Your Questions
Your Questions
Q: Dr. Eppley, I have some questions about implant rhinoplasty for my Asian nose. The original surgeon who performed my first rhinoplasty knew that I did not want an implant initially but sold me on the implant because the only thing that he offered that would be equivalent in terms of withstanding the test of time is fascia. He described it as a thin piece of skin from the scalp area that would show little difference. He never mentioned anything about rib grafts or diced cartilage wrapped in fascia. I feel that I was mislead purposely. Is it common for plastic surgeons in the United States to do this to make a buck and is this medically ethical?
A: There are numerous approaches to augmentation of the Asian nose including implants and rib cartilage grafts as you have mentioned. It is certainly true that fascia alone would provide no nasal augmentation at all due to its very thin and pliable tissue characteristics. It is good to encase a diced cartilage graft but is not an augmentation material per se.
Surgeons naturally present and offer to patients for any surgical procedure what they know and are comfortable performing. Presumably what they have to offer for any cosmetic condition is what they feel will work well and is in the best interest of the patient. It is also far easier for surgeons to offer implant rhinoplasty over rib grafts for nasal augmentation because it is simpler, easier to perform and costs the patient less. Even if presented with the rib graft option, many patients initially choose implants for all of those reasons also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read your article on natural vs. artificial implants in rhinoplasty. I was wondering why you prefer natural material. I also know diced cartilage wrapped in fascia has been offered fairly recently. Do you know if this is a fairly new procedure or if this has been offered since 2009? I am considering tip revision but also want to keep my bridge area in mind if need be. I have an implant in my nose as mentioned earlier but do not know if these implants last a lifetime. I had mine placed when I was 38. Is there some kind of average, for example, 20 or 30 years? Thanks.
A: Significant nasal augmentation in rhinoplasty can be done with either nasal implants, usually made of silicone, or rib cartilage. There are advantages and disadvantages with each type of implant/graft and both can have successful long-term results. Silicone nasal implants never change in shape or structure, can not degrade or break down and never need to be replaced because they fail. The issue with any synthetic nasal implant is that the tissues change around them in some cases (if they are big enough) and this means that the skin over the implant thins. This can lead to potential long-term issues such as implant show, exposure or infection. This never happens with cartilage grafts which is why they are preferred in larger nasal augmentations if one is willing to invest the greater effort up front.(longer surgery, scar, expense)
The use of diced cartilage wrapped in fascia or surgical in rhinoplasty is not new and has been around for several decades. It s biggest advantage over en bloc or solid rib grafts is that there is no potential for warping or edging. They can be used to cover a nasal implant particularly in the tip area. But the use of ear cartilage would actually be better for this purpose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty with rib graft. The surgery was to reduce the height in the bridge of the rib graft. Now the center vault of my nose feels soft, mushy. I think the surgeon removed my graft in the center bridge area. I am afraid, another surgeon said that if you remove the rib graft without replacing it, the nose can retract. Is this correct? How long do i have after the surgery to get a rib graft to replace what was taken out? Question, how soon after surgery can I have the rib graft replaced? I hope I phrased this correctly. Please help.
A: If I understand your situation correctly, you originally had an augmentative rhinoplasty with a rib graft. Then 11 days ago you had a revision to reduce the height of the rib graft in its upper portion over the bridge. Now there is a concern that the middle portion of the nose (or rib graft) is ‘missing’.(soft and mushy) It is unclear if the actual height of the graft in the bridge/radix area was adequately reduced or not. Since the tip also feels soft and high, I assume this revisional procedure was done through an open approach.
Your question is whether this missing portion of the rib graft should be replaced due to fear of irreversible skin contraction. I would not have similar concerns about the middle vault skin irreversibly contracting. While some skin contraction may occur, it can always be stretched out later to accommodate more graft material. If the tip in a rib graft rhinoplasty loses considerable underlying support, skin retraction there may be kore problematic. The real question is not skin retraction but whether you feel there has been adequate reduction in the bridge and/or too much reduction in the middle of the graft. While only being 11 days after surgery, swelling would usually make that hard to judge. But you are very familiar with after rhinoplasty swelling so you are in a better position to judge these early results than many. If one is convinced too much cartilage has been removed or additional adjustments needed, then that may be a valid reason for an additional revisional procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty done about a year ago to extend and derotate my tip and columnella. In the process I also had a premaxillary implant which was inserted in the nasal spine area through an incision through the inside of my upper lip. All of these were rib cartilages.
