Nose and paranasal augmentation: autogenous, fascia, and cartilage

The up-to-date plastic surgeon should consider using augmentation rhinoplasty with relative frequency. In selected cases, for improving the face integrally, it is desirable to augment the paranasal area. In the author's hands, grafts of cartilage and fascia are the preferred tissues, based on the experience of many years. Fascia can be used alone or combined, and in the last few years we have used it alone quite often. A temporoparietal fascia graft has great versatility in the correction of a number of nasal deformities. A depressed nasal dorsum can be augmented by utilizing fascia grafts. A depressed nasal radix can be corrected successfully by utilizing fascia grafts. Submucosal placement of strips of fascia has proved to be an effective method of reconstructing the roof of the middle cartilaginous vault. For augmenting the nasal dorsum when it is a case of primary rhinoplasty, the author prefers the use of fascia alone, but if the patient is having a secondary rhinoplasty, then the graft of fascia and cartilage combined is preferred.     

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.     

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.     

鼻中隔软骨联合自体真皮组织在鼻综合整形术中的应用

目的探讨应用鼻中隔软骨行鼻尖塑形,并联合采用自体真皮组织隆鼻的临床疗效。方法本组36例求美者均采用鼻小柱开放式切口,应用自体鼻中隔软骨,根据需要做鼻小柱支撑物、鼻尖移植物或鼻中隔延伸移植物;于臀下皱襞处取真皮组织瓣,去除表皮及皮下脂肪,切开真皮,缝合成多层置于鼻背筋膜下,妥善固定。结果36例求美者术后无切口感染裂开及软骨外露,鼻外形自然饱满,鼻尖表现点明显,侧面观弧线圆润。术后随访3个月至2年,切口无明显瘢痕增生,鼻外形无显著变化,效果满意。结论鼻中隔软骨联合自体真皮组织移植是综合鼻整形中的有效方法,值得临床推广应用。     

Modification of the Skoog dorsal reduction for preservation of the middle nasal vault

Preservation of the middle nasal vault has increasingly become a topic of interest and concern in rhinoplasty. Modification of the nasal dorsum with traditional techniques may create unfavorable cosmetic results and adverse functional sequelae due to collapse of the middle nasal vault. Nasal dorsal reduction invariably involves separating the upper lateral cartilage (ULC) attachments from the dorsal septum. A number of procedures are used to reestablish the width of the middle nasal vault and competence of the internal nasal valve. Spreader grafts are the most frequently used technique. Although these grafts reliably preserve the middle vault, dorsal irregularities may result. Alternative techniques, such as suture suspension of the ULCs to dorsal onlay grafts or direct suturing of the ULCs to the septum, may pose similar problems. We have found that a modification of the Skoog technique for dorsal hump reduction preserves both a favorable aesthetic contour of the middle nasal vault and proper function of the internal valve. This procedure involves removal of the osseocartilaginous dorsum en bloc. The nasal dorsum is further reduced; the removed portion of nasal dorsum is sculpted and then replaced anatomically. Once a favorable position is found for the native dorsal graft, the upper lateral cartilages are resuspended to the graft with suture fixation. The dorsal segment thus acts as a dorsal onlay spreader graft, reestablishing a natural dorsal contour and preserving the middle nasal vault. We can avoid osteotomies in patients with an appropriate preoperative width of their bony base while correcting the open roof with the replaced dorsal segment.     

Augmentation rhinoplasty with mortised septal cartilage

This report addresses cartilage graft fabrication for augmentation of the full length of the nasal dorsum. The author describes a mortise/tenon joint for synthesis of discontinuous pieces of autologous septal cartilage into a structurally sound graft. The functional geometry of that mortise/tenon joint is reviewed. Specific details of surgical technique are presented. Excellent results in 14 of 16 consecutive cases of nasal dorsal onlay grafting by this method are reviewed. Unfavorable results in two cases are analyzed. The advantages and disadvantages of the technique are discussed. The mortise/tenon joint is proposed as a method for fabrication of a large, strong dorsal onlay graft from separate pieces of septal cartilage.     

耳郭软骨皮下筋膜组织复合物在鼻尖整形中的应用

目的：介绍自体耳郭软骨皮下筋膜组织复合物在鼻尖整形中的应用方法。方法：应用耳郭软骨皮下筋膜组织复合物对57例就医者实施手术。结果：术后鼻尖塑形满意，无畸形，无并发症发生。结论：应用耳郭软骨皮下筋膜组织复合物可保护鼻尖皮肤，鼻尖塑形满意，值得推广应用。     

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.     

