Patient preparation

General anesthesia with orotracheal intubation is preferred when performing rhinoplasty with costal cartilage harvest. The patient’s nasal deformities are palpated and delineated with a surgical marking pen to document bony and cartilaginous prominences and deficiencies, tip asymmetry, midvault pinching, and presence of allografts if present. Photo documentation is performed before and after surgical marking in both the frontal and lateral views. Neosynephrine-soaked neurosurgical cottonoids are placed in the nasal cavities to decongest mucosa. The vibrassae are trimmed with a small scissors and the nasal vestibule is swabbed with iodine.

The right chest is exposed, and the sixth rib is palpated below the right breast. The chest incision is planned directly above the cartilaginous portion of the rib just medial to the osseo-cartilaginous junction, which is easily identified by probing the rib with a 1.5-inch hypodermic needle. This technique is also useful to assess if any calcifications are present within the rib cartilage. A marking pen is used to draw a linear incision measuring 1.5 to 2.0 cm in length and is positioned in the inframammary crease for patients without breast implants. In patients with breast augmentation, three modifications ensure better exposure while avoiding damage to the implant: the incision is planned inferior to the inframammary crease by at least 2 cm, the incision is lengthened, and needle probing is performed over the seventh rib with firm superior retraction of the implant. The placement of the scar on the right chest avoids future confusion about cardiac procedures associated with left chest scars. It is covered by a brassiere or bikini top and is positioned laterally enough to be hidden even when the patient wears V-neck fashioned blouses.

Local anesthesia

Local anesthetic, typically 1% lidocaine with epinephrine in 1 : 100,000 concentration, is injected into the nose and chest using a 27-gauge needle. Even under general anesthesia, the local anesthetic with adrenaline improves postoperative analgesia, reduces intraoperative bleeding, and allows for a lighter plane of anesthesia. Key injections for the nose include internal and external sites: the septum is injected in a sub-mucoperichondrial plane to assist with hydrodissection of the soft tissue from the septal cartilage; the vestibules are injected along the marginal incisions; the pyriform aperture is infiltrated along the nasal side wall externally and lateral nasal cavity internally via a needlestick just above the inferior turbinate anterior attachment to the maxilla; the dorsal skin is infiltrated in a supra-perichondrial plane over the upper lateral cartilages and a supra-periosteal plane above the nasal bones to achieve hemostasis of this vascular area; the tip and columella are injected from a median needle stick between both domes. Following identification of the cartilaginous portion of the rib, local anesthesia is infiltrated along the perichondrium and within the dermis at the site of the planned chest incision. Local anesthetic injection precedes iodine sterile scrubbing in order to allow ample time for the medication to take effect.

Cartilage harvest

Costal cartilage harvest typically precedes the nasal surgery in order to maintain sterility and decrease the possibility of cross-contamination from the nose to the chest. Several choices exist when harvesting costal cartilage. Cadaveric studies have advocated harvesting the seventh rib as an ideal choice because of its superior length, greater thickness, and its location inferior to the lung pleura and lateral to the course of the internal mammary artery.⁸ The senior author prefers the sixth rib due to its close proximity to the inframammary crease (Fig. 44.1). Sometimes both sixth and seventh ribs are harvested through a single common incision when a large amount of grafting material is required (e.g. grafts for dorsal and premaxillary augmentation). The fifth rib has the benefit of fewer connections to neighboring ribs, but it tends to be more curved and shorter than the sixth rib. Selection of the rib is thus case specific and depends upon accessibility, presence of calcifications, volume of graft required, and rib configuration.

Fig. 44.1 The incision for harvesting costal cartilage is made at the lower aspect of the right breast. The incision typically lies over the sixth rib. In most patients, the incision is in the crease while lying in the supine position.

Preoperatively, a thorough history should include questions about previous chest surgery, breast augmentation, and type of breast implants if present. In the female patient, breast size can limit the surgeon’s ability to adequately expose the more superiorly situated ribs. Access is further complicated by the presence of implants that both increase the breast size and require a more inferior dissection path in order to avoid entering the implant capsule.

The harvesting procedure begins with the skin incision and sharp dissection through subcutaneous adipose and breast tissue down to the pectoralis muscle fascia. The fascia is sharply divided and the muscle fibers are bluntly spread using a hemostat (Fig. 44.2A). Blunt dissection with a cotton dissector clears the remaining soft tissue off the rib to expose the perichondrial surface. The osseous junction is confirmed using a 27-gauge needle, and this landmark marks the lateral most extent of the useful costal cartilage. The perichondrium is incised along the osseochondral junction and along the superior and inferior edge of the anterior surface of the rib to create a “window” through the perichondrium to the cartilage below. The strip of perichondrium within this window is elevated with a Freer elevator, excised in a 5–8 cm length, and stored in sterile saline for later use. Next, the rib is dissected away from the remaining perichondrium circumferentially, taking care to avoid injury to the deep perichondrium, which intimately overlies the lung pleura (Fig. 44.2B). An incision is made halfway through the rib just medial to the osseochondral junction. A medial incision is also made based on the length of cartilage required for the augmentation (Fig. 44.2C). A blunt-tipped Freer elevator is used to complete the cartilage incisions and dissect through the neighboring rib costal attachments. This isolates the dissected segment of costal cartilage, which is removed and set aside in sterile saline to soak. Attention is then directed to the medial and lateral margins of the in-situ rib. A rongeur is used to bevel the sharp edges, which prevents potential visibility or edge palpability. Irrigation solution is then instilled into the surgical bed and the anesthesiologist is asked to perform a Valsalva maneuver. If there were any openings into the pleural space, bubbles in the irrigation fluid would indicate an air leak. Closure of the wound is deferred until the end of the procedure in case additional rib or perichondrium is needed. The wound is lightly packed with a moistened cotton gauze and covered to maintain sterility.

Fig. 44.2 Harvesting costal cartilage. A, Exposure of the underlying rib is obtained by careful blunt dissection by spreading the muscle fibers without cutting or tearing. B, Perichondrium is dissected from the rib circumferentially leaving the deep perichondrial layer and underlying pleura intact. C, A lateral cut is first made at the osseo-cartilaginous junction followed by a medial cut at an appropriate distance from the first cut to provide sufficient length of graft material.

The most technically challenging aspect of augmentation rhinoplasty using costal cartilage is carving the grafts. Costal cartilage must be carved sequentially, over several hours, with frequent soaking periods to allow the natural warping tendencies of each piece to be declared. The dorsal graft must have minimal warping, and is best carved from the central core of the rib.^9,10 (Fig. 44.3).

Fig. 44.3 When carving costal cartilage the central core tends to bend or warp less than the periphery.

Rhinoplasty approach

The rhinoplasty is performed using an external approach starting with an inverted V-shaped incision in the mid-columella. This incision is located 1 to 2 mm closer to the upper lip rather than exactly at the columella midpoint in anticipation of anterior movement of the scar with increased tip projection. Initial incision placement is critical to avoid visible scars from incisions placed too close to the tip lobule. The columella incision extends into each nostril, makes a right angle to continue along a marginal incision within each vestibule. Sharp dissection is preferred over blunt dissection along the supra-perichondrial plane of the lower and upper lateral cartilages to minimize intraoperative and postoperative edema. Once the dorsum is in view with both upper lateral crura exposed, a Joseph periosteal elevator is used to expose the nasal bones via a subperiosteal dissection plane. A precise pocket is created that extends no further than the nasal starting point and not wider than the planned augmented dorsal width. Hemostasis is improved with the application of a neosynephrine-soaked cottonoid placed gently in the dissected pocket.