Whatever the cause, my smile has been warped for the worst. Before surgery, when I smiled, my upper lip used to be mobile, flip up, and thick and my columnella and tip would also droop down resulting in a nice natural smile that wasn’t tense. Now my smile is frozen looking. My upper lip is thin, tense and my nose tip and columnellar are also wooden looking and do not move with my smile the way it used to. It looks off and disturbing according to many of my friends. I am very upset with this. Is this my tip and columnella rib work that is doing this or is it a result of my premaxillary graft? I would certainly like to remove my premax graft if this will fix my smile. Thank you very much.
A: When you add a lot of rib cartilage grafts to the tip of the nose and the underlying pyriform aperture/nasal spine area, there is the possibility of stiffening how the upper lip moves. While it is possible that it is the combination of the effects of all the cartilage grafts (I have no idea as to teh details of where they were placed exactly and their size), the most likely culprit is the premaxillary graft. Its removal would be a good place to start and would also not affect to any significant degree the rhinoplasty result. Whether it will produce a complete normalization of your smile can not be predicted and it is not known if that could ever be achieved even with removal of all of the rib cartilage grafts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions after my rib graft rhinoplasty surgery. I’ve noticed that the very top of my nose bridge has started to warp to the right. It’s at the very top and it’s kind of hard to notice in person, it’s more apparent to me and then in pictures. Also a bump/hump has developed on the upper nasal bridge. I just didn’t know what possible things could be done about this if this indeed is a problem. Also, I know I’m jumping to conclusions, but if there had to be a revision surgery, how long would I have to wait? I’ve done research on revisional rhinoplasties and some doctors suggest waiting 6 to 12 months. But I saw that this was more for patients who thought their nose tip was too bulbous or the nose was too big, so the doctors suggested to wait for the swelling to go down. Another doctor suggested that he’s performed surgery as soon as two months on patients who’s revisions would be easier to fix sooner rather than later. How long would I have to wait to do a revisional rhinoplasty?
A: The timing of revisional surgery for any procedure fundamentally comes down to knowing that one has a stable target. This translates into three issues to consider: all swelling has resolved, the tissues have shrunken down and adapted to the new underlying framework and one has had enough time to accommodate to the new look. When all of these factors are considered, the timing of revisional surgery will vary based on the exact rhinoplasty procedure that was done. In general, most plastic surgeons would say that six to 12 months is when any type of revisional rhinoplasty can be done. This is, of course, a general statement and each nose and the concerns must be considered separately.
The key concept is that you don’t want to chase a ‘moving target’ when it comes to revisional surgery. Patience can be difficult but critical with secondary surgery. You don’t want to play ‘wack a mole’ with revisional surgery by jumping in too soon.
It is true that nasal dorsal issues are different then nasal tip issues because of the quicker resolution of swelling and tissue adaptation. Since your specific concern appears to be at the upper end of the rib graft in the radix, this type of revision might be considered sooner than other post rhinoplasty concerns. Some slight deviation and/or step-off of the upper end of the rib graft is not uncommon and can often be felt. How visibly significant that is will determine whether any revision is worth the effort.
The key concept is that you don’t want to chase a ‘moving target’ when it comes to revisional surgery. This is particularly true when one has had multiple procedures as one would like only undergo one revisional procedure. You don’t want to play ‘wack a mole’ with revisional surgery but jumping in too soon.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ethnic rhinoplasty. I have a very flat noseand would like to narrow bridge significantly to enhance my facial features as well as narrow the tip. My ideal nose features are those of Halle Berry, Beyonce and Vanessa Williams. Can you achieve this finish by reshaping my nose?
A: The first issue about ethnic rhinoplasty, and any rhinoplasty for that matter, is that trying to have the nose of someone can never be achieved. It is good to have a desired rhinoplasty goal. But in the end, no matter how well executed a rhinoplasty is done, factors such as the thickness of the overlying nasal skin will have a major influence on the final nose shape result.
I have done some imaging work on your pictures. The picture quality is not great but they are useable. Your nose is interesting because it looks the way it does because the nose has little cartilage support from the underlying septum which is why the tip is flat, the bridge is low and the nostrils are flared/wide. This is not unusual in African-American noses who often has weak septal support and widely splayed nasal cartilages with short nasal bones.
