Augmentation rhinoplasty with dermal graft and review of the literature

Nasal augmentation required following a trauma or a rhinoplasty operation poses a challenging problem to many plastic surgeons. Currently, allografts and autologous tissues are used for nasal augmentation; however, an ideal technique has not yet been described. Although preferred for augmentation of different parts of the body, pure dermal graft use has not been described for nasal augmentation. The authors performed nasal augmentation using a dermal graft in 90 patients in their hospital between 1994 and 2000, and they followed up the patients for 6 months to 8 years. In this article, the early and late results of dermal grafts for nasal augmentation are presented, and their advantages and disadvantages are discussed with a review of the literature. It was concluded that the easily obtained dermal graft could be an appropriate alternative in nasal augmentation, though it has not been used widely for this purpose.     

Nasal reconstruction with full-thickness cranial bone grafts and rigid internal skeleton fixation through a coronal incision

The use of iliac and rib bone as onlay grafts to the nasal dorsum often fails because endochondral grafts resorb unpredictably. Membranous cranial bone grafts are less likely to resorb, especially when used with rigid internal fixation techniques. However, when split, they are often too thin and can be difficult to contour. Full-thickness cranial bone grafts were used to achieve nasal augmentation in 26 patients with end-stage nasal skeleton deficiency. All procedures were carried out using only a coronal incision. Grafts were harvested through a craniotomy, carved meticulously, and secured rigidly with miniplates or bicortical screws. Donor sites were reconstructed with split cranial grafts, leaving an intact cranial vault. No graft was lost to infection, and there was no significant donor-site morbidity. In carefully selected patients this method of full-thickness cranial bone graft reconstruction yields good results.     

The use of alloderm for the correction of nasal contour deformities

What rhinoplasty surgeon has not been frustrated by unmet expectations from unreliable graft materials? The quest for an ideal graft continues. Septal cartilage is not always adequate in amount or substance. Ear cartilage may cause unsightly irregularities over time. Cranial bone or rib harvest sites add to the complexity of the procedure and can be intimidating for many operators. This article describes the authors' successful experience with AlloDerm onlay grafts for the correction of nasal contour deformities in 58 primary and secondary rhinoplasty cases by means of the open and endonasal approaches. Forty-two patients received an open-approach procedure; the remaining 16 received grafting through an endonasal or closed approach. Thirty-seven of the patients were secondary rhinoplasty patients, and some underwent multiple nasal corrections. The indications, intraoperative surgical technique of graft placement, and representative results will be discussed. Long-term follow-up showed good results, though partial graft resorption occurred in some patients. Overall, this experience with AlloDerm for nasal augmentation was encouraging.     

Segmental bone and cartilage reconstruction of major nasal dorsal defects

This article describes the results of segmental bone and cartilage reconstruction of significant nasal dorsal defects. Solid bone graft reconstructions frequently lead to an unnatural hardness of the nasal tip. Rib cartilage reconstructions are pliable and soft but are a problem because they easily undergo warpage. The operation is performed using the open approach. Outer cranial bone graft is used for the bone component and extends at least two-thirds of the length of the dorsum. It is secured in place with a compression screw and a Kirschner wire. The cartilage component consists of an abbreviated L strut constructed of septal or conchal cartilage. It is slotted into the cranial bone in a tongue-in-groove manner and is sutured to it through a drill hole in the bone. The dorsal profile is completed with a single cartilage onlay graft or multiple sagittal cartilage grafts secured to the sides of the L strut. Twelve patients underwent segmental reconstruction of nasal deformities. Within this group, five patients underwent secondary rhinoplasty, five underwent posttraumatic rhinoplasty, and two underwent nose augmentation for Oriental features. There were seven men and five women. In all cases, good nasal tip mobility was maintained, and the nasal tips were soft. The interface between the bone graft and cartilage graftwas well camouflaged. The two did not separate. This procedure follows the principle of replacing lost tissue with like materials.     

Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases

Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the nasal framework. The technique described by Erol ( 105: 2229, 2000) uses Surgicel-wrapped diced cartilage grafts in rhinoplasties. The advantages include its ease of preparation, the large volume of graft substrate available for use, and the avoidance of contour irregularities in the areas of placement. A retrospective case review of 67 consecutive patients who were treated with a Surgicel-wrapped diced cartilage graft as part of an aesthetic and/or functional rhinoplasty, in a 5-year period between 1995 and 2000, was performed in this study. All cases of congenital nasal deformities or deformities caused by trauma or tumors in which the technique was used were excluded. The charts were reviewed to determine demographic variables, the surgical procedures performed, prior operations, the rhinoplasty approach used, and the graft donor and recipient sites. Preoperative and postoperative photographs were examined, and the results were assessed. Data on the donor and recipient sites, complications, and the necessity for revisionary procedures were tabulated. There were two complications, namely, an infection, which resolved with aspiration and oral antibiotic therapy, and a recurrence of a dorsal depression, which necessitated repeated augmentation within 6 months. The technique of using Surgicel-wrapped diced cartilage proved to be effective for the augmentation of various areas of the nose. The complication and revision rates were acceptable and comparable to those of other techniques. Patient satisfaction with the aesthetic results was rated highly, with no reports of graft extrusion or contour irregularities. This technique is recommended for nasal augmentation and contouring for selected rhinoplasty patients.     

Early results of vermilion lip augmentation using acellular allogeneic dermis: an adjunct in facial rejuvenation

The definitive approach to lip augmentation has yet to be defined. Herein is described a technique using acellular allogeneic dermal grafts that is easy, effective, and reproducible. Our results over the past 2 years include 47 patients (94 grafts). Three grafts to the upper lip have exhibited significant resorption, which warranted further augmentation. Early in the series, one graft was malpositioned too superiorly along the vermilion-cutaneous border. There have been no cases of infection, hematoma, or graft exposure. The overall complication rate was 4 percent (4 of 94). Our early results by using acellular allogeneic dermal grafts for lip augmentation are encouraging. Further studies are under way to better objectively define long-term results.     

An evaluation of hard palate mucosa graft as a lining material in alar reconstruction: a 7-year experience applied to the full-thickness alar defect

The authors present their experience with 25 hard palate mucosa grafts used as lining material in the reconstruction of full-thickness alar defects. Good "take" was obtained in 22 grafts; the other three grafts incurred necrosis of the overriding skin flaps and postoperative infection. Degree of shrinkage was 11 to 15 percent of grafted size in patients with the type of defect that did not include the alar margin; shrinkage was 26 to 35 percent in patients with the type that included more than 50 percent of the alar margin. In all patients who had a good graft take, the nasal cavities were maintained and there was no nasal obstruction or collapsing during strong breathing. The healing time of the palate donor site varied from 7 days to 5 weeks, depending on the size of the defect. No patients experienced any symptoms at the donor site after healing. The authors concluded that hard palate mucosa can be considered a useful material in alar reconstruction because of the ease in graft harvesting and its support features. When the defect is large enough to involve the total unilateral ala nasi, even though the degree of postoperative shrinkage is comparatively high, hard palate mucosa may be the most suitable material to ensure good take of the graft and less possibility of donor-site morbidity.     

Combined conchal cartilage-ethmoid bone grafts in nasal surgery

Septal cartilage grafts are frequently required in rhinoplasties and nasal reconstructions. Unfortunately, sufficient septum is not always available for graft purposes. Conchal cartilage can serve as a substitute, but its usefulness is limited because of its soft, elastic nature. Applying thin sheets of pliable ethmoid bone to conchal cartilage gives the cartilage greater strength and, at the same time, allows it to retain some flexibility. This article examines the role of combined conchal cartilage-ethmoid bone grafts in nasal surgery. These grafts are simple to construct and are versatile in their application. By maintaining a free cartilage edge, they are readily sutured into place. The results seem to last long term.     

Nasal augmentation with split calvarial grafts in Orientals

This study reports on my experience with autogenous split calvarial grafts in nasal augmentation in 62 Orientals. In 78 percent of patients, the procedure was performed under local anesthesia in an outpatient setting. Total operating time for harvesting of split calvarial grafts ranged from 20 to 55 minutes, with a mean of 32 minutes. Patients ranged in age from 16 to 48 years, with a mean of 27 years. Follow-up was from 6 months to 8 years, with an average of 3.1 years. Intraoperative discomfort was uniformly low and well tolerated when local anesthesia was used. The complication rate was 8.0 percent, with three cases of minor seroma-hematoma formation at the bone-graft donor site. These were treated with aspiration. There were two recipient-site complications, with one case of complete bone resorption that occurred in a densely fibrotic nose with preexisting septal perforation and a case of overcorrection that was successfully rasped 1 year later. Because of their easy accessibility beneath the scalp, split calvarial grafts to the nose are useful in various types of nasal augmentation, and the technique is offered as a practical alternative to the use of alloplastic materials.     

Lip augmentation with superficial musculoaponeurotic system grafts: report of 103 cases.

