ACTA oTorhinolAryngologiCA iTAliCA 2013;33:190-195 Rib grafts in septorhinoplasty Innesti di costa nella settorinoplastica A. Moretti1, S. Sciuto2 1 Department of Medical, oral and Biotechnological Sciences, eNt Section, “G. d’Annunzio” university of chieti- Pescara, italy; 2 casa di cura Nostra Signora della Mercede, rome, italy SummAry Autogenous cartilage has generally been considered the gold standard grafting material in reconstructive septorhinoplasty for volume filling and structural support. in the restructuring of the nasal skeleton, autogenous cartilage can be harvested from the nasal septum, the auricle or the rib, but costal cartilage is considered the best graft material in patients requiring major reconstruction. rib cartilage is an outstanding material in reconstructive septorhinoplasty, especially in revision surgery and when large amounts of tissue are required. This autologous material has a low rate of complications such as resorption, infection and extrusion compared to homografts and alloplastic implants. in the present study, the authors analyze and discuss the use of autogenous rib cartilage in 54 patients who underwent primary and revision septorhinoplasty. its use is also suggested in cases in which there is a need to have a fair amount of cartilaginous tissue to be grafted for nasal framework reconstruction and respiratory function improvement. Key wordS: Reconstructive septhorhinoplasty • Grafts • Rib cartilage riASSunTo La cartilagine autologa viene generalmente considerata come il materiale di prima scelta per gli innesti nella cosiddetta settorinoplastica ricostruttiva sia per quanto riguarda il sostegno strutturale del naso che per gli effetti di riempimento che da essa si possono ottenere. Nella ristrutturazione dell’architettura di sostegno nasale il tessuto cartilagineo può essere ricavato dal setto, dal padiglione auricolare o dalla costa. Quest’ultima sede rappresenta il sito donatore principale nelle ricostruzioni maggiori ed in particolare nella chirurgia di revisione da eseguire in pazienti con deplezione cartilaginea. La cartilagine costale autologa se confrontata con omoinnesti ed impianti alloplastici presenta una bassa percentuale di complicanze, soprattutto infezioni ed estrusione anche se non è scevra da possibile riassorbimento e distorsione. Nel presente studio gli Autori analizzano e discutono l’impiego della cartilagine costale autologa in 54 pazienti sottoposti a settorinoplastica primaria o di revisione e ne suggeriscono l’impiego in tutti quei casi in cui vi è la necessità di avere a disposizione una congrua quantità di tessuto da innestare per ristabilire la struttura di sostegno e migliorare la funzionalità nasale. PArole ChiAve: Settorinoplastica ricostruttiva • Innesti • Cartilagine costale Acta Otorhinolaryngol Ital 2013;33:190-195 Introduction ble when large amounts of tissue and multiple grafts are required, especially in patients already surgically treated, Grafts in septorhinoplasty can be obtained from different with cartilage depletion. Usually two teams work simul- autologous and homologous tissues or from alloplastic taneously, but since most warping occurs within 15-60 materials. Autologous cartilage presents many advantag- min of harvesting (early warping), the same surgeon can es compared to other kinds of grafts: it survives as a liv- harvest the rib before modeling the graft and preparing ing tissue, seldom undergoes resorption, does not stimu- the recipient site, preferably using an open approach, to late an immune response, is ideal for all types of grafting verify cartilaginous structure modifications. The central and presents only biological costs, but its use requires portion of the 5th to 8th rib is preferred by some surgeons 9; longer operation time. Septum, auricular concha and rib however, the 11th and 12th free-floating ribs are naturally are the best cartilaginous donor sites for autologous na- straighter, require less carving and undergo less warp- sal grafting. Rib cartilage is the graft material of choice ing 10. To reduce the warping effect, Gunter suggested to for dorsal augmentation and reconstructive support when reinforce larger grafts (dorsal onlay graft and columellar sufficient septal cartilage is not available 1. Autologous strut) with a centrally placed Kirschner-wire to provide rib cartilage is often overlooked in reconstructive sep- a more stable and predictable result 6. The graft is pref- torhinoplasty because of potential donor-site morbidity erably harvested from the right side to prevent the pos- and the warping effect 2-8; however, its use is indispensa- sibility of confounding any cardiac chest pain, although 190 Rib grafts in septorhinoplasty in some cases, to facilitate a two-team approach, rib car- saddle nose, septal perforations, valvular collapse and na- tilage harvesting is performed on the patient’s left side. sal airflow obstruction, the procedure included placement Rib cartilage can be harvested circumferentially, after of septal grafts, alar, tip and dorsal onlay grafts, spreader superior and inferior perhicondrium elevation, taking grafts, columellar struts and shield grafts. special precaution not to injure the inferior line neuro- In male patients, an incision was made over the seventh vascular bundle or closely adherent pleura on the medial costal cartilage and in the women under the breast crease surface. Rib harvesting can be also limited to the outer to hide the scar. After skin incision, the external oblique lamella preserving the internal costal arch. By preserv- muscle was reached and the fascia over this muscle was ing the inner lamella of the rib, postoperative morbidi- opened. The overlying muscles were spread, parallel of ties, including pain, splinting and pneumothorax, are