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Dean Toriumi, M.D.


FAQ

 
Why do I prefer using costal cartilage in many patients undergoing rhinoplasty?
 

Costal (rib) cartilage is the strong abundant cartilage from the rib cage. The ribs are usually made-up of both cartilage and bone.  This cartilage is excellent for grafting in the nose.  I typically use the costal cartilage from the 6th or 7th ribs.  I take the cartilage from the right side of the chest through a small incision (approximately 1.5 inches long). Costal cartilage can bend or warp if not used properly, so I use special techniques to prepare the costal cartilage that significantly decrease the chances of warping or bending. In fact, we have had no warping in our last 120 rhinoplasties using costal cartilage grafts.

My preferred cartilage grafting material is septal cartilage.  In many patients, there is not enough septal cartilage to create adequate structural support or proper contour.  When septal cartilage is not sufficient, alternative grafting materials are needed.  I prefer to use cartilage over any other material, including implants.  In fact, I do not use any type of artificial implant material, such as Gore-Tex or Silicone. These materials can become infected, extrude, or damage the overlying skin.  If the septal cartilage is not adequate, ear cartilage can be used.  Unfortunately, ear cartilage is relatively weak, is irregular in shape, and only provides smaller pieces of cartilage.  This is why, when septal cartilage is not available, I will often use costal cartilage.  Not only does it allow me to perform a rhinoplasty to my satisfaction, but I have found costal cartilage to be the strongest and most abundant cartilage source available. We also have a very low complication rate harvesting and using costal cartilage. I prefer to use costal cartilage for augmentation rhinoplasty in Asian patients, saddle nose repair, short nose repair, and secondary rhinoplasty.

Costal cartilage provides an abundant source of cartilage for grafting, which is very important in the secondary rhinoplasty patient. From the same small incision in the chest, I  can get both costal cartilage and soft tissue for camouflage.  This soft tissue, called perichondrium, is the fibrous covering over the cartilage and is an excellent material for camouflaging cartilage grafts so they do not show up over time. The perichondrium can also be used to thicken very thin skin and to help hide small irregularities on the dorsum and tip.

I have also found that it takes less time and is less painful for patients to take a rib graft than to take cartilage from both ears. We use a technique of rib cartilage harvest that minimizes the postoperative pain, and the small incision on the bottom of the right breast hides well under a bra or two piece bathing suit.

Costal cartilage is very strong, and it resists the forces of scar contracture that can destroy a good rhinoplasty outcome.  In the absence of infection, we have not seen any resorption of the costal cartilage over time.  We have seen resorption of costal cartilage in cases of severe infection. This is one reason why we have patients take antibiotics after surgery  We have been using costal cartilage for over 17 years and have developed sound techniques for working with this excellent grafting material.

It is my opinion that a large number of rhinoplasties fail because of a lifelong scar contracture affect that tends to narrow and collapse the nose.  Many patients who have undergone rhinoplasty had a good or reasonable outcome initially that worsened over time.  Most patients whom I see for secondary rhinoplasty state that their nose was improved at first but then got worse and worse over many years.  The reason is that the previous operation weakened the nose, setting it up for collapse and excessive narrowing over time as the skin over the cartilages contracts. Additionally, every time the patient breathes in, there is a suction effect on the cartilages and soft tissues of the nose, which contributes to collapse of the lateral wall and middle segment (middle nasal vault) of the nose. I also believe that, after surgery, the nose will continue to heal and change over the patients entire lifetime. Most of these changes tend to present as narrowing or pinching.  For this reason, placing strong cartilage grafts to resist these forces will provide the best chance for a good long-term outcome.

To help prevent graft visibility and deformity, I use the perichondrium that covers the rib cartilage to make the skin thicker and intentionally create extra swelling.  Although this tends to make the nose swollen longer right after surgery, perichondrium helps to provide a better long term outcome. I am much less concerned about the short term result and focus heavily on attaining a good long term outcome. In many thin skinned patients I intentionally create swelling by using perichondrium and crushed cartilage to help avoid deformity over the long term. I do this because many secondary patients that I see have had multiple previous secondary operations, with each one looking better for awhile then going bad over time. I am trying to end this cycle and give the patient an outcome that will last his or her lifetime. This requires a completely different approach that compromises the patients short-term result due to swelling and a slight degree of over-correction. I tend to over-correct by about 10% in terms of the width of the nose. This over-correction factor accounts for the changes that will occur over the patients lifetime, including scar contracture that will tend to shrink the nose and create collapse.

The ideal scenario is that the patient will experience gradual improvement in their nasal appearance over the first 3 months, with the nose looking good but still large at 9 months to a year. These patients noses will continue to shrink and improve over their lifetime instead of looking good early on and then getting worse and worse over time, eventually requiring another operation. I have many patients that have large noses for a couple of years then shrink and look very good after two or three years with additional improvement over 10 to 15 years. My philosophy is that if I am to operate on a patient my primary goal is to give them a life long aesthetic and functional outcome. This approach is time consuming and difficult which explain why my operations average 4 to 5 hours for a primary and 5 to 7 hours for a secondary rhinoplasty. Other surgeons can do a couple of rhinoplasties in the time it takes me to one rhinoplasty. However, my goal is not to do a lot of rhinoplasties but rather do the best I can to provide the patient with a good result that last for their lifetime. This approach to rhinoplasty surgery has worked well for my patients.

Below is a description of a surgery using costal cartilage.

 

<click on images to enlarge>

Pre-Operative Photo Post-Operative Photo

 
This patient underwent two  previous rhinoplasties and excision of a skin lesion from the left side of her nose, leaving her with a very short nose and severe retraction of her left alar margin. She had nasal obstruction due to nasal valve collapse. She also has a low dorsum. She had her septal cartilage and ear cartilage harvested in previous surgeries. Correction required harvesting costal cartilage from her right chest. We used a 1.5 incision under her right breast to harvest the rib cartilage.
 
Pre-Operative Photo Post-Operative Photo

 
The rib cartilage was needed because of the tightness and scarring of her skin. Ear cartilage would not allow adequate correction of the defect. The rib cartilage is very strong and provided a sturdier reconstruction that will be longer lasting and more permanent. This case nicely demonstrates the versatility and capability of costal cartilage. I could not make such changes with septal or ear cartilage.
 
Pre-Operative Photo Post-Operative Photo

 
Initially her nose was very swollen, but the swelling went down nicely over about six months. She has relatively thin skin, so I would prefer that the swelling go down at a slower rate to minimize the chances of graft visibility.
 
Pre-Operative Photo Post-Operative Photo

 

 

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