Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

1025
71 Revision Rhinoplasty of Asian Noses
good exposure and to prevent the occurrence of a
postoperative hematoma (Fig. 71.20 ).
Dissecting in between the external abdominal
oblique muscle will allow the perichondrium of
the costal cartilage to be inspected. After expos-
ing the super fi cial part of the perichondrium of
the cartilage, make an incision line at the per-
ichondrium with a knife, and then perform dis-
section using a periosteal elevator or Freer
elevator. All following manipulation must be per-
formed on the inside of the perichondrium for it
to be safe. Dissecting the perichondrium at the
super fi cial part of the cartilage is relatively easy,
but the upper and lower area is so fi rmly attached
that it is best to dissect this area carefully a la
slowly stripping the onion. And although it is
proper to dissect the whole length of the cartilage
rather than forcefully perform dissection while
the surgical exposure is poor, it is better to dissect
just two-thirds of the radius. In particular, the sur-
geon must be particularly careful not to exert too
much force while dissecting in order to prevent
the surgical instrument from entering too deeply
and tearing the pleura (Fig. 71.21 ).
Fig. 71.19 After ( Left ) marking the incision line at the eight costal cartilage area, ( Right ) dissect all the way down to
the fatty layer of the super fi cial fascia
Fig. 71.20 After ( Left ) the fascia of the external abdominal oblique muscle is exposed, ( Right ) use a mosquito forceps
to carefully spread the muscles by dissecting in between the muscles

1026
C.H. Park
After the perichondrium is dissected to some
extent, make a partial incision line at the junction
between the bone and the cartilage, and likewise
make an incision line at the edge of the cartilage
to be harvested. Cutting the cartilaginous area in
increments rather than at once can prevent pleu-
ral damage by the blade. By hooking one side of
the Dorian elevator to the cartilage and lifting up
the costal cartilage by dissecting it from one side,
the cartilaginous area attached to the perichon-
drium will fall off naturally, enabling it to be har-
vested. It is important that the edge of the Dorian
elevator be inserted in a careful manner so that it
does not stick to the pleura. The risk of damaging
the pleura is greatest during this maneuver
(Fig. 71.22 ). The pleura can be torn slightly when
a particularly strong force is exerted during the
dissection so that the instrument enters too deeply.
In such a case, the torn area can be sutured while
the lung is expanded. However, if the tear is too
large, fi rst insert a nelaton catheter into the tho-
racic cavity and, while the suction is placed in
position, suture the circumference of the nelaton
catheter with a Vicryl 3-0 so that the perimeter of
the nelaton can be closed in a purse-string shape.
Then, if the suture is swiftly performed as the
nelaton is being removed, the chest tube need not
be inserted after surgery (Fig. 71.23 ).
After the costal cartilage is harvested, it is
deemed essential that a saline solution be poured
in and the chest pressed down to verify the exis-
tence of air bubbles due to pneumothorax fol-
lowed by saline irrigation and hemostasis. If
needed, bone wax can be used for hemostasis
(Fig. 71.24 ). When repairing the cartilage harvest
area, each layer must be sutured separately, and if
Fig. 71.22 ( Left ) Cartilage being excised using a knife. ( Right ) Cartilage then being lifted using a Dorian elevator
Fig. 71.21 ( Left ) Perichondrium being dissected. ( Right ) After the dissection is performed

1027
71 Revision Rhinoplasty of Asian Noses
there is no any particularly severe oozing, place-
ment of a drain is not necessary and the stitch-out
is usually performed on the seventh day.
71.8.5 Trimming the Costal Cartilage
The warping of the costal cartilage occurs due to
the alteration in the balance between the tension
in the subchondral layer, which is the outermost
layer of the cartilage, and the expansile force in
the inner layer. This, according to is called a
“ balanced cross section principle.” Therefore,
since the bending of the costal cartilage reaches
its maximum within the fi rst 1 h of trimming, it is
best to soak it in saline solution during this period
and perform the grafting after the hour has
elapsed [ 21 ] .
The success or failure of a dorsal augmenta-
tion using the costal cartilage depends on how
properly it is trimmed. Thus, trimming the carti-
lage with utmost dedication so that it is trimmed
well conforming with the desired shape of the
nasal dorsum is the surest way to success
(Fig. 71.25 ).
71.8.6 Technique of Inserting
the Costal Cartilage
Grafting can be performed using either an open
approach or an intranasal approach method,
which are similar to inserting a typical allo-
plastic implant. However, as the costal cartilage
has a rather strong solidity and slippery dispo-
sition, there is a high risk that the implant will
a
b
Fig. 71.23 After connecting suction to the nelaton catheter, ( a ) perform a purse-string suture around the nelaton and
then ( b ) suture the laceration area rapidly while pulling out the nelaton catheter
Fig. 71.24 ( Left ) The wound fi lled with saline solution after the costal cartilage has been harvested to check for air
bubbles. ( Right ) Harvested costal cartilage

1028
C.H. Park
either sway or slip after insertion. It is impor-
tant that the graft be trimmed as smooth as pos-
sible in order to make the skin smoothly cover
the graft. In case it is uneven, it should be
trimmed over again. If the pocket is created too
large so that the graft does not stay fi xed but
move around, a 24-G needle can be used to
temporarily fi xate the implant to the nasal dor-
sum (Fig. 71.26 ).
71.8.7 Dorsal Augmentation Using a
Costal Cartilage
Costal cartilage is one of the best autologous
implants in cases where a substantial amount of
augmentation is needed, where a previous graft is
causing a rejection or infection, or where a patient
requests for an augmentation using an autologous
implant (Fig. 71.27 ).
Fig. 71.26 Fixation of graft needle: after binding the cartilage to the nasal bone using a 24-gauge needle, ( a ) bend the
edge, ( b ) then fasten it with a tape
Fig. 71.25 Methods of trimming the costal cartilage

1029
71 Revision Rhinoplasty of Asian Noses
a
b
Fig. 71.27 ( a ) Preoperative patient with a lowered nasal
dorsum requesting an autologous implant surgery. ( b )
Postoperative after receiving dorsal augmentation and
nasal tip surgery using the costal cartilage. ( c ) Extracted
costal cartilage and worksheet

1030
C.H. Park
71.8.8 Application of Costal Cartilage
for Other Areas
The greatest advantage of a costal cartilage is that
it is an autologous implant that is relatively solid
and has a low rate of resorption. Therefore, it can
be used variously in areas requiring hardness and
volume. It is particularly useful in cases where a
strong tip support is needed due to the contrac-
ture of the nose resulting from a previous surgery
or accident and when a strong tip projection is
needed (Figs. 71.28 and 71.29 ).
Minor deformity or warping can occur follow-
ing a costal cartilage graft and, in such a case, an
18-gauge needle can be used to easily correct this
problem (Fig. 71.30 ).
a
b
Fig. 71.28 ( a ) Columellar strut and ( b ) tip graft from costal cartilage
Rhinoplasty worksheet
Hospital No:
Name:
Sex/Age:
c
Fig. 71.27 (continued)

1031
71 Revision Rhinoplasty of Asian Noses
Rhinoplasty worksheet
Hospital No:
Name:
Sex/Age:
c
b
a
Fig. 71.29 ( a ) Preoperative patient with a severely low-
ered nasal dorsum and vestibular stenosis due to scar con-
tracture resulting from smallpox. ( b ) Postoperative
augmented nasal dorsum and a widened nostril. ( c ) The
patient required a strong support and extension of the sep-
tum, so costal cartilage was used. To correct the destroyed
lower lateral cartilage and to widen the nostril, a compos-
ite (conchal cartilage and skin) grafting was performed

1032
C.H. Park
a
b
c
Fig. 71.30 ( a ) Preoperative patient showed signs of a
protruding costal cartilage at the nasal dorsum 6 months
after undergoing a dorsal augmentation procedure
using a costal cartilage. ( b ) Following simple local
anesthesia, an 18-gauge needle is inserted into the pro-
truding area and, using the edge of the needle, grinding
down the protrusion and remove by attaching a suction
to it. ( c ) Postoperative

1033
71 Revision Rhinoplasty of Asian Noses
71.8.9 Revision Rhinoplasty Case Using
Costal Cartilage (Fig. 71.31 )
A 39-year-old female who had three prior rhino-
plasties using a dorsal silicone implant and who
sustained multiple infections after rhinoplasty
presents with a severely contracted nose with poor
skin elasticity and integrity. This case had a severe
contracted tip with the destruction of lower lateral
cartilage and skin with soft tissue depression due
a
b
c
Fig. 71.31 ( a ) Preoperative 39-year-old female who had
three prior rhinoplasties using a dorsal silicone implant
and who sustained multiple infections after rhinoplasty
presents with a severely contracted nose with poor skin
elasticity and integrity, severe contracted tip with the
destruction of lower lateral cartilage, and skin with soft
tissue depression due to infection (lower third deformity).
( b ) Three months postoperative after removal of a silicone
implant, insertion of a 4-mm-thick augmentation graft,
and septal extension graft, both carved from rib cartilage.
There is the desired increased nasal extension, tip pro fi le,
and dorsal augmentation. ( c ) Operative procedure of
removal of silicone and insertion of augmentation and
septal extension grafts

