Page 80 - Read Online

Rajbhandari et al. Plast Aesthet Res 2019;6:8 I http://dx.doi.org/10.20517/2347-9264.2018.86 Page 3 of 10

A B

Figure 1. A: Incision site for harvesting the seventh rib; B: an approximately 5 cm rib harvested from a 2 cm incision

Figure 2. Harvested 7th rib cartilage with intact overlying perichondrium and two pieces of conchal cartilage

a considerable amount of calcification and if we suspect deficient septal cartilage, a short segment of the
adjacent rib is also harvested, to use as splinting grafts or as a caudal septal extension graft.

The next crucial step is performing a Valsalva maneuver to check for injury to the lung pleura. The donor
site is irrigated with thermal saline and positive pressure ventilation is applied to see the presence of bubbles.
After ensuring that there is no pneumothorax, the wound is carefully closed in layers. The most important
step is proper closure of fascia over the muscle with interrupted sutures. This will facilitate drainage of blood
and avoidance of hematoma. Proper closure of this layer will also reduce postoperative pain over the chest
area by a great extent. We generally use a 3-0 vicryl suture for closure of fascia over the muscle, 4-0 vicryl
for subcutaneous closure and 6-0 nylon for interrupted closure of the skin. In female patients, we prefer to
use 5-O PDS or vicryl suture for subcutaneous closure instead of 6-O nylon for skin closure; to avoid suture
removal [Figure 3]. We then apply dressing over the wound to keep it dry and clean. The graft is put in
normal saline with gentamycin solution and observed for warping.

Carving the rib cartilage
Carving and smoothening of the rib cartilage is crucial to get an even and aesthetically favorable outcome.
Whilst carving a graft, we consider the patient’s skin thickness. Asians have a thick skin, compared to that
of Caucasians. This quality of skin comes with both an advantage and disadvantage. Minor irregularities
on the nose may not be as obvious as it would be in the thinner Caucasian skin. But, for a patient requiring
minimal changes, the final outcome may not be apparent and the patient might not be completely satisfied.
It is difficult to achieve the desired level of definition and refinement because sharp lines and angles of the
graft can appear blunted under a thick skin.