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Chapter Dorsal Augmentation: Onlay Graing Using Shaped Autologous Septal Cartilage 285
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e patient is shown months postoperatively. On frontal view, there is renement of the dorsal aesthetic lines and tip shape. On lateral view, the dorsum
appears more balanced, and there is repositioning of the nasofrontal angle to
the lash line.
Part ree e Dorsum286
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is patient presented for secondary rhinoplasty. He was unhappy with his
overreduced dorsum and unrened, asymmetrical tip. e frontal view shows
ill-dened dorsal aesthetic lines and severe tip asymmetry. On lateral view, the
dorsum is overreduced and concave.
e operative goals included the following:
■
Rene the tip.
■
Create a straight dorsum with dorsal augmentation and smooth dorsal
aesthetic lines.
■
Reposition the radix more superiorly.
Surgical Plan
1. Use an open approach with a stair-step transcolumellar incision and bilateral
infracartilaginous extensions.
2. Harvest septal cartilage.
Chapter Dorsal Augmentation: Onlay Graing Using Shaped Autologous Septal Cartilage 287
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3. Augment the dorsum using an A-frame gra.
4. Perform a cephalic trim of the lateral crura and reposition with sutures.
5. Resect the caudal septum.
6. Place a columellar strut gra with medial crural−columellar strut sutures.
7. Perform lateral osteotomies.
e patient is shown years postoperatively. e frontal view shows smooth
dorsal aesthetic lines, and a symmetrical, balanced tip. e lateral view shows a
straight dorsum and superior repositioning of the nasofrontal angle.
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is primary rhinoplasty patient requested improvement in her prole along with
her dorsal aesthetic lines and increased tip rotation and renement.
e operative goals included the following:
■
Create a straight dorsum with dorsal augmentation and repositioning of
the radix more superiorly.
■
Create smooth dorsal aesthetic lines.
■
Increase tip rotation and renement.
Two layers
inferiorly
Inverted U-frame
Morselized
cartilage
Morselized
cartilage
Extend into vestibule
on left side only
Surgical Plan
1. Use an open approach with a stair-step transcolumellar incision and bilateral
infracartilaginous extensions.
2. Harvest septal cartilage.
3. Augment the dorsum using an inverted-U-frame gra.
Chapter Dorsal Augmentation: Onlay Graing Using Shaped Autologous Septal Cartilage 289
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4. Perform a cephalic trim of the lateral crura and reposition with sutures.
5. Place le alar batten gra.
6. Place a columellar strut gra with medial crural−columellar strut sutures.
7. Place morselized cartilage gra at the nasolabial junction.
8. Rene the tip with transdomal sutures.
9. Perform lateral osteotomies.
10. Perform alar base excisions.
e patient is shown months postoperatively. On the frontal view, she has
smooth dorsal aesthetic lines and improved tip renement. On the lateral view,
she has a balanced dorsum with a supratip break, as well as improvement in tip
rotation and position of the infratip lobule.
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CONCLUSION
Autologous septal cartilage dorsal onlay gras are appropriate in primary and
secondary rhinoplasty patients in whom a minimal to moderate amount of dorsal
augmentation is desired. In general, better results are obtained if the total length
of the dorsum from radix to septal angle is augmented rather than only a portion of it. However, if partial augmentation is all that is needed, it is important to
bevel the ends of the gra and taper them to a thin edge so they will not create a
step-o where they terminate on the dorsum.
It is preferable to augment the entire length of the dorsum from radix to septal
angle rather than only a portion of the dorsum.
e disadvantages of using shaped autologous onlay gras of septal cartilage for
augmentation of the nasal dorsum are the limited amount of cartilage that can
be obtained from the septum and the occasional diculty in shaping the gra
when dealing with a severely deviated septum because of the angulation of the
septal cartilage.
KEY POINTS
■
Autologous septal cartilage dorsal onlay gras are appropriate in primary and
secondary rhinoplasty patients in whom a minimal to moderate amount of
dorsal augmentation is desired.
■
Dorsal augmentation is based on the relationship of the dorsum to the tip projection and nasofrontal angle.
■
Dorsal onlay graing is indicated in patients with a low nasofrontal angle, diminished dorsal height or an excessive concavity of the dorsal prole on lateral view.
■
e edges of the gra should be beveled at approximately a -degree angle to
avoid the appearance of a step-off postoperatively.
■
e inverted V-frame and U-frame gras t better over the arched contour of
the dorsum and are more stable than a at piece of septal cartilage.
■
It is preferable to augment the entire length of the dorsum from radix to septal
angle rather than only a portion of the dorsum.
■
e only disadvantages of these techniques are the amount of septal cartilage
available may be insucient or the available cartilage may be extremely deviated, making shaping of the onlay gra dicult.
Chapter Dorsal Augmentation: Onlay Graing Using Shaped Autologous Septal Cartilage 291
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REFERENCES
1. Powell N, Humphries B. Proportions of the Aesthetic Face. New York: ieme, .
2. Daniel RK, Farkas LG. Rhinoplasty: image and reality. Clin Plast Surg :-, .
3. Gunter JP. Facial analysis for the rhinoplasty patient. Presented at the Basic Rhinoplasty Sympo-
sium, University of Texas Southwestern Medical School, Dallas, February .
4. Grabb WC, Smith JW. Implant materials. In Blocksma R, Braley S Jr, eds. Plastic Surgery, ed . Bos
ton: Little Brown, .
5. Rees TD. Aesthetic Plastic Surgery, vol . Philadelphia: WB Saunders, .
6. Hiraga Y. Complications of augmentation rhinoplasty in the Japanese. Ann Plast Surg :-,
.
7. Raghavan U, Jones NS, Romo R III. Immediate autogenous cartilage gras in rhinoplasty aer al-
loplastic implant rejection. Arch Facial Plast Surg :-, .
