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Emerging Issues In Rhinoplasty

 
Perfecting techniques of costal cartilage grafting in rhinoplasty
 
Grafting of costal cartilage (the cartilage that connects the sternum to the ends of the ribs) in rhinoplasty is highly complex and requires great attention to detail. Most surgeons would agree that the efficient use of costal cartilage in rhinoplasty requires many years of experience. Very few surgeons have experience working with costal cartilage, and there are no textbooks or medical literature describing costal cartilage grafting techniques. In many ways it is uncharted territory, and older techniques using costal cartilage can be imprecise and poorly defined.

Complicated rhinoplasties such as those that have been previously operated on, or those damaged due to trauma, frequently require cartilage grafting to repair the deformity. Most surgeons use ear cartilage when they require additional cartilage, even though it typically is weak and in short supply. After using ear cartilage for many years we found that noses reconstructed with ear cartilage tended to collapse or weaken over time.

In many cases, we noticed that noses lengthened using ear cartilage actually shortened over time with return of the initial deformity. Many of the patients we saw had multiple previous surgeries, and their ear cartilage previously had been harvested. Such cartilage-depleted noses required using rib cartilage to be repaired effectively.

Most surgeons who perform secondary rhinoplasty must use either ear or costal cartilage. Those who do not use costal cartilage are limited as to the degree they can repair complex nasal deformities such as the short nose.

Many surgeons are hesitant to use costal cartilage because of potential problems associated with its use. Some of the problems are associated to the morbidity of costal cartilage harvest. We use a very small incision usually measuring less than 2 cm in length. The scar from this incision can be hidden under a nickel, noting that the smaller incisions typically leave a smaller scar. Many surgeons will make a 4 to 5 cm incision leaving a very large scar on the chest.
The above scar is noted by the two black dots.  
The nickel is just right of the scar 

Another patient’s chest scar earlier postop shown at the bottom of the right breast. This scar will continue to fade with time.

Pain – some of it excessive – is also associated with rib cartilage harvest. Using our muscle preserving technique with limited dissection, most patients experience minimal post-surgical pain that is easily controlled with medication and decreases significantly within 36 hours of surgery. A recent study that we performed showed that the pain associated with costal cartilage harvest is no greater than that associated with ear cartilage harvest using our rib harvesting technique.

With costal cartilage, the grafts can warp or bend after being carved or shaped, due to the internal stresses of costal cartilage, as a result, bending needs to be controlled to prevent against deformity. Some surgeons use steel wires in cartilage grafts to avoid warping, and others dice the cartilage to avoid warping. Both techniques can have consequences. Using our technique of carving rib cartilage and selecting the proper graft has, over the last 20 years of using costal cartilage, minimized the chance of warping of grafts.

 We recently refined our technique to minimize other ill effects associated with costal cartilage. To reduce the effect of a stiff, unnatural feeling nose, for example, we have refined our technique so that grafts are used in a manner that minimizes stiffness in the nose, leaving the nose feeling more natural. To control the nose’s size and width, another unwanted side effect, we use numerous intraoperative measurements of nasal length, projection, and width to help insure that the agreed upon aesthetic goals are achieved.

We have tried to take the art of costal cartilage grafting in rhinoplasty to a new level. Using our costal cartilage techniques we are able to correct severe secondary rhinoplasty, post-traumatic, and even congenital cases.  

This patient underwent previous rhinoplasty that resulted in severe alar retraction and pinching of the middle nasal vault of the nose.  

Three years after reconstruction with costal cartilage improves the nasal shape and corrected the nostril deformity.

The patients lateral view shows the nostril retraction.

The postoperative lateral view shows the improved nostril position and smooth profile.

 

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