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ORIGINAL ARTICLE
Use of Irradiated Homologous Costal Cartilage in
Rhinoplasty: Complications in Relation to Graft Location
Man Koon Suh, MD, Seung Jong Lee, MD, and Yeon-Jun Kim, MD
Background: Nasal septal cartilage and conchal cartilages are
preferred sources of grafts in augmentation rhinoplasty. Rib carti-
lage can also be used, but it may evoke a patient’s concerns about a
scar and an extensive surgery. In such cases, irradiated homologous
costal cartilage (IHCC) can be a useful alternative. However,
controversy still exists in many literatures regarding complications
with use of IHCC. Therefore, the authors reviewed our experiences
with IHCC in rhinoplasty and analyzed the complications in relation
to graft location.
Methods: A retrospective chart review was made of all patients
who underwent rhinoplasty with IHCC between 2007 and 2015. A
total of 323 patients were included. The authors considered the
cases that required revision surgery for external aesthetic changes as
complications. The authors defined major complications, including
resorption, infection, fracture, or warping.
Results: The total complication rate was 8%. Two fractures (0.6%), 4
fragmentation (1.2%), 4 resorptions (1.2%), 4 infections (1.2%), and
2 warpings (0.6%) were noted. Most of these complications occurred
for the septal extension graft. Other complications, including 1 nasal
obstruction, 2 visible contours, 3 caudal septal deviations, and 4 cases
of unfavorable results (patient unsatisfactions), were noted.
Conclusions: Based on the outcomes of this study, the authors
concluded that IHCC is a useful and reliable source of cartilage
graft and can serve as an alternative graft material for rhinoplasty.
However, care must be taken in use of IHCC graft in areas under
tension such as septal extension graft, though its complication rate
is low.
Key Words: Graft, homologous costal cartilage, rhinoplasty
(J Craniofac Surg 2018;00: 00–00)
A sian rhinoplasty differs from Caucasian rhinoplasty in many
aspects. Typical Asian nose appears to be small and has a weak
lower lateral cartilage with low dorsum. Therefore, augmentation
rhinoplasty is required in most cases. A number of grafting materi-
als are being used in the augmentation rhinoplasty. Nasal septal
cartilage and conchal cartilages are preferred sources of the graft.1
However, most Asian patients have very small and insufficient
septal cartilage. Moreover, the incidence of secondary rhinoplasties
has drastically increased in recent times, and for many patients, their
From the JW Plastic Surgery Center, Seoul, Korea.
Received April 18, 2017.
Accepted for publication January 10, 2018.
Address correspondence and reprint requests to Yeon-Jun Kim, MD, JW
Plastic Surgery Center, Samsin Building, 836 Nonhyeon-ro, Gangnam-
gu, Seoul 135-893, Korea; E-mail: kimyj.md@gmail.com
The authors report no conflicts of interest.
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004440
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
septal and conchal cartilages have already been used previously,
thus necessitating additional sources of cartilage such as their own
rib cartilage.
Use of autogenous rib cartilage, however, may evoke the
patient’s worries about a scar on the chest wall, and the patients
are often unwilling to undergo extensive surgery. In such cases,
irradiated homologous costal cartilage (IHCC) can be a useful
alternative choice.2 Previous reports have shown IHCC use for
structural grafts, including dorsal augmentation, septal extension,
columellar struts, spreader grafts, batten graft, and alar rim graft.3– 9
However, controversy still exists in the literature regarding com-
plications of IHCC such as resorption, warping, infection, and
extrusion.10–15 To our knowledge, there are no reports on a
relationship between graft location and incidence of complications.
To evaluate usefulness and reliability of IHCC in rhinoplasty,
we reviewed our experiences with IHCC in our practice and
analyzed the relationship between graft location and complications.
We also suggest ways for reducing potential complications.
METHODS
Patients
A retrospective chart review was made of all patients who
underwent augmentation rhinoplasty with IHCC between 2007
and 2015. Patients who had been followed for at least 1 year were
considered for this study. A total of 323 patients (102 male and 220
female) were included. There were 108 primary rhinoplasties and
215 secondary rhinoplasties. All surgeries were performed by 1
senior surgeon (MK Suh). Data collected from the patient charts
included demographic information, findings from their physical
examination, findings in the surgery, location of the IHCC graft, and
the presence of complications. We defined major complications
such as resorption, infection, fracture, warping, and extrusion. Other
complications such as nasal obstruction, visible contour, caudal
septal deviation, and patient unsatisfaction were defined as minor
complications. We performed a revision operation in all cases in
which major complications were suspected. We evaluated the
complications in consideration of the physical findings, pre- and
postoperative photographs, and the surgical findings. The external
aesthetic changes were determined after 12 months of follow-up,
and were compared with follow-up done within 6 months of the
operation. The average follow-up period was 14.2 months. Their
mean age was 27.5 years.
RESULTS
Table 1 shows detailed information on the graft location, number,
and complications. Irradiated homologous costal cartilage was used
as a septal extension graft in 95 cases, derotation graft in 1 case,
columellar strut graft in 11 cases, tip onlay or shield graft in 24
cases, spreader graft in 20 cases, lateral crural strut graft in 5 cases,
alar contour graft in 7 cases, and dorsal onlay graft in 7 cases.
Additional grafts, which means small graft for reinforcing another
graft or structure, were in 142 cases. Table 2 provides detailed
information about the type and number of complications. Total
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Suh et al The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018