1034
C.H. Park
to infection (lower third deformity). The patient
had a 4-mm-thick augmentation after removal of
a silicone implant and septal extension graft, both
carved from rib cartilage. Postoperatively, she had
the desired increased nasal extension, tip pro fi le,
and dorsal augmentation.
71.9
Dorsal Augmentation Using
Dermis-Fat
The dermis-fat can be used as an alternative mate-
rial for reconstructing the de fi cit areas of the face,
breast, and limb. In particular, in rhinoplasty,
dermis-fat is being used to reconstruct the nasal
dorsum in secondary rhinoplasty for the correc-
tion of a failed alloplastic implant.
71.9.1 Advantages
1. Easy to harvest.
2. Diverse application is possible.
3. Relatively high survival rate and low absorp-
tion rate.
71.9.2 Disadvantages
1. Donor site morbidity
2. Dif fi culty in predicting the absorption rate
71.9.3 Harvesting the Dermis-Fat
Though it is possible to harvest the dermis-fat
from various regions, it is mostly harvested from
the buttock below the coccyx or from the ingui-
nal area. However, although this area offers the
advantage that the dermis-fat can be harvested
in large quantity, it also has the disadvantage
that the surgical area will be broad and perform-
ing dressing after surgery will be dif fi cult. It is
best to minimize the incision during harvesting
and the damage to the dermis-fat from the for-
ceps if the absorption rate is to be reduced. Also,
this area being in frequent friction, the skin
suture should be performed with the greatest
precision to prevent the dehiscence of the skin.
Furthermore, thorough hemostasis is of an
utmost importance.
71.9.4 Revision Rhinoplasty
Case Using Postauricular
Dermis-Fat
The use of a postauricular dermis-fat is usually
favored because of such advantages of the donor
site being within the same surgical fi eld of head
and neck area and that it is easy to perform disin-
fection with limited scarring [ 22, 23 ] . Figure 71.32
shows a patient who had previously undergone
more than three rhinoplasties including a dorsal
augmentation procedure using silicone. Following
those surgeries, nasal contracture occurred and
the nasal tip areas have thinned out. Postauricular
dermis-fat and Gore-Tex were used to perform a
dorsal augmentation as well as tip surgery for
this patient.

1035
71 Revision Rhinoplasty of Asian Noses
Fig. 71.32 ( a ) Preoperative. ( b ) Operative procedure. ( c ) Postoperative
a
b
c

1036
C.H. Park
References
1. Min BY, Chu HR, Park CH, Chun JH, Kim DY, Jung
KN, Hong SJ (2004) A study on the current status of
rhinoplasty in the Department of Otorhinolaryngology
in Korea. J Clin Otolaryngol 15:222–226
2. Jang YJ, Park CH (2007) Practical septorhinoplasty:
an asian perspective. Koonja Publishers, Seoul
3. Park CH, Kim IW et al (2009) Revision rhinoplasty of
Asian noses: analysis and treatment. Arch Otolaryngol
Head Neck Surg 135(2):146–155
4. Vuyk HD, Watts SJ (2000) Revision rhinoplasty:
review of deformities, aetiology and treatment strate-
gies. Clin Otolaryngol 25(6):476–481
5. Parkes ML, Kanodia R, Machida BK (1992) Revision
rhinoplasty: an analysis of aesthetic deformities. Arch
Otolaryngol Head Neck Surg 118(7):695–701
6. Holt GR, Garner ET (1987) Postoperative sequelae
and complications of rhinoplasty. Otolaryngol Clin
North Am 20(4):853–876
7. Tardy ME, Brown RJ (1990) Surgical anatomy of the
nose. Wiley, New York
8. Park CH (2005) Clinical study of patients that rhino-
plasty was performed concomitantly with nasal bone
fracture reduction. J Rhinol 12(1):21–26
9. Kamer FM, McQuown SA (1988) Revision rhino-
plasty. Analysis and treatment. Arch Otolaryngol
Head Neck Surg 114(3):257–266
10. Parkes ML, Walter TS (1988) Practical application of
nasal asymmetries in rhinoplasty. Am J Cos Surg
5:37
11. Park CH, Lee SO, Hong SJ (2005) Use of septal exten-
sion grafts in nasal tip plasty. Korean J Otolaryngol
48:1219–1223
12. Rich JS, Friedman WH, Perlman SJ (1991) The effect
of lower lateral cartilage excision on nasal tip projec-
tion. Arch Otolaryngol Head Neck Surg 117(1):56–59
13. Adamson PA (1990) The failed rhinoplasty. Curr Ther
Otolaryngol Head Neck Surg 4:137–144
14. Petroff MA, McCollough EG, Hom D, Anderson JR
(1991) Nasal tip projection. Quantitative changes fol-
lowing rhinoplasty. Arch Otolaryngol Head Neck
Surg 117(7):783–788
15. Han GH, Park CH (2008) All of the medical photo-
graphs. Koonja Publishers, Seoul
16. Park CH, Chun JH (2008) Histological and morpho-
logical change of implanted reinforcement Gore-Tex ®
in nasal dorsum of rabbit. Korean J Otolaryngol
51(8):705–711
17. Park CH (2008) Histological study of expanded
polytetra fl uoroethylene implanted in the human nose.
Rhinology 46(4):317–323
18. Romo T, Kwak ES, Sclafani AP (2006) Revision rhi-
noplasty using porous high-density polyethylene
implants to reestablish ethnic identity. Aesthetic Plast
Surg 30(6):679–684
19. Park CH, Kim DY, Chu HR, Chun JH, Choi YH, Huh
WS, Moon HJ, Jung DH (2005) Histological evalua-
tion of Gore-Tex ® used in nasal augmentation of
human. Korean J Otolaryngol 48:182–188
20. Jung DH, Moon HJ, Choi SH, Lam SM (2004)
Secondary rhinoplasty of the Asian nose: correction of
the contracted nose. Aesthetic Plast Surg 28(1):1–7
21. Gibson T, Davis WB (1955) Some further observa-
tions on the use of preserved animal cartilage. Br J
Plast Surg 8(2):85–92
22. Park CH (2005) Rhinoplasty using postauricular der-
mofat graft. J Rhinol 12(1):46–49
23. Park CH, Hong SJ, Lee JH, Chang KH (2007) A case
of augmentation rhinoplasty with abdominal keloid
tissue. J Rhinol 13(1):56–59

1037
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_72, © Springer-Verlag Berlin Heidelberg 2013
72
72.1
Introduction
Two main categories of secondary rhinoplasties that
are treated with an open approach by the authors
include:
1. Those related to a deformity following a trauma
with bony pyramid symmetry, septum devia-
tion, and airway incompetence, often associ-
ated to pre-existing aesthetic problems.
2. Those, related to deformity following a primary
rhinoplasty, resulting in a poor overall result, or
a real secondary complication, as well to the
aesthetic appearance of the nose, or airway
obstruction, or lack of projection of the tip,
asymmetry of the alar cartilages, or the many
other complications which may result from an
improper performed operation.
Open rhinoplasty has become a common pro-
cedure as the patients willing to correct poor
results after primary rhinoplasties or after trauma
have increased. The more aggressive the fi rst rhi-
noplasty, the more complicated will be the repair-
ing process of the nose. The authors often
consider this a reconstructive surgery commit-
ment, of course related not only to the aesthetics
of the nose but also to the functionality of the
airway. In most of the cases, the key for a suc-
cessful secondary rhinoplasty is to reconstruct
the lower third of the nose, often compromised
by the fi rst operation or by a trauma.
The modi fi ed skeletal elements must have
proper form and support to give shape to the
overlying soft tissue envelope, the so-called
S-STE. A skeleton that lacks this load-bearing
function becomes distorted or may collapse under
the weight of the overlying structure and the
forces related to scar contracture. The quality of
the soft tissue of the S-STE is a vital element in
assessing the fi nal proper result of the lower third
of the nose. If the skin is thick and inelastic, the
scar tissue may represent a problem as well as an
excess of the skin, as in older patient rhinoplasty.
In cases of over-resection of structures limited to
the lower third of the nose, the discrepancy
between the reduced skeleton and the overlying
S-STE will result in a major problem. The dead
space that may result will produce fi brosis and an
amorphous nasal tip, which is hard to correct.
In secondary cases, a conservative reduction
of the overall fi brotic tissue is advised in order to
follow a better redraping of the tissue allowing
better tip de fi nition. All the dynamics of the lower
third of the nose is connected to the supporting
structure represented by the alar cartilages. They
act as a tripod, with the medial crus acting as the
supporting base of the tripod and the swinging
lateral crus as the aisle of an aeroplane (Fig. 72.1 ).
These elements are integrated with anatomical
structures as the interdomal ligaments, hanging
Open Rhinoplasty in Secondary
Cases
Alberto Di Giuseppe and Luca Grassetti
A. Di Giuseppe , M.D. () • L. Grassetti , M.D.
Department of Plastic and Reconstructive surgery ,
Torrette hospital , Ancona , Italy
e-mail: adgplasticsurg@atlavia.it ;
lucagrassetti2000@gmail.com

