**7. Discussion**

*Cosmetic Surgery*

The caudal end of the harvested rib graft is tapered and it should stop right above the lower lateral cartilages, for mobility of the lower one third of the nose. The final result should be a nose that is in tone with the rest of the Asian facial features. The onlay graft is secured in position by fixing with 2 or 3 fixation sutures with PDS 5.0, around the graft and through bilateral upper lateral cartilages. Capsule from a previous silicone implant is preserved during nasal dissection and used as a camouflage graft. Similarly, the harvested perichondrium from the rib or temporalis fascia

From the remaining portions of the rib, splint grafts, lateral crura strut grafts, caudal septal extension grafts (CSEG), columellar struts, etc. are carved (**Figure 7**). A CSEG is approximately 2 mm in thickness and trapezoidal in shape. If the septal cartilage is sufficient, a CSEG may be carved from the harvested septal cartilage. It can be fixed to the nasal L-strut in an end to end or overlapping fashion. Splint grafts are used on either side of the CSEG/L-strut complex to preserve the strength and resilience of the lower third of the nose. Extensive osteotomy may require spreader grafts as well to prevent internal valve collapse. In our experience, we have concluded that Asian clients rarely require osteotomies. Intranasal medial and lateral osteotomies are done for crooked bony dorsum. Medial osteotomy is done from the beginning of junction of upper lateral cartilage and nasal bone at a paramedian position; it is gently curved outwards at an angle of 10–15° as it proceeds upwards

can also be used to wrap around the rib and hide irregularities (**Figure 6**).

**24**

**Figure 6.**

**Figure 5.**

*Deep temporal fascia wrapped around the graft to hide irregularities.*

*CSEG and splint grafts carved from the remaining portion of the harvested rib.*

Artificial nasal implants (silicone, goretex) and filler injections have widely been used to augment the dorsum, increase the length of the nose and project the nasal tip in Asians. However, these render complications of their own such as a shrunken nose, an artificial appearance and hard feel of the nose, skin discoloration, and migration of implants, skin erosion and extrusion [12]. Asians expect a facially harmonized look and thus undergo more than three revision surgeries, to correct previous surgeries, improper use of implants, or surgical complications [13]. Rib graft is an ideal material for primary or revision rhinoplasty, owing to its abundant supply and rigid support (**Figures 8–10**). Chances of skin infection, necrosis and shrinkage are less with the use of costal cartilage. Many surgeons prefer harvesting the rib from the sixth, seventh or occasionally the eighth rib [14]. In female clients, the sixth costal cartilage is preferred as the oblique incision scar to harvest it may be hidden in the inframammary fold, and females generally would not prefer a long nose. In males, we harvest the seventh rib for a longer dorsum. Some Asian clients seek a Western esthetic nose; hence, surgeons may need to harvest more than one rib. The most common complications of rib grafting are the chances of warping and infection. Precise carving as mentioned above and soaking the rib in saline-gentamicin solution may reduce the risk of post surgery warping. Meticulous dissection during surgery, effective antibiotics and postoperative care are important. Multiple

grafts may affect skin tension, and scar tissues from previous surgeries can reduce the vascular supply to the graft and increase probability of infection [15].

#### **Figure 8.**

*Case 2. This female underwent open rhinoplasty with autogenous costal cartilage grafting and ear cartilage grafting for tip refinement. These pictures are taken before and 3 months after surgery.*

#### **Figure 9.**

*Case 3. A case of cleft nasal deformity underwent open rhinoplasty with autologous rib cartilage grafting. These pictures are before and 1 year after surgery.*

**27**

**Conflicts of interest**

**Figure 10.**

**Authors' contributions**

concept of the study.

There are no conflicts of interest.

study and provided cases and material for the study.

*Costal Cartilage Graft in Asian Rhinoplasty: Surgical Techniques*

*harvested for nasal dorsal, premaxillary and paranasal augmentation.*

Cadaver rib may also be used for rhinoplasty, but since it is not live, autologous tissue, it may form a capsule due to unassimilated tissue, has higher long term absorption rate, risk of transmitting diseases such as HIV, hepatitis, etc. and possibility of soft tissue loss if infection control is delayed [16, 17]. Calvarial bone grafts are also becoming popular with the advances in craniofacial surgery. When morphologically compared with endochondral bone, membranous bone has a thicker cortical plate, smaller endocortical cancellous area, and stronger intracortical struts [18]. Hence, calvarial bones are also a good material of choice for augmentation rhinoplasty. This bone also resembles the other facial bones and can be easily incorporated into the nasal framework. The risk of significant absorption is less, however, there is a possibility of injury to the dura and intracranial structures, hematoma/seroma, with inadequate training [19]. The fundamental strength of the osseocartilaginous rib graft lies in replacing like with like [8]. A rib graft allows for bony integration with the nasal dorsum, immobilizes the graft and allows for meticulous sculpting of the nasal tip. However, autologous costal cartilage should be used keeping the possibility of complications

*Case 4. A case of saddle nose deformity who had augmentation with silicone implant previously. Two ribs were* 

in mind, especially when a large amount of graft material is required.

Dr. Chuan-Hsiang Kao made contribution to the conception and design of the

Dr. Sarina Rajbhandari made contribution to the presentation of the text and

*DOI: http://dx.doi.org/10.5772/intechopen.91613*

#### **Figure 10.**

*Cosmetic Surgery*

grafts may affect skin tension, and scar tissues from previous surgeries can reduce

*Case 2. This female underwent open rhinoplasty with autogenous costal cartilage grafting and ear cartilage* 

*Case 3. A case of cleft nasal deformity underwent open rhinoplasty with autologous rib cartilage grafting.* 

*grafting for tip refinement. These pictures are taken before and 3 months after surgery.*

the vascular supply to the graft and increase probability of infection [15].

**26**

**Figure 9.**

*These pictures are before and 1 year after surgery.*

**Figure 8.**

*Case 4. A case of saddle nose deformity who had augmentation with silicone implant previously. Two ribs were harvested for nasal dorsal, premaxillary and paranasal augmentation.*

Cadaver rib may also be used for rhinoplasty, but since it is not live, autologous tissue, it may form a capsule due to unassimilated tissue, has higher long term absorption rate, risk of transmitting diseases such as HIV, hepatitis, etc. and possibility of soft tissue loss if infection control is delayed [16, 17]. Calvarial bone grafts are also becoming popular with the advances in craniofacial surgery. When morphologically compared with endochondral bone, membranous bone has a thicker cortical plate, smaller endocortical cancellous area, and stronger intracortical struts [18]. Hence, calvarial bones are also a good material of choice for augmentation rhinoplasty. This bone also resembles the other facial bones and can be easily incorporated into the nasal framework. The risk of significant absorption is less, however, there is a possibility of injury to the dura and intracranial structures, hematoma/seroma, with inadequate training [19].

The fundamental strength of the osseocartilaginous rib graft lies in replacing like with like [8]. A rib graft allows for bony integration with the nasal dorsum, immobilizes the graft and allows for meticulous sculpting of the nasal tip. However, autologous costal cartilage should be used keeping the possibility of complications in mind, especially when a large amount of graft material is required.

## **Conflicts of interest**

There are no conflicts of interest.

## **Authors' contributions**

Dr. Chuan-Hsiang Kao made contribution to the conception and design of the study and provided cases and material for the study.

Dr. Sarina Rajbhandari made contribution to the presentation of the text and concept of the study.

*Cosmetic Surgery*
