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Page 2 of 8 Göksel et al. Plast Aesthet Res 2019;6:17 I http://dx.doi.org/10.20517/2347-9264.2019.12

INTRODUCTION
Nasal framework reconstruction in secondary and more rarely in primary rhinoplasty is often restricted
by quantity and quality of cartilaginous framework. The most commonly used donor site for cartilage
harvesting is considered to be septal cartilage, however surgeons frequently face such problems as:
paucity of available graft material, especially in secondary cases and cartilaginous insufficiency in severe
deformities cases. Both arguments are particularly true in secondary rhinoplasty when over resection of the
osseocartilaginous framework is observed. Considering all these surgeons may often need an alternative
source of grafting material in order to correct both aesthetic deformities and functional problems.

Satisfactory and consistent long-term results rely on using not only adequate quantity of cartilage, but also
on graft quality: low resorption rate, sufficient strength for appropriate support, rejection and allergy safety.
Thus, the most suitable and preferred graft material nowadays is considered to be autologous tissue. From
all potential donor sites for autologous graft, the rib provides the most abundant cartilage source for graft
[1]
fabrication and is the material of choice when reliable support is required .
[2]
Conventional rib harvesting techniques included 3-5 cm incision and cutting the muscles . Nevertheless,
autogenous graft harvesting is associated with several disadvantages such as postoperative pain, visible scar,
[3,4]
risk of pleura perforation and often requires advanced surgical skills . With regard to above mentioned
complexities, we suggest the method of endoscope-assisted rib cartilage harvesting. This technique is less
invasive and enables reducing risks of bleeding and pleura perforation due to extended visualization and
better remote access incision site.

In last two years we performed 52 endoscopic-assisted rib harvesting. We observed significant decrease in
postoperative pain, bleeding and therefore faster recovery and better aesthetic result.

ENDOSCOPIC RIB HARVESTING OPERATIVE TECHNIQUE
Marking
Rib cartilage harvesting is preferentially performed on the patient’s right side. Marking starts with palpating
the sternomanubrial junction, which corresponds to the position of the second rib. The ribs are then
numbered according to their position. We prefer to harvest 6th rib as it provides abundant cartilage supply
and is straight and wide enough for future graft fabrication.

Placement of the incision line is determined by the sex of the patient. In female patients, the inframammary
fold offers a good position for camouflage and the incision line is marked at approximately 5 mm above the
[5]
inframammary fold . The incision should not extend beyond the medial border of the inframammary fold
in order to avoid postoperative visibility. In male patients, the incision is placed right over the selected rib.

Incision
The main advantage of this method is short incision, about 1-2 cm [Figure 1]. Some experienced surgeons
do harvest the rib through such small incision with direct vision without using endoscope, but usually it
requires advanced surgical skills and is still associated with bad visualization and, therefore, higher risk of
pneumothorax and bleeding for the not enough experienced surgeons.

When placement of the incision is chosen, harvesting procedure begins by incising the skin using 15th
blade. The subcutaneous and fascial layers are transected using electrocautery or blade. The muscle itself
was not cut, instead, it was divided bluntly by spreading following the direction of the muscle fibers.
Dissection was concluded with Freer elevators. This step enables to reduce postoperative pain and possible
[6]
intraoperative bleeding [Figure 2].