Irradiated rib grafts

What repeats

Five findings that hold across the literature.

The largest single series ran 24 years and the complication rate stayed low

Three hundred and fifty-seven patients received 1,025 irradiated grafts, with follow-up from 4 days to 24 years and a mean of 13.45 years. The total complication rate attributed to the grafts was 3.25%: warping in 10 of 941 palpable grafts (1.06%), infection in 9 of 1,025 (0.87%), infective resorption in 5 of 1,025 (0.48%), non-infective resorption in 5 of 943 (0.53%) and graft mobility in 3 of 941 (0.31%). Patient satisfaction across appearance, breathing, symptoms and quality of life rose from 91.31% to 94.18% over a mean 7.87 years.

Rests on: Kridel et al., long-term use and follow-up.

Pooled against the patient's own rib, most outcomes come out the same

A meta-analysis of 28 studies and 1,041 patients having en bloc dorsal onlay grafts found no difference between the patient's own rib, irradiated rib and Tutoplast-processed cartilage in warping (5%), resorption (2%), contour irregularity (1%), infection (2%) or revision surgery (5%). A larger analysis of 50 studies and 4,482 patients reported pooled warping of 2.9%, resorption 1.6%, infection 1.9%, revision 5.0% and dissatisfaction 4.0%, with no significant difference between graft types on any outcome.

Rests on: Vila et al., systematic review and meta-analysis · Jullamusi et al., four graft types compared · rib cartilage grafts.

Resorption is the one complication that separates it from the patient's own rib

A review of 14 studies and 1,358 patients having tip-stabilising grafts found resorption in 2.4% of irradiated grafts against 0.49% of the patient's own (p = 0.002), and a slightly higher overall complication rate, 5.0% against 4.6% (p = 0.01). A stratified meta-analysis of 7 studies and 1,184 patients found the raised resorption risk sat entirely in the irradiated subgroup, relative risk 4.595 (95% CI 1.279 to 16.503), while fresh-frozen and alcohol-preserved grafts did not differ from the patient's own.

Rests on: Kowalski et al., tip stabilising grafts · Wael Moftah et al., preparations compared.

One clinical series reports a much higher resorption rate than the pooled figures

Sixty-three patients had rhinoplasty with their own rib and 20 with irradiated rib, all followed more than a year. Notable resorption occurred in 6 of the irradiated group (30%) against 2 of the autologous group (3%) (P = .002). Aesthetic satisfaction was also lower: 30% of irradiated patients were very satisfied against 73% of autologous patients (P = .001), with no difference in functional satisfaction. Histology showed larger, more evenly distributed chondrocytes and more collagen and proteoglycan in the patient's own cartilage.

Rests on: Wee et al., autologous against irradiated.

It shortens the operation and removes the chest wound

Surgical time was significantly shorter with irradiated cartilage in a 143-patient institutional comparison (p < 0.01), where revision rates were 14.8% and 14.6% (p = 0.98) and infection rates 4.9% and 3.7% (p = 0.71). Pooled operative time across the stratified meta-analysis was 66.56 minutes shorter with donated cartilage.

Rests on: Drake et al., institutional comparison · Wael Moftah et al. · costal cartilage harvest.

By where the graft is placed

The same donated cartilage behaves differently depending on the job.

On the dorsum, as a single carved block

The commonest use is raising the bridge in a nose with no septal cartilage left. Published practice places irradiated rib as a preferred alternative when the septum is gone and the ear is not enough, and warns that ear cartilage on the dorsum shows through thin skin over time. Graft shape matters more than source: laminated dorsal grafts warped in 0.0% of cases against 5.42% for single-block grafts (P = .004).

Rests on: Kridel and Sturm, dorsal augmentation · Malone and Pearlman, dorsal augmentation review · Jullamusi et al. · the saddle nose.

As a septal extension graft, under tension

A 323-patient review found a total complication rate of 8%, made up of 2 fractures (0.6%), 4 fragmentations (1.2%), 4 resorptions (1.2%), 4 infections (1.2%) and 2 warpings (0.6%). Most of these occurred where the graft was used as a septal extension graft, and the authors advise care wherever the graft carries tension.

Rests on: Suh et al., complications by graft location · the columellar strut.

Repairing a hole in the septum

In the same 24-year series, 162 irradiated grafts were used in 53 septal perforation repairs with a complication rate of 2.46%, against 8% for the 25 autologous grafts used in the same setting.

Rests on: Kridel et al..

Rebuilding a revision nose that has nothing left

A UK series of 57 patients, 41 of them revision cases and 98.2% done through an open approach, recorded 3 infections (5.3%) and one columellar wound breakdown needing revision (1.8%), with no warping, resorption or extrusion at a median follow-up of 279 days. An earlier 65-patient series across secondary, traumatic and primary indications found no significant resorption at a mean 33 months, with minor complications in 4 patients (6%).

