The use of lower turbinate bone grafts in the treatment of saddle nose deformities

Saddle nose reconstruction is based on the use of support grafts to manage aesthetic and functional problems. Bone (calvarial, iliac crest, costal, nasal hump, ulnar, and heterogeneous origin), cartilage (septal, costal, heterogeneous), and synthetic materials (silicon, silastic, polyethylene) were used as support grafts. Three patients have been included in this study to define the surgical management and long-term aesthetic and functional results of patients undergoing rhinoplasty with support grafts for a saddle nose deformity. Open rhinoplasty was employed. Both the lower turbinates were excised and the bone dissected from the soft tissues in two cases and in one case, only mucosa was removed. The amount of support needed was measured by using bone wax. The bone was used shaped in layers, according to the defect, and sutured to each other by vycril suture, and wrapped around by surgicell. The graft was then inserted in its place and fixed with external prolene sutures. Results were satisfactory in both function and aesthetics. Ten to 16-month follow-ups had no complications. Saddle nose surgery basically requires the use of a support graft to repair the nasal dorsum. A lower turbinate bone graft procedure has some advantages: it is cheap and safe, it is ready to use and not time-consuming, there is no donor area and no additional donor site morbidity, and it enlarges the airway and the passage to prevent nasal airway obstruction.     

Reconstruction of the major saddle nose deformity using composite allo-implants

The major saddle nose deformity leaves a patient with an obvious aesthetic deficit as well as an equally disturbing functional handicap. Reconstructing the collapsed dorsum and tip and simultaneously restoring nasal function present a formidable challenge which has elicited a wide variety of solutions ranging from the use of a toothbrush handle to split calvarial grafting. As Murakami et al pointed out, the "variability exists to a large extent, because the saddle nose deformity is not a single entity but rather a spectrum of abnormalities." Attempts to categorize saddle nose deformities are useful; however, they often lack the simple impact and clarity of the pre-operative photograph. Moreover, the categorizations have not led to a uniform approach to this complicated problem. Nevertheless, Tardy's classification of minimal, moderate, and major saddle nose deformities provides a helpful framework for discussion of reconstructive options. Minimal deformities demonstrate a supratip depression of 1 to 2 mm and are easily corrected with cartilage or fascial overlays. Moderate saddle nose deformities are characterized by a significant loss of dorsal height as well as columellar retraction and broadening of the bony pyramid. A major deformity demonstrates "all of the stigmata of the moderately saddled nose, only to a more marked degree." In Tardy's opinion, an open approach may be warranted in these cases. We offer one solution to the major saddle nose deformity using a composite allo-implant of porous high-density polyethylene (PHDPE) (Medpor surgical implants, Porex Surgical, Inc., College Park, GA) and purified acellular human dermal graft (Alloderm, Life Cell Corp., TX.). While we readily admit that autogenous tissue is the preferred grafting material, we have encountered patients in whom this is not an option. Major saddle nose deformities typically require more augmentation than stacked septal or auricular cartilage can provide. Additionally, in patients seeking revision rhinoplasty, sufficient donor septal or auricular cartilage is often lacking. Resorption of irradiated cadaveric rib grafts has led us away from this material. Split calvarial bone grafts are our next recommendation for these patients; however, many patients refuse this option. In these patients we have turned to a composite allo-implant of PHDPE and acellular human dermal graft for reconstruction of the collapsed dorsum and tip.     

Saddle Nose: Our Approach to the Problem

Saddle nose is usually caused by a trauma or by excessive resection of the septal cartilage. Nevertheless, there are other, less frequent causes of injury, such as congenital, syphilis, leishmaniosis, and leprosy. Within this context, it is very likely to see widening of the bony bridge and dropping of the tip of the nose. For this clinical status, we found extremely satisfactory a therapy in which we use a dorsum cartilage graft, followed by narrowing of the nasal bridge and shortening of the nose. To achieve this aim, different kinds of materials were employed. The authors usually prefer rehydrated (0.9% saline solution) human costal cartilage. This material was used in a study of a series of patients with saddle nose in which we used open rhinoplasty and cartilage homografts.     

Correction of Major Saddle Nose Deformities with Nasomaxillary Depression Using an Intraoral and External Open Rhinoplasty Approach

Nasomaxillary depression, which may be seen with major saddle nose deformities, especially as a sequel to childhood nasal trauma, generally is overlooked during management of the saddle nose. To handle both the saddle nose deformity and nasomaxillary depression, the authors used a one-stage intraoral and external open rhinoplasty approach for 12 patients. Lateral nasal osteotomies and correction of midface retrusion with crescent-shaped autogenous rib cartilage grafts were performed through two bilateral intraoral gingivobuccal incisions. The external open rhinoplasty approach was used for the correction of the saddle nose deformities. The mean follow-up period after the surgery was 2 years (range, 1–3.5 years). The correction of nasal tip depression resulting from midface retrusion was evaluated by lateral cephalometric radiographs. The mean movement of the nasal tip anteriorly in the sagittal plane 1 year after the operation was 5.5 mm (range, 4–7 mm). The functional and aesthetic results were satisfactory for all the patients. As the findings show, the intraoral part of the approach provides a route for the placement of cartilage grafts to correct the depressed nasal tip, augment the paranasal area, and provide support to the lateral alar bases and the controlled low-to-low lateral osteotomies. The external part of the approach provides correction of the saddle nose deformity.     

