Role of Rib Graft in Primary Rhinoplasty

Goals/Purpose: The indications for the use of rib graft in primary rhinoplasty have not been clearly delineated. Rib graft is more commonly needed in revision rhinoplasty as the septum and lateral cartilages have already been harvested. In primary rhinoplasty, the use of harvested septal cartilage and excised portions of the upper and lower lateral cartilages often preclude the need for rib graft. There are a number of indications for the use of rib graft in primary rhinoplasty. Often, the surgeon can predict the need for a rib graft preoperatively based on exam and preoperative nasal analysis and there are certain circumstances when the need for rib graft can only be identified intraoperatively. The purpose of this study is to identify and describe the indications and techniques for rib graft use in primary rhinoplasty.

Methods/Technique: The study evaluated 638 patients who underwent primary rhinoplasty by a single surgeon over a 5-year period. From this cohort, a subset of 30 patients (6 male and 24 female) who underwent primary rhinoplasty using fresh frozen allograft rib cartilage were identified. The procedures were performed at the Dallas Plastic Surgery Institute (Dallas, Texas) from 2018 to 2022 by the senior author (R.J.R.). Retrospective reviews of medical records and photographic analysis were performed. Additionally, preoperative, intraoperative, and postoperative data was gathered.

Results/Complications: Thirty (4.7 percent) of 638 primary rhinoplasties required rib graft. Regarding patient demographics, there was no significant difference in age or sex between the primary rhinoplasties requiring rib graft and those that did not. However, primary rhinoplasties requiring rib graft demonstrated a history of nasal trauma at a higher rate than primary rhinoplasties not requiring rib graft. Further, a higher proportion of primary rhinoplasty patients requiring rib graft were from Asian, Middle Eastern, Hispanic, Indian, and African American backgrounds (Table 1). The perioperative data identified that all primary rhinoplasties utilizing rib graft implemented a septal extension graft. Other grafts were found to be used much less consistently. There were no differences in complications or patient outcomes.

Conclusion: Rib grafting in primary rhinoplasty is a powerful maneuver. The present study demonstrates that patients who require a rib graft in primary rhinoplasty invariably receive a septal extension graft. Additionally, certain ethnic groups were demonstrated to be predisposed to the need for rib graft in primary rhinoplasty for a variety of anatomical characteristics. This technique allows for precise projection, rotation, and tip shaping in noses with thick skin and a weak cartilaginous framework. The septal extension graft serve as a fixed-mobile graft, allowing the lower lateral cartilages to be tensioned, tip defining points to be precisely placed, and nasal tip skin to be appropriately draped. Knowledge of the indications for rib graft use in primary rhinoplasty allows surgeons to educate and manage their patients while ultimately achieving consistent, long-lasting, and excellent results.

Table 1 Ethnicity and History of Nasal Trauma in Primary Rhinoplasty with Rib Graft

Ethnicity	Number of Patients (%)
Asian	7 (23.3)
Middle Eastern	4 (13.3)
Hispanic	7 (23.3)
Indian	1 (3.3)
African American	9 (30)
Caucasian	2 (6.7)
History of Nasal Trauma	7 (23.3)