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Rhinoplasty frequently uses cartilage grafts to aid in the reshaping of the nose. They are used to either create a shape in the nose that did not exist before to providing support of native cartilage structures that have been altered. Most commonly septal cartilage is harvested and used, not only because of anatomic proximity, but also because it provides straight and reasonably strong graft material.

Rib grafts are another source of cartilage grafts for use in rhinoplasty of which their primary benefit is the volume of material they provide. Their role in primary rhinoplasty is usually only when major augmentations are needed in which the patient does not want the use of an implant. In revisional rhinoplasties rib grafts come into play when septal and ear harvests sites are exhausted or if the length/straightness of the facial harvest sites is inadequate.

One of the unique types of rib grafting is in the revisional rhinoplasty where the patient desires the bottom third of the nose to be extended. Specifically an extension of the columella forward with increased tip projection and a sharper/more pointy nasal tip. This requires a straight and strong cartilage graft to achieve this effect in the previously grafted and scarred nose. 

They cartilaginous end of rib #9 is a good harvest site when the need is for a straight 3 to 4 cm long cartilage piece. It is harvested through a 3 cm subcostal skin incision. It can be shaved into a narrow in width piece that matches the existing with of the medial footplates of the columellar. It must be placed resting inferiorly just above the anterior nasal spine up to the tip. It is held into place initially with a 30 gauge needle.

Once sutures are placed firmly securing the graft the needle is removed. The amount of tip extension is adjusted based on redraping of the nasal skin over the tip of the nose. If excessive blanching of the tip skin occurs the length of the rib graft is reduced by a millimeter or two.

Rib grafts provide the necessary structural support that is needed in many revisional rhinoplasties where contour expansion is needed. There are numerous rib graft site harvest options and that choice depends how much graft is needed. The subcostal margin offers a plentiful source if the patient can tolerate a small skin incision to do so.   

Dr. Barry Eppley

Indianapolis, Indiana

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