Many patients suitable for a lip augmentation are of face lift age, and could benefit from a simultaneous lip enhancement during the rhytidectomy procedure. The healthy, live superficial musculoaponeurotic system (SMAS) tissue obtained from the face lift can be recycled and grafted with minimal additional operating time. From April of 1995 to January of 2000, 103 patients (99 women and four men) underwent a lip augmentation procedure by the senior author (N.L.) using SMAS grafts harvested from a simultaneous rhytidectomy. Indications for surgery were purely aesthetic in all 103 cases. The surgical technique used for the SMAS graft lip augmentation is as follows: Using a narrow tenotomy scissors, an intramuscular tunnel was created with blunt and sharp dissection across the lip. The graft, obtained from the posterior edge of the SMAS dissection, is left as long as possible, and is pulled through the tunnel with a tendon forceps. The lips are then stretched manually from the central point upward and downward, respectively. It is important to avoid suturing the ends of the graft into the closure; the grafts should be allowed to move freely, to avoid postoperative tethering on smiling or mouth opening.Most patients expressed some initial concern with their early appearances caused mainly by the swelling. By 2 weeks, most patients were extremely pleased with the size and shape, and their main concern was that the lip fullness would shrink even more. By 3 to 4 weeks, shrinkage largely ceased and the correction remained for varying periods, some as long as 5 years. A sampling of the results was obtained by means of a questionnaire mailed to all patients having undergone the SMAS graft lip augmentation. Fifty-four patients (52 percent) returned the questionnaire with their responses. Of those who responded to the survey, 42 patients (78 percent) reported fuller lips than before their operation. Significantly, 11 of 14 patients (79 percent) followed up after 24 months postoperatively reported fuller lips and excellent or good results. Complications and unsatisfactory results were very rare, occurring generally at the beginning of the learning curve of the series.SMAS grafts are useful for long-lasting lip augmentation, producing a youthful appearance by adding natural, soft roundness and fullness to lips without the artificial look and feel of synthetic material.     

Radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late

It is universally acknowledged that correction of a cleft lip nasal deformity continues to be a difficult problem. In developing countries, it is common for patients with cleft lip deformities to present in their early or late teens for correction of severe secondary lip and nasal deformities retained after the initial repairs were carried out in infancy or early childhood. Such patients have never had the benefit of primary nasal correction, orthodontic management, or alveolar bone grafting at an appropriate age. Along with a severe nasal deformity, they present with alveolar arch malalignments and anterior fistulae. In the study presented here, a strategy involving a complete single-stage correction of the nasal and secondary lip deformity was used.In this study, 26 patients (nine male and 17 female) ranging in age from 13 to 24 years presented for the first time between June of 1996 and December of 1999 with unilateral cleft lip nasal deformity. Eight patients had an anterior fistula (diameter, 2 to 4 mm) and 12 patients had a secondary lip deformity. An external rhinoplasty approach was used for all patients. The corrective procedures carried out in a single stage in these patients included lip revision; columellar lengthening; repair of anterior fistula; augmentation along the pyriform margin, nasal floor, and alveolus by bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; fixation of the alar cartilage complex to the septum and the upper lateral cartilages; augmentation of nasal dorsum by bone graft; and alar base wedge resections. Medial and lateral nasal osteotomies were performed only if absolutely indicated. The median follow-up period was 11 months, although it ranged from 5 to 25 months. Overall results have been extremely pleasing, satisfactory, and stable.In this age group (13 years of age or older), it is not fruitful to use a technique for nasal correction that corrects only one facet of the deformity, because no result of nasal correction can be satisfactory until septal deviations and maxillary deficiencies are addressed along with any alar repositioning. The results of complete remodeling of the nasal pyramid are also stable in these patients because the patients' growth was nearly complete, and all the deformities could be corrected at the same time, leaving no active deforming vector. These results would indicate that aesthetically good results are achievable even if no primary nasal correction or orthodontic management had been previously attempted.     

Cantilever nasal bone grafting with miniscrew fixation

A technique of rigid miniscrew fixation of cantilever nasal bone grafts is described. This produces stable, predictable nasal contour and tip projection without significant bone graft resorption.     

