Costal cartilage harvest

What repeats

Five findings that hold across the literature.

The serious risks of the chest wound are rare

A systematic review of 21 studies pooled donor site complications as pneumothorax 0.1%, pleural tear 0.6%, infection 0.6%, seroma 0.6% and severe donor site pain 0.2%. A separate meta-analysis of 10 studies and 491 patients, mean follow-up 33.3 months, put pneumothorax at 0% with a 95% confidence interval of 0% to 0.32%.

Rests on: Varadharajan et al., systematic review · Wee et al., meta-analysis.

The scar is the commonest donor site complaint

Hypertrophic chest scarring pooled at 5.45% in the meta-analysis and scar-related problems at 2.9% in the systematic review, higher than any other donor site figure. In an 83-patient series the mean chest incision was 2.4 cm, there was no pneumothorax or significant donor site pain, and two patients developed a hypertrophic chest scar.

Rests on: Wee et al. · Varadharajan et al. · Park and Jin, Asian rhinoplasty series.

Warping is the problem at the nose, not the chest

Pooled warping was 3.08% in one analysis and 5.2% in the other, against resorption of 0.22% and 0.9% and infection of 0.56% and 2.5%. In the 83-patient series the graft-related complication rate was 12%, made up of five warped grafts and five infections, all of which settled on intravenous antibiotics.

Rests on: Wee et al. · Varadharajan et al. · Park and Jin · rib cartilage grafts.

How the cartilage is cut decides how much it bends

Human rib cartilage cut with a jig and photographed over four weeks bent significantly less when sliced transversely across the sixth to seventh junction than when carved eccentrically or concentrically (P < 0.0001). Warp increased with time for eccentric and concentric carving and not for the transverse slices (P = 0.56). In pooled clinical data, laminated dorsal grafts warped in 0.0% of cases against 5.42% for single-block grafts (P = .004).

Rests on: Teshima et al., transverse slicing · Jullamusi et al., pooled graft comparison.

How much rib is taken decides how much it hurts

Forty patients were split evenly between preserving and dividing the joints between the sixth rib and its neighbours. Mean pain scores on days 1, 3, 7, 14 and 30 were 4.15, 1.95, 0.80, 0.05 and 0.0 where the joints were preserved, every one of them lower than in the group whose joints were divided, which started at 5.10 and reached 0.1 by day 30. Harvested lengths were 33.2 +/- 3.79 mm and 32.45 +/- 3.5 mm. A half-harvest method that leaves the outer cortex and perichondrium in place reports no pneumothorax or rib fracture, with most patients back to daily activities within a week.

Rests on: Gan et al., preserving the interchondral joints · Kim and Son, half-harvest technique · what recovery looks like.

By what changes at the harvest

Five decisions the surgeon makes before the first cut.

Which rib

Published harvests name the sixth, seventh, eighth and ninth. The sixth to seventh junction is the site used for transverse slicing, and the sixth alone is the site in the pain study, where a preoperative CT scan was used to check the cartilage for calcification before choosing it.

Rests on: Teshima et al. · Gan et al. · Kim and Son.

How much of the rib

Full-thickness harvest takes the whole cross-section. The half-harvest takes the inner half and leaves the lateral cortex and perichondrium behind, which is described as reducing donor site soreness and leaving the possibility of the rib regenerating.

Rests on: Kim and Son.

Where the incision goes

The standard route is a short incision over the rib. A trans-areola route was compared with it in 26 women against 35 having the standard route. The trans-areola group had a significantly longer operation and a higher pneumothorax rate, 7.7% against 2.9%, with significantly better scar quality and higher overall satisfaction at one year. Long-term problems in that group were visible scars in 2 of 26 (7.7%), a breast hollow in 1 of 26 (3.8%) and local chest pain in 1 of 26 (3.8%).

Rests on: Zhao et al., trans-areola approach.

What the cartilage is cut with

A Gigli saw passed around the sixth, seventh or eighth cartilage after the perichondrium is lifted is described as cutting cleanly with less risk to the tissues behind the rib and a shorter operation.

Rests on: Dogan et al., Gigli saw technique.

Whether the patient is a child

Forty-one harvests through 36 incisions in 33 children, mean age 2.5 years, produced one intraoperative pleural leak (2.8%) and one wound infection (2.8%). No drains were used and there were no haematomas or seromas. Both cases of hypertrophic scarring (5.6%) occurred where skin was also taken through the same incision.

Rests on: Lonergan and Scott, harvest in children.

What to ask about a rib harvest

Questions the evidence supports asking.

What is the risk to the lung

Pooled pneumothorax is 0.1% and pleural tear 0.6%. Ask what the surgeon does if the lining of the chest is opened during the operation, and whether a chest x-ray is taken afterwards.

Rests on: Varadharajan et al. · Lonergan and Scott.

Where will the scar be and how long

Reported mean incision length is 2.4 cm. Scar problems are the most frequent donor site complaint at 2.9% to 5.45%. Ask where the incision sits relative to the bra line, and to see photographs of the chest at one year.