Rests on: Jama et al., complex functional septorhinoplasty · Demirkan et al., versatile grafting material · revision rhinoplasty.

Rebuilding a nose collapsed by disease

Thirteen patients with granulomatosis with polyangiitis had external nasal reconstruction, all while the disease was in remission. The single irradiated rib repair failed, and the review states irradiated materials in that series appeared more prone to resorption. Irradiated grafts were reported as stable over 2.08 and 10 years in two autoimmune patients in the long-term series.

Rests on: Congdon et al., Wegener's granulomatosis · Kridel et al..

What to ask about an irradiated rib graft

Questions the evidence supports asking.

Where does the cartilage come from and how was it treated

It is donated human rib from a tissue bank, sterilised by gamma irradiation. Other bank preparations exist: Tutoplast processing, fresh frozen and alcohol preserved, and they do not behave identically. Alcohol-preserved grafts had a lower warping risk than the patient's own rib, relative risk 0.106, and fresh-frozen grafts had the lowest warping rate of any en bloc dorsal graft at 0.60%.

Rests on: Wael Moftah et al. · Jullamusi et al..

Will it dissolve

Pooled resorption sits between 1.34% and 3%. One clinical series reports 30%. Ask what the surgeon has seen in their own patients at three years, and what they would do if the bridge dropped.

Rests on: Luan et al., meta-analysis · Liyanage et al., pooled comparison · Wee et al..

Will it bend

Warping is reported at 2.07% in one meta-analysis and 6% in another, the same figure as the patient's own rib in that analysis. Ask whether the dorsal graft will be carved as one block or laminated, since that difference measured 5.42% against 0.0%.

Rests on: Luan et al. · Liyanage et al. · Jullamusi et al..

What does it save me

No chest incision, no chest scar, no chest pain, and a shorter operation by about an hour in pooled data. Set that against a resorption risk that most, though not all, comparisons put slightly higher.

Rests on: Drake et al. · Wael Moftah et al. · what recovery looks like · what rhinoplasty costs.

Does less radiation help

A series of 26 patients receiving 100 non-irradiated or minimally irradiated bank grafts reported a graft-related complication rate of 3.6%: 2 partial non-infective resorptions of 77 palpable grafts (2.6%), 1 infection of 100 grafts (1.0%) and no warping or mobility. The authors state larger studies are needed before concluding that lower radiation improves outcomes.

Rests on: Rogal et al., non- and minimally irradiated cartilage.

The terms, defined

The words used about this graft.

• Irradiated homologous costal cartilage: donated human rib cartilage sterilised with radiation and stored by a tissue bank. [19917899]
• Autologous costal cartilage: the patient's own rib, harvested at the same operation. [28334327]
• Homologous or homograft: from another human, as opposed to autologous, from the patient. [19917899]
• Tutoplast: a solvent-based tissue bank processing method, counted separately in the pooled analyses. [32077916]
• Fresh frozen: bank cartilage preserved by freezing rather than irradiation. [42374829]
• Warping: the graft bending after it is carved and placed. [35354546]
• Resorption: the graft losing volume as the body breaks it down. [38669105]
• En bloc graft: a dorsal graft carved from one piece, as opposed to a laminated graft built from layers. [42374829]
• Septal extension graft: cartilage fixed to the septum and carried to the tip, the location where irradiated grafts failed most often in one series. [29521744]

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, whatever the graft material.

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

The regulator

Banked human rib is regulated tissue, not a device. The US Food and Drug Administration lists the rules the tissue bank works under, the donor screening and testing it must perform, and the register of establishments that supply it. A patient can look up the bank by name.

• Tissue and Tissue Products, the rules for human cells, tissues and tissue-based products.
• Questions about Tissues, written for the public.
• Testing donors of human cells, tissues, and cellular and tissue-based products, the screening a donor goes through.
• Human Cell and Tissue Establishment Registration, the searchable register of banks.
• Medical Devices, the separate route the synthetic dorsal implants take.

The surgeons' own textbook chapters

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

• Irradiated Rib Grafts in Rhinoplasty
• Rib Grafts In Rhinoplasty

The reference summary

Cartilage Graft in StatPearls covers graft sources, handling and complications 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.

What is not settled

• There is no randomised trial. Every comparison is retrospective, and one large meta-analysis rates the risk of bias across its included studies as serious to critical with evidence of small-study effects. [42374829]
• The resorption figures do not agree. Pooled estimates run 1.34% to 3%, one review finds 2.4% against 0.49% for the patient's own rib, and one clinical series reports 30%. [35354546] [38669105] [28334327]
• Aesthetic satisfaction was significantly lower with irradiated grafts in the one study that asked patients directly, 30% against 73% very satisfied, in groups of 20 and 63. [28334327]
• Follow-up is uneven. The longest series averages 13.45 years, while recent series report a median of 279 days. [19917899] [39824508]
• Whether the radiation dose matters is untested against a control. The one series using minimally irradiated cartilage has 26 patients and no comparison group. [32522045]