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Figure 1.
Creating the Multiplanar Costal Cartilage Graft
Creating the Multiplanar Costal Cartilage Graft

A, A full-thickness segment of rib cartilage is harvested, and (B) the autologous costal cartilage block carved in 3 dimensions. C, After completed, the construct will be submerged in a saline bath.

Figure 2.
Clinical Images and Placement of Multiplanar Costal Cartilage Graft
Clinical Images and Placement of Multiplanar Costal Cartilage Graft

A and B, Photographs of the lateral view and anterior view of the constructed cartilage graft. C, Photograph of the intraoperative placement of the cartilage graft.

Figure 3.
Results of Reconstructive Rhinoplasty Using Multiplanar Costal Cartilage Grafting
Results of Reconstructive Rhinoplasty Using Multiplanar Costal Cartilage Grafting

A, Photograph of a patient prior to undergoing reconstructive rhinoplasty using multiplanar costal cartilage grafting; (B) intraoperative photograph of the cartilage graft; and (C) a postoperative photograph of the patient demonstrating improved nasal airway and improved aesthetic appearance of the nose.

Figure 4.
Results of Reconstructive Rhinoplasty Using Multiplanar Costal Cartilage Grafting
Results of Reconstructive Rhinoplasty Using Multiplanar Costal Cartilage Grafting

A, Photographs of a patient prior to undergoing reconstructive rhinoplasty using multiplanar costal cartilage grafting, and (B) postoperative photographs of the patient demonstrating improved nasal airway and improved aesthetic appearance of the nose.

Table.  
Multiplanar Costal Cartilage Graft for Nasal Reconstruction
Multiplanar Costal Cartilage Graft for Nasal Reconstruction
1.
Stewart  MG, Witsell  DL, Smith  TL, Weaver  EM, Yueh  B, Hannley  MT.  Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale.  Otolaryngol Head Neck Surg. 2004;130(2):157-163.PubMedGoogle ScholarCrossref
2.
Farkas  JP, Lee  MR, Lakianhi  C, Rohrich  RJ.  Effects of carving plane, level of harvest, and oppositional suturing techniques on costal cartilage warping.  Plast Reconstr Surg. 2013;132(2):319-325.PubMedGoogle ScholarCrossref
3.
Gunter  JP, Cochran  CS, Marin  VP.  Dorsal augmentation with autogenous rib cartilage.  Semin Plast Surg. 2008;22(2):74-89.PubMedGoogle ScholarCrossref
4.
Gunter  JP, Clark  CP, Friedman  RM.  Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping.  Plast Reconstr Surg. 1997;100(1):161-169.PubMedGoogle ScholarCrossref
5.
Isac  C, Mihajlovic  D, Bratu  T, Isac  A.  Severe saddle nose deformity reconstructed with rib cartilage.  Chirurgia (Bucur). 2012;107(6):809-815.PubMedGoogle Scholar
6.
Cervelli  V, Bottini  DJ, Gentile  P,  et al.  Reconstruction of the nasal dorsum with autologous rib cartilage.  Ann Plast Surg. 2006;56(3):256-262. Review.PubMedGoogle ScholarCrossref
7.
Bilen  BT, Kilinç  H.  Reconstruction of saddle nose deformity with three-dimensional costal cartilage graft.  J Craniofac Surg. 2007;18(3):511-515.PubMedGoogle ScholarCrossref
8.
Moretti  A, Sciuto  S.  Rib grafts in septorhinoplasty.  Acta Otorhinolaryngol Ital. 2013;33(3):190-195.PubMedGoogle Scholar
9.
Ozturan  O, Aksoy  F, Veyseller  B, Apuhan  T, Yıldırım  YS.  Severe saddle nose: choices for augmentation and application of accordion technique against warping.  Aesthetic Plast Surg. 2013;37(1):106-116.PubMedGoogle ScholarCrossref
10.
Gibson  T, Davis  WB.  The distortion of autogenous cartilage grafts: its cause and prevention.  Br J Plast Surg. 1958;10:257.Google ScholarCrossref
11.
Wee  JH, Park  MH, Oh  S, Jin  HR.  Complications associated with autologous rib cartilage use in rhinoplasty: a meta-analysis.  JAMA Facial Plast Surg. 2015;17(1):49-55.PubMedGoogle ScholarCrossref
12.
Hsiao  YC, Abdelrahman  M, Chang  CS,  et al.  Chimeric autologous costal cartilage graft to prevent warping.  Plast Reconstr Surg. 2014;133(6):768e-775e.PubMedGoogle ScholarCrossref
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Original Investigation
May/Jun 2016

