Correcting the saddlebag deformity in the massive weight loss patient

Skin redundancy of the trunk and thigh is treated by a circumferential abdominoplasty and a lower body lift. Despite preservation and tight approximation of the subcutaneous facial system, the authors have failed to adequately correct severe saddlebag deformity and midthigh laxity in the massive weight loss patient. The technique used in the last nine of the senior author's 43 lower body lifts was modified by fully abducting each operated thigh on a side utility table, before closure in the prone position. This maneuver permits an increase in width of skin excision and causes the lateral thigh skin to be taut upon leg adduction. This is a retrospective review of the senior surgeon's experience over a 3-year period. Postoperative follow-up of the nine-patient cohort ranged from 8 to 12 months. A standardized set of six-view preoperative and postoperative photographs was available for each patient. A regional grading system was developed to assign points for deformity seen in preoperative and postoperative photographs. To compare the effect of the new technique on the correction of hip/lateral thigh deformities, the authors used this same grading system to analyze 10 other lower body lift patients treated by the same surgeon without full thigh abduction who had six sets of standardized photographs. A deformity severity score was determined for each anatomic region by four trained observers blinded to the surgical technique. The nonparametric Mann-Whitney U test using exact p values was used to compare preoperative and percentage change in deformity severity score from preoperative to postoperative scores relative to preoperative scores for each anatomical region among subjects in each treatment group. The nonparametric Wilcoxon signed rank test using exact p values was used to evaluate the change in deformity severity score from preoperative to postoperative values. The change in technique resulted in an observable symmetrical correction of the severe saddlebag deformity and better contour to the distal lateral thighs. All evaluated patients were satisfied with the lateral thigh skin contour. The grading system revealed that patients treated with or without intraoperative thigh abduction had similar preoperative deformity severity scores for each anatomic region (p > 0.05). Postoperatively, all subjects showed improvement in scores for all treated regions. However, patients closed during full thigh abduction had significantly lower deformity severity scores for the hip/thigh complex when compared with patients treated without full thigh abduction (p < 0.05). Complications in these 19 patients consisted of one 6-cm superficial skin layer dehiscence due to a broken polyester suture that healed spontaneously. There were three seromas that responded to a short series of aspirations or catheter drainage. There were no infections. Distal abdominal flap tip skin necrosis in four patients responded to outpatient débridement and healed secondarily. A new grading system for body contour deformities was successfully utilized to judge differences in the quality of trunk and thigh deformity and outcome in 19 patients with adequate photographic records. Tight suture closure in full thigh abduction in the prone position results in improved treatment of significant saddlebag deformity and midthigh skin laxity in the massive weight loss patient. The essential principles are meticulous planning, careful isolation, tight closure of the lateral trunk and thigh subcutaneous fascial system, and artistic contouring of remaining tissues. Dehiscence, undesirable scarring, and seromas were minor issues in the entire group of 43 patients.     

Brachioplasty technique with the use of molds

Over previous years many surgical techniques have been developed to correct lipodystrophy and brachial skin laxity while providing a natural, discreet contour and symmetrical scars, a goal that has not always been achieved. In this study, the authors classify the alterations of the arm into three degrees and propose a different surgical treatment, to be used alone or associated with another procedure, for each classification. They developed a new technique that uses a mold to mark the incision in an italic double S-shape. From 1996 to 1998, 20 patients who underwent this surgery showed symmetrical and smaller scars with better results and minimal complications.     

Minibrachioplasty: minimizing scars while maximizing results

The growing popularity of bariatric surgery has increased the number of brachioplasties performed. One of the major drawbacks of brachioplasty is the unsatisfactory appearance of the surgical scar. The author describes a short-scar brachioplasty, or minibrachioplasty, that can achieve much of the improvement of a traditional brachioplasty while concealing the scars within the confines of a short-sleeve shirt or blouse. Eight patients treated with this technique saw a significant improvement in the appearance of their upper arms.     

An algorithmic approach to upper arm contouring

There has been a renewed interest in upper arm contouring given the recent advances and subsequent patient interest in weight loss. Patients undergoing bariatric surgery are often left with a significant amount of redundant skin and laxity of their upper extremity. Some patients within this group have excess fat in their upper arms with relatively good skin tone, while others have a paucity of excess fat with a significant amount of redundant skin. The optimal treatment for each patient can vary. A clinical algorithm is presented that is designed to select the best method for upper arm contouring based on the aesthetic analysis of the upper arm. Case examples are provided demonstrating results that were obtained by following this algorithm.     