1038
A. Di Giuseppe and L. Grassetti
from the medial crura and the anterior portion of
the septum, and the medial crura to the anterior
septum or nasal spine (Figs. 72.2 and 72.3 ).
Many of the secondary defects connected with
a secondary rhinoplasty are derived from the loss
of integrity of the lower third of the nose, result-
ing in a weakened nose. No support means sec-
ondary distortion, asymmetry, lack of support for
S-STE, skin collapse, scar formation, and thus
further retraction and deformity (Fig. 72.4 ). In
secondary cases, careful resection of fi brofatty
subcutaneous tissue is mandatory in order to free
the amorphous tip and has to be done under direct
inspection (Figs. 72.5 and 72.6 ). In the presence
of a thin skin, we face the opposite problem, thus
buckling, valve collapse, knuckling, etc.
72.2
Restructuring the Lower Third
of the Nose
The lower third of the nose is a combination of
dynamic structures in relationship between them
such as cartilages, ligaments, muscles, and over-
lying skin envelope, which conditions and limits
the movements of the underlying elements. The
open rhinoplasty approach allows the surgeon to
sculpture and narrow properly the lower third of
the nose, in a predictable fashion and in a proper
way. Many surgeons’ manoeuvres are directed to
create or restore a nice-looking lower third of the
nose, which normally in fl uences deeply the out-
look of the nose.
Evaluating the shape of the cartilages under
direct vision may direct the successful restora-
tion of the compromised integrity of the lower
Fig. 72.1 Tripod-like structure of the lower nasal third—
the aisles of the tripod are made up of joined medial crura
and both lateral crura
Fig. 72.2 Medial crural–inferior septal angle–nasal spine
ligamentous attachment
Fig. 72.3 Interdomal ligaments between lateral crura
(domal region) and the anterior septal angle

1039
72 Open Rhinoplasty in Secondary Cases
Fig. 72.4 Scar contracture resulting in buckling of the weakened nasal skeleton
Fig. 72.6 Debulking fi brofatty tissue from the lower
nasal third. The excision has to be conservative in the sub-
dermal plane
Fig. 72.5 ( Arrow ) Fibrofatty tissue causing supratip fullness

1040
A. Di Giuseppe and L. Grassetti
third (Fig. 72.7 ). Normally, a bulbous tip is ini-
tially related to wide arch alar cartilages and
must be analysed in a vertical and a horizontal
plane in order to evaluate how to correct an exist-
ing deformity, or reconstruct a proper balanced
alar cartilages septum relationship (Fig. 72.8 ).
The manoeuvres advised are:
1. A conservative resection of the cephalic por-
tion of the alar crura, which leads to narrowing
of the nose.
2. Resection of the curvature between the lateral
crura and the upper lateral cartilage.
3. The division of the dome with cartilage exci-
sion and reconstitution of the intact lateral
crural strip.
4. Narrowing lateral wall of the nose.
5. Tip grafting (Fig. 72.9 ).
6. Debulking fi brofatty tissue from the underly-
ing surface of the nasal skin.
The columella structure also plays a role in
lower third balance (Fig. 72.10 ). Weakened
medial crura may result in collapse of the colu-
mella, lacking projection and support to the
overlying elements of the nose. Structural carti-
lage graft, harvested from the septum or the auri-
cle, has become a secondary routine procedure
in rhinoplasties, where most of the time the pre-
vious columella elements have been weakened.
The supporting cartilage graft must be secured
on position under direct view and fi xated prop-
erly to ensure support and stability (Fig. 72.11 ).
The graft must be planned 2 mm longer than the
alar dome itself, in order to contribute to tip
elongation in a depressed nose, which normally
follows a primary rhinoplasty (Fig. 72.12 ). This
cartilage strut graft guarantees the support to the
entire structure, as seen in most of the revision
rhinoplasties.
In secondary cases, the alar cartilages, more
than resected, have to be reconstructed. All pri-
mary operations tend to be aggressive, and the
general problem is overdoing. Even in expert
hands, this is a tendency dif fi cult to be corrected.
Cartilage grafts from the auricle are mostly per-
fectly as suitable for this reconstructive purpose
and must be done under direct vision for proper
placing and proper securing.
If possible, the pleasant relationship between
the columella and the nasal septum must be
replaced. Anterior nasal spine and mimic muscles
play a role in order to establish this relationship.
In an aesthetically pleasing nose, the long axis of
the columella is in balance to the alar rim
(Fig. 72.13 ). In secondary cases, this angle must
be restored with a cartilage graft added to the
septum or anteriorly to the tip of the nose.
In primary cases, there is a typical tendency for
inferior rotation of the anterior half of the nostril
Fig. 72.7 Well-shaped nose tip with good position of the
lateral and medial crura
Fig. 72.8 Shape of nasal tip cartilages in vertical (AB)
and horizontal (CD) planes

1041
72 Open Rhinoplasty in Secondary Cases
as a result of a tip ptosis, which re fl ects the loss
of tip support (iatrogenic or post- traumatic). The
key to success in a secondary rhinoplasty is often
the reconstruction of the alar rim complex, con-
trol of the tip projection, reshaping the dorsum,
and correction of the fi brotic tissue of the lower
third. Tip projection reconstruction is often the
main issue, achieved in a second step following an
over-reduction typical of a primary aggressive
rhinoplasty. Control of nasal tip projection is the
key to open structure rhinoplasty, and the nasal
tip graft is the surgical act which may restore tip
strength, integrity, and functionality.
If it is true that a signi fi cant amount of candi-
dates for primary rhinoplasty lack tip projection,
then nearly 100% of secondary cases present
with the problem. Suturing a tip graft under direct
control allows a perfect shape and de fi nition of
the nasal tip projection, which normally lack
when a cartilage graft is just added in a blind
pocket, as in the “onlay graft”. Sheen tip graft [ 1 ]
provides projection but not support. Malposition
or displacement is frequent in non-expert hands.
Tip graft is set at a level that blends well with
the modi fi ed dorsum of the nose. Balance between
the two anatomic structures, tip and dorsum, are
Fig. 72.9 Tip graft projects the tip, increases the height of the basal triangle, lengthens the nostrils, and helps tip de fi nition
Fig. 72.10 Reconstructing buckled medial crura with the
strut graft
Fig. 72.11 Columella cartilage structural graft in place

1042
A. Di Giuseppe and L. Grassetti
essential to obtain a nice-looking lower third of
the nose. The exposure allowed by the open
approach permits accurate suturing and fi xing of
the graft to the underlying alar cartilages forming
a unique element with the medial crura and
rebuilding the dynamic of the so-called tripod
lost after the primary surgery. Projection and
shape are controlled, double checked, in harmony
with the lower third of the nose and the dorsum.
If caudal septum deformity is present, it can be
repaired through a trans fi xion incision.
The material chosen for tip graft or columella
structural graft is cartilage septum as a primary
choice or ear cartilage as a second option. For
major alar cartilage, the authors prefer ear scapha
or bilateral ear grafts. For dorsum reconstruction,
ear cartilage is the primary choice for the good
natural shape and for the great amount required to
achieve a secondary correction after over-resec-
tion occurred in a primary case. Dorsal graft may
be used as a single unit or as a double unit, as well
as tip graft may be single layered or multiple lay-
ered, following the patient’s need (Fig. 72.14 ).
In order to achieve good support of the tripod,
the so-called crural–septal suture ensures the tip
cartilages to the septum. One or two sutures, 4/0
Fig. 72.12 Different-sized tip grafts secured in stable
position to ensure projection and support to the tip
Fig. 72.13 Angle of inclination of the long axis of the nostril
rim should range from 10 to 30° above the Frankfort plane
Fig. 72.14 Dorsal graft from auricle or septum to correct
secondary deformity of the dorsum

1043
72 Open Rhinoplasty in Secondary Cases
nylon or Prolene, are placed between the medial
crura then through the septal cartilage and then
passed back between the medial crura, and a knot
is tied (Figs. 72.15 and 72.16 ). This suture enables
the tip cartilages to be secured to the caudal edge
of the septum and helps prevent tip dropping
postoperatively. A second suture is the dome suture,
which keeps each dome narrow and mitigates the
need for scoring the cartilage. The suture is done
with 5/0 nylon or Prolene (Fig. 72.17 ). The suture
passes through the cephalic border of each dome and
maintains the desired shape and narrowness (dome
suture) (Fig. 72.18 ). Another suture is the inter-
crural, which keeps the middle crura together and
prevents them to be displayed by the weight of the
overlying skin (Figs. 72.19 and 72.20 ). Of course,
tip or dorsal graft requires precise suturing with 4/O
or 5/O nylon, respectively, as well as the columella
structural graft (Figs. 72.21 and 72.22 ). An optional
suture that has been advised by Tebbetts [ 2 ] , called
the spanning suture, is placed from one lateral crus
to the other in order to narrow the nose, and even
to increase slightly tip projection (Fig. 72.23 ). The
last suture could be the so-called dome tails after the
cephalic border of the lateral crus is resected; there
Septum
Fig. 72.15 Spanning suture to correct convexity of the
lateral crura
Fig. 72.16 Spreader graft to correct depression of the
lateral wall or collapse of the nasal valve
Fig. 72.17 Crural septal suture

1044
A. Di Giuseppe and L. Grassetti
is often a small portion of the lateral most medial
crus which remains and can be suture and tailored
and sutured to the cartilage septum. This helps
de fi ning the tip, preventing the supratip deformity,
and leaving a nice small concavity which increase
de fi nition, shape, and natural-looking appearance
(Figs. 72.24 , 72.25 , 72.26 , 72.27 , 72.28 , 72.29 ,
72.30 , 72.31 , 72.32 , and 72.33 ).
72.3
Ethnic Nose: South American
Nose, Black Peoples’ Nose
For ages, Italy had been populated originally by
Caucasians, with the standard nose already
described for centuries. The Medici family nose,
from Renaissance age, was the classic expression
of the male or female deformity that needed an
operation. In the last decade, with the massive
immigration from Africa, middle Asia, South
America, the population has changed, and plastic
surgeons had to face new feature and facial
Fig. 72.18 Dome suture
Fig. 72.19 Intercrural suture
Fig. 72.20 Additional intercrural suture

1045
72 Open Rhinoplasty in Secondary Cases
> 6−8 mm
Fig. 72.21 The tip should project above the dorsal aspect
of the septum by at least 6–8 mm internally, so that a
3-mm projection is noted externally
Fig. 72.22 Transecting the lateral crus as needed to rec-
reate a natural arch
Fig. 72.23 The spanning
suture to narrow the tip
cartilage and to achieve
further tip projection
prevents the tip from falling
off the end of the septum

1046
A. Di Giuseppe and L. Grassetti
proportions previously unknown and unable to
treat properly.
The black nose is anatomically quite different
from the Caucasian nose. Main features are:
1. Radix usually low and inferiorly set with an
obtuse nasofrontal angle.
2. Bridge wide and fl attened with rally short nasal
bones with an average width of 2.5 cm and with
a de fi ciency of the osteocartilaginous support.
3. Tip usually thick-skinned, round, and slightly
depressed with minimal projection; dome is
broad with abundant subcutaneous tissue.
Because of fullness, de fi nition is minimal.
4. Base is wide with thickened alar sidewalls,
and nostrils are more horizontal than vertical
and thus provide a fl attened appearance.
5. The nostrils are fl aring; the alar walls project beyond
the intercanthal line and the alar–facial junction.
6. Columella is short and recessed; medial crura
are hypoplastic.
7. Nasolabial junction is usually retracted.
8. Other associated features may be large lips,
retrusive chin, hypoplastic maxilla, hyperplas-
tic frontal bone, or orbital bridges.
To follow, the classic desires of a black rhino-
plasty patient is to achieve a straight and concave
nose, a shapely tip with a fi ne projection, a columella
projecting below the alar margin, vertical oblique
nostrils, a narrow bridge, and a moderate depth at
the nasion groove. The general plan includes:
1. Dorsal bone graft (Fig. 72.34 )
2. Thinning of the bridge through medial osteo tomies
3. Alar wedge resection
4. Maxilla or nasal base grafting
5. Tip grafting
In detail, the treatment of the nasal dorsum
and bridge with a straight, concave graft is the
key for improving the shape of the entire nose. In
all the cases the authors have performed, a long
graft harvested from each ear in a fusiform shape
was used and has been suf fi cient to correct the
depressed dorsum and recreate a nice-looking
nose. Proximal and distal ends have to be fi xed
with a pull-out suture to the end of the graft and
secured into the desired position (Fig. 72.35 ).
A second graft from the ear is necessary to cor-
rect the depressed tip of the nose and allows
acquiring more tip projection, as a structural col-
umella graft, tied into position and secured.
Another graft is placed, if necessary, to lengthen
the short columella and tip, in front of the dome
to increase tip projection.
South American noses are expression of racial
characteristic with typically long nose, poor tip
de fi nition, prolonged tip, high radix, straight dor-
sum, and narrow nose and nostrils (Figs. 72.36 ,
72.37 , and 72.38 ).
Fig. 72.24 Operative planning for a 43-year-old patient
after primary rhinoplasty

1047
72 Open Rhinoplasty in Secondary Cases
Fig. 72.25 ( a – d ) Operative planning for a 43-year-old patient after primary rhinoplasty

1048
A. Di Giuseppe and L. Grassetti
Fig. 72.26 ( a )
Preoperative
43-year-old patient
after primary
rhinoplasty. ( b )
Postoperative
a
b
Fig. 72.27 Preoperative planning for a 38-year-old
patient after primary rhinoplasty

1049
72 Open Rhinoplasty in Secondary Cases
a
b
Fig. 72.28 ( a ) Preoperative 38-year-old patient after primary rhinoplasty. ( b ) Postoperative

1050
A. Di Giuseppe and L. Grassetti
a
b
Fig. 72.29 ( a ) Preoperative 32-year-old patient after primary rhinoplasty. ( b ) Postoperative

1051
72 Open Rhinoplasty in Secondary Cases
Fig. 72.30 Operative planning for a 44-year-old patient after rhinoplasty ( a – b ) frontal view, ( c – d ) lateral view

1052
A. Di Giuseppe and L. Grassetti
a
b
Fig. 72.31 ( a ) 44-year-old patient after rhinoplasty with dome deformity. ( b ) Post-reconstruction with tip graft,
spreader graft, and dorsal graft
Fig. 72.32 ( a ) Preoperative 20-year-old patient with severe deformity of the bony pyramid after trauma and two previous
rhinoplasties. ( b ) Postoperative
a
b

1053
72 Open Rhinoplasty in Secondary Cases
b
a
Fig. 72.33 ( a ) Preoperative 38-year-old patient after primary rhinoplasty. ( b ) Postoperative after nose shortening and
tip graft for projection

1054
A. Di Giuseppe and L. Grassetti
1
2
3
4
5
Fig. 72.34 Cartilage grafts for improving dorsum tip
projection and premaxillary projection of the black nose.
1, 4, 5 Cartilage grafts 2,3 premaxillary projection
2.5 cm
0.5 cm
Fig. 72.35 Cartilage graft to lengthen the nose
Fig. 72.36 Alar rim and nostril correction for fl ared
black nose

1055
72 Open Rhinoplasty in Secondary Cases
a
b
Fig. 72.37 ( a ) Preoperative 28-year-old patient with classic black nose features. ( b ) Postoperative following tip graft,
columella structural graft, and dorsal graft

1056
A. Di Giuseppe and L. Grassetti
a
b
Fig. 72.38 ( a ) Preoperative18-year-old male patient from Latin America with classic features. ( b ) Postoperative after
tip projection increase with graft, columella strut graft, and dorsal cartilage graft
Acknowledgment
Some of the anatomical drawings
are taken from the book “Rhinoplasty: State of the Art” by
Ronald Gruber and George Peck and from the book “Open
Structure Rhinoplasty” by Calvin Johnson and Dean
Toriumi.
References
1. Sheen JH (1993) Tip graft: a 20-year retrospective.
Plast Reconstr Surg 91(1):48–63
2. Tebbetts JB (1996) Rethinking the logic and techniques
of primary tip rhinoplasty. A perspective of the evolution
of surgery of the nasal tip. Clin Plast Surg 23(2):
245–253

