Revision rhinoplasty is a very complicated procedure demanding an intense understanding and appreciation for the correction of the undesired nasal deformity. What makes revision rhinoplasty very complicated is the fact that, as a surgeon, one never knows what lies underneath the skin and soft tissue of the nose. The normal anatomy of the nose—cartilages and bones—have been altered by the initial surgery. The nose is essentially composed of two pairs of cartilages, those pertaining to the middle portion of the nose, the upper lateral cartilages, and those which make up the tip, the lower lateral cartilages. Additionally, the septum of the nose and the nasal bones provide the foundation of structure and support. The septum is composed of both cartilage towards the front of the nose and bone in the deeper aspects. Most, if not all, of these components are altered in some way during a rhinoplasty. The degree and the manner of their alteration are not known by the revision rhinoplasty surgeon beforehand. Cartilage grafts whether taken from the septum, ear, or rib are used to provide shape to the nose. Cartilage grafts also provide the added benefit of supporting the structure of the nose. Septal cartilage is the ‘ideal’ cartilage to use for these purposes—it is a strong, thin cartilage. Oftentimes, however, septal cartilage is missing or has been removed during the previous rhinoplasty. In order to revise a rhinoplasty, grafting material is nearly always needed to correct the underlying deformities.
Given the missing septal cartilage, the only available cartilage grafting material left available to the surgeon is either from the ear or the rib. Ear cartilage is a great option for revision rhinoplasty when used in specific locations and for certain problems. I opt to use ear cartilage when I encounter the need for grafting material in certain locations within the nose and for specific purposes. For the purposes of this article on rib cartilage grafting, I will defer these indications for ear cartilage and its benefits permitting me to write more extensively on rib cartilage itself. It may come as a surprise to most that our ribs are composed of cartilage as they approach the middle of our chest or the sternum. It surprises most patients because of the strength of our rib cages. Harvesting of rib cartilage does not necessarily weaken our strong rib cages. I aim to remove rib cartilage from the 6th and, at times, the 7th rib. The 6th rib lies approximately directly below the breast crease in women and below the larger chest muscles in men, allowing for a camouflaging of the incision within this crease. Harvesting of rib cartilage from the 6th rib is different than where some other surgeons choose to harvest as some harvest from ribs lower in the rib cage. An additional benefit of removing cartilage from the 6th rib is that the 6th rib is not a ‘free-floating’ rib—it has firm bony attachments to the surrounding rib cage and the sternum (chest plate bone at the center of our chests). Removing a small piece of rib cartilage from the center of this firmly attached rib provides the benefit of reducing discomfort after surgery.
Discomfort is minimized by limiting removal of the rib to this site specifically while keeping the surrounding tissue intact. In this same manner, risk is minimized to the surrounding chest and underlying lungs through this preservation of the tissues underlying and surrounding the rib. Given the great deal of attention which plays into the harvesting (removal) of the rib cartilage, it is actually what to do next with the rib cartilage which is most intimidating to revision rhinoplasty surgeons. The difficulty in using rib (and the reason why most surgeons do not perform rib graft revision rhinoplasty) lies in the ‘when, how, and where’ to use the rib. The risk of using rib cartilage in the hands of surgeons inexperienced with its use is that rib cartilage has a tendency to warp or change shape. It is not that surgeons with more experience with rib cartilage somehow magically prevent rib from warping or changing shape. On the contrary, it is the use of the rib in the proper locations, with the proper techniques, which greatly reduce the possibility that any changes within the shape of the rib cartilage will create changes in the outward appearance of the nose. When used properly, rib cartilage provides a great material from one’s own body, without the need to implant synthetic materials, to give a nice aesthetic, long-term outcome to the shape of the revised nose.