Stabilization of the nasal base

The first structural support in augmentation rhinoplasty is the establishment of a stable nasal base. This initial maneuver enables the surgeon to control several variables including nasal length, nasolabial angle, degree of tip rotation, columella–ala relationship, and underlying tip support upon which projection and tip refinement is built. The importance of this initial step cannot be overemphasized. The complexity of possible outcomes that result from improper nasal base stabilization makes this first step a critical foundation to the rest of the operation. Several stabilization techniques are possible and will be discussed in increasing complexity.

When the patient requires no modifications to nasal length, nasolabial angle, tip rotation or columella-ala relationship, a floating columellar strut is an acceptable choice. This graft is carved from septal or costal cartilage measuring 8 to 14 mm long, 3 to 4 mm wide and 1 to 2 mm thick. Placement between the medial crura should not extend down to the anterior nasal spine. A soft tissue cushion should remain to prevent a “clicking” sensation when the patient smiles or manipulates the nose postoperatively. The graft is secured using a 4-0 plain gut mattress suture on a straight septal needle. The columellar strut graft adds support to the tip to prevent subsequent postoperative tip deprojection or rotation. The effect of this graft is to stabilize the tip position, but usually does not alter it.

For patients who require increased nasal length, changes to tip rotation, and alteration to the columella–ala relationship, but do not require premaxillary augmentation, the caudal extension graft is the preferred method.¹¹ This graft is also placed between the medial crura but is placed end to end or overlaps with the caudal septum and is fixed directly to the caudal septum with a 5-0 PDS mattress suture. Placement of the graft can correct nostril asymmetry by placing the graft on the side of the larger nostril to reduce its size. The surgeon can customize the shape and placement of the graft in order to control changes to nasal length, columella position and tip rotation. Figure 44.4 illustrates the counter-rotation affect of a graft that is longer along the superior margin; whereas Fig. 44.5 demonstrates the increased rotation created by a graft with a longer inferior margin. Graft dimensions are highly variable depending on the desired affective change; however, at least 3 to 4 mm of graft should overlap with the septum to achieve adequate base stability. Additional stability and major nasal lengthening can be achieved with the use of extended spreader grafts fixed directly to the caudal extension graft placed end to end (Fig. 44.6). The medial crura are sutured to the caudal edge of the caudal extension graft with 4-0 plain gut on a straight septal needle.

Fig. 44.4 A–C, To counter-rotate the nasal tip, a caudal extension graft should be longer along the superior margin to push the nasal tip down.

Fig. 44.5 A–C, To increase tip rotation and blunt the nasolabial angle, the caudal extension graft should be longer along the inferior margin.

Fig. 44.6 Major lengthening of the nose is achieved with extended spreader grafts sutured directly to the caudal extension graft or extended columellar strut graft which increases nasal dorsal length and pushes the tip caudally.

Patients who require augmentation of the premaxilla need more complex tip support methods. The extended columellar strut can be used with a premaxillary graft for maximal premaxillary augmentation, or without the premaxillary graft for modest premaxillary augmentation. When the extended columellar strut is placed without a premaxillary graft, it is placed in a pocket between the medial crura and fixed directly to the nasal spine via two possible techniques. First, it can be sutured to thin splinting grafts placed bilaterally, which are in turn sutured to the nasal spine through a predrilled hole using a 16-gauge needle (Fig. 44.7). Alternatively, a notch can be created through the nasal spine with a 5 mm osteotome, and the extended columellar strut can be slotted into the notch and fixed with two 4-0 PDS sutures tied directly to the bone through a similarly predrilled hole (Fig. 44.8A–D). The amount of premaxilla augmentation is directly proportional to the degree of caudal extension of the extended columella graft that extends caudal to the nasal spine. The nasal length and columella-ala relationship are also controlled by the caudal extension of the graft. Rotation of the tip can be precisely controlled by altering the angle of the graft prior to securing the anterior projection to extended spreader grafts from above. Tip projection is determined by graft length, and columellar thickness on base view is directly proportional to graft thickness. The extended columella graft is a powerful technique that also enables the surgeon to correct deviations of the nasal base from midline. When the nasal spine does not align with a vertical line dropped down from the nasion, the extended columella graft can be placed left or right of the nasal spine to correct for this deviation. The combination of an extended columella graft and premaxillary graft is useful to maximize augmentation of the premaxilla. The premaxillary graft is placed, depending on its size, either through the medial intercrural pocket or a separate sublabial incision. It is sutured directly to the nasal spine with suture either through periosteum or the pre-drilled hole. A notch carved on the anterior surface of the premaxillary graft supports the extended columellar graft (Fig. 44.9).

