Klinik für Plastische Gesichtschirurgie, Marienhospital Stuttgart, Stuttgart, Germany
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The online version of this chapter (doi:10.1007/978-3-662-49706-7_8) contains supplementary material, which is available to authorized users.
KeywordsSaddle noseAugmentation rhinoplastyCartilage graftDiced cartilage in fascia (DC-F graft)Allogenic fascia lataDeep temporalis fasciaFree diced cartilage (FDC)
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8.1 Surgical Principles in Secondary Saddle-Nose Deformity
The principles of secondary dorsal augmentation are largely the same as those used in primary rhinoplasty. However, owing to the previous surgical disruption of nasal soft tissues, scar contracture and/or fibrosis may complicate or limit secondary dorsal augmentation. Frequently, wide undermining of the soft-tissue envelope is necessary to enable adequate dorsal augmentation. In severe cases preoperative conditioning of the fibrotic skin envelope with stretching exercises and/or repeated massage is necessary to gradually loosen the tethered and noncompliant soft-tissue envelope. Unfortunately, the nose is poorly suited to the use of conventional tissue expanders, and while self- or autoinflating expanders may offer effective alternatives, we have no experience with these devices.
If there is minor but full-length saddle deformity, we augment the defect with allogenic fascia lata grafts (Figs. 8.1 and 8.2). When necessary, allogenic fascia lata can be applied up to four layers thick. If the saddling is limited to a small area, we prefer using free diced cartilage (FDC) minced to a paste-like consistency to precisely fill the indentation (Fig. 8.3). Before the advent of FDC, a single layer of allogenic fascia lata was used to cover and smooth the coarsely diced cartilage (Fig. 8.4).
Multilayered fascia graft
Specimen of Tutoplast fascia graft
(a, b) Free diced cartilage of pastelike consistency
Free diced cartilage covered with allogenic fascia graft (Tutoplast)
Revision of a previous dorsal augmentation with solid rib cartilage is most often prompted by warping of the original augmentation graft material (Fig. 8.5a). There are two possible options for correcting this problem. The first is removal of the original graft, followed by reshaping and reinsertion. However, because the risk of deformation increases with decreased graft thickness, this approach is not always successful. Alternatively, the solid rib graft can be removed and used as donor material for a DC-F graft (Fig. 8.5b–d). This approach completely eliminates the risk of warping because the graft is no longer a solid implant material. Instead, the graft becomes a malleable augmentation material that can be digitally manipulated in situ to achieve the desired dorsal contour. And by leaving the caudal end open, diced cartilage can be expressed from the open end and removed with suction when the graft is too large. However, it is best to close the transcolumellar skin incision before making final determinations regarding graft size. The marginal incision can then be used for access to remove additional graft material when necessary. Once the desired shape is established, it is reinforced with Proxi-Strips (Ethicon, Inc., Somerville, New Jersey), a flexible adhesive tape that stretches in two directions to better maintain the desired contour. Regardless of the augmentation graft tissue of origin (e.g., rib or conchal cartilage), we use the DC-F conversion technique for all dorsal implants in which shape deformation has occurred.
(a–d) Reconstruction of a DC-F graft from warped rib cartilage and allogenic fascia lata
8.2 Case Studies
8.2.1 Case 1: Overresected Dorsum Augmented with Multilayered Allogenic Fascia Lata
A 25-year-old female presented with an overresected dorsum seeking revision rhinoplasty. Using the closed approach, six layers of allogenic fascia lata were applied to the overresected dorsum (Fig. 8.6).
Augmentation with allogenic fascia lata (TutoplastR). (a) Intraop procedure and result. (b–d) Front view, profile view, base view pre-op/post-op
8.2.2 Case 2: Augmentation with Free Diced Cartilage
A 36-year-old female presented after previous reduction rhinoplasty with irregularities of the nasal dorsum, including a slight dorsal depression and a small residual hump. A ptotic tip was also observed. Using the open rhinoplasty approach, dorsal exploration revealed three layers of allogenic fascia lata, which accounted for the small dorsal hump. Consequently, the outer layer of fascia lata was removed, creating a small dorsal depression. Conchal cartilage from the right ear was then harvested and diced to a very fine consistency and loaded into a tuberculin syringe. The ptotic tip was then rotated using a tip suspension suture with an anterior sling, and after partially closing the skin flap, finely diced ear cartilage was injected into the dorsal depression via the marginal incision. Using digital massage, smoothing of the dorsum established a satisfactory dorsal contour, and after closure of the marginal incision, an elastic paper tape (3 M) dressing was applied to maintain the desired dorsal contour during initial healing (Fig. 8.7).
(a) Dorsal augmentation with pastelike free diced cartilage. (b–d) Front view, profile view, basal view pre-op/post-op
8.2.3 Case 3: Augmentation with Free Diced Cartilage
A 36-year-old female presented with saddling of the cartilaginous dorsum after two previous rhinoplasties. Examination also revealed a C-shaped nasal deviation with an oblique columella and asymmetrical nostrils. In addition to the saddle indentation, profile examination revealed an overprojected bony vault. Using the open rhinoplasty approach, surgical exploration revealed a previously placed right spreader graft that was not strong enough to keep the dorsal septum from bending. Consequently it was replaced by an extended spreader graft fashioned from cartilage harvested from the ninth rib. The 8.0-cm long rib specimen was split into several 2-mm-thick strips, and additional graft material was used to replace a warped and weak columellar strut graft. The newly inserted strut graft was sutured to the extended spreader graft for stabilization. After lowering the overprojected bony dorsum with a powered cylindrical burr, the nasal pyramid was straightened with (internal) parasagittal medial osteotomies followed by percutaneous low-to-low lateral and transverse osteotomies. The remaining rib cartilage was finely diced and injected beneath the nasal skin flap with a tuberculin syringe (after closure of the columellar incision) for final contouring of the nose (Fig. 8.8).
(a) Augmentation with free diced cartilage. (b–d) Front view, profile view, base view pre-op/post-op
8.2.4 Case 4: Augmentation with Conchal Cartilage and Simultaneous Reconstruction of the Lateral Crura
A 35-year-old female presented for revision rhinoplasty after two previous nasal surgeries. Examