EXPLORE
Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘rib graft rhinoplasty’

Complications in Rib Graft Rhinoplasty

Sunday, December 7th, 2014

 

While rhinoplasty is a very common aesthetic facial procedure around the world, most do not require a large amount of cartilage grafting. But certain types of augmentative rhinoplasties in some ethnic groups do (e.g., Asian noses) and only the ribs can supply an unlimited amount of donor cartilage. While some rhinoplasty surgeons feel very comfortable harvesting and using ribs, many do not. Both donor and recipient complications can occur with their use but the actual incidence of their occurrence has never been studied in large patient numbers.

In the Online First Section of the November/December 2014 issue of the JAMA Facial Plastic Surgery journal, an article was published entitled ‘Complications Associated With Autologous Rib Cartilage Use in Rhinoplasty – A Meta-Analysis.’  In this paper, the authors performed a review of the potential complications associated with using autologous rib cartilage in rhinoplasty surgery. This was done by reviewing published articles on the topic from 1946 to 2013. Qualified papers included clinical studies with at least 10 patients and at least one after surgery complication from either the autologous rib recipient or donor site.

The paper included ten clinical studies with just under 500 patients. Using meta-analysis, the occurrence of recipient site complications include a 3% incidence of rib warping, a very low rate of rib resorption (0.2%), 0.4% for graft displacement, 0.6% for infection, and a 14% rate of revisional surgery. The occurrence of donor site complications included a 5% rate for poor chest donor site scarring and a 0% occurrence for pneumothorax.

This study did not necessarily reveal any new complications from using rib grafts in rhinoplasty but their various occurrences merit discussion. I was surprised that the warping of rib grafts was so low. Depending upon how you define the level of symptomatic warping, my experience is that is it somewhat higher than a few percent. Warping of ribs is a reflection of the donor site and the skill of shaping the harvested rib graft as well as the size of the rib graft.  Rib graft resorption occurred very rarely and this is no surprise given the low cellularity and metabolic activity of this type of tissue. (the only rib grafts I have ever seen resorb is in the face of infection) Similarly, infection in nasal rib grafting was also very low. (I have actually only seen it occur twice)

Hypertrophic chest scarring was seen in one out of twenty patients (5%) and is probably a reflection of the predominant Asian population which undergoes this type of augmentative rhinoplasty. Skin type and length of the harvest incision are major determinants of this complication. Pneumothorax is the most feared complication in rib grafting harvesting for any reason but it really shouldn’t be as this paper shows. When grafts are taken at the subcostal rib area, the apex of the lung lies way above it and there is no risk of violating the lung pleura. When taken at the inframammary breast fold in women, which is much higher, the lung is directly underneath but even small pleural tears do not result in any obvious pneumothoraces.

Like all rhinoplasties, the revision rates are fairly high and adding a rib graft to it only adds to the potential for postoperative aesthetic issues. At a near 15% rate, revision rhinoplasty includes such issues as revising warped and malpositioned grafts as well as graft edging and projection issues. Adding projection of the tip also exposes the risks of nostril asymmetry and alar rm retraction.

Dr. Barry Eppley

Indianapolis, Indiana

Diced Cartilage Graft Rhinoplasty Wrappings

Wednesday, March 26th, 2014

 

Cartilage grafting to the nose for significant dorsal augmentation almost always requires a rib graft for the volume needed. A rib graft provides ample amounts of graft material to augment the nose to just about any degree but it does have a well known tendency for warping. Even a well carved and positioned rib graft placed on the nasal dorsum does not always guarantee that it will forever remain perfectly straight.

Diced Cartilage Rhinoplasty Indianapolis Dr Barry EppleyThis one drawback to nasal rib grafting has led to the re-emergence of changing the stiffness of the rib cartilage into a diced shaped graft. This is an historic nasal grafting method known as a ‘Turkish Delight’ as originally described by the Turkish surgeon Erol.  By changing a one-piece stiff rib graft into hundreds of small 1mm cubes, it can be shaped and adapted to the desired nasal form and there is no chance of warping or graft distortion.

But to successfully place a diced cartilage graft into the nose, the many small cartilage ‘cubes’ must be placed into some type of containment sac to create a moldable cartilage graft. This has historically been done with the use of a Surgicel wrapping. Surgicel is best known as a hemostatic agent that was introduced long ago in 1947. It is composed of an oxidized cellulose polymer and comes as a very pliable mesh sheet. It can be rolled into a ‘sausage casing’ to contain a diced cartilage graft.

