COSMETIC

Harvesting Rib Cartilage Grafts forSecondary Rhinoplasty

Vincent P. Marin, M.D.Alan Landecker, M.D.

Jack P. Gunter, M.D.

Dallas, Texas; and Sao Paulo, Brazil

Background: Reconstruction of the nasal osseocartilaginous framework is thefoundation of successful secondary rhinoplasty.Methods: Achieving this often requires large quantities of cartilage to correctboth contour deformities and functional problems caused by previous proce-dures. Satisfactory and consistent long-term results rely on using grafts with lowresorption rates and sufficient strength to offer adequate support. Auricularcartilage, irradiated cartilage, and alloplastic materials have all been used asimplantable grafts with limited success.Results: In the senior author’s experience (J.P.G.), rib cartilage has proven tobe a reliable, abundant, and relatively accessible donor with which to facilitatesuccessful secondary rhinoplasty surgery.Conclusions: The authors describe in detail the techniques that they have foundto be integral in harvesting rib cartilage grafts for secondary rhinoplasty. (Plast.Reconstr. Surg. 121: 1442, 2008.)

Reconstruction of the nasal osseocartilagi-nous framework is the foundation of suc-cessful secondary rhinoplasty.1,2 Achieving

this often requires large quantities of cartilage tocorrect both contour deformities and functionalproblems caused by previous procedures.3–5 Satis-factory and consistent long-term results rely onusing grafts with low resorption rates and sufficientstrength to offer adequate support.4,6–8 As in primaryrhinoplasty, autologous tissue is always preferred be-cause the use of alloplastic material increases therate of infection and/or extrusion.9–14

There are five potential donor sites for autol-ogous grafts in secondary rhinoplasty: septal carti-lage, auricular cartilage, rib cartilage, and iliac andcalvarial bone.1,3–5,15–17 The septum is the preferredsource in secondary rhinoplasty because it requiresno additional incisions, there is no significant donor-

site morbidity, and its harvest may correct septaldeviations and improve the airway.4,17,18

Unfortunately, the quantity of septal cartilageavailable is frequently insufficient, which mandatesthe use of alternative donor sites. In the senior au-thor’s (J.P.G.) experience, the rib provides the mostabundant source of cartilage for graft fabricationand is the material of choice when reliable structuralsupport is needed. Ear cartilage is used occasionallybut is less successful when structural support ismandatory.3,16 Finally, bone is rarely used because ofits variable postoperative resorption and diffi-cult handling properties.15,17 In this article, rel-evant aspects of harvesting rib cartilage are pre-sented and analyzed.

RIB CARTILAGEAs previously mentioned, the rib offers an

abundant supply of cartilage for use in virtually

From the Department of Plastic Surgery, University of TexasSouthwestern Medical Center, and private practice.Received for publication June 4, 2006; accepted December 4,2006.Video, Supplemental Digital Content 1: Harvesting of ribcartilage graft.Video, Supplemental Digital Content 2: Secondary rhino-plasty using rib cartilage grafts.Reprinted and reformatted from the original article publishedwith the April 2008 issue (Plast Reconstr Surg. 2008;121:1442–1448).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318269c36e

Disclosure: None of the authors has a financialinterest in any of the products, devices, or drugsmentioned in this article.

Please go to the online version of the Journalat www.PRSJournal.com to see the online vid-eos associated with this article.

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every aspect of secondary rhinoplasty and is thepreferred donor site when rigid support is neces-sary. The most significant advantage of rib carti-lage is that grafts can be produced with consider-able versatility with respect to shape, length, andwidth. This facilitates reconstruction of the nasalframework in patients with virtually all types offunctional and aesthetic requirements.

