Techniques used to lessen the degree of rib (costal) graft warping in nose surgery

Rib carving is a tedious procedure, says Dr. Paul Nassif in this video. He soaks the rib graft in normal saline solution to soften it up and gives you the curve of where the cartilage is going to go.  The inner cortex of rib has less chance of warping, so its left intact. For rim grafts you need to carve the cartilage which is very delicate process, since you have to make sure the graft doesn't end up splintering.


Symmetric carving of the costal cartilage graft will minimize the chance of the graft warping over time.

Here's an interesting study on comparison of  warping after using different techniques of carving.  Concentric grafts warped less than Eccentric grafts.

David W. Kim, MD; Anil R. Shah, MD; Dean M. Toriumi, MD

  http://www.shahfacialplastics.com/carvedcostal.html

Dr.Jack Gunter, has devised a technique in which the larger grafts, the dorsal onlay graft and the columellar strut, are reinforced with a centrally placed Kirschner (K)- wire to decrease warping and provide a more stable and predictable result.
"Graft warping can occur in autogenous rib cartilage and lead to long-term postoperative distortions of nasal shape. The use of stabilizing K-wires placed through the center of these grafts has been a successful technique to counterbalance the tendency of the grafts to warp. To avoid warping of smaller grafts, we follow the principle of carving balanced cross-sections originally described by Gibson and later substantiated by Kim et al"
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884866/

 http://journals.lww.com/plasreconsurg/Abstract/1997/07000/Internal_Stabilization_of_Autogenous_Rib_Cartilage.26.aspx

Control of grafted rib cartilage warping using K wire by Dr. A. Nakamura
http://www.springerlink.com/content/t33w777gk6668438/

More info regarding techniques to avoid warping of costal grafts:

Controversies in Otolaryngology: By Myles L Pensak
http://books.google.ca/books?id=xJNDV-KxYjcC&pg=PA176&lpg=PA176&dq=how+to+avoid+rib+warping+k+wire&source=bl&ots=yqnbTNt4GH&sig=M50C2vLAynJ_zlsAvkUBkhIlY90&hl=en&ei=_Z_TTLW5KIzCnAfTwLyOBg&sa=X&oi=book_result&ct=result&resnum=3&ved=0CCIQ6AEwAg#v=onepage&q=how%20to%20avoid%20rib%20warping%20k%20wire&f=false

Revision Rhinoplasty: By Daniel G. Becker, Stephen S. Park
http://books.google.ca/books?id=vwHmwB8qSeAC&pg=PA112&lpg=PA112&dq=how+to+avoid+rib+warping+k+wire&source=bl&ots=wJ4csX9UTT&sig=AY6roDDVffKe5bniZhAz3neSmAM&hl=en&ei=_Z_TTLW5KIzCnAfTwLyOBg&sa=X&oi=book_result&ct=result&resnum=6&ved=0CC4Q6AEwBQ#v=onepage&q=how%20to%20avoid%20rib%20warping%20k%20wire&f=false

More concerns when harvesting costal cartilage for use in nose surgery.

Image via Wikipedia

Two major concerns about, harvesting rib cartilage are: 1. the risk of  pneumothorax, a release of air from the lungs and 2. the concern about as we age rib cartilage tends to calcify therefore the cartilage becomes more like bone. 

According to Dr. Barry Eppley, a plastic surgeon in Indianapolis, his preference is the 7th, 8th, and free floater 9th rib for harvesting.  He claims it " 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." See link below (exploreplasticsurgery).

He continues,  "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 7^th 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 7^th and most certainly at the 6^th rib."  So for those seeking revision rhinoplasty and need rib grafts, don't forget to ask the surgeon at time of consult which rib he uses, how many has he done like that, and has he/she had any complications with it. 

Another nose revision surgeon , Dr. Anil Shah in Chicago prefers to use the 5th, and 6th rib. He says "either the 5th or 6th rib are most commonly used.  The 5th rib has the advantage of being straighter and not really connected to any of the other ribs.  The disadvantage is it tends to be smaller.  The 6th rib tends to be longer but more curved than the 5th rib.  In addition, it tends to connect to other ribs." See link below (shahfacial plastics).

How about calcification of the ribs as we age?

According to Dr. Shah,  "as we age, the cartilage portion of the rib cage becomes calcified and eventually actually turns to bone. This process is typically complete at age 55, but I operated on patients well over fifty who have had substantial cartilage remaining in their ribs".  When your over the age of 40 there is normally more calcification which makes the costal graft harder to shape, however the upside to this is there is less chance of warping over the years. 

