When Less Is More: A Costal Cartilage-Sparing Technique for Cartilage Graft Harvest in Rhinoplasty

Success in revision rhinoplasty relies on the rhinoplasty surgeon’s ability to use a variety of operative techniques to address both functional and aesthetic concerns. The use of autologous costal cartilage is an important tool in revision rhinoplasty and is particularly useful when the patient’s cartilaginous septum has been resected during the index operation. The disadvantages of using costal cartilage include donor-site morbidity in the form of pain, splinting, and pneumothorax. Cadaveric cartilage has emerged as an alternative graft source, but long-term results remain mixed.1,2 In this communication, we present a costal cartilage-sparing technique for cartilage grafting in rhinoplasty. This retrospective case series was approved by the institutional review board. Three patients underwent the proposed costal cartilage-sparing technique for revision rhinoplasty (one female and two male patients; age range, 58 to 71 years). All patients had a history of rhinoplasty and septal resection without a history of costal cartilage grafting. There were functional and cosmetic components addressed in all patients. All patients had tip, columellar strut, and bilateral spreader grafts placed; one patient also had lateral crural strut grafts placed. All revision rhinoplasties were performed using a standard open transcolumellar approach. Once the amount of cartilage necessary for grafting was determined, the septum was reassessed and excluded as a potential donor site. A 3- to 5-cm incision was then made overlying the right fifth or sixth rib (in men) or just inferior to the inframammary fold (in women) medial to the midclavicular line. Dissection was carried down to the rectus abdominis muscle, which was split along its fibers. Once exposed, the perichondrium was incised longitudinally and reflected superiorly and inferiorly to expose the underlying costal cartilage. A no. 15 blade was used to incise the costal cartilage. A wedge of cartilage was removed from the superior, inferior, medial, and lateral margins of the graft. This key maneuver was performed to facilitate transection of the central graft at the appropriate angle along its base. Harvest of the central graft was performed using a Woodson or standard periosteal elevator (Fig. 1). Care was taken to preserve continuity of the costal cartilage to maintain structural integrity of the rib and minimize discomfort. [See Figure, Supplemental Digital Content 1, which shows rib continuity maintained following graft harvest. Superior and inferior costal cartilage borders remain intact (arrowheads), with intact central costal cartilage (asterisk), https://links.lww.com/PRS/E624.] A Valsalva maneuver with saline was performed to ensure that the pleura had not been violated. After this, anesthetic was infiltrated throughout the surgical site, the perichondrium was repaired primarily, and the incision was closed in layers. To minimize graft warping, the outer layer of cartilage was removed and grafts were fashioned equally on all sides. No donor-site complications using this technique were encountered.Fig. 1.: Costal cartilage harvesting technique. (Above, left) An incision is made along the right fifth or sixth rib in male patients or along the inframammary fold in female patients. (Above, center and right) The perichondrium is incised and reflected to expose the costal cartilage. (Center) A wedge of cartilage was removed from the superior, inferior, medial, and lateral margins of the graft to achieve the appropriate angle to transect the central graft component along its base; the perichondrium is repaired after harvest. (Below) Costal cartilage graft following harvest.Our approach to costal cartilage harvest presented adds to a growing list of techniques focused on minimizing donor-site morbidity for costal cartilage graft harvesting.3–5 In this communication, we demonstrate a technique that is easily performed with readily available surgical instruments. The presented technique can also be applied to older patients, in whom costal cartilage can be brittle. Although the presented data are limited, future work is necessary to evaluate the effects of this approach on postoperative pain. DISCLOSURE The authors have no financial interests to disclose.