A new technique for brachioplasty

A new technique for brachioplasty is proposed, aiming at correction of ptosis without excision. It is based on rolling a deepithelialized flap around from the rear and sliding it underneath the inside frontal skin of the arm, recreating the roundness of the arm and a firmer consistency. This technique has been utilized in 12 patients so far, with a follow-up ranging from 8 months to 4 years. No postoperative edema were observed, but one case of hyperesthesia appeared for a period of 2 months. The main preoccupation is scar sequelae, which must limit the intervention to patients clearly aware of the possibility of healing complications.     

OPERATIONS IN UPPER EXTREMITY AMPUTEES

The surgeon is obligated to prepare the patient mentally as well as physically for amputation. Acceptance of his loss by the patient, his family and contemporaries is important in his adjustment to his environment. He must provide the best stump possible, direct the postoperative shrinking and conditioning of the stump, prescribe the prosthetic device best suited to the needs of the individual, make sure it fits and functions, and that the patient is instructed in its maximum use.There are definite indications for ablation of a part. All possible length in the upper extremity should be preserved.Amputation in children with congenital deformities should usually be postponed until demanded by the family. The growth centers should be preserved if feasible. Congenital upper extremity amputees should ordinarily be fitted within the first two years.Neuromata, spurs, redundant tissue, scars, and phantom pain should generally be treated by other than surgical methods. Revisions, including cineplasty, should be undertaken only after careful study and when there are clear indications that benefit to patient will ensue.     

Belt lipectomy for circumferential truncal excess: the University of Iowa experience

When some patients with circumferential truncal excess undergo traditional abdominoplasty, the trunk is not addressed as a unit. Belt lipectomy, a procedure that combines abdominoplasty with circumferential excision of skin and fat, is often more ideal for these patients. In this article, the authors review the literature on belt lipectomy and evaluate their series of 32 patients who underwent belt lipectomy at the University of Iowa. The evolution and current preoperative markings, intraoperative surgical technique, and postoperative care are described. The patients' charts and their preoperative and postoperative photographs were examined retrospectively. It was found that belt lipectomy improved abdominal contour, abdominal wall laxity, mons pubis ptosis, back rolls, waist contour, and buttocks contour. Initially, the procedure was performed on post-weight-reduction patients only, but its indications were extended to three other groups: patients who were 30 to 50 pounds overweight, patients of normal weight who desired a significant overall truncal improvement, and an obese patient with persistent intraabdominal excess. The improvements were significant in all groups of patients except for the latter patient. Complications included a 37.5 percent seroma rate, a 9.3 percent pulmonary embolus rate, and one dehiscence that required reoperation. The authors concluded that belt lipectomy should be seriously considered for patients who present with circumferential truncal excess and for a select group of normal-weight patients. It is not recommended for the obese patient with excessive intraabdominal content. Furthermore, belt lipectomy should be undertaken only in patients who are well informed about the possible risks and complications.     

Correcting a stairstep deformity secondary to lower abdominal scars by the use of a decorticated hypogastric flap

The author describes a decorticated hypogastric flap used in the correction and prevention of retracted scars and suprapubic stairsteps. These deformities are common after cesarean sections and in patients who undergo liposuction followed by the retrieval of excess skin. The surgical technique is described. The author also analyzes the advantages and results that occur without an increase in either the time of surgery or complications.     

Modified Antia-Buch repair for full-thickness upper pole auricular defects

Various reconstructive techniques have been described for repair of full-thickness upper pole auricular defects. The wedge excision commonly used for treatment of upper pole tumors allows excision and reconstruction in a single stage. However, this technique suffers from major deficiencies. We apply the concept of crescentic scaphal excision and the Antia-Buch advancement-rotation flap principle to repair various full-thickness upper pole auricular defects resulting from excision of skin lesions in eight consecutive patients. The technique achieves a natural auricular shape in three dimensions with minimal disruption of the anatomic landmarks and avoids conspicuous scars. It has several advantages over the original Antia-Buch repair and other techniques used for reconstruction of full-thickness upper pole auricular defects.     

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem.Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.     

Severe ectropion: repair with a modified Tripier flap

Classical techniques, such as wedge resection, are well suited for mild cases of lower lid ectropion, but they often fail to cure severe cases. The reason these techniques often fail is because they address only the laxity and elongation of the ectropic lid, not the root cause. In nearly every case of severe ectropion, the root cause is importance of the pretarsal orbicularis muscle; i.e., there is inadequate muscle support for the pretarsal lower eyelid. A bipedicled musculocutaneous flap, transferred from the upper lid, was used to treat nine cases of severe lower eyelid ectropion. Eight patients had a good/excellent result. Four patients had electromyographic studies in the late postoperative period, without a single instance of even mild denervation. In cases of severe ectropion, this flap is an effective replacement for the missing skin and impotent muscle. It uses the often discarded blepharoplasty tissue, which has a perfect color and texture match. A single anatomic unit is rebuilt, transferring a strong new muscle strap with ideal supporting vectors and leaving scars in natural creases. This "blepharoplasty flap" may prove useful in other types of eyelid reconstruction.     