To make any significant changes to your nose, you would need an L-shape cartilage graft to both build up the tip and the bridge. Much like making a roof on a house, underlying support is need to build up your nose to give it more projection which is what will make it look more narrow and refined. This amount of support can only come from a shaped rib cartilage graft. Your nostrils would also need to be reduced/narrowed at the same time. The imaging predictions show some of the changes but be aware the frontal view image does not do justice to what would really happen when the entire bridge and nose comes forward as the computer software can not really show what happens as the nose is pulled forward. In short, the real result would look much better from the front that the imaging shows. I don’t know if your nose would look exactly like Vanessa Williams but it would be a lot closer than it is now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty that lengthens my nose. I had a rhinoplasty several years that ended up shortening and lifting my nose too much. This is not a good look for a man. I have read that the best way to do the procedure is with cartilage grafts and the rib may be the best source if substantial lengthening is needed. Does the rib graft make the nose feel any different such as being very rigid?
A: When considering revision rhinoplasty for tip lengthening and derotation, it is important to understand the anatomy of the nasal tip cartilages. The nasal tip cartilages are the only structures in the nose that are ‘free floating’, they are not attached to the underlying septum or upper lateral cartilages by fixed rigid attachments. This is why one can move the tip of the nose around freely and it is compressible, unlike the upper nasal bones or cartilages for example. When any tip lengthening procedure is done, which requires cartilage grafts, by definition more structural support is added and it will become more rigid. It will never be as soft and compressible as when it has less cartilage support. How rigid it may become is a function of the type and amount of cartilage grafts that are needed and how they are placed.
The cartilage grafts needed for significant tip lengthening/derotation must be placed between the fixed structures of the nose and the free floating tip cartilages. This is the way you drive down the tip of the nose. In essence, you are building up the underlying support to push out and down the tip. The grafts can not merely be placed on top of the nasal tip cartilages, that is only effective if you need just a few millimeters of lengthening or derotation effect. To really be effective for tip lengthening, straight pieces of cartilage are needed that are placed in an almost tripod fashion behind the tip cartilages. The use of a rib graft ensures that an adequate amount of cartilage is available.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rib graft rhinoplasty. I consulted with a local doctor and he said that because of the height and projection of the nasal implant it made my nostril more visible. I think I’m leaning more towards rib cartilage as use for the implant. What I want to accomplish is a nose that’s less deviated, less nostril visibility and appears less short. Also, being that I have thin skin, what can we do to prevent the rib graft from being visible when someone is looking at me? At the moment, my nose looks thin and skeletal like and I want to remedy that.
For my chin, I want the implant removed and fat grafting done to the area. I just want a chin with an appropriate projection in relation to my face and nose. Also, I would like to see if we can use fat grafting to restore a natural jawline to my face before resorting to implants. I would like fat grafting to my nasal labial folds as well as the cheek/hollows of my eyes.
A: There us nothing wrong with using injectable fat and that is clearly a treatment approach that you find most comfortable. However, you need to be aware that fat grafting never works the same as an implant regardless of how it is presented in surgeon’s websites. Fat grafts are soft and don’t have the same push on the overlying soft tissues. As a result, the amount of augmentation and the definition it creates is far inferior to a firm implant. But with that being said, I think fat grafting is reasonable since you have other fat grafting needs so ti is worth the effort. There is certainly nothing to lose by so doing.
It is difficult in any rib graft to a nose with thin skin to not have it look skeletal. Ways to lessen that aesthetic risk are carving the edges of the graft so that they are round and not sharp and to cover the rib graft with a thin layer of allogeneic dermis. Together these two approaches can be effective at softening the look of a rib graft to the nose.
In replacing a chin implant with fat, it is again important to know that it will not create the same effect and many not even survive inside the relatively avascular lining surface of the chin implant pocket. But again it is a reasonable approach with little risk other than complete graft absorption.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rib graft rhinoplasty. I am a 32 year-old Asian woman that has a bad nose problem now. I had a silicone implant rhinoplasty done severn years ago. It looked good and was fine until about six months ago when my nose got really red and the implant got infected for no apparent reason. It had to be removed.:( Now my nose is sunken in and the tip is really short, it looks worse now than beforeI had the implant put in. Based on what I have read, it appears that a cartilage graft from the rib would be needed to get my nose back to the way I want it to look.
