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Page 6 of 7 Olcott et al. Plast Aesthet Res 2019;6:3 I http://dx.doi.org/10.20517/2347-9264.2018.79

Figure 6. Post-operative pain management

facility. There was less difference between in-office vs. ambulatory facilities (14.8%) than there was between
in-office or ambulatory facility and a hospital (21.5%). This indicated that the decision of location choice was
mainly on hospital vs. non-hospital facilities rather than ambulatory vs. office-based surgery centers.

In order to keep the survey simple, specific medical services available at non-hospital facilities were not
solicited. These included the availability of X-ray, chest tube set, thoracic surgeons and the proximity to
a hospital for transfer and admission. This is a significant limitation of the study. In addition, our online
survey was distributed via email by the AAFPRS which might have explained the lower response rate when
mass emails were frequently ignored by members.

A suggestion to future study should include a discussion of the intervention performed by the surgeons if
an air leak is found or suspected intraoperatively since a formal chest tube is rarely needed. Typically, an
intraoperative air leak can be detected by a visual rent in the posterior perichondrium and pleura. Most
surgeons also have the anesthesia provider perform a Valsalva maneuver while looking for air bubbles
forming under saline irrigation at the rib graft harvest site. If an air leak is detected, the next step will be to
first place a small red-rubber catheter through the pleural defect, temporarily secure it with a purse-string
suture in multiple layers, then withdraw the catheter under suction. Patients are then observed for shortness
of breath and an elective chest X-ray is obtained in the post-anesthesia care unit, at a nearby radiology
facility or emergency department. A small pneumothorax may be seen in those situations and treatment
often is observation. In rare cases, insertion of a small suction catheter (much smaller than a conventional
chest tube) may be required and placed by a thoracic surgeon, which will be left in place for a few days.

In conclusion, we summarized the current practice trend of US facial plastic surgeons in autologous costal
cartilage harvest for rhinoplasty. The very low percentage of pneumothorax after rib harvest and the use