Dorsal augmentation with diced cartilage enclosed with temporal fascia in secondary endonasal rhinoplasty

Investigation of Two New Grafting Techniques for Dorsal Augmentation Rhinoplasty: An Experimental Study with New Zealand White Rabbits

INTRODUCTION

Cartilage is an important source in supporting the structure of the nose for dorsal augmentation rhinoplasty. However, it is known that its viability is not always on the ideal level. Various wrapping materials are used to increase the strength of cartilage. Donor site morbidity, which develops following the harvesting of both cartilage and fascia as one such cover material, has attracted interest in recent years.

OBJECTIVE

In this study, we aimed to investigate the potential of dermis and tendon autografts as alternatives to fascia and cartilage.

MATERIAL AND METHOD

The sample of the study included 16 New Zealand white rabbits. The right auricular cartilage of all rabbits was amputated, and it was transformed into diced cartilage autografts. The dermis autografts from the right gluteal areas of the rabbits were deepithelialized, and lumbosacral fascia autografts were harvested from the same incision. Additionally, the Achilles tendon of each rabbit was harvested and transformed into diced tendon autografts. Four different autografts were embedded under the skin of each rabbit from 4 different pouches opened in the back of the rabbit. These autografts included diced cartilage alone (Intervention 1), fascia-wrapped cartilage (Intervention 2), dermis-wrapped cartilage (Intervention 3) and fascia-wrapped tendon (Intervention 4) autografts.

RESULTS

Intervention 1 had the most irregular appearance, the outcomes in Intervention 4 were volumetrically smaller and softer. Connective tissue formed between the diced pieces in all interventions, and it was observed that the dermis and fascia had a capsule-like appearance, and their viability was preserved. The differences between the initial and final measurements of the volumes of interventions 1, 2 and 3 were statistically significant (p < 0.05). There was no significant difference between the initial and final volumetric measurements of intervention 4 (p > 0.05). More peripheral proliferation was observed in the interventions of fascia-wrapped and dermis-wrapped diced cartilage compared to the other interventions. The intervention including fascia-wrapped diced tendon grafts had displayed more fibrosis, fragmentation and collagen fibers, while it showed a lower amount of elastic fiber. There were no significant differences among the intervention in terms of other histological parameters.

CONCLUSION

Tendon autografts may be a good option for dorsal augmentation rhinoplasty as they are easily harvested and have minimal donor site morbidity. Dermis autograft usage is more advantageous than fascia usage in terms of accessibility and convenience.

NO LEVEL ASSIGNED

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Ethnic rhinoplasty: Preliminary results of our technique in the pursuit of the harmonious nose

INTRODUCTION

According to the American Society of Plastic Surgery, cosmetic surgery procedures for "ethnic patients" are annually increasing. Ethnic rhinoplasty traditionally represents a difficult challenge for plastic surgeons. Herein, we describe our personal technique to ethnic rhinoplasty to achieve a harmonious nose maintaining the characteristics of individual ethnicity and identity.

MATERIALS AND METHODS

In this study, we retrospectively reviewed ethnic patients treated with rhinoplasty at our institution between January 2019 and October 2022. We described our personal rhinoplasty technique step by step. At a minimum follow-up time of six months, postoperative pictures were taken, and patients were reassessed, evaluating aspects such as global symmetry and shape and contour of the nose. Finally, patient satisfaction was investigated according to rhinoplasty outcomes evaluation (ROE) questionnaire.

RESULTS

A total of 1321 patients were included in the study. They reported a significant satisfactory aesthetic result in nasal image, as indicated by the mean postoperative ROE score (92.12). No cases of nasal contracture were recorded. None of the grafts was extruded or collapsed. Wounds healed without reported major infection.

CONCLUSION

This study demonstrated that our approach is a safe procedure that contributes to improved functional outcomes with a high patient satisfaction rate and a low rate of postoperative complication. The creation of a solid base structure, nasal skin preparation, and an integrated patient approach are key elements of this surgery.

