What is the most suitable graft option for a patient undergoing revision septorhinoplasty with a collapsed nose and virtually no remaining septal cartilage?

Graft Selection for Revision Septorhinoplasty with Saddle Deformity

Direct Recommendation

For a patient with collapsed nose, saddle deformity, and virtually no remaining septal cartilage requiring revision septorhinoplasty, autologous costal cartilage (iliac crest option c) is the most appropriate graft choice. 1, 2

Rationale for Costal Cartilage Selection

Volume Requirements

• Saddle deformity with collapsed nose requires substantial structural support that only costal cartilage can provide in adequate volume. 1
• Septal cartilage is already depleted (virtually none remaining), eliminating it as an option 1
• Conchal cartilage, while useful for smaller grafts, cannot provide sufficient volume for major structural reconstruction needed in saddle deformity 3

Evidence-Based Outcomes

• Autologous costal cartilage demonstrates excellent long-term outcomes with low complication rates (4.6% overall) in complex reconstructive cases 2, 4
• Costal cartilage is specifically advocated for septorhinoplasty cases requiring large volume of tissue when septal cartilage is insufficient 1
• Follow-up data spanning 3-72 months shows sustained structural support without significant resorption 1

Why Other Options Are Inadequate

Conchal Cartilage (Options a and b)

• Conchal cartilage is insufficient for major structural reconstruction - it works well for minor grafts but cannot provide the volume needed for complete L-strut replacement 3
• Laminated or rolled conchal cartilage still lacks the structural rigidity required for saddle deformity correction 3
• Permacol wrapping (option b) adds foreign material risk without solving the fundamental volume deficit

Synthetic Materials (Options d and e)

• PDS (polydioxanone) is absorbable and will not provide permanent structural support - it biodegrades over time, making it unsuitable for definitive reconstruction 5
• Silastic splints (option e) are temporary devices, not permanent grafts 5
• Guidelines emphasize autologous cartilage as the gold standard due to superior resistance to infection and minimal resorption 6, 3

Surgical Approach Algorithm

Step 1: Harvest Costal Cartilage

• Extract adequate volume from rib (typically 6th, 7th, or 8th rib) to reconstruct entire L-strut and provide dorsal augmentation 1
• Harvest technique should preserve perichondrium on one side to minimize warping risk 1

Step 2: Construct L-Strut Framework

• Fashion a complete dorsal and caudal strut replacement from costal cartilage 5
• The bony-cartilaginous junction of rib can be utilized as an integrated unit for enhanced stability 7
• Anchor caudal strut to anterior nasal spine with permanent sutures 8

Step 3: Dorsal Augmentation

• Use additional costal cartilage for dorsal onlay grafts to correct saddle deformity 8
• Carve grafts to appropriate contour and secure with sutures 5

Step 4: Additional Structural Support

• Place spreader grafts if nasal valve collapse is present 8
• Consider batten grafts for additional stabilization of reconstructed framework 5

Critical Considerations

Warping Risk

• Costal cartilage has 1.7% deviation/warping rate, which is the most common complication with autologous costal cartilage 4
• Minimize warping by: carving grafts from central portion of rib, balancing cartilage stress, and allowing grafts to equilibrate before final placement 1

Alternative: Irradiated Homologous Costal Cartilage

• If patient refuses autologous harvest, irradiated homologous costal cartilage (IHCC) is an alternative with similar revision rates (14.6% vs 14.8%) 2
• However, IHCC has significantly higher resorption rate (2.4% vs 0.49%, p=0.002), making it less ideal for major structural reconstruction 4
• IHCC offers shorter operative time but requires longer-term monitoring for resorption 2

Common Pitfalls to Avoid

• Do not attempt major structural reconstruction with insufficient graft material - conchal cartilage alone will fail in this scenario 3, 1
• Avoid synthetic permanent implants (silicone, Medpor) in revision cases - higher infection and extrusion rates compared to autologous tissue 6
• Do not use absorbable materials (PDS) for permanent structural support - they will degrade and allow recurrent collapse 5
• Ensure adequate follow-up (minimum 12-24 months) to monitor for late complications including warping or resorption 1, 2