graft malposition and a crooked nose are virtually eliminated. A diced cartilage approach can also be used when one has multiple small pieces of cartilage, none of which are long and straight enough for a good dorsal augmentation.
The vast majority of diced cartilages grafts in rhinoplasty are placed through an open approach. The cartilage is diced and placed in a fascia or surgical wrap and inserted like a one-piece rib graft. The injectable cartilage approach is only used for very small defects of the nasal dorsum.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: diced cartilage graft in rhinoplasty, dr barry eppley, indianapolis, rib graft rhinoplasty
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Tuesday, November 29th, 2011
Q: I am interested in a rhinoplasty to build out my nose as it is very short. I am of Asian background and have a small flat nose which is inherited. I have read that it can be done with either a rib graft or using a synthetic implant. I would definitely prefer using rib as that would be more natural. I have done some imaging of my nose in profile to show how I would like it to look afterwards. Can this type of result be done?
A: In looking at your profile and predictive imaging, I would make two points. First, using a rib graft for the short nose is the best long-term approach. This is particularly true when there is a significant amount of augmentation desired. Large amounts of synthetic material will put the nose skin under tension ultimately leading to thinning of the skin and tissues and risks of exposre or extrusion. A little synthetic material on the dorsum of the nose can work well. A lot is a recipe for complications. Secondly and of equal importance, you have unrealistic results. That amount of augmentation is not possible no matter how it is done. The skin of the nose will simply not stretch enough to accommodate that much augmentation. And even if it would, you would not want it to. You should realistically expect about half of that rhinoplasty result that you are showing.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, rib graft rhinoplasty
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Friday, August 19th, 2011
Q: Dr. Eppley, I am interested in a rhinoplasty which builds up the bridge of my nose.I would definitely want to use a rib cartilage tissue for it due to good long term results and safety which are my main concerns. However, I still have some questions about the operation. How will the rib operation affect my ability to function? I go to gym and exercise a lot and I wondered if there might be some long term problems with the operated rib?
A: There will be no long-term sequelae/dysfunction from taking a portion of a lower rib for rhinoplasty. Not only is the rib harvest not bone but cartilage but it is a small portion of it and not the whole rib. Th function of ribs is to provide structural support to the chest wall but it would take many whole ribs being removed to destabilize that function. This is just a portion of one of the lower ribs ( 8, 9 or 10) which actually have no real function for chest wall support and pulmonary function as they lie below the level of the bottom portion of the lung. What is associated with some rib removal is pain and discomfort. To manage this immediately after surgery I inject a 24 hour local anesthetic into the surrounding rib tissues from the harvest so one does not wake up in severe pain. While this does wear off, it gives one time to acclimate to the soreness. One can usually return comfortably in 3 to 4 weeks to exercise and more strenuous activities.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, rib graft rhinoplasty
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Friday, August 19th, 2011
Q: Dr. Eppley, There are several parts of my face that I wanted to improve, but I feel like the nose is the most significant feature that I want to change. I attached some pictures which show the amount that I want my nose to be built up. I would like to know if this is realistic. What is the best way to accomplish this, implants or your own tissues. I have heard implants can get infected and that rib cartilage is known for warping. I am uncertain as to which choice to make. What do you recommend?
A: What you are demonstrating is nasal dorsal augmentation from the frontonasal junction down to the supratip area below and behind the lower alar cartilages. The greatest amount of dorsal augmentation is in the radix because it is also the lowest. I think the kind of result you have imaged is realistic.
The major question is what material to use for nasal dorsal augmentation. There are two main choices; synthetic implants and rib cartilage of which I have used both. (although many more rib cartilage grafts than implants) While there are advocates for each, I would heavily lean towards the use of rib cartilage given your young age and skin type and quality. While it requires a greater investment of time and recovery up front, the use of your own tissues will not give you any infection, extrusion or tissue thinning problems for the remainder of your long life. In using rib cartilage, it can be done as a whole piece or as a fabricated diced roll construct. Which one is better is based on the quality of the rib tissue harvested and surgeon’s preference. Because most rib cartilages have some curve to them, it requires good surgical technique in how to harvest and shape them to avoid the potential for warping concerns. I always use the cartilages from either the 8th or 9th rib. Sometimes a very straight piece can be obtained and shaped and then I use it as a solid graft. If the rib is very curved and a very straight piece can not be fashioned out of it, then it is cut into very small pieces (1mm) and packed into a surgical wrap to create a very moldable long implant like a piece of sausage. Once in place it is easy to shape and the splint after surgery holds it into place. It becomes very solid in a short period of time as the small pieces of cartilage allow very rapid fibrovascular ingrowth. As a young man, you should have very good rib tissue and I suspect the solid rib graft for your rhinoplasty will work just fine. That has been my experience in younger male patients.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianapolis, nasal augmentation, rib graft rhinoplasty
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Saturday, April 30th, 2011
Q: I am interested in getting a rhinoplasty done. I want a more streamlined look to my nose. It needs to be straighter with less of a downward slope or dip in the bridge area. I think the dip is the result of a barbell bar that I dropped on my nose when I was about 12 yrs old. I have attached some pictures of my nose for you to see. What are your rhinoplasty recommendations?
