Costal Cartilage Graft in Asian Rhinoplasty: Surgical Techniques

*Sarina Rajbhandari and Chuan-Hsiang Kao*

## **Abstract**

Asian rhinoplasty is one of the most difficult and challenging surgeries in facial plastic surgery. As many Asians desire a higher nasal bridge and a refined nasal tip, they undergo various augmentation procedures such as artificial implant grafting and filler injections. Autologous rib graft is a very versatile graft material that can be used to augment the nose, with lesser complications, if done precisely. In this chapter, we have discussed the steps of rib graft harvesting, carving and setting into the nose to form a new dorsal height.

**Keywords:** rhinoplasty, costal cartilage, Asians, warping

### **1. Introduction**

Asian rhinoplasty is one of the most difficult and challenging surgeries in facial plastic surgery. In Asians, the most common complaints regarding appearance of the nose are a low dorsum and an unrefined tip. Thus, most Asian rhinoplasties include augmentation of the nasal dorsum using either autologous or artificial implant, and/or nasal tip surgery. Clients who have had augmentation rhinoplasty previously frequently opt for revision. Hence, when a client comes for augmentation or Asian rhinoplasty, the surgeon has to confirm whether the client has had any rhinoplasty (or several rhinoplasties) earlier. Artificial nasal implants for augmentation are still in vogue, owing to their simplicity and efficiency, but they are accompanied by several major and minor complications. Revision surgeries for these complications include correcting nasal contour deformities and fix functional problems, and require a considerable amount of cartilage. Revision surgeries are more complex than primary Asian rhinoplasty as they require intricate reconstruction and the framework might be deficient.

The debate regarding optimal graft material still persists. Silastic silicone implants cause a high incidence of early and late complications. There is a modern trend of minimal invasive rhinoplasty, such as threads insertion rhinoplasty and injectable filler rhinoplasty. But, these necessitate repeated procedures which may result in complications.

Autologous cartilage was first used in rhinoplasty in 1900 by Von Mangoldt for syphilitic noses [1]. Septal cartilage, conchal cartilage, and costal cartilage are the most common autologous graft materials used for augmentation. Each of these has their own advantages and disadvantages. Grafts with low resorption rates and sufficient strength for framework support offer consistent long-term results. Since alloplastic material increases the rate of infection, wound contracture and extrusion, autologous tissue is preferred [2].

We need to understand the characteristics of autologous grafts and consider where and how to apply them. Ear cartilage is highly elastic and has sufficient thickness and a natural curve. Hence, it can be used in areas requiring curvature, or can be manipulated by cutting in half and suturing the opposite sides; to be used as a straighter graft [3]. Septal cartilage may be abundant in Westerners but scarce and frail in Asians to be used for augmentation. Furthermore, in revision cases, patients might not have remaining or harvestable septal cartilage or even conchal cartilage. Costal cartilage has an advantage of providing a significant volume, but might cause warping, which is a common and unpredictable complication, and also leaves a scar in the chest [4, 5]. Grafts having low complication rates and high long-term patient satisfaction are considered ideal for grafting [6]. These qualities are noticed in autografts and are regarded as better alternatives for Asian rhinoplasty. Every Asian patient undergoing rhinoplasty must be properly evaluated as the outcome may vary in every patient.

In this chapter, we have discussed our techniques of harvesting and using the costal cartilage to augment and enhance the nose in Asians. Despite its abundance, costal cartilage also brings complications. But, when autologous rib cartilage rhinoplasty is performed by an experienced surgeon, it will provide an excellent, reliable, and lasting result with low risk [7]. Below, we have mentioned how to minimize the complications of harvesting and utilizing a costal cartilage and improve our surgical results.

#### **2. Preoperative assessment**

An elaborate understanding of the client's expectations should be understood. What the surgeon might feel as an appropriate nasal dorsum height or nasal tip projection might not be satisfactory for the client. In these instances, simulation techniques to exhibit the probable post operative outcomes can be discussed with the client, but realistic results should be clarified.

Before surgery, we ask the client to carry out common investigations required for general anesthesia; such as complete blood count, bleeding profile, blood grouping, renal function tests, X-ray of the chest and electrocardiogram. Rib harvesting might also call for a CT scan of the chest to check for ossification of the rib, which is often seen in individuals over 40 years of age, although, we have experienced circumstances where even younger individuals presented with ossified ribs.

The surgery can be carried out by a single team or could be a two team approach where one team works on the nose and the other focuses on harvesting the rib. The second approach accounts for a lesser operative time and the rib is generally harvested from the left side, since the surgeon operating on the nose is usually on the right. In our practice, we have the same team operating on the nose and harvesting the rib, hence, we harvest the rib from the right chest wall.

