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Chapter Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 295
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e shape of the gra can be either uniform or tapered. Tapered gra is thicker
cephalically or caudally. e shape should be as accurate as possible before insertion. Surgeons should not expect to create the ideal shape with molding.
Containment
Diced cartilage alone can be placed directly into a tight pocket for contour, lay
ered on either side of a rigid dorsal gra for blending, or placed in parapiriform
pockets to advance the midface. When it is used as dorsal or radix gras, Iprefer to wrap the diced cartilage in autologous fascia to conne the gra, smooth
irregularities, and encourage it to function as a neoperichondrium. Itried the
Turkish delight method described by Erol,
and absorption with clinical failure
occurred in all cases, which Iattributed to a foreign body reaction to Surgicel.
Diced cartilage gras are not new. ey have been used ever since modern plastic
surgery began. For the past decade, Ihave used DC-F rather than solid dorsal
gras for dorsal augmentation.
INDICATIONS AND CONTRAINDICATIONS
During the past years, the indications for using DC-F have expanded to include the entire range of rhinoplasty cases without restriction as to age ( to
years), ethnicity, cause, or number of prior surgeries.
-
Dorsum
Diced cartilage has dramatically revolutionized dorsal gras in rhinoplasty surgery. Compared with rigid cartilage gras, it is a far simpler technique, quicker
(minutes versus to hours), more exible as to height ( to mm) and length
( to mm), and has fewer postoperative problems and in my opinion superior
aesthetic results. As shown in case studies, DC-F has truly changed what can
be achieved in primary cases that require very rened gras. e indications in
primary cases include low dorsum, ethnic nose, and partial-length gras in the
radix/dorsum.
ous prior operations and in cases in which cadaver cartilage has failed. e indications for DC-F gras in secondary cases can be divided into the categories of
contour augmentation and composite reconstruction. A contour augmentation is
,
In secondary cases, diced gras have survived despite numer-
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designed to create an ideal dorsal aesthetic prole. A composite reconstruction
is composed of a deep structural layer to provide nasal support with an overlying
aesthetic layer of DC-F that achieves the nal dorsal contour.
,
A DC-F construct is carefully placed in the nose using percutaneous sutures. e
skin is redraped and the contour checked. Pieces of cartilage can be removed from
the open caudal end to achieve nal shape.
Radix
My initial interest in using Turkish delight gras was to replace the need to harvest fascia for radix gras. e failure of these gras in my cases led me to use
DC-F gras in the radix. Based on my prior overcorrection with Turkish delight
gras, Iovercorrected my initial six DC-F gras and had to reduce them. Subsequently, some of the DC-F gras in the radix were visible, especially in patients
with very active eyebrow excursion. Ihave reduced two cases. us Itend to use
fascia alone for minor and moderate-sized radix gras. Ireserve DC-F gras for
major radix defects and half-length radix/dorsal gras. Visibility has not been a
problem in these cases probably because of thicker skin in the former and more
caudal placement in the latter.
When the shape of the dorsum is satisfactory, a Denver splint is applied with the
foam pad, helping to ensure a smooth dorsum. When the cast is removed, the
patient is instructed not to massage the nose or wear glasses for 4 to 6weeks.
ere are no specic contraindications if dorsal augmentation is required. Ihave
used DC-F gras for immediate reconstruction aer removal of infected silicone
implants, extensive nasal collapse in cocaine patients, and under extremely thin,
scarred skin envelopes. Perhaps the best validation of the technique is that for
the past decade Ihave placed DC-F exclusively for dorsal augmentation and no
longer use solid dorsal gras.
DC-F gras can be used in the entire range of rhinoplasty cases, from primary
cases requiring augmentation to unexpected defects encountered in secondary
cases to composite reconstruction for a collapsed nose, and for burned out cases
requiring an aesthetic reconstructive rhinoplasty.
Chapter Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 297
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PREOPERATIVE ASSESSMENT AND PLANNING
Preoperative planning for a DC-F gra is the same as for any rhinoplasty. Idiscuss the need for gras with every patient. All primary patients must sign for
the harvesting of fascia and ear cartilage, and all secondary patients must also
agree to a rib gra. Ind that drawing basic angles (nasofacial, tip, and columellar inclination) and lengths (tip projection and ideal dorsum) on full-size photographs is helpful. Photographic analysis and planning are extremely valuable
for determining ideal and realistic results. Planning in secondary cases is obviously more complex, especially those requiring composite reconstruction. ese
are incredibly dicult cases that are oen an aggregate of a dicult primary followed by a failed secondary rhinoplasty. Frequently, septal support is absent or
compromised, with perforations an all too common occurrence. Preoperative
preparation and planning must be thorough. Itry to obtain the previous operative reports. Isummarize the previous operations on a Gunter diagram, using a
dieren
in the operating room. CT scans can be invaluable for assessing the bony vault.