Primary definitive nasal correction in patients presenting for late unilateral cleft lip repair

Almost 25 percent of unilateral cleft lip and palate patients present with their deformity in their teens or later years in the developing world. Because more than 80 percent of the world population lives in the developing world, the established protocol for repair of these deformities is not applicable to these patients. Despite the magnitude, there are no significant reports in the literature that deal with this problem. Several issues need to be addressed, but the author limits himself here to the correction of the nasal deformity. The patients at this age are very much concerned with the aesthetic outcome. Procedures described hitherto for primary nasal correction in infants are not successful in restoring nasal shape and symmetry at this late age of presentation. Our experience with radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late prompted us to extend the concept by undertaking a definitive primary correction of the nasal deformity in cleft patients presenting late. Twenty-two patients with unilateral cleft lip deformity (nine male patients and 13 female patients) with ages ranging from 13 to 22 years, presenting between August of 1997 and December of 2000, are included in this study. Of these, 11 patients had a cleft of the lip alone, eight also had a cleft of the alveolus, and three had a cleft of the palate continuous with the cleft lip. All patients showed some maxillary hypoplasia. An external rhinoplasty with lip repair was carried out in all patients. The corrective procedures on the nose included columellar lengthening; augmentation along the pyriform margin, nasal floor, and alveolus using bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; and augmentation of nasal dorsum by bone graft. Clinical follow-up ranged from 4 to 24 months, and the median follow-up period was 13 months. Results have been very good, and much better than results seen earlier with other primary rhinoplasty techniques. While repairing unilateral cleft lip in adolescents, the author thinks it would be most appropriate to address the entire gamut of the deformity in a single stage, provide complete vector reorientation, and augment the hypoplastic elements by autologous tissue. It is not just the fear of poor follow-up, but that merely correcting the lip deformity in these patients without attempting definitive rhinoplasty, in the author's opinion, would be insufficient surgical intervention.     

Frequently used grafts in rhinoplasty: nomenclature and analysis

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately name the most frequently used grafts in primary and secondary rhinoplasty. 2. Describe the precise anatomical position of each graft. 3. Discuss the clinical indications of each graft. SUMMARY: In this article, the authors present the grafting techniques most commonly used to sculpt the nasal framework in primary and secondary rhinoplasty. The grafts are described in terms of their nomenclature, anatomical location, and clinical indications, presenting a simple and easy-to-reference guide for both beginners and expert surgeons.     

Long-term outcome of autogenous rib graft nasal reconstruction.

Whereas reconstruction of the hypoplastic nose with rib grafting is common, the long-term outcomes of nasal growth and aesthetics are unknown. This study assessed nasal morphometrics, patient satisfaction, and the perception of nasal appearance by others up to 15 years after nasal reconstruction using cantilevered autogenous chondro-osseous rib grafting with rigid internal fixation in children. Records of all patients who received nasal rib grafts between 1983 and 1998 by one senior surgeon were reviewed. Patients in this study were operated on before their late teens and had greater than 1-year follow-up including serial photographic documentation. Nasal growth was determined by comparing anthropometric measurements preoperatively, perioperatively, and postoperatively. Patient satisfaction was determined through a questionnaire that addressed memory, donor-site morbidity, and nasal perception. Independent, blinded skilled observers who reviewed frontal and lateral photographs of the preoperative, perioperative, and postoperative intervals assessed nasal aesthetics. Thirty-two patients who underwent 38 rib graft reconstructions of the nasal dorsum and tip at an average age of 8.8 years constitute the study population. Six patients underwent secondary augmentation. The average interval between initial nasal reconstruction and evaluation for this study was 7.9 years. Comparative anthropometric measurements before and after surgery documented increases in both tip projection (2.3 percent) and nasal length (3.0 percent) and a decrease in nasolabial angle (1.9 percent). Patient satisfaction interview response rate was 100 percent of those whom we were able to contact (28 of 32). The average age at interview was 17.2 years. Most patients recalled the operation and denied recollection of pain. Donor-site long-term morbidity was not an issue for 86 percent of patients. Sixty-four percent of patients remembered their preoperative nasal appearance and 89 percent of these preferred the postoperative change and were not concerned with nasal scars or texture. Almost two-thirds of the patients had fixation screws removed from the nasal dorsum because of skin erosion, easy palpability, or visibility. Although several patients expressed a desire to make minor additional changes to their nose, only one of these elected offered presurgical consultation and none have had such surgery. The postoperative nasal appearance compared with that preoperatively was rated as improved for 66.3 percent of responses, 26.5 percent as unchanged, and 7.2 percent as deteriorated. Cantilevered autogenous chondro-osseous rib graft reconstruction of the nasal dorsum is an effective means of reconstruction for the hypoplastic nose in childhood with respect to morphometric measurements, patient self-perception, and the assessment of nasal appearance by others.     