Saddle nose deformity reconstruction with a split calvarial bone L-shaped strut

OBJECTIVE: To describe a technique for creation of a split calvarial bone L-shaped strut that provides dorsal support while increasing tip projection in patients with substantial septal saddle nose deformities from various underlying inflammatory conditions and surgical resection. METHODS: Case series and review of the literature. RESULTS: Fifteen patients underwent nasal reconstruction at our institution using the split calvarial bone L-shaped strut technique with postoperative follow-up to 36 months (range, 9-36 months). The causes of septal perforation leading to saddle nose deformity included cocaine use, infection, sarcoidosis, malignant lesion, iatrogenic causes, and Wegener granulomatosis. All cases resulted in an augmented, straightened nasal dorsum and increased tip projection. Results were maintained throughout follow-up with no evidence of graft infection, resorption, or migration. CONCLUSIONS: The split calvarial bone L-shaped strut provides dual benefits of dorsal support and increased tip projection. Numerous techniques have been discussed for dorsal augmentation with varied success; however, the long-term maintenance of this graft in patients with severely compromised vascularity owing to underlying inflammatory conditions such as Wegener granulomatosis highlights its presumed advantages. The procedure can be performed using the external rhinoplasty approach, obviating the need for radix incisions for plating or intranasal mucosal incisions. These advantages make the L-shaped strut technique excellent for nasal reconstruction in patients with substantial septal saddle nose deformities regardless of cause and duration of defect.     

Bone Chips and Diced Cartilage: An Anatomically Adopted Graft for the Nasal Dorsum

Since 1996, cranial bone chips or septal bone chips harvested during septal deviation surgery and small chips of ear or septal cartilage have been used in 67 patients for dorsal nasal augmentation or for smoothing dorsal nasal irregularities. In this study, 59 overresections of ostecartilaginous nose structures during previous aesthetic nose surgeries and 8 primary rhinoplasties occasioned the use of bone or cartilage grafts. For 57 patients both bone and ear cartilage grafts were used for the reconstruction. Bone grafts were used for seven cases and cartilage grafts for three cases.The results from 7 years, of experience with this method of nasal dorsum reconstruction were satisfactory and durable. The most important advantage of this method is that the bony side of the nose is reconstructed with bone and the cartilage side with cartilage. Another advantage is that the bone chips are incorporated with both nasal bones, building a strong dorsal nasal bony monoblack.This technique also is useful for augmenting mild saddle nose deformity and dorsal nasal projection deficiency on the bony part, cartilage part, or both parts.Presented at 16th Congress of ISAPS, Istanbul, Turkey, 26–29 May 2002 and 24th National Meeting of the Turkish Plastic Reconstructive Aesthetic Surgery Society, Ankara, Turkey, 18–20 October 2002.     

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.     

Umbrella graft of columella tip: 20 years' experience

We present our experience with nasal grafts over 20 years. The nose, located centrally, always plays a key role in facial aesthetics. Public recognition of this makes rhinoplasty the most popular operation. From the traditional aesthetic point of view, propogated by the media, the nose must be narrow and straight and have correct nasolabial and forehead angles. It is the desire of every surgeon to obtain permanent and satisfactory cosmetic results. However, it is not always possible to obtain good cosmetic appearance using conventional methods when the nose is small or large, when the columella is short, or when the skin is thick. Mostly, nasal tip projection cannot be achieved. In the present article, we report our experiences in primary asthetic rhinoplasty using cartilaginous grafts obtained from septum, costa, and ear as umbrella grafts of columella type.     