However, use of rib cartilage has several disad-vantages. First, an additional incision at a distantdonor site is required to harvest the cartilage. For-tunately, the resulting scar is relatively short (ap-proximately 5 cm) and is generally inconspicuous inwomen because of its placement under the breast.Additional concerns include postoperative pain, therisk of pneumothorax, and the potential of rib car-tilage to warp.19 The latter may lead to long-termpostoperative distortions of nasal shape. The use ofstabilizing Kirschner wires placed through the cen-ter of these grafts has been a successful technique forcounterbalancing these tendencies.20 In olderpatients, ossification of the cartilaginous rib is a sig-nificant concern. Therefore, a limited computed to-mographic scan of the sternum and ribs is recom-mended in those patients where there is a high indexof suspicion (Fig. 1). Experienced radiologists candetermine the extent of calcification in the cartilag-inous rib, which will indicate the likelihood of suc-cess with a rib grafting procedure (Fig. 2). In ouroffice, we commonly order a limited computed to-mographic scan of the sternum with special requestfor axial images of the sternum and costosternaljunctions with coronal reformations.

Extensive calcification of the cartilaginous ribs willgreatly impair graft preparation and use. In patientswhoneedmultiplecartilagegrafts,wewillnormallynot proceed with attempts at autologous reconstruction

when these findings are encountered.

MARKINGRib cartilage harvesting is preferentially per-

formed on the patient’s left side to facilitate atwo-team approach. Marking is initiated by pal-pating the sternomanubrial joint, which indicatesthe position of the second rib. The ribs are thenpalpated and numbered according to their posi-tion. The fifth, sixth, or seventh rib is most oftenselected for harvest.

In female patients, the incision is marked ap-proximately 5 mm above the inframammary foldand measures 5 cm in length. The incision shouldnot extend beyond the medial extent of the in-framammary fold. This avoids postoperative visi-bility of the incision if the patient wears low-cutclothing (Fig. 3).Fig. 1. Normal rib cartilage with limited calcification.

Fig. 2. Calcified right and left rib cartilage.

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In male patients, placement of the incision isnot as important unless there is a hair-bearing areain which the incision can be camouflaged. If not,the incision is usually placed directly over the cho-sen rib to facilitate the dissection (Fig. 4).

TECHNIQUEThe amount of cartilage required dictates

whether the cartilaginous segment from one rib,one rib and a portion of another, or the entirecartilage segments of two ribs need to be har-vested. In general, one should choose the carti-laginous portion of a rib that provides a straightsegment with sufficient cartilage to fabricate allgrafts. It is often possible to construct all requiredgrafts from the cartilaginous portion of a singlerib. If additional grafts are needed, a part or the

entire cartilaginous portion of a remaining ribmay be harvested.

After placement of the incision has been de-cided, the harvesting procedure begins by incisingthe skin using a no. 15 blade. The subcutaneous,fascial, and muscle layers are then transected us-ing electrocautery (Fig. 5).

If the patient has had a previous breast aug-mentation, it is best to avoid entering the capsuleor exerting undue pressure superiorly to avoidrupturing the implant. Gentle retraction can beused to displace the implant during the dissection.It is generally prudent to attempt to harvest ribsthat are more distant from the capsule first. If thecapsule is violated, extensive irrigation of thepocket with an antibiotic solution and careful clo-sure with absorbable sutures is recommended.Once the muscle fascia has been reached, it isimportant to palpate the underlying ribs to ensurethat the dissection proceeds directly over the lon-gitudinal axis of the chosen rib.

Knowing the position of both bony-cartilagi-nous junctions is important to ensure that the

Fig. 3. Incision placement in a female patient.

Fig. 4. Incision placement in a male patient.Fig. 5. (Above) Rectus muscle fascia. (Below) Rectus musclefascia divided.

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maximum length of each rib is harvested, therebyoptimizing the efficiency of the procedure. Afterexposing the selected rib, a longitudinal incisionis made through the perichondrium along thelength of the central axis of the rib (Fig. 6). Per-pendicular cuts are also made at the most medialand lateral aspects of the cartilaginous rib to fa-cilitate reflection of the perichondrium.