TABLE 1. Type of Graft and Number of Complications

Type of Graft Total No. (%) Total Major Complication

Septal extension 95 (29.4) 15

Tip onlay or shield 24 (7.5) 0
Spreader 20 (6.2) 0
Columellar strut 11 (3.4) 1
Alar contour 7 (2.2) 0
Dorsal onlay 7 (2.2) 0
Lateral crural strut 5 (1.5) 0
Derotation 1 (0.3) 0
Additional graft as a reinforcement 142 (44) 0
Total 323 16

TABLE 2. Details of Complications

Complications Total No. (%)

Major complications 16 (4.7)

Infection 4 (1.2)
Partial resorption 1 (0.3)
Total resorption 3 (0.9)
Fracture 2 (0.6)
Fragmentation (resorbed fracture) 4 (1.2)
Warping 2 (0.6)
Extrusion 0
Minor complications 10 (3.1)
Nasal obstruction 1 (0.3)
Visible contour 2 (0.6)
Caudal septal deviation 3 (0.9)
Unfavorable results 4 (1.2) FIGURE 1. Case 1. Preoperative views (above) and postoperative 6 months
Total 26 (8) results (center) of a 26-year-old woman with a contracted nose and retracted
alar. After 5 years, the nasal length and tip projection had returned to nearly
their original state (below).

complication rate was 8%. Major and minor complication rate was was performed. After 8 months, nasal length and tip projection were
5% and 3.1%, respectively. All major complications were con- not diminished. At 9 months of postoperation, when she coughed
firmed by surgical findings in the revision operation. Two fractures hard, she sensed a clicking sound and the nasal tip was upturned.
(0.6%), 4 fragmentation (1.2%), 4 resorptions (1.2%), 4 infections She came to our clinic at 18 months of postoperation, and the nose
(1.2%), and 2 warpings (0.6%) were noted. All infections occurred showed a slightly diminished nasal tip projection (Fig. 3). In
within 2 months postoperatively. Graft deformations (resorption, revision operation, we found that the tip of the IHCC graft had
fracture, warping) were detected 2 to 10 months (mean 6) avulsed from the dome of alar cartilage. But the IHCC itself showed
after surgery. the same size and thickness (Fig. 4).
Most of major complications occurred in cases that were using
IHCC as a septal extension graft. Minor complications, including 1
nasal obstruction, 2 visible contours, 3 caudal septal deviations, and
Patient 3
4 cases of an unfavorable result (defined as patient unsatisfaction), A 46-year-old female patient presented with short nose. In our
were noted. clinic, she underwent augmentation rhinoplasty using IHCC as
septal extension graft. She was not satisfied with the result though
Patient 1
A 26-year-old woman presented with a contracted nose and
retracted alar. An augmentation rhinoplasty with septal extension
graft using IHCC was performed. After 6 months, lengthened nasal
appearance and tip projection were well maintained. After 5 years,
however, the nasal length and tip projection had returned to their
near-original state (Fig. 1). In revision operation, we found that the
tip portion of the IHCC graft had been totally resorbed (Fig. 2).

Patient 2
A 32-year-old woman presented with a contracted nose. An FIGURE 2. Case 1. Intraoperative view of the tip in the revision operation (left).
augmentation rhinoplasty with septal extension graft using IHCC The tip portion (white box) of IHCC graft had totally been resorbed (right).