Complications of Diced Cartilage Wrapped in Blood Products in Rhinoplasty: A Meta-Analysis

BACKGROUND

Diced cartilage wrapped in blood products has been increasingly advocated in rhinoplasty. The complication is a major concern of the procedure. This meta-analysis aims to assess the complication rates and revision rate of this procedure.

METHODS

All original articles published up to March 2022 were searched through PubMed, Embase, and Web of Science databases. Additional articles were added through reference searching. Articles were included for meta-analysis according to inclusion criteria. Data were extracted by 2 individuals independently and the analysis was conducted through Stata 12.0 software (StataCorp., College Station, Texas).

RESULTS

A total of 559 articles were initially found and an additional 1 article was added through reference searching. A total of 11 articles including 469 patients were included for meta-analysis. The results indicated that the total complication rates were 1.2% for irregularity, 0.2% for visibility, 0.7% for deviation, 1% for erythema, and 0% for graft resorption, depression, and infection. The revision rate was 1.2%.

CONCLUSIONS

The overall complication and revision rates of diced cartilage wrapped in blood products in rhinoplasty were relatively low. Considering the limited number of related studies, a larger sample size, long-term follow-up, clear diagnostic criteria, and detailed methods of measurement are expected in further research.

3D Printing Technique Assisted Autologous Costal Cartilage Augmentation Rhinoplasty for Patients with Radix Augmentation Needs and Nasal Deformity after Cleft Lip Repair

OBJECTIVE

to better reconstruct the nasal shape after cleft lip repair with 3D printing assisted autologous costal cartilage augmentation rhinoplasty, especially for patients with radix augmentation needs.

METHOD

20 patients with nasal deformity secondary to cleft lip repair and radix augmentation needs had received surgical treatment from July 2016 to November 2021. A total of 10 cases were treated with autologous costal cartilage augmentation rhinoplasty for nasal deformity after cleft lip repair, and 10 cases were treated with the help of 3D printing. According to the characteristics of nasal deformity, autologous costal cartilage was carved and implanted into the nose back.

RESULTS

3D printing assisted autologous costal cartilage augmentation in the treatment of nasal deformity after cleft lip repair, the incision healed well, and there were no complications in the thoracic cartilage donor area. The shape of the nose is satisfactory, the height and shape of the nose tip and the size of both nostrils are mostly symmetrical, the nasal columella is elongated, the original nose tip is flat, the collapse of the nose wing is satisfactory, and the nose lip angle is close to normal.

CONCLUSIONS

3D printing assisted autologous costal cartilage augmentation is an ideal treatment for nasal deformity after cleft lip repair.

Indications, Techniques, and Postoperative Outcomes of Temporalis Fascia Grafting in Rhinoplasty

To investigate the indication, site, techniques, and complications at the donor and recipient sites of temporalis fascia grafting in rhinoplasty, and patients' satisfaction with the surgical outcomes.

Use of an Autologous Diced Cartilage Graft and Fat Graft Combination to Improve Regeneration in Rhinoplasty

BACKGROUND

In rhinoplasty, many techniques are used to increase the permanence of the planned final shape of the nose. Cartilage grafts can be diced and applied directly to the nasal dorsum, or by wrapping with a material. We aim to show that mixing and using diced cartilage grafts with fat grafts can contribute to the viability of cartilage grafts by comparing our early postoperative and long-term results.

MATERIALS AND METHODS

A total of 228 cases were analyzed. Postoperative 1-month, 6-month, and 1.5-year photographs of the patients were compared and the places that descended on the nasal dorsum were measured. In addition, dorsal height was measured and compared. Preoperative and postoperative first-year rhinoplasty outcome evaluation scales were performed. Specimens from 6 patients were examined histopathologically.

