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