Alloderm in Rhinoplasty Dr Barry Eppley IndianapolisWhile easy to use, the enveloping Surgicel has been criticized as causing a mild inflammatory reaction as it resorbs and could cause the cartilage graft to resorb. This has led to the use of tenporalis fascia as the wrapping which experimental studies have shown to not induce a similar inflammatory reaction due to its autogenous nature. However, harvesting temporalis fascia requires a donor site and an associated temporal scalp scar.

In the August 2011 issue of the Journal of Plastic, Reconstructive & Aesthetic Surgery, a study was reported whose aim was to compare the viability of diced cartilage wrapped in autogenous fascia to diced cartilage wrapped in AlloDerm in a rabbit model. Diced cartilage grafts wrapped in lumbar fascia vs Alloderm were compared after six months of implantation by standard and immunohistochemical staining. Their histological analysis showed that the chondrocyte regeneration potential, matrix collagen content, and metaplastic bone formation of the AlloDerm-treated group were significantly superior to those of the fascia-treated group. With respect to other histological parameters, the AlloDerm-treated group showed better results than the fascia-treated group, but these results were not statistically significant. Their experimental results indicate that AlloDerm may be an excellent material for diced cartilage grafting. At the least, it appears as if it is just as good as autogenous fascia.

Surgicel Diced Cartilage Rhinoplasty Dr Barry Eppley IndianapolisWhile this was a limited animal study, it makes perfect sense that an allogeneic dermis would offer similar advantages to fascia with one significant exception…it does not require a donor site. As long as the Alloderm layer is not too thick (less than 1mm or 65/1000s of an inch), revascularization of a diced cartilage rhinoplasty should happen fairly quick.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: The Use of Rib Grafts in Revisional African-American Rhinoplasty

Monday, April 8th, 2013

Background: Rhinoplasty in the non-caucasian ethnic nose poses different challenges than many typical rhinoplasty procedures. The goal of making a more defined and less wide nose requires a major change in the cartilage construct of the nose. Increasing the height of the bridge and the tip requires a considerable push from beneath to lift often heavy and thick nasal skin. Such skin also limits how nasal definition can eventually be seen.

Such augmentation rhinoplasties usually encounter the classic debate of how to do it…synthetic implants vs rib cartilage grafts. There are advocates on both sides of that discussion and patients will often have a preference as well. Most of the time surgeons and patients will choose a synthetic implant because it is easier and has a much quicker recovery. While I am not a personal fan of synthetic materials in the nose, I do recognize why it is a frequent and appealing choice.

Despite a surgeon’s best efforts, synthetic implant augmentation rhinoplasties can and do fail. Failure may be defined as either an inadequate amount of aestheic projection or an infection or exposure of the implant. Once either occurs, the balance is now tipped towards an autologous cartilage graft approach which means a rib harvest must be considered.

Case Study: This 35 year-old African-American female had two prior rhinoplasties in effort to give her nose more definition and height. The first rhinoplasty used her septal cartilage and the second procedure used Gore-tex sheeting on top of her prior cartilage grafts. She remained unhappy due to the lack of any significant dorsal height increase and a persistently flat and broad nasal tip. She also had a bump along the right middle vault which I assumed was either cartilage or implant-related.

Under general anesthesia, an open rhinoplasty approach was done. The Gore-tex sheeting was removed and the dorsal line smoothed down. Rib grafts were harvested from her left left subcostal margin. A portion of the free-floating 9th rib was used as a large columellar strut and a portion of the 8th rib was used as a long dorsal graft. The two were joined over the dome area providing increased tip projection and definition.

She had moderate pain over the rib harvest area as expected but none on the nose. There was some moderate swelling and firmness over the nose for a few weeks. It took six months to completely settle and see the final definition of the nose. Her results showed much improvement in her nasal height and definition. She was finally pleased with the improvement and also took solace in knowing that this is the most that could be done.

The use of rib grafts in the nose usually produces unparalled results in nasal augmentation. It is understandable, however, why patients are reticient to opt for them as their first operation even though it may be the best approach in the long-run. But when forced to use them as a salvage/revisional surgery, rib grafts in rhinoplasty offer a resource of material to do virtually any form of reconstruction or augmentation. They are particularly valuable in the ethnic nose where significant augmentation is needed.

Case Highlights:

1) Significantly improving the nose shape of the African-American nose is often inadequate from septal cartilage only or small amounts of synthetic materials.