RESULTS

After the first month, the mean regression in the dorsum was measured as 1.4 mm. The decrease in dorsal height between 1 month and 6 months was significantly greater than the decrease between 6 months and late periods. According to the rhinoplasty outcome evaluation (ROE) scale, the average preoperative score of the patients was 45, while the mean postoperative score was 81.5. The viability of chondrocyte cells was measured as 85-90% histopathologically.

CONCLUSION

This approach has been evaluated as an application that satisfies both the surgeon and the patient due to the advantages of fat grafts such as preventing the cartilage and osteotomy lines from being palpated in thin-skinned patients, holding the diced cartilage grafts together by acting as a glue, increasing the viability of cartilage grafts.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Crushed Septal Cartilage-Covered Diced Cartilage Glue (CCDG) Graft: A Hybrid Technique of Crushed Septal Cartilage

BACKGROUND

Diced cartilage glue (DG) grafts have been widely used in dorsal augmentation but can induce dorsal irregularities. The authors evaluated the postoperative feasibility of a crushed septal cartilage-covered diced cartilage glue (CCDG) graft.

METHODS

The medical records of 38 patients who underwent dorsal augmentation rhinoplasty with an open approach were retrospectively reviewed. DG graft was used in 18 patients (47.4%), and CCDG graft was used in 20 patients (52.6%). Surgical outcomes were assessed by comparing anthropometric data on facial photographs and satisfaction questionnaires on aesthetic outcomes and palpable irregularities on nasal dorsum before and after surgery.

RESULTS

Both groups showed successful aesthetic outcomes. Dorsal height, radix height, and tip projection were all increased postoperatively in both groups. Tip rotation did not significantly increase (p > 0.05). Both groups showed similar outcomes in terms of aesthetic satisfaction but a significant difference in palpable irregularity. CCDG graft group showed significantly better (p = 0.04) satisfaction with dorsal irregularities (4.15 ± 0.75) than the DG graft group (3.56 ± 0.92). CCDG graft group also showed significantly better mean values (p = 0.048) in the degree of irregularity by two surgeons (3.85 ± 0.65) than the DG graft group (3.25 ± 0.97). No patient had significant complaints about irregular dorsum, and none of them underwent a revision rhinoplasty.

CONCLUSION

CCDG graft can be a complementary option for avoiding postoperative irregular dorsum complications.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Three-Dimensional Analysis of Definitive Secondary Unilateral Cleft Rhinoplasty Using Cartilage Graft

OBJECTIVE

Three-dimensional assessment of nasal morphology in patients with unilateral cleft lip nose treated by cartilage graft augmentation.

DESIGN

Retrospective study.

PATIENTS AND INTERVENTION

Thirteen patients with unilateral cleft lip nose underwent definitive secondary rhinoplasty and postsurgical changes were examined using a three-dimensional (3D) laser scan.

MAIN OUTCOME MEASURE

Nasal dorsum length, nasal tip, alar width, and alar base width in frontal view; nasion depth, nasal tip projection, nasal dorsal angle, and nasal tip angle in lateral view; nostril width, nostril height, and nasal tip height in basal view were measured at preoperative (T1: within 6 months), short follow-up (T2: 2-10 weeks), and long follow-up (T3: 9-14 months).

RESULTS

A significant change in alar width, alar base width, nostril width, and nostril height at the cleft side, nasal dorsum length, nasion depth, nasal tip projection, and nasal tip height was observed from T1 to T3 follow-up after rhinoplasty (P < .05), whereas the nostril height at the noncleft side was also significantly increased at T2 follow-up but the mean change in height relapsed at T3 follow-up. Alar width, alar base width, and nostril width at the noncleft side, and nasal tip angle did not change significantly after surgery at any follow-up period.

CONCLUSIONS

3D imaging evaluation after secondary cleft rhinoplasty demonstrated improved functional and aesthetic outcomes using a septal or conchal graft.