A: A rib graft rhinoplasty is the best choice for you now without question. The short nose of Asians can pose a real challenge when complications have occurred from a prior rhinoplasty. Unlike Caucasians rhinoplasty problems which are often the result of too much supportive cartilage removal, revisional Asian rhinoplasty problems result from augmentation problems from implants or grafts. When nasal implants get removed due to either infection or skin thinning, scar contracture will cause the tip to rotate upward as well as lower the height of the bridge due to the implant removal. This accentuates the naturally short nose of most Asians not to mention the scar tissue that has been created.
How effectively the Asian nose can be effectively built back up and lengthened is the result the result of the cartilage donor source. (an implant is obviously not a good choice when a prior implant has had to be removed) The amount of cartilage then controls what type of structural support and lengthening manuevers can be done. Rib grafts provide the most amount of cartilage one can use allows long straight grafts to be made for septal extension, columellar strut and extended spreader grafts as well as dorsal onlay grafts. No amount of tip or dorsal grafting from the ear or septum can produce the effects of what a rib graft can provide.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m actually planning to have a revision rhinoplasty done at the end of the year to remove the L-shaped silicone implant that was initially placed. But I am just curious as to what my options are. If I would like to get a sharper and lowered nose tip, together with a higher nose bridge and some glabella augmentation, do you think a silicone implant for the bridge and ear cartilage for the nose tip and glabella would be preferable to rib grafts?
A:By definition, to replace the existing L-strut silicone implant in your nose you would need the same dimensions and that would mean a rib graft. Even with lowering the tip I think there is the need for just too much cartilage to rely on an ear conchal graft alone. This would be particularly true when trying to make the nose tip more defined (pointy) as it would be much safer and and more effective to have a strut graft ‘doing the pushing’ so to speak. Such a graft harvest would then allow a more complete rhinoplasty to be done with the dorsal bridge and glabellar area to be cartilage grafted as well
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am sending you pictures of my face and how I want to look like at the end of surgery. The first 3 is me, the last 2 is how I want to look like. I believe we will need a nose job, mouth reduction, and some facial bones work.
A: Thank you for sending your pictures and demonstrating your objectives. First, let me make some general statements about your facial enhancement objectives. If your goal is to look very close to the pictures you have shown, that is not a realistic goal. Besides some similarities in skin color (actually his skin is much lighter than yours) he has a completely different facial bone structure and soft tissue makeup. Your facial structures are radically different. Thus there is no way with any surgical procedures that you are going to look remotely like him. It is simply not possible. You can not be made to look like someone else. You can be a better facially balanced and proportioned you but you can not be him. While I understand why his face and those objectives are appealing, you will have to focus on what you do within the limits of change in your own face.
What I see on your face that can be improved is the following.
1) Your facial bone structure is known as bimaxillary protrusion where the jaws and the teeth stick out. That can not be changed but your chin is comparatively very short. A sliding genioplasty to move the chin forward would improve your facial proportions.
2) Your nose is very classic being low and broad. Building up the nose with a rib graft rhinoplasty and narrowing the nose will create more of a narrow and slimmer looking nose. Your thick nasal skin prevents your nose from ever being very refined but this will help.
3) You have a tremendous amount of lip tissue, particularly in the size of the exposed vermilion. (pink tissue) An upper and lower lip reduction will help although there is a limit as to how much lip reduction can be achieved.
I have done some imaging which is attached so you can see how these proposed changes may help in a realistic facial enhancement effort.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in Asian rhinoplasty. May I know what charges and how much time will be spend on it. And what is best option for Asian rhinoplasty, cartilage graft or something else.