re- the direction of their fibres and appropriately retracted, duced 10. In revision rhinoplasty, the dorsum is frequently to reduce postoperative pain, until exposing the underly- over-resected and the septal L-structure is weakened. In ing costal cartilage. The perichondrium was incised paral- these cases, dorsal spreader grafts should be placed along lel to the outer surface and circumferentially elevated to either side of the septum to provide a stable recipient site perform full-thickness harvesting of the rib cartilage. In for the dorsal onlay graft 11. The spreader grafts should some cases, when the harvesting was limited to the outer be stabilized with horizontal mattress sutures at the same lamella, the perichondrium was elevated only to the ex- level as the septum and extend from the keystone area to ternal surface. Once elevation was complete, the desired the septal angle in preparation for receiving the dorsal section of the rib was performed. onlay graft. Spreader grafts are used to widen a narrow dorsum when necessary to obtain better symmetry of the middle third of the nose, but also to improve the acute angle of the internal nasal valve when related respira- tory insufficiency is present. To restore effective L-strut support, it is very important to prepare a precise pocket between the medial crura for placement of the columellar strut. To obtain a stable and strong medial framework in most severe depleted cartilaginous cases, it is necessary to hinge the columellar strut with the dorsal graft 11. The present study describes the authors’ experience in the use of autologous rib grafts in primary and revision cases of septorhinoplasty. Methods We retrospectively analyzed data from 54 patients who underwent septorhinoplasty using autologous rib cartilage Fig. 1. Full-thickness harvesting of the rib. grafts in the last 10 years. The study population consisted of 33 male and 21 female patients (mean age: 34 years; age range: 16-64 years). All septorhinoplasties were performed under general anaesthesia in patients with depletion or de- formities of the osteocartilagineous nasal framework using an open approach. Twelve patients were primary cases: 8 with post-traumatic deformities and 4 presented congenital abnormalities. Three patients showed stigmata of cocaine abuse, 1 presented sequelae due to haematoma of the sep- tum, and 38 were revision cases, 7 of which previously treated with alloplastic implants. The patients had several degrees of saddle nose deformity and complained of nasal obstruction: in 42 cases, most of the septum was absent, and 6 patients had previous aggressive septoplasty with septal perforation in 2 cases. Eleven patients had internal nasal valve insufficiency. All patients showed tip deform- ity and alteration of the relationship between dorsal lines and columella-tip complex. In correction of the iatrogenic nasal deformities such as stigmata of alloplastic implant, Fig. 2. Harvesting of the rib limited to the outer lamella. 191 A. Moretti, S. Sciuto Rib cartilage can be removed full-thickness (Fig. 1), tak- 17 patients to provide further stability to the septal graft or ing special precaution to the neurovascular bundle or the to improve nasal valve function. In each case, the dorsum closely adherent pleura medially. The harvesting can be was made as flat and smooth as possible before the dorsal also conducted only to the outer portion to maintain the onlay graft was placed (Fig. 5). Alar and tip onlay grafts continuity of the internal costal arch (Fig. 2). By preserv- (Fig. 6) had various combinations with the previous grafts ing the inner lamella of the rib, postoperative morbidities, in 48 patients to address structural defects. Only in three including pain, splinting and pneumothorax, are reduced. cases, with underprojected tip, was a shield graft used. After the graft was removed, the donor site was closed in layers without drains. The harvested costal cartilage was Results shaped as a vertical strip except in patients with severe saddle nose deformity when a large amount of cartilage is The follow-up ranged from 6 to 36 months, with an av- required to recreate the new L-structure with a columellar erage of 18 months. None of the patients had any intra- strut hinged with a large dorsal graft (Fig. 3). The central operative complications. Oral analgesic was always ad- portion was usually used in dorsal reshaping (dorsal and equate for pain control and chest pain subsided within spreader graft) and for septal reconstruction, while the pe- 1 to 6 weeks postoperatively. Cosmetic appearance and ripheral portion was shaped in alar and tip replacement nasal obstruction were improved in all cases. Regarding grafts after approximately 30 min to allow most of the complications, none of the 54 patients had grafts extru- warping to occur. All the grafts were inserted using an sion. Four patients had infection in recipient sites (3 on open approach that offers the best exposure of nasal struc- the columella and 1 on the dorsum) with significant grafts tures by providing graft positioning and stabilization in resorption in 2 cases with a history of cocaine abuse. the desired locations without distorsion. The costal carti- Warping defect was noticed in 3 patients after the oedema lage grafts were used as dorsal, septal and columellar strut subsided. In 2 of these, distorsion occurred in the dorsal in all cases (Fig. 4), while spreader grafts were utilized in onlay graft and revision surgery was required. In the third Fig. 3. Preoperative and 2-years postoperative photo- graphs of a patient who had two previous aggressive septorhino- plasty. All the grafts used were harvested from rib cartilage. 