A written step-by-step operative plan helps surgeons to determine the essential
steps in advance.
t-colored ink for each one, and display it with the patient’s photographs
Preoperative planning can include photographic analysis using angles and
lengths, CT scans, and a review of previous operative reports.
OPERATIVE TECHNIQUE
Diced cartilage has revolutionized dorsal graing. e basic concept is to dice
cartilage into small bits (less than . mm) that can be placed into a fascial sleeve
that is slipped into the dorsal defect.
A gra will solidify within a matter of months and can be easily trimmed or removed in its entirety, shaped, and reinserted as necessary.
Fascial Harvest
e largest possible sheet of deep temporal fascia is harvested. Idraw a straight
line directly up from the tragus and then mark a .cm transverse posteriorly
oriented “.” incision whose apex touches the line. e incision is thus placed
behind the anterior temporal vessels, and when retracted, the V shape provides
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greater access than a straight line. e facial incision extends superiorly to the
periosteal junction, anteriorly to the deep temporal fascial split, then inferiorly
toward the concha, and posteriorly as far back as possible. e fascia is swept
o the underlying muscle. A small vein is present at the o’clock position. is
can be preserved or cauterized. e wound is closed in layers and the staples removed week postoperatively. Extensive experience has been reported on the
use of diced cartilage wrapped in cadaver fascia (Tutoplast; Davol Inc., Bard Inc.,
Warwick, RI), and some authors have reported on the use of acellular dermal
matrix (AlloDerm; LifeCell, Branchburg, NJ).
Deep temporal fascia should be harvested in as large a piece as possible, oen
measuring 5 to 6cm vertically by 6 to 8cm transversely. Fascia contracts dramatically!
Dicing the Cartilage
Excised cartilage (dorsum, alar, septal, conchal, and rib) is diced into bits smaller
than .mm. In general, the circulating nurse puts on sterile gloves and dices the
cartilage into squares while the surgeon continues to operate. It is important to
cut the cartilage with two No. blades without traumatizing it (that is, without
overmorselizing or crushing it). A cc tuberculin syringe is lled with diced cartilage. e plunger is inserted, and the cartilage is compressed maximally. Fluid
and air can be removed by inserting a No. needle through the opening and
compressing the cartilage. e cartilage should be diced so ne that it moves
through the hub of the syringe, thus passing the spurt test. Because the cartilage
is so nely diced, the hub does not have to be cut o of the syringe with a No.
blade. If diced cartilage alone is used to build up the piriform area, then the cartilage can be diced less ne ( to mm) and the hub removed.
e cartilage cannot be diced too ne. It is compressed until it is virtually a solid
paste and can be passed through the hub of a tuberculin syringe.
Constructing the Fascial Sleeve
e dorsal defect is measured so that an exact DC-F construct can be made on
the back table and inserted into the defect. e fascia is pinned on a Silastic block
and folded into an to by to mm sleeve. e cephalic end is sutured at
its corners using two sutures of - plain on straight SC- needles. en the free
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edge is trimmed and sutured closed with a locking suture of - plain catgut.
is sleeve is similar to a double-layer dorsal fascia gra. Multiple methods are
available for making the construct, but Iprefer to ll the sleeve with highly compressed diced cartilage as opposed to folding the fascia over a mound of loose,
diced cartilage.
e fascial sleeve is made to measure to t the defect. e fascia is pinned to a
Silastic block under slight tension and folded to a width of 8 to 10mm. e length
is determined by the size of the dorsal defect.
Filling the Construct
Compression of the cartilage is conrmed, and the syringe is slipped into the
open end of the sleeve. e diced cartilage is injected into the sleeve until the desired thickness is obtained. e critical step is to achieve very specic dimensions
of thickness ( to mm), length ( to mm), and shape (tapered or uniform).
e nondominant hand is used to mold the cartilage as it is slowly injected into
the sleeve with the dominant hand. e length of the dorsal gra is trimmed to
the exact length required. It is important to mold the gra to the exact dimensions and not overgra the nose.
e goal is to create a dorsal gra with ideal dimensions and contour. e volume of cartilage will determine the height, whereas the curved, natural contour
is achieved with the nondominant hand at the time of lling. e dorsum should
not be overgraed, because the gra will not be absorbed!
Inserting the Gra
e percutaneous sutures are inserted at the nasion level, and the shaped gra
is slipped into the recipient bed. e gra is held at its cephalic end and molded
from cephalic to caudal. If necessary, diced cartilage can be expressed out of the
fascial sleeve. en the skin is redraped and the dorsal contour evaluated. e
supratip area is checked to ensure that the gra has not widened. Ioen use suction to remove cartilage from the open end of the gra. e gra is then closed
and xed to the cartilage vault with a - plain catgut suture. In general, Iprefer
to achieve the exact dimensions of the construct on the back table and minimize
molding.