Reconstructive Rhinoplasty Using Multiplanar Carved Costal Cartilage

Author Affiliations
  • 1Department of Facial Plastic Surgery, Virginia Mason Medical Center, Seattle, Washington
  • 2Division of Otolaryngology–Head and Neck Surgery, University of New Mexico, Albuquerque
  • 3Department of Otolaryngology, University of Texas Southwestern, Dallas
JAMA Facial Plast Surg. 2016;18(3):207-211. doi:10.1001/jamafacial.2015.2251
Abstract

Importance  Reconstructive rhinoplasty often requires the use of cartilage grafts. Full-thickness autologous costal cartilage grafts provide a large amount of cartilage in a single uncarved block and are often used for major reconstructions. Warping is frequently described as a complication of rib cartilage use in rhinoplasty.

Objective  To describe an approach to cartilage carving whereby a single block of cartilage is carved in a multiplanar manner to mimic or redefine the anatomic relationships and resist warping.

Design, Setting, and Participants  A retrospective review of reconstructive rhinoplasty cases using multiplanar costal cartilage grafting technique was performed. A consecutive sample of 11 patients with complex nasal deformity underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions to address complex deformities at the University of New Mexico Hospital between January 2010 and December 2014. The follow-up period ranged from 3 to 36 months.

Interventions  Autologous rib cartilage harvest was performed to obtain a full-thickness segment of rib cartilage. The deficient or malformed nasal cartilage is defined and soft tissue prepared using an open rhinoplasty approach. Rib cartilage graft curvature is removed to create a uniform, symmetric, solid block of cartilage. A cartilage graft is carved in a multiplanar fashion to simulate normal nasal anatomy.

Main Outcomes and Measures  Postoperative evaluation of nasal airway function, cartilage graft warping, and aesthetic outcomes were reported in the follow-up period. Nasal Obstructive Symptom Evaluation (NOSE) scores are documented in the majority of cases and were obtained at least 3 months postoperatively.

Results  Overall, 11 patients with complex nasal deformity underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions. The most common use was for reconstruction of the septum with the upper lateral cartilage. There were no major complications. No patients experienced graft warping in the follow-up period. Several patients required minor revision procedures. All patients reported improved nasal airway and improved aesthetic appearance of the nose.

Conclusions and Relevance  Multiplanar costal cartilage grafting is a useful surgical technique for complex reconstructive rhinoplasty that yields optimal and predictable results.

Level of Evidence  4.

Introduction

Reconstructive rhinoplasty after traumatic, congenital, or postsurgical deformity often requires the use of cartilage grafts. Full-thickness autologous costal cartilage grafts provide a large amount of cartilage in a single uncarved block. We describe an approach to cartilage carving whereby a single block of cartilage is carved in a multiplanar manner to mimic or redefine the anatomical relationships. This technique is particularly useful when anatomical junction zones, such as the septum and upper lateral cartilage, are notably deformed, absent, or structurally deficient. The use of a single cartilage block carved in multiple planes allows for a 3-dimensional reconstruction with decreased reliance on suture fixation to maintain the required angular relationships and resist warping.

Methods

Institutional review board approval was obtained prior to initiating this study. A retrospective review of a consecutive samples of reconstructive rhinoplasty cases using multiplanar costal cartilage grafting technique was performed at the University of New Mexico Hospital. Nasal Obstructive Symptom Evaluation (NOSE) scores are documented in the majority of cases. Postoperative NOSE scores are obtained at least 3 months postoperatively.