Rests on: Park and Jin · Wee et al. · Zhao et al..

How much will the chest hurt and for how long

Published pain scores fall from about 4 or 5 on day 1 to under 2 by day 7 and effectively zero by day 30. Ask which harvest method the surgeon uses, since preserving the joints between the ribs lowered every one of those scores.

Rests on: Gan et al. · Kim and Son · what recovery looks like.

Will the graft bend afterwards

Warping runs 3.08% to 5.2% pooled, and it is the commonest problem at the nose. Ask how the dorsal graft will be carved: transverse slices and laminated construction both measured lower warp than a single carved block.

Rests on: Teshima et al. · Jullamusi et al. · Wee et al..

Why not use a donated rib instead

Bank cartilage removes the chest wound entirely. Pooled complication rates for irradiated bank rib are resorption 1.14%, warping 0.5% and infection 1.2% across 1,017 patients, and fresh-frozen bank rib had lower warping than the patient's own, 1.2% against 3.9% (P = .00038). One review of revision cases put overall complications at 9.25% for fresh-frozen and 15.7% for irradiated grafts. Graft complications were higher for bank cartilage in one meta-analysis (P = 0.02) until donor site complications were counted, after which the difference disappeared.

Rests on: Kadakia et al., irradiated cartilage meta-analysis · Bohler et al., fresh frozen against autologous · Hosseini and Keyhan, allograft review · Pfaff et al., cadaveric grafts · irradiated rib grafts.

What does the harvest add to the bill

A cost analysis put primary outpatient rhinoplasty at $8,342 with the patient's own rib and $8,075 with bank cartilage. An overnight observation stay raised the rib figure to $8,609. A one-day inpatient admission, or a revision admitted with a pneumothorax, raised it further, and the authors put the upper limit for an engineered implant at about double the outpatient cost.

Rests on: Starr et al., cost utility analysis · what rhinoplasty costs.

The terms, defined

The words used about this operation.

• Costal cartilage: the cartilage joining the front end of a rib to the breastbone, the part harvested for grafting. [25429595]
• Perichondrium: the sheath around the cartilage, lifted before the cut and sometimes left behind on purpose. [42452447]
• Interchondral joint: the joint between one rib cartilage and the next, whose preservation lowered postoperative pain scores. [42230370]
• Pneumothorax: air in the chest cavity from a tear in the lining behind the rib, pooled at 0.1%. [26229125]
• Pleural tear: a hole in that lining, pooled at 0.6%. [26229125]
• Warping: the carved graft bending after it is placed. [26716554]
• Balanced cross-section: carving so that opposing forces in the cartilage cancel out, the principle behind transverse slicing. [26716554]
• En bloc graft: a dorsal graft carved from one piece, against a laminated graft built from layers. [42374829]
• Autologous: from the patient, as opposed to homologous, from a donor. [42212058]
• Half-harvest: taking the inner half of the cartilage and leaving the outer cortex in place. [42452447]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and document before operating, whichever graft source is chosen.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries two chapters on rib cartilage and a filmed operation showing the harvest. They are written for surgeons and go further into technique than a patient page should.

• The Harvest of Costal Cartilage in Rhinoplasty
• Rib Grafts In Rhinoplasty
• Primary Asian Female Rhinoplasty with Costal Cartilage Harvest, Dr Yong Ju Jang, in the archive video library.

The reference summary

Cartilage Graft in StatPearls covers the donor sites, the handling of the graft and the complication list in full text at no charge. Rhinoplasty in StatPearls gives the anatomy and the operation around it.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Two registered studies test the harvest and the cartilage it yields.

• Effect of Costal Harvesting Technique on Postoperative Donor-site Morbidity: Does Muscle Sparing Technique Cause Less Postoperative Pain? A Clinical Trial, status unknown, 20 participants.
• Study of the Biomechanical and Histological Properties of Septal, Auricular, and Costal Cartilage in the Context of Optimizing Total Nasal Reconstruction, not yet recruiting, 33 participants.

What is not settled

• Complication definitions differ between studies. The meta-analysis states that inconsistent definitions and small numbers limit its own pooled figures. [25429595]
• Pneumothorax rates disagree by an order of magnitude, from 0% to 7.7%, and the highest figure comes from the approach with the best scar. [25429595] [31960891]
• Revision surgery pooled at 14.07% in one meta-analysis, far above the graft complication rates in the same paper, and the reasons for those revisions are not broken down. [25429595]
• Whether leaving the perichondrium and outer cortex lets the rib regrow is stated as a theoretical benefit, not measured. [42452447]
• Whether the harvest is worth avoiding depends on figures that keep moving. Fresh-frozen bank cartilage now measures lower warping than the patient's own rib, on retrospective data with a mean follow-up under two years. [42212058] [39896219] [38669105]
• Crushing costal cartilage lowers chondrocyte survival from 65% intact to 53% severely crushed on day 1, and no clinical series links that to how the graft behaves in the nose. [20418106]