1057
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_73, © Springer-Verlag Berlin Heidelberg 2013
73
73.1
Introduction
The aims of both primary and revision rhinoplasty
reconstruction have the same objectives. While
these include maintaining or augmenting long-
term tip projection, restoring rigid dorsal stability,
and restoring optimum respiratory function, the
methods set forth to obtain these objectives are
inherently different due to the intrinsic nasal prin-
ciples at the time of a revision rhinoplasty.
To achieve an esthetically pleasing result that
is in harmony with the rest of the face, septal and
auricular cartilage grafts are frequently used to
design columellar struts, tip grafts, and dorsal
onlay grafts during a primary rhinoplasty [ 1 ] . The
problem that arises during revision procedures is
that these materials are in limited supply due to
their depletion during the primary rhinoplasty. In
the case of congenital nasal deformities, the sep-
tum is normally underdeveloped and is frequently
severely deviated. One of the main problems that
arise with the use of auricular cartilage grafts is
that they frequently do not contain the structural
rigidity to withstand the contractile forces that
follow a revision rhinoplasty when used for
anything more than tip grafts or alar grafts.
Therefore, when faced with problems such as
the traumatic saddle deformity, defects following
neoplastic resection, congenital nasal deformi-
ties, severe tip weakness or underprojection, rhi-
noplasty in the ethnic patient, and revision
rhinoplasty, alternative options must be explored.
While autogenous grafts, alloplastic implants,
and homografts are all viable options available to
address these problems, controversy exists as to
which augmentation material is best suited for
this job [ 1– 4 ] .
Alloplastic materials such as silicone and Gore-
Tex gained use due to their ease of placement, abil-
ity to withstand resorption, availability, and lack of
donor site morbidity. However, their use has been
limited due to signi fi cant complications, such as
lack of mobility, foreign body reaction, and higher
rates of infection and extrusion, especially when
used for dorsal augmentation [ 2, 3, 5 ] .
Irradiated costal cartilage [ 6, 7 ] and acellular
dermis [ 8 ] are homografts that have been applied
with variable success. Advantages of irradiated
rib include its lack of donor site morbidity, short-
ened operating time due to elimination of graft
harvest, resistance to warping [ 9 ] , and excellent
tissue tolerance. The theoretical transmission
of disease, material shortage within the tissue
banks, and a variable or potentially increased
rate of resorption and infection have limited the
use of these materials in the setting of revision
The Decision Process in Choosing
Costal Cartilage During Rhinoplasty
Robert J. DeFatta
R. J. DeFatta , M.D., Ph.D.
Head and Neck Center,
Sacred Heart Hospital ,
900 West Clairemont Avenue ,
Eau Claire , WI 54701 , USA
e-mail: robert.defatta@shec.hshs.org

1058
R.J. DeFatta
rhinoplasty. However, it should be noted that sev-
eral authors use irradiated costal cartilage as their
material of choice without encountering these
complications.
Autogenous grafts are widely viewed as the
gold standard when substantial nasal reconstruc-
tion is required. Some of the reasons for this are
due to the perfect biocompatibility, durability,
low infection rates, and low extrusion rates. It
should be noted that although this is the best
option for the reconstruction in this setting, this
option does not come without its downfalls. Most
signi fi cantly, these include availability, varying
degrees of resorption and warping, harvesting
dif fi culties, donor site morbidity, and increased
operating time. While autogenous bone grafts are
an option, this should be viewed as a secondary
option due to the unnatural stiffness in the lower
two-thirds of the nose, the potential for overlying
skin necrosis, graft fracture, and a high rate of
resorption [ 2, 3 ] .
The indications for costal cartilage, harvesting
techniques, carving techniques, and complica-
tions will all be discussed in this chapter.
73.2
History
The use of costal cartilage for nasal reconstruc-
tion was a signi fi cant advance in nasal recon-
struction. One of the major drawbacks frequently
encountered was the tendency of the graft to
warp following the completion of the surgery.
The fi rst technique to combat this problem was
presented by Mowlem in 1941 [ 10 ] . He recom-
mended banking the carved grafts in an abdomi-
nal pocket for 3 months before they were used
for dorsal nasal augmentation, feeling that this
was ample time to allow for warping to halt, and
if necessary, he would recontour the graft before
implantation. In 1958, Gibson and Davis [ 11 ]
demonstrated that costal cartilage warped in a
predicable manner. They further described the
use of balanced cross sections that make use of
the center of the rib to minimize warping.
However, it should be noted that a curved rib
cannot be modi fi ed into a straight dorsal or
columellar graft without violating the principles
set forth by Gibson and Davis. This understand-
ing is echoed by a later publication where Gibson
[ 12 ] concluded that the only de fi nite method to
avoid cartilage warping is to avoid grafting with
costal cartilage.
To date, four techniques have been brought
forth in an attempt to prevent warping of the car-
tilage. The fi rst of these was in 1940 when Brown
[ 13 ] used Vitallium pins to stabilize carved carti-
lage grafts. The second was when Dingman and
Grabb [ 14 ] fi rst presented the use of irradiated
homograft costal cartilage for correction of facial
contour deformities. They reported no evidence
of curling or bending. While other studies sup-
port this fi nding [ 15, 16 ] , Adams et al. [ 17 ] per-
formed an in vitro controlled study and found
that there was no difference in the rate of warping
in irradiated and autogenous costal cartilage. The
next signi fi cant advance was brought about when
Harris et al. [ 18 ] discovered that grafts cut from
the central portion of costal cartilage warped less
than the peripheral portions. This fi nding was
later substantiated by Kim et al. [ 19 ] who later
reported that concentric carved costal cartilage
underwent a statistically signi fi cant lower amount
of warping than eccentric grafts. Lastly, Gunter
et al. [ 20 ] introduced the use of the Kirschner
wire as an internal stabilization device in autog-
enous costal cartilage grafts.
73.3
Indications
There are many indications that allow for the use
of costal cartilage in rhinoplasty procedures. One
of the most common indications is in the trauma
setting. In this instance, a saddle deformity fre-
quently ensues from a septal fracture that reaches
the dorsal surface. The severe loss of dorsal height
occurs due to the loss of structural support. One
must be cognizant of the fact that the loss of struc-
tural support can lead to a shrink-wrap effect in
the soft tissue envelope of the nasal dorsum.
Hence, if a costal cartilage graft is not to be per-
formed in the immediate setting, one should con-
sider using a temporary tissue expander, such as a

1059
73 The Decision Process in Choosing Costal Cartilage During Rhinoplasty
Silastic implant, until the de fi nitive surgery is to
be performed. Another frequent occurrence is fol-
lowing the resection of neoplastic malignancies
(Fig. 73.1 ). In this instance, large defects are left
where the structural integrity has been severely
disrupted to clear the surgical margins. Due to the
large loss of both tissue and cartilage, the recon-
struction requires a material that will be able to
withstand not only the structural forces that are
placed on the newly placed nasal infrastructure
but also the forces of a substantial amount of soft
tissue that will be transferred, i.e., paramedian
forehead fl ap.
Congenital nasal deformities are always a
challenging procedure where a large amount of
cartilage is required for the reconstruction. In this
instance, the defect is commonly one of severe
loss of dorsal height, and since this is a congeni-
tal problem, the soft tissue envelope places severe
pressure on the reconstructed dorsum which can
result in warping or resorption. Therefore, intrinsic
strength of costal cartilage makes it an excellent
choice for the reconstruction material to with-
stand these forces.
In revision rhinoplasty cases as well as ethnic
rhinoplasties, the patient is frequently suffering
from severe tip weakness due to loss of caudal
support or underprojection. Therefore, the
strength and volume granted through the use of
costal cartilage allows for an optimal result that
will be able to withstand the stresses that will be
placed on the structural architecture over time.
Hence, the author feels that costal cartilage is the
best choice to ful fi ll these requirements.
One should have a relatively low threshold for
the use of costal cartilage grafting in the instances
that have been discussed above. The bene fi ts far
outweigh the risks when it comes to signi fi cant
dorsal augmentation and caudal support due to
the relentless forces that the grafts need to with-
stand over time.
73.4
Harvesting
The attachment where the sixth through eighth
ribs converge is the section of costal cartilage that
is used to obtain the longest possible segment for
dorsal reconstruction. However, it should be
noted that a horizontal incision in the inframam-
mary crease will allow for the harvest of a section
of the rib that should span the length of any nasal
dorsum (Fig. 73.2 ). In addition, if a second rib is
needed for further grafting, the dissection can be
extended inferiorly in a plane deep to the pectora-
lis major muscle to give access to the next infe-
rior rib without lengthening the skin incision.
This is the approach that is always used by this
a
b
Fig. 73.1 ( a ) This patient was treated with radiation
therapy approximately 8 years ago for a large nasal basal
cell carcinoma. ( b ) This shows the long-term effects of
radiation and the dif fi culties it causes in reconstruction

