Autologous costal cartilage
What is Autologous costal cartilage?
Rhinoplasty is one of the most difficult operations in plastic surgery. Long-term success is dependent on employing grafts with sufficient strength for proper support and low resorption rates. Rhinoplasty grafts can be made from autologous, homologous, or alloplastic materials. When sufficient septal cartilage is unavailable, autologous rib cartilage is used as a graft material for secondary rhinoplasty. Autologous indicates that the transplanted cells or tissues are obtained from the same person.
Many patients choose augmentation procedures such as artificial implant grafting and filler injections to achieve a taller nasal bridge and a smoothed nasal tip. If done correctly, autologous rib graft is a very flexible graft material that may be utilized to augment the nose with fewer problems.
Rhinoplasty is one of the most difficult surgeries in aesthetic surgery. The cornerstone of a successful secondary rhinoplasty is the reconstruction of the nasal osseocartilaginous (bone and cartilages) structure. Secondary surgery is often performed 12 months after the initial rhinoplasty. A correct clinical diagnosis and a detailed investigation of the nasal abnormalities and architecture are required for a successful secondary rhinoplasty.
Why do patients seek autologous costal cartilage?
A low dorsum and an unrefined tip are the most common nose aesthetic issues. As a result, most rhinoplasties comprise both nasal dorsum augmentation with autologous or artificial implants and nasal tip surgery.
Internal support is frequently lost in revision rhinoplasties as well as some initial rhinoplasties, such as ethnic rhinoplasties. The nasal airway collapses and aesthetic defects emerge as a result of the lack of internal support. One of the key goals of advanced rhinoplasty is to repair and restore this internal support, which is often done through the use of cartilage transplants.
Patients who have previously had augmentation rhinoplasty often want revision. As a result, when a patient comes in for augmentation, the surgeon must determine if the client has previously had rhinoplasty (or multiple rhinoplasties).
Because of their simplicity and effectiveness, artificial nasal implants for augmentation remain popular, although they are associated with a number of major and minor problems. Revision operations for these problems involve fixing nasal shape abnormalities and correcting functional issues, which need a significant quantity of cartilage. Revision rhinoplasty is more difficult than primary rhinoplasty because it requires sophisticated reconstruction and the framework may be weak.
Von Mangoldt employed autologous cartilage in rhinoplasty for the first time in 1900 for syphilitic noses. The most frequent autologous transplant materials utilized for augmentation are septal cartilage (from nasal septum), conchal cartilage (from ear cartilages), and costal cartilage (from rib cartilages). Each of them has its own set of benefits and drawbacks.
Grafts with low resorption rates and enough strength to sustain the framework provide consistent long-term outcomes. Autologous tissue is recommended over alloplastic material because of the lower rate of infection, wound contracture, and extrusion in autologous implants.
We must first comprehend the properties of autologous transplants before deciding where and how to use them. Ear cartilage is very elastic, with enough thickness and natural curvature. As a result, it may be employed in locations that require curvature, or it can be modified by cutting it in half and suturing the opposing sides to create a straighter graft.
Septal cartilage is plentiful in Westerners but rare and weak in Asians, making it unsuitable for augmentation. Furthermore, individuals undergoing revision surgery may not have any residual or harvestable septal cartilage or even conchal cartilage. Costal cartilage has the benefit of supplying a high quantity, but it can induce warping, which is a common and unexpected consequence, and it also leaves a scar on the chest.
Grafts with minimal complication rates and excellent long-term patient satisfaction are thought to be the best for grafting. These characteristics are observed in autografts (e.g., autologous costal cartilage), which are regarded as preferable choices for rhinoplasty. Every patient having rhinoplasty must be thoroughly examined since the outcome varies from patient to patient.
Preoperative assessment
A thorough understanding of the patient's requirements is required. What the surgeon considers to be an adequate nasal dorsum height or nasal tip projection may not be sufficient for the patient. In these cases, modeling approaches to demonstrate anticipated postoperative outcomes can be shared with the patient, but realistic outcomes should be clarified.
