In any rhinoplasty procedure, structural support in the nose is paramount for natural, beautiful, and lasting results. Structural support is also a prerequisite for sustained functional breathing. The upper third of the nose is supported with the nasal bones, and the bony portion of the nasal septum (the midline wall inside the nose). Cartilage comprises the support for the lower two thirds of the nose, including the front part of the septum, and upper lateral cartilages (attached to the nasal bones), and the nasal tip cartilages (alar cartilages). Cartilage damage to the nose secondary to past rhinoplasty, assault injuries, sports or motor vehicle injuries, drug use, or autoimmune vascular compromise, can lead to deformation or collapse of the involved sites. Restoration of form and function during rhinoplasty often requires the use of cartilage as graft material. Typically, septum cartilage (the wall in the middle of the nose) is the best source material during rhinoplasty. However, septum cartilage may not be available or insufficient for intended use during rhinoplasty. In such cases, we can use ear cartilage or rib cartilage. Rib cartilage has several advantages: it is plentiful, strong, and straight. In instances of major nasal reconstruction, rib cartilage is our go-to source material for rhinoplasty.
There are two possible sources for rib cartilage: rib cartilage harvested from the patient (autologous), and rib cartilage available from commercial suppliers of cadaveric tissue. In general, we prefer autologous rib cartilage because of lower risk of rejection or infection. Additionally, the autologous cartilage quality is often superior since cadaveric rib is manipulated chemically and with radiation to eliminate any active biologic or infectious materials from the donor. Autologous rib is easier to shave, contour, and manipulate.
Autologous rib cartilage is harvested as a precursor to rhinoplasty. The procedure takes one hour to perform. We commonly use the sixth or seventh rib from the right side of the chest. The small incision in the chest results in a well-hidden scar. There is no visible depression or deformity at the site of rib harvest. The rib cartilage is then cut into appropriate grafts to be used during rhinoplasty. The cadaveric cartilage has the advantage of being available off-the-shelf in a frozen package. There is no additional incisions or surgical time.
In choosing which source of rib cartilage during rhinoplasty, we have a thorough discussion with each patient in reviewing the advantages and risks of autologous cartilage vs cadaveric rib cartilage. In the older patients, who may be at risk for additional time under general anesthesia, we favor the cadaver rib option. In healthy and younger patients, in patients with vascular compromise such as Wegener’s, and in cases where large volumes of cartilage are necessary such as saddle nose deformity, we recommend autologous rib cartilage. The ultimate decision on which option to use is made jointly with the patient.
The most common scenarios for use of rib cartilage are revision rhinoplasties. In cases of failed rhinoplasty, often too much supporting cartilage is removed, resulting in a bridge that is too low, nasal tip that is pinched, or a tip that is excessively upturned. Rib cartilage is also commonly used in patients who develop saddle nose deformity. Saddle nose is collapse of the middle part of the nose due to loss of support from the septum, usually seen in patients with autoimmune vascular problems or associated with septum perforation due to use of recreational drugs. Traumatic deformities of the nose are the next common indication for rib cartilage rhinoplasty. Having had extensive experience in harvest of autologous rib cartilage and performance of reconstructive and revision rhinoplasties, Dr Khosh is uniquely qualified to address the most intricate and complicated rhinoplasty cases.
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