Allogenous Cartilage Graft Versus Autogenous Cartilage Graft in Augmentation Rhinoplasty: A Decade of Clinical Experience

Cartilage grafts have great value in augmentation rhinoplasty. For most surgeons, an autogenous cartilage graft is the first choice in rhinoplasty because of its resistance to infection and resorption. On the other hand, an allogenous cartilage graft might be preferred over an autogenous graft to avoid additional morbidity and lengthened operating time. Allogenous cartilage grafts not only have the advantage of averting donor site morbidity but also are resistant to infection, resembling autogenous cartilage grafts. The authors present their experience with 41 patients who underwent augmentation rhinoplasty using 22 autogenous and 19 allogenous cartilage grafts between June 1994 and August 2004. For evaluation of adequate augmentation rates, photographic analyses were performed on preoperative, early postoperative, and late postoperative photographs from all the patients. To assess patient satisfaction, the Facial Appearance Sorting Test (FAST) was applied preoperatively and late postoperatively in both groups. These results were compared, and it was concluded that in terms of resorption, there was no difference in the early and late postoperative follow-up data between allogenous and autogenous cartilage grafts. Evaluation of the preoperative and early postoperative photographic outcomes showed statistically significant differences with respect to adequate augmentation rates between the two groups. The FAST scores showed statistically significant differences between preoperative and late postoperative outcomes. There were no infections in the two groups of patients. Commentary to DOI: .     

Secondary rhinoplasty: management of the overresected dorsum

Any discussion of grafting the dorsum in secondary rhinoplasty must take into account the different indications (aesthetic, augmentation, and structure) as well as recent changes in materials and techniques (fascia, diced cartilage). We have placed solid dorsal grafts with diced cartilage grafts either as an isolated diced cartilage graft in fascia graft or as the aesthetic dorsal contour layer of a composite reconstruction. The rational for this profound change in selection and indication of dorsal grafts for revising the overresected dorsum will become clear as the various alternative materials and techniques are analyzed. Currently, we only employ autogenous tissues.     

The use of augmentation rhinoplasty techniques for the correction of the non-caucasian nose

To refine, enlarge, and enhance the mestizo nose, it is necessary to augment the structural support. The authors report on a series of more than 3000 patients over the last 20 years, exploring the possibilities of autogenous graft for augmentation of the nose. Their series showed minimal resorption of the bone grafts, no loss of volume of the cartilage grafts, and satisfactory long-term results.     

Extracorporeal Septoplasty Combined with Open Rhinoplasty

Extracorporeal septoplasty is a radical solution for the severely deviated nose. The major problems associated with this procedure are fixation of the septal cartilage graft and dorsal irregularities. Extracorporeal septoplasty was performed in combination with open rhinoplasty in 17 patients with severe nasal deformities. In this technique septum was totally removed through the columellar incision of open rhinoplasty, corrected outside, and replaced as a free ``L' shaped cartilage graft. The cartilage graft was fixated to the upper lateral cartilages to restore the natural relations of the anatomical structures. Additional rhinoplastic manipulations were also performed. The follow-up period was up to 18 months. The overall result was successful in all patients. Nasal deviation did not recur and secondary revisions were not needed for any patient during follow-up.     

Modified Alar Swing Procedure in Saddle Nose Correction

Reconstruction of the saddle nose may involve the use of different augmentation materials, from autogenous bone and cartilage to alloplastic materials. The most important problems when considering the choice of reconstructive technique, besides underlying pathology and expected result, include: long-term stability, donor morbidity, tendency of the implant to infection, extrusion, and resorption. The use of the lateral crura of the lower lateral cartilages as dorsal onlay was reserved for the corrections of minor supratip depressions (flying wing and alar swing procedure). The authors suggest the use of pedicled flaps of cephalic portions of lateral crura as dorsal septal strut, which may increase the profile line more than dorsal onlay. Reconstruction is performed using open rhinoplasty approach. Pedicled flaps of the cephalic portions of lateral crura are transfixed in the sagittal plane and, following separation of upper lateral cartilages and medial crura, placed on the dorsum of nasal septum. Upper laterals are sutured to newly formed cartilaginous dorsum, or a new bridge is created using conchal cartilage. Columellar strut may be formed of the septal cartilage. Authors have performed such corrections in 15 patients with good long-term functional and aesthetic results.     

Our Experience with Silicone in Rhinomentoplasty

Based on a review of the literature and our own experience, we propose criteria for the site of implantation that, in our eyes, is suitable for a silicon implant or a cartilage transplant. Special interest is focused on rhinoplasty and chin augmentation, as both determine the facial profile of the patient. During the last 17 years we have treated 443 patients with augmentation rhinoplasty, of whom 360 received autologous ear cartilage grafts and 83 received autologous rib cartilage grafts. At the same time we saw 30 patients requiring removal of artificial implant materials that were used by other surgeons for rhinoplasty augmentation purposes. Since 1986 we have performed 60 chin augmentations with anatomically shaped silicone implants (McGhan), of which 40 patients had a combined rhinomentoplasty done.     