Rhinoplasty and the nasal SMAS augmentation graft: advantages and indications

We evaluated the nasal superficial musculoaponeurotic system (SMAS) as an autologous augmentation graft material in the thick-skinned patient undergoing cosmetic rhinoplasty using a retrospective review. Representative case reports demonstrated preliminary long-term results after augmentation with the nasal SMAS graft in an academic rhinoplasty practice. En bloc excision of the nasal SMAS in thick-skinned patients produced uniformly favorable improvements in nasal tip definition without adverse sequelae. Moreover, in 10 patients, the harvested material was also used for volume augmentation at various adjacent nasal sites, including the radix, nasal sidewall, and nasal dorsum. Long-term follow-up ranging from 1 to 3 years suggests stable volume augmentation in this initial patient series. No donor morbidity was observed in properly selected patients, and enhancements in nasal tip definition were uniformly favorable. Additional studies are needed to more accurately characterize long-term nasal SMAS graft survival in all patients.     

自体鼻中隔软骨在鼻背凹陷充填术中的应用

目的 介绍用自体鼻中隔软骨充填鼻背凹陷的方法。方法 按常规鼻中隔矫正术切取鼻中隔软骨，根据鼻背凹陷的不同程度和部位，将充填软骨修削成单层卵圆形，或将软骨分割成2～3块叠加后缝合在一起，或将软骨制成倒“V”形，根据鼻背凹陷的大小和形状进行鼻背部充填。结果 43例患者短期效果全部满意，30例经6个月至5年随访，其中3例软骨有轻度吸收，鼻背稍凹陷，其余均较满意。结论 自体鼻中隔软骨充填鼻背整形，取材在同一手术野内完成，方法简便易行，软骨能与周围组织融合在一起，无排斥反应，长期效果较好，可作为鼻背美容整形的选择材料。     

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.     

自体耳廓软骨盾牌形移植在固体硅胶假体隆鼻术中的应用

目的:介绍自体耳廓软骨盾牌形移植在固体硅胶假体隆鼻术中应用的方法。方法:在固体硅胶假体隆鼻术中,将盾牌状的自体耳廓软骨通过右鼻翼软骨缘切口移植于鼻翼软骨穹隆前下方,增强美学效果。结果:23例患者进行了3个月至15个月的随访,术后鼻部外形美观,鼻尖无畸形,无并发症发生,效果良好。结论:自体耳廓软骨盾牌形移植对于预防或减轻隆鼻术后鼻尖上旋、增加鼻尖表现点、保护鼻尖皮肤方面具有不可替代的作用。     

The Fate of Diced Cartilage Grafts of Traumatized Versus Nontraumatized Origin

Background Diced cartilage grafts have long been used in rhinoplasty. Along with their various reported advantages, they also have some disadvantages. The irregular resorption rate of the engrafted mass is one of the major issues noted with diced cartilage grafts. An explanation for the unpredictable resorption rate has not yet been elucidated. This study aimed to determine the role of traumatized versus nontraumatized cartilage as the source of diced cartilage grafts. Methods This study included the noses of 32 patients (19 traumatized noses and 13 nontraumatized noses) who underwent surgery using Surgicel-wrapped diced cartilage grafts. Results The most remarkable result noted in this study was that a Surgicel-wrapped diced cartilage graft, if prepared from traumatized cartilage (in 19 patients), failed to maintain a stable long-term volume. Partial volume loss was noted in 100% of these patients. However, the rate of this partial resorption was different for every individual and could not be predicted. The highest retention of cartilage graft volume was seen primarily over the nasal osseocartilaginous junction. In nontraumatized patients, however, the engrafted mass maintained long-term volume stability. These patients evidenced no visible external irregularities, and only a few very slight imperfections were noted with finger palpation. Conclusion Diced cartilage of traumatic origin is not recommended for any purpose. In such cases, the authors’ engrafting algorithm consists of autobone or ear conchal cartilage grafts for dorsal augmentation, columellar struts from the nontraumatized part of the septum, and spreader grafts from the nontraumatized part of the septum or ear concha.     

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: .     

Recycling the distal dorsum as a sheen graft

Background: Surgeons performing rhinoplasty are increasingly faced with secondary procedures in graft-depleted patients. Objective: A method is described for recycling resected distal dorsum as a Sheen tip graft. Methods: Each of 16 primary rhinoplasty patients was treated with a Sheen graft to the nasal tip harvested from the distal cartilaginous dorsum; the dorsal cartilaginous hump was removed without dorsal mucosal disruption. Intact dorsal vestibular mucosa acts as a mucosal spreader graft by adding width between the dorsum and the resected upper lateral cartilages. The hump must be large enough that resection of the distal dorsum will not result in overresection of the midvault. Results: Postoperative photographic analysis of each of the 16 patients after 1 to 5 years of follow-up shows increased nasal tip projection, establishment of a tip-defining point, and a double break (a supratip and infralobular break). No graft absorption was clinically noted. Conclusions: Recycling of the distal dorsum as a Sheen graft in selected patients results in an aesthetic contour. This method limits surgical dissection to a single donor area, saves time, preserves the septum, avoids potential septal perforation or hematoma, and decreases hemorrhage and edema.     