A Systematic Review and Meta-Analysis of Complications Associated With Autogenous Diced Cartilage Wrapped in Fascia Used in Nasal Dorsum Augmentation

BACKGROUND

Nasal dorsum augmentation is a highly challenging rhinoplastic procedure. Problems encountered in this surgery, such as residual humps, irregularities, and asymmetry, account for a significant number of revision rhinoplasties.

OBJECTIVES

The aim of this meta-analysis was to assess complication rates and graft harvesting site morbidity and revision rates.

METHODS

We carried out a systematic review of the literature for pertinent materials in PubMed/Medline and Google Scholar up to and including August 2020. In addition, the reference list of included studies was searched manually. The criteria used were those described in the PRISMA Declaration for performing systematic reviews.

RESULTS

The initial search yielded 236 results. After 3 stages of screening, 16 papers (18 groups) were included in the systematic review and meta-analysis. Our results indicated that the total rates for the complications studied were as follows: graft resorption, 2.52%; insufficient augmentation, 3.93%; deviation (graft displacement), 1.77%; infection, 2.30%; irregularity, 1.36%; supra-tip depression, 1.13%; overcorrection, 3.06%; hematoma at recipient site, 1.36%; and visible bulging of the graft, 2.64%. The total rates for donor site hypertrophic scar and donor site hematoma were 2.64% and 3.58%, respectively. The rate of the revision surgery was 3.03%.

CONCLUSIONS

Current findings suggest the overall complications and revision rates with the use of diced cartilage wrapped in fascia for dorsum augmentation were relatively low and this technique is a reliable treatment choice for patients with primary/secondary dorsum deficiencies. Further studies with larger sample sizes and long-term follow-ups, clearer definitions of complications, and objective measurements are warranted to draw reliable practical conclusions.

LEVEL OF EVIDENCE: 4

Long-Term Complications from Diced Cartilage in Rhinoplasty: A Meta-analysis

Objective: To analyze the incidences of long-term complications and revision surgery associated with diced cartilage grafts in dorsal augmentation rhinoplasty. Methods: The PubMed, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for clinical studies on the use of diced cartilage for dorsal augmentation published. A meta-analysis was conducted to pool the estimated rates of infection, overcorrection, visible irregularity, absorption, and revision surgery. Result: A total of 14 studies involving 2380 patients were included in the systematic review. The combined rates were 11.5% for overall complications and 5.3% for revision surgery. The rates of the most frequently reported complications were 4.5% for infection, 5.3% for visible irregularity, 0.7% for overcorrection, and 0.5% for absorption. There was no significant difference in the rates of visible irregularity (p = 0.23) and revision surgery (p = 0.71) among the wrapped diced cartilage, glued diced cartilage, and free diced cartilage groups. Conclusion: This meta-analysis presents the first comprehensive and quantitative report of long-term complications associated with diced cartilage in dorsal augmentation rhinoplasty. Infection and visible irregularity were the most frequently reported complications. The rates of irregularity and revision surgery were not correlated with the diced cartilage packing methods.

Conservative Surgery of the Nasal Dorsum: Septal Pyramidal Adjustment and Repositioning

The term SPAR (septum pyramidal adjustment and repositioning), aims to conserve the nasal dorsum without detachment of the upper lateral nasal cartilage of the nasal septum, based on the Cotte's principles, unlike classical rhinoplasty. The aim of the study is to describe surgical technique of SPAR with the surgical steps used to reviewing the literature on the surgical treatment of the nasal dorsum. This is a less invasive form of rhinoplasty, but no less effective, not being necessary additional techniques to nasal reconstruction, and preservation of essential nasal structures. It is an evolution of push down and the other conservative surgery, making a more modern technique and may be suitable for most types of cavities. More studies are needed, especially comparative, showing the following late sequelae, complications, and their long-term results.

Tubed Temporalis Fascia for Nasal Dorsal Contouring: A Novel Technique

INTRODUCTION

Nasal dorsum irregularities may occur after nasal trauma or as a postrhinoplasty complication. Here, we present a novel technique using temporalis fascia (TF) grafting for primary and revision rhinoplasty to repair the nasal dorsum, hide nasal irregularities, and improve nasal contouring.

