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Won et al. Plast Aesthet Res 2019;6:6 I http://dx.doi.org/10.20517/2347-9264.2018.82 Page 5 of 16

A B C

Figure 4. Sagittal CT scan of a 36-year-old female patient who underwent a rhinoplasty 6 years ago complaining of nasal tip pain,
tenderness, and overly projected tip. Dorsal silicone implant and suspicious bone at the caudal septal area used as a septal extension
graft (A, B); Intraopertaive photos show an L-shaped Medpor implant used as septal extension graft (C). After implant removal and
reconstructing of the tip without over projection using autologous cartilage, the pain disappeared

tissue contraction. Remnant septal and ear cartilage are the first choice of grafting materials in revision
rhinoplasty cases with minor deformities. However, secondary rhinoplasty more often than not requires a
larger amount of tissue that requires a robust source of grafting material. This usually exceeds the available
septal cartilage and the need for adequate strength precludes the use of conchal cartilage. Autogenous
costal cartilage may be the only practical choice in these circumstances. Common scenarios that frequently
require the use of rib cartilage include the following: contracted short nose, significant loss of dorsal
volume and/or septal support and/or tip support that is usually associated with removal of the alloplast.

We rarely use homologous rib cartilage because we believe that it is unpredictable in terms of long-term
resorption. In cases with problems of the skin-soft tissue envelope, temporalis fascia, costal perichondrium,
mastoid periosteum, or autologous dermis is used to reinforce the skin that may have been overly-thinned
or weakened. Homologous fascia or dermis (Alloderm®, Surederm®) can be feasible alternatives. Lastly,
although not common in our hands, alloplastic implants can be used again for revision, if the patient
recognizes and agrees to the risks of complication, when there is no demonstrable infection, and in the
presence of relatively thick skin.

COSTAL CARTILAGE HARVESTING
Before harvesting, it is prudent to check the rib series X-ray to look for possible calcifications. Even
young patients can have severe calcification of the costal cartilage, which is more common in females.
Calcification makes harvesting and carving of the cartilage more difficult and if totally calcified, it cannot
be used as a grafting material.

The costal cartilage is commonly harvested from the sixth or the seventh rib. The incision is made directly
over the chosen rib in male patients and just above the infra-mammary crease in female patients to conceal
the chest scar [Figure 5]. The size of the incision may vary and is usually 2 cm in length in thin skinned
patient and 2-2.5 cm in the thick skinned patient. The costochondral junction is confirmed by serial
puncture with a 26-gauge needle for precise placement of the incision. The skin and subcutaneous tissue
are incised with a no.10 blade and the subcutaneous tissue is retracted using retractors until exposing the
external oblique muscles. Instead of cutting them with a Bovie, the muscle fibers are separated with Kelly
forceps and retracted with an Army-Navy retractor which can minimize postoperative pain. After adequate
exposure, two parallel incisions are made along the superior and inferior borders of the rib cartilage,
leaving an intact central strip of perichondrium on the anterior surface. Several small incisions are made
perpendicular to the longitudinal incision to facilitate reflection of the perichondrium [Figure 6].