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ACTA oTorhinolAryngologiCA iTAliCA 2013;33:190-195

Rib grafts in septorhinoplasty

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Key wordS: Reconstructive septhorhinoplasty • Grafts • Rib cartilage

riASSunTo

La cartilagine autologa viene generalmente considerata come il materiale di prima scelta per gli innesti nella cosiddetta settorinoplastica

ricostruttiva sia per quanto riguarda il sostegno strutturale del naso che per gli effetti di riempimento che da essa si possono ottenere. Nella

ristrutturazione dell’architettura di sostegno nasale il tessuto cartilagineo può essere ricavato dal setto, dal padiglione auricolare o dalla

costa. Quest’ultima sede rappresenta il sito donatore principale nelle ricostruzioni maggiori ed in particolare nella chirurgia di revisione

da eseguire in pazienti con deplezione cartilaginea. La cartilagine costale autologa se confrontata con omoinnesti ed impianti alloplastici

presenta una bassa percentuale di complicanze, soprattutto infezioni ed estrusione anche se non è scevra da possibile riassorbimento e

distorsione. Nel presente studio gli Autori analizzano e discutono l’impiego della cartilagine costale autologa in 54 pazienti sottoposti asettorinoplastica primaria o di revisione e ne suggeriscono l’impiego in tutti quei casi in cui vi è la necessità di avere a disposizione una

congrua quantità di tessuto da innestare per ristabilire la struttura di sostegno e migliorare la funzionalità nasale.

PArole ChiAve: Settorinoplastica ricostruttiva • Innesti • Cartilagine costale

Acta Otorhinolaryngol Ital 2013;33:190-195

Introduction

Grats in septorhinoplasty can be obtained rom dierent

autologous and homologous tissues or rom alloplastic

materials. Autologous cartilage presents many advantag-

es compared to other kinds o grats: it survives as a liv-

ing tissue, seldom undergoes resorption, does not stimu-

late an immune response, is ideal or all types o grating

and presents only biological costs, but its use requires

longer operation time. Septum, auricular concha and rib

are the best cartilaginous donor sites or autologous na-

sal grating. Rib cartilage is the grat material o choice

or dorsal augmentation and reconstructive support when

sucient septal cartilage is not available 1. Autologous

rib cartilage is oten overlooked in reconstructive sep-torhinoplasty because o potential donor-site morbidity

and the warping eect 2-8; however, its use is indispensa-

ble when large amounts o tissue and multiple grats are

required, especially in patients already surgically treated,

with cartilage depletion. Usually two teams work simul-taneously, but since most warping occurs within 15-60

min o harvesting (early warping), the same surgeon can

harvest the rib beore modeling the grat and preparing

the recipient site, preerably using an open approach, to

veriy cartilaginous structure modications. The central

portion o the 5th to 8th rib is preerred by some surgeons 9;

however, the 11th and 12th ree-foating ribs are naturally

straighter, require less carving and undergo less warp-

ing 10. To reduce the warping eect, Gunter suggested to

reinorce larger grats (dorsal onlay grat and columellar

strut) with a centrally placed Kirschner-wire to provide

a more stable and predictable result 6. The grat is pre-erably harvested rom the right side to prevent the pos-

sibility o conounding any cardiac chest pain, although

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in some cases, to acilitate a two-team approach, rib car-

tilage harvesting is perormed on the patient’s let side.

Rib cartilage can be harvested circumerentially, ater

superior and inerior perhicondrium elevation, taking

special precaution not to injure the inerior line neuro-

vascular bundle or closely adherent pleura on the medialsurace. Rib harvesting can be also limited to the outer

