Patients may have unsatisfactory results in their first rhinoplasty that may lead them in seeking a secondary rhinoplasty or revision rhinoplasty. Secondary rhinoplasty may also be needed for traumatic nasal injuries, particularly when the nasal bridge is impacted inward. (saddle nose deformity)
Many plastic surgeons prefer to use autologous cartilage tissue whenever possible for these types of rhinoplasty due to its much lower risk of infection or long-term exposure or extrusion. Autologous cartilage will be incorporated into the surrounding tissues of the nose allowing it to remodel if necessary rather than the overlying skin or internal lining (mucosa) breaking down.
These type of nasal deformities may require a good source of cartilage. Of the three cartilage donor sources, (septum, ear, and rib) rib cartilage is a natural and only autologous source that can offer an unlimited amount of cartilage that has more than adequate lengths.
One of the main advantages of rib grafts is its plentiful supply. However, rib grafts are almost always curved and cartilage is well known for its memory. (recall of shape) As a result, it has a tendency to warp or return somewhat to its original shape despite being carved and shaped. Symmetric concentric carving of the rib cartilage will lessen the incidence of postoperative warping. Another way to prevent warping is to insert a thin metal pin through the graft to keep it straight.
The most common reason for a rib graft rhinoplasty is the saddle nose deformity. Correction of this nasal problem requires a significant amount of graft material. The rib graft is carved and reconstructed by assembling it into a two-piece L-shaped graft which is placed through an open rhinoplasty. A longer larger piece is shaped into a dorsal graft and a smaller piece into a columellar strut. If an intact septum is present, then only the onlay dorsal graft will be needed to correct the deformity. Careful graft carving and assembly is needed to minimize the risk of graft warping. Once positioned, the tip cartilages (dome) can be sutured over the end of the rib grafts.
One of the big concerns for patients who require rib graft rhinoplasties is the location and pain from the donor site. Rib cartilage grafting is the taking of cartilage from the cartilaginous portion of the rib. (the rib also has a bony portion too) While many take the fifth or sixth rib, I find this is usually not necessary. This takes more work and risk and causes a substantial amount of pain after surgery. Having done a lot of ear reconstructions with rib cartilage from this area, this is far more cartilage than is needed. I prefer to harvest the graft from the free floating 10th rib and the attached 9th rib. This is more than an ample amount of cartilage. In some cases, a split or shaved cartilage graft can be taken from the outer portion of the 8th rib. This is easier to harvest although it will have some curve to it. When the grafts are harvested from these areas, there is nor risk of pneumothorax, a release of air from the lungs by perforating its lining. The access incision is small, about 4 cms., and will lie along the bottom of one side of the rib cage.
Dr. Barry Eppley
Indianapolis, Indiana