Use of Autologous Costal Cartilage Combined with Expanded Polytetrafluoroethylene in Asian Rhinoplasty

BackgroundThe corresponding author's experience and recent methods employed in autologous costal cartilage grafts combined with expanded polytetrafluoroethylene (ePTFE) in Asian rhinoplasty were presented in this study.ObjectivesThe purpose of this study was to assess the outcomes of rhinoplasty performed on patients using autogenous costal cartilage grafts combined with an ePTFE implant.MethodsSeventy-five rhinoplasty cases with autologous costal cartilage grafts and an ePTFE implant were retrospectively reviewed. Graft types, complications associated with the graft itself or graft harvesting, surgical outcomes, and patient satisfaction were assessed.ResultsThe mean follow-up time post-operation was 13.5 months. A total of 42/75 patients underwent revision surgeries. Graft-related complications were found in 8% of cases, including two warped graft and four infection cases. Three individuals with infections had mild graft resorption. One patient with an infection removed the implant. Graft exposure, mobility, and substantial resorption were not recorded. A total of two cases underwent revision procedures for infection and perforation, respectively. Chest incision lengths for graft harvesting averaged 2.1 cm. No pneumothorax or significant donor-site pain was found. Donor-site scars were negligible, although two cases had hypertrophic chest scars. In general, functional and esthetic outcomes were mostly satisfactory among the assessed patients.ConclusionsRhinoplasty using autologous rib cartilage provides adequate support and sufficient cartilage amounts for correcting nasal contouring. Meanwhile, ePTFE alone for nasal dorsum augmentation safely achieves satisfactory outcomes. Rib cartilage rhinoplasty performed by an experienced surgeon yields excellent, long-lasting results with minimal risk; however, the potential for infection should be considered following revision surgery.     

自体肋软骨移植综合鼻成形术

目的探讨应用自体肋软骨移植行综合鼻成形术的方法,观察手术效果。方法鼻部应用开放切口．取自体肋软骨移植行综合鼻成形术。截取6～7cm长第6或7肋软骨用于结构移植：（1）雕刻成柳叶形鼻背移植物用于隆鼻术;（2）雕刻成长条形鼻小柱支撑移植物用于鼻小柱支撑及鼻延伸术;（3）雕刻成盾牌形移植物用于鼻尖成形术。结果52例患者均获得满意的鼻背及鼻尖美学效果。鼻背轮廓线、鼻尖表现点、鼻尖上区转折清晰。无移植物外露、移位、软骨变形。亦未见气胸、感染、血肿等并发症发生,胸壁瘢痕不明显,效果满意。结论应用自体肋软骨移植行综合鼻成形术,可以满足对假体存在心理排斥的患者的求美需求,亦可为二次或多次鼻成形术后畸形的患者提供足够的自体修复材料,并大大的降低了再次手术感染的风险。其效果良好,并发症少,值得推广。     

Use of costal cartilage cantilever grafts in negroid rhinoplasties

Dorsal augmentation and nasal tip refinement are important objectives in Negroid rhinoplasty. Use of a costal cartilage cantilever graft will achieve these objectives. We report on our experience in 19 patients. The technique offers an excellent solution to supplying the large amount of material often required to adequately augment the dorsum in these patients. The graft is also versatile enough to allow nasal tip refinement. There are additional aesthetic benefits as the cantilever causes a lengthening in the nasal columella, a reduction in the flare of the nostrils, and increases the columellar-labial angle. The procedure is relatively simple to perform. The problem of warping is minimized by symmetrical carving and the use of large grafts with a substantial cross-section.     

Maxillonasal dysplasia (Binder's syndrome) and its treatment with costal cartilage graft: A follow-up study

Maxillonasal dysplasia or Binder''s syndrome is an uncommon congenital condition characterized by a retruded mid-face with an extremely flat nose. We report here six patients with maxillonasal dysplasia whose noses were corrected with onlay costal cartilage grafts using a combined oral vestibular and external rhinoplasty approach for nasal dorsal augmentation, columellar lengthening, and premaxillary augmentation. The cartilage graft was dipped in a solution of 100 ml 0.9% NaCl and one vial (80mg) gentamicin for 30 min to prevent warping. L struts made for nasal augmentation, columellar lengthening, and premaxillary augmentation were fixed to one another by slots made in the graft. This technique has been used in children, adults, and for secondary cases with promising results. All patients were of class I dental occlusion. The nasal and premaxillary augmentation which was monitored by serial photography was found to be stable over a follow-up period of three years.