Reduction mammaplasty with the "owl" incision and no undermining

Reduction mammaplasty has traditionally been done using the Wise pattern of incision. Because of the box-like effect in breast shape, the lack of projection, and the long scars associated with the inverted T incision, two techniques have emerged as alternatives: the vertical reduction of Lassus/Lejour and the "round block" periareolar technique popularized by Benelli. Each of these techniques has its pros and cons.The "owl" incision combines the features of the large periareolar reduction (Benelli's) and the vertical reduction (Lassus/Lejour); the horizontal inframammary scar is either made very short or completely eliminated. Volume reduction is done through a heart-shaped parenchymal resection, leaving the nipple-areolar complex over a supero-central pedicle. Maintenance of the central parenchyma behind the nipple-areolar complex and mobilization of the vertical pillars toward the center of the breast give excellent projection and diminish the lateral fullness. Enlargement of the periareolar skin resection diminishes the length and pleating of the vertical scar; conversely, inclusion of the vertical component to the periareolar technique eliminates the pleating effect of the periareolar incision. The short horizontal excision eliminates any resultant "dog ears" in the new inframammary fold. Thus, the discrepancy in the length of scars is better distributed. There is no skin or parenchymal undermining, so drains are not needed. Excellent results are obtained immediately on the operating table, and large volumes of glandular resection and correction of severe ptosis can be accomplished without compromising vascularity of either the nipple-areolar complex or the skin flaps.Ninety-four patients in a 7-year period were operated upon using this technique. Seventy-two had bilateral reductions up to 1900 gm per breast, 12 had unilateral reduction for symmetry following breast reconstruction, and 10 were patients with severe ptosis. Complications were rare and of a minor nature. No conversion to free grafts was done, even in the larger resections. One case required minor revision under local anesthesia, one case required bilateral re-reduction, and another case required unilateral re-reduction for continued growth of breast tissue. Almost 90 percent of the patients underwent procedures as outpatients.The owl-type incision and the supero-central pedicle flap are elements of a reduction mammaplasty technique that provides excellent projection and shape with minimal visible scars. It takes advantage of the positive features of the periareolar and vertical reduction techniques and minimizes their negative features. The new design of parenchymal resection improves the vascularity of the residual flaps. Additionally, it may better preserve the sensation to the nipple-areolar complex and lactation is not compromised.     

Body contouring

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. List patient selection factors for body lift surgery. 2. Describe operative approaches for brachioplasty, upper body lift, abdominoplasty, lower body lift, and thigh lift. 3. Identify complications and pitfalls related to body lifting and describe how to avoid them. SUMMARY: The author discusses the preoperative assessment, surgical treatment plan, postoperative management, outcomes, and possible complications for a comprehensive spectrum of body-contouring surgical procedures. Preoperative planning includes medical history and physical examination, along with an open discussion with the patient. Surgical procedures for brachioplasty, upper back lift, abdominoplasty, lower back lift, gluteal augmentation and thigh lift are discussed. Postoperative management pearls are shared, as well as pitfalls to be avoided.     

Vertical mammaplasty

Current criticisms regarding vertical mammaplasty include problems with poor immediate postoperative appearance, nipple-areola complex malposition, and excessive lower pole length. These problems can be avoided by proper patient selection, by utilizing correct concepts of skin design, and by observing correct glandular resection and closure concepts. Vertical mammaplasty also can result in other problems, such as hypertrophic circumareolar scars and lower pole deformities, including notching, boxy shape, infra-areolar depression, and flatness. These problems are also largely avoidable by using correct technique. Several basic concepts described previously have not proven necessary to achieve good results. Abandoning some of these principles has contributed to the ability to establish an aesthetically ideal breast shape intraoperatively as well as to a decrease in morbidity. This includes eliminating liposuction as a major integral component of the procedure, eliminating suturing the gland to the pectoralis muscle, not undermining the lower pole skin, and avoiding overly wide skin resection and tight wound closure that produces significant lower pole distortion in the early postoperative period. An important concept that has proven reliable is to use a "closed" design that does not predetermine the areolar opening whenever circumstances permit. When this is not possible, a modification that utilizes the smallest possible circumference as an open design is better than a large "mosque." These alternatives allow greater flexibility in determining final nipple position and also reduce the risk of hypertrophic circumareolar scars. Important glandular resection concepts include creating pillars that are attached to both the skin and the chest wall; making them of adequate dimension to avoid postoperative lower pole shape problems, such as flattening; resecting closer to the skin lateral to the pillars to avoid a boxy breast shape; and using a drain both to assist in accurately determining the endpoint of resection and to avoid postoperative seromas. Key closure concepts include approximation of the superior surfaces of the pillars at their base to maintain vertical height and thereby prevent lower pole flattening; approximation of the inferior surfaces of the pillars to the base of the breast to prevent notching; and proper management of the vertical incision by restricting the purse-string suture effect to only the inferior portion of the incision, where there may be skin excess present. Inclusion of these concepts leads to predictable and improved aesthetic results in vertical mammaplasty. This allows full realization of the purported advantages of vertical mammaplasty and allows this method to be utilized with a level of confidence similar to that seen with inverted-T techniques.     