Before surgery, the doctor requests that the patient undergo standard general anesthetic tests such as a complete blood count, bleeding profile, blood grouping, renal function tests, X-ray of the chest, and Electrocardiogram (ECG). Rib harvesting may also necessitate a CT scan of the chest to check for rib ossification, which is common in people over the age of 40, though younger people may also have ossified ribs. The procedure can be performed by a single team or by two teams, with one team focusing on the nose and the other on rib harvesting. The second method requires less surgical time, and the rib is normally harvested from the left side because the surgeon working on the nose is usually on the right.
What is the procedure for autologous costal cartilage implantation?
Choosing the suitable cartilage:
The amount of cartilage necessary decides which rib to harvest, and it should offer the straightest and longest portion. Typically, the incision is made above the right sixth or seventh rib. Floating ribs (the last two pairs of human ribs) near the inferolateral costal border are also preferred by certain surgeons.
Similarly, when more cartilage is needed, surgeons will take the eighth or ninth rib. The medial region of the seventh rib cartilage is long enough to accommodate a caudal septal extension graft or a columellar strut, and a dorsal implant can be readily cut from its wide and thick midrib portion.
The incision:
In male patients, the incision is done immediately above the selected rib. The incision in females is made 5 mm above the inframammary (below the breast) fold and is 5 cm long. For cosmetic reasons, the incision should not extend beyond the medial limit of the inframammary fold.
The scar from the incision site is the most significant worry when harvesting a rib, however a smaller incision with careful suturing and burying the scar in the inframammary fold conceal the post-operative scar and resolve the patient's concerns about it. After the markings have been made, the area is injected with 1% lidocaine with 1:100,0000 epinephrine. A 2-3 cm long incision using a No. 10 or 15 blade in the center of the inframammary fold.
When a female patient decides to undergo breast augmentation in the future, the incision should be 7.5-8 cm below the nipple, which is the expected new inframammary fold. In a female who has already had breast augmentation, the surgeon must be careful not to rupture the implant capsule.
Dissection and extraction of the rib graft:
The surgeon next carefully dissects the subcutaneous tissue and muscle fascia planes, reaching and splitting the extra-costal muscle immediately above the rib. The rectus abdominis and oblique abdominis muscles are divided and retracted vertically.
By pricking the underlying rib with a syringe needle, the rib is identified and examined for ossification. The chosen rib is therefore revealed, followed by a longitudinal incision into its perichondrium along its middle axis. Under the rib, a careful circumferential sub-perichondral incision is performed, revealing its posterior surface. It is critical to avoid injuring the perichondrium, which can lead to problems such as pneumothorax.
Surgeons also harvest some perichondrium from the superior side of the rib to serve as graft material. A curved or right-angled elevator is employed under direct view to elevate the rib from the underlying perichondrium.
A knife is used to incise the rib halfway through its thickness before proceeding with an elevator. The rib is incised medially near the sternum and laterally at the bony rib junction. The length of this extracted rib is 4.5-6 cm. In revision situations, the doctor may also need to harvest a portion of the neighboring rib. These graft materials are immersed in normal saline with gentamicin. While the nose is being operated on, the graft is kept in this solution and checked for warping.
Closure:
We rinse the donor site with thermal saline before closure and look for air bubbles when positive pressure ventilation is used. This will help us guarantee that there is no lung pleura damage or pneumothorax (when air leaks into the space between your lung and chest wall).
Closure is performed by layers. The fascia above the muscle is closed using interrupted sutures made of vicryl 3-0 sutures to alleviate postoperative pain and promote appropriate blood drainage. Vicryl 4-0 sutures are used for subcutaneous closure, while nylon 6-0 interrupted sutures are used for skin closure. To prevent suture removal, 5-0 PDS or vicryl might be used subcutaneously.
Dissection of the nose
The open trans-columellar technique was used, using an inverted-V incision. An inverted V incision is made along the mid-columella, which is joined to bilateral marginal incisions.
Using tenotomy scissors and elevators, the skin flap is lifted to the level of the perichondrium of the lower lateral cartilage. Excess subcutaneous tissue in patients with thick skin may be excised (but not aggressively) for better post-operative tip definition.
