Cantilever Rib Grafting in Salvage Rhinoplasty

Ghaith F. Shubailat, M.B.B.S., F.R.C.S. (Ed), F.A.C.S.

Amman, Jordan

Abstract. Loss of nasal skeletal support, whether congeni-tal, following trauma or secondary to multiple failed sur-geries, calls for reconstruction aiming at restoring rigid

dorsal stability, maintaining tip projection, and restoringrespiratory function. Where septal and conchal grafts areinadequate to be used as building blocks, our procedure ofchoice has been the cantilever osseocartilagenous rib graft

with microscrew fixation. In the past 10 years, 48 patientswere candidates for this salvage procedure. Long-termfunctional and cosmetic results have been highly satisfac-

tory.

Key words: Cantilever rib graft—Salvage rhinoplasty

Historical Review

Millard [1] supported the cantilever concept in whicha bone graft, rigidly fixed at the glabella, maintaineddorsal contour and tip projection obviating the needfor a columellar strut. Sheen and Sheen [2] used the9th or 10th rib for dorsal support. Chait et al. [3]reported 25 cases of osseocartilagenous grafts fromthe 5th rib for nasal reconstruction. To avoid exces-sive tip rigidity, they maintained a segment of carti-lage for the distal nasal reconstruction. They used theclosed intranasal approach and single wire fixationcephalically. David and Moore [4] first described theuse of osseocartilagenous rib graft rigidly fixed with amicroscrew. Congenital deformity was the main in-dication in 19 out of their 25 cases. Only six wereposttraumatic nasal deformities. In all but three,nasal bone grafting was combined with other cra-

niomaxillary procedures. Song et al. [5] reported bonegraft resorption in two of 22 cases of cantilever graftsand favored the use of cartilage grafts. Lack of rigidbony contact and fixation with consequent lack ofvascularization could explain the cause for bony re-sorption. Gunter [6] favored the pure cartilaginousrib graft with a small K-wire placed in the center tominimize warping. Graft was taken from the 7th and8th synchondrosis and was sutured to the cartilagi-nous nasal vault. Daniel [7] presented his techniquefor monobloc osseocartilagenous autogenous ribgraft rigidly fixed with double ultramicroscrews at theradix on a well-prepared cancellous bony platform.This was coupled with a cartilage columellar strut fordefining a well supported tip. Burget [8] pointed outthat the 8th, 9th, and 10th mobile ‘‘false’’ ribs areattached only by fibrous union and may be harvestedthrough relatively short incisions. The grafts had anatural nasal shape, and there was less chance ofpleural perforation. Gurley et al. [9] evaluated long-term morphometrics, patient satisfaction and inde-pendent observer review of 32 children. Osseocarti-lagenous rib grafts harvested from the synchondrosisof the 5th, 6th, and 7th ribs were fixed with metalscrews to a prepared bed over the nasal bones. Withan average follow-up of 8 years, long term survivalwas established and satisfactory outcome was re-ported.

Materials and Methods

Over the past 30 years, more than 2500 rhinoplastyprocedures have been performed by the author. Ofthese, 845 cases were operated on in the past 10 years(1992–2002). In 5% skeletal support was badly defi-cient or absent because of previous surgery, trauma,and congenital craniofacial anomalies. Local septalskeletal grafting material and conchal cartilages wereinsufficient for reconstruction. These cases wereclassified as salvage rhinoplasties. To obtain rigid

Correspondence to Ghaith F. Shubailat, P.O. Box 5180,Amman 11183, Jordan; email: lasercare@index.com.jo

Aesth. Plast. Surg. 27:281–285, 2003DOI: 10.1007/s00266-003-3035-9

dorsal support, maintain tip projection, and restorefunction, our technique of choice has been the use ofa an osseocartilagenous rib graft with microscrewfixation. Forty-eight patients underwent such a pro-cedure; 72% were female and 28% were male. Agesranged from 8 to 40 years. In 45 salvage cases thedeformity followed multiple previous rhinoplasties(one to five operations) that had destroyed the bonyand cartilaginous skeletal support. In two severeposttraumatic cases, septal support was impossible tomaintain and rib grafting was done as a primaryprocedure (Fig. 1). In one 8-year-old child who wasborn with complete bilateral clefts of the primary andsecondary palate, the septum was missing followingearlier repair operations performed somewhere else.Cantilever bone grafting was coupled with an Abbeflap (Fig. 2).