1060
R.J. DeFatta
author, and the need to obtain a second rib is
almost never necessary but easily obtainable.
Lidocaine with epinephrine (1:100,000) is fi rst
in fi ltrated into the desired area. While this is tak-
ing effect, the patient is marked out to determine
exactly how long the costal cartilage graft will
need to be, and if cartilage will need to be, har-
vested for grafts besides the large dorsal onlay
graft. Once this has been performed, a 5-cm incision
is made through the skin in the inframammary
crease and continued until the rib is exposed. The
region of rib has been exposed; the length of the
nasal de fi ciency requiring rib is measured and
marked on the ribs. At this time, an “H” incision
is made on the surface of the rib to hasten a sub-
perichondrial elevation of the costal cartilage.
Once the section of rib has been removed, the site
is tested for a possible air leak. The perichondrium
is then closed using a 3-0 PDS, and the skin is
closed in running subcuticular fashion. Steri-
Strips are placed and a Tegaderm dressing is
fi nally placed.
73.5
Carving
There is a great variation in the desired length
needed to reconstruct an individual’s nasal dor-
sum. However, certain principles hold true for all
patients. The typical dorsal onlay graft takes the
shape of a canoe, where the ventral surface is
slightly curved to fi t the native nasal dorsum, the
dorsal surface is gently curved, and the lateral,
cephalic, and caudal edges are tapered (Fig. 73.3 ).
The graft to be harvested from the section of
desired rib typically measures 3–5 cm, and this
procedure is performed using a #15 scalpel blade.
It is always the goal to carve the rib to the desired
dimensions in such a manner that equal amounts
of peripheral cartilage are removed from all points
around the fi nal graft specimen. At this time, a
cutting burr is used to gently hone the graft in a
manner to remove any rough edges and make the
fi nal tapering modi fi cations to the graft.
73.6
Implantation
Once the graft has been carved to its desired size
and shape, it is then placed in the pocket that has
been elevated over the nasal dorsum, and once
the desired placement has been determined, a 5-0
PDS is used to secure the graft caudally. It should
be noted that before the graft is placed into the
dorsal pocket, a rasp is used to roughen the per-
ichondrium and periosteum over the nasal dor-
sum to improve the adherence of the graft.
Another technique that is sometimes employed is
to pass a 0.28-mm Kirschner wire through the
center of the graft, which is used to attach the rib
Fig. 73.3 Initial carving of the costal cartilage graft using
a #15 scalpel blade. Note that the graft takes the shape of a
canoe, where the ventral surface is slightly curved to fi t the
native nasal dorsum, the dorsal surface is gently curved,
and the lateral, cephalic, and caudal edges are tapered
Fig. 73.2 This shows the length of rib that can routinely
be obtained through an inframammary incision

1061
73 The Decision Process in Choosing Costal Cartilage During Rhinoplasty
to the frontal bone. If harvested rib is to be used
to reconstruct upper or lower lateral cartilages
that have been resected during an oncological
procedure, these are attached to the dorsal onlay
graft with 5-0 PDS sutures in the same manner as
would occur if septal or auricular cartilage was
being used. It should be noted that barring an
oncologic reconstruction, the author feels that the
two main indications for costal cartilage are for
dorsal augmentation and caudal support.
By using this technique, graft displacement or
movement has not been encountered. The choice
as to where to use a K-wire is one that is made
intraoperatively and is partially dependent on the
harvesting and carving of the graft. If the graft
was felt to be more eccentric than would be
desired and the tendency to warp was feared, then
the K-wire technique was employed.
73.7
Revision Rhinoplasty
Revision rhinoplasty can be extremely dif fi cult
for multiple reasons. First, if during the previous
surgery, the removal of cartilage was not per-
formed judiciously, you can be left with a carti-
lage-depleted nose. Over time, this can lead to
the nose becoming deformed and collapsed due
to the constant forces exerted on the nose from
this dynamic process (Fig. 73.4 ). When auricular
a
b
c
Fig. 73.4 ( a ) This patient has previously undergone
two open rhinoplasties and three endonasal rhinoplasties.
Note the almost complete internal valve collapse. ( b )
Intraoperative use of costal cartilage for internal valves
and a nasal dorsum. ( c ) Two years following the use of the
costal cartilage. Note the signi fi cant increase in the nasal
opening through the use of the costal cartilage. Patient
states complete satisfaction with the operation

1062
R.J. DeFatta
cartilage is used in this situation, over time, it
cannot withstand the external pressures during
the healing process and will almost invariably
begin to resorb or warp over time. Unlike auricular
cartilage, costal cartilage can withstand these
pressures over time and give a reliable, long-lasting
result (Fig. 73.4 ).
73.8
Trauma
The nose is the most commonly occurring
facial fracture. Although the injury may not
seem particularly bad at the time, the collapse
or deviation will inevitably worsen with time
(Fig. 73.5 ). Hence, a large portion of patients
who present with nasal airway obstruction can
remember a signi fi cant trauma that they sus-
tained at some point during the remote past. In
addition, a small septal hematoma can easily
go undiagnosed if not carefully evaluated at
the time of injury. Over years, this can lead to
a signi fi cant saddlenose deformity (Figs. 73.6
and 73.7 ).
73.9
Oncologic Reconstruction
In this instance, signi fi cant defects are left from
where either a large resection was performed to
clear the surgical margins or radiation was used
to treat the cancer. Either procedure can leave
you with a large loss of tissue, cartilage, and even
bone. Therefore, the reconstruction requires a
material that will be able to withstand not only
the structural forces that are placed on the newly
placed nasal infrastructure but also the forces
of a substantial amount of soft tissue that will
be transferred, i.e., paramedian forehead fl ap
(Fig. 73.8 ).
Conclusions
Due to the excellent and consistent results
autologous costal cartilage grafts provide
when faced with problems such as the trau-
matic saddle deformity, defects following
neoplastic resection, congenital nasal defor-
mities, severe tip weakness or underprojec-
tion, rhinoplasty in the ethnic patient, and
revision rhinoplasty, they are an invaluable
resource to the rhinoplasty surgeon. Once the
surgeon becomes comfortable and pro fi cient
at harvesting this graft, it inevitably will
become the graft of choice when substantial
amounts of cartilage are required.
Fig. 73.5 Example of septal cartilage that has been
removed. This patient was 5 years status post a signi fi cant
traumatic injury to his nose. Note the severe distortion that
has occurred over time since the accident

1063
73 The Decision Process in Choosing Costal Cartilage During Rhinoplasty
a
b
Fig. 73.6 ( a ) Patient 2 years following a signi fi cant nasal
trauma. Note the severe saddle deformity that has occurred
over time. ( b ) Two years following the use of costal cartilage.
Note the signi fi cant improvement in the saddle deformity.
Also note that the patient was still left with a supratip break
through careful carving and placement of the cartilage

1064
R.J. DeFatta
a
b
Fig. 73.7 ( a ) Patient who sustained a traumatic injury to
his nose 10 years prior to his presentation. Note the sad-
dlenose deformity. ( b ) Two years following the use of
costal cartilage. Note the restoration of the patient’s dorsal
height through the use of a costal cartilage dorsal onlay
graft

1065
73 The Decision Process in Choosing Costal Cartilage During Rhinoplasty
a
b
Fig. 73.8 ( a ) Preoperative patient following the treatment
of his nasal basal cell carcinoma with radiation therapy
(Note Fig. 73.1 ). ( b ) Patient 1 month after having under-
gone a paramedian forehead fl ap and the use of costal car-
tilage for the restoration of his nose status post his
restoration rhinoplasty. Note the projection that was
returned to the patient. Due to the extensive nature of the
procedure and the patient’s age, the placement of nostrils
was delayed to prevent loss of the internal lining. Their
placement was to take place in 2 weeks; however, the
patient was happy with his result and decided not to forgo
any more surgeries
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Grafts and implants in rhinoplasty and nasal recon-
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113–141
2. Vuyk HD, Adamson PA (1998) Biomaterials in rhino-
plasty. Clin Otolaryngol Allied Sci 23(3):209–217
3. Adamson PA (2000) Grafts in rhinoplasty: autogenous
grafts are superior to alloplastic. Arch Otolaryngol
Head Neck Surg 126(4):561–562
4. Toriumi DM (2000) Autogenous grafts are worth the
extra time. Arch Otolaryngol Head Neck Surg 126(4):
562–564
5. Conrad K, Gillman G (1998) A 6-year experience
with the use of expanded polytetra fl uoroethylene in
rhinoplasty. Plast Reconstr Surg 101(6):1675–1683

