Contracted Nose Correction: Rib Cartilage or Ear Cartilage? Which Should Be Used?

Contracted nose correction is regarded as a highly difficult operation because, among rhinoplasty procedures, it is demanding and extensive.

As is already well known, the causes of a contracted nose are silicone, the capsule, and the inflammatory response. These three factors are the necessary conditions.

Once contracture has occurred, with the nose upturned and the tip deformed, correcting it

must not involve artificial implants such as silicone;

 the surgery must be performed with autologous tissue or human donor tissue.

Because correcting a contracted nose means lengthening a nose that has shrunk and turned upward, autologous cartilage is needed,

and the most commonly used are costal (rib) cartilage and ear cartilage.

Many of the patients who come to my clinic say they were told that contracted nose correction must be done with costal cartilage,

so you may be wondering whether costal cartilage really must be used for contracted nose correction, or whether ear cartilage can also be used.

Which material to choose depends on the patient's condition, so a careful diagnosis is needed.

In this case study, we will look case by case at which cartilage should be used for surgery.

Costal Cartilage vs. Ear Cartilage: Pros and Cons

*Costal Cartilage

- Abundant in quantity

- Firm, with strong support

(Therefore suited to patients with severe contracture and insufficient ear cartilage)

- Harvesting costal cartilage is a burden

- Higher cost

- After surgery, the nose feels firm and fixed

*Ear Cartilage

-  Soft and relatively pliable

-  Less burdensome to harvest

-  Lower financial burden

(Therefore suited to patients who still have ear cartilage and less severe contracture)

- The amount of cartilage is small, so in revision surgery

   it is often insufficient

-  When the skin is tight with no slack, or 

    when contracture is severe, the length 

    sometimes cannot be extended enough

1. Degree of Contracture

When contracture is severe, a large amount of cartilage is needed, and lengthening the nose

requires strong support, so costal cartilage  is the better choice.

 If the contracture is not very severe and the ear cartilage on one side remains unused, ear cartilage is the more appropriate material.

2. Original Length of the Nose

When contracture occurs in someone whose nose was originally short and the patient wishes to make the nose longer,

strong support is required, so costal cartilage is needed;

  when the aim is only to restore the original length, ear cartilage is used.

3. Skin Condition

When the skin is thin and soft, or when the skin has become very thin

after removal of the capsule and scar tissue, costal cartilage shows too visibly

 and places excessive tension on the skin, so it is not advisable; ear cartilage is preferable.

4. Amount of Remaining Cartilage

If the ear cartilage was all used in previous surgery and none remains,

or the amount is insufficient, there is no choice but to use costal cartilage.

After augmentation rhinoplasty with silicone 40 years ago, contracture gradually developed;

the silicone on the dorsum is now heavily calcified,

and because of the contracture the nostrils are highly visible from the front.

- Before surgery the contracture was more severe, so the nose was much shorter and the tip deformity was also severe.

▶ About 30% lengthening was needed, so costal cartilage was used.

- The skin was relatively thick, and the skin of the glabella and dorsum was fairly loose, so there was skin to spare.

As this shows, it is important to judge how far the nose can be lengthened from the mobility of the skin before surgery and from past photographs.

Autologous costal cartilage was used to make an “L”-shaped strut to lengthen the nose,

and the dorsum was augmented with acellular dermal matrix.

1st: August 2014 at another clinic, 4mm silicone + ear cartilage (open) => the nose became crooked; dissatisfied with the shape.

2nd: February 2018 at another clinic, silicone lowered + tip plasty with ear cartilage harvested again (open) 

=>more nostril show, cartilage protruding at the columella inside the left nostril, and nostril asymmetry

3rd: June 2018, tip cartilage trimmed and asymmetry of the tip and nostrils corrected

=> At present, the nose is gradually shortening and the nostrils show. Nostril asymmetry.

The columella is tilted and the nostrils are slightly visible. 

The patient said the nose had originally been rather short.

The skin contracture was relatively mild, and deformity of the skin and tip was less marked.

