In What Situations is Costal Cartilage Grafting Needed in Nose Aesthetic Surgery?
Rhinoplasty is one of the most common surgical procedures performed to improve facial aesthetics and respiratory function. Sometimes, during this operation, it may be necessary to take a cartilage graft from outside the nose to reshape it. In modern rhinoplasty techniques, natural appearance, long-term structural support, and functional success are prioritized. Therefore, the selection of the graft material to be used during the operation is of great importance.
While in many rhinoplasty operations, cartilage tissue taken from the patient's own nasal septum is sufficient, in some cases, a larger amount of cartilage that provides stronger support may be needed. At this point, rib cartilage (costal cartilage) emerges as an important option. Especially in patients with severely altered nasal anatomy due to various reasons, those with significant aesthetic deformities after trauma or repeated surgery, or those with necrosis of nasal tissues due to cocaine use, a strong and durable cartilage graft like rib cartilage may be needed during rhinoplasty.
Rib cartilage is one of the most valuable autologous (obtained from the patient's own tissue) graft sources, especially in advanced revision rhinoplasty, severe nasal deformities, and cases requiring a large amount of graft. Sometimes, donor rib cartilage from other individuals can also be used.
Sometimes, in noses of Asian and African origin with flattened features, thick skin, and insufficient septal cartilage, rib cartilage may need to be used during augmentation rhinoplasty, even in primary rhinoplasty.
What is Rib Cartilage?
Rib cartilage is the strong cartilage tissue located on the front of the ribs in the rib cage, connecting the ribs to the sternum. During surgery, it is usually harvested through a small incision in one of the lower ribs.
The characteristics and advantages of this rib cartilage can be summarized as follows:
- It is a stronger graft tissue.
- It can be obtained in large volumes.
- It is malleable.
- It is not rejected by the body.
- It can maintain its structural support for many years.
Because of these characteristics, it is preferred, especially in complex rhinoplasty cases.
What are the Cartilage Sources Used in Rhinoplasty?
Autologous cartilage used in nose surgery is primarily obtained from three sources:
Nasal Septal Cartilage
Taken from the nasal septum.
Advantages:
- Occurs in the same surgical field
- No additional incision required
- Straight structure
- Easy to process
- However, the quantity may be insufficient in patients who have undergone previous surgery or in cases requiring a large graft.
Auricle Cartilage
Taken from behind the ear.
Advantages:
- Easy to harvest
- Scar is usually not noticeable
- Curved structure
- Limited structural support
- May not be sufficient for large-volume reconstructions
Rib Cartilage
This is the source that provides the largest amount of cartilage.
Advantages:
- Available in large quantities
- Strong
- Allows for the preparation of large structural grafts
- Ideal for revision rhinoplasties
- Can provide long-term support
- Helps create strong projection on the nasal dorsum and nasal tip
- It can provide a high-volume graft source for augmentation rhinoplasty.
Disadvantages:
- Requires an additional incision in the chest wall to harvest the cartilage.
- May prolong surgery time compared to septum or ear cartilage.
- Pain and tenderness in the chest area may occur in the first few days.
- Rarely, scarring may be noticeable.
- As age progresses, calcification (calcification) may develop in the cartilage, making graft preparation more difficult.
- There is a risk of warping over time if not properly prepared.
- Very rarely, complications such as pneumothorax (air leakage in the lung membrane), bleeding, or infection may occur.
However, when performed by experienced rhinoplasty surgeons, rib cartilage is currently considered one of the most reliable and potent autologous graft sources, particularly for advanced revision rhinoplasties and the correction of severe nasal deformities.
In Which Cases Is Rib Cartilage Used?
