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Yi. Plast Aesthet Res 2019;6:7 I http://dx.doi.org/10.20517/2347-9264.2018.77 Page 5 of 7

Figure 4. About a 2 cm transverse incision is made along the skin crease. The incision line (red dotted line) starts from the
osseocartilaginous junction (blue dotted line) to obtain a maximal length in the piece of harvested cartilage

technique has been increasingly applied to reduce donor site discomfort [19,20] . Instead of transection, a
blunt dissection of the external oblique muscle can significantly reduce pain during rest and movement.
Thus, some authors recommend routine use of a muscle-sparing technique in autologous costal cartilage
[20]
harvesting . With these procedures, regular pain pills are sufficient to control postoperative chest pain.
The author usually prescribes routine antibiotics and oral pain pills for a week after surgery with this muscle
sparing technique. The pain tends to be peaked in 3-4 days and diminishes slowly over a week. Long lasting
chest pain is a rare entity after rib cartilage harvest, however, long-lasting pain even months after surgery
is possible especially when multiple rib cartilages were harvested. Even with a little pain after harvest of rib
cartilage, restriction of activity is not recommended and rather light daily activities like walking, sitting are
recommended from the day after surgery. However, more heavy activities like running, weight training, or
playing with instruments are recommended to resume in 3 weeks.

Scar management is also an important part of postoperative care. To minimize unwanted skin abrasion,
unidirectional skin retraction is helpful during harvest to prevent skin margin abrasion. The wound is closed
in 4 layers; muscle, fascia, subcutaneous tissue and skin. Multilayered sutures are helpful to reduce vertical
tension from stretch of upper body. Antibiotic ointment is put to incision scar once a daily for a week. A
patient with a history of keloids or hypertrophic scar, triamcinolone can be injected at the costal cartilage
[1]
harvest site as a preventative measure . Wound stitch-out is performed in a week and then silicone scar
sheets can be applied for two months to reduce visible scars. The author experienced elevated scar flattening
after triamcinolone injection twice at two weeks interval at the donor site scar and the results were often
[21]
acceptable in most patients. Yang et al. compared a VAS cosmetic score of costal cartilage harvest site scar
from a retroauricular skin incision scar and reported that there was no significant difference at 6 months
post operation.

Infection prevention needs special attention when heavy amount of rib cartilage was used in multiply revised
patients. They tend to have poor blood supply, often the skin is stretched more, and the septum is also
explored which all contribute to raise the infection chance. In this case, I give them IV antibiotics for a few
more days after surgery and pay special attention to the intranasal hygiene to prevent retrograde infection
from the nasal cavity. Everyday dressing of the nasal cavity and the wound with betadine solution and
antibiotic ointment for a week is recommended. I teach patients to soak the nasal cavity often with betadine
gauze for a week at home. After casting and stitch at one week postoperatively, I see them once again after
a week to check any sign of infection and tell them to pay special attention to any sign of swelling, redness,
and pain of the nose till follow-up time.