Fig. 44.7 The extended columellar strut can be fixed to the nasal spine region by using paired splinting grafts on both sides of the nasal spine. The splinting grafts act to stabilize the graft in the midline and are secured by suturing through predrilled holes in the bony spine.

Fig. 44.8 The extended columellar strut can also be fixed to the nasal spine by creating a notch in the nasal spine and setting the graft inside the notch. A, A 5 mm osteotome is used to create a notch in the nasal spine. B, The notch is made at the center of the nasal spine so each splayed half of bony spine serves as a splint for the graft. C, A 16-gauge need is used to drill a hole through the nasal spine posterior to the notch. D, The extended columellar strut is carved with a corner cut out to create a groove. This groove secures the graft once placed in the notch to prevent anterior or posterior movement of the graft.

Fig. 44.9 For maximal premaxillary augmentation, the extended columellar strut can be integrated into a notch in a premaxillary graft placed into a pocket over the premaxilla.

Nasal tip contouring

After setting the base, the tip can be shaped through a variety of tip contouring techniques. The surgeon’s choice of method to project the tip should meet the patient’s aesthetic goals while suiting their anatomical limitations.

Dome binding sutures are a simple method of tip contouring for patients with thinner skin who require very little additional projection. A 5-0 clear nylon suture is placed in a horizontal mattress configuration to create a more acute bend at the dome. Projection and rotation can be achieved by placing the sutures slightly more laterally than the naturally occurring dome, which recruits cartilage from the lateral crus to the dome and effectively lengthens the medial crural component to increase tip projection and rotation. The limitations of this method are primarily the strength of the lower lateral cartilages, the requirement of thinner skin, and the relatively small amount of projection achievable without subsequent tip rotation. When small changes are desired in a thin-skinned patient, this method is useful. Unfortunately, most Asians have thick skin and structurally weak crura.

The tip shield graft can project into thick skin, creating favorable nasal tip contours. A tip shield graft is most effective with a slight convexity and placement above the dome by at least 2 mm. The edges are beveled and the graft is sutured to the caudal margin of the medial crura with at least four 6-0 Monacryl sutures. The top edge of the graft is camouflaged to prevent visibility in the future. If the top of the graft is between 2 and 3 mm above the dome it can be camouflaged with a buttress graft sutured immediately behind the graft (Fig. 44.10A,B). The cephalic trim cartilage can be used as the buttress graft and sutured just behind the leading edge of the shield graft. The buttress graft should extend laterally a millimeter or two beyond the shield graft to provide adequate camouflage.¹² When additional projection is needed and the graft projects more than 3 mm above the existing domes, lateral crural grafts should be sutured to the posterior surface of the graft (Fig. 44.11A,B). These grafts are carved and sutured so that they are at 45 degrees to the back surface of the tip graft, creating a smooth transition between the graft and the lateral crura. Flat pieces of cartilage create the best tip contour. These grafts also provide structural support to the tip, preventing cephalic rotation of the shield graft, and should be of adequate strength. The lateral crural grafts are sutured to the lateral crura with 6-0 Monacryl sutures. Further camouflage can be achieved with a strip of perichondrium. This tissue is sutured over the leading edge of the shield graft with 6-0 Monacryl in a horizontal orientation (Fig. 44.12). This additional tissue adds tip projection and creates a more rounded tip, which is ideal for the Asian patient.

