Chuan-Hsiang Kao, M.D.
Department of Otolaryngology-Head and Neck Surgery,
Cosmetic and Laser Center,
Tri-Service General Hospital,
National Defense Medical Center, Taipei, Taiwan, R.O.C.
Asian aesthetic rhinoplasty differs greatly from Western rhinoplasty because of its unique underlying anatomy. To achieve the ideal aesthetic result, most Asian rhinoplasty is composed of both dorsum augmentation and tip plasty. There are varieties of allografts such as silastic silicone, GoreTex,…etc, which have been used for dorsal augmentation in Asian patients for several years with acceptable complication rate. However, the ideal material for an onlay graft must have the characteristics of both low complication rates and high long-term patient satisfaction. The autogenous material, such as auricular, septal and costal cartilage can achieve this goal. Due to the amounts of septal and ear cartilage being limited, we recommend using costal cartilage for the augmentation rhinoplasty when the patients have moderate to severe degrees of saddle nose, short nose, and complications from previous alloplastic material implantation.
The harvesting of costal cartilage is begun through an incision of about 2-3 cm in length on the inferior aspect of the right breast. The 6 th or 7 th costal cartilage is identified after making incision on the muscle fascia and dissecting through the muscle layers. Incisions are made on the perichondrium near the periphery of the costal cartilage, and dissection in the sub-perichondrium plane is performed around the circumference of the costal cartilage. The curved segment of the costal cartilage is cut off after estimating that the length of the straight segment is sufficient for dorsal augmentation. The long segment is sculpted and fashioned to be the onlay graft and the short segment can be prepared for the other grafts as necessary.

When a large supply costal cartilage is necessary for the correction of severe short or saddle nose, the adjacent costal cartilage may need to be harvested.
The right 7 th rib appears to be the most ideal costal cartilage segment for grafting because of its relatively safe location and its thick caliber and length. The long segment of the curved costal cartilage graft is marked on the midline for symmetric and balanced carving to decrease the warping. Four strips of costal cartilage are taken from each quadrant of the graft and the central core of the costal cartilage is carved for the dorsal onlay graft. All the cartilage grafts are soaked in antibiotic saline solution for at least 20-30 minutes.
Prior to placement of the costal onlay graft, we have to check if there is any warping. If any curvature of the graft is noticed during carving, the costal cartilage is carved on the concave side to help release the cartilage memory and deformity. A central groove is carved on the inferior aspect of the onlay graft to have good contact with the nasal dorsum. We record intraoperative profile measures of starting point, rhinion, supratip area and nasolabial angle before we adjust the shape of rib cartilage onlay graft. During the onlay graft placement, we can recheck these measures again and again to make sure not to over augmentation or result in unnatural looking.
under general anesthesia
We found that carving the costal cartilage as dorsal implant for augmentation rhinoplasty with intraoperative precisely adjustment of nasal profile can maximize the aesthetic outcome .