The dissection should be carried medially un-til the junction of the rib cartilage and sternumcan be palpated. The most lateral extent of thedissection is demarcated by the costochondraljunction. Identification of the junction is facili-tated by the subtle change in color at the interface;the cartilaginous portion is generally off-white incolor, whereas the bone demonstrates a distinctreddish gray hue. In older patients, the cartilagetends to be more yellow and friable, often withfocal calcifications.

To ensure the position of the lateral bony-car-tilaginous junction, the sharp point of the Bovieneedle is pressed against the anterior surface ofthe rib. It will easily penetrate into cartilage but notbone (Fig. 7). A Dingman elevator is then used toelevate perichondrial flaps based on the superiorand inferior borders of the rib cartilage (Fig. 8).

The dissection is then continued subperichon-drially until the posterior aspect of the rib is ex-posed. During elevation, the perichondrium maybecome tight and limit further dissection. If thisoccurs, it is useful to perform additional perpen-dicular back-cuts on the anterior surface of theperichondrial flap to release tension. Perichon-drial elevators are then used to release the pos-terior adherence between the cartilage andperichondrium as far as possible (Fig. 9). Acurved rib stripper completes the posterior dis-

section (Fig. 10). We have found it useful to passthe tip of the rib stripper with gentle upwardforce to stay within the subperichondrial space.However, care must be taken to not enter thebody of the cartilaginous rib or cause a fracturethat may limit graft fabrication.

Fig. 8. Perichondrial flap reflected superiorly with a hemostat.

Fig. 6. Longitudinal perichondrial incision.

Fig. 7. (Above) Penetration of a Colorado needle into cartilage.(Below) Nonpenetration of a Colorado needle into bone.

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The remainder of the subperichondrial dis-section is generally straightforward and bloodless,provided that the perichondrium is not violatedand the correct plane is maintained. The curvedrib stripper is slid back and forth along the rib,taking care to stay between the cartilage andperichondrium until the undermining is com-plete (Fig. 11). Perichondrial tears should beavoided so that a tight postoperative closure canlater be accomplished to help “splint” the wound,which aids in relieving postoperative pain.

The final step involves separating the cartilag-inous rib from its medial attachments near thesternum and laterally at the bony rib. This is per-formed by making a partial-thickness right-angledincision using a no. 15 blade at the aforemen-tioned junctions (Fig. 12). The separation canthen be completed by inserting a curved rib strip-per under the incision sites and the sharp end of

a Freer elevator used with gentle side-to-side move-ments to complete the incision (Fig. 13). Once thecartilage segment is released both medially andlaterally, the graft is easily removed from thewound and placed in sterile saline with gentamicin(50 mg/500 cc) until the surgeon is ready forfabrication (Fig. 14).

If more grafting material is required, a portionof cartilage or the entire cartilaginous part of an-other rib should then be harvested. After choosingan adjacent donor rib, access to the perichon-drium is obtained by undermining deep to theexisting muscle. By avoiding an additional incisionthrough the fascia and muscle, this prevents thecreation of a “bridge” of denervated and devas-cularized muscle between adjacent ribs, whichmay result in delayed healing at the donor site.

After exposing the perichondrium on the an-terior surface of the adjacent rib, harvesting of itsentire cartilaginous portion is performed as out-

Fig. 9. Posterior dissection of the perichondrium.

Fig. 10. Placement of the rib stripper.

Fig. 11. The rib stripper completes the posterior dissection.

Fig. 12. Incision of cartilage at the osseocartilaginous junction.

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lined above. In some situations, it may be sufficientto harvest only a segment of the subsequent rib. Ifthis is the case, the perichondrium does not needto be elevated circumferentially as previously de-scribed. Instead, the desired amount of cartilageshould be defined and marked. Then, a perichon-drial flap is created by incising and elevating theperichondrium only over the surfaces of themarked cartilage. The chosen segment is thenincised with a no. 15 blade and harvested using asharp elevator.