Technique

A 3 to 5 cm incision is made on the right chest overlying rib level 8 or 9 in men to place the incision low and more lateral along the rib margin, or level 5 or 6 in women to place the incision in the inframammary crease. A full-thickness segment of rib cartilage is harvested sharply as shown (Figure 1) and submerged in a saline bath. The chest incision is then filled with saline during ventilation and a Valsalva maneuver is performed to confirm that no pleural leak is present. The rib cartilage donor site is then closed in multiple layers. In most cases requiring significant reconstruction, an open rhinoplasty approach is used to access the middle vault and remaining septum. The deficient or malformed anatomy is defined, and the dimensions are transferred to the cartilage block. How the cartilage is carved depends largely on what nasal anatomy is being replaced. For an internal nasal valve reconstruction with septum and upper lateral cartilage components, the superior or inferior edge of the costal graft will become the dorsal aspect, taking advantage of the height of the rib for the septal replacement segment of the graft. If there is significant warping or natural bend to the rib in the axial plane, this is removed prior to anatomical carving. The rib graft curvature is removed by direct excision to create a uniform, symmetrical, solid block of cartilage. Once the most uniform surface is chosen for the best dorsal component, the septum component is made by successively removing cartilage from either side, working from inferior to dorsal and medial to lateral making sure to preserve the connection between the neoseptum and neodorsum/upper lateral cartilage. Carving of the cartilage block is performed using a series of standard surgical blades and gouges. A punch biopsy can be used as a gauge. Any remaining perichondrium is removed. Care is taken to simulate normal nasal anatomy by carving the single solid cartilage graft in multiple planes (Figure 1, B and C). Cartilage fragments removed from the graft should be preserved in saline until completion of the case, as additional cartilage grafts are necessary in some cases. Photographs of a carved multiplanar cartilage graft is shown in Figure 2A. Intraoperative placement of the graft is shown in Figures 2C and 3B, and preoperative and postoperative photographs are shown in Figures 3 and 4.

Results

Eleven patients with complex nasal deformities underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions to address complex deformities by the senior author (MJN) between January 2010 and December 2014. The most common use was for reconstruction of the septum with upper lateral cartilage. There were no major complications. The follow-up period ranged from 3 to 36 months. One patient experienced a mild contour deformity at the junction of the graft with the nasal bone that required a minor revision with endonasal rasping at the radix junction at 6 months postoperatively. One patient experienced a traumatic injury to the nose in the early postoperative period and is awaiting revision. Two of the 3 patients treated for large septal perforations (>2 cm diameter) had successful closure of the perforation. One patient with a remaining perforation underwent posterior septectomy to reduce the symptoms related to the perforation. No patients experienced graft warping in the follow-up period. All patients reported improved nasal airway and improved aesthetic appearance of the nose. In the majority of cases, a preoperative and/or postoperative (at least 3 months) Nasal Obstruction Symptom Evaluation (NOSE) score was obtained. These results are shown in Table.

Discussion

Complex nasal reconstruction can be challenging. It is widely reported that rib grafts provide necessary autologous cartilage.29 Use of costal cartilage includes carving traditional rhinoplasty grafts, such as dorsal onlay, spreader, or septal extension grafts.36,8,9 The possibility of warping is the major deterrent to the use of costal cartilage4,9,10 despite low rates of infection or extrusion. Warping is often considered the most common complication of rib cartilage use in rhinoplasty.11 Use of a chimeric autologous costal cartilage graft is reported by Hsiao et al12 and describes a combination of bone and cartilage to construct a single dorsal onlay graft to prevent cartilage warping. Billent and Kilinc7 report 9 patients using a 3-dimensional dorsal graft that allows a groove for the septum and bony vault,7 yet the septum is still reconstructed with a separate graft. We report using a similar concept to replace as much anatomical defect as can be accomplished with a single graft. In the report by Billent and Kilinc, they postulate the 3-dimensional shapes allow the graft to have a larger interface with surrounding and underlying tissue, helping to resist displacement and warping.7 We postulate that the act of carving in multiple planes creates counter forces of torsion to resist warping, leaving a greater amount of the original supportive structure of the rib intact. Gibson and Davis10 described this concept in 1958, showing the tensional forces in costal cartilage reaching equilibrium across a fulcrum. The multiple planes needed in nasal reconstruction when the septum is included generally allow for carving planes to meet at right angles. It is our theory and experience that warping is most likely to occur perpendicular to the flat plane of a traditional graft. Therefore, if a strut of cartilage is maintained in the perpendicular plane it sustains an intrinsic resistant force to prevent the warping. The resistance is provided by the intrinsic tensile strength of the cartilage itself. This leaves a perpendicular force to prevent warping in any given plane. Farkas et al2 show that costal cartilage will warp regardless of the plane in which it is harvested, yet they did not evaluate warping when multiple planes remain intact. Further biomechanical studies are needed to confirm this concept.

