Rib Grafting Simplified - Clinical Tree

The use of rib grafting in rhinoplasty has revolutionized the ability to treat complex nasal deformities. Its can be helpful for both primary nasal deformities (including posttraumatic, cocaine induced, and others), as well as secondary nasal deformities (including postoperative saddle deformities and otherwise graft-depleted patients). Situations in which patients have had their septal cartilage or the majority of their conchal cartilage harvested during previous interventions leave few options for autogenous graft material. In addition, some primary nasal surgeries (i.e., patients with Binder syndrome) or other complex nasal reconstructions require the incorporation of structural grafting material using cartilage volumes that are not available even in the previously unoperated concha or septum. Although other autogenous material, homografts, and alloplastic materials are also available, they can be associated with potential complications including absorption, infection, and extrusion. The lower likelihood of complications associated with costal cartilage grafts has popularized its use and made them the standard for complex nasal reconstruction despite the associated increased operative time and potential for donor site morbidity.

Many preeminent surgeons have described their successful use of rib grafts in reconstructive rhinoplasty. Daniel modernized the use of rib grafting.

Costal cartilage harvesting can be conceptualized as the natural progression and modification of the standard lateral and anterolateral thoracotomy exposures used during thoracic and cardiothoracic operations. Currently, harvesting the fifth and sixth ribs through an inframammary incision is the most commonly used technique. However, this approach is technically demanding, provides limited graft alternatives, and leaves a scar in an awkward location in male patients. The authors prefer a subcostal approach because of its ease of exposure, limited scarring, quick operative time (30 to 60 minutes), low morbidity, and great versatility of available graft material through the same incision. Furthermore, the subcostal approach is technically less demanding, making it an excellent choice for surgeons who are learning to incorporate costal grafting into their practice.

Costal cartilage harvesting is a safe technique, but the selected rib (or ribs) to be harvested will vary based on the specific grafting needs. Furthermore, rib anatomy will vary between individual patients. This chapter will discuss the technique of costal cartilage harvesting and will establish a practical approach toward rib selection based on individual grafting needs. Several rib graft harvesting techniques and choices are available, and each surgeon may develop a preferred algorithm to select one. The technique suggested here is meant to serve as a basic guide such that any surgeon can decide which approach best suits him or her.

Evaluation of the Problem

Describing the surgical decision-making process leading to the plan behind a complex nasal reconstruction is beyond the scope of this chapter. However, in the course of configuring an operative plan several factors must be incorporated. The plan begins with the defect to be addressed, which incisions need to be made to provide access to the surgical site, the operative maneuvers required to accomplish the desired modification, and, specifically with regard to rib cartilage harvesting, which grafts will need to be used. After having a clear idea of the grafts to be used, the surgeon can then select an appropriate donor site from which to harvest them, taking into account the quality and amount of cartilage necessary and available from each donor site (i.e., septum, conchae, or ribs). It is important to be clear about the intrinsic properties of cartilage and/or bone at each harvest site. The experience with harvesting and cutting cartilage grafts from different locations helps the surgeon to become familiar with the varying degrees of cartilage strength and consistency. The patient's age is important, as costal cartilage tends to ossify and become more brittle with advancing age. Marin et al. have advocated preoperative computed tomography imaging for selected patients in order to assess for rib cartilage calcification.

As the surgeon selects the cartilage grafts necessary to perform the operation, the donor site morbidity associated with each site should be considered, operative reports from previous operations should be reviewed, and detailed physical examination of the septum and conchae will reveal if any residual cartilage remains to be harvested. Secondary septal surgery is technically challenging and rarely produces an adequate amount of cartilage. Even if available in sufficient quantity, conchal cartilage often lacks the structural strength required to counteract the robust contractile forces resulting from cicatricial wound healing in a reoperated nose.

Once the decision to use costal cartilage has been made, the surgeon must next decide which rib or ribs will best serve the purposes for the planned operation ( Figure 15-1 ). Factors integral to this decision include both the problem the surgeon is trying to solve with the cartilage graft and the patient's desires in terms of donor site morbidity. The most important questions the surgeon must ask are: What skin incision is required to obtain the necessary exposure to harvest the costal cartilage, and which rib or ribs will work best to carve the grafts? Of course this choice is both patient and problem dependent, but some guidelines to help make that decision will be outlined.

