Endoscopic-assisted rib cartilage harvesting for revision rhinoplasty

Marking

Rib cartilage harvesting is preferentially performed on the patient’s right side. Marking starts with palpating the sternomanubrial junction, which corresponds to the position of the second rib. The ribs are then numbered according to their position. We prefer to harvest 6th rib as it provides abundant cartilage supply and is straight and wide enough for future graft fabrication.

Placement of the incision line is determined by the sex of the patient. In female patients, the inframammary fold offers a good position for camouflage and the incision line is marked at approximately 5 mm above the inframammary fold^[5]. The incision should not extend beyond the medial border of the inframammary fold in order to avoid postoperative visibility. In male patients, the incision is placed right over the selected rib.

Incision

The main advantage of this method is short incision, about 1-2 cm [Figure 1]. Some experienced surgeons do harvest the rib through such small incision with direct vision without using endoscope, but usually it requires advanced surgical skills and is still associated with bad visualization and, therefore, higher risk of pneumothorax and bleeding for the not enough experienced surgeons.

Figure 1. Incision 1.2 cm in length

When placement of the incision is chosen, harvesting procedure begins by incising the skin using 15th blade. The subcutaneous and fascial layers are transected using electrocautery or blade. The muscle itself was not cut, instead, it was divided bluntly by spreading following the direction of the muscle fibers. Dissection was concluded with Freer elevators. This step enables to reduce postoperative pain and possible intraoperative bleeding^[6][Figure 2].

Figure 2. Separating the muscle fibers via blunt dissection

Endoscopic-controlled harvesting

Once the muscles are separated, we are able to see the rib clearly. Assistant retract the wound upward to make room for endoscopic work. We use 30 degrees angled endoscope. Surgeon is holding endoscope with one hand, while using Freer elevator with the other hand. Other instrument may be used if needed [Figure 3].

Figure 3. Using the endoscope - surgeon is holding the endoscope with left arm. Second arm is holding the elevator. Assistant is helping to open the wound with the retractor

Then we reach the rib with the help of endoscope, which gives us clear wound imaging. Now, one can see the perichondrium clearly [Figure 4]. It’s crucial to know the position of both sided bony cartilaginous junctions for ensuring that the maximum possible length of the cartilage is harvested, thereby optimizing the efficiency of the procedure.

Figure 4. Clear visualization of the perichondrium with the help of endoscope

Then, we are making a so-called “window” incision to the perichondrium - creating a quadrangular perichondrial flap, with its 3 from 4 sides incised [Figure 5].

Figure 5. Perichondrial flap

After perichondrium elevation one should pay attention to another tissue layer - under the perichondrium there is a thin layer of cartilaginous capsule. In order to perform the procedure safe in a bloodless plain, surgeon has to be under the capsule. Once the layer beneath is approached - one is safe for performing the dissection [Figure 6].

Figure 6. Elevation of the perichondrium

We perform the whole dissection using Freer elevator in my second hand, although it’s not a must Dissection is limited by the junction of the rib cartilage and the sternum medially, and by demarcated costochondral zone laterally. Both can be clearly seen via endoscope.

During capsule elevation care must be taken to not enter the cartilage, harm the cartilaginous surface or cause the fracture that may limit future graft fabrication.

When undermining is completed right-angled circular incision to the cartilage is performed using 15th blade. We make semi-circular incision on one side first, then we turn around the rib and finish the incision connecting both lines.

After incision is made the cartilage segment is released both medially and laterally by means of disarticulation using Freer elevator [Figure 7].

Figure 7. Disarticulation of the rib

Cartilage is easily removed from the wound and placed in sterile saline solution until the graft fabrication [Figure 8].

Figure 8. Cartilage is easily removed from the wound after disarticulation

Calcified cartilage

Despite appropriate preoperative screening, occasionally patients may present with premature calcification of the cartilaginous rib. Frequently, the main calcification area can be observed at the junction of the osseous and cartilaginous rib.

In most of cases, one can manage this problem using the elevator to gently lift the calcification for providing an adequate access to the underlying cartilage. But in some more severe cases, usually by elder patients, calcification is too strong and tightly welded to the rib. In such cases the use of Piezo electric device has proven to be very helpful in contouring areas of calcification. In this situation, we prefer to enlarge the incision and use piezo electric instrument under direct vision because it’s not easy to use piezo device with endoscopic view. As the Piezo electric device does not harm any soft tissue, one can be safely cut out the calcified area without injuring the perichondrium^[7].

Small calcifications may also be found within the body of the rib cartilage itself. This fact should be drawn to surgeon’s attention as it can impair the preparation of individual grafts and act as a site of weakness, often having a tendency to fracture.

Safety check

After cartilage removal it’s important to make sure that pleura is left intact. We perform insufflation test - filling the wound with saline solution and using positive thoracic pressure^[6]. If no bubbles observed- one is safe and pleura is intact. After the test we wash the cavity with rifampicin solution [Figure 9].

Figure 9. Insufflation test - filling the wound with saline solution

Wound closure

We close the wound layer by layer for faster healing and avoiding tension. Closure is initiated from perichondral layer by putting 2-3 stitches with 4.0 rapid vicryl. Then the subcutaneous layer is closed with 4.0 vicril.

Skin is closed with separate sutures using 5.0 prolene. We haven’t used any drain application on any of our cases [Figure 10].

Figure 10. Closed wound. Separate skin sutures using 5.0 prolene

Graft fabrication

We suggest to use the rib according to the oblique split method, described by Dr. Eren Tastan [Figure 11]. As warping has been the main problem by costal cartilage grafting, oblique split method provides straight costal cartilage grafts of varying thicknesses without the risk of warping.

Numerous clinical cases have shown that a cross-sectional graft obtained through an oblique cut to the long axis of the rib results in a graft with equal circumferential forces of contracture that have a decreased chance of warping^[8].

Figure 11. Cutting harvested cartilage according to oblique split method

Postoperative pain

Usually the main patient’s complain after conventional rib harvesting is postoperative pain. Due to the fact that thoracic muscles are used for such physiological process as breathing and many other everyday activities such as getting up, speaking, walking and so forth - the thorax cannot be immobilized completely in postoperative period. In the majority of cases these movements may cause pain conditioned by the cut muscle fibers.

On the contrary, one of the key advantages of the endoscopic rib harvesting is reduced postoperative pain. Significant decrease in pain is attained by means of delicate muscle undermining under endoscopic-assisted vision, which enables to preserve the majority of muscle fibers. The use of muscle-sparing technique contributes to faster healing with reduced postoperative pain [1.6 ± 0.9 Visual Pain Analog Scale (VAS)]. This benefit is more pronounced in the early postoperative period and is especially dramatic in reducing movement pain^[6].