Rib cartilage is one of the most frequently used graft sources in rhinoplasty, particularly in advanced revision surgeries. In patients who have undergone one or more previous nose surgeries, the amount of cartilage that can be harvested from the septum may be depleted, or the existing cartilage may be too weak to provide structural support. Especially in multiple revision rhinoplasties, collapse of the nasal bridge, loss of support at the nasal tip, and asymmetries may occur. In such cases, rib cartilage is frequently preferred to obtain a sufficient quantity and durability of graft. In patients undergoing their third or fourth surgery, rib cartilage is often the most reliable autologous graft source.
Rib cartilage also plays an important role in patients with severe collapse of the nasal dorsum. Trauma, previous nose surgeries, infections, or congenital anomalies can cause the loss of supporting structures on the nasal dorsum. This can negatively affect not only the aesthetic appearance but also nasal breathing. Thanks to dorsal grafts prepared from rib cartilage, the nasal dorsum can be reconstructed, nasal height can be increased, and airway support can be restored.
Rib cartilage is also frequently used in cases of saddle nose deformity, characterized by a significant collapse in the middle section of the nasal bridge. In advanced stages of this deformity, which can develop as a result of trauma, septum loss, previous surgeries, infections, or certain autoimmune diseases, small grafts are insufficient. Therefore, rib cartilage, which can provide strong and voluminous reconstruction, is often considered the most suitable option.
Rib cartilage also offers significant advantages in patients with severe nasal deviations. Especially in cases of severely deviated nasal septums resulting from trauma or congenital deviations, the septum may be severely deformed. In such cases, strong support grafts are needed to reconstruct the nasal framework and ensure long-term stability. Rib cartilage is an ideal material for preparing spreader grafts, septal extension grafts, and various structural support elements.
Rib cartilage is also frequently used in cases of cartilage and bone loss following severe facial trauma or nasal fractures. In deformities resulting from trauma, existing tissues are often insufficient for adequate reconstruction. In these cases, rib cartilage can be used to restore both aesthetic appearance and nasal function.
Congenital nasal anomalies are also an important indication for the use of rib cartilage. In particular, cleft lip and nose deformities, various craniofacial syndromes, and nasal developmental defects may present with insufficient cartilage structures. Since strong and long-lasting structural support is required in these patients, rib cartilage is frequently preferred.
Rib cartilage can also be an important option in cases of inadequate support of the nasal tip. If the nasal tip is drooping, excessive cartilage has been removed in previous surgeries, or there is a significant loss of support, strong septal extension grafts may be needed. Structural grafts prepared from rib cartilage can increase the projection of the nasal tip and help maintain support for many years.
Nasal deformities resulting from cocaine use are one of the most important areas of application for rib cartilage (coke nose or cocaine nose). Long-term cocaine use can cause serious damage to the vascular structures within the nose, leading to septal perforation, nasal dorsum collapse deformity, and even tissue loss in the nasal tip and columella. Repairing the advanced structural losses in these patients requires large-volume and strong grafts. Rib cartilage is often the most valuable graft source in such complex reconstructions.
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| Nasal Deformities Developed After Rhinoplasty Due to Cocaine Use (Coke Nose or Cocaine Nose) The image above shows before and after photos of a complicated revision rhinoplasty performed on a patient who had undergone rhinoplasty at another clinic and subsequently experienced nasal atrophy and collapse in various areas following cocaine use. Prior to the operation, the patient had collapse in the left nasal wing, columella retraction, and nasal tip collapse. A temporal fascia graft was also used in the procedure. |
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| Nasal Deformities Developed After Rhinoplasty Due to Cocaine Use (Coke Nose or Cocaine Nose) - Before The Rib Cartilage Rhinoplasty |
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| Nasal Deformities Developed After Rhinoplasty Due to Cocaine Use (Coke Nose or Cocaine Nose) - After The Rib Cartilage Rhinoplasty |
Rib cartilage is also commonly used in patients requiring augmentation rhinoplasty. Particularly in individuals of Asian descent and those with thick nasal skin, strong volume-providing grafts may be needed to elevate the nasal dorsum and accentuate the nasal tip. In these cases, dorsal onlay grafts and various structural support grafts prepared with rib cartilage help achieve natural-looking and long-lasting results.
