Costal cartilage may be autologous or homologous (irradiated cadaveric) and is frequently a preferred grafting material in revision rhinoplasty, when septal cartilage is insufficient or of poor quality. The advantage of rib cartilage is its abundant availability, ability to provide strong structural support, and decreased risk of infection or extrusion when compared with alloplastic implants. Although autologous costal cartilage harvest, usually of the sixth rib, carries the risk of donor site morbidity (pain, pneumothorax, etc.) and prolonged surgical time, the challenge does not lie in the harvest but rather in the preparation and use of the grafting material. Many complicated decisions must be made regarding the type of graft and most suitable cartilage segment to be used; choosing a suboptimal cartilage segment may result in warping or deformity.
The ideal age range for costal cartilage grafting is 30 to 50 years of age. A younger patient’s rib cartilage is soft, which makes harvesting and sculpting easier at the expense of an increased risk of warping. An older patient’s rib cartilage is calcified and more brittle, making it more prone to fracture with manipulation but less susceptible to warping. The superficial perichondrium may be harvested for later use as a soft tissue onlay graft. Once harvested, the rib cartilage is cut longitudinally into three segments; the thickness of each segment varies, depending on the patient’s needs. Each segment is thinned initially, with final sculpting just prior to graft placement. Carving the grafts in this manner will allow for warping tendencies to manifest intraoperatively so that undesirable postoperative warping may be minimized. To exclude a pneumothorax, all patients who undergo autologous costal cartilage grafting should have a chest radiograph taken prior to discharge.
Homologous cadaveric rib cartilage may be used instead of autologous cartilage. The advantage of cadaveric rib lies in the absence of donor site morbidity and decreased surgical time when compared with autologous grafts; however, availability is frequently limited in certain geographic areas, and it is also quite expensive in comparison. Furthermore, perichondrium for onlay grafting is not available from cadaveric rib. Whether neovascularization of the implanted cadaveric rib occurs has yet to be shown. The potential lack of revascularization may contribute to the occasional partial resorption of cadaveric rib.
Source: Cummings Otolaryngology, 6E (2015)