Dr. Eppley mentions "one can always find enough cartilage to use. I have done rib grafts up to age 65 and adequate cartilage has always been found". 

http://exploreplasticsurgery.com/2010/04/10/rib-grafts-for-rhinoplasty 

http://www.shahfacialplastics.com/costal%20cartilage%20grafting.html

Irradiated cartilage (cadaver) grafts in nose surgery

So you need to have your nose built up but you don't have enough septal, or ear cartilage for support and you don't want synthetic implants in your nose, and your concerned about having your rib section operated on in order to harvest rib cartilage for nose grafting. Your option, Cadaver cartilage grafts. This is a controversial area, some nose surgeons say its much inferior to your own rib cartilage because of absorption problems, while others like Dr. Russell Kridel,  a facial plastics e.n.t. feels its a great option which shouldn't be overlooked and has shown studies (see medpagetoday link below) that support his view. Maybe it's a e.n.t. perspective vs the plastic surgeon's perspective. Most e.n.t.'s don't harvest rib cartilage for nose surgery (although this trend is changing) so it makes perfect sense they would be in favor of another option. But that's what makes things so interesting. The more options the better for the nose patient, however the debate between which is better can cause the patient to freeze in their tracks wondering who to believe and trust. Every surgeon has their own unique and favorite approach and so you have to consider what is best for you the patient and see if the surgeon has a lot of experience in the approach your seeking. What's right for one patient isn't right for another. Our general health, age, previous surgery's puts us all at a different place in time and has to be taken into consideration by the surgeon. It would be in the best interest of the surgeon to let the prospective patient know what options they provide and feel is appropriate. However they should not be afraid to also recommend another colleague to the patient, if that colleague does a procedure that they don't offer or specialize in yet is what  the patient is seeking. The surgeon will gain more respect from the patient this way, (meaning more referrals and positive internet forum comments) and therefore should not be afraid of losing the patient to someone else, since the patient will at the end go with who they feel is not only most qualified but with who can  offer what they want, making them feel more comfortable knowing they're on the same page with that particular surgeons view.

The Rate of Warping in Irradiated and Nonirradiated Homograft Rib Cartilage: A Controlled Comparison and Clinical Implication.      

In this study it was concluded that there was no difference in warping characteristics between irradiated and nonirradiated homograft (allograft) rib cartilage.  Make note:
The centrally cut pieces of cartilage in each group warped less than peripherally cut blocks in each group.

http://journals.lww.com/plasreconsurg/Abstract/1999/01000/The_Rate_of_Warping_in_Irradiated_and.42.aspx

http://archfaci.ama-assn.org/content/12/2/114.abstract

 Prevailing concerns with ICC and Costal AutoGrafts:
Homologous irradiated costal cartilage (ICC) has been shown to resorb on long-term follow-up and has the potential to warp but studies have shown contradictory results. In addition to problems with resorption, warping, and bacterial infection fear of viral transmission despite extensive sterilization has severely reduced its usage. However, irradiation of soft tissue allografts (ICC) with high dosage(>3Mrad) radiation can sterilize allograft tissue, destroying bacteria and viruses including HIV and hepatitis. [For more info. on risks of infection and transmitted diseases from allografts see my post Nov.25/10]  Costal cartilage autografts provides a large volume of graft material with excellent structural support.Autogenous rib grafts are known to warp,buckle and absorption can occur and be somewhat unpredictable, but there are techniques a well informed  or experienced surgeon will incorporate to limit warping capabilities in rib grafts. [See my post on techniques used to reduce warping - dated Nov 7/2010].  So the general disadvantages of Costal grafts are warping,  potential donor site morbidities, including pneumothorax, scar visibility, and chest wall deformity, but once again  keep in mind these can be avoided or be marginalized when performed by a surgeon who's well experienced in performing costal grafting. 

http://books.google.ca/books?id=2qq56LYomagC&pg=PA397&lpg=PA397&dq=RISK+OF+TRANSMITTED+DISEASE+WITH+ALLOGRAFTS&source=bl&ots=cU9MnbRoBB&sig=KSY91n5fKiD2lVksKSU6A8vG204&hl=en&ei=iqHuTMmwAcnFnAf0u5jwCg&sa=X&oi=book_result&ct=result&resnum=10&ved=0CFIQ6AEwCTge#v=onepage&q=RISK%20OF%20TRANSMITTED%20DISEASE%20WITH%20ALLOGRAFTS&f=false 

 http://www.entandallergy.com/afp/media/pdfs/lin_rhinoplasty_complications.pdf

Allograft vs. Autograft

  http://www.harthosp.org/TissueBank/HumanTissueGraftInformation/AllograftvsAutograft/default.aspx

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

http://www.ncbi.nlm.nih.gov/pubmed/15277829

Rib Cartilage Safe for Rhinoplasty
http://www.medpagetoday.com/Surgery/PlasticSurgery/17037

Irradiated costal cartilage in augmentation rhinoplasty
http://www.optecoto.com/article/S1043-1810%2807%2900107-8/abstract

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Removing Rib Grafts from the nose

Image via Wikipedia

If your considering a revision to remove rib grafts, you will have to consider the consequences. One of the consequences is that your nose grafts support your nose now, and some of your previous supporting structures may of been partially removed or reshaped.  A better solution if you feel your rib grafts are too large, is too have the grafts made smaller in thickness, however, warping can then become a problem.You will have to see your nose revision surgeon or a new surgeon if that isn't an option to discuss your options, and hopefully the operative report is complete and specific enough to guide the surgeon contemplating correcting this issue. Maybe a ct-scan of the nose would reveal more information before attempting to perform such a surgery.

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• Removing Rib Grafts in Revision Rhinoplasty (realself.com)
• Will Nose Return to Previous State After Rib Graft Removal? (realself.com)