A: Thank you for your inquiry. The first place to start is to see some pictures of you and see what your goals are. Even though I likely know what they are, I would like to hear your nasal goals. Secondly, since almost every Asian rhinoplasty involves either dorsal or dorso-columelar augmentation, one has to decide whether one wants it done by cartilage grafting or a synthetic implant. There are advantages and disadvantages with both approaches and that choice significantly affects the time of surgery, cost and recovery. Although an implant rhinoplasty is relatively easy to go, has a lower cost and a very short recovery, the use of an implant in the nose has a significant incidence of long-term complications including infection, thinning of the overlying skin and implant extrusion. A rib graft in the nose requires more skill to perform, involves a donor site, costs more and has a longer recovery. But once healed, rib grafts become a permanent and natural part of the nose. From my perspective a rib cartilage graft rhinoplasty is always better in the long run but it is involves a bigger commitment up front.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I recently had augmentation rhinoplasty to build up my bridge a and bilateral spreader graft to widen my nose. I am not sure the use of ear cartilage was appropriate for my wants. I wanted my radix to tip slightly augmented and my Dr. used ear cartilage. I never had an over done rhino before either it was a just tip work on my first. I just decided I wanted a more masculine nose. I am looking for some answers about a possible third rhinoplasty yikes. I have never had cartilage taken out of my nose. I am 25 year old caucasian male. I am looking for a surgeon who works well with rib grafts.
A: My assumption is that based on your description that the ear cartilage graft was used to build up the radix. But that has left you with more of a ‘scooped out ’ dorsum with too high of a radix and the rest of the dorsum too low or that the entire dorsum is now too high and more of a hump? When trying to build up the entire dorsum, I find it difficult to do that with a curved piece of cartilage that simply doesn’t have adequate shape for the complete dorsal line. But it is often used when a septal graft is not available and the concept of a rib graft seems too extreme. In a subsequent revisional rhinoplasty, the ear cartilage graft can be removed and replaced with a rib cartilage graft which offers a straighter piece that can be more assuredly shaped to the desired result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is it true that it is hard to have a bloc rib cartilage inserted into the nose since I've got so many diced rib cartilage pieces in the nose? Will the surgery be somewhat messy and exhibit unpredictable outcome? A surgeon I consulted said he may need to remove all those diced pieces and that he doesn’t believe I will have enough rib cartilage to be harvested and carved into a bloc graft. I was somewhat speechless, because I thought rib cartilage is abundant. Then he pointed out that since I'm already 26 years old most of the rib cartilage has ossified. I'm really confused. Please help, thanks very much Dr Eppley.
A: With a prior diced cartilage graft nasal augmentation, it does make it more difficult to replace it with a new solid cartilage graft. But just because it is a little more difficult does not make it impossible. Many times diced cartilage grafts can be removed without a lot of difficulty because they have fused into a near solid mass that is held together by scar/fibrous tissue. I do not see the inswelling diced cartilage being a big obstacle to a second effort at a rhinoplasty for more dorsal augmentation. It is not true that at age 26 most of your ribs are ossified. I can assure you that your ribs # 6,7,8, and 9 are still very cartilaginous and abundant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Let me say right off the bat that I've had rhinoplasty 3 times. The first one, done in 1999, was kind of silly because the change was so minute that I felt I wasted my time and money. My complaint was that I wanted my bridge to be higher. The doctor took a bone off my hip, and placed it on top my nose. Basically it looked the same. Yet, I dealt with it and moved on but the feeling that the surgery was a failure never went away. I did a second rhinoplasty in 2005. The doctor placed Gortex on top my nose towards the bridge, which made my nose look a little dented in at the middle part of the nose. For a few years, I tried to convince myself of a positive change, but to no avail. Lastly, the third surgery was done in 2009 to address the dent. The surgery was successful in removing the slight dent but it didn't remove how I felt about my profile. All the doctors made conservative changes to my nose which I am fine with since my intention was not to change the racial characteristics of my nose. Again, I did it with the hope that it would improve my facial profile.
None of these surgeries addressed my main concern which is to make my profile at the midface less pushed in looking when I am expressive with my face. When I do this my profile looks ape-like, so I try not to make expressive facial profile which is really hard to do. It is not easy to walk around stoned face. I also had Invisilign work done last year. This was not done to correct crooked or misaligned teeth, as I have relatively straight teeth. It was to hopefully undo the imperfection I see in my profile while at the same time maintaining my facial identity. My teeth still flares out. The results were not a major difference from what I started with. So basically my teeth is the same way. The orthodontic treatment was done by filing in between the teeth to create space for the teeth to move back. I did this because I absolutely didn't want to loose four teeth to create space. I didn't see any noticeable change.
