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Chapter Harvesting Autologous Gras for Primary Rhinoplasty 205
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epinephrine. In addition to hemostasis, this is used to hydrodissect the proper
plane of dissection.
e initial incision is made with a No. blade, and aer two single hooks are
placed for traction on the skin edge, the remaining dissection is performed with
curved, ne-tipped scissors. e tips of the scissors should be pointed toward the
skin to prevent inadvertent scoring of the cartilage during dissection that would
damage the gra material.
e incision is placed approximately 3mm inside of the conchal bowl both to
camouage the scar within the concha and preserve the antihelix to prevent contour deformities of the ear.
Once the skin has been elevated from the anterior aspect of the conchal bowl,
a full-thickness cut is made at the level of the initial skin incision and extending through the posterior perichondrium. Scissors are used to dissect the posterior perichondrium o the postauricular skin. Again, the tips of the scissors are
pointed toward the skin. e harvest is completed by incising the cartilage as far
medially as required. Typically, the maximal medial extent of harvest should not
involve the cartilage of the external auditory meatus. Hemostasis is obtained and
closure is accomplished using a running - plain gut suture.
If the surgeon prefers, ear cartilage can be harvested
through a posterior approach. e incision may be
placed parallel to and just lateral to the conchal bowl.
A large piece of cartilage can also be harvested through
this approach. However, when a large gra is required,
-
tent of harvest (mainly preservation of the antihelix) to
-
tilage to be harvested. is is performed by passing the
needle from anterior to posterior through the cartilage
Part Two Basic Surgical Concepts206
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A cotton and petrolatum gauze tie-over bolster on the anterior and posterior
sides is used to obliterate the resulting dead space and prevent hematoma for
mation. is is secured by placing a - nylon suture through the anterior and
posterior skin; the suture is normally removed aer to days.
Operative Technique for Posterior Approach
-
it becomes more challenging to assess the maximal ex
prevent contour deformities of the ear.
A -gauge needle is used to mark the amount of car
aer tingeing it with methylene blue.
Chapter Harvesting Autologous Gras for Primary Rhinoplasty 207
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When tattooing the cartilage, it is important to preserve at least mm of conchal
bowl cartilage adjacent to the antihelix, a shoulder of cartilage inferiorly at the
insertion with the incisura intertragica, and another shoulder of cartilage superiorly at the root of the antihelix. Leaving these structures intact is essential to
avoid a noticeable donor site deformity aer harvesting of the cartilage.
e posterior and anterior auricular skin over the cartilage to be harvested is inltrated with % lidocaine with epinephrine. e posterior auricular incision is
made through skin only, and the skin is dissected from the conchal bowl using
curved ne-tip scissors. During dissection the scissor tips are always directed
away from the cartilage to prevent inadvertent cartilage scoring. Once the conchal bowl is completely dissected, the cartilage is incised using a No. blade
along the methylene blue marks. With the use of a single hook for traction, the
conchal bowl cartilage is dissected from the anterior skin. e resection is completed with another full-thickness incision through the medial conchal bowl,
taking care not to perforate the anterior conchal bowl skin.
Again, hemostasis is obtained and closure is performed with a running - plain
gut suture.
e h, sixth, and seventh ribs are preferred. An incision
approximately to cm long is placed directly over the
junction of these ribs. In a female patient, the scar can also
be designed to lie in the inframammary fold, which makes
a very inconspicuous donor site. Once the subcutaneous
tissues have been incised, it is possible to use retractors to
obtain more exposure of the ribs while limiting the size
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As before, a cotton and petrolatum gauze tie-over bolster is used to obliterate the
resulting dead space and prevent hematoma formation.
RIB CARTILAGE
In cases that demand a signicant amount of cartilage, it may be necessary to
harvest rib cartilage.
over ear cartilage when gras for structural support are required.
-
If septal cartilage is inadequate, rib cartilage is preferred
When septal cartilage is inadequate, rib cartilage is preferred over ear cartilage
when gras for structural support are required.
Operative Technique
of the skin incision.
In a female patient, the scar from harvest of rib cartilage can also be designed
to lie in the inframammary fold, which makes a very inconspicuous donor site.