Which Ribs Are Used for Rib Cartilage Grafting?
Rib cartilage grafts used in rhinoplasty are generally obtained from the 5th, 6th, 7th, or 8th ribs. The most frequently preferred sources are the 6th and 7th rib cartilages because these areas contain cartilage of sufficient length and thickness. The surgeon decides which rib to use based on the amount of graft needed, the patient's anatomical characteristics, and the scope of the planned reconstruction. In female patients, the incision can usually be hidden in the natural crease under the breast, while in male patients, it is placed along the natural lines of the chest wall.
How is the Rib Graft Harvest Procedure Performed?
Rib cartilage harvesting is generally performed under general anesthesia. An incision approximately 2-4 cm long is made in the front of the chest wall to access the relevant rib cartilage. The membrane covering the cartilage, called the perichondrium, is carefully lifted, and the required amount of cartilage is removed. To preserve the structural integrity of the rib cage, the surgeon usually removes only the necessary portion of the cartilage, not the entire cartilage. At the end of the procedure, the area is carefully closed to ensure there is no bleeding or air leakage in the surgical area.
How is Rib Cartilage Cut After Removal?
After rib cartilage is removed, it is transformed into grafts to be used in rhinoplasty. The central portion of the cartilage is often preferred to reduce the risk of warping. Surgeons can prepare grafts in different ways; one of these is the "oblique split thickness" technique. In this method, the cartilage is cut at an oblique angle to obtain thinner and more durable grafts with a larger surface area. In addition, cuts of various sizes and shapes can be made for different purposes, such as septal extension grafts, spreader grafts, dorsal onlay grafts, or columellar struts. The balanced and symmetrical carving of the cartilage is an important step in reducing the risk of postoperative deformation.
Risk of Warping in Rib Cartilage Grafts
Rib cartilage may tend to warp over time.
Experienced surgeons can significantly reduce this risk by using:
- Balanced carving techniques
- Lamination methods
- Stabilization techniques
How Long Does Pain Last After Rib Cartilage Graft Removal?
Pain felt in the area where rib cartilage was removed is usually most pronounced in the first few days. Most patients describe the pain as similar to muscle pain or tenderness in the chest area. The pain usually decreases significantly within the first 1-2 weeks and no longer significantly affects daily activities. Mild tenderness or discomfort to touch may persist for a few more weeks. Thanks to modern pain control methods, many patients experience a more comfortable recovery process than they expected.
At What Age is Rib Cartilage Harvesting Not Suitable?
While there is no specific age limit that definitively prevents the use of rib cartilage, the likelihood of calcification (degenerative joint formation) in the cartilage tissue increases with age. Calcification is more frequently observed, especially after the age of 50 and in postmenopausal women. Cutting and shaping calcified cartilage can be more difficult. However, many older patients still have sufficient healthy cartilage available for use. Therefore, the decision should be made individually based on biological age and imaging findings.
What are the Pain Reduction Techniques During Rib Cartilage Harvesting?
Many surgical techniques have been developed to reduce pain during rib cartilage harvesting. The most common method is subperichondrial dissection. In this method, the perichondrium surrounding the cartilage is preserved as much as possible, and trauma to surrounding tissues is reduced. Furthermore, careful protection of the intercostal nerves, minimizing muscle separation, and the use of small incisions can reduce postoperative pain. In recent years, long-acting local anesthetic injections, intercostal nerve blocks, and multimodal pain control protocols have also significantly improved patient comfort.
What are the Risks of Rib Cartilage Grafting?