2) Revision rhinoplasty of a ‘failed’ primary augmentation procedure requires cartilage grafting, usually from the rib given the volume needed.

3) Increasing dorsal height and improved tip projection requires a dorso-columellar strut rib graft configuration.

Dr. Barry Eppley

Indianapolis, Indiana

The Use of Synthetic Implants In Rhinoplasty

Wednesday, September 5th, 2012

 

The need for augmentation and support in rhinoplasty is common. Whether it is building up the dorsum, adding supporting to the columella or reconstructing the middle vault with spreader grafts, adding volume is a common cosmetic and reconstructive need. The need for volume is most magnified in many ethnic rhinoplasties where an entire dorso-columellar strut support is needed.

When it comes to grafting in the nose, the choice and debate between a cartilage graft and a synthetic implant is historic. The advantages and disadvantages are well known for each type of implant material. In the end, cartilages grafting is generally considered to be better as a natural material that can integrate although it is harder to use and requires more effort. (and sometimes skill) Conversely, the use of implants is more convenient because it is off-the-shelf and often preformed making it easier to insert and the outcome somewhat more predictable. But it does so at a cost…the risk of infection which is much more rarely seen with cartilage grafts.

But what is the risk of implants in the nose and are there differences in the various implant materials used for these risks? In the August online version of the journal, Archives of Facial Plastic Surgery, a study was published on ‘Complications Associated With Alloplastic Implants in Rhinoplasty’.  In a single academic center, over 650 rhinoplasties done by three different surgeons over a period of nine years was retrospectively reviewed. In 23% of these rhinoplasties cases (151 out of 662 cases),  a nasal implant of either Gore-tex or Medpor was used. Of all the cases, 19 patients (3% of all rhinoplasties in the series or 13% of those rhinoplasties that received synthetic implants) developed infection or extrusion of the implant. Not a single case of infection or extrusion occurred when cartilage grafting from the septum, ear or rib was used. Between the two materials, a higher rate of infection occurred in those cases that used Medpor (20%) versus Gore-tex. (5%)

This is by far the largest report or series on the use of synthetic implants in the nose that I have ever seen. Its findings parallel one basic concept that is well accepted…cartilage grafts are safer and do not suffer the rate of infection or extrusion that a synthetic implant will. What is novel in the study is the much higher rate of complications with Medpor implants than Gore-tex that was seen. Initially this seems at conflict with how Medpor is supposed to work, its porous surface allowing tissue ingrowth while Gore-tex is a solid largely non-porous material. But biology aside, it is important to realize that the body (nose) is not as enamored with tissue ingrowth as one would think. An implant after all is still not a natural material and even with tissue ingrowth it is still largely a synthetic material.

But I suspect the real culprit in the infection/extrusion risks between Medpor and Gore-tex is the size of the implants and how they were used. Medpor comes in a variety of difference shape and sizes for anything from a large dorsal shell implant to columellar struts and batten implants. Conversely, Gore-tex does not come in preformed nasal implants and must be modified from smaller flexible sheets. Gore-tex is also soft and flexible, Medpor is rigid and inflexible from a tissue pressure standpoint. This inadvertently the use of Medpor implants almost always results in larger implanted volumes with more tissue push/strain than Gore-tex. This is a set-up for a higher complication rate.

Interestingly this study did not look at the use of silicone implants which would be the most common alternative in dorsal and dorso-columellar  augmentation needed in many ethnic rhinoplasties. One could speculate what those complications would be. But it would be far to say that cartilage grafts would still have a near zero incidence of infection/extrusion.

Overall, this study supports the well known concept that the use of synthetic implants in the nose has a much higher rate of complications than cartilage grafts. This does not mean that cartilage grafts have a zero incidence of problems, which includes that of the donor area in which a synthetic implant does not have. But cartilage grafts complications in the nose are largely aesthetic, failing to achieve the desired result due to lack of volume or adequate shape.

In my experience, there is a small role for synthetic implants in rhinoplasty but judicious application must be done. The implant should never be close to the internal nasal mucosa, should be small in size and should not stress the overlying nasal skin in any way. They are also probably best avoided in any type of revisional procedure. Cartilage grafts, despite the understandable aversion of patients to them (particularly rib), are always safer and have negligible risks of infection and long-term exposure.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Lengthening of the Nose with a Rib Graft Rhinoplasty

Monday, June 7th, 2010

Background: The evolution of rhinoplasty surgery over the past twenty years has leaned heavily towards a cartilage preservation approach. Focus has been more on cartilage reshaping and less on cartilage removal. As a result, the once common over-reduced or ‘ski-slope’ nose is now a rare finding rather than a common one. When an over-reduced nose presents, the concept of nasal lengthening or expansion is needed for secondary revision.