lamella preserving the internal costal arch. By preserv-

ing the inner lamella o the rib, postoperative morbidi-

ties, including pain, splinting and pneumothorax, are re-

duced 10. In revision rhinoplasty, the dorsum is requently

over-resected and the septal L-structure is weakened. In

these cases, dorsal spreader grats should be placed along

either side o the septum to provide a stable recipient site

or the dorsal onlay grat 11. The spreader grats should

be stabilized with horizontal mattress sutures at the same

level as the septum and extend rom the keystone area to

the septal angle in preparation or receiving the dorsal

onlay grat. Spreader grats are used to widen a narrow

dorsum when necessary to obtain better symmetry o the

middle third o the nose, but also to improve the acute

angle o the internal nasal valve when related respira-

tory insuciency is present. To restore eective L-strut

support, it is very important to prepare a precise pocket

between the medial crura or placement o the columellar

strut. To obtain a stable and strong medial ramework in

most severe depleted cartilaginous cases, it is necessary

to hinge the columellar strut with the dorsal grat 11. The

present study describes the authors’ experience in the useo autologous rib grats in primary and revision cases o

septorhinoplasty.

Methods

We retrospectively analyzed data rom 54 patients who

underwent septorhinoplasty using autologous rib cartilage

grats in the last 10 years. The study population consisted

o 33 male and 21 emale patients (mean age: 34 years; age

range: 16-64 years). All septorhinoplasties were perormed

under general anaesthesia in patients with depletion or de-

ormities o the osteocartilagineous nasal ramework usingan open approach. Twelve patients were primary cases: 8

with post-traumatic deormities and 4 presented congenital

abnormalities. Three patients showed stigmata o cocaine

abuse, 1 presented sequelae due to haematoma o the sep-

tum, and 38 were revision cases, 7 o which previously

treated with alloplastic implants. The patients had several

degrees o saddle nose deormity and complained o nasal

obstruction: in 42 cases, most o the septum was absent,

and 6 patients had previous aggressive septoplasty with

septal peroration in 2 cases. Eleven patients had internal

nasal valve insuciency. All patients showed tip deorm-

ity and alteration o the relationship between dorsal linesand columella-tip complex. In correction o the iatrogenic

nasal deormities such as stigmata o alloplastic implant,

saddle nose, septal perorations, valvular collapse and na-

sal airfow obstruction, the procedure included placement

o septal grats, alar, tip and dorsal onlay grats, spreader

grats, columellar struts and shield grats.

In male patients, an incision was made over the seventh

costal cartilage and in the women under the breast creaseto hide the scar. Ater skin incision, the external oblique

muscle was reached and the ascia over this muscle was

opened. The overlying muscles were spread, parallel o

the direction o their bres and appropriately retracted,

to reduce postoperative pain, until exposing the underly-

ing costal cartilage. The perichondrium was incised paral-

lel to the outer surace and circumerentially elevated to

perorm ull-thickness harvesting o the rib cartilage. In

some cases, when the harvesting was limited to the outer

lamella, the perichondrium was elevated only to the ex-

ternal surace. Once elevation was complete, the desired

section o the rib was perormed.

Fig. 1. Full-thickness harvesting o the rib.

Fig. 2. Harvesting o the rib limited to the outer lamella.

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Rib cartilage can be removed ull-thickness (Fig. 1), tak-

ing special precaution to the neurovascular bundle or the

closely adherent pleura medially. The harvesting can be

also conducted only to the outer portion to maintain the

continuity o the internal costal arch (Fig. 2). By preserv-

ing the inner lamella o the rib, postoperative morbidities,including pain, splinting and pneumothorax, are reduced.

Ater the grat was removed, the donor site was closed in

layers without drains. The harvested costal cartilage was

shaped as a vertical strip except in patients with severe

saddle nose deormity when a large amount o cartilage is

required to recreate the new L-structure with a columellar

strut hinged with a large dorsal grat (Fig. 3). The central

portion was usually used in dorsal reshaping (dorsal and

spreader grat) and or septal reconstruction, while the pe-

ripheral portion was shaped in alar and tip replacement

grats ater approximately 30 min to allow most o the

warping to occur. All the grats were inserted using an

open approach that oers the best exposure o nasal struc-

tures by providing grat positioning and stabilization in

the desired locations without distorsion. The costal carti-

lage grats were used as dorsal, septal and columellar strut

in all cases (Fig. 4), while spreader grats were utilized in

17 patients to provide urther stability to the septal grat or

to improve nasal valve unction. In each case, the dorsum

was made as fat and smooth as possible beore the dorsal

onlay grat was placed (Fig. 5). Alar and tip onlay grats

(Fig. 6) had various combinations with the previous grats

in 48 patients to address structural deects. Only in threecases, with underprojected tip, was a shield grat used.