#### **3. Harvesting the rib cartilage**

The incision site is normally over the right sixth or seventh rib. Some surgeons also prefer the floating rib at the inferolateral costal margin [8]. Similarly, when additional cartilage is required, we also harvest the eighth or ninth rib. The medial portion of the seventh rib cartilage is long enough for a caudal septal extension graft or a columellar strut and a dorsal implant can be easily carved from its midrib portion, which is wide and thick enough. A premaxillary graft can be carved from its lateral portion. Our incision is a short linear inframammary incision. The incision site scar is the most major concern while harvesting a rib, but a smaller incision with detailed suturing and hiding the scar in the inframammary fold conceal the post operative scar and settle the client's

**21**

**Figure 1.**

*Costal Cartilage Graft in Asian Rhinoplasty: Surgical Techniques*

issues regarding it. After infiltrating local anesthesia, we make an incision with a No. 10 or 15 blade, at the middle of the inframammary fold, around 2–3 cm in length, although in beginners, it is better to make a longer incision for better view and ease. In males, the incision is made directly over the concerned rib. To avoid exaggerated scarring, it is better to not extend the incision beyond the vertical line from medial nipple-areolacomplex [9]. When a female client has decided to have a breast augmentation in the future, we make sure to place out incision 7.5–8 cm below the nipple, which is generally the anticipated new inframammary fold. In a female who has already undergone breast

augmentation, we have to be careful to not rupture the capsule of the implant. We then perform meticulous dissection along the subcutaneous tissue and muscle fascia plane, reaching and dividing the extracostal muscle directly over the rib. The oblique abdominis and rectus abdominis muscle are vertically split and retracted. The underlying rib is identified and checked for ossification by pricking it with a syringe needle. Medially, our dissection is the junction of the rib cartilage with the sternum and laterally is the osteochondral junction. The selected rib is thus exposed, followed by a longitudinal incision through its perichondrium, along the length of its central axis. Careful circumferential subperichondrial dissection is carried out underneath the rib, exposing its posterior aspect. One must be cautious to not injure the perichondrium, which might cause complications such as pneumothorax. From the superior aspect of the rib, we also harvest some perichondrium to use as graft material. Under direct vision, a curved or right angled elevator is used to lift the rib from the underlying perichondrium. The rib is incised halfway through its thickness with a knife and proceeded with an elevator. Medially, the rib is incised at its attachment near the sternum and laterally, at the bony rib junction. This harvested rib measures 4.5–6 cm in length (**Figure 1**). In revision cases, we may require to harvest a part of the adjacent rib as well. These graft materials are submerged in normal saline with gentamicin solution. While operating on the nose,

the graft remains in this solution and is observed for warping.

Before closure, we irrigate the donor site with thermal saline and check for absence of air bubbles when positive pressure ventilation is provided. This will help us ensure that there is no injury to the lung pleura/or absence of pneumothorax. Closure is done in layers. To reduce post operative pain and to facilitate proper drainage of blood, the fascia over the muscle is closed with interrupted sutures, using vicryl 3-0 sutures. Subcutaneous closure is done by vicryl 4-0 sutures and skin closure by nylon

*Perichondrium is harvested along with the 7th rib cartilage. The cymba and cavum concha are also harvested.*

*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*

*Cosmetic Surgery*

**2. Preoperative assessment**

**3. Harvesting the rib cartilage**

the client, but realistic results should be clarified.

We need to understand the characteristics of autologous grafts and consider where and how to apply them. Ear cartilage is highly elastic and has sufficient thickness and a natural curve. Hence, it can be used in areas requiring curvature, or can be manipulated by cutting in half and suturing the opposite sides; to be used as a straighter graft [3]. Septal cartilage may be abundant in Westerners but scarce and frail in Asians to be used for augmentation. Furthermore, in revision cases, patients might not have remaining or harvestable septal cartilage or even conchal cartilage. Costal cartilage has an advantage of providing a significant volume, but might cause warping, which is a common and unpredictable complication, and also leaves a scar in the chest [4, 5]. Grafts having low complication rates and high long-term patient satisfaction are considered ideal for grafting [6]. These qualities are noticed in autografts and are regarded as better alternatives for Asian rhinoplasty. Every Asian patient undergoing rhinoplasty

In this chapter, we have discussed our techniques of harvesting and using the costal cartilage to augment and enhance the nose in Asians. Despite its abundance, costal cartilage also brings complications. But, when autologous rib cartilage rhinoplasty is performed by an experienced surgeon, it will provide an excellent, reliable, and lasting result with low risk [7]. Below, we have mentioned how to minimize the complications