Redefining the Septal L-Strut to Prevent Collapse

During septorhinoplasty, septal cartilage is frequently resected for various purposes but the L-strut is preserved. Numerous materials are inserted into the nasal dorsum during dorsal augmenation rhinoplasty without considering nasal structural safety. This study used a finite element method (FEM) to redefine the septal L-strut, to prevent collapse as pressure moved from the rhinion to the supratip breakpoint on the nasal dorsum and as the contact percentage between the caudal L-strut and the maxillary crest changed. We designed a 1-cm-wide L-strut model based on computed tomography data. At least 45% of the width of the L-strut in the inferior portion of the caudal strut must be preserved during septoplasty to stabilize the septum. In augmentation rhinoplasty, the caudal L-strut must either be preserved perfectly or reinforced to prevent collapse or distortion of the L-strut. The dorsal augmentation material must be fixed in an augmentation pocket to prevent movement of graft material toward the supratip breakpoint, which can disrupt the L-strut. We conducted a numerical analysis using a FEM to predict tissue/organ behavior and to help clinicians understand the reasons for target tissue/organ collapse and deformation.     

Grafting the nasal dorsum with tandem ear cartilage

A technique for autogenous grafting of the nasal dorsum with ear cartilage is suggested based on the results of 25 consecutive cases. The technique involves (1) harvesting the entire cymba conchae and cavum conchae of the ear; (2) separating them and suturing them to each other in tandem fashion; (3) filling the underside concavity of the cymba conchae part of the graft with scraps of cartilage; (4) avoiding any bruising or crushing of the graft; and (5) filling any minor residual irregularities of the dorsum with soft tissue or cartilage from the cephalic trim of the lateral crus. The results suggest a consistent augmentation of the nasal dorsum for deficiencies from 3 to 6 mm in size. Four of the 25 cases did require secondary correction for dorsal convexity, inadequate augmentation, and surface irregularities. The technique, however, has been helpful in that ear cartilage is invariably available, allowing septum to be used for more important grafts. The procedure is easily performed under local anesthesia with no significant distortion to the donor site.     

Use of cartilaginous autografts in nasal surgery: 8 years of experience

Although the cartilaginous autografts are one of the tissues more utilized in nasal surgery, a comparative study does not exist to determine which are better options and their precise indications. It is for this reason that a histopathologic analysis was carried out comparing the characteristics and properties of the four principal cartilages that are utilized in aesthetic functional surgery of the nose. Considering these particularities, the precise indications for the employment of the different cartilage as nasal autografts were determined. Of 1120 aesthetic functional rhinoplasties during a period of 8 years, 930 (83 percent) required cartilaginous autografts, 86 percent were primary, 11 percent were secondary, and 3 percent had two or more surgeries. Eighty-three percent of the grafts used were from nasal septum, 12 percent from the auricle, 3 percent from alar cartilages, and 2 percent from the rib. The anatomic sites in which they were employed consisted of the following: 64 percent between the medial crura, 28 percent as in Sheen's graft, 19 percent in the nasal dorsum, 8 percent as spreader grafts, 8 percent as in Peck's graft, and 3 percent in the rim to improve alar collapse. We followed at all times the previous indications for obtaining and placing the nasal autografts. Eighty-four percent of the patients were totally satisfied and only 8 percent required a second surgical procedure to achieve the results desired. Based on this study, it is recommended to utilize the cartilaginous autografts in nasal surgery considering three parameters: the physical and histologic characteristics of each cartilage, the anatomic site in which they are to be placed, and the effect desired with their application.     

The residual unilateral cleft lip nasal deformity: a three-phase correction technique

The author presents a three-phase correction technique for the residual unilateral cleft lip nasal deformity. This procedure involves a sculpting excision of the alar rim, use of this alar rim as an interpositional flap in lengthening the columella, and augmentation of the nasal tip and perialar sulcus with a free ear conchal cartilage graft. The concept has been incorporated in the revisionary surgery program of 74 patients over a period of 5 years with a minimal follow-up of 2 years. The majority of the patients are operated on between the ages of 5 and 7 years based on the concept of a need for a "tidy appearance" by first grade.     

Orthognathic surgery in cleft patients treated by early bone grafting

For the past 25 years at Children's Memorial Hospital in Chicago a protocol has been followed for complete clefts that involves placement of an infant maxillary orthopedic appliance prior to lip closure, surgical closure of the lip, autogenous split-rib grafts to the alveolus to stabilize maxillary segments, and palatal closure, generally within the first year of life. The oldest 36 patients whose skeletal growth was for all practical purposes finished have been followed to determine the need for and type of orthognathic surgery. Of the total sample, 8 patients (22.2 percent) required some type of sagittal orthognathic surgery (1 patient in this group also required vertical maxillary alignment) and 2 patients required maxillary augmentation only in the form of an onlay graft. This report may serve as a baseline for others who wish to report on the incidence and type of orthognathic surgery in their cleft palate centers.