Managing Complications Related to the Augmented Dorsum

10 Managing Complications Related to the Augmented Dorsum
Philip J. Miller and Andres Bustillo

Over the past 10 years, the need for nasal dorsal augmentation has increased. This is due in part to today’s enhanced nasal aesthetic evaluation, which focuses on harmony rather than on reductive ideals. The augmentation of the nasal dorsum can allow the rhinoplasty surgeon to improve nasal aesthetics to achieve a balanced appearance. Despite the plethora of available augmentation materials, there is not a perfect autologous graft or synthetic implant that is free of potential complications or consequences. This chapter addresses the ramifications of dorsal augmentation, including the material used and how to manage complications.

Anatomy

The nasal dorsum comprises the nasal bones and the middle cartilaginous vault. The bony and cartilaginous vaults are not simply joined at a seam; they are overlapping. Thus, after reduction of the bony hump by rasping, the cartilaginous vault is uncapped.

The cartilaginous vault is a single anatomic entity. It becomes a septum and two upper lateral cartilages after dorsal reduction. Resuspension of the upper lateral cartilages or placement of spreader grafts is aimed at recreating the normal anatomy. The shape of the cartilaginous vault changes from a T shape under the nasal bones to a Y shape at the rhinion and on to an I shape at the septal angle.1

The soft tissue envelope varies along the length of the dorsum. It is thickest at the radix, in part caused by the procerus muscle. It is thinnest at the rhinion. The supratip area then becomes thick again, masking the downward sloping cartilaginous dorsum. These characteristics are not only important for dorsal reduction but also for augmentation. In much the same manner as the rhinon should be left as the highest part of the dorsum during reduction, the dorsal graft should have a gentle convex curve in the area that will correspond to the rhinion. This will allow for a straight dorsum.

Surgical Treatment

Augmentation Materials

The authors prefer cartilage for dorsal augmentation. The degree of augmentation determines the source of cartilage used. For small-to-moderate augmentation, septal cartilage is used.² It is readily available in most rhinoplasties. In revision rhinoplasty, where the septal cartilage may have been harvested previously, auricular cartilage may be used. If the auricular cartilage has been exhausted, then a frank conversation with the patient must be performed. In this situation, the factors at hand include the amount of augmentation needed and the need for structural support.

In the absence of septal or auricular cartilage, when the revision rhinoplasty requires a small to moderate augmentation, Gore-Tex (W. L. Gore and Associates, Flagstaff, AZ) can be used. It is available in either layered sheets or in a solid block that is carved to shape. Advantages to Gore-Tex include the following: availability, the avoidance of an external thoracic scar, lack of resorption or warping, and its ability for tissue ingrowth. The latter will allow for the fixation of the implant. The main disadvantage is the risk of infection or extrusion, which is approximately 3%.^3–6 Conrad and Gillman evaluated the use of expanded polytetrafluoroethylene (ePTFE) implants in 189 patients undergoing rhinoplasty. Follow-up intervals varied from 3 months to 6 years (average, 17.5 months) with five cases (2.6%) of implant removal secondary to infection. Two implants were removed because of chronic inflammation and soft tissue reaction. No cases of implant extrusion, migration, or resorption were reported.³

When a significant amount of dorsal augmentation is needed, the authors favor autologous rib grafts. Although the risk of infection with an autologous rib is significantly lower than with alloplasts, it is still a possibility and must be discussed. These infections do respond to conservative treatment, differentiating them from those involving alloplasts. Autologous rib may warp if not carved from the center. Carving should be performed in a symmetric fashion using the central core of the rib (as opposed to the peripheral area) to minimize warping. Allowing the rib to soak in saline in regular intervals during the carving stage will allow it to warp and thus the carving may be tailored.⁷ Some authors advocate using a K-wire through the center of the graft to avoid warping.⁸

The rib is carved in a canoe-like shape and placed in a tight subperiosteal pocket above the nasal bones. The graft should be carved so that its lateral sidewalls align properly with the nasal sidewalls to allow for smooth dorsal aesthetic lines. The dorsum should be smoothed to allow for a proper base for the graft. Occasionally, a suture may be placed to secure the graft to the inferior dorsum just slightly above the anterior septal angle.

The authors strongly recommend autologous rib where structural support is needed. These cases often require the reconstitution of the L-shaped strut with costal cartilage. The dorsal segment is placed in a subperiosteal pocket above the nasal bones and locked in a tongue-in-groove fashion to the columellar strut, also made from costal cartilage.7

Other materials used for dorsal augmentation include soft tissue fillers such as nasal or postauricular subcutaneous musculoaponeurotic system (SMAS).⁹ These materials are autologous and have all of the advantages associated with such. Several authors have published favorable results with their use. The use of acellular dermis has decreased in the last few years, owing to less-than-favorable long-term results.

Irradiated rib has been described for dorsal augmentation. Proponents site avoidance of a second surgical site and the low incidence of complications compared with the use of alloplasts. There are mixed reports regarding the rate of resorption of irradiated rib. Murakami et al used irradiated rib cartilage to reconstruct 18 saddle-nose deformities. With a follow-up of 1 to 6 years (mean, 2.8 years), no cases of infection, extrusion, or noticeable resorption were noted. One (6%) graft had to be removed secondary to warping, and two (11%) displaced caudal struts had to be repositioned under local anesthesia.¹⁰ This may be a reasonable alternative in older patients who may have calcified ribs and need structural support.

Only gold members can continue reading. Log In or Register to continue