All the above doctors I visited were never aware of my underlining concern which is that I am not please with my profile because it make me look ape-like, due to how the mid part of my face is position with respect to the lower part, especially when I make facial expressions. This is not an easy issue for me to talk about so I kept it to myself instead of disclosing my feelings to the doctors. The orthodontist I visited last year told me that I have a large lower jaw and a smaller upper jaw which is the reason he was having trouble getting my teeth in the position he wanted, which was more vertical. Hence, the teeth moved backed, but not much. The change was so imperceptible (honestly I don't think It made any difference what so ever to my face) that no one ever commented to me of any change.
That is pretty much my situation in a nutshell. I am not happy with my profile, and as you would expect it is hurting my ability to live a happy, social life because of the way I feel about myself. I've attached pictures for you to look at. Pictures are of me after all procedures.
A: Thank you for sharing your surgical history, concerns and pictures. Your fundamental underlying problem is maxillary alveolar prognathism, which is common with your ethnicity. I am not surprised that orthodontics alone, of any form, did not improve that problem., It never had a chance to, its movements are too small for your problem. Ultimately you would have to have upper teeth extracted and the entire cant of the maxillary incisors brought back in to make a visible difference. Your rhinoplasty using a bone graft was a poor choice because that type of nasal augmentation will end up just resorbing, even if you get enough dorsal augmentation. A cartilage rib graft would have been much better. You had had three inadequate dorsal augmentation approaches because the materials and their volumes used were insufficient. You need a combined dorsal onlay with a columellar strut approach to get a much higher dorsal profile.
There are other midfacial procedures that can be used to help change your profile at rest or in expression but their effectiveness is uncertain. These include augmentations of the paranasal and cheek bones. And perhaps a good nasal augmentation with paranasal implant enhancement may be beneficial. I have attached a computer imaging prediction of that potential outcome.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m an Asian patient who underwent augmentation rhinoplasty 4 months ago with diced rib cartilage, but the augmentation isn’t enough. When I consulted the surgeon, he said the diced cartilage technique either undercorrects or overcorrects the nose. With bloc rib rhinoplasty, it’s easier to control precision of the augmentation required but subject to warping. Is that true? I’m planning to have another revision to augment the height again using bloc rib cartilage. What do you think? How long more do I have to wait for a revision? I just wish to push for more height. Thanks.
A: In general, diced cartilage for total dorsal augmentation can be a very satisfactory technique if the amount of height required is no more than 3 or 4mms. For most Asian rhinoplasties, sufficient dorsal height is usually closer to 7mms. Thus a diced cartilage dorsal augmentation may be insufficient because the push of the skin at this amount of augmentation is significant and the diced cartilage construct is not strong enough to resist it. So even if the diced cartilage roll was 7mm in height, it would be pushed back down and flattened somewhat. A bloc cartilage graft is much more successful in displacing the dorsal nasal skin upward the required amount for the obvious reason thatit is solid and can not be deformed. While it is true that bloc cartilage has the risk of warping, the key to prevention of that problem lies in the harvest. Rib grafts are absolutely needed and getting a fairly straight cartilage graft of 3.5 to 4cms in length can be difficult but it can be done.
As for the timing of the revision, since you know you desire more now that the initial swelling has gone down you could proceed at any time with a revisional rib graft rhinoplasty.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, when using diced cartilage graft for nose augmentation do you overgraft to compensate for potential resorption? Did you use a columellar strut on your nasal augmentations and do you do anything for wide and flared nostrils? In some rib graft rhinoplasty results, the nose looks pinched. I have read that some doctors place two extra grafts on each side of the nose giving the frontal view a very nice look to it. What are these grafts and how are they done? While I love the idea of diced cartilage mainly because there is less chance of warping, I am concerned that there would not be enough build up to achieve the height that I desire with this. In addition, my rib graft rhinoplasties that I see have a tip that is bulbous and not sharp. I would like a much pointier and defined tip. I feel like this is one of the biggest flaws I keep seeing over and over in the before and after results that I have seen on asian ethnicity patients. It seems as if the surgeons augmented the bridge and completely forgot the tip.
A: In answer to your questions:
1) In looking/suspecting the degree of augmentation that you want from your rhinoplasty, I would ‘overgraft’ as much as possible. The limiting factor in any augmentation rhinoplasty is what the skin will accomodate (how much can it be stretched) and how much recoil (deformational elastic limit) the skin will do. The thicker the skin, the greater the elastic recoil will be. (push back) This is what leads to resorption of cartilage more than any other factor.