Case Study: This is a case of a 56 year-old female who came in having had three prior rhinoplasty procedures. Her primary rhinoplasty appeared to have been for reduction of a hump and narrowing and shortening of the nasal tip. Apparently the primary rhinoplasty created a reverse problem, that of a saddle nose deformity and a retracted shortened tip with excessive nostril exposure.  Her original surgeon performed two subsequent revisions, using septal and both ear cartilages for donor sites during the two procedures. While improvement was clearly obtained, she was still unhappy with the shortened tip and nostril exposure. Her original surgeon informed her that she had no more cartilage to give and she sought other opinions.

Her fourth rhinoplasty, (third revision), used the 11th free floating rib for a cartilage source. Grafts were placed as septal extenders between the caudal end of the septum and the medial footplates, extension grafts from the end of the upper lateral cartilages to the underside of the domes, a columellar strut, and an onlay tip graft was done. All these were done to drive the tip out and down and provide more tip definition. Extensions were also placed on the caudal side of the lower alar cartilages to try and lessen the nostril show/retraction.

Any effort to improve nasal tip retraction requires cartilage expansion. Even if her ear and septal grafts had not been taken, I may still have used rib cartilage. You never want to limit what the operation can achieve by the amount of graft  you have to work with. Successful nasal lengthening is largely a function of the amount and construct of the cartilage grafts. As understandably unappealing as the thought of rib harvesting is, it always will provide the most graft material.

The two undesired aspects of rib harvesting, pain and scar, can be controlled by surgical technique. Injecting with a long-acting local anesthetic keeps the discomfort at bay at least for the first 24 hours after surgery. Waking up with severe rib pain can be avoided. The incision for rib graft harvesting can be kept quite small. The skin slides freely over the ribcage so there is no need to make a long incision.

At one month after surgery, she was pleased with the improvement and felt that she had finally reached a nose shape which made her feel comfortable and not self-conscious. Her rib discomfort had largely gone away except for an occasional twinge when she twisted or rotated her body significantly. Both her nose and rib scars were very acceptable to her.

 

Case Highlights:

1)  The success of revisional rhinoplasty is often dependent on adequate cartilage grafts. Recovery from prior rhinoplasty procedures in the over-reduced nose requires cartilage restoration for soft tissue expansion and lengthening.

2) Cartilage graft harvesting from the rib always provides an adequate amount of cartilage. While there is more discomfort from the harvest site, its use should always be considered when septal and ear grafts have been previously harvested. The scar is usually cosmetically acceptable.

3) The need for a second or third rhinoplasty revision is rare and can be overcome with a commitment to full exposure and cartilage grafting.

Dr. Barry Eppley

Indianapolis, Indiana

The Use of Rib Grafts in Rhinoplasty

Saturday, April 10th, 2010

Reconstruction of certain nasal deformities requires significant structural support. Despite the ease of use of synthetic implants, the use of cartilage is associated with minimal risk of severe implant problems such as infection or extrusion. In the very visible nose, this is a huge advantage. Infections and extrusions in the nose from foreign materials may end up destroying or distorting skin or internal lining, problems from which creating a normal looking nose may not be possible.

Adequate cartilage is the key to recovery from many rhinoplasty problems. The nasal septum and the ears can usually suffice. But problems such as saddle nose deformity, short nose problems, large nasal defects from tumor resections and multiply operated and scarred noses may require more than cartilage sites above the neck can provide. The final cartilage harvest stop is the ribs.

Use of a rib graft in rhinoplasty is also known as costal cartilage grafting. It requires a small incision on the chest wall based on the rib number which is to be used. Many plastic surgeons use the fifth or sixth rib for rhinoplasty but my preference is for lower level rib harvesting. Having substantial experience in microtia ear reconstruction, harvesting the free floater 9th rib and portions of ribs 7 and 8 is easier and provides plentiful options of shape and configurations. A small subcostal incision can be moved around to provide good visibiity and the underlying rectus muscle is split vertically for access rather than transecting it.