METHODS

This prospective cohort study was conducted from January 2019 to June 2019 and evaluated nasal dorsal contouring using the TF in a tubed form. The outcome variables were patient satisfaction, dorsal irregularity, and contour definition. The predictor variable was the use of tubed TF for dorsal augmentation. Other associated variables were age, sex, indication for surgery, surgery type, and graft size. Patient satisfaction was evaluated using the Rhinoplasty Outcome Evaluation questionnaire. A rhinoplasty specialist other than the surgeon who performed the procedure evaluated the dorsal augmentation outcomes by inspection and palpation of the dorsum. All statistical analyses were performed using the SPSS software.

RESULTS

Seventy-four patients (21.6% men and 78.4% women) were treated with the tubed TF. The mean age was 28.97 years. Thin skin was the most common indication (48.6%) for using TF. The graft size was 2-5 cm; inspection and palpation revealed no irregularities. No reception site complications occurred. One patient had a mild hematoma at the donor site. The mean patient satisfaction score was 10.14 preoperatively and 19.95 postoperatively (p = 0.001).

DISCUSSION/CONCLUSIONS

Our novel technique of using the TF graft in a tubed form was easy to perform. Furthermore, the tubed TF covers all irregularities, is good for dorsal augmentation, and improves dorsal contouring and definition.

"Radix Pillow" Constructs with Fascial Extension for Radix Augmentation in Primary Rhinoplasty

Temporalis fascia and diced cartilage, in varying combinations, are currently commonly employed for augmentation of the radix in rhinoplasty. Although existing literature is replete with papers and suggested variations, there is some lack of practical detail on how to use such techniques. The authors present a reproducible, multilayered, "pillow" construct of temporalis fascia for selective radix augmentation in primary rhinoplasty, with or without the addition of diced cartilage. Precise measurements for accurate multiple folding, exact tailoring of the construct to recipient size dimensions, and fixation by a "litter" concept with proximal and distal fixation point are key to this technique. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of Nasal Implants and Dorsal Modification When Treating the East Asian Nose

Dorsal augmentation and tip surgery are essential procedures for East Asians seeking rhinoplasty, because they generally have thicker skin and poorly developed nasal dorsum and tip. For dorsal augmentation, many Asian surgeons prefer using alloplastic material, like silicone, Gore-Tex, and filler injection, for cost-effectiveness, easy handling, and short operation times. Compared with autologous implant materials, the use of synthetic implant is suggested to be associated with many complications, such as infection, extrusion, and deviation. However, even with the use of the autologous material, problems such as reabsorption after grafting, donor site complications can take place.

Onlay Fascial Grafts to Silicone-Polytetrafluorethylene Composite Implants in Augmentation Rhinoplasty: A Retrospective Study of 241 Cases

BACKGROUND

Silicone-polytetrafluoroethylene composite implants are fast gaining popularity in Asian rhinoplasty. Nonetheless, implant displacement, erythematous reactions, and infections still occur in the authors' patient group during long-term follow-up.

OBJECTIVES

The authors reported successful experience of combining the utilization of silicone-polytetrafluoroethylene composite implants with onlay temporal fascial grafts to circumvent these complications.

METHODS

Sixty-four patients of Asian ethnicity underwent augmentation rhinoplasty utilizing an I-shaped composite implant with an onlay fascial graft from January 2015 to June 2018, with a mean follow-up period of 13.5 months. This patient group was compared with a control group of 177 Asian patients who underwent augmentation rhinoplasty utilizing the same composite implant but without the addition of a fascial graft; the control group was treated from February 2012 to June 2015, with a mean follow-up of 42.0 months. Complications were compared between these 2 patient groups, specifically focusing on malposition/deviations, erythema, and infections.