The septum is approached by separating the two medial crura and the sub-perichondral plane of the caudal septum is identified.
The septum is isolated from the upper lateral cartilage by raising bilateral mucoperichondrial flaps. The septum's dorsal-caudal L-shaped strut is retained for septal stability. Although this harvested septal graft can be employed as a caudal septal extension graft (CSEG) or splint graft, it may be inadequate in revision situations.
Carving and placement the rib cartilage:
We measure the height of the nose at the nasion, rhinion, and nasal tip before carving the costal cartilage transplant. This allows us to determine the amount of our graft's carving. The dorsal and spreader grafts are cut from the excised rib's central section. While cutting the graft, the patient's skin thickness is taken into account.
The eventual result may not be as visible in thick-skinned persons as it is in thin-skinned ones. Sharp lines and angles are softened by thick skin. Surgeons shape the graft into a "fusiform" shape with tapering ends and a broader mid-section. The concave section of the graft serves as the implant's bottom.
To identify the appropriate height and width of the predicted nasal shape, precise carving and smoothening are performed, followed by serial verification by placing the graft into the nasal skin-soft tissue flap.
To prevent warping, balanced incisions are made in numerous directions in the cartilage. The majority of warping happens within 15-60 minutes of harvesting; hence it is critical to wait for early warping to realign the graft before placing. Thus, the graft is sliced equally on both sides, resulting in a balanced graft cross-section.
The graft's superior portion, which will be placed over the radix, is positioned in an upward converging orientation to rest on the underlying bone. For extra augmentation, additional rib cartilage may be placed beneath the onlay graft.
The harvested rib graft's caudal end is tapered and should terminate just beyond the lower lateral cartilages, allowing mobility of the bottom one-third of the nose. The end result should be a nose that suits the rest of the facial features. The onlay graft is anchored in place using 2 or 3 PDS 5.0 fixation sutures wrapped around the graft and passing through bilateral upper lateral cartilages.
During nasal dissection, a capsule from a prior silicone implant is saved and utilized as a camouflage graft. Similarly, harvested rib perichondrium or temporalis fascia can be utilized to wrap around the rib and conceal abnormalities.
Postoperative care
Following wound closure, a standard postoperative chest X-ray might be advised. To avoid hematoma, the chest incision is gently bandaged and preserved for three days. In most circumstances, drain is not required.
Regardless of the goal or amount of the costal cartilage harvest, pain is the most prevalent complaint. Many writers observed that donor site soreness often peaked in the first week and gradually faded over the next three months. Scar control is an essential component of autologous costal cartilage aftercare. Unidirectional skin retraction is useful during harvest to reduce skin margin abrasion and decrease undesired skin abrasion.
The wound is closed in four layers: muscle, fascia, subcutaneous tissue, and skin. Multilayered sutures can aid to minimize vertical tension caused by upper body stretching. Once a day for a week, antibiotic ointment should be applied to the incision scar. Triamcinolone can be injected at the costal cartilage harvest site as a prophylactic strategy in a patient with a history of keloids or hypertrophic scar. The wound is stitched out in a week, and silicone scar sheets can be used for two months to minimize visible scars.
What are the advantages of autologous costal cartilage?
When substantial volumes of tissue are required, autologous costal cartilage is an excellent choice. Costal cartilage has a pleasant feel and a high vitality, and it is easily collected in large numbers. When sufficient septal cartilage is unavailable, autologous costal cartilage is used as a graft material for secondary rhinoplasty. It is the most plentiful source of cartilage for autologous grafts.
It also offers structural support and dorsal augmentation, which are frequently required when the abnormalities discovered are significant. In this scenario, the necessity for significant volume and strength limits the use of septal and auricular cartilage.
These properties make it a great material for contour enhancement and, in particular, structural support. However, claiming specific benefits of rib grafts in each deficiency requires more research with a bigger sample size in each category of deformities and a longer follow-up.
What are the disadvantages and adverse effects of autologous costal cartilage?
Costal cartilage has the benefit of supplying a large volume, but it can induce warping, which is a common and unforeseen consequence, and it also leaves a scar on the chest.