After hemostasis is achieved, the donor site ischecked to ensure that no pneumothorax has oc-curred. The wound is filled with saline solutionand the anesthesiologist applies positive pressureinto the lungs. If no air leak is detected, a pneu-mothorax can be excluded. A 16-gauge Angiocathcatheter (Becton Dickinson, Franklin Lakes, N.J.)is inserted through the skin and placed in the

subperichondrial space. The wound may then beclosed in layers. Particular attention should bedirected at reapproximating the perichondrium.It is important to attempt to close the perichon-drium tightly because this layer is fairly rigid andmay help to “splint” the wound and reduce post-operative pain. The Angiocath is secured to theskin to avoid accidental removal.

Wound closure is completed by approximat-ing the muscle and fascial layers using 2-0 Vicrylsutures (Ethicon, Inc., Somerville, N.J.). Skin clo-sure is carried out using deep dermal and subcu-ticular 4-0 Monocryl sutures (Ethicon) (Fig. 15)(see Video, Supplemental Digital Content 1,which demonstrates harvesting of rib cartilagegraft, http://links.lww.com/A397).

CALCIFIED CARTILAGEDespite appropriate preoperative screening,

occasionally patients will present with prematurecalcification of the cartilaginous rib. Frequently,this is limited and at the junction of the osseousand cartilaginous rib. A straight osteotome or el-

Fig. 13. Disarticulation of cartilage with a Freer elevator.

Fig. 14. Harvested rib cartilage graft.

Fig. 15. (Above)Finalclosurewithcathetersecured. (Below)Finaldressing.

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evator can gently lift the calcification to provideadequate access to the underlying cartilage.

Small foci of calcification may also be foundwithin the body of the rib cartilage itself. This canimpair the preparation of individual grafts and actas a site of weakness, often having a tendency tofracture. We have found that the use of a smoothdiamond burr can also prove useful in contouringareas of calcification to salvage these uncommoncircumstances. If the cartilage is unexpectedlyfound to be so extensively calcified at the time ofthe operation that it is unusable, we would thenconsider the use of irradiated donor cartilage, ac-cepting the increased risks of progressive resorp-tion over time.

COMPLICATIONSIf a pneumothorax has been diagnosed, this

usually represents an injury only to the parietalpleura and not to the lung parenchyma itself. Assuch, this does not mandate chest tube placement.Rather, a red rubber catheter can be insertedthrough the parietal pleural tear into the thoraciccavity. The incision should then be closed, as pre-viously described, in layers around the catheter.Positive pressure is then applied and the catheteris clamped with a hemostat until the surgeon isprepared to remove it. At the end of the operation,the anesthesiologist applies maximal positive pres-sure into the lungs and holds this as the catheteris placed on suction and removed. A postoperativechest radiograph should be taken if there is anyconcern about the effectiveness of reestablishingnegative pressure within the pleural space.

POSTOPERATIVE ANALGESIABefore the patient leaves the operating room, 10

ml of 0.25% Marcaine solution (AstraZeneca, Lon-don, England) is injected into the subperichondrialspace before removal of the Angiocath. This mea-sure has helped reduce patient discomfort at thedonor site and may therefore help decrease the oc-currence of splinting and postoperative atelectasis.Finally, the incision is dressed with Steri-Strips (3M,St. Paul, Minn.), gauze, and an occlusive dressing.

At the time of this writing, implantable painpumps are being studied to determine their ef-fectiveness as adjunctive measures for minimizingthe discomfort after surgery. (See Video, Supple-mental Digital Content 2, which demonstrates thecomplete procedure of secondary rhinoplasty us-

ing rib cartilage grafts in a 24-part video, http://links.lww.com/A398.)

Vincent P. Marin, M.D.Gunter Center for Aesthetics and Cosmetic Surgery

8144 Walnut Hill Lane, Suite 170Dallas, Texas 75231

drmarin@gunter-center.com

ACKNOWLEDGMENTThe authors acknowledge Yung Yu, M.D., for par-

ticipation in the videos accompanying this article.

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