1066
R.J. DeFatta
6. Kridel RW, Konior RJ (1993) Irradiated cartilage
grafts in the nose. A preliminary report. Arch
Otolaryngol Head Neck Surg 119(1):24–30
7. Strauch B, Wallach SG (2003) Reconstruction with
irradiated homograft costal cartilage. Plast Reconstr
Surg 111(7):2405–2411
8. Gryskiewicz JM (2005) Waste not, want not: the use
of AlloDerm in secondary rhinoplasty. Plast Reconstr
Surg 116(7):1999–2004
9. Swanepoel PF, Fysh R (2007) Laminated dorsal beam
graft to eliminate postoperative twisting complica-
tions. Arch Facial Plast Surg 9(4):285–289
10. Mowlem R (1941) Bone and cartilage transplants
their use and behaviour. Br J Surg 29(114):182–193
11. Gibson T, Davis WB (1957) The distortion of autog-
enous cartilage grafts: its cause and prevention. Br J
Plast Surg 10:257–274
12. Gibson T (1977) Transplantation of cartilage. In:
Converse JM (ed) Reconstructive plastic surgery.
Saunders, Philadelphia
13. Brown JB (1940) Preserved and fresh homotrans-
plants of cartilage. Surg Gynecol Obstet 7:599
14. Dingman RO, Grabb WC (1961) Costal cartilage
homografts preserved by irradiation. Plast Reconstr
Surg Transplant Bull 28:562–567
15. Schuller DE, Bardach J, Krause CJ (1977) Irradiated
homologous costal cartilage for facial contour restora-
tion. Arch Otolaryngol 103(1):12–15
16. Murakami CS, Cook TA, Guida RA (1991) Nasal
reconstruction with articulated irradiated rib carti-
lage. Arch Otolaryngol Head Neck Surg 117(3):
327–330
17. Adams WP Jr, Rohrich RJ, Gunter JP, Clark CP,
Robinson JB Jr (1999) The rate of warping in irradi-
ated and non irradiated homograft rib cartilage: a con-
trolled comparison and clinical implications. Plast
Reconstr Surg 103(1):265–270
18. Harris S, Pan Y, Peterson R, Stal S, Spira M (1993)
Cartilage warping: an experimental model. Plast
Reconstr Surg 92(5):912–915
19. Kim DW, Shah AR, Toriumi DM (2006) Concentric
and eccentric carved costal cartilage: a comparison of
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20. Gunter JP, Clark CP, Friedman RM (1997) Internal
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Surg 100(1):161–169

1067
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_74, © Springer-Verlag Berlin Heidelberg 2013
74
74.1
Introduction
A suf fi cient amount of strong yet fl exible carti-
lage is the basis on which a successful second-
ary rhinoplasty is built [ 1, 2 ] . The correction of
both functional as well as cosmetic deformities
frequently requires considerable amounts of
grafting material [ 3 – 7 ] . Grafts associated with
high success and low resorption rates are
imperative for successful outcomes [ 8 ] . This is
not limited to revision surgery alone, and cer-
tain primary rhinoplasty procedures requiring
signi fi cant dorsal augmentations may also
mandate substantial grafting material. These
grafts must be of adequate strength, durability,
and fl exibility to provide enough material for a
complete correction. There are numerous donor
options; however, ideal materials demonstrate
low resorption, extrusion, and infection rates
with ample amounts available and limited asso-
ciated morbidity [ 8 – 14 ] .
Five distinct donor sites exist for harvest:
septal cartilage, auricular cartilage, rib cartilage,
and iliac and calvarial bone [ 5 – 7 ] . The septum
is the ideal graft source and should be the site
of choice when available. The grafts are thin and
pliable, match the existing nasal cartilage shape
and appearance, require no additional incisions,
and there is normally no appreciable associated
morbidity [ 7 ] . Also, the harvest of deviated septal
cartilage has the potential to correct preexisting
airway obstruction.
Unfortunately, revision surgeries or patients
requiring signi fi cant dorsal augmentations fre-
quently have limited or no septal cartilage avail-
able for harvest. This mandates the use of
secondary sources of cartilage or bone to success-
fully reconstruct the “operated” nose [ 3, 15, 16 ] .
The rib provides the most abundant and useful
source of donor cartilage (Fig. 74.1 ). Costal car-
tilage facilitates almost limitless fabrication for
any graft shape and size with varying ranges of
fl exibility based upon cartilage thickness [ 19 ] .
Auricular cartilage is occasionally employed in
certain scenarios, but the in trinsic curvature lim-
its its usability where straight, durable grafts are
the standard [ 3 ] . Rarely, calvarial or iliac bone
grafts can be used; however, signi fi cant limita-
tions exist regarding the ability to carve functional
Harvesting Rib Cartilage Grafts
for Secondary Rhinoplasty
Vincent P. Marin and C. Spencer Cochran
V. P. Marin , M.D., FACS ()
Marin Aesthetics , 1431 Camino Del Mar ,
Del Mar, CA 92014 , USA
e-mail: drmarin@marinaesthetics.com
C. S. Cochran , M.D.
Gunter Center for Aesthetics and Cosmetic Surgery ,
8144 Walnut Hill Lane, Suite 170 ,
Dallas , TX 75231 , USA
Department of Otolaryngology – Head and Neck
Surgery , University of Texas Southwestern
Medical Center at Dallas ,
Dallas , TX , USA
e-mail: drcochran@gunter-center.com

1068
V.P. Marin and C.S. Cochran
grafts, and there is a higher incidence of extru-
sion of autogenous bone grafts especially when
used in the tip [ 16, 17 ] .
74.2
Rib Grafts
Rib cartilage is the preferred source of graft mate-
rial in primary and revision rhinoplasty when
septal sources are not available. Rib cartilage
provides an abundant source of rigid yet fl exible
cartilage grafts ideally suited for rhinoplasty [ 19 ] .
Grafts are easily produced with considerable
variation regarding the length, width, as well as
shape of the grafts. These versatile properties
facilitate both functional and cosmetic nasal
reconstruction in nearly all circumstances.
Autogenous rib cartilage is not without
several distinct limitations. Most notably, there
is a separate and distinct harvest location with
an associated scar. This scar is relatively short
(approximately 5 cm) and normally inconspic-
uous, hidden in the inframammary crease or
within the chest hair of a male. Postoperative
pain is also an expectation relating to the dis-
ruption of the well-innervated costal perichon-
drium. Intraoperative risk of pneumothorax and
the tendency of cartilage grafts to warp are con-
cerns that must be addressed during the course
of the operation. Cartilage warping, the most
frequent complication seen with autogenous
rib, must be assessed prior to graft placement
as this can lead to postoperative nasal deformi-
ties months to years after surgery. Techniques
have been described to address this tendency
Fig. 74.1 Grafts fashioned
from rib cartilage and
harvested rib

1069
74 Harvesting Rib Cartilage Grafts for Secondary Rhinoplasty
with the use of K-wires; however, complica-
tions also exist with the placement of a foreign
body within the cartilage graft [ 18 ] . Finally,
the possibility of ossi fi cation of the costal car-
tilage also must be addressed in a patient over
50 years of age [ 19 ] . Bony segments within the
cartilage can impair the surgeon’s ability to
fashion speci fi c grafts.
To address this possibility, a limited axial CT
scan of the sternum and associated costal car-
tilage should be ordered preoperatively in the
appropriate candidates. Experienced radiologists
can easily determine the extent of calci fi cation
present within each of the cartilaginous seg-
ments, helping to determine the likelihood of
success with a rib grafting approach. We have
found our individual reading of these scans to
be very bene fi cial with respect to selecting the
“ideal” segments for harvest prior to embark-
ing upon the procedure. Diffuse calci fi cation of
the costal cartilage greatly limits the surgeon’s
ability to adequately prepare the speci fi c grafts.
Under these circumstances, it is advisable to
abort autologous reconstruction when these
fi ndings are revealed preoperatively. Alternative
sources such as double auricular cartilage har-
vest as well as irradiated homografts should
then be discussed with the patient (Fig. 74.2 ).
74.3
Preoperative Marking
Rib cartilage harvest can be performed from either
side of the patient, unless otherwise dictated by
preexisting disease or fi ndings from a preoperative
CT. However, if a two-team approach is used, the
left side is preferred to facilitate a simultaneous
opening of the nose and reduction in overall opera-
tive time. Ribs are counted from the easily pal-
pated second rib at the sternomanubrial joint
caudally to the level of the fi fth, sixth, or seventh
rib. In females, the incision is placed slightly above
the medial aspect of the inframammary fold so that
it remains on the undersurface of the breast but
well covered in a bikini or bra (Fig. 74.3 ). The
incision should not extend beyond the medial
extent of the IMF to again limit the potential expo-
sure in a “low-cut” top or bathing suit. In males,
the incision is usually located directly over the rib
planned for harvest or in a hair-bearing area in
which the incision can be easily camou fl aged.
74.4
Operative Technique
After careful preoperative analysis of the nose
and estimation of the number of grafts needed,
the surgeon can make the determination of how
Fig. 74.2 Preoperative CT demonstrating spotty peripheral
calci fi cation of costal cartilage
Fig. 74.3 Preoperative marking, female

