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Nasal dorsal reconstruction with autologous rib

Article-Nasal dorsal reconstruction with autologous rib

Orlando, Fla.—Autogenous costal cartilage, used as grafts in nasal dorsal reconstruction procedures, is notorious for internal stresses that make shaping difficult and, in turn, can produce postoperative distortions.

Dr. Constantian
Despite this reputation, however, costal cartilage can provide autogenous reconstructions that have a high likelihood of success and quality results. Many secondary patients, however, have shallow dorsal defects (1 mm to 2 mm), which, in the past, have not been suitable for rib grafts.

Mark B. Constantian, M.D., is a strong advocate of autogenous costal cartilage's positive potential in nasal dorsal reconstruction. At the 2006 Annual Meeting of the American Society for Aesthetic Plastic Surgeons, Dr. Constantian presented the results of a series of 53 patients in whom he used a new technique to reconstruct shallow defects in secondary rhinoplasty patients with autogenous rib cartilage.

Dr. Constantian, a private practitioner in Nashua, N.H., and adjunct assistant professor of surgery at Dartmouth Medical School, relates the results of a record review he'd compiled on 53 patients in whom he had placed perichondrial/cartilage grafts and on whom there was adequate follow-up. Dr. Constantian tells Cosmetic Surgery Times that his review is an extension of the work of retired plastic surgeon Jack H. Sheen, M.D., who pioneered the use of slices of rib cartilage with attached perichondrium, singly or in laminates, to correct nasal dorsal defects.

The 53-patient record review observed a group of 39 women (74 percent of the total) and 14 men (25 percent), which is typical of Dr. Constantian's prior patient series. He notes, however, that median age at the time of the rib graft was 41 years (range: 17 years to 58 years) older than the median age in prior series (35 years). Median postoperative follow-up was 17 months.

The quality of the donor rib and the surgical result were each graded on a scale of one to five, with five being best. Results graded three or under were considered sufficiently flawed to require additional reconstruction. Postoperative deformities — lateral or anteroposterior deviation, or visible graft edge, also were documented. Any postoperative graft distortion or visibility was counted whether or not it was significant enough to merit revision.

Harvest, placement specifics

In all of these cases, Dr. Constantian says, the eighth or ninth rib was used for the reconstruction and was harvested full-thickness; occasionally a split rib was harvested through an inframammary incision.

Once the perichondrial strip was harvested, it usually deformed toward the perichondrial side, the degree being dependent on cartilage thickness and any contained calcifications. Short, transverse cuts were made in the center of the graft throughout its length, leaving the edges intact. Following this, interdigitating cuts were made along the edges so that all perichondrial fibers were interrupted at some point. When additional thickness was needed, two perichondrial/cartilage strips were fashioned into a laminate, using fine, permanent suture. Grafts were placed endonasally through cartilage-splitting incisions and immobilized only by a tape-and-plaster splint.

"All told, there were 30 single perichondrial/cartilage strips and 23 laminates," Dr. Constantian says. "Thirty-nine percent of the patients had donor ribs that were judged very good or excellent in quality — grade four or five. We noted, however, that patients over 40 were more likely to have good or excellent quality donor rib — about 76 percent of these patients had ribs graded three, four or five, compared with 57 percent of those patients under 40 (p<0.01). This is likely due to the fact that as one ages, ribs generally tend to calcify, which makes them harder to contour but also makes them less likely to deform."

As might be expected, donor-rib quality directly affected the quality of the result in this group, Dr. Constantian says.

"Of the patients whose donor ribs were graded four or five, all achieved results of four or five, while among patients whose rib was graded three, four or five, 94 percent had reconstructive results of four or five," he says. "However, if donor ribs were graded one or two, only 50 percent had results of four or five (p< 0.0001)."

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