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Original Article |

The Oblique Split Method:  A Novel Technique for Carving Costal Cartilage Grafts

Eren Taştan, MD; Ömer Taşkın Yücel, MD; Emine Aydın, MD; Filiz Aydoğan, MD; Kaan Beriat, MD; Mustafa Gürhan Ulusoy, MD
JAMA Facial Plast Surg. 2013;15(3):198-203. doi:10.1001/jamafacial.2013.671.
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Importance Autogenous rib cartilage is widely used in the septorhinoplasty cases with major structural grafting requirements. However, there is a risk of warping over time.

Objective To introduce a novel method for carving costal cartilage grafts to obtain straight grafts of varying thicknesses and to eliminate the risk of warping.

Design Between 2007 and 2011, a total of 43 consecutive patients underwent septorhinoplasty using autogenous costal cartilage grafts carved by the oblique split method (OSM).

Setting The Ankara Training and Research Referral Hospital, Ankara, Turkey.

Participants The study included 43 patients with saddle nose deformity and revisional rhinoplasty with a depleted source. All patients were followed-up for a period ranging from 12 to 37 months (mean, 19.2 months) after surgery.

Interventions All patients underwent open or closed septorhinoplasty. Autogenous costal cartilage was carved with the OSM to obtain grafts suitable for use as columellar strut, dorsal onlay, L-strut, lateral crural strut, caudal extension, and tip or speader grafts in selected cases.

Main Outcome Measures Patients were evaluated by inspection, palpation, and photographic documentation before surgery. Inspection, palpation, and photographic documentation were carried out every 6 months and 12 months after surgery and once a year thereafter.

Results Patient satisfaction in terms of form and function was achieved in 41 patients (95%). Two patients required reoperation for further tip projection (n=1) and alar batten graft displacement (n=1). No complication was observed as a result of graft warping, resorption, or fracture.

Conclusions and Relevance The OSM provides straight costal cartilage grafts of varying thicknesses without the risk of warping. Because they strictly preserve their straight form, the grafts may safely be modified into rectangular shape or carved asymmetrically and/or have their edges beveled. Current data from this study suggest that the OSM offers a flexible and reliable reconstructive option for the rhinoplasty surgeon.

Level of Evidence 4.

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Figure 1. Splitting the seventh-rib cartilage segment and carving the grafts with the oblique split method. A, A 45° oblique split to the long axis of the rib segment. B and C, Straight grafts, approximately 35 mm in length, with an intact surface layer surrounding the cartilage. D and E, Two cartilage segments are sewn side by side to form the caudal septal strut. A thin piece of costal cartilage graft is used for rigid fixation of the 2 segments. F, The L-strut reconstruction of septum and columellar strut. Spreader grafts reconstruct the dorsal component, and a wide caudal septal strut replaces the vertical component. A perpendicular plate of ethmoid bone graft is used for rigid fixation of the caudal strut. A columellar strut is sutured to the caudal septum. The units of measure are centimeters.

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Figure 2. Dorsal onlay grafts can be obtained by 2 cartilage grafts that are sutured end to end (A), side by side (B), or by overlapping (C). To create a smooth transition, rib perichondrium may be sutured over the dorsal onlay graft. The units of measure are centimeters.

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Figure 3. Preoperative (A-D) and 13th-month postoperative (E-H) views of a 28-year-old man with traumatic saddle nose deformity. Reconstruction of the L-strut was followed by placement of spreader, columellar strut, right lateral crural onlay graft, and side-by-side sutured dorsal onlay oblique split method grafts.

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Figure 4. Preoperative (A-D) and 15th-month postoperative (E-H) views of a 27-year-old woman who had previously undergone rhinoplasty at an outside institution. Spreader, alar batten, and overlapping dorsal onlay oblique split method grafts grafts were placed through a closed approach. Because of the dorsal skin compromise, costal perichondrium was sutured over the dorsal graft for camouflage and soft-tissue padding.

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Figure 5. Intraoperative view of the oblique split method graft to be banked between the septal mucoperichondrial flaps (A) and a 6-month postoperative view of the same graft during the revision procedure (B). Ten-month postoperative views of the alar batten graft in a patient who underwent a second operation for graft displacement (C and D). The oblique split method graft perfectly retained its straightness, and even, sharp, beveled edges can be seen after 10 months. The units of measure are centimeters.

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