1070
V.P. Marin and C.S. Cochran
much cartilage needs to be harvested. A portion
of one rib, one entire rib, or up to two full ribs can
be safely removed during harvest. After the cos-
tochondral segment of the ribs is exposed, it is
prudent to choose the rib that provides the lon-
gest and straightest segment of cartilage. Ideally,
this will provide for the possibility of one rib
being suf fi cient to facilitate the fashioning all of
the required grafts. However, if additional mate-
rial is needed, one can easily remove another seg-
ment or entire rib depending upon the extent of
the reconstruction.
Once the markings have been performed, the
area is routinely injected with 1% lidocaine with
1:100,000 epinephrine to facilitate local vasocon-
striction. The skin is incised with a #15 blade
scalpel, and the soft tissues are divided with elec-
trocautery. The inferior aspect of the pectorals or
superior aspect of the rectus fascias must be
divided as well as the underlying musculature
exposing the anterior aspect of the costal per-
ichondrium. Occasionally, the dissection leads to
the con fl uence of the insertions of the caudal
edge of the pectoral fascia and cephalic margin of
the rectus fascia. This area is particularly dif fi cult
to dissect when compared to the freely exposed
regions immediately above or below this region.
If possible, dissection should be directed away
from this dual fascial insertion.
Many female patients have previously under-
gone a breast augmentation, and this must be
addressed during the approach to the rib. Avoiding
entering the capsule is recommended to not con-
taminate the implant pocket with skin fl ora poten-
tially increasing the patient’s risk for late capsular
contracture. This can usually be accomplished with
gentle cephalic traction on the implant and capsule
displacing it away from the area of dissection. If
the capsule is directly interfering with the surgical
approach to the underlying rib, or the capsule is
inadvertently violated, we recommend irrigating
the pocket with triple antibiotic solution and clos-
ing the pocket with an absorbable suture. Formal
closure of the pocket limits the potential for post-
operative deformities relating to implant herniation
through the capsule.
Once the muscular fascia is reached, it is
important to palpate the underlying rib to ensure
that dissection proceeds directly over the carti-
laginous rib (Fig. 74.4 ). Failure to perform this
maneuver can lead to a dissection plane through
the intercostal musculature potentially injuring
both the parietal and visceral pleurae resulting in
a pneumothorax.
Once the fascia and underlying rib have been
selected, a longitudinal cut is made along the
length of the rib with a needle tip cautery. This is
done through the mid-anterior axis of the entire
length of the cartilaginous rib (Fig. 74.5 ). The
perichondrial cut is normally divided into a per-
pendicular “T” at both the medial and lateral
extent to facilitate the re fl ection of the perichon-
drium. This enhances the surgeon’s ability to pro-
cure the maximal amount of cartilage from each
Fig. 74.4 Exposed rectus fascia
Fig. 74.5 Scored anterior perichondrium

1071
74 Harvesting Rib Cartilage Grafts for Secondary Rhinoplasty
rib, potentially preventing the need for additional
rib harvest (Fig. 74.6 ).
Once the entire length of the dissection is com-
plete anteriorly, exposure should span the medial
costosternal junction and the costochondral junc-
tion laterally. The medial border is immediately
lateral to the costosternal joint, and the lateral bor-
der is marked usually through a slight color
change from an off-white to a red-blue hue.
Determining the extent of cartilage present can
easily be facilitated by the placement of a needle
tip cautery into both the cartilage and bone. The
surgeon will fi nd that the tip easily penetrates the
cartilage, whereas it encounters immediate resis-
tance over bone (Fig. 74.7 ). Older patients can
demonstrate a more yellow, friable cartilage fre-
quently with focal areas of calci fi cation depend-
ing upon their age and health.
A Dingman elevator is used to elevate the pre-
determined perichondrial fl aps over the superior
and inferior edges of the rib. The dissection pro-
ceeds to the posterior surface elevating as much
of the tight perichondrium as possible to facilitate
further dissection (Fig. 74.8 ). A rib stripper is
then used to complete the posterior dissection
connecting the two dissection planes (Fig. 74.9 ).
It is easy for the leading edge of the rib stripper to
penetrate the posterior perichondrium. This can
incompletely detach the rib and limit the ability
Fig. 74.6 Re fl ected superior perichondrium
Fig. 74.7 Needle tip penetrating cartilage at junction
with bone
Fig. 74.8 Blunt posterior dissection of perichondrium
Fig. 74.9 Rib stripper passed behind rib

1072
V.P. Marin and C.S. Cochran
of the surgeon to remove the graft as it continues
to maintain an unappreciated and unreleased deep
connection. Forcibly removing the rib runs the
risk of a tear and possible violation of the inter-
costal muscle and possibly parietal pleura. Pass-
ing the rib stripper with a gentle upward pressure
helps to direct the leading edge through a suprap-
erichondrial path.
The rib stripper is then gently advanced and
retracted completely releasing the posterior sur-
face. The rib is separated by performing both a
medial and lateral partial thickness cut with a #15
blade scalpel (Fig. 74.10 ). The release is completed
using a sharp Freer elevator while simultaneously
lifting upward on the rib stripper, providing an
extra margin of safety (Fig. 74.11 ). The rib stripper
completes the dissection, and the cartilaginous rib
is then easily removed from the wound and placed
in antibiotic impregnated sterile saline (gentamicin
50 mg/500 mL) (Fig. 74.12 ).
In cases where additional grafting material is
required, a segment or an entire second cartilagi-
nous rib can be harvested. Once the appropriate rib
segment is selected, the perichondrium is exposed
deep to the muscle, making every effort to not
divide the adjacent muscle layer. This will help to
limit any additional discomfort and preserve the
vascular in fl ow to the muscle fi bers. The dissec-
tion should then proceed in a similar fashion as
previously described. If merely a segment of rib is
required, only the perichondrium directly overly-
ing the rib should be elevated. A limited perichon-
drial fl ap is created that facilitates access to the
underlying cartilage segment. The cartilage is then
initially divided with a #15 blade scalpel, and the
deeper cuts are completed with a sharp elevator.
Once all of the cartilage is successfully har-
vested, the dissection cavity must then be inspected
for a pneumothorax. Saline solution is introduced
into the wound, and the anesthesiologist applies
positive airway pressure looking for evidence of
an air leak. If no leak is detected, one can proceed
with formal closure of the wound.
A #16-gauge angiocath (Becton Dickinson,
Franklin Lakes, NJ) is then introduced into the
subperichondrial space under direct vision. The
perichondrial fl aps are then re-approximated using
2-0 Vicryl sutures (Ethicon, Inc., Somerville, NJ)
on a taper needle. A tight closure helps to “splint”
Fig. 74.10 Super fi cial cut of cartilage with scalpel
Fig. 74.11 Completion of cut with blunt elevator
Fig. 74.12 Successfully harvested rib cartilage graft

1073
74 Harvesting Rib Cartilage Grafts for Secondary Rhinoplasty
the segment where the cartilage has been removed,
helping to limit postoperative pain. The muscle
fascia is repaired using the same suture to prevent
any postoperative depression. The remainder of
the skin is closed with 3-0 Monocryl sutures
(Ethicon, Inc., Somerville, NJ) in the deep dermis
followed by a running subcuticular suture along
the length of the incision (Fig. 74.13 ). Final dress-
ings are applied using Mastisol and Steri-Strips, a
sterile gauze and occlusive dressing. The angio-
cath is secured to the skin using sterile tape to pre-
vent inadvertent removal (Fig. 74.14 ).
74.5
Calci fi ed Cartilage
Infrequently, patients will present with intraopera-
tive fi ndings of peripheral calci fi cations surround-
ing the chosen cartilage segment. Often, this is
limited to the osseocartilaginous junction and can
be easily addressed by elevating off the osseous seg-
ment providing access to the underlying cartilage.
However, more commonly small foci of
calci fi cation can be found within the body of the
cartilaginous rib. These bony segments can both
weaken the cartilage itself and impair the sur-
geon’s ability to fabricate the required grafts. The
use of a smooth diamond burr can be particularly
helpful in contouring these areas without weak-
ening the graft itself.
If the cartilage is unexpectedly found to be
extensively calci fi ed to the degree that no useable
grafts can be carved, one must consider the use of
irradiated donor cartilage. The increased risk of
premature resorption must be weighed against
the inability to provide the breadth of cartilage
grafts required.
74.6
Complications
In the unlikely event that a pneumothorax is diag-
nosed, it is most commonly an injury to the pari-
etal pleura alone. As a result, no formal chest tube
placement is necessary. The recommendation is to
place a red-rubber catheter through the tear in the
parietal pleura and into the thoracic cavity. The
wound is then closed in layers over the catheter in
a standard fashion. The anesthesiologist applies
positive airway pressure and the red rubber cath-
eter attached to a 20-mL syringe and is removed
while applying negative pressure. If there is any
concern regarding the integrity of the visceral
pleura or the effectiveness of the procedure, then
a postoperative upright chest radiograph should
be obtained in the recovery room.
74.7
Postoperative Pain
Management
Prior to extubation, 10 mL of 0.25% Marcaine
solution (AstraZeneca, London, England) is
injected into the 16-gauge angiocath previously
placed in the subperichondrial space. This is per-
formed to help limit postoperative pain and
Fig. 74.13 Wound closed with angiocath secured in place
Fig. 74.14 Final dressing