Brow suspension,a minimally invasive technique in facial rejuvenation

People tend to prefer noninvasive or minimally invasive methods of facial rejuvenation, especially when it involves their face, which is the hallmark of a person's identity and impossible to hide. It is widely known that brow ptosis gives the face a "tired look" and also accentuates deformities of the upper eyelid. Most people who are interested in facial rejuvenation may not accept even a minor surgery, such as an endoscopic surgery. The senior author has developed a minimally invasive method of suspending the brow at a higher position. In this technique, there is neither surgical dissection nor a surgical incision except for four stab incisions and suture insertion, which is why we refer to it as a nonsurgical brow suspension. It is done under local anesthesia, and the brows are fixed in the position that they assume when the patient is supine. In the past 6 years, we performed 387 brow suspensions on 324 female and 63 male patients. The youngest patient was 19 years old, and the oldest was 74 years old. A retrospective chart review was done. These 387 cases were reviewed by comparison of preoperative and postoperative photographs. This approach was not only used for patients who were not interested in surgical rejuvenation but was also combined with lipofilling, laser resurfacing, and/or upper blepharoplasty. This technique is useful for correcting postsurgical brow asymmetry. We present this technique as an adjunct to the established techniques of facial rejuvenation. Despite the high patient acceptance and technical ease, it is not a replacement for the established techniques of facial rejuvenation.     

Optimizing body contour in massive weight loss patients: the modified vertical abdominoplasty

In morbid obesity, contour deformities of the abdomen are common after bariatric surgery and radical weight loss. Traditional abdominoplasty techniques often fail to maximally improve body contour in these cases because adjacent sites such as the hip rolls and flanks are not treated, leaving the patient with large lateral tissue redundancies and dog-ears. In an attempt to solve these challenging problems, the authors present the modified vertical abdominoplasty technique, a single-stage procedure that involves a combined vertical and transverse approach in which an "en bloc" resection of the redundant tissues is performed without undermining, drainage, or reinforcement of the abdominal wall. The latter is only carried out when diastasis and/or hernias are present, and Marlex mesh may be utilized when indicated. In patients with simultaneous large umbilical hernias and/or excessively long stalks, neoumbilicoplasty is recommended. A significant improvement of abdominal contour was obtained in the vast majority of patients because the resection design offers simultaneous treatment of both vertical and transverse tissue redundancies in the abdomen and neighboring regions, with more harmonic results when compared with purely vertical or transverse approaches. The modified vertical abdominoplasty technique is an easy, fast, and reliable alternative for treating these patients, with less intraoperative bleeding, reduced overall cost, and low morbidity rates. In selected cases, the technique is capable of offering excellent results in terms of contouring and maximizes the overall outcome of treatment protocols for these patients, who can then be integrated into normal life with heightened self-esteem, happiness, and productivity.     

The expanded transposition flap: shifting paradigms based on experience gained from two decades of pediatric tissue expansion