Figure 15-1, Inframammary fold and subcostal access incisions.

Inframammary Fold Incision

This incision is useful in that it is cosmetically favorable for most women. We have found that some men find a breast scar unacceptable. It allows excellent access to the fifth, sixth, and sometimes even the seventh costal cartilage. Although it would seem that the risk of pneumothorax would be higher with this incision, this has not been found to be the case based on published studies. The disadvantages to this approach include that it can be more technically difficult for the novice surgeon and the amount of cartilage harvested is typically less. Also, in patients who have previously undergone a breast augmentation procedure, there is a small yet distinct risk of damaging the existing implant. Nonetheless, this approach is popular and allows surgeons to accomplish the goal, and it rarely requires drain placement.

Abdominal Skin Incision

The authors recommend the subcostal approach, as previously advocated by Sheen and Daniel, for multiple reasons ( Figure 15-2 ). The incision is generally no longer than 3 to 4 cm and is located well onto the abdomen, making it inconspicuous and unobtrusive. Second, the approach is safer, with a lower risk for pneumothorax since there is relatively more connective tissue in between the rib and the parietal pleura at this level. Third, and most important, the volume and variability of cartilage available at this location are much greater than with the inframammary approach. Multiple ribs can be taken through the same incision, and in cases where osteochondral grafts are required, the incision simply needs to be shifted or extended to a more lateral position.

Figure 15-2, Subcostal incision closed with ninth rib cartilage and a portion of eighth rib cartilage.

Costochondral Graft Harvest

With the patient in the supine position, a 3- to 4-cm incision is designed over the junction between the floating ninth rib tip and the eighth rib above it (see Figures 15-1 and 15-2 ). The right rib cage is usually selected, particularly in older patients where postoperative chest pain could potentially mask cardiac-related pain. The incision is injected with 10 cc of lidocaine 1% with epinephrine 1 : 100,000 prior to preparation and draping, observing standard sterile technique. The incision is made and dissection is carried down through the external oblique muscle to identify the interspace between the eighth and ninth ribs ( Figure 15-3 ). Commonly, the incision is carried deep at a point that is lateral to the lateral edge of the rectus abdominis muscle ( Figure 15-4 ). Doing so allows medial retraction (instead of division) of the rectus muscle and results in less postoperative pain and muscular dennervation. For a ninth rib graft, the mobile, medial cartilaginous tip is identified and dissected in a retrograde and extraperichondrial fashion. Since it is a “floating rib,” the extraperichondrial dissection is extremely quick with a total harvest time of less than 20 minutes in most cases. For the eighth rib, subperichondrial hydrodissection is performed using lidocaine 2-3 cc of 1% with epinephrine 1 : 100,000. Serial “H” incisions are carried out through the ventral perichondrium to allow a subperichondrial dissection. Frequently, these incisions must be carried both laterally and medially beyond the required amount of needed graft to facilitate dissection and prevent accidental tearing of the perichondrium. The costal arch is then freed with a periosteal elevator from the caudal aspect of the seventh rib (at the syncytium) and then dissected in a retrograde fashion to the bone–cartilage junction under direct vision. The bone–cartilage junction is easily identified both by a palpable ridge and by the very distinct color change from the white color of the cartilage to the reddish-gray color of the associated bone. This dissection is facilitated with a Doyen retractor ( Figure 15-5 ), but caution must be heeded as tear of the intimately associated underlying pleura can occur if too much force is used. After the rib is transected under direct vision and removed ( Figure 15-6 ), pleural integrity check is performed by filling the cavity with saline and having the anesthesia provider simulate a Valsalva maneuver. The wound is closed in different layers. Closure of the ventral perichondrium helps to splint the interspace and reduces postoperative pain. Closure of the external oblique fascia must be performed meticulously to help prevent the development of a postoperative hernia. Intramuscular and subcutaneous infiltration of 10 cc of bupivicaine 0.25% with Epinephrine during surgical closure greatly reduces immediate postoperative discomfort.