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.
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