Once the rib is exposed, the perichondrium is incised
A periosteal elevator is used to dissect the perichondrium
o the anterior surface of the rib cartilage. is dissection
is continued around the superior and inferior surfaces of
the rib. e posterior dissection is completed using a rib
A No. blade is used to incise the skin, and needle-tip
electrocautery is used to dissect to the deep fascia. Before
-
pated to verify that the incision is directly over cartilage
Chapter Harvesting Autologous Gras for Primary Rhinoplasty 209
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incising through the deep fascia, the underlying rib is pal
and oriented along its longitudinal axis.
with needle-tip electrocautery.
elevator or small periosteal elevator.
To maximize the length of rib harvested, dissection should extend to the osteocartilagenous junctions medially and laterally. A No. blade is used to incise
through the medial and lateral rib cartilage to free the cartilage. ere may still
be some attachments remaining posteriorly, and these should be released with
the periosteal elevator.
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e amount of cartilage required will dictate whether cartilage from one or more
ribs is harvested. If only a small amount of cartilage is required, it is possible to
harvest the superior half of the rib cartilage, leaving the inferior half of the cartilage behind. us the continuity of the rib remains intact, which will be benecial for the patient’s recovery, since this generally causes less postoperative pain
compared with a procedure in which the rib’s continuity is compromised.
If only a small amount of cartilage is required, it is possible to harvest the superior half of the rib cartilage, leaving the inferior half of the cartilage behind.
Hemostasis is obtained, and before closure, the donor site is inspected to ensure
that no pneumothorax has occurred. e wound is lled with saline solution and
positive-pressure ventilation is given by the anesthesiologist. Bubbles will be seen
if there has been a violation of the parietal pleura. If there has been a breach of
the parietal pleura, careful inspection of the area is required to identify the air
Chapter Harvesting Autologous Gras for Primary Rhinoplasty 211
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leak. Once the air leak has been identied, the surgeon must decide whether a
suture closure should be attempted. Generally, the pleura is very fragile and does
not tolerate larger needles or tension with a suture. Rather than enlarging the existing leak, the tissues around the leak are assessed. Oen a small turnover ap
from surrounding fascia or periosteum can be used to seal the defect o. If no
appropriate tissues are adjacent to the perforation, a small piece of periosteum
can be harvested and used as an onlay repair. Before putting in the last stitch in
any repair, positive airway pressure should be given to fully expand the lungs.
Before closure, the rib cartilage donor site is inspected to ensure that no pneumothorax has occurred.
In the absence of a pneumothorax, the fascia and skin are closed in layers using
- Vicryl sutures in the fascial layer, followed by - Monocryl inverted deep
dermal sutures and a running intradermal suture.
TEMPORAL FASCIA
Recently, temporal fascia gras have found utility as an autologous gra material
in rhinoplasty for camouage or as composite gras, such as diced cartilage gras
wrapped in temporal fascia.
donor site morbidity and an inconspicuous scar in the temporal scalp.
Temporal fascia gras have found utility as an autologous gra material in rhinoplasty for camouage or as composite gras, such as diced cartilage gras
wrapped in temporal fascia.
-
Temporal fascia can be harvested with minimal
e surgeon should attempt to harvest the largest
-
-
cle’s attachments to the skull periosteum superiorly
and posteriorly and where it begins to divide into
deep and supercial layers anteriorly. e temporal
fascia should be harvested inferiorly to the level of
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Operative Technique
e anterior limit of the incision is made in line with the tragus. A posteriorpointing, V-shaped incision is used, because this gives the widest exposure for
the subcutaneous dissection. e incision is approximately cm in craniocaudal
dimension and spans approximately .cm in anteroposterior dimension. e
skin of the scalp is inltrated with ml of % lidocaine with epinephrine. It is unnecessary to clip the hair of the incision. Instead, hemostats can be used to clamp
the hair and expose the skin where the incision is to be made. A No. blade is
used to incise the skin down through the temporoparietal fascia to expose the
deep temporal fascia. Needle-tip electrocautery is used to dissect the areolar tissues o the supercial surface of the deep temporal fascia.
A posterior-pointing, V-shaped incision is used to harvest temporal fascia, because this gives the widest exposure for the subcutaneous dissection.
piece of temporal fascia possible. is involves incis
ing the temporal fascia close to the temporalis mus
the ear.
