What is a nose correction using rib graft?

In some cases, after one or several rhinoplasties the nose of the patient has been over-resected to such an extent that the nose needs to be reconstructed using cartilage taken from one of the patient’s ribs.

As this is very specialized work that demands a lot of expertise, this procedure is performed in our clinic by the internationally known Dr Enrico Robotti from Bergamo (http://www.enricorobotti.it/). He is very famous all over the world for this type of nose reconstruction. Twice a year, in November and in June, he comes to o2 Clinic to operate the patients that we have selected for him.

Advantages

  • Very stable results.
  • Even the worst cases of nose destruction can be successfully treated.
  • The rib donor site is inconspicuous.
  • Any functional problem can be corrected at the same time.

Disadvantages

  • Duration and complexity of the procedure (surgery requires time and special care).
  • A rib graft needs to be taken.
  • Your nose will feel rather rigid.

How does a secondary rhinoplasty using rib graft work?

A piece of cartilage, of about three cm long, will be harvested from a patient’s rib. In women, the scar will be hidden in the crease under the breast. The rib will be divided into slices of cartilage of about 1 – 1,5 mm thick, which can be used to build up the nose.

What can a secondary rhinoplasty using rib graft do for you?

With this procedure we can create a very straight and firm nose that stays stable over time and ensures a good breathing through the nose.

Who is a good candidate for a secondary rhinoplasty using rib graft?

Any patient in good health whose own cartilage of the nose has been over-resected resulting in an unattractive nose, often accompanied by breathing problems.

How is a secondary rhinoplasty using rib graft performed?

Through an incision of 3 cm long over a rib in the region of the skinfold under the breast, a piece of cartilage is taken. A small catheter for the injection of a painkiller during the first 24 hours after surgery is left in the wound and the wound is closed in layers. The rib graft is cut in slices of about 1 – 1,5 mm thick and kept in saline (water with a bit of salt).

The open or external rhinoplasty approach makes use of a small bridging incision, called a trans-columellar incision, to connect the right and left nostril incisions.

The open or external rhinoplasty approach makes use of a small bridging incision, called a trans-columellar incision, to connect the right and left nostril incisions.

In fact, most rhinoplasty experts regard open rhinoplasty as the procedure of choice for noses with a difficult anatomy of any type, and many of the most effective techniques of contemporary rhinoplasty can only be performed through the open approach.

When performed correctly, the healed trans-columellar incision is often invisible and seldom results in an objectionable scar.

Sequence of procedures

  1. Injection of local anaesthesia into the nose.
  2. Correction of septum (correction of deviation, lengthening, shortening).
  3. The reconstruction starts at the bridge of the nose. Two pieces of cartilage pointing downwards are fixated to the bony part of the septum.
  4. Another piece of cartilage is fixated on one side to the anterior nasal spine (at the junction between the upper lip and the nose) and to the two pieces of cartilage mentioned under 3. This way, the basic frame that will support all other cartilages to reconstruct the nose is built.
  5. Thin pieces of rib cartilage are used to reconstruct the lower lateral cartilages that give support to the wings of the nose, so it does not collapse during forced inhalation.
  6. Osteotomies of the bony part of the bridge of the nose (lateral and medial, intermediate on indication). Sometimes bone can be manipulated by osteoplasty instead of, or in addition to, osteotomy. Such bone manipulations are currently carried out by electrical or piezoelectrical instruments (small and precise burrs and saws)
  7. On indication, rim grafts or small on-lay grafts can be used to further give the nose its desired shape.
  8. Insertion of a piece of temporalis fascia (strong fibrous layer around the muscle in the region of the temples) that can be wrapped around some diced cartilage (cartilage cut in very small pieces) on top of the bridge and sometimes the tip of the nose. This makes everything very smooth and avoids irregularities.
  9. Closure by suturing.
  10. Basal excisions if needed (nostril size reduction, alar flaring reduction)
  11. Internal and external splinting of the nose. Splints will be removed after a week.

What to expect and do during the recovery period after a rhinoplasty using rib graft?

The day of the procedure

  • Pain—Strange enough, pain is not really an issue after a rhinoplasty.
  • Congestion—The most obvious and slightly annoying symptom after a rhinoplasty is congestion. Because there is internal swelling in your nose, you will experience some congestion in the first few weeks afterwards, until the swelling slowly subsides. This is usually at its worst in the first few days after the surgery. After two to three weeks, your breathing should have normalized.
  • Swelling and bruising—Swelling and bruising on the outside of your nose and cheeks is seen after surgery as well. This can sometimes be moderate and sometimes almost non-existent, but usually it falls somewhere in the middle of this continuum. Even in the worst cases, bruising is usually mostly gone within seven to fourteen days after the surgery.

The first week

  • Most patients plan to take about a week from work and other major activities.
  • You will have a cast on your nose and some stitches that need to be removed. This is all done six days after the surgery. Once the cast is removed, you will look presentable within one to two weeks after the surgery. You should not plan to have your wedding the week after, but your friends and colleagues should not be aware of anything. You can wash your face gently and put on a little cover-up makeup or foundation after one week.

The first month

  • Two to three weeks after the surgery, about 70% of the swelling is gone, so you should be starting to appreciate some changes. You will not really see the details yet though until about six weeks after surgery when about 80 to 85% of the swelling has gone down. While you will be looking pretty good after two weeks, you might still feel a little self-conscious. That is because your nose (especially your tip) will feel a little (or sometimes a lot) numb after surgery, no matter what technique was used. It can take anywhere from several weeks to six months or more for the feeling to return completely. During the first six weeks or so, your nose just will not feel like your own. Things like smiling and talking animatedly will feel strange.
  • Many patients are very afraid that they will do something to harm their result. While it is true that a major bump in the nose can cause unwanted healing problems, there are not too many things you can do to really harm the result, so there is no use in avoiding touching your nose. There are some things you can do, however, to speed up the healing process and get you back into camera-ready shape more quickly. Keep your head up after surgery. Keep some cool compresses over your eyes and cheeks in the first 48 hours. For a few weeks, avoid bending, lifting anything over a few pounds, exercising or anything that gets your blood pressure up. This may increase swelling and cause bleeding. Get a lot of sleep. Go outside and take some light walks. Eat well. In the first weeks, things will not look perfect so try to avoid staring in the mirror or over-analysing small changes.
  • Some other symptoms are also common in the months after surgery. Your nose may run more easily, especially when irritated. Your nose will tend to swell up a little when you exercise or do anything exceptional. The skin over your nose can break out more easily and can be more sensitive to sunburn. It is important to remember that with each subsequent revision surgery, this entire process of recovery is slowed down a bit. As a result, it is not uncommon that it takes up to two years or more to see some of the changes you seek if you have already had a revision procedure.

What are the risks of a rhinoplasty using rib graft?

  • Anaesthesia risks (like any surgical procedure)
  • Bleeding (hematoma)
  • Infection
  • Poor wound healing or scarring
  • Change in skin sensation (numbness or pain)
  • Nasal septal perforation (a hole in the nasal septum) is rare.
    Additional surgical treatment may be necessary to repair the septum but it may be impossible to correct this complication.
  • Unsatisfactory nasal appearance
  • Skin discoloration and swelling
  • Possibility of revision surgery
  • Pneumothorax (collapse of a lung, extremely rare) which is caused by a small whole in the lung which should be closed.

How long can I expect the results of a rhinoplasty using rib graft to last?

The results of a well-performed rhinoplasty last forever. Nevertheless, keep in mind that the natural aging process may mildly affect the shape and size of the nose.

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