2 # 2018 Mutaz B. Habal, MD

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018
FIGURE 3. Case 2. Preoperative views (left) and postoperative 8 months results
(center) of a 32-year-old woman with a contracted nose. She came to our clinic
after 18 months postoperation, and showed a slightly diminished nasal tip
projection (right).
nasal length and tip projection were improved and maintained.
After 12 months, revision operation was performed (Fig. 5). In the
operation, we found that the IHCC graft was intact without any
signs of resorption. However, fibrous tissue was observed on suture
sites of the graft (Fig. 6).
DISCUSSION
The IHCC grafts were first reported in 1961 by Dingman and
Grabb,16 and have been widely used since then. Although there have
been some reports on high long-term absorption rate for IHCC,10
recent studies have showed a low overall complication rate associ-
ated with IHCC grafts in rhinoplasty.3– 7,9 Irradiated homologous
costal cartilage can be used for nearly any structural support of the
nose, much like that of an autogenous cartilage.2 It can be utilized as
septal extension, columellar strut, dorsal onlay, batten, and tip graft.
However, there have been no reports studying the relationship
between location of IHCC grafts and complications in rhinoplasty
until now. Also, few reports have suggested methods to reduce the
complications of IHCC grafts.
In 1990, Lefkovits published the report on the use of IHCC in
rhinoplasty in 24 patients and reported complication rates of 7.4%
infection and 14.8% warping.11 Demirkan et al9 reported a low
complication rates of 1.3% warping and 1.3% extrusion in 65
patients in 2003. In 2004, Strauch et al3 described the use of IHCC
in augmentation rhinoplasty in 17 patients. Only one late compli-
cation (shifting of graft) was documented in his report. In 2008, he
also reported no significant warping and resorption except for one
case of early partial resorption in 56 cases.4 Kridel et al7 published
the largest series of IHCC for rhinoplasty in 357 patients in 2009.
The total complication rate was 3.25%, which included warping
(1.06%), infection (0.87%), infective resorption (0.48%), noninfec-
tive resorption (0.53%), and graft mobility (0.31%).
In 2012, we reported minimal 2-year follow-up cases where the
IHCC graft used was solely in septal extension graft.5 No resorption
FIGURE 4. Case 2. Intraoperative view of the tip in the revision operation. The
tip of IHCC graft was avulsed from the dome of alar cartilage (left). Avulsion
fracture of caudal upper portion of IHCC (white box), but IHCC itself shows the
same size and thickness at 18 months postoperatively (right).
# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Homologous Costal Cartilage in Rhinoplasty
FIGURE 5. Case 3. Preoperative views (left) and postoperative 12 months
results (right) of a 46-year-old woman with short nose. The nasal length and
tip projection were maintained.
cases were reported and increased nasal length was maintained in all
cases. However, our previous report had certain limitations, namely,
the sample size was small, and the graft type was confined to
septal extension.
In this study, we included all patients who underwent augmen-
tation rhinoplasty with IHCC, regardless of graft location. The
retrospective review demonstrated a low complication rate for
IHCC grafts. The resorption rate of 1.2%, fracture rate of 0.6%,
and warping rate of 0.6% were confirmed. These results are in close
agreement with those of numerous authors.3,4,7,9,11 Our focus in this
study was, however, on the relationship between graft location and
complications. Our findings indicate that most of the complications
occurred for the septal extension graft cases. We postulate that the
reason is that septal extension graft is under a relatively high tension
to support the tip projection and rotation. Complications of cartilage
autograft, such as a resorption, are known to be associated with high
tensile force,1,17,18 and IHCC displays similar features.10,13 Clini-
cally, of course, most of resorptions would be imperceptible
because it is replaced by fibrous tissue.1 However, as septal
extension graft supports various tensions, its resorption or fracture
can cause external aesthetic changes even if they are small. More-
over, we evaluated the complications based on the external aesthetic
changes. Consequently, complications only for septal extension
grafts may have been tallied, and complications for grafts in other
locations might have been underestimated in our study. A compli-
cation for a graft other than for septal extension might show fewer
external aesthetic changes because the fibrous tissue from resorp-
tion, for example, would maintain its volume.10
Most Asians have noses with thick skin and relatively weak
lower lateral cartilage. The nasal tip is usually underprojected and
FIGURE 6. Case 3. Intraoperative view of the tip in the revision operation. The
IHCC graft was intact without any signs of resorption (left). However, fibrous
tissue (white box) was observed on suture sites of the graft (right).