Technique

The open transcolumellar approach through a step orinverted V-incision was used. Exploration and defi-nition of the damage preceded clearing up of fibroustissue and previously placed alloplastic material,cartilage, or bone grafts (Fig. 3). Through a 5-cmincision over the right 10th rib, the osseocartilagen-ous part of the rib is exposed. Only the bony part is

dissected subperiosteally, leaving the periosteumcovering the bone cartilage junction intact (Fig. 4, Aand B). The cartilaginous part is dissected with elec-trocautery. The wound is drained and closed. A bonyplatform is prepared with a glabellar rasp. The graftis fitted in and tried for size, position, and shape. Thecartilage end is trimmed like a spearhead, and thebone-to-cartilage ratio of the graft is fashioned to be70:30. With a 1.5-mm drill bit, a hole is drilled 8–10mm from the proximal bony edge of the graft. Atrough to house the screw head is made with acountersink instrument (Fig. 4C). The graft is fittedinto position and through a 2-mm stab in the gla-bellar crease; the drill is guided through the hole inthe graft and directed into the bony platform. A 2-mm tab is next introduced, followed by a microscrew2-mm in diameter and 14–16 mm long (Fig. 4, D).The domes of the lower lateral cartilages, when pre-sent, are anchored to the cartilaginous tip, andtransverse supratip rib cartilage grafts have beenadded to augment the tip in the majority of cases. Acolumellar strut may be used to support weak ordamaged medial crura. Where there is total loss of thelower lateral cartilages, to relieve external valve col-lapse, anatomical alar grafts were fashioned fromavailable septal or rib cartilage that were anchoredmedially to the cartilaginous tip with permanent su-tures (Fig. 5). Whenever remnants of the upper lateralcartilages were present, they were anchored to eitherside of the rib graft. If depressions showed on eitherside of the rib, they were filled up with crushed ordiced cartilage wrapped with surgicel: the Turkishdelight graft (Fig. 6) [10].

Results

Follow-up ranged from 1 to 10 years. Rigid bonyunion was attained clinically and radiologically in allpatients within the first year. There was no warping inany case. In eight cases the microscrew head becamepalpable within the first year and was only removed ayear postoperatively following complete bony union.

Fig. 1. Primary rib grafting. (A) Before. (B) After.

Fig. 2. Bilateral cleft lip. (A) Before. (B) After rib graft andAbbe flap.

Fig. 3. Fifth rhinoplasty. (A) Before. (B) After clearing up.

282 Cantilever Rib Grafting

Fig. 4. (A) Exposure of 10th rib. (B)Osseocartilagenous rib graft. (C)Countersink trough. (D) Micro-screw fixation.

Fig. 5. Alar and tip grafts added.Fig. 6. Crushed cartilage graft filler.

Fig. 7. Posttraumatic deformity. (A) Before. (B) After. Fig. 8. (A) Previous bone graft. (B) After rib graft.

G.F. Shubailat 283

We believe that limited bony resorption, thoughclinically insignificant, contributed to the extrusion ofthe screw head from its original position in thetrough. There were no infections. None had anyperforations of the pleura or peritoneum. With in-creasing experience, the operative time was reducedto 90 min. Patient and surgeon satisfaction was veryhigh (Figs 7–13).

Discussion

In the great majority of patients who presented withmajor postrhinoplasty and posttraumatic deformi-

Fig. 9. (A) Postrhinoplasty deformity. (B)After rib graft.

Fig. 10. (A) Postrhinoplasty deformity. (B) After rib graft.Fig. 12. Basal view. (A) After five rhinoplasties. (B) Afterrib graft.

Fig. 11. (A) Postrhinoplasty deformity. (B) After rib graft.

Fig. 13. Lateral view. (A) Before. (B) After.

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ties, we have used septal cartilage, vomerine, andethmoidal bone grafts to attain our aims of recon-struction. However, in 5% of our cases, the damagethat had been done left very little or no local skeletalmaterial to rebuild a functioning and cosmeticallypleasing nose. The 10th and 11th ribs presented theideal donor site for an osseocartilagenous graft, andmicroscrew fixation guaranteed rigid bony union ofthe cantilever rib graft with the recipient nasal bonyplatform. The cartilaginous distal part served as asoft but stable site onto which the reconstructedlateral cartilages were anchored. The 10th and 11thdonor ribs have a straight nasal shape that needsvery little shaving at the chondrocostal junction. Thecomplication of pleural perforation, frequently seenwhile harvesting the 5th, 6th, and 7th ribs, has beencompletely avoided. Warping of the short cartilagi-nous segment did not take place in our series. Thereis a learning curve, but with increasing experience,the operative time was reduced to 90 min, which isour average time for a primary rhinoplasty. In ourhands the cantilever rib graft with microscrew fixa-tion yielded excellent results with the least compli-cations and a high degree of patient and surgeonsatisfaction.

References

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5. Song C, Mackay DR, Chait LA, Manders EK, KellyMA: Use of costal cartilage cantilever grafts in Negroidrhinoplasties. Ann Plast Surg 27:201, 1991

6. Gunter JP: Secondary rhinoplasty: The open approach.In: Daniel RK Eds. Aesthetic plastic surgery: rhinopl-asty. Little, Brown, Boston, pp 833–847, 1993

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8. Burget G: Costal cartilage for nasal reconstruction.Perspect Plast Surg 7:129, 1993

9. Gurley JM, Pilgram T, Perlyn CA, Marsh JL: Long-term outcome of autogenous rib graft nasal recon-struction. Plast Reconstr Surg 108:1895, 2001

10. Erol OO: The Turkish Delight: a pliable graft forrhinoplasty. Plast Reconstr Surg 105:2229, 2000

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