**6. Carving the rib cartilage**

Before carving the costal cartilage graft, we measure the height of the nose at the nasion, rhinion and nasal tip. This helps us to decide the extent of carving of our graft. The dorsal graft and spreader grafts are carved from the middle portion of the harvested rib. The client's skin thickness is kept in consideration while carving the graft. In thick skinned people, the final outcome may not be as obvious as in thin skinned people. Sharp lines and angles appear blunted under a thick skin (**Figure 3**).

**23**

**Figure 4.**

*augment the radix height.*

**Figure 3.**

*operative differences.*

*Costal Cartilage Graft in Asian Rhinoplasty: Surgical Techniques*

maintaining a balanced cross section of the graft.

We carve the graft into a "fusiform" shape; which is tapered off at both ends with a wider mid region (**Figure 4**). The concave portion of the graft acts as the bottom of the implant. Precise carving and smoothening, with serial checking by inserting the graft inside the nasal skin-soft tissue flap is done, to determine the suitable height and width of the anticipated nasal shape. Balanced cuts are made in the cartilage in several directions to prevent warping. Most warping occurs within 15–60 min of harvesting and it is important to wait for early warping and reshape the graft before placement [10, 11]. Thus, the graft is carved equally on both sides,

The superior aspect of the graft to be placed over the radix is placed in an uphill converging manner to rest over the underlying bone (**Figure 5**). An additional rib cartilage may be assembled underneath the onlay graft for extended augmentation.

*Measurement of the nose is taken at the nasion, rhinion and nasal tip to determine the pre operative and post* 

*(a) Rib graft is carved in a fusiform shape. (b) Perichondrium is sutured to the cephalic end of the graft to* 

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

#### *Costal Cartilage Graft in Asian Rhinoplasty: Surgical Techniques DOI: http://dx.doi.org/10.5772/intechopen.91613*

We carve the graft into a "fusiform" shape; which is tapered off at both ends with a wider mid region (**Figure 4**). The concave portion of the graft acts as the bottom of the implant. Precise carving and smoothening, with serial checking by inserting the graft inside the nasal skin-soft tissue flap is done, to determine the suitable height and width of the anticipated nasal shape. Balanced cuts are made in the cartilage in several directions to prevent warping. Most warping occurs within 15–60 min of harvesting and it is important to wait for early warping and reshape the graft before placement [10, 11]. Thus, the graft is carved equally on both sides, maintaining a balanced cross section of the graft.

The superior aspect of the graft to be placed over the radix is placed in an uphill converging manner to rest over the underlying bone (**Figure 5**). An additional rib cartilage may be assembled underneath the onlay graft for extended augmentation.

#### **Figure 3.**

*Cosmetic Surgery*

suture removal (**Figure 2**).

**Figure 2.**

**4. Dissection of the nose**

**5. Harvesting the conchal cartilage**

**6. Carving the rib cartilage**

6-0 interrupted sutures. 5-0 PDS or vicryl may be used subcutaneously to avoid

*The scar immediately after wound closure is almost invisible 1 year after surgery.*

We make an inverted V incision along the midcolumella, which is connected with bilateral marginal incisions. The skin flap is elevated to the level of perichondrium of the lower lateral cartilage. We use tenotomy scissors and elevators for this step. In presence of excess subcutaneous tissue in thick skin clients, it may be removed (but not aggressively) for more post operative tip definition. Septum is approached by separating the two medial crura and the subperichondrial plane of the caudal septum is identified. The septum is exposed by elevating bilateral mucoperichondrial flaps and separated from the upper lateral cartilage. A dorsal-caudal L-shaped strut of the septum is preserved for septal support. This harvested septal graft may be used as caudal septal extension graft (CSEG) or splint grafts, but they may be deficient in revision cases.

Cavum and cymba conchal cartilage is preferred for tip grafts and lateral crura strut grafts (LCSG) due to its curvature and elasticity. This is done via a post auricular approach, making an incision with a no. 15 blade. Skin and perichondrium are elevated from the underlying perichondrium and dissection is proceeded using appropriate scissors or also blunt dissection can be done with cotton-tip applicators. We should stop the dissection short of the cartilage of the external auditory canal. We generally preserve the radix helicis, to preserve the ear position. The cymba and cavum conchal are harvested as two separate entities and put in the saline-gentamicin solution along with the harvested rib and septum. The incision is sutured using nylon 6-0 running mattress sutures.

Before carving the costal cartilage graft, we measure the height of the nose at the nasion, rhinion and nasal tip. This helps us to decide the extent of carving of our graft. The dorsal graft and spreader grafts are carved from the middle portion of the harvested rib. The client's skin thickness is kept in consideration while carving the graft. In thick skinned people, the final outcome may not be as obvious as in thin skinned people. Sharp lines and angles appear blunted under a thick skin (**Figure 3**).

**22**

*Measurement of the nose is taken at the nasion, rhinion and nasal tip to determine the pre operative and post operative differences.*

#### **Figure 4.**

*(a) Rib graft is carved in a fusiform shape. (b) Perichondrium is sutured to the cephalic end of the graft to augment the radix height.*

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

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

**Figure 5.** *CSEG and splint grafts carved from the remaining portion of the harvested rib.*

**25**

Asians.

**Figure 7.**

*are taken before and 1 year after surgery.*

**7. Discussion**

*Costal Cartilage Graft in Asian Rhinoplasty: Surgical Techniques*

to connect with the lateral osteotomy. Lateral osteotomy is started just above the level of the inferior turbinate and is usually performed in a low-low-high fashion in

*Case 1. A young female underwent open rhinoplasty with autologous rib cartilage augmentation. The pictures* 

afterwards, but in some cases, it may be performed.

When augmentation is done, the client might not need an alar flare reduction

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

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

**Figure 6.** *Deep temporal fascia wrapped around the graft to hide irregularities.*

**Figure 7.** *Case 1. A young female underwent open rhinoplasty with autologous rib cartilage augmentation. The pictures are taken before and 1 year after surgery.*

to connect with the lateral osteotomy. Lateral osteotomy is started just above the level of the inferior turbinate and is usually performed in a low-low-high fashion in Asians.

When augmentation is done, the client might not need an alar flare reduction afterwards, but in some cases, it may be performed.