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Suh et al The Journal of Craniofacial Surgery
FIGURE 7. H&E immunohistochemical staining (40) of IHCC. Well-
maintained extracellular matrix and chondrocytes are seen. However,
degenerative changes are also seen (white arrows). The inner brittle area of
IHCC might correspond to this degenerative portion.
the nasolabial angle is relatively acute. Considering these anatomic
characteristics of the average Asian nose, septal extension graft is a
very useful method for Asian rhinoplasty.19,20 The desired nasal tip
projection and rotation can be achieved at the same time.21 For this
method, a sufficient amount of cartilage is needed to maintain the
tip projection and rotation. However, as we mentioned earlier, it is
difficult to harvest enough autologous cartilage for Asian rhino-
plasty. For these reasons, we have used IHCC as a septal extension
graft in a limited number of cases.5,22 Of course, the best way to
prevent the complications associated with IHCC in rhinoplasty may
simply be not to use IHCC for septal extension graft. However, if it
is necessary, it should be used in an appropriate manner with careful
consideration of the immunological characteristics of IHCC.
Irradiated homologous costal cartilage is composed of chon-
drocytes and a matrix composed of collagen and proteoglycans.
Chondrocytes are highly antigenic, but the matrix is considered
immunologically nonreactive. As the matrix isolates chondrocytes
from exposure to immune cells and the circulating antibodies, the
cartilage is immune-privileged.23,24 Therefore, theoretically, IHCC
would not have antigenicity if the perichondrium were to be
removed correctly. However, manipulation of cartilage such as
carving does result in exposure of chondrocyte at the cutting surface
and this may lead to an immunologic reaction,5,24 but this reaction
would be limited to the cutting surface.
We experienced most cases of major complications in the early
years of the use of IHCC for rhinoplasty. Based on the immuno-
logical characteristics and our experience with IHCC in rhino-
plasty, we established the following criteria to reduce
complications with IHCC. First, selection of an outer dense area
of IHCC is important. The density of the IHCC is different from
part to part for the same piece of IHCC, as there is a dense outer area
and a brittle inner area. Chance of degeneration of the brittle area
would be high (Fig. 7), and this brittle area should thus be
discarded. Second, it is important to thoroughly cleanse the graft
piece after carving to reduce an innate immune response. During
carving of the IHCC, the lacuna can be destructed, leading to
exposure of chondrocytes and the presence of extracellular cell
debris such as DNA, RNA, lipids, and carbohydrates. These might
cause an innate immune response.13 Cleansing of the graft would
reduce the immune response that may contribute to the complica-
tions. Third, during fixation, care should be taken as to minimize
exposing too much of the cutting surface for the IHCC graft,
4 #
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 00, Number 00, Month 2018
particularly for a septal extension graft. As we mentioned earlier,
exposure could lead to an immunogenic reaction with the graft
chondrocytes. A few penetrations on the graft would not present a
problem, as any immune reactions would be confined to the cutting
surface of the hole (Fig. 6). However, too many penetrations and a
large hole by a cutting needle might cause structural weakness,
followed by graft fracture. Therefore, it is prudent to perform a
minimum amount of suturing by using a round needle. The tip
portion of the IHCC graft should also not be sutured directly.
Penetration of this portion can cause an avulsion fracture even if
the number of sutures is few (Fig. 4). It is also preferable to use
toothless forceps to avoid microtrauma to the surface of graft by
forceps teeth.
This is the first study that evaluated the relationship between
graft location and complications of IHCC in rhinoplasty. However,
this study has important limitations, mostly stemming from its
small sample size, short follow-up period, and a retrospective
design. In addition, we evaluated the complications based on
the external aesthetic changes. As a result, complications that
did not bring a change in outward shape were not evaluated.
Therefore, a large, long-term, histologic, and/or radiologic study
would be required to verify and validate the findings and
recommendations made.
CONCLUSIONS
Based on the outcomes of this study, we concluded that IHCC is
a useful and reliable source of cartilage graft and can serve as an
alternative graft material for rhinoplasty. However, care must be
taken in use of IHCC graft for areas under tension such as for
septal extension grafts, although its complication rate is low.
Also, the methods that we suggest would be important to reduce
the complications.
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# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Homologous Costal Cartilage in Rhinoplasty
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