Fig. 44.10 A&B, Tip grafts projecting less than 3 mm beyond the existing domes are camouflaged with a small buttress graft placed superiorly to the most projecting edge of the tip graft. The length of the buttress is slightly longer than the width of the tip graft to create smooth transition to the lateral crura.

Fig. 44.11 A&B, Tip grafts projecting greater than 3 mm beyond the existing domes can be camouflaged with lateral crural grafts. Note how the lateral crural grafts are secured to the lateral crura and are oriented obliquely from the posterior surface of the most projecting edge of the tip graft.

Fig. 44.12 Additional camouflaging of the tip graft can be achieved by adding a layer of perichondrium over the leading edges of the tip graft to help minimize the chances of graft visibility.

Dorsal augmentation

Establishing the dorsal height is the next step after setting the tip projection. Unless the nasal bones are deviated, we do not perform osteotomies, as a wider bony vault will provide a better foundation for a dorsal graft and help to ensure a smooth transition from dorsal graft to the bridge of the nose. In most Asian rhinoplasty cases, the dorsal graft is carved from costal cartilage. Although auricular and septal cartilage are also possible augmentation graft materials, costal cartilage is typically preferred because of its greater thickness, smaller risk of resorption, and more abundant availability in the majority of Asian patients.

When auricular cartilage is used it is important to understand that this material tends to deform and curl along its edges over time leaving visible distortions in the skin envelope. When the required augmentation exceeds the auricular cartilage thickness, it can be stacked; however, the senior author’s experience has shown occasional resorption of the stacked auricular cartilage, and thus, loss of dorsal projection over time.

Septal cartilage shows no resorption and very rare incidence of bending, but most Asians have an insufficient septal thickness or quantity for most augmentation requirement. Therefore the preferred material used most often is costal cartilage.

The key to successful use of costal cartilage lies in the carving technique. Preparing costal cartilage for use as a dorsal graft requires sequential modifications over several hours of soaking in antibiotic solution between carvings. The warping tendency of each piece of cartilage declares itself over time, and the sequential carving modifications can utilize the natural bending in an advantageous configuration. Dorsal grafts become problematic when visible irregularities are seen through the skin. This can occur when the graft shifts, the edges curl up from the dorsal foundation to tent up the skin, or the entire graft bends left or right of midline. It is imperative to carve the dorsal graft sequentially in order to orient the block of cartilage with the bending surface facing down on the dorsum and the lateral edges aligned straight and parallel. A canoe-shaped graft takes form with the concave surface oriented against the nasal dorsum, the sides parallel to each other and straight, the convex surface up against the skin, the cephalic end contoured to a narrower tip, and all edges appropriately beveled with rounded edges. This configuration creates an anatomically correct brow-tip aesthetic line and decreases the chance of unwanted bending since the bending tendency of the cartilage is resisted by the tension of the overlying skin cover against the graft and dorsum. Graft edge camouflage is further enhanced by the placement of a perichondrium cover over the graft such that the edges of the perichondrium extend beyond the graft edges, much like a tablecloth drapes over a table. When the use of perichondrium is anticipated, the added thickness of the perichondrium should be accounted for when carving the appropriate thickness of the costal cartilage.

Placement of the dorsal graft, like the carving procedure, is equally important to establish a natural contour on the dorsum. The cephalic end of the graft should fit snugly into the radix pocket, which establishes the cephalic extent of the augmentation and prevents twisting or shifting movement off the nasal bones. The nasal starting point is therefore established by the superior pocket and should lie in line with the midpupillary level on profile view. The graft is sutured directly to the underlying spreader grafts or upper lateral cartilages in at least two fixation points on each side of the graft. Additional security against graft movement is accomplished by suturing a small rectangle of perichondrium to the graft’s undersurface, which acts like a Velcro patch to adhere the graft to the cartilaginous and bony dorsum. The graft, with its appropriately contoured edges and perichondrium covering, can create a narrower dorsum when it is sutured on top of the upper lateral cartilages. However, when more dorsal width is preferred, the upper lateral cartilages can be sutured to the graft edges in an overlapping manner.