An elaborate understanding of the client's expectations should be understood. What the surgeon might feel as an appropriate nasal dorsum height or nasal tip projection might not be satisfactory for the client. In these instances, simulation techniques to exhibit the probable post operative outcomes can be discussed with

Before surgery, we ask the client to carry out common investigations required for general anesthesia; such as complete blood count, bleeding profile, blood grouping, renal function tests, X-ray of the chest and electrocardiogram. Rib harvesting might also call for a CT scan of the chest to check for ossification of the rib, which is often seen in individuals over 40 years of age, although, we have experienced circum-

The surgery can be carried out by a single team or could be a two team approach where one team works on the nose and the other focuses on harvesting the rib. The second approach accounts for a lesser operative time and the rib is generally harvested from the left side, since the surgeon operating on the nose is usually on the right. In our practice, we have the same team operating on the nose and harvesting

The incision site is normally over the right sixth or seventh rib. Some surgeons also prefer the floating rib at the inferolateral costal margin [8]. Similarly, when additional cartilage is required, we also harvest the eighth or ninth rib. The medial portion of the seventh rib cartilage is long enough for a caudal septal extension graft or a columellar strut and a dorsal implant can be easily carved from its midrib portion, which is wide and thick enough. A premaxillary graft can be carved from its lateral portion. Our incision is a short linear inframammary incision. The incision site scar is the most major concern while harvesting a rib, but a smaller incision with detailed suturing and hiding the scar in the inframammary fold conceal the post operative scar and settle the client's

must be properly evaluated as the outcome may vary in every patient.

of harvesting and utilizing a costal cartilage and improve our surgical results.

stances where even younger individuals presented with ossified ribs.

the rib, hence, we harvest the rib from the right chest wall.

**20**

issues regarding it. After infiltrating local anesthesia, we make an incision with a No. 10 or 15 blade, at the middle of the inframammary fold, around 2–3 cm in length, although in beginners, it is better to make a longer incision for better view and ease. In males, the incision is made directly over the concerned rib. To avoid exaggerated scarring, it is better to not extend the incision beyond the vertical line from medial nipple-areolacomplex [9]. When a female client has decided to have a breast augmentation in the future, we make sure to place out incision 7.5–8 cm below the nipple, which is generally the anticipated new inframammary fold. In a female who has already undergone breast augmentation, we have to be careful to not rupture the capsule of the implant.

We then perform meticulous dissection along the subcutaneous tissue and muscle fascia plane, reaching and dividing the extracostal muscle directly over the rib. The oblique abdominis and rectus abdominis muscle are vertically split and retracted. The underlying rib is identified and checked for ossification by pricking it with a syringe needle. Medially, our dissection is the junction of the rib cartilage with the sternum and laterally is the osteochondral junction. The selected rib is thus exposed, followed by a longitudinal incision through its perichondrium, along the length of its central axis. Careful circumferential subperichondrial dissection is carried out underneath the rib, exposing its posterior aspect. One must be cautious to not injure the perichondrium, which might cause complications such as pneumothorax. From the superior aspect of the rib, we also harvest some perichondrium to use as graft material. Under direct vision, a curved or right angled elevator is used to lift the rib from the underlying perichondrium. The rib is incised halfway through its thickness with a knife and proceeded with an elevator. Medially, the rib is incised at its attachment near the sternum and laterally, at the bony rib junction. This harvested rib measures 4.5–6 cm in length (**Figure 1**). In revision cases, we may require to harvest a part of the adjacent rib as well. These graft materials are submerged in normal saline with gentamicin solution. While operating on the nose, the graft remains in this solution and is observed for warping.

Before closure, we irrigate the donor site with thermal saline and check for absence of air bubbles when positive pressure ventilation is provided. This will help us ensure that there is no injury to the lung pleura/or absence of pneumothorax. Closure is done in layers. To reduce post operative pain and to facilitate proper drainage of blood, the fascia over the muscle is closed with interrupted sutures, using vicryl 3-0 sutures. Subcutaneous closure is done by vicryl 4-0 sutures and skin closure by nylon

**Figure 1.** *Perichondrium is harvested along with the 7th rib cartilage. The cymba and cavum concha are also harvested.*

**Figure 2.** *The scar immediately after wound closure is almost invisible 1 year after surgery.*

6-0 interrupted sutures. 5-0 PDS or vicryl may be used subcutaneously to avoid suture removal (**Figure 2**).