192 Rib grafts in septorhinoplasty ing occurs within 15 to 60 min of harvesting, it is very important to wait for early warping to occur and reshape the graft before placement 16 17. Possible warping defects can be prevented by using balanced carving, using rigid cartilage-bone fixation or laminated graft for dorsal aug- mentation, or by using a diced cartilage graft 18-22. Long- term warping, especially in larger dorsal and columellar grafts, can be also overcome using K-wires as advocated by Gunter et al. 6. One of the most important advantages of autogenous rib cartilage is the low rate of infection and extrusion com- pared to other non-autogenous materials or alloplastic implants 1 14. Various types of allografts have been used in reconstructive septorhinoplasty, particularly for dorsal augmentation, including silastic, high-density porous poly- ethylene (Medpor), and expanded polytetrafluoroethylene (Gore-Tex) 7. Alloplastic implants have the advantages of being easy to use, readily available and an unlimited supply. Unfortunately, because of their permanent nature, many of these allografts are associated with long-term complica- Fig. 4. Intraoperative view of the case shown in Figure 3. The dorsal on- tions such as infection, migration, extrusion and palpabil- lay graft positioned over spreader grafts was used to make the dorsum as ity 23-25. In contrast to conventional beliefs, some Asian sur- flat and smooth as possible and to improve internal nasal valve dysfunction. geons report that autologous rib cartilage is associated with Caudal portion of the dorsal rib graft is placed under the cephalic margin of the alar cartilages to make the internal nasal valve angle more rounded. a relatively high complication rate and a relatively low aes- Umbrella tip graft is sutured over the domes to achieve more tip projection. thetic satisfaction outcome 21. They also report that compli- cations, especially infections in revision rhinoplasty cases, are related to the possibility of poor blood supply in the patient, minor warping occurred in the caudal septum and recipient area particularly when large masses of graft are columella, and revision was not required. Only two pa- used. In fact, multiple grafts may affect skin tension, and tients developed donor site complications: 1 patient with scar tissues from previous surgery can reduce the vascular early wound infection was successfully treated with oral supply to the graft site and increase the probability of infec- antibiotics, and no further intervention was required; the tion 21 26. The relatively high complication rate is also fre- other initially developed a seroma and a keloid scar of the quently observed in patients with bad lifestyle and related chest incision, which was treated with steroid injections. to a history of cocaine abuse and/or alcohol consumption or in smoker patients with metabolic diseases. Discussion Conclusions The goal of septorhinoplasty is reconstruction of the na- sal skeleton to provide adequate structural support allow- In selected primary septorhinoplasty and in patients ing for optimum functioning of the nasal airway while where there is previous compromise septal and conchal achieving an aesthetically pleasing result with the rest of donor sites, the only alternative is to use distant autog- the face. Overall, autogenous grafts, particularly cartilagi- enous tissue, homografts, or alloplastic materials. Auto- nous types, have been the gold standard largely because grafts do not induce an immune response, and also have of their large acceptance rate, durability, virtual lack of the lowest infection and extrusion rates of any currently an immunogenic response, low infection, and extrusion available materials. Autogenous rib cartilage grafts are rates 7 12-15. Autogenous costal cartilage graft is a viable the gold standard for nasal reconstruction in patients with option in reconstructive septorhinoplasty. We advocate cartilage depletion and when large amounts of tissue are the use of this graft in septorhinoplasty cases requiring needed. We have found, according to other similar expe- a large volume of tissues with severe structural defects in riences, that autogenous costal cartilage grafting offers which adequate septal tissue is not present 7 12. The main strength for nasal support to replace or augment missing disadvantage of the autogenous costal cartilage graft is its tissue with similar tissue and recreates the nasal anatomy tendency to warp from tension forces on its surface 16. The as close to normal as possible. key to minimizing this effect is to make sure to carve the We conclude that autogenous rib cartilage grafts are an cartilage equally on each side, and thus maintain a bal- outstanding material in septorhinoplasty when structural, anced cross section of the graft 6 8 17. Because most warp- functional and aesthetic problems are present and when 193 A. Moretti, S. Sciuto Fig. 5. Above: saddle nose as the result of septoplasty with complications leading to almost total resorption of the septum and collapse of the cartilaginous vault. Below: the end result ob- tained by balancing the profile through reconstruction of the cartilaginous dorsum and exci- sion of the osseous dorsum an effective volume filling and reconstruction of the nasal structures are needed. Its use should however be adopted keeping in mind the possibility of complications. References 1 Porter JP. Grafts in rhinoplasty, alloplastic vs autogenous. 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Received: December 15, 2012 - Accepted: January 7, 2013 Address for correspondence: Antonio Moretti, Department of Me- dical, Oral and Biotechnological Sciences, ENT Section “G. d’An- nunzio” University of Chieti-Pescara, via dei Vestini, 66100 Chieti, Italy. Tel. +39 0871 3554070 . E-mail: [email protected] 195