Results

The ollow-up ranged rom 6 to 36 months, with an av-

erage o 18 months. None o the patients had any intra-

operative complications. Oral analgesic was always ad-

equate or pain control and chest pain subsided within

1 to 6 weeks postoperatively. Cosmetic appearance and

nasal obstruction were improved in all cases. Regarding

complications, none o the 54 patients had grats extru-

sion. Four patients had inection in recipient sites (3 onthe columella and 1 on the dorsum) with signicant grats

resorption in 2 cases with a history o cocaine abuse.

Warping deect was noticed in 3 patients ater the oedema

subsided. In 2 o these, distorsion occurred in the dorsal

onlay grat and revision surgery was required. In the third

Fig. 3. Preoperative and2-years postoperative photo-graphs o a patient who had twoprevious aggressive septorhino-plasty. All the grats used wereharvested rom rib cartilage.

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193

patient, minor warping occurred in the caudal septum and

columella, and revision was not required. Only two pa-

tients developed donor site complications: 1 patient with

early wound inection was successully treated with oral

antibiotics, and no urther intervention was required; the

other initially developed a seroma and a keloid scar o the

chest incision, which was treated with steroid injections.

Discussion

The goal o septorhinoplasty is reconstruction o the na-

sal skeleton to provide adequate structural support allow-

ing or optimum unctioning o the nasal airway while

achieving an aesthetically pleasing result with the rest o

the ace. Overall, autogenous grats, particularly cartilagi-

nous types, have been the gold standard largely because

o their large acceptance rate, durability, virtual lack o

an immunogenic response, low inection, and extrusion

rates 7 12-15. Autogenous costal cartilage grat is a viable

option in reconstructive septorhinoplasty. We advocate

the use o this grat in septorhinoplasty cases requiring

a large volume o tissues with severe structural deects in

which adequate septal tissue is not present 7 12. The main

disadvantage o the autogenous costal cartilage grat is its

tendency to warp rom tension orces on its surace 16. The

key to minimizing this eect is to make sure to carve thecartilage equally on each side, and thus maintain a bal-

anced cross section o the grat 6 8 17. Because most warp-

ing occurs within 15 to 60 min o harvesting, it is very

important to wait or early warping to occur and reshape

the grat beore placement 16 17. Possible warping deects

can be prevented by using balanced carving, using rigid

cartilage-bone xation or laminated grat or dorsal aug-

mentation, or by using a diced cartilage grat 18-22. Long-term warping, especially in larger dorsal and columellar

grats, can be also overcome using K-wires as advocated

by Gunter et al. 6.

One o the most important advantages o autogenous rib

cartilage is the low rate o inection and extrusion com-

pared to other non-autogenous materials or alloplastic

implants 1 14. Various types o allograts have been used

in reconstructive septorhinoplasty, particularly or dorsal

augmentation, including silastic, high-density porous poly-

ethylene (Medpor), and expanded polytetrafuoroethylene

(Gore-Tex) 7. Alloplastic implants have the advantages o

being easy to use, readily available and an unlimited supply.

Unortunately, because o their permanent nature, many o

these allograts are associated with long-term complica-

tions such as inection, migration, extrusion and palpabil-

ity 23-25. In contrast to conventional belies, some Asian sur-

geons report that autologous rib cartilage is associated with

a relatively high complication rate and a relatively low aes-

thetic satisaction outcome 21. They also report that compli-

cations, especially inections in revision rhinoplasty cases,

are related to the possibility o poor blood supply in the

recipient area particularly when large masses o grat are

used. In act, multiple grats may aect skin tension, andscar tissues rom previous surgery can reduce the vascular

supply to the grat site and increase the probability o inec-

tion 21 26. The relatively high complication rate is also re-

quently observed in patients with bad liestyle and related

to a history o cocaine abuse and/or alcohol consumption or

in smoker patients with metabolic diseases.