8. Clark JM, Cook TA. Immediate reconstruction of extruded alloplastic nasal implants with irradi-
ated homogra costal cartilage. Laryngoscope :-, .
9. Dingman RO. Personal communication, .
10. Peck GC. Techniques in Aesthetic Rhinoplasty. New York: Goner Medical Publishing, .
11. Sheen JH, Sheen AP. Aesthetic Rhinoplasty, ed . St Louis: Quality Medical Publishing, .
12. Ortiz-Monasterio F, Michelena J. e use of augmentation rhinoplasty techniques for the correc-
tion of the non-Caucasian nose. Clin Plast Surg :-, .
13. Stuzin JM, Kawamoto HK. Saddle nasal deformity. Clin Plast Surg :-, .
14. Ortiz-Monasterio F, Ruas EJ. Cle lip rhinoplasty: the role of bone and cartilage gras. Clin Plast
Surg :-, .
15. Whitaker LA. Biological boundaries: a concept in facial skeletal restructuring. Clin Plast Surg :
1-, .
16. Erol O. e Turkish delight: a pliable gra for rhinoplasty. Plast Reconstr Surg :-; dis-
cussion -, .
17. Daniel RK, Calvert JW. Diced cartilage gras in rhinoplasty surgery. Plast Reconstr Surg :-
, .
18. Brenner KA, McConnell MP, Evans GR, et al. Survival of diced cartilage gras: an experimental
study. Plast Reconstr Surg :-, .
19. Cakmak O, Bircan S, Buyuklu F, et al. Viability of crushed and diced cartilage gras: a study in rab-
bits. Arch Facial Plast Surg :-, .
20. Gunter JP, Clark CP, Friedman RM. Internal stabilization of autogenous rib cartilage gras in rhi-
noplasty: a barrier to cartilage warping. Plast Reconstr Surg :-, .
21. Kim DW, Shah AR, Toriumi DM. Concentric and eccentric carved costal cartilage: a comparison
of warping. Arch Facial Plast Surg :-, .
22. Sheen JH. Spreader gra: a method of reconstructing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg :-, .
23. Regnault P, Daniel RK, eds. Aesthetic Plastic Surgery. Boston: Little Brown, .
24. Sheen JH. Secondary rhinoplasty. Plast Reconstr Surg :-, .
25. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: dorsal onlay graing using shaped autogenous
septal cartilage. Plast Reconstr Surg :-, .
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16
Dorsal Augmentation: Temporal
Fascia– Wrapped Diced Cartilage
Rollin K. Daniel
T
he use of diced cartilage gras wrapped in fascia (DC-F) has numerous advantages and very few disadvantages.
tilage with no risk of rejection. Any combination of excised, septal, conchal, or
rib cartilage can be used. In contrast to solid gras, it is not necessary to harvest
a perfect and rarely found by mm piece of septal cartilage or fuse two pieces
of curvy conchal cartilage. Warping is not a risk, and foreign material (K-wire) is
not needed. e gra is easily and quickly prepared by the circulating nurse or a
junior assistant who dices the cartilage and loads the syringe. It is easily customized for thickness ( to mm), shape (tapered or uniform), and length. e ability to construct a gra with a specic shape for a specic defect is extraordinary.
Molding of the gra is possible both intraoperatively and early postoperatively.
e gra can be easily revised using a percutaneous No. needle to remove a
sharp edge, or a No. blade to shave o prominences. Infection has not been a
problem. Absorption has not occurred in more than cases with a maximum
follow-up exceeding years. Over a period of months, the diced cartilage solidies. e interspace between the diced cartilage bits is lled with brous tissue
within the fascial sleeve. When removed, the gra is quite solid and semirigid.
Pieces excised for shaping purposes are suciently solid for use as tip gras. Histologic studies conrm that the individual pieces of cartilage have survived and
suggest that the fascia has become a neoperichondrium.
-
ese are autologous gras of viable car-
DC-F gras have several distinct advantages over other techniques in rhinoplasty
surgery for dorsal augmentation.
293
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BACKGROUND
A discussion of the role of diced cartilage gras in rhinoplasty surgery requires a
review of several important points. First, the fundamental technique is not new.
e use of diced cartilage alone, without a fascial sleeve, was extremely popular
in Europe between the World Wars, with numerous surgeons developing cartilage dicers and chondrojet injectors.
Second, many surgeons have used the technique for over years and are pleased
with its long-term viability.
,
One of the most impressive uses of diced cartilage
is cranioplasty, which demonstrates that the individual pieces coalesce into a
semirigid gra with time. ird, the term diced cartilage gra can encompass a
wide variation as to type of cartilage, method of preparation, and containment,
which leads to confusion when comparing clinical indications, techniques, and
results. A discussion of each of these points is essential.
,
It is critical to create a symmetrical dorsal platform on which to place the DC-F
gra. e gra acts as a capstone to a pyramid; if the pyramid is crooked, the
DC-F gra will appear to be displaced.
Cartilage
I use only autologous cartilage, which can be derived from excised material, septum, or distant gras (conchal or rib). Isee virtually no justication for routine
use of cadaver cartilage gras with their known long-term absorption. Under
exceptional situations of age, ethnicity, or systemic risks, cadaver cartilage warrants consideration. ese account for less than % of cases.
e length, width, thickness, and shape of the construct must be carefully designed.
Preparation
e cartilage should be diced—never morselized, bruised, or crushed. e goal
is complete gra survival, similar to a columellar strut or spreader gra. e cartilage is cut into .mm or smaller cubes using two blades and then inserted
into a small tuberculin syringe for easy placement. e cartilage should be diced
so ne that it can be ejected from the syringe (positive spurt test).
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