The caudal end of the graft can be customized to individual patient needs. If a patient needs major tip support, significant counter rotation, or extra lengthening, the dorsal graft can be integrated into an extended columellar strut by notching the dorsal graft’s caudal edge (Fig. 44.13). This creates a reliable and structurally sound way of controlling nasal length, tip rotation, and projection in conjunction with the aforementioned tip stabilization techniques. The combination of grafting maneuvers in the tip and dorsum enables the surgeon to significantly modify nasal contours (Figs 44.14 and 44.15).

Fig. 44.13 The extended columellar strut can be integrated into a notch in the caudal margin of the dorsal graft. The higher the dorsal graft is integrated on the extended columellar strut, the higher the dorsum and supratip. Note the canoe shaped dorsal graft.

Fig. 44.14 A patient who had a silicone L-shaped implant that extruded through her nasal tip leaving a tip scar. Reconstruction was accomplished using costal cartilage extended columellar strut, premaxillary graft, and dorsal graft. The extended columellar strut was integrated into a notch in the caudal margin of the dorsal graft. A, C, E and G, Preoperative views. B, D, F, and H, Postoperative views.

Fig. 44.15 This patient had a shortened, upturned nose after previous rhinoplasty. Costal cartilage was harvested to create a caudal extension graft secured to two extended spreader grafts to increase nasal length. Lateral crural strut grafts were used to lower the retracted nostrils. The nasal dorsum was augmented with a septal cartilage dorsal graft. A, C, E and G, Preoperative views. B, D, F and H, Postoperative views.

Wound closure

Closure of the columellar incision begins with a subcutaneous 6-0 PDS suture in the midline. This suture decreases the tension on the columellar skin incision and helps to preserve a very thin scar. Skin is sutured with a 7-0 black nylon in an interrupted vertical mattress closure, and mucosal incisions are closed with a 5-0 chromic simple interrupted suture. Septal quilting sutures are placed with 4-0 plain gut on a straight septal needle. The nose is packed with a Telfa dressing coated in antibiotic ointment. Hypoallergenic paper tape is applied to the nose followed by a malleable thermoplastic splint.

The chest wound is closed in layers starting with the pectoralis muscle fascia. Simple interrupted 3-0 PDS suture closes the fascia tightly to help split the costal defect. The subcutaneous tissue and dermis are closed with 4-0 and 5-0 PDS suture before closing the skin with a vertical running mattress 6-0 black nylon suture.

Alar base reduction is indicated when the alar base width is excessive as determined on base view. A favorably beveled incision is planned to excise a conservative ellipse of excess alar skin to appropriately narrow the base. The ellipse extends through the lateral nostril sills (when nostril diameter requires reduction) or is limited to the lateral ala skin 2 to 3 mm superior to alar crease (when nostril diameter is appropriate). Primary closure with interrupted vertical mattress 7-0 black nylon sutures completes the procedure (Fig. 44.16).

Fig. 44.16 Base reduction for large nostrils or flaring lateral ala is performed with small excisions of skin wedges from the alar base. A, Large nostrils with flaring alae before base reduction. B, Planned incisions placed 2 mm above and parallel to the alar crease inferiorly with an ellipse of skin including nostril margin. C, Reduced nostrils and alar flaring after skin excision and primary closure with interrupted vertical mattress 7-0 nylon sutures. Note a similar closure to the columellar inverted V-shaped incision.

Complications from augmentation rhinoplasty

Complications from auricular tissue donor site

Complications of costal cartilage harvest