Optimal Costal Cartilage Graft Selection According to Cartilage Shape: Anatomical Considerations for Rhinoplasty

Bender-Heine AN, Zdilla MJ, Russell ML, Rickards AA, Holmes JS, Armeni MA, Lambert HW.

PubMed 29195250 Publisher (DOI)Free full text (PMC)

What this paper says

Measuring 96 cadaveric rib cartilages, the authors found the fifth is the straightest and best suited to bridge onlay grafts, while the sixth and especially the seventh curve most sharply and suit L-shaped grafts.

Overview

Rib cartilage is a common graft source in rhinoplasty, and surgeons disagree about which rib level gives the best graft. Grafts are usually shaped to match where they will go. The authors note that descriptions of rib cartilage shape have been largely anecdotal, so they measured the shapes directly.

Sections of note

96 cadaveric costal cartilages were analyzed using geometric morphometric analysis.
The study focused on the most commonly grafted levels, the fifth through seventh cartilages.
Reported graft shapes in the literature include boat, C, canoe, U, crescent, L, semilunar, straight, and Y shaped.
The fifth costal cartilage was the straightest.
The fifth is therefore described as particularly suitable for nasal dorsum onlay grafting.
The lateral portions of the sixth, and especially the seventh, cartilages had the most acute curvature.
Those are described as suited to an en bloc L-shaped or hockey stick-shaped dorsum and columellar strut graft.

What it means for a patient

Which rib the surgeon takes affects what shape of graft can be carved from it.
A straight rib suits building up the bridge; a curved one suits a single piece that supports both the bridge and the tip.
This is anatomical measurement in cadavers, not a study of surgical outcomes.
The study does not report warping, resorption, donor site pain, or how the grafts performed in patients.

Why this paper matters

Rib harvest level has been chosen by habit and access rather than by measured shape. Providing measured curvature by level makes the choice deliberate. Whether choosing by shape improves surgical results is not tested here.

Terms

Costal cartilage: The cartilage joining a rib to the breastbone, used as a graft source.
Cadaveric: From donated bodies, studied after death.
Geometric morphometric analysis: A statistical method for comparing shapes using landmark coordinates.
Onlay graft: A graft laid on a structure to add height or contour.
En bloc: In one continuous piece.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

Abstract

Costal cartilage grafting is a commonly used reconstruction procedure, particularly in rhinoplasty. Although costal cartilage is broadly used in reconstructive surgery, there are differing opinions regarding which costal cartilage levels provide the most ideal grafts. Grafts are typically designed to match the shape of the recipient site. The shapes of costal cartilage grafts have been described as “boat-shaped,” “C-shaped,” “canoe-shaped,” “U-shaped,” “crescent-shaped,” “L-shaped,” “semilunar,” “straight,” and “Y-shaped.” The shapes of costal cartilages are thought to lend themselves to the shapes of certain grafts; however, there has been little study of the shapes of costal cartilages, and most reports have been anecdotal. Therefore, this study is aimed to detail the average shapes of the most commonly grafted cartilages (i.e., the fifth to seventh cartilages). A total of 96 cadaveric costal cartilages were analyzed through geometric morphometric analysis. The fifth costal cartilage was determined to have the straightest shape and would therefore be particularly suitable for nasal dorsum onlay grafting. The lateral portions of the sixth and, particularly, the seventh costal cartilages have the most acute curvature. Therefore, they would lend themselves to the construction of an en bloc “L”-shaped or hockey stick-shaped nasal dorsum-columellar strut graft.

Abstract as indexed by PubMed; the article is open access (PubMed Central).