Warping:
Warping is seen as a significant drawback of costal cartilage transplants. Warping is the natural propensity of cartilage to bend or curve over time, resulting in a deformed esthetic profile in the postoperative period. Warping is the most common complication of rib cartilage transplant usage in rhinoplasty, accounting for 10% of all cases.
For warping, several hypotheses have been offered. Some claim that surface tension forces cause costal cartilage to flex. Others have shown that protein polysaccharides in cartilage cause internal tensile stresses that alter the structure. In reality, warping is caused by the cumulative action of all such forces.
The cartilage should be cut equally on either side to preserve symmetrical transplant cross-sections. The majority of warping happens within 15 to 60 minutes following harvesting. Waiting for early warping and then adjusting the graft before implantation can greatly reduce this issue.
Although the use of K-wires to anchor rib cartilage transplants might avoid warping, especially in larger dorsal and columellar grafts, problems such as infection, discomfort, numbness of the anterior palatal mucosa, and K-wire extrusion can occur.
Pneumothorax:
The most important possible consequence during costal cartilage harvesting is pneumothorax, which can be readily prevented by preserving the perichondrium on the undersurface of the rib. The preservation of the inner perichondrium also promotes chondrocyte (cartilage cells) development, minimizes resorption, and improves tensile strength.
Pain:
Post-rib harvesting soreness was identified as substantial morbidity in a meta-analysis research. This can be decreased by doing graft harvest with muscle "split" rather than "cut," infiltrating the wound with xylocaine (local anesthetic) at the end of the process, and using postoperative analgesia.
To alleviate severe surgical pain, a long-lasting anesthetic drug was previously applied locally to the intercostal nerve. Other studies, however, have recently demonstrated that extreme pain may be reduced by modifying rib harvest procedures. For example, extra care is necessary not to harm the inferior line neurovascular bundle following superior and inferior perichondrium elevation.
Infection:
Despite the fact that infection rates are minimal, it happens in the setting of revision surgery, prolonged operation duration, and the use of perichondrium. It is treatable with drainage and intravenous antibiotics, and complications are uncommon.
Displacement of the cartilage:
The displacement of autologous costal cartilage has been linked to the surgeon's expertise rather than the cartilage itself.
Conclusion
To attain a higher nasal bridge and a smoother nose tip, many patients choose augmentation treatments such as artificial implant grafting and filler injections. When performed appropriately, autologous rib graft is a very flexible graft material that may be used to enlarge the nose with fewer complications.
The most prevalent nose cosmetic concerns are a low dorsum and an unpolished tip. As a result, most rhinoplasties include both autologous or artificial nasal dorsum augmentation and nasal tip surgery.
In 1900, Von Mangoldt used autologous cartilage in rhinoplasty for the first time on syphilitic noses. Septal cartilage (from the nasal septum), conchal cartilage (from the ear cartilages), and costal cartilage are the most often used autologous transplant materials for augmentation (from rib cartilages). Each has its own set of advantages and disadvantages.
Costal cartilage has the advantage of providing a large amount, but it can cause warping, which is a common and unanticipated side effect, and it also leaves a scar on the chest.
Grafts with low complication rates and high long-term patient satisfaction are considered the best for grafting. These properties are shown in autografts (for example, autologous costal cartilage), which are regarded as preferred options for rhinoplasty. Because the success of rhinoplasty differs from patient to patient, each patient must be properly assessed.
It is necessary that the doctor have a full awareness of the patient's needs. What the surgeon deems to be a suitable nasal dorsum height or nasal tip projection for the patient may not be sufficient. In these circumstances, modeling methodologies that indicate expected post-operative results can be discussed with the patient, but realistic outcomes must be specified.
Pain is the most common complaint, regardless of the purpose or amount of costal cartilage harvested. Many professionals noted that donor site pain usually peaked in the first week and then progressively diminished over the next three months.
The most common risks of autologous costal cartilage harvesting are warping and postoperative discomfort. Other less common concerns include scar development, infection, pneumothorax, and cartilage displacement.