One of the major concerns about rib harvesting is the risk of pneumothorax as the lung pleura  is close by underneath. But at the level of the 7th ribs and lower, the lower apex of the lung is higher so this is not going to happen. In over 65 cases of rib harvest at this chest wall level, the pleura has never been violated. It becomes evident at the level of the 7th and most certainly at the 6th rib.

But many cases of using rib graft material in the nose do not require a full-thickness graft harvest. A split-thickness graft can be easily and quickly harvested, sparing the bottom side of the rib. This can be very useful for smaller straight grafts of the columella, middle vault spreader grafts, and septal extension grafts. Doral augmentation grafts must usually be 3 to 4 cms. long.

One known risk of using rib grafts is warping. This has been an historic concern. With time, rib segments can change shape and warp. This is particularly prone to occur if one tries to shape a curved piece into a straight graft. It is far better to harvest enough of a segment that you do not have to try and change its natural shape.

It has been a belief that beyond a certain age, rib sites become calcified and largely unusable. While there is no question that at the age of roughly 50 and older, ribs do become harder to work with and have isolated areas of partial calcification, one can always find enough cartilage to use. I have done rib grafts up to age 65 and adequate cartilage has always been found. There is a flip side to a partially calcified rib, it largely resists warping and will not usually change shape anytime after surgery.

Dr. Barry Eppley

Indianapolis Indiana

Rib Graft Rhinoplasty for Saddle Nose Deformity and Secondary Reconstructions

Tuesday, June 30th, 2009

Patients may have unsatisfactory results in their first rhinoplasty that may lead them in seeking a secondary rhinoplasty or revision rhinoplasty.  Secondary rhinoplasty may also be needed for traumatic nasal injuries, particularly when the nasal bridge is impacted inward. (saddle nose deformity)

Many plastic surgeons prefer to use autologous cartilage tissue whenever possible for these types of rhinoplasty due to its much lower risk of infection or long-term exposure or extrusion. Autologous cartilage will be incorporated into the surrounding tissues of the nose allowing it to remodel if necessary rather than the overlying skin or internal lining (mucosa) breaking down.

 These type of nasal deformities may require a good source of cartilage. Of the three cartilage donor sources, (septum, ear, and rib) rib cartilage is a natural and only autologous source that can offer an unlimited amount of cartilage that has more than adequate lengths.

One of the main advantages of rib grafts is its plentiful supply. However, rib grafts are almost always curved and cartilage is well known for its memory. (recall of shape) As a result, it has a tendency to warp or return somewhat to its original shape despite being carved and shaped. Symmetric concentric carving of the rib cartilage will lessen the incidence of postoperative warping. Another way to prevent warping is to insert a thin metal pin through the graft to keep it straight.

The most common reason for a rib graft rhinoplasty is the saddle nose deformity. Correction of this nasal problem requires a significant amount of graft material. The rib graft is carved and reconstructed by assembling it into a two-piece L-shaped graft which is placed through an open rhinoplasty. A longer larger piece is shaped into a dorsal graft and a smaller piece into a columellar strut. If an intact septum is present, then only the onlay dorsal graft will be needed to correct the deformity. Careful graft carving and assembly is needed to minimize the risk of graft warping. Once positioned, the tip cartilages (dome) can be sutured over the end of the rib grafts.

One of the big concerns for patients who require rib graft rhinoplasties is the location and pain from the donor site. Rib cartilage grafting is the taking of cartilage from the cartilaginous portion of the rib. (the rib also has a bony portion too) While many take the fifth or sixth rib, I find this is usually not necessary. This takes more work and risk and causes a substantial amount of pain after surgery. Having done a lot of ear reconstructions with rib cartilage from this area, this is far more cartilage than is needed. I prefer to harvest the graft from the free floating 10th rib and the attached 9th rib. This is more than an ample amount of cartilage. In some cases, a split or shaved cartilage graft can be taken from the outer portion of the 8th rib. This is easier to harvest although it will have some curve to it. When the grafts are harvested from these areas, there is nor risk of pneumothorax, a release of air from the lungs by perforating its lining. The access incision is small, about 4 cms., and will lie along the bottom of one side of the rib cage.

Dr. Barry Eppley
Indianapolis, Indiana

 


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

Read More


Free Plastic Surgery Consultation

*required fields



Pricing

The cost of any type of elective plastic surgery plays a major role in the decision to undergo the procedure(s).

Get Your Quote Here


My Plastic Surgery Story

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits


Categories