Conclusions

Multiplanar costal cartilage grafting is a useful surgical technique for complex reconstructive rhinoplasty that yields functional and predictable results.

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Article Information

Corresponding Author: Michael J. Nuara, MD, Associate, Department of Facial Plastic Surgery, Virginia Mason Medical Center, Seattle, WA 98101 (Michael.Nuara@virginiamason.org).

Published Online: February 18, 2016. doi:10.1001/jamafacial.2015.2251.

Author Contributions: Drs Nuara and Loch had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Nuara, Loch, Saxon.

Acquisition, analysis, or interpretation of data: Nuara, Loch.

Drafting of the manuscript: Nuara, Loch, Saxon.

Critical revision of the manuscript for important intellectual content: Nuara, Loch.

Administrative, technical, or material support: Nuara, Loch, Saxon.

Study supervision: Nuara.

Conflict of Interest Disclosures: None reported.

Funding/Support: None reported.

Additional Contributions: We acknowledge and thank Pearl Benavidas for her administrative assistance in obtaining patient consent for inclusion of the photographs. We also thank the patients for granting permission to publish this information.

Additional Information: Drs Saxon and Nuara designed the images in Figure 1 and were previously affiliated with the Division of Otolaryngology–Head and Neck Surgery, University of New Mexico, Albuquerque, New Mexico.

References
1.
Stewart  MG, Witsell  DL, Smith  TL, Weaver  EM, Yueh  B, Hannley  MT.  Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale.  Otolaryngol Head Neck Surg. 2004;130(2):157-163.PubMedGoogle ScholarCrossref
2.
Farkas  JP, Lee  MR, Lakianhi  C, Rohrich  RJ.  Effects of carving plane, level of harvest, and oppositional suturing techniques on costal cartilage warping.  Plast Reconstr Surg. 2013;132(2):319-325.PubMedGoogle ScholarCrossref
3.
Gunter  JP, Cochran  CS, Marin  VP.  Dorsal augmentation with autogenous rib cartilage.  Semin Plast Surg. 2008;22(2):74-89.PubMedGoogle ScholarCrossref
4.
Gunter  JP, Clark  CP, Friedman  RM.  Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping.  Plast Reconstr Surg. 1997;100(1):161-169.PubMedGoogle ScholarCrossref
5.
Isac  C, Mihajlovic  D, Bratu  T, Isac  A.  Severe saddle nose deformity reconstructed with rib cartilage.  Chirurgia (Bucur). 2012;107(6):809-815.PubMedGoogle Scholar
6.
Cervelli  V, Bottini  DJ, Gentile  P,  et al.  Reconstruction of the nasal dorsum with autologous rib cartilage.  Ann Plast Surg. 2006;56(3):256-262. Review.PubMedGoogle ScholarCrossref
7.
Bilen  BT, Kilinç  H.  Reconstruction of saddle nose deformity with three-dimensional costal cartilage graft.  J Craniofac Surg. 2007;18(3):511-515.PubMedGoogle ScholarCrossref
8.
Moretti  A, Sciuto  S.  Rib grafts in septorhinoplasty.  Acta Otorhinolaryngol Ital. 2013;33(3):190-195.PubMedGoogle Scholar
9.
Ozturan  O, Aksoy  F, Veyseller  B, Apuhan  T, Yıldırım  YS.  Severe saddle nose: choices for augmentation and application of accordion technique against warping.  Aesthetic Plast Surg. 2013;37(1):106-116.PubMedGoogle ScholarCrossref
10.
Gibson  T, Davis  WB.  The distortion of autogenous cartilage grafts: its cause and prevention.  Br J Plast Surg. 1958;10:257.Google ScholarCrossref
11.
Wee  JH, Park  MH, Oh  S, Jin  HR.  Complications associated with autologous rib cartilage use in rhinoplasty: a meta-analysis.  JAMA Facial Plast Surg. 2015;17(1):49-55.PubMedGoogle ScholarCrossref
12.
Hsiao  YC, Abdelrahman  M, Chang  CS,  et al.  Chimeric autologous costal cartilage graft to prevent warping.  Plast Reconstr Surg. 2014;133(6):768e-775e.PubMedGoogle ScholarCrossref
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