自体耳软骨移植79例鼻成形术的临床分析

目的探讨自体耳软骨移植鼻成形术的临床效果。方法针对外鼻短小，鼻尖低平、肥大钝圆。以及部分隆鼻术后效果不佳的国人，在隆鼻的同时切除鼻翼大软骨外侧脚的上外侧部，并水平褥式缝合，将鼻翼大软骨内侧脚缝合，以缩小鼻小柱宽度及延长鼻小柱；切取自体耳软骨，用以抬高及延长鼻尖。结果对本组79例求美者进行了3～18个月的随访，效果稳定，无并发症及继发畸形的发生。结论自体耳软骨移植鼻成形术其方法较好，效果明显，值得在临床上推广应用。     

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.     

Nasal reconstruction using split calvarial grafts.

The reconstruction of nasal deformities after trauma or surgical procedures presents an arduous task for the reconstructive surgeon. The anatomic alteration of supporting cartilage and nasal bones, as well as scar formation, compound the difficult nature of this type of reconstruction. In the past, multiple autogenous and alloplastic implants have been used in nasal reconstruction. Autogenous implants include auricular and septal cartilage as well as rib and iliac crest bone grafts. Alloplastic materials include acrylic, supramid mesh, Gortex, and silicone rubber. Autogenous grafts have been shown to provide excellent long-term reliable results in nasal reconstruction. In our study, autogenous split calvarial bone grafts were used in the nasal reconstruction of 17 patients. Among the corrective procedures were dorsal augmentation for saddle-nose deformities, insertion of columella struts for nasal tip ptosis, and insertion of nasal battens for nasal valve collapse. Patient followup has been from 1 to 5 years, with no significant resorption noted during that time. Complications were limited to one seroma at the donor site before wound drains were routinely used. No major complications, including hematoma formation, CSF leak, or infection, have been observed.     

The healing of bone and cartilage

Transplantation of bone should be preceded by careful assessment of the recipient site. The function of the transplanted bone as an interposition graft, as an onlay graft, or in restoration or construction of a missing part of the skeleton must be considered. Cortical bone provides superior mechanical strength and can be incorporated with plate fixation to span interposition defects. Membranous bone used as onlay grafts for augmentation of craniofacial skeletal contour has been shown to be superior to endochondral grafts in maintaining volume. The use of rigid fixation to secure onlay grafts may eliminate the differences in resorption seen with membranous versus endochondral bone. The vascularity and quality of soft tissue at the recipient site may necessitate the use of vascularized bone or composite free tissue transfer. The calvarium is the most popular donor site for bone grafts used in craniofacial skeletal procedures. This membranous bone undergoes less resorption and revascularizes faster than endochondral bone. Cranial bone has excellent mechanical strength due to its large cortical component. The calvarial donor site causes less discomfort to the patient compared with rib or iliac crest, and the scar is well hidden. Harvesting and shaping cranial bone require special expertise, and there is potential morbidity. In cartilage transplantation, the surgeon must take into account the properties of viscoelasticity, the intrinsic balanced system of forces, and immunologic privilege. Cartilage deformed by an external force will tend to return to its original shape unless the deformation is maintained for several months. Surgical carving produces changes in the balance of intrinsic tensile and expansile forces, causing distortion in cartilage shape. Distortion can be minimized by carving in balanced cross-section. Carved cartilage grafts should be used for special indications in rhinoplasty. Autogenous cartilage is the framework of choice in ear construction. Composite grafts incorporating cartilage have been used successfully in eyelid reconstruction. Fresh autogenous cartilage is preferable to preserved allogeneic sources, as the latter undergo eventual resorption because there are no viable chondrocytes to maintain the matrix.     

Chin augmentation using diced cartilage

Eight patients with microgenia have undergone augmentation with diced nasal cartilage. Cartilage grafts were harvested from the nose during rhinoplasty. These grafts were cut into 0.5 to 1.0 mm pieces using a #11 blade and were wrapped in one layer of Surgicel (oxidized regenerated cellulose). This cartilage mass was inserted into the chin pocket. All patients underwent clinical evaluation, magnetic resonance imaging (MRI), and photography. These investigations showed that diced cartilage grafts maintained 75% of their dimensions at six months after implantation. The follow-up period was 12 months, and the aesthetic results were satisfactory. Received: 5 May 1997 / Accepted: 21 August 1997     

Nasal bone grafting using split skull grafts

The nose has been reconstructed with bone grafts, cartilage, and silicone. Each of these methods has disadvantages, but the bone graft is most trouble free. It is possible to take a split skull graft with a high speed drill and an osteotome. The position of the graft site on the skull determines its shape. This can be tailored to the desired nasal contour. Several grafts may be used to build up the nasal dorsum further. This method has been used in patients suffering from acute trauma and deformities resulting from previous trauma, rhinoplasty, congenital anomalies, and after cancer resection. Apart from 1 scalp wound infection, there have been no complications in 24 cases. The degree of bone graft resorption has been minimal, and the level of patient satisfaction has been high.