RESULTS

There was a marked decrease in complication rates with the addition of an onlay temporal fascial graft to cover the composite implant in augmentation rhinoplasty (7.8% vs 14.7%) as well as the rate of erythematous reactions (0% vs 6.2%, P = 0.04), infection (1.6% vs 1.1%), and implant malposition/deviation (0% vs 4.5%). Harvesting the temporal fascia and fashioning the onlay graft added an additional 33 minutes on average per procedure. No donor site morbidity was encountered.

CONCLUSIONS

Although the operative time increased, the benefits of adding onlay fascial grafts to silicone-polytetrafluoroethylene implants in alloplastic augmentation rhinoplasty outweigh the drawbacks, as evidenced by the decrease in erythematous reactions.

LEVEL OF EVIDENCE: 4

A Modified Suction-Assisted Technique of Transfer of Diced Cartilage Graft to Carrier Material and Outcome of Direct Injection of Unwrapped Diced Cartilage in Rhinoplasty

OBJECTIVE

To describe a modified suction-assisted technique (MSAT) of transfer of diced cartilage (DC) graft to a carrier material and to determine the clinical outcome of direct injection of unwrapped diced cartilage (UDC) in rhinoplasty.

PLACE AND DURATION OF STUDY

Department of Plastic Surgery, KEMU, Mayo Hospital, Lahore from February 2011 to January 2015 METHODS:: Forty-seven patients of both genders with types 0 to 3 saddle nose deformity were included. Patients with types 4 and 5 saddle nose deformity, diabetes, hypertension, hepatic or renal disorders were excluded. Open tip rhinoplasty was performed in all patients. Eighth and/or ninth costal cartilage was harvested. Cartilage graft was diced into 1 to 2 mm pieces. The DC graft was transferred to carrier material (1-mL syringe) with MSAT. The UDC was then injected into nose and clinical outcome was determined.

RESULTS

Out of 47 patients included in the study 62% were females with mean (standard deviation [SD]) age 22 (4) years. Thirty-four (72%) procedures were primary rhinoplasties while 13 (28%) were secondary rhinoplasties. Mean (SD) carrier material filling time was 12±3 seconds. All operating surgeons involved in study were satisfied with modified suction technique and declared it better than the traditional manual technique of filling the carrier material. Most of the patients were satisfied with their postoperative nasal appearance and complications were minimal. One patient required revision of surgery due to dorsal contour irregularities and another due to partial cartilage absorption at 13 ± 2 months follow-up.

CONCLUSION

Our MSAT of transfer of DC and injection of UDC is simple, easy to perform, reduces operative time and produces acceptable cosmetic outcome as regard patient's satisfaction.

Puzzle-Formed Modified Turkish Delight for Nasal Dorsum Augmentation

Structural deficiencies of the nasal dorsum are most commonly of congenital, traumatic, or iatrogenic etiology. Various grafts, including autografts, homografts, and synthetic materials, have been used to this end and are described in the literature.Autologous septal cartilage is the most commonly used graft material when limited augmentation rhinoplasty is planned. However, it is difficult to retain sufficient cartilage to allow of such augmentation in instances where most of the septal cartilage has been used. The authors place moderately crushed cartilage beneath a monolayer of surgicel when performing limited nasal dorsum augmentation. The aim of the present study is to describe authors' approach and its utility by reviewing other methods reported in the literature.

Key and Keyhole Model for Dorsal Onlay Cartilage Grafts in Correcting Nasal Deformities

BACKGROUND

The shaping of the cartilage and keeping it in place is very significant for patients who need nasal reconstruction with costal grafts at traumatic or secondary rhinoplasties. In this study, a template is prepared during the surgery that shows the dorsal defect in a 3-dimensional manner and acts as a guide while shaping the cartilage.

