Rib cartilage rhinoplasty: your own rib cartilage vs. donor rib cartilage

When is rib cartilage used?

Rib cartilage is the cartilage that forms the front part of the ribs, and in rhinoplasty it is used as a material to raise the bridge of the nose or to rebuild the nasal tip and septum ^[1]. Because it is plentiful and highly biocompatible, it is regarded as having many advantages over other graft materials, and its use in East Asian rhinoplasty is described as having grown steadily ^{[1, 2]}.

A 2024 review explains that rib cartilage can be used in a first rhinoplasty when there is not enough septal cartilage, and in revision surgery when septal cartilage has already been used or removed in a previous operation ^[5]. The review described rib cartilage as a source that can be harvested through a small, well-hidden incision and that often provides ample, good-quality cartilage ^[5].

How your own rib cartilage differs from donor rib cartilage

With autologous costal cartilage, the cartilage is taken from the patient's own ribs. Donor rib cartilage is an allograft made by processing rib cartilage from a deceased donor (cadaveric costal cartilage), and the studies mainly looked at irradiated homologous costal cartilage ^{[3, 6]}.

A 2022 review explained that the patient's own materials vary in the quality of the cartilage harvested and in the burden on the harvest site, and concluded that allografts should be recognized as an option when an autologous graft is difficult or not wanted ^[6]. The review took the view that, as processing techniques for donor cartilage have advanced, donor cartilage has become an attractive second option ^[6].

A research team with long experience using donor rib cartilage pointed out that harvesting a patient's own rib cartilage lengthens surgery and anesthesia time and adds to the potential for complications ^[4]. They therefore concluded that donor rib cartilage can be considered as an alternative or even a first-choice material when septal or ear cartilage is insufficient ^[4]. It should be kept in mind that this conclusion comes from the experience of a single practice.

Findings from studies comparing the two materials

Studies comparing surgical outcomes between a patient's own rib cartilage and donor rib cartilage are rare ^[3]. One retrospective study looked at patients who had septorhinoplasty with rib cartilage between 2009 and 2014, comparing 63 who received their own rib cartilage with 20 who received donor rib cartilage over more than 1 year of follow-up ^[3].

Of the complications observed, the only one that occurred more often in the donor group was noticeable resorption: 6 of 20 patients (30%) in the donor group and 2 patients (3%) in the autologous group ^[3]. The proportion who were very satisfied with the cosmetic result also differed, at 37 of 51 patients (73%) in the autologous group and 6 of 20 (30%) in the donor group ^[3]. On the other hand, subjective satisfaction with nasal function did not differ between the two groups, and objective cosmetic assessment scores in both groups were above 3.1, between good and excellent ^[3].

On tissue examination, the cartilage cells in the patients' own rib cartilage were larger and more evenly distributed, and the cartilage contained more collagen and proteoglycans ^[3]. Based on this, the researchers interpreted the patient's own rib cartilage as a material less likely to be resorbed over the long term ^[3]. However, this was a retrospective study with level 3 evidence, and the donor group was small, at 20 patients ^[3].

Other studies have reported different results. In a study that reviewed the records of 357 patients who had rhinoplasty with donor rib cartilage at a university-affiliated private practice, follow-up ranged from 4 days to 24 years (mean 13.45 years), and the overall complication rate for the 1,025 donor rib cartilage grafts was 3.25% ^[4]. Counted per graft, the overall resorption rate was 1.01% for donor rib cartilage compared with 1.37% for the patients' own cartilage used in the same operations, and no allergic reactions or systemic illnesses caused by donor rib cartilage were reported ^[4].

Warping, resorption, and harvest-site problems

Complications reported with a patient's own rib cartilage include warping, infection, and shifting of the grafted cartilage, and problems at the harvest site can include a collapsed lung (pneumothorax), pain, or a chest scar ^[2]. The review authors explain that many of these problems can be reduced by following recommended surgical techniques ^[2].

Several methods to reduce warping have also been described. The literature notes that carving the rib cartilage first and soaking it in saline before the rhinoplasty begins can give the cartilage time to reveal any tendency to warp ^[5]. A technique that stacks rib cartilage in several layers when raising the bridge has been described as able to reduce warping and the difficulty of carving the cartilage ^[7].

In the study with long-term follow-up of donor rib cartilage, 10 of the 941 grafts that were palpable or placed close to the surface (1.06%) warped, and infection occurred in 9 of the 1,025 grafts (0.87%) ^[4]. Regardless of the material, warping, infection, and resorption are risks to understand before rib cartilage rhinoplasty.

Different ways of raising the bridge

When rib cartilage is used to raise the bridge of the nose, common methods include carving it into a single piece (solid block) or using finely diced cartilage, either on its own or wrapped in other tissue ^[1]. The patient's own materials used to build up the bridge in East Asian patients include temporal fascia, dermis-fat grafts, solid blocks of rib cartilage, and diced cartilage, and of these, dermis-fat, solid rib cartilage, and diced cartilage are recommended for substantial augmentation ^[8].

Diced cartilage wrapped in temporal fascia is described as having a lower resorption rate and as able to conform easily to the contour of the bridge, but its final height is harder to predict than that of solid cartilage ^[8]. Which method is right is decided by considering both the height needed and the condition of your nose.

What to ask during your consultation

Rib cartilage rhinoplasty involves many choices, from the material to how it is harvested, carved, and grafted, and choosing these techniques appropriately is described as important for reducing complications ^[1]. Even with the same material, results vary from person to person depending on the condition of the nose and any previous surgery. Consider raising the points below at your appointment.

• Whether septal or ear cartilage would be enough, or whether rib cartilage is really necessary
• The pros and cons of your own rib cartilage and donor rib cartilage, and why one is chosen in your case
• Whether solid or diced cartilage will be used
• How warping, resorption, or infection would be handled if it occurs, and the possibility of revision surgery
• If your own rib cartilage is used, the risks at the harvest site, such as scarring, pain, and a collapsed lung