Crushed cartilage grafts for concealing irregularities in rhinoplasty

OBJECTIVE: To assess the clinical outcome of crushed cartilage grafts used to conceal contour irregularities in rhinoplasty. METHODS: We reviewed the medical records of 462 patients in whom crushed autogenous cartilage grafts were used, selected from a total of 669 patients in whom rhinoplasty procedures were performed at our institution between June 1, 1999, and June 1, 2006. The grafts were used as slightly, moderately, significantly, or severely crushed. RESULTS: Eight hundred nine cartilage grafts (41 slightly crushed grafts [5%], 650 moderately crushed grafts [80%], and 118 significantly crushed grafts [15%]) were used in 462 patients. Resorption occurred in 11 of the 462 patients (2.4%). All of the resorbed grafts (6 moderately crushed grafts and 5 significantly crushed grafts) had been placed in the dorsal area. The resorption rate of those grafts was lower in the moderately crushed cartilage grafts (6 of 284 grafts [2.1%]) than in the significantly crushed grafts (5 of 38 grafts [13.1%]). There was no resorption of slightly crushed grafts. CONCLUSIONS: The degree of crushing applied is important for long-term clinical outcome of autogenous crushed cartilage grafts. Slight or moderate crushing of cartilage creates an outstanding graft material for concealing irregularities and provides both excellent long-term clinical outcome and predictable esthetic results.     

The use of spreader grafts in primary rhinoplasty

Some candidates for primary rhinoplasty are at greater risk of postoperative complications due to the presence of certain very specific anatomic characteristics. The authors describe their experience with spreader grafts in primary rhinoplasty and provide an analytic method of identifying the types of patient needing such grafts who present a high risk of complications. Sixty patients were treated with spreader grafts during primary rhinoplasty. Bilateral spreader grafts were used in cases of "narrow nose syndrome" (short nasal bones, long and weak upper lateral cartilages, thin skin) and in cases of disproportionate nose with narrow middle vault and bulbous tip. Unilateral spreader grafts were placed on the concave side in cases of crooked nose. After an average follow-up of 17 months, all the patients reported improvement in functional and esthetic problems, with no complications related to the preoperative features.     

Immediate autogenous cartilage grafts in rhinoplasty after alloplastic implant rejection

BACKGROUND: It is accepted in rhinoplasty that complications are more common with alloplastic implants than with autografts. There is little guidance in the literature on how to deal with the cosmetic and/or functional problems that follow alloplastic implant rejection. The conventional advice has been to remove the allograft and not place any graft at the same time. The present article presents our experience treating allograft rejection and immediately repairing any structural defect with autografts. OBJECTIVE: To demonstrate that immediate nasal reconstruction using autogenous cartilage is a good technique when an alloplastic material has to be removed because of rejection, inflammation, or infection. DESIGN: A retrospective analysis of outcome for a case series. METHODS: A retrospective review of the management of 8 patients who presented to 2 tertiary referral centers with alloplastic implant rejection following rhinoplasty. In 7 cases, the alloplastic implant had to be removed because it had migrated and caused a foreign body reaction; in 1 case, the implant had caused a bacterial infection. RESULTS: In all 8 cases, the nasal deformity that followed the removal of the allograft was so marked that the nose was immediately reconstructed with autogenous cartilage. The patients all made a good recovery after immediate reconstruction, although skin changes associated with the alloplastic implant remained after a mean follow-up of 3 years 3 months. CONCLUSION: The use of autogenous cartilage is a good option for nasal augmentation immediately after the removal of an alloplastic implant.     

Tragal cartilage grafts in rhinoplasty: a viable alternative in the graft-depleted patient.

OBJECTIVE: To describe a simple technique for harvesting tragal cartilage and describe its use in rhinoplasty. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: Rhinoplasties performed between January 2005 and June 2007 in which tragal cartilage grafts were utilized by the senior author (CSC) were reviewed to assess type of graft, preservation of tragal contour, and donor-site morbidity. RESULTS: Tragal cartilage grafts were used in three primary and three secondary rhinoplasty patients. Postoperative follow-up ranged from six months to 12 months. Tragal cartilage was used as five alar contour grafts, one lateral crural onlay graft, one dorsal onlay graft, and one infratip lobule graft. Tragal cartilage was used to close the septal perforation of one patient. Tragal contour was preserved in all patients, and there were no complications noted with this procedure. CONCLUSION: The tragus provides a simple, convenient alternative source of cartilage for rhinoplasty in graft-depleted patients.     

Cleft lip rhinoplasty: the role of bone and cartilage grafts

Correction of the cleft lip nasal deformity involves repositioning of the lower lateral cartilage on the cleft side to raise the dome, lengthening the columella and bringing it toward the midline, and correcting any asymmetries of the nasal floor. Additional structural support in the form of bone or cartilage grafts is often required in order to achieve the desired projection and angularity. Our experience with these grafts in a large number of patients over the past 20 years has shown them to produce good, predictable results that are long lasting, with minimum donor site morbidity. Long-term follow-up indicates that these grafts maintain their volume and original features, resulting in satisfaction among our patients.     