In addition, the nose had originally been rather short, so ear cartilage was used.

The silicone, capsule, tip cartilage, and so on were all removed, and in the course of correcting the contracture there was not enough ear cartilage,

so no lengthening graft was placed; only a lateral crural strut graft (LCSG) was performed to correct the pinched tip deformity,

and the dorsum was augmented with acellular dermal matrix.

During surgery, a perforation of the mucosa (vestibule) inside the nose was found, so mucosa was harvested from the mouth and grafted.

=> The height and lengthening of the nose were achieved appropriately.

​

- After nose surgery with silicone 2 years earlier, the nose had shortened severely, and the tip deformity and asymmetry were marked.

- On palpation there was fluctuance with discharge collected inside, and the tip was very hard. The tip was badly twisted.

- Infection was judged to be present, so a 1st surgery was performed to remove the silicone, capsule, and infected tissue,

and surgery to correct the contracture was planned for 6 months later.

In the meantime, adipose-derived stem cell treatment was given to promote tissue regeneration and help the tissue soften sooner.

​

- Ear cartilage remained, but the tip deformity was severe and the nose had shortened considerably,

so a large amount of cartilage was needed, and it was decided to perform the 2nd surgery with costal cartilage.

- 6 months later, an “L”-shaped strut was built with costal cartilage to lengthen the nose,

and a lateral crural strut graft was placed at the tip to bring the tip down and improve its asymmetric shape.

- Nothing was placed in the dorsum.

In the photographs before correction, the tip looked as if pulled upward, and the columella was curved, causing asymmetry;

after surgery, the tension at the tip was gone, and the symmetry of the columella and nostrils improved markedly.

The nose has been lengthened sufficiently, and its balance has improved.

- 2 years ago at another clinic: L-shaped silicone + ear cartilage at the tip (closed)

=>Contracture noticed 5 months ago. The nose is upturned and the nostrils show. It is hard.

- A feeling of pressure across the whole nose since immediately after surgery.

- The alar rim is pulled upward (nostril notching), exposing the nostrils.

- The silicone, capsule, scar tissue, tip cartilage graft, and so on were all removed.

- Lengthening graft with ear cartilage (derotation graft) + columellar strut (CS) were performed.

- To correct the deviated septum, a spreader graft of septal cartilage and

the swing door procedure, which moves the septum to the midline, were performed.

- Acellular dermal matrix was placed in the dorsum.

In the photographs before correction, the tip was pulled upward, and the tip and columella were curved.

The septum was shifted to the right; after surgery, the tip came down,

and you can see that the columella and septum are now straight.

The nose has been lengthened sufficiently, and its balance has improved.

Nasal bone fracture from trauma 10 years ago.

1st: 10 years ago, silicone + ear cartilage at the tip (open) => 4 months later the silicone came out inside the nose

2nd: 4 months later, silicone replaced => it became crooked

3rd: 6 months later, silicone removed

4th: 8 years ago, silicone placed again => the nose became upturned. Severe contracture.

The contracture was severe, and the skin was thick and tough, so costal cartilage with strong support was needed.

The nose was lengthened sufficiently, and the tip deformity also improved well.

What is very important in contracted nose correction is to remove enough of the scar tissue along with the capsule

so that the elasticity of the skin is restored.

1st: 2016, silicone + ear cartilage (closed) => the nose began to bend 3 months later.

2nd: November 2016, correction of the bent silicone (closed) => something seemed wrong from spring 2017, and it bent progressively.

3rd: 2018, silicone corrected again (closed) => from fall 2019, odor from the nose and redness. Something visible at the tip.

4th: March 2020, silicone removed (closed) => received 2 injections to soften the hard tip.

5th: summer 2020, SMR (ENT)

=> After the silicone was removed, the shape of the nose became odd. Contracture was felt from winter.

The patient complained of difficulty breathing on the right side.

The skin was relatively soft and thin.

The contracture was also relatively mild, so ear cartilage was used.