METHODS

Seventeen patients who required secondary rhinoplasties because of trauma or previous operations were included in this study. The patients were operated on between the years 2009 and 2013. The mean age of the patients was 24 years (19-38 years). According to the surgical technique, bone wax was placed in a sheath prepared from the finger of a sterile nylon surgical glove before the dorsal reconstruction. It was placed to the nasal dorsum and shaped over the skin with digital maneuvers. Afterward, the bone wax was stripped off the nylon glove, and it was used as a template to shape the cartilage graft.

RESULTS

No need for revision rhinoplasties was seen in any of the patients during the mean follow-up period of 19 months. The patients stated that they were satisfied by both the functional and the aesthetic results.

CONCLUSIONS

The bone wax template and the defect fit in a key and keyhole fashion. It is supported by multiple points on the nasal bone and the septum. Thus, it does not slide and its warping is avoided. We think that it gives satisfactory results and it shortens the learning process.

Long-Term Results and Refinement of the Turkish Delight Technique for Primary and Secondary Rhinoplasty: 25 Years of Experience

BACKGROUND

All grafts present the potential problem of late visibility, distortion, and (occasionally) absorption. To overcome these problems and obtain a smoother surface, in 1989, the author initiated the use of finely diced cartilage wrapped in Surgicel. It is well known that the resolution of edema at the end of 1 year postoperatively is approximately 90 to 95 percent. Complete resolution continues until the end of 4 years postoperatively. However, it is important to understand what occurs beyond 4 years, and how the nose changes as the face ages.

METHODS

The author presents his experience of the past 25 years on 9398 primary and secondary rhinoplasty patients treated using his personal approach, the Turkish delight. Patients with a postoperative range from 4 to 25 years were selected.

RESULTS

The Turkish delight type of cartilage graft (diced cartilage wrapped in Surgicel) has been free of late show complications often experienced with other types of tip grafts. Long-term results from 4 to 25 years are very satisfactory, with an acceptably low complication rate.

CONCLUSIONS

This technique is safe, reliable, effective, simple, and easily applicable by plastic surgeons at all levels of experience. Early and long-term results from 1 to 25 years are very satisfactory. The overall complication rate is very low compared with other techniques. In addition, there is no late show as is sometimes seen with other types of cartilage grafts such as crushed, oval, or rectangular grafts.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Management of Saddle Nose Deformity Using Dermal Fat and Costal Cartilage "Sandwich" Graft: A Problem-Oriented Approach and Anthropometric Evaluation

PURPOSE

In the surgical treatment of saddle nose deformity (SND), costal cartilage is often used. However, it can result in some potential complications such as resorption, bending, displacement, and its appearance under the skin (silhouette deformity). We prepared a composite "sandwich" graft by camouflaging the costal cartilage underneath the dermal fat graft as a novel method and applied it on SNDs using the closed rhinoplasty technique to prevent or minimize these risks.

MATERIALS AND METHODS

The method was used for 21 patients (12 males and 9 females). Six anthropometric measurements, including the nasal dorsum projection, nasal supratip projection, nasal tip projection, nose length, labiocolumellar angle, and nasofrontal angle, were taken using the ImageJ program (National Institutes of Health, Bethesda, MD) on preoperative and postoperative lateral photographs. The data were compared statistically.

RESULTS

The mean follow-up time was 29.95 months. No donor site complications developed. The sandwich grafts transferred to the nose were well tolerated in all patients. A partial graft failure and a mild bending, which were treated conservatively without supplemental surgery, developed in 1 patient each. No resorption, migration, bending, or appearance under the skin of the sandwich grafts were seen in the remaining patients. A statistically significant difference was found in all anthropometric measurements from the preoperative and postoperative groups except for 2.

CONCLUSIONS

The severity of the deformity should be exactly determined before surgery, and cartilage grafts should be used accordingly for successful repair of SND. The sandwich technique, as a practical, effective, and long-lasting treatment method, could minimize the potential complications and risks of revision.