Chapter Harvesting Autologous Gras for Primary Rhinoplasty 213
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Although this area is about by cm in dimension, temporal fascia contracts signicantly, and this generally yields a temporal fascia gra that is about by cm
in dimension. e deep temporal fascia is incised with needle-tip electrocautery
and then swept o the underlying temporalis muscle. Muscle bers should not
be harvested with the temporal fascia gra. Hemostasis is obtained, and the skin
is closed in layers with - Vicryl inverted deep dermal sutures, followed by a
running - chromic gut suture.
An attempt should be made to harvest the largest piece of temporal fascia possible, because temporal fascia contracts signicantly.
KEY POINTS
■
Autologous cartilage is preferred, because it is usually accessible with relatively
minimal morbidity, integrates well into the recipient site, and has a signicantly
lower rate of complications when compared with alloplastic materials.
■
Septal cartilage is the primary choice for almost all gras used in primary rhinoplasty because it is already within the operative eld and no additional incisions are necessary for harvesting the cartilage.
■
If reduction of the dorsum is indicated, this should be done before septal harvest to ensure that an adequate L-strut is preserved.
■
e submucoperichondrial plane is identied by the distinct gray-blue appearance of the cartilage, the gritty feel of it, and the relative lack of resistance.
■
Small, unilateral mucosal perforations typically do not require repair. If large
perforations or bilateral opposing perforations occur, they should be repaired.
■
In cases of septal deviation, the mucoperichondrium on the convex side of the
deviation is typically attenuated and more fragile making dissection more difcult; mucosal perforations occur more readily on this side.
Part Two Basic Surgical Concepts214
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■
In many instances, the width of the dorsal and caudal L-strut should be mm
or more to ensure long-term support. Curving the transition points between
the perpendicular plate of the ethmoid and the dorsal L-strut and between the
dorsal and caudal L-strut can help add strength.
■
Microfracture of the septum should be performed in a careful and controlled
manner to avoid uncontrolled fractures into the superior nasal septum and
cribriform plate. is is particularly important in posttraumatic cases where
there may have been a prior septal fracture.
■
Given its accidity and the convolutions inherent in its structure, ear cartilage
is ideal for reconstructing the lower lateral cartilages.
■
e anterior approach provides excellent exposure and is especially useful
when a very large piece of cartilage is required.
■
e incision is placed approximately mm inside of the conchal bowl both to
camouage the scar within the concha and preserve the antihelix to prevent
contour deformities of the ear.
■
When septal cartilage is inadequate, rib cartilage is preferred over ear cartilage
when gras for structural support are required.
■
In a female patient, the scar from harvest of rib cartilage can also be designed
to lie in the inframammary fold, which makes a very inconspicuous donor site.
■
If only a small amount of cartilage is required, it is possible to harvest the superior half of the rib cartilage, leaving the inferior half of the cartilage behind.
■
Before closure, the rib cartilage donor site is inspected to ensure that no pneumothorax has occurred.
■
Temporal fascia gras have found utility as an autologous gra material in rhinoplasty for camouage or as composite gras, such as diced cartilage gras
wrapped in temporal fascia.
■
A posterior-pointing, V-shaped incision is used to harvest temporal fascia, because this gives the widest exposure for the subcutaneous dissection.
■
An attempt should be made to harvest the largest piece of temporal fascia possible, because temporal fascia contracts signicantly.
REFERENCES
1. Araco A, Gravante G, Araco F, et al. Autologous cartilage gra rhinoplasties. Aesthet Plast Surg
:-, .
2. Gunter JP, Landecker A, Cochran CS. Frequently used gras in rhinoplasty: nomenclature and
analysis. Plast Reconstr Surg :e-e, .
3. Sajjadian A, Rubinstein R, Naghshineh N. Current status of gras and implants in rhinoplasty: Part
I. Autologous gras. Plast Reconstr Surg :e-e, .
4. Sajjadian A, Naghshineh N, Rubinstein R. Current status of gras and implants in rhinoplasty: Part
II. Homologous gras and allogenic implants. Plast Reconstr Surg :e-e, .
5. Lee M, Callahan S, Cochran CS. Auricular cartilage: harvest technique and versatility in rhinoplasty.
Am J Otolaryngol :-, .
6. Cervelli V, Bottini DJ, Gentile P, et al. Reconstruction of the nasal dorsum with autologous rib cartilage. Ann Plast Surg :-, .
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