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Time is taken to create the ideal-shaped construct while it is on the back table.
Surgeons should not expect to make major changes by molding the gra once it
is in the nose.
Ten Technical Tips to Minimize Problems
With Diced Cartilage Gras Wrapped in Fascia
1. in skin is a greater challenge than thick skin. If the skin is very thin (steroid
damaged), then an overlay gra of fascia above the DC-F gra should be considered.
2. e bony cartilaginous vault needs to be smooth and straight before insertion of
the DC-F gra. Lateral wall asymmetry is corrected with appropriate osteotomies
and spreader gras.
3. Some surgeons prefer to use a set of Silastic dorsal implant sizers to determine
the approximate shape of the DC-F gra to be constructed.
4. e dorsal construct is designed to t the defect (length, width, and height) and
is built on the back table. e cartilage must be diced extra ne so that it can be
squirted out of a tuberculin syringe. e cartilage needs to be rigidly compressed
in the syringe before it is placed in the fascial sleeve.
5. e shape is controlled at the time of ll. Will it be uniform, caudally tapered,
or cephalically tapered? In a uniform gra, the ll is even from one end to the
other. In tapered gras, pinching with the nondominant thumb and index nger
controls the amount of cartilage and produces a gentle dorsal curve.
6. e cephalic end of the DC-F gra should not extend above the nasion. To create
a nasofrontal angle, a separate radix gra is placed rst, followed by a DC-F gra
along the dorsum.
7. e middle portion of the DC-F gra must not be overlled. Prior overresection
of the dorsum is usually at the caudal end. e skin at the rhinion is thin, which
can lead to visibility. ese gras are not resorbed—what the surgeon sees on the
table is what the patient will see.
8. e caudal end should not be overlled, especially if molding of the gra in situ
has forced the diced cartilage toward the open, caudal end. Suction is used to incrementally remove excess diced cartilage, the end is tapered, and the construct
is closed with a - plain suture.
9. If a small irregularity is present when the cast is removed on day , the dorsal gra
is molded digitally and a new Denver splint is applied with its foam under pad.
is is le in place for to days. e process is repeated once more if necessary.
10. If a surgical revision is necessary year later, a closed approach is considered to
treat minor irregularities (visible edges or volume reduction from the undersurface of the gra). An open approach is reserved for major changes, which are
usually associated with other requirements. DC-F gras are solid at a year, and
the dissection plane between fascia and subcutaneous tissue is easily found if removal is necessary.
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CASE ANALYSES
is -year-old girl presented for a cosmetic rhinoplasty. She thought that her
nose was too wide and at and that her tip had no denition. On the anterior
view, her nose looked at. Her dorsal aesthetic lines were progressively more
divergent from radix to rhinion to tip. Her tip was mm wide. On the lateral
view, her nose looked long with a dependent tip and a at dorsum. Her chin was
retruded. Flatness of the bridge was evident on the oblique view. Her tip appeared
droopy and her chin retruded. On hemibasal views, her tip was very amorphous
and the nostrils had a reverse-teardrop appearance.
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Because the patient wanted a more rened “model’s nose,” the goal was to narrow
the dorsum and tip as much as her tissues allowed. Specically, the dorsum will
be narrowed using paramedian osteotomies and a curved DC-F gra for slight
augmentation. e patient agreed to a small chin implant.
Surgical Plan
1. Insert a small chin implant through a submental incision.
2. Harvest a sheet of deep temporal fascia.
3. Make initial bilateral infracartilaginous incisions for subcutaneous dissection over the lobule.
4. Using an open approach through the transcolumellar incision, elevate the
skin and defat tissue off the underlying cartilages.
5. Make a right transxion incision for septal exposure and harvest.
6. Reduce the le inferior turbinate using coblation plus outfracture of both
inferior turbinates.
7. Narrow the dorsum from to mm using paramedian and low-to-high osteotomies.
8. Mark the midline.
9. Mark the desired width of mm at the bony-cartilaginous junction.
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10. Cut the cartilage vault along a tapered line from the anterior septal angle to
the junction.
11. Use a straight osteotome for paramedian cuts a maximum width of mm on
either side.
12. Insert a columellar strut.
13. Shape the tip with the following sutures: columellar, domal creation, interdomal, domal equalization, tip position, and lateral crural convexity.
14. Use a shield-shaped gra plus a small booster gra for additional tip denition.
15. Insert a radix gra of fascia.
16. Construct and insert a uniform DC-F gra that measures by by .mm
for dorsal augmentation.
17. Close all incisions and apply a cast.
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One year postoperatively, the patient’s nose is narrower on anterior view, and
her dorsum is more curved on oblique view. Her nose is shorter and the tip
more rotated on lateral view. On the basal view, her tip is more triangular and
less amorphous. A narrower, natural-appearing dorsum has been created using
a DC-F gra.
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