Utility of Cartilage Grafts Wrapped With Amniotic Membrane in Dorsal Nasal Augmentation

OBJECTIVES

The success of rhinoplasty may be compromised with postoperative problems like rough and rigid nasal dorsum. Biological grafts or alloplastic materials are required to hurdle and correct nasal dorsal deformities and also irregularities. The purpose of this experimental study was to compare pure cartilage graft, cartilage graft wrapped in amniotic membrane, and diced cartilage grafts wrapped in amniotic membrane for soft tissue augmentation.

METHODS

All grafts were transplanted through a subcutaneous tunnel created in the nasal dorsum of 18 rats, 6 in each group. After 3 months follow-up, the histopathological changes in all groups were evaluated by light microscopy and volumetric measurements.

RESULTS

With regard to cartilage viability, cartilage wrapped in amniotic membrane had a higher success rate than pure cartilage graft. Also, a further increased success rate was found in the diced group.

CONCLUSIONS

In the soft tissue augmentation after rhinoplasty surgery, especially diced cartilage wrapped in amniotic membrane keeps the graft viable and adjoined.

Various applications of deep temporal fascia in rhinoplasty

PURPOSE

In Asians, nasal dorsal and tip augmentation procedures are usually performed at the same time, and most dorsal augmentations use implants. In this study, dorsal augmentation was given by various types of grafts using deep temporal fascia (DTF) for primary rhinoplasty cases using only autologous tissues to improve the curve of hump noses and depressions. For secondary rhinoplasty cases, DTF was used to improve implant demarcation and transparency. Such effectiveness and utility of DTF is discussed.

MATERIALS AND METHODS

Between May 2009 and May 2012, we performed rhinoplasty using DTF in 175 patients, which included 78 secondary surgery patients and 128 female patients. The mean age of the patients was 31.4. DTF was utilized with various types of grafts without implants to improve the curve in dorsal augmentation of hump noses and cases that required curve betterment. DTF was used to improve implant demarcation and transparency for secondary cases.

RESULTS

The mean follow-up duration was 1.5 years. Of the 175 patients, 81% were satisfied with the natural correction achieved, whereas 19% complained of undercorrection, which was resolved with additional surgery. No specific complications such as nasal inflammation or contractures were observed.

CONCLUSION

DTF can be used with various graft methods for correction of radix, dorsal, and tip irregularities. It can also be used to correct implant contour transparency in secondary rhinoplasty and thus may be considered as a useful supplementary graft material in rhinoplasty for Asians.

Rib Diced Cartilage-Fascia Grafting in Dorsal Nasal Reconstruction: A Randomized Clinical Trial of Wrapping With Rectus Muscle Fascia vs Deep Temporal Fascia

BACKGROUND

Rib cartilage is an abundant source for cartilage grafts when significant dorsal nasal augmentation or structural support is indicated. Diced cartilage wrapped in fascia was developed to counteract warping, visibility, and displacement of rib cartilage as a dorsal solid graft. The technique for wrapping diced cartilage has evolved during the past several years.

OBJECTIVES

The authors compared 2 distinct fascial sleeves for wrapping rib diced cartilage in the treatment of patients who required major dorsal nasal augmentation.

METHODS

Thirty-six patients who planned to undergo major dorsal nasal reconstruction with diced costal rib cartilage were assigned randomly to 1 of 2 groups: the intervention group, which received grafts wrapped with rectus muscle fascia from the rib cartilage harvesting site, or the control group, which received deep temporal fascia harvested separately. Outcomes were compared between the groups.

RESULTS

Patients in the intervention group had significantly shorter operating times, significantly higher average satisfaction scores, and significantly shorter postoperative hospital stays than did patients in the control group.

CONCLUSIONS

Harvesting rectus muscle fascia for wrapping diced rib cartilage is a feasible and reliable technique in dorsal nasal reconstruction surgery. It is associated with favorable outcomes and a high level of patient satisfaction.

LEVEL OF EVIDENCE

4.