The authors present their experience with the design of expanded skin flaps gained over the past two decades in a large series of 995 expanded flap reconstructions performed in 626 operations in 430 patients. The indications for tissue expansion were giant congenital pigmented nevi (72.7 percent), scar contractures (11.2 percent), and a remainder for a variety of congenital and acquired deformities. Surgical strategies were reviewed retrospectively to determine the location in the body where the tissue expansion was performed, the number of procedures required to accomplish the reconstructive goal, and the design of the expanded flap that was used to reconstruct the involved area. Specific points that were noticed included contour deformities (such as webbing, dog-ears, or decreased limb circumference) following flap reconstruction, anatomic distortions (such as distortion of the eyebrow or the distance from the brow to hairline) following reconstruction, final position of the scars in relation to anatomic landmarks, borders of aesthetic units, and relaxed skin tension lines, and the potential for later scar contracture. Careful examination of reconstruction by region of involvement demonstrated significant advantages in the use of expanded transposition flaps over pure advancement. These advantages and the modifications in the design of expanded flaps for each body region are discussed in a series of representative cases. They emphasize the ability of transposition flaps to dissipate tension away from the flap apex and distribute it more proximally, thus redirecting the tension lines so there is less likelihood of anatomic distortion in the reconstructed area. Also, flaps designed in this manner allow improved contour by avoiding webbing, tenting across concavities, and bunching of skin laterally. The authors conclude that restricting the expanded flap design to advancement alone to minimize potential scarring severely limits the reconstructive capabilities of the added tissue and distracts from the surgeon's ability to accomplish the initial reconstructive goal. The cost of additional incisions is worthwhile to achieve better final contour of the reconstructed part, lesser risk of anatomic distortion, better position of the scars, and lowered risk of scar contracture.     

Marriage abdominoplasty expands the mini-abdominoplasty concept

The marriage of aggressive superwet liposculpture of the abdomen and adjacent anatomic regions with a modification of well-established open surgical techniques to address skin excess and perform muscle plication was used to treat 29 patients presenting for aesthetic abdominal contouring over the past 3 1/2 years. The charts of 57 patients who had aesthetic contouring procedures on the abdomen performed from December of 1994 to July of 1998 were retrospectively reviewed. Fifteen patients underwent suction lipectomy alone, 13 patients were treated with conventional abdominoplasty, and 29 underwent "marriage abdominoplasty." The 29 patients who underwent marriage abdominoplasty presented with deformities marked by excess lower abdominal skin and adipose tissue, with or without muscle laxity (Psillakis types II, III, and IV). Seventeen procedures were performed under local anesthesia with deep conscious sedation on an outpatient surgical basis. In 12 patients, the operation accompanied a hysterectomy, urologic procedure, or additional aesthetic surgical procedure(s) and was done under general anesthesia. Suction aspirates ranged between 540 and 2600 cc (mean, 1160 cc) and were accompanied by lower abdominal skin excision in every case, which was performed predominantly through short and medium-length incisions (mean, 15 cm). Rectus abdominis muscle plication was performed where necessary, using vertical plication of the infraumbilical rectus muscles in 27 patients (93 percent) and full-length plication in two patients (7 percent). All patients demonstrated significantly improved contours and have seemed to manifest less pain when compared with patients treated by full traditional abdominoplasty. Postoperative complications have included upper abdominal skin waviness (2), annoying paresthesias and discomfort persisting for 6 months (1), seroma (1), and marginal skin necrosis with an open wound (1). The latter problem occurred in the only patient who was treated with a revision procedure. Thus, the complication rate was 17 percent (5 of 29 patients). The marriage of aggressive superwet liposculpture of the entire abdomen with standard open surgical techniques used to treat skin excesses and allow abdominal muscle plication where necessary offers the advantage of reduced surgery when compared with full abdominoplasty, while consistently achieving significant contour improvement. This concept is applicable to the majority of patients presenting for the treatment of abdominal deformities and has markedly expanded the application of the mini-abdominoplasty concept.     

Guidelines in concentric mastopexy

The scope and technique of concentric mastopexy remain unclear and controversial. In our hands, the procedure has application for mild nipple ptosis, glandular ptosis, and areola asymmetry, as well as the tuberous breast. Early disappointment has changed to increasing satisfaction as we have gained confidence in predicting our results based on the identification of three simple principles of concentric mastopexy. The first and most important, which states Doutside less than or equal to Doriginal + (Doriginal - Dinside), requires that the outer concentric circle must be drawn not to exceed the original areola diameter by more than the original areola diameter exceeds the inner concentric circle diameter. The second principle, Doutside less than or equal to 2 X Dinside, recommends that the outer circle diameter be drawn not to exceed twice that of the inner circle, to prevent poor scarring or over flattening of the breast. The third principle, Dfinal = 1/2(Doutside + Dinside), allows prediction of the final areola size as the average of the diameters of the inner and outer concentric circles. These three principles allow excision of a maximum amount of areola and periareola skin without the side effect of poor scars, dilated areola, or misshapened breasts. Applying these three principles to concentric mastopexy with or without augmentation mammaplasty, one may confidently correct a wide variety of deformities, producing more symmetrical, attractive breasts with areolae of a predictable size.     

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.