Jul 13

Rib Cartilage in Rhinoplasty Surgery: The Beverly Hills Profiles Perspective

If you are reading this post, you likely had previous rhinoplasty and have now seen a revision surgeon who has recommended that you have rib cartilage removed during your revision surgery. The use of rib cartilage in revision rhinoplasty has become increasingly popular over the last many years as revision rhinoplasty surgeons continue to seek out alternative sources of cartilage for grafts that are often necessary during revision.

In our Los Angeles practice, we have always searched to replace “like with like.” And in this regard, whenever possible and it is available we prefer to use septal cartilage. Septal cartilage is usually considered the preferred first-line grafting material. It is usually firm and flexible and can provide the structural support needed as a grafting material.

Sometimes, however, the septal cartilage is too thin and flimsy and unsuitable for use; even in primary cases. And especially in revision rhinoplasty, the quantity and quality of remaining septal cartilage may be inadequate for reconstruction because of an aggressive previous septoplasty or simply because of the extent or number of defects requiring repair.

When septal cartilage is not available or is insufficient for the required revision we then discuss the various options with our patients. In our practice, these options include auricular cartilage, your own rib cartilage or irradiated cadaveric cartilage.

At Profiles, we find auricular cartilage to be primarily of us in those revision cases that require contouring issues to be resolved. In other words, if the lateral crus portion of the tip cartilage(s) are missing and causing a pinched appearance but not valve collapse ear cartilage can work well. Also in cases where retraction of the nostril has occurred ear cartilage can be used as either a composite graft or a “rim graft” to correct alar retraction. Moreover, contouring irregularities that cause the nose to look slightly crooked or the tip to be blunted can have ear cartilage used for correction. As a result, we use ear cartilage primarily in cases when a patient requires contouring but not structural support elements to be replaced.

As a result, in general we find auricular cartilage to be of limited use because of its intrinsic curved shape, which may make it an inappropriate material when caudal struts, caudal septal replacement grafts, or long straight dorsal augmentation onlays are necessary. Moreover, because auricular cartilage tends to be soft we do not think it works best for septal extension, tip grafts or other structural grafts.

So in the absence of sufficient septal cartilage and because of the shortcomings associated with ear cartilage, our next choice of graft material has been irradiated donor rib cartilage as opposed to your own rib cartilage.

First, the reasons why we have chosen not to turn to your own rib cartilage are numberous and meaningful:

  1. 1. There is no second incision or scar in your rib cage area and thus no risk of a hypertrophic scar in the region of your chest/ breast.
  2. Less postoperative pain- The reality is that when your own rib cartilage is harvested there is often days if not weeks of pain, which literally can occur with each breath as your rib cage expands and settles with each breath. One report cited up to 6 weeks of pain.
  3. There is a small but real possibility of  your lung collapsing (pneumothorax), or blood collecting around your lungs (hemothorax), and chest wall deformites.
  4. The harvest procedure alone adds to operative and anesthetic time and expense.
  5. Furthermore, as we age, rib cartilage begins to calcify, making some harvested rib cartilage difficult to carve.

The benefits of irradiated donor cartilage are numerous:

  1. No donor site morbidity.
  2. Irradiated rib cartilage material is readily available.
  3. Gamma irradiation could also cause stiffness and suppress resorption of cartilage.
  4. The irradiated cartilage is very well tolerated with minimal immune response.
  5. Costal cartilage is obtained from donors who are young (< 25 years, so that the ribs are not calcified) and have been screened and found negative for systemic diseases and local infection, metastatic cancer, or intravenous drug use, and were nonreactive to the Venereal Disease Research Laboratory test and tests for hepatitis and human immunodeficiency virus (HIV) antibodies.
  6. 6. Most importantly, in the largest study of its kind (Dr Russell Kridel in Houston) using irradiated rib cartilage in over 300 patients over a median range of 10 years follow up with over 1000 grafts found the average rate of graft warping (1%), infection (0.5%), and resorption (0.5%) was on par if not better than the numbers found in studies using patients own rib cartilage.

Revision rhinoplasty with irradiated rib cartilage

Revision Nose Job with Rib Cartilage

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2 comments

2 Comments so far

  1. Roberto Nibali September 6th, 2012 10:13 am

    In your short overview of cartilage grafts, you state that in the absence of sufficient septal cartilage your preference of graft material would be irradiated donor rib cartilage as opposed to one’s own rib cartilage. My question is, why not use irradiated donor septal cartilage before harvesting donor rib cartilage, knowing its shortcomings?

  2. admin September 7th, 2012 10:11 am

    Hi Roberto,

    Thank you for your excellent question. It would make sense that tissue banks could and should harvest septal cartilage as well but the likelihood is that septal cartilage is not present in sufficient stock, quantity, or demand to make it a feasible undertaking. More and more research is being done on tissue engineering to ‘manufacture’ septal cartilage from chondrocytes in the lab. This will be the future of tissue grafting.

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