The History of Rhinoplasty ⑩ — Why we take from our own body to repair our own body

Let me look at it strangely for a moment.

You open a perfectly sound chest and take out the cartilage attached to a rib. You carve it and put it inside a nose. You damage a sound part of the body in order to save another part.

This is autologous rib cartilage rhinoplasty. And the idea is not new.

A question repeated for 2,600 years

In part two, Sushruta took skin from a sound forehead or cheek to make a nose. In part four, Tagliacozzi used a sound inner upper arm. In part eight, Gillies used a sound chest and forehead.

Different ages, different countries, the same structure. You give something up somewhere to get something back somewhere else.

The reason reconstructive medicine has never escaped this arrangement is simple. The body pushes out what is not its own.

Only your own tissue survives in your body without trouble. So to restore something, something else has to be pulled down.

It is not that medicine has failed to answer this for 2,600 years; there was never an answer to be had in the first place. And so the question always turns into a different one. What will you give up?

Autologous rib cartilage began to be used as a graft in the late 1800s. Gillies, too, moved rib bone in facial reconstruction during the First World War.

But rib cartilage came with an old problem. Warping.

At the time of the graft you can carve it into the shape you want. Then, as time passes, the cartilage tries to return to its original form.

The first person to point this out was Gillies, in 1920.

Which is to say it has been a known problem for over a hundred years. Recent reviews still name warping as the commonest complication of autologous rib cartilage grafting.

I find the phenomenon interesting.

Cartilage is tissue that was doing a different job where it was. It was attached to a rib, holding up the chest, and one day it is cut out and set inside a nose.

And in time it tries to return to the form it used to have.

Medically this is a matter of the arrangement of collagen fibres and internal tension.

But whenever I see it I think that tissue has something of its own like a memory. Being placed somewhere new does not mean it accepts a new role straight away.

So what was done about it

How to handle this problem has been the central axis of development in rib cartilage technique.

One direction was to change how it is cut. The tendency to warp differs with how the cartilage is divided. It is an approach that understands the nature of the tissue and works with it.

The other direction turned the idea on its head. Don’t use it whole — dice it.

Diced cartilage is an old concept in itself, but it became widely known when Erol in Turkey published a method of wrapping and grafting it in 2000.

Researchers afterwards went on studying ways to reduce resorption by changing the wrapping material.

It is this second approach that impresses me. Because it is a method that does not try to beat the tissue, but accepts that the tissue cannot be beaten. Used whole, the force pulling it back to its original form goes on working. Divided small, that force is dispersed.

That what a century of trial and error arrived at was not a technique for subduing tissue but a way around the nature of it — I think that is a case showing that progress in medicine does not always come in the shape of conquest.

On the misconception that rib cartilage is for revision

Let me take up one idea that is common in Korea: that rib cartilage is for revision surgery.

It is easy to see where the idea came from. Revision cases often lack usable tissue, so situations calling for rib cartilage come up frequently, and that is where people hear about rib cartilage first.

But the criterion is not which number of operation this is. It is how much structural support that nose needs. There are first operations for which rib cartilage is right, and revisions for which it is unnecessary.

When I do recommend autologous rib cartilage, though, there is one thing I always say first.

It requires an additional incision on the chest.

It sounds obvious, but this is the essence of the operation. You give up part of a rib in order to gain a nose.

A small scar remains, there is a recovery period, and there is pain. There is no material with advantages only.

So the judgement narrows to one thing. Is this nose in a state that warrants giving up that much?

If it is needed, I use it. If it is not, I do not. That is about as far as I can answer a question that has been running for 2,600 years.

Sushruta opening a forehead, Tagliacozzi fixing an arm in place — they will have been making the same judgement.

Is what this person stands to get back greater than what they give up? The technique has become incomparably finer; the nature of the decision has not changed in the slightest.