Although rib cartilage grafting is generally a safe procedure, it carries some risks, as with any surgical intervention. These include bleeding, infection, scar formation, long-term tenderness, and rarely, chest wall deformation. One of the most frequently observed complications is pneumothorax, or the accumulation of air in the chest cavity due to involuntary rupture of the lung membrane. This complication is quite rare when performed by experienced surgeons. Temporary numbness or sensory changes may also occur in the graft area. With appropriate surgical techniques and careful patient monitoring, the incidence of serious complications is quite low.
Rib cartilage is an extremely valuable graft source in modern rhinoplasty, especially in revision surgeries and the correction of severe nasal deformities. It is frequently preferred in cases where cartilage obtained from the septum or ear is insufficient, due to its ability to provide strong structural support.
When performed with the right patient selection, appropriate surgical planning, and by an experienced rhinoplasty surgeon, the use of rib cartilage can provide successful and long-lasting results in terms of both aesthetics and function.
Is Rhinoplasty with Rib Cartilage Safe?
Rhinoplasty with rib cartilage is generally considered a safe method when performed by the right patient selection and an experienced surgeon. Especially in advanced revision rhinoplasty and severe structural nasal deformities, it offers significant advantages in terms of long-term results because the body's own tissue is used. Because it is autologous (the patient's own) cartilage, there is no risk of allergic reactions or tissue rejection.
The safety of this method is not limited to the nasal area; it also depends on the safe protection of the chest wall area from which the rib cartilage is taken. Modern surgical techniques use small incisions, subperichondrial dissection, and careful anatomical planning, resulting in a very low risk of complications. In experienced hands, rib cartilage harvesting is considered a routine and safe surgical procedure.
However, as with any surgical procedure, the use of rib cartilage carries some potential risks. These may include temporary pain and tenderness in the chest area, rarely infection, bleeding, or, very rarely, pneumothorax (air accumulation in the lung membrane). Long-term complications such as warping (shape change) of the cartilage graft are also technically possible. However, these risks can be significantly reduced with appropriate surgical techniques.
Generally speaking, rib cartilage is one of the strongest and most reliable graft sources, especially in complex rhinoplasty cases where septum and ear cartilage are insufficient. With the correct indication, good surgical planning, and experienced execution, it is possible to achieve high success rates in terms of both aesthetics and function.
Post-Rib Cartilage Rhinoplasty Care Recommendations, Pain Control, and Recovery
The recovery process after rhinoplasty using rib cartilage is somewhat more extensive than standard rhinoplasty because it involves both the nasal area and the chest wall from where the rib cartilage was taken. Swelling, bruising, and a feeling of congestion around the nose are considered normal in the first few days, while tenderness and pain that increases with movement may be experienced in the chest area. This process is generally more controlled and tolerable than the patient expects.
Pain control is one of the most important components of postoperative comfort. In modern surgery, pain can be significantly reduced thanks to multimodal analgesia protocols, long-acting local anesthetic applications, and nerve blocks when necessary. Patients generally experience more discomfort in the first 2-3 days, after which pain rapidly decreases, and most patients can return to their daily activities quickly. Pain in the chest area is mostly similar in character to muscle pain and subsides and disappears over time.
Protecting the nasal area is of great importance during the care process. Avoid blows to the nose, don't wear glasses in the first few weeks, and clean your nose as recommended by your doctor. Elevating the head to reduce swelling, applying cold compresses regularly, and avoiding smoking will accelerate healing. Gradually increasing physical activity is also recommended, and strenuous exercise should generally be avoided for 3-4 weeks.
For the chest area, keeping the incision line clean and dry is important. Avoiding excessive arm movements and limiting sudden twisting and stretching movements in the first few days will reduce pain and support healing. The suture line usually heals within a few weeks, and the scar gradually fades.
The final results of rhinoplasty using rib cartilage take time to appear. While the nose shape may not fully settle in the first few months due to swelling, it generally takes 6-12 months to acquire a more natural and stable form. Although the healing process in both the nose and chest areas varies depending on individual factors, with proper care and regular follow-up, highly successful and long-lasting results can be achieved.
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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
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