2) Columellar struts are used in every augmentation rhinoplasty. The length of the columellar strut and its stiffness (thickness) depends on how much nasal tip lengthening is needed. Most non-Caucasian rhinoplasties need and get nostril narrowing as part of their rhinoplasty.
3) There is no question that whole rib grafts are going to give more of a push on the skin and resist recoil than any diced cartilage graft. Given the result you are showing, a whole rib graft would need to be used as that is pushing it to the limits of what the skin can tolerate. What you are referring to as ‘side grafts’ are known as lower alar rim grafts, sometimes called batten grafts. (although this is not technically correct) They are placed obliquely to the rib graft at the nasal tip. This adds expansion/fullness to the lower alar cartilages so that when the tip gets significcantly elevated, it is not like a tent pole sticking out of the top of the tent. (pinched look)
4) What you are seeing in the tip is more often a conservative approach to tip projection/stress, rather than ignoring the refinement of the tip area. You have to remember that when you significantly push the tip up in an open rhinoplasty, the tip skin over the graft has very little blood supply. There is a real risk of tip skin necrosis after surgery, a disastrous event in rhinoplasty. There are well documented cases of it happening and I have seen it with a bone graft many years ago. In your type of nose, the columella is very short. Once you push up the tip area with rib grafting, the open rhinoplasty incision must be closed. If the rib graft is too high, one can not close the columellar incision. Pulling the tip skin down pushes the partially devascularized nasal tip skin tight over the graft. This is where the risk of tip skin death is and the blood supply may get cut off. This is an important issue to recognize during surgery as a sharp point on the end of the rib graft, if the skin is too tight, will cause this problem to occur. It is far better to have a more rounded end of the rib graft and not too tight of columellar skin closure over it to avoid this nightmare of a problem. This is the likely biologic explanation for some of the nasal tip results you are seeing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, why is diced cartilage used in rhinoplasty? What is the risk of cartilage graft resorption in the nose? Does diced cartilage resorb less than regular cartilage? In using diced cartilage wrapped in surgicel, I keep coming upon studies showing that when compared to a patient’s fascia, it is much more often reabsorbed, at a much faster and greater rate. I would not like to use fascia just because I don’t feel it is 100% necessary in my case as well as avoiding another part of my body altered for this rhinoplasty. However, I am quite concerned about resorption of these diced cartilage grafts. What would you say would be your estimated percentage of resorption if it were to occur? Rib rhinoplasty is quite a major operation, I would not like to go through such a procedure with an additional scar on my body for an outcome that wasn’t dramatic or only to be reabsorbed down the line.
A: The concept of ‘dicing’ cartilage for rhinoplasty is to make it more malleable, eliminate warping (and the insertion of metal pins into solid grafts to try and avoid that problem) and to avoid excessive pressure on the overlying skin when solid graft is used. The cartilage graft is cut into small 1mm cubes and then placed into a collagen container. (sausage roll) This creates many tiny pores/channels into the graft that allow it to become very quickly revascularized and filled with collagen fibrous tissue which makes it become firm. Whether diced cartilage grafts or solid cartilage grafts have more or less resorption is a matter of debate and there is no clear science that demonstrates that one is necessarily better than the other when it comes to resorption resistance. In theory, the rapid revascularization and nourishing of the diced cartilage would lead to less resorption long-term. As the what causes a graft, of any source and tissue type, to resorb or not is how quickly it can re-establish nourishment. (blood supply) That being said, I have not seen significant resorption with either type of cartilage grafting in the nose.
There is largely one animal study that has created the spin-off of the negative use of Surgicel in diced cartilage grafts. Whether that translates to humans is speculation and has never been proven or shown. Certainly Surgicel is more convenient for the patient as it avoids a donor scalp scar. But when the patient will permit it and is accepting of a temporal scalp scar, the use of one’s own fascia is always a more natural choice that will have less inflammatory response than that of an oxidized cellulose material. It would seem logical that less of an inflammatory response would lower the potential risk of some cartilage graft resorption.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, My Dr suggested that I can benefit from Rib Graft rhinoplasty about a year and half ago. At that time I did not exactly what that consist of, and I figured he knew best, so he went on and performed it. I hated the way it looked and felt. So a year later, I had him remove it. Once he removed it, my nose right underneath my lip felt loose. And when I looked in the mirror it was really visibly loose, when turn my head on either side. Another example is, when onlooker under my bed, I can feel it sliding once side to the other. He told me that he sutured the anterior nasal spine to the caudal septum, and he is depending on scar tissue hold tight. Based on their notes from the rib graft, they removed a piece in the anterior spine, but I don’t know how much they removed, because it still feels normal. Please give me your advice or a solution.
