Dean Toriumi: Secondary Rhinoplasty surgeries

Secondary Rhinoplasty: 3

Why does Dr. Toriumi only use rib cartilage for secondary rhinoplasty surgeries? 

Dean Toriumi's Answer: 

I noted that when I used ear cartilage for dorsal augmentation, the edges of the ear cartilage grafts would tend to curl or deform over time leaving dorsal irregularity. I also noted that if I stacked multiple layers of auricular cartilage to gain height on the nasal dorsum, some of this cartilage resorbed over time. For this reason I usually avoid stacking more than two layers of ear cartilage. Less severe deformities such as those limited to the tip, lateral wall of the nose or less severe middle vault collapse often can be corrected with ear and/or septal cartilage.

It has become apparent to me that most patients who come to my office are prepared to hear that I may need to use a rib graft in their surgery. It is true that most secondary rhinoplasty patients will need a rib graft to get the maximal outcome. However, on occasion, a patient's rib cartilage is calcified or they prefer that I use ear cartilage instead of rib cartilage. In many of these patients I am able to do a more than adequate reconstruction using ear cartilage. I actually have more experience using ear cartilage for secondary rhinoplasty than I do with rib cartilage. It has only been over the past six years that I have gone primarily to rib cartilage for secondary rhinoplasty, although I have used rib cartilage for over 18 years, but, in my early years in practice, I only used rib cartilage in more severe cases that required a lot of grafting material or when both ears were already taken. As I gained more experience with rib grafting we found that the patients did well and the pain from the rib graft harvest was no greater or less than the ear cartilage harvest. For many surgeons, harvesting and using rib cartilage is a big ordeal with a large incision, risk of a collapsed lung, and bending or warping of the cartilage. Over the years I have become very efficient harvesting and using rib cartilage leaving the patient with only a very small scar (usually less than 2 cm), short-lived postoperative pain, and very low risk of bending or warping of the rib cartilage.

Over the past three years I have done more than 300 rib grafts in patients and have further refined my technique so I am able to make the grafts much thinner and smaller without warping. We measure the thickness of nearly all structural grafts placed in the nose. Using these measurements I know what graft thickness is necessary for a narrow nose or wider nose. This allows me to reliably control the width, length and rotation of the nose. Unfortunately, numerous sources have deemed that I like "big wide noses." I can assure you that this is not the case. It is true that many patients will have swelling early postoperatively that will make their nose wider and larger. However, with time, this swelling will dissipate, and the nose will look narrower and smaller. Patients with thick skin are at the highest risk of being swollen for a long period of time. With healing almost all noses will get smaller and narrower over time. Therefore, our patients will improve over time and tend not to collapse, as I have seen in patients who had ear cartilage grafts placed in surgery. The postoperative follow-up is critical to insuring that the nose heals properly. Some patients will need to perform nasal exercises or tape their nose to create the proper width and shape. If patients do not come back for their follow-up they are at much higher risk for a suboptimal outcome.

If a patient desires to have ear cartilage used for reconstruction and the defect is amenable, I am willing to consider using ear cartilage as long as he or she understands the differences in the potential outcome. The disadvantages with ear cartilage are that the long-term outcome may not be as good with ear cartilage compared to rib cartilage, with a higher chance of unfavorable changes occurring years after surgery. This problem with ear cartilage is apparent in many patients who have undergone a revision every two to five years after using ear cartilage. The nose initially looks good and then narrows and pinches over time. When performing reconstructions on patients with ear cartilage in place, the ear cartilage grafts are very weak and are frequently deformed. The ear cartilage frequently breaks apart when it is dissected and is usually not usable. Because of the lack of ear cartilage strength, it is useful as a filler graft but not as a structural graft. There also may be some change to the shape of the ear donor site and the initial postoperative pain with the ear cartilage is frequently greater than harvesting rib cartilage.

With rib cartilage the patient will have a scar at the bottom of the right breast. In most patients this scar heals nicely. We have decreased the length of our rib cartilage harvest scars to 2 cm or less. Most of our scars measure between 1.5 cm to 1.7 cm . This smaller scar is much easier to hide. Patients in whom I use rib cartilage for grafting usually will note that they have a stiffer nose, which can be worrisome to the patient, but improves over time. The more dramatic the deformity, the more likely the nose will be stiff because of the need for more structural grafting in the severely deformed nose. We have made our columellar struts thinner and more pliable, which makes the nose less stiff with a more normal feel. I think these refinements have allowed me to make much smaller and narrower noses. Rib cartilage grafting is very technique-dependant and executing these techniques requires a great deal of experience. This is a very important advancement in rib grafting and will allow patients who desire smaller noses to be treated with rib cartilage. 

I felt compelled to answer this question on my website because I have been told by many patients that those interested in secondary rhinoplasty who do not want a rib graft do not come to see me. I was also told by many patients that other surgeons tell them that Dr. Toriumi only does rib grafts. I can assure you that my experience is not limited to rib grafting, and I can always call on my years of experience using ear cartilage to correct secondary rhinoplasty deformities in patients with deformities that are treatable with ear cartilage. It is also important to know that I will not compromise a potential outcome to use ear cartilage in a patient who really needs a large amount of cartilage to correct their deformity.

The primary reason that I have transitioned to rib cartilage is that I was frequently frustrated by the scenario where I was short on cartilage and forced to make a compromise on certain grafts during surgery. By following these patients long term I found that the compromised graft frequently resulted in an unfavorable outcome many years later. Now I am rarely in this situation because there is always enough of rib cartilage available. Seven years ago it was a big deal to take a rib graft with longer operating time and longer recovery. At this time harvesting rib does not add much time to the surgery and it has become routine. In my hands the disadvantages to using rib cartilage are few but the advantages are numerous.