Is a septorhinoplasty with rib cartilage worth it for a deviated septum?
One way to approach this question is to weigh the pros vs cons:
- Generally, septorhinoplasty, even with a rib harvest, is considered a very safe procedure.
- You get to breathe better!
- Correct Obstructive Sleep Apnoea: A deviated septum can occasionally cause or worsen obstructive sleep apnoea - which is a real medical condition that needs to be treated. Untreated, you are at risk of developing heart problems, high blood pressure even diabetes, just to name a few.
- You get to look better
- no implant related problems (infection, rejection, replacement issues etc)
- insurance eligible (at least partially)
- long surgery (but may not matter to you since you are under GA anyway)
- chest scar - approx 3cm line on the chest
- can be fairly costly (but insurance eligible)
- low risk does not mean no risk. Complications can still happen
Generally, most patients are very glad to have done it, as it kills many birds with one stone, and once recovered well, you have very little issues to deal with in future.
Understandably, there may be a mental barrier for most patients, especially if they are encountering the prospect of needing to harvest the rib for the first time. However, I genuinely believe that rib septorhinoplasty is really a very good choice over many other options.
If your doctor(s) all recommend a rib rhinoplasty, chances are it is because a normal septoplasty won't be good enough to improve your breathing. And while you are at it, you can actually make improvements to the appearance without the use of implants (no future headaches).
Thanks for the question. The answer depends on the severity of the deviation and the details would be in the planning of the surgery. You should discuss with your surgeon the options for cartilage harvest and how it is necessary to achieve your objectives.
What is a deviated septum?
The nasal septum is the thin cartilage and bone that separates the right and left nostrils. It is not uncommon to have a septum that is slightly off the midline. However some patients have a septum that is way-off the midline and this can cause symptoms of difficulty breathing, blocked nose, dry nose symptoms and affect the straightness of the nose.
Treatment of deviated septum
The surgery to correct a deviated septum is called a septoplasty and this is usually done by an ENT surgeon or a plastic surgeon. The surgery involves cutting part of the nasal septum to straighten it or shift it back to the centre.
The level of improvement you can expect depends on the severity of the deviation. Symptoms due to nasal obstruction usually resolve completely. However symptoms that arise from allergies will not be cured with surgery. During the septoplasty, surgery to reshape the nose (rhinoplasty) can also be performed.
Depending on the severity of the deviation and association of other problems, cartilage grafts may be required to reinforce the cartilage structure of the nose.
What is cartilage harvest and why the rib?
As part of the rhinoplasty procedure, a nasal graft is often required to create a stable, natural appearance that lasts. Artificial material such as silicone can be used but these may be unreliable and impermanent, so whenever possible I would like to use the patient’s own (autologous) cartilage.
Autologous cartilage is considered the gold standard grafting material for both structural support and volume augmentation. Autologous tissue presents many advantages: it survives as a living tissue, hence seldom undergoes resorption, does not stimulate an immune response or rejection and the only downsides are the presence of a donor scar and a slightly longer operation time.
Some of the options for autologous grafts include the nasal septum, ear cartilage or the rib cartilage but rib (costal) cartilage is considered the best graft material.
Options for Autologous cartilage:
Nasal Septum - The nose cartilage is straight and firm and is located in the same operative site as a septoplasty hence it is the preferred cartilage. However, especially in Asians, there may not be sufficient cartilage to work with. This is especially so in revision rhinoplasty surgery where the amount of work to be done and cartilage required is more.
Ear cartilage - Ear cartilage is available and accessible via a short incision hidden at the back of the ear. The cartilage tends to be weaker than nasal cartilage and it tends to be curved so it many not be strong enough to support nose during major reconstruction.
Rib cartilage - Rib cartilage is the gold standard with it’s proven record of safety. It can provide a large volume of cartilage material for both structural support and volume augmentation. The characteristic of rib cartilage is that it is straight and strong hence giving reliable results that do not change over time.
How is rib harvest done?
Depending on the rib that is harvested, an 2-3 cm incision is made over the chest to access the ribs. In females, this scar is placed under the crease of the breast to hide the scar. After skin incision, the underlying muscle is split to expose the rib cartilage.
The outer layer of the rib (peri-chondrium) is carefully peeled away form the rib and a short segment of rib (about 4-5 cm) is removed leaving it intact. The perichondrium is then repaired after rib harvest.
Most of the over the chest would resolve over 1-6 weeks. Once the donor site has healed you would not notice much difference from day to day. Occasionally some patients may have a contour irregularity if the wound closure is not perfect. Once the scar tissue has formed, the absence of this segment will not be felt and there should be no functional disability from the harvest.
Is rib harvest worth it?
Having understood the pros and cons of rib cartilage harvest and its utility in reconstructive rhinoplasty I hope you will have more information to decide if this operation is worth it. Not all cases of septal deviation would require rib cartilage harvest during its correction.
Understanding the problem, precise planning and economical use of cartilage can often avoid the use of rib cartilage unless necessary. In general, I would use septal cartilage or ear cartilage for primary cases and reserve rib cartilage for revision cases or for complex reconstruction rhinoplasty cases. Having said that the best person to advise on this would be your surgeon.
You should go through the operation plan with your surgeon in detail so that you can understand why rib cartilage is necessary in your case. Every nose is different so the considerations and need for cartilage also vary.
I hope this answers your question. Please feel free to ask more questions if you have any.
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