A: By your description it sounds like the columellar skin is loose. The anterior nasal spine is a bony structure and does not move. Neither does the caudal end of the septum being a cartilaginous structure. You did not say whether your rib graft rhinoplasty was a dorsal only graft or a combined L-strut dorso-columellar graft. But that issue aside, the only way to stabilize the columella is a cartilage graft placed between the medial footplates (columellar strut graft) and anchored to the anterior nasal spine.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about the best material to use in an ethnic rhinoplasty. (I happen to be Asian) Surgeons seem to prefer rib cartilage because they feel it is safer. How big would the scar to take it be? Could you provide me with more information about using rib cartilage. I have looked at some before and afters with a couple of different docs and it seems you are able to do more with rib cartilage to achieve the rather large difference I am looking for as far as height of the bridge and tip goes. What do you think of the noses in the desired result photos I have attached?
A: In further detail about rhinoplasty augmentation, there is no question in my mind that the better long-term material for many ethnic rhinoplasties thqt require significant dorsal augmentation as well as tip projection by grafting is cartilage. To not limit oneself by the amount of graft material, rib cartilage is always better because there is no restriction on volume. While rib graft rhinoplasty is harder on both the patient and the surgeon, and there is a resultant scar, your own tissue is always best over the rest your long remaining lifetime. Speaking of the scar, it is about 3.5 cms long low along the costal margin on the left or right side. (lower end of the middle of the rib cage) I usually take it from the opposite of the patient’s hand dominance so there may be less discomfort afterwards with less arm/body motion. While some surgeon’s use the rib graft as a whole block that is carved for dorsal augmentation, I find it much better to cut the rib grafts into tiny 1mm pieces (cubes) and rhen placed those inside a wrapped collagen sheet, making a moldeable implant. (aka diced cartilage graft) Then once it is placed it can be shaped into the desired form and amount of augmentation. Once held together for a week with the nasal splint, it becomes quite firm amazingly quickly. This not only makes for a customized shaped graft but avoids the biggest problem with dorsal rib grafts…malposition and warping. There is also the possibility of a little external molding when the splint is removed for adjustment until it becomes one firm solid graft.
In looking at some of the noses you sent, the question is whether your nose can achieve that look. I think the best way to think about it is probably not. There noses are more refined and, most importantly, they have thinner skin…the final determinant that ultimately influences much of a rhinoplasty result. But with significant dorsal augmentation, a columellar strut to increase nasal projection and a tip graft, you will end up a lot closer than where you are now.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had a terrible broken nose when I was 10. The resulting deviated septum (and septal perforation) caused terrible nosebleeds throughout adulthood, but the structure of my nose looked good visibly. I had a septoplasty to correct the deviation in 2005 and hopefully stop the horrific nosebleeds. The results were terrible. My septum (which I was told before surgery had a pinhole in it) collapsed and I now have a saddle deformity and the tip is much wider and bulbous. I am told the hole in the septum is about the size of a pinky fingernail. Functionally, it is average. The septum is straight but crust builds up in the perforation and usually blocks one side of my breathing. Aesthetically, I am very disappointed. I still have very bad nosebleeds, but not quite as severe. How experienced are you with this procedure? About how many have you done? Successful results? If you think you may be able to help correct this, I would like to set up a consult. Thanks!
A: You appear to have two separate but challenging nasal issues, that of a septal perforation and a saddle nose deformity from collapse. This combination nasal problem is not rare and loss of septal support is the main reason for a saddle nose problem. The saddle nose deformity is best corrected through an open rhinoplasty approach using a rib cartilage graft to build back up the dorsal line and provide some tip projection and support. That is a very effective and successful procedure. Septal perforation repair, particularly if it is large, is a very difficult problem and has a high rate of failure. This is due to the lack of good mucosal tissue to move and provide a vascularized lining coverage on both sides of the nose. If it is a perforation bigger than 10mm in diameter, it may prove to be quite difficult to try and fix and you may be better served to leave that part of your nasal problem alone.
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
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
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
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
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
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
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
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