A: Your pictures and your history show a classic saddle nose deformity. Your nasal bones and middle vault (upper and middle third of your nose) are collapsed and your internal septum is underdeveloped. This also results in a low and broad nasal tip, short columella and flared nostrils. The key to a successful result in the saddle nose deformity is building up of the entire dorsal line from the bridge down to the nasal tip. Without question the best material for this is your own cartilage. Your septum, however, would not provide adequate donor material. Ideally a rib graft should be used. This provides the best amount and shape that this buildup requires. One could use a synthetic implant, which is easier, but there is a definite risk of long-term problems with foreign materials in the nose. Otherwise, your rhinoplasty would be done through an open approach with dorsal graft and columellar grafting, nasal tip refinement and nostril narrowing. This would provide a more streamlined and straighter look to your nose as the attached computer imaging illustrates.
Dr. Barry Eppley
Indianapolis, Indiana
Tags: dr barry eppley, indianaoplis, plastic surgery of the nose, rhinoplasty for saddle nose deformity, rib graft rhinoplasty
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Tuesday, January 25th, 2011
Q: I have heard of rib graft nose augmentation. Is this method better than using silicone implants? It seems that most people use silicone so why rib? Can a rib graft be carved like silicone with a nice shape ? Can it get warped and twisted? How many people are fixing their nose using rib grafts? How many people need to be redone because of problems with the rib graft? I want to fix my nose but am scared of using a rib graft because of what I have heard about them.
A: Rhinoplasty with dorsal nasal augmentation can be done using either a synthetic implant or an autogenous rib graft. While there are advocates for both approaches, either one can have very successful results. It is not a function that one is better than the other, they just have different advantages and disadvantages. Synthetic implants to the nose are relatively simple to do and require less operative time and surgical skill to do but they have potential long-term problems such as infection and extrusion in some patients. Rib grafts to the nose are harder to do and require greater skill and familiarity in working with this type of graft as well as requiring a donor site but they do not have long-term problems of infection or risk of graft extrusion.
In my experience, diced rib cartilages to the nose eliminate the risk of warping or twisting and mold nicely for dorsal augmentation. Solid rib grafts must be very carefully harvested, shaped and secured to avoid the problems to which you refer. I have done both techniques successfully and decide between the two rib cartilage graft techniques based on the quality and shape of the rib graft harvest.
The vast majority of patients wanting primary dorsal augmentation rhinoplasty for esthetic reasons, such as the Asian patient, is going to choose a silicone implant because of its simplicity and lack of the need for a donor site.
Dr. Barry Eppley
Indianapolis Indiana
Tags: asian rhinoplasty, dr barry eppley, indianapolis, plastic surgery of the nose, rib graft rhinoplasty
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Wednesday, December 22nd, 2010
Q: I have been thinking about getting a rhinoplasty. I have never had any nose surgery before. I am filipino and my nose is short and too small for my face. What I would like to achieve is the following in my rhinoplasty; augment the dorsum, lengthen the columella, improve tip projection and definition, alar base reduction and show less nostril. I would like costal cartilage rhinoplasty, definitely no silicone or GoreTex implant for dorsum augmentation. Been thinking of rhinoplasty for a long time. I have attached some pictures for your review and imaging.
A: Thank you for sending the picture and your detailed analysis and goals. Given your smaller and short nose, you are absolutely correct in determining that only a rib graft rhinoplasty could achieve your goals. What you need is a combined dorso-columellar augmentation or the geometry of a L-strut configuration. Only a rib graft or a synthetic implant can possibly achieve that degree of augmentation. You have stated you want to avoid an implant and I assume you feel so because of their potential long-term problems, even though they are the ‘easiest’ to do. A rib graft would provide the best long-term graft retention without problems even though it has the short-term ‘problem’ of a donor site and resultant scar. I have attached some predictive imaging for your review. Please note that the increased columellar show in the side vie does not appear as it is not present at all in the original photo. (you can’t morph what is not there!)
Dr. Barry Eppley
Indianapolis Indiana
Tags: costal cartilage rhinoplasty, dr barry eppley, indianapolis, plastic surgery, rib graft rhinoplasty
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