Conclusions

In selected primary septorhinoplasty and in patients

where there is previous compromise septal and conchal

donor sites, the only alternative is to use distant autog-enous tissue, homograts, or alloplastic materials. Auto-

grats do not induce an immune response, and also have

the lowest inection and extrusion rates o any currently

available materials. Autogenous rib cartilage grats are

the gold standard or nasal reconstruction in patients with

cartilage depletion and when large amounts o tissue are

needed. We have ound, according to other similar expe-

riences, that autogenous costal cartilage grating oers

strength or nasal support to replace or augment missing

tissue with similar tissue and recreates the nasal anatomy

as close to normal as possible.

We conclude that autogenous rib cartilage grats are anoutstanding material in septorhinoplasty when structural,

unctional and aesthetic problems are present and when

Fig. 4. Intraoperative view o the case shown in Figure 3. The dorsal on-lay grat positioned over spreader grats was used to make the dorsum asat and smooth as possible and to improve internal nasal valve dysunction.Caudal portion o the dorsal rib grat is placed under the cephalic margino the alar cartilages to make the internal nasal valve angle more rounded. Umbrella tip grat is sutured over the domes to achieve more tip projection.

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an eective volume lling and reconstruction o the nasal

structures are needed. Its use should however be adopted

keeping in mind the possibility o complications.

References

1 Porter JP. Grafts in rhinoplasty, alloplastic vs autogenous.Arch Otolaryngol Head Neck Surg 2000;126:558-61.

2 Brent B. The versatile cartilage autograft: current trends inclinical transplantation. Clin Plast Surg 1979;6:163-80.

3 Kim DW, Shah AR, Toriumi DM. Concentric and eccentriccarved costal cartilage. Arch Facial Plast Surg 2006;8:42-6.

4 Agaoglu G, Erol OO. In situ split costal cartilage graft har-vesting through a small incision using a gouge. Plast Recon-str Surg 2000;106:932-5.

5 Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Fa-cial Plast Surg 1997;13:279-90.

6 Gunter JP, Clark CP, Friedman RM. Internal stabilization of cartilaginous rib cartilage grafts in rhinoplasty: a barrier tocartilage warping. Plast Reconstr Surg 1997;100:161-9.

7 Moshaver A, Gantous A. The use of autogenous costal carti-lage graft in septorhinoplasty. Otolaryngol Head Neck Surg2007;137:862-7.

Fig. 5. Above: saddle nose asthe result o septoplasty withcomplications leading to almosttotal resorption o the septumand collapse o the cartilaginousvault. Below: the end result ob-tained by balancing the profle

through reconstruction o thecartilaginous dorsum and exci-sion o the osseous dorsum

Fig. 6. Intraoperative photograph o the case shown in Figure 5. Recon-struction o an L-shaped structure to support the dorsum completed withgrats to ensure the projection and defnition o the tip.

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8 Gibson T, Davis WB. The distortion of autogenous car-tilage grafts: its cause and prevention. Br J Plast Surg1958;10:257-73.

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18 Swanepoel PF, Fysh R. Laminated dorsal beam graft to elim-inate postoperative twisting complications. Arch Facial PlastSurg 2007;9:285-9.

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20 Daniel RK. Diced cartilage grafts in rhinoplasty surgery:current techniques and applications. Plast Reconstr Surg2008;122:1883-91.

21 Moon BJ, Lee HJ, Jang YJ. Outcomes following rhinoplastyusing autologous costal cartilage. Arch Facial Plast Surg2012;14:175-80.

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Address or correspondence: Antonio Moretti, Department o Me-

dical, Oral and Biotechnological Sciences, ENT Section “G. d’An-

nunzio” University o Chieti-Pescara, via dei Vestini, 66100 Chieti,

Italy. Tel. +39 0871 3554070 . E-mail: [email protected]

Received: December 15, 2012 - Accepted: January 7, 2013

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