Sources of Cartilage
The septum is the structure that divides the nose into the left and right sides. It is comprised of cartilage toward the front and bone toward the back of the nose. The bone and cartilage is covered on each side by a layer called the mucoperichondrium. This layer provides nourishment in the form of blood supply to the septum and also functions as the inner lining of the nose. The septum may run right down the middle of the nose or be deviated to the left or right. In cases of a deviated septum, straightening it may improve the patient’s breathing. In such cases, insurance coverage may help to cover some of the cost of the revision rhinoplasty surgery. When this cartilage is taken, the flaps on each side of the bone/cartilage are lifted up. After a window of cartilage/bone is removed, the flaps are sutured back together. Therefore, it would be very unlikely that a perforation or hole is created in the septum.
Nasal septal cartilage is ideal for creating grafts used during primary and revision rhinoplasty. There are several benefits of septal cartilage. First, taking cartilage from this area eliminates the need to create a second surgical site, such as the ear or rib. Second, the cartilage is strong and straight, yet thin enough to avoid being excessively bulky. For grafts which require strength, such as spreader grafts or a caudal septal extension graft, septal or rib cartilage are generally used. Finally, if portions of the septal cartilage have been used already in prior rhinoplasty surgery, the bony portion of the septum, towards the back, can be used for certain types of grafts.
In cases in which the septal cartilage has been used during a previous rhinoplasty surgery or a large amount of cartilage is needed, ear cartilage can be a good source for creating grafts during revision rhinoplasty. This cartilage is a bit thinner and more flimsy than septal or rib cartilage. Therefore, ear cartilage can be an excellent option for grafts which are placed on top of the framework of the nose (shield grafts, onlay grafts, etc.). This can be useful for making the nose appear a bit longer or higher on the bridge.
Ear cartilage is taken by making a small incision in the crease behind the ear, where the ear meets the head. The cartilage is taken from the bowl of the ear and, when done properly, generally does not change the shape of the ear to any great extent. The ear may sit 1-2 mm closer to the head but this is generally not noticeable. A single running stitch is used to close the back of the ear and removed one week after surgery. The other common use of ear cartilage is to create what are called composite grafts. These are grafts comprised of both skin and cartilage, which is taken from the concha cymba, the “cave” portion of the ear above the opening to the ear canal. The composite grafts are very useful for lowering the nostrils in patients with moderate or severe nostril retraction, meaning too much visibility of the nostrils on front or side view.
In cases in which the bridge is significantly lower than desired, an excellent option can be the use of diced ear cartilage wrapped in temporalis fascia. This technique, which has been called the “Turkish Delight”, is done by harvesting the ear cartilage in the manner described above. A tiny incision is made behind the hairline, above the ear. A small portion of the covering of the temporalis muscle is removed. This muscle is the one which bulges in one’s temple during chewing. The ear cartilage is then diced into very fine pieces, ~1mm in size and the fascia is wrapped around this diced cartilage, like a tortilla when making a burrito. The fascia is stitched to itself using dissolvable stitches and the entire package is inserted along the bridge of the nose. The advantage of using this technique is that the edges are soft and malleable and unlikely to show through the skin as irregularities.
In revision cases in which the septal cartilage is no longer available and the patient requires a large amount of strong, straight grafts, rib cartilage can be a very good option. Rib cartilage is generally taken by making a very small incision (2-3 cm) on the right side of the chest. In omen, this can be placed underneath the breast, hidden in the crease or at least above the lower border of a bikini top or bra. The muscle of the chest is gently parted with retractors and a segment of the rib cartilage is taken from the area where the 6th, 7th, and 8th ribs come together. This removal is performed very carefully, as the ribs sit immediately over the pleura, the covering of the lung. After removal of the segment of rib cartilage, the site is inspected carefully to ensure no injury to the pleura and the tissue is stitched back together with dissolvable stitches. The skin is stitched back together with a single running subcuticular 5-0 Prolene suture which is removed one week after surgery. The incision heals quite well, generally to a very fine line. The entire rib cartilage harvest procedure generally takes 45 minutes to an hour.
Rib cartilage can be useful for a wide variety of grafts used during revision rhinoplasty including spreader grafts, caudal septal extension grafts, dorsal onlay grafts, shield grafts, columellar struts, lateral crural strut grafts, rim grafts, among others. Immediately after harvest, the rib cartilage is carved into smaller pieces and placed in saline, to observe for any signs of warping. The straight pieces are used in areas where the straightness is essential and curved pieces can be useful in other locations.
If you’re still curious about cartilage, contact us.