How Is A Diced Rib Cartilage Graft Done In Rhinoplasty?
Q: Dr. Eppley, I definitely have come to the conclusion Silicone/Goretex, and a foreign implant of any sortfor my rhinoplasty is not the route I want to go. Not only am I worried about the complications as far as infections, extrusions, and any deformity it might bring to the skin if it ever decides to reject these implants, but I don’t think it would be the ideal material to use for my desired augmentation of the nose.
At this point, I am pretty much set with using rib grafts for my rhinoplasty. Following are some questions I have for you regarding rib graft rhinoplasty:
- How big is the scar for the rib harvest?
- Which rib do you harvest? Are you familiar with the method of making the incision right on the breast crease and then using an endoscope to find the 7th rib? thoughts?
- Will that area on my rib ever look ”odd,” ”off,” or worse, deformed?
- The collagen that diced cartilage grafts are wrapped in, is it either Alloderm or Surgicel? One of my main concerns with wrapped diced cartilage is reabsorption. I have read that the reabsorption rate can be anywhere from 0.5% to full absorption. Though this is quite concerning, I am aware there is a chance of reabsorption in any case using cartilage of any kind.
- I have read that you can ”mold the nose” externally even after the surgical procedure with diced cartilage.How exactly is this done and what kind of changes can one make at that point?
A: I think you are wise, in the long run, to avoid a snythetic implant for dorso-columellar augmentation rhinoplasty. A lot of stress on the skin over time with an avascular rigid implant could cause problems.
Here is some general information on rib grafts and their use and harvesting. Rib grafts can be all cartilage, all bone or a combination of both. The choice of the donor site controls what the graft will be composed of. Rib grafts harvested through the lower breast crease gain access to the costochondral junction (rib-bone interface) and have a much greater risk of pneumothorax. (collapsed lung) The only time I go there for a rib graft is for a costochondral graft for TMJ mandibular reconstruction. The ribs are a lot of bone at this level and are right over the lung. This is not my choice for a rhinoplasty rib graft harvest. The lower 4 ribs (6,7,8 and 9), also known as the subcostal location, are all cartilage with a large volume of material. There is no risk of pneumothorax as the apices of the lung is just at the upper edge of rib #6. This necessitates a subcostal incision along the bottom part of the rib cage. The incision can be as small as 3.5 to 4 cms because the skin slides freely over the rib cage, thus being able to work over a wide area of the rib cage through a small incision. I have no knowledge or experience in trying to do this harvest through an endoscope from the lower breast crease. These ribs are long and slightly curved but have not shortage of donor material. The amount that is harvested for a rhinoplasty will not cause an external chest deformity. (this is an issue in ear reconstruction where much larger volumes are harvested.
A pure cartilage rib graft can be either solid (enbloc) ot diced. When talking about the use of such rib grafts in rhinoplasty, it is important to separate where on the nose it would be used and what its construct should be. For the columellar strut, the only choice is a solid graft as this must act like a tent pole. The only question about columellar struts is how long they need to be. They act essentially by being a pole onto which the lower alar cartilages are attached to raise the tip height and to some degree its angle. The dorsum, however, can be augmented with either solid or diced cartilage. I have gone away from solid cartilage grafts because they definitely have risks of warping and shifting position. Also the amount of dorsal height they can create is limited by how thick the rib graft is. (in most cases this is not an issue but it is a limited factor) Diced cartilage created into a rolled construct (sausage if you will) generally avoids warping and ‘edge’ show. It is placed into the nose and molded after insertion both at the time of surgery but also critically by the shape of the splint applied over it and the patient wears for a week afterwards. It usually sets up pretty firm in a very short time but can even be further shaped after the splint is removed by pinching it further together if needed. It may be placed like a sausage roll it is pinched and squeezed into the desired shape once it is placed into the nasal pocket. Once can even do a combo, having a solid inner core onto which diced cartilage is placed around and on top of it. Diced cartilage requires an ‘envelope’ to make it into an insertable graft and there are numerous options from surgical, alloderm to the patient’s fascia. It is not presently clear if one of these has an advanatage over the other. Surgicel is the most convenient technique for making a diced cartilage dorsal graft.
Like all cartilage grafts, there is always the risk of some resorption but my experience in this larger diced graft is that it seems to be very low.
Dr. Barry Eppley