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Page 2 of 10 Rajbhandari et al. Plast Aesthet Res 2019;6:8 I http://dx.doi.org/10.20517/2347-9264.2018.86

resorption rates and sufficient strength for framework support. Autologous tissue is always preferred as the
use of alloplastic material increases the rate of infection, wound contracture and extrusion .
[1]

For achieving successful results in Asian rhinoplasty, an appreciation of the Asian patient’s anatomical
characteristics, a conceptual approach as well as an appreciation of recent trends of beauty should be fully
understood . Asian patients generally seek a high dorsum and nasal tip refinement. Silastic implants were
[2]
used traditionally (and are still in use), but they cause a high incidence of early and late complications.
Minimally invasive rhinoplasty, such as threads insertion rhinoplasty and injectable filler rhinoplasty have
recently become popular, but repeated procedures may result in complications.

The ideal material for grafting or implantation in rhinoplasty must have the characteristics of low complication
rates and high long-term patient satisfaction . Thus, autografts are considered as better alternatives for
[3]
augmentation in Asian rhinoplasties. Costal cartilage is commonly used for augmentation of the nasal
dorsum and for infrastructure reconstruction as it provides an ample amount of autogenous cartilage, but is
frequently associated with warping . When an autologous rib cartilage rhinoplasty is performed properly by
[4]
an experienced surgeon for complicated cases or for a short nose, it will provide excellent, reliable, and long-
lasting results with low risk . Warping rate of costal cartilage and unpredictable cosmetic results are topics
[5]
of concern for both patients and surgeons. In this paper, we will discuss how to minimize complications and
improve the surgical results.

SURGICAL TECHNIQUE
Harvesting the rib cartilage
We usually harvest the rib cartilage from the right sixth or seventh rib, with a short linear inframammary
incision [Figure 1A]. In women, we place an oblique incision carefully on the inframammary fold, to conceal
the scar. The incision is around 2-3 cm in length. If a female patient wishes to opt for a breast implant in
the future, we make the inframammary fold incision 7.5-8.0 cm below the nipple, so that the scar is hidden
within the anticipated, future inframammary fold after breast implantation. If the patient has had a previous
breast implant, the incision is made a little lower and we are careful not to rupture the capsule and prevent
chances of breast implant infection.

We make an incision with a No. 10 or 15 blade and perform meticulous dissection of the subcutaneous
tissue after infiltration of local anesthesia. Once we reach and divide the muscle fascia, the extra-costal
muscle is divided directly over the rib. We identify the underlying rib and a syringe needle is stabbed on
the costal cartilage to check for calcification. The medial dissection is near the junction of the rib cartilage
and the sternum, while the lateral dissection is up to the osteochondral junction. We further carry out sub-
perichondrium dissection underneath, along the longitudinal axis of the rib. Since we also aim to harvest
some amount of perichondrium from the superior aspect of the rib, we make a rectangular incision on its
superior aspect. Dissection is carried out carefully, with patience and accuracy, to leave the perichondrium
on the lower aspect intact. We often use a curved or a right angled elevator to lift the rib off its underlying
perichondrium. A blade is used to make an incision halfway through the rib and the costal cartilage is severed
laterally near the osteo-chondral junction. The harvested rib measures 4.5-6.5 cm in length [Figure 1B]; we
tend to harvest more costal cartilage in revision cases. The perichondrium on the superior aspect of the
harvested rib [Figure 2] is preserved and kept aside. A sharp, curved Freer’s elevator is used to make an
incision at the medial end and sever the rib. A drill may be used to cut through the rib cartilage in cases
of ossification, which is often seen in individuals over 40 years of age. Hence, we ask patients older than
40 years old to have a CT scan of the chest wall, for evaluation of costal cartilage calcification. But in our
experience, rib calcification in younger individuals has also been noticed. In some patients, where there is