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turbinate. This can avoid step-like deformity, nasal block or collapse with preservation of periosteum along
the osteotomy route.

Other steps such as alar flare reduction and rim strut grafts are performed as needed. We make sure to
preserve as much tissue as possible to avoid scarring (which could be a result of multiple rhinoplasties).

DISCUSSION
Rib grafting has several advantages in revision rhinoplasty, especially for complications from filler injection
rhinoplasty or artificial nasal implantation, which is very common in Asian patients. It offers an abundant
supply of cartilage for use and rigid support. The chances of infection, skin necrosis and shrinkage are
minimized. Many surgeons prefer harvesting the sixth, seventh or occasionally the eighth rib . We harvest
[6]
the sixth rib cartilage in females because the oblique incision scar can usually be hidden over the infra-
mammary fold, and the seventh rib cartilage in males because the seventh rib cartilage is usually the longest
one. If the patient is older than 40 years, a CT scan of chest wall may be needed to evaluate calcification of
cartilage.

Complications such as warping can be overcome by balanced carving and allowing 15 min for maximal
warping to occur . We harvest the rib perichondrium as it can serve as an extra graft material. It can be
[7]
used to camouflage skin thinning of the nasal tip and can also be used over the rib onlay graft to minimize
noticeable graft contour. The incision for harvesting a rib graft may vary from 1.0-5 cm, depending on
the patient’s anterior chest wall thickness and surgeon’s skill. Rib carving requires a lot of experience and
versatility on the surgeon’s part. The edges of the dorsal onlay graft may show irregularities even after fine
trimming. Infection is not uncommon in secondary rhinoplasty. Meticulous dissection during surgery,
effective antibiotics and appropriate postoperative care are very important. Cigarette is absolutely prohibited
at least two weeks before and 1-2 months after surgery. The pre and post operative pictures of a few of our
cases are listed below [Figures 12 and 13]. In cases of wound infection, the patients are treated with wound
debridement, removal of inflamed cartilage and intravenous antibiotics. The reasons for infection could be the
mass effect of harvested graft that affect the skin tension and disturb the nutrient/waste exchange diffusion
process and also due to the poor blood supply in the recipient area in revision cases .
[7]

To obtain aesthetically pleasing results, ensure patient satisfaction and minimize complications, the
rhinoplasty surgeon must possess a thorough knowledge of nasal anatomy and ideal facial aesthetic
proportions . Many Asian patients undergo more than three revision surgeries to correct or offset
[8]
improperly performed surgeries, the improper use of implants or surgical complications . In a study by
[9]
Park and Jin , 47 percent were revision cases of rhinoplasty and four of five infection cases occured in their
[10]
revision operations.

The current best evidence for techniques and complication rates in costal cartilage associated with rhinoplasty
are based on case series . Hence, complication rates depend on the surgeon’s surgical skills as well as the
[11]
patient’s compliance.

In conclusion, revision rhinoplasty in Asians is a challenging surgery. Most of the revision cases require
previous graft removal or reshaping, harvesting of a new graft, creating a clean plane and facing the scar
tissues formed by previous surgeries. When a large amount of grafting is required, the costal cartilage can
provide an ample amount of cartilage graft material. As the possibilities of complications should also be
anticipated in revision rhinoplasty, rhinoplasty surgeons need more experience and learning from follow-up
patients.