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Page 2 of 7 Apaydin. Plast Aesthet Res 2019;6:9 I http://dx.doi.org/10.20517/2347-9264.2018.73

Figure 1. In the reconstruction of a crooked nose, a subtotal reconstruction was done by L-strut obtained from the 6th rib. It had warped
and a revision was needed

METHODS
Costal cartilage sculpting methods
The principle of the balanced cross-section
This principle is still the fundamental technique when costal cartilage use comes into consideration in
[1]
saddle noses corrections or revision rhinoplasties . The sculpted cartilage grafts are used as structural grafts
and augmentation grafts. Besides, the integrated dorsal graft/columellar strut has been used in many cases
[3]
where the caudal septal support was poor . It has been reported that careful symmetric carving of costal
[3]
cartilage could minimize the chance of cartilage warping over time . Our experience has shown us that
costal cartilage warping can still occur despite careful symmetric carving, especially while using structural
grafts [Figure 1]. The one-piece L-strut graft obtained from the costal cartilage was described by Rettinger
[4]
and its use has been effective for decades . Our experience of dorsal onlay grafts is that they rarely have
clinically apparent warping. However, warping has remained the primary concern with the use of costal
cartilage grafts. Many cutting and additional techniques have been developed to overcome this issue. For
the last 19 years we have been utilizing balanced cross-sectional carving and although warping was rarely
seen, concerns always remained. The use of thicker grafts employed by us and other experienced rhinoplasty
surgeons to minimize warping resulted in stiffer noses, which was undesirable to some patients.

Freehand carving/sculpting of costal cartilage with a scalpel has historically been the technique of choice
for fashioning grafts. The creation of thin grafts using the technique is however technically challenging and
carries a higher risk of warping. Dermatome blades overcome the technical challenges of producing thin
[5]
grafts, the unfavorable warping characteristics however remains .
An observed major limitation was the paucity of grafts that can be obtained by this method.

The central portion of the rib is utilized as a graft, with the remaining peripheral cartilages portions/
shavings often unusable due to the unfavorable warping characteristics. Typically in the correction of saddle
nose deformity, we use the central rib portion for caudal septal graft and the one outer layer/shaving for
dorsal onlay graft. However, in revision rhinoplasties variation in graft type, size and amount graft material
required limit the use of balanced cross-section carving rib carving.

Oblique split method
I have learned this technique during a meeting from Dr. Taştan in 2008, several years prior to its
[2]
publication . Impressed with the simple logical solution to this common and difficult problem I adopted
his technique. My preferred ribs have been the 5th and the 6th due to the ease of access through the infra-
mammary incision in females. After harvesting the 4 to 6 cm long rib, the cutting angles, direction and
the length of the implants are calculated dependent on the requirements. The idea is to obtain the longest
possible implants depending on the shape of the harvested cartilage [Figure 2].