Harvesting Rib Graft for Dorsal Augmentation and Nasal Reconstruction
Harvesting rib cartilage for African-American and Ethnic Rhinoplasty for reconstructive and/or augmentation, is one option available to Plastic Surgeons. In my opinion, there are better alternatives to rib cartilage for dorsal augmentation; however, when no other option is available, for various reasons, rib cartilage can be a good source of usable cartilage.
Rib Graft Harvesting Surgery
Rib cartilage is typically harvested from the confluence of the seventh to tenth rib. Straight segments of the cartilaginous portion of a rib should be used to allow sufficient cartilage to fabricate all grafts. The incision is made over the skin overlying the eighth rib the soft tissue is dissected using a needle tip cautery down to the perichondrium overlying the cartilaginous rib harvest site. It is important to palpate the underlying ribs to ensure that the dissection proceeds directly over the longitudinal axis of the chosen rib. A longitudinal incision is made through the perichondrium along the length of the central axis of the rib cartilage.
Once the perichondrium is incised the cartilage exposed, a perichondrial elevator is then used to elevate perichondrial flaps based on the superior and inferior borders of the rib cartilage. The dissection is then continued subperichondrial, until the posterior aspect of the rib is exposed. The final step involves separating the cartilaginous rib from its attachments near the sternum and the bony rib.
The wound should be closed in layers including perichondrium, deep and superficial fascia. If at any point during the surgery, the surgeon suspects that the pleural cavity (lung cavity) has been violated, and then procedures to diagnose and treat a pneumothorax (air entering the lung cavity) should be undertaken.
Grafts for Septorhinoplasty can be obtained from different homologous tissues or from alloplastic materials. Homologous grafts (patient's own tissue) include septum, auricular concha and rib. The most common alloplastic materials include silicone implants, Gore-Tex and Medpor.
Disadvantages of Rib Cartilage Grafts vs. Silicone Implants for Dorsal Nasal Augmentation
Rib cartilage has several disadvantages. First, an additional incision at a distant donor site is required to harvest the cartilage. Complications can include postoperative pain, the risk of pneumothorax (life threatening air in the lung cavity), and the potential of rib cartilage to warp. If the surgeon does not harvest enough of the rib, the graft size will be not adequate, and the surgeon will not have enough material to address reconstructive or cosmetic issues for the patient. Rib grafts (or any graft) not placed in the proper tissue plane with adequate securing can show irregularities through the skin, become infected and extrude.
In Revision Rhinoplasty, removal of rib cartilage grafts can be difficult because surrounding tissue has grown into the graft and removal of rib grafts will include removal of normal tissue, which can cause visual as well as functional nasal abnormalities.
In contrast, custom carved silicone grafts, when placed and secured in the right tissue plane, will look natural and last a lifetime. Although, there is a small risk, of silicone implant infection or extrusion, they can be easily removed as the body forms a smooth capsule around the implant. Silicone implants are the most common implant to be used for breast, cheek, jaw, and chin.
Consider the amount of silicone breast implants used every year worldwide. If silicone implants were the problem, many more patients would have extrusion and infection. In my opinion, dorsal augmentation with silicone implants, placed in the right tissue plane and secured properly are superior to rib cartilage dorsal augmentation.