Combined silicone and cartilage implants: augmentation rhinoplasty in Asian patients

Various alloplastic materials are used for nasal augmentation in Asian patients. Of these, silicone is the most prevalent because it is durable and facilitates sculpting. However, silicone grafts have been associated with complications, including tip extrusion, infection, and graft shifting. Often the nasal tip is involved, with skin discoloration and possible implant extrusion due to increased mechanical pressure. Autogenous material provides a safer alternative for nasal augmentation, but the supply of septal or auricular cartilage in Asian patients is limited. To augment optimally and reduce extrusion risk, we use auricular cartilage grafts at the nasal tip and silicone implants for the nasal dorsum in Asian patients. We report the results of this technique in 100 Asian patients with up to 5 years of follow-up. Patients were extremely satisfied, and no implant extrusions resulted. Other complications included further surgical revision due to misalignment of the silicone dorsal implant (5 patients), tip graft shifting (2 patients), and recurrent dorsal edema over the implant requiring removal (1 patient).     

Tip grafts in revision rhinoplasty

In the patient who undergoes revision rhinoplasty, tip grafts are used often when overresection has resulted in structural deficit of deformity. As a result, the last 20 years have witnessed a progressive movement toward more conservative handling of the nasal tip. Still, as some surgeons have not adopted that philosophy and because many more surgeons have not adopted that philosophy and because many more surgeons now take on difficult primary tip problems because of the advent of the external approach, major tip problems continue to plague the final result. Despite these potential variables, when used correctly, the tip graft is critical in achieving the successful reconstruction of the nasal tip region. This article reviews the indications and techniques for tip grafts in revision rhinoplasty and explores how these indications and techniques for tip grafts in revision rhinoplasty and explores how these indications could be prevented in the primary setting.     

Postauricular cartilage storage in rhinoplasty

In the past decade, the number of patients demanding rhinoplasty has increased, and this has increased the use of grafts. Although different materials are used as grafts, cartilage is the most popular one. In secondary rhinoplasties the need for cartilage is very frequent. The most suitable cartilage grafts are the ones extracted during primary rhinoplasty. These grafts are disposed of after the operation and in a secondary operation, grafts are obtained from a new donor site. In our department, the surplus cartilages obtained during primary rhinoplasties of the patients who are thought to be probable secondary rhinoplasty candidates are stored in a postauricular pocket after their volumes are measured and marked down. In the secondary operations the volume of the grafts are measured again and the grafts are used. We have found out that there is no significant difference between the initial and secondary volumes of lower lateral cartilages (3.6% of initial volume is lost), but the difference between the initial and secondary volumes of septal cartilages is significant (6.9% of initial volume is lost), and the stored cartilages are sufficient qualitatively and quantitatively for the secondary rhinoplasties.     

Auricular cartilage in revision rhinoplasty

Revision rhinoplasty is a challenge in reconstruction to the rhinoplasty surgeon, both in the techniques of repair and the choice of implant material for augmentation grafting. Often, patients seeking revision or reconstructive rhinoplasty have previously undergone septoplasty with sacrifice of major amounts of septal cartilage. These situations confront the surgeon with the need for a decision about the material that will be used for structural grafting. The senior author follows the time-tested approach of generations of surgeons who have used exclusively autogenous material for nasal reconstruction because of its superior long-term survival characteristics, its ready availability in the head and neck region, its resistance to infection and resorption, and its bendability and flexibility when implanted in the nose. With this in mind, the subject of this article is the use of auricular cartilage in revision rhinoplasty. Careful strategic planning must be undertaken to get the maximal and ideal benefit from the auricular cartilage. The revision rhinoplasty surgeon must understand the anatomy of the external ear and must be able to manage the precious cartilage supply to get the maximum use of it in reconstructive rhinoplasty.     

The decision process in choosing costal cartilage for use in revision rhinoplasty

The aims of rhinoplasty reconstruction include maintaining or augmenting long-term tip projection, restoring rigid dorsal stability, and restoring optimum respiratory function. The methods set forth to obtain these objectives are inherently based on the intrinsic nasal principles at the time of the rhinoplasty. Because of the excellent and consistent results autologous costal cartilage grafts provide when faced with problems such as the traumatic saddle deformity, defects after neoplastic resection, congenital nasal deformities, severe tip weakness or underprojection, rhinoplasty in the ethnic patient, and revision rhinoplasty, they are an invaluable resource to the rhinoplasty surgeon. Once the surgeon becomes comfortable and proficient at harvesting this graft, it inevitably will become the graft of choice when substantial amounts of cartilage are required.     

The use of preserved autogenous septal cartilage in "touch-up" rhinoplasty

The management of minor contour irregularities after primary aesthetic rhinoplasty often requires correction of soft tissue defects with autogenous cartilage, allograft materials, xenograft matrix, or alloplasts. Inasmuch as the use of native cartilage requires an additional procedure (and potential donor site morbidity) and alloplast insertion raises the specter of extrusion or cicatrical deformity, the use of preserved autogenous cartilage is an attractive alternative, particularly for minor revision surgery. This study describes the experience and technique of the senior author (P.F.G.) with the use of isopropyl alcohol-preserved autogenous nasal cartilage during revision rhinoplasty in which only minor contour correction is required. When grafts are needed for revision surgery, they are inserted via small intranasal stab incisions into minor irregularities of the tip, alae, and dorsum. This technique eliminates the need for additional surgery to obtain graft material, reduces costs and risks associated with alloplasts, and is particularly useful for minor revision rhinoplasty. Office-based techniques for preserving cartilage are reviewed.     

Nasal grafts and implants in revision rhinoplasty

Problems associated with primary rhinoplasty are often due to overresection of the nasal skeleton. One of the primary goals in revision rhinoplasty is to restore nasal architecture. To do so, the facial plastic surgeon can choose from numerous grafting materials. A key understanding of the benefits and limitations of each implant or graft and implants commonly used in revision rhinoplasty surgery.