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Page 2 of 7 Yi. Plast Aesthet Res 2019;6:7 I http://dx.doi.org/10.20517/2347-9264.2018.77
[1]
provide all of the necessary grafts from a single donor site with fewer complications . However, many
novice surgeons in rhinoplasty who are not familiar with chest anatomy, have difficulty in initiating the
use of rib cartilage. The essential guidelines for use of rib cartilage in rhinoplasty are safe harvesting, and
effective and appropriate carving of the rib cartilage. There are also several important factors to consider
in a preoperative consultation for rib cartilage rhinoplasty. These considerations include an assessment of
cartilage availability, and the choice of cartilage for harvesting. In addition, postoperative management is
also important for optimal results. Herein, we introduce preoperative evaluation for assessment of proper rib
cartilage and postoperative care.

PREOPERATIVE EVALUATIONS
Decision to use a rib: consideration factors
When the decision is made that rib cartilage is required, the first step is to check its availability. According
[1-5]
to previous studies, sex and age are best related to the quality of rib cartilage . In general, younger patients
have more flexible and softer cartilage than older persons [1-5] . Contrary to our expectations, however,
[6]
surgeons often encounter severely calcified rib cartilage, especially in young females. Sunwoo et al. reported
that 22.5% of teenage female patients showed calcification, and as early as 14 years old in some, which
[6,7]
can suggest that the onset of rib cartilage calcification is earlier in women than in men . Calcification
makes it difficult not only to perform the graft manipulation, but also makes it more difficult to predict
[7]
outcome because of its irregular absorption . In addition, the risk of donor site morbidity may increase
[6]
if the rib cartilage is severely calcified . Therefore, preoperative assessment of the calcification degree by
obtaining a series of radiographs of the rib or by pricking the rib cartilage with a fine needle are necessary
regardless of a patient’s sex or age [Figure 1]. Computed tomographic (CT) scans of chest are best used to
[5-8]
specify calcification pattern with overall features of rib in many previous studies . However, CT is more
expansive and the radiation exposure is higher than simple X-ray. In my practice, simple rib X-ray provides
enough information regarding the degree of calcification and size and shape of cartilage, thus, enables me
to judge its availability in rhinoplasty safely with relatively low cost. Luckily, not all calcified cartilages are
contraindication for harvest. Grades of cartilage calcification can be classified by the percentage of calcified
[6]
lesion, and more than 25% can be regarded as meaningful calcification . A mild degree (< 25%), marginal
type calcification (calcification along the periphery of rib cartilage) is often acceptable, but a central/granular
[6]
type with moderate calcification (> 25%) is not suitable in most cases .

In selection of an appropriate amount of rib cartilage, costal cartilage is harvested from the sixth through
eighth ribs according to its shape and purposes [1,6,8] . Right side cartilages are commonly preferred than
the left to avoid injury to the pericardium and confusion of postoperative chest pain from angina [1-9] .
Interestingly, however, a study revealed that the greatest amount of costal cartilage from the sixth, seventh,
[10]
and eighth rib was identified on the left side than right on CT scan data . Therefore, rib cartilage harvesting
from the left side can be a viable option in those patients who have had previous rib surgery, radiotherapy, or
[10]
trauma with destruction of costal cartilage on the right side .

The sixth rib is usually at an ideal depth and the width is wide. But the straight piece is shorter than the
seventh rib and has slight genu. Furthermore, if the patient has a history of breast implant, care should be
taken not to injure implant material since the sixth rib is typically directly located under an implant [1,6,8] .
Seventh rib cartilage has been known as the safest anatomically. It is situated over the abdominal cavity
and thus can lessen the chance of pneumothorax since the parietal pleura of the lung runs down to reach
the lower edge of the sixth rib at the xyphoid-chondral junction to the upper edge of the ninth rib cartilage
laterally. The internal thoracic artery and vein also descend medial to the ribs from the seventh rib and
[8]
therefore vascular injury is rare . Its contour is also suitable for any rhinoplasty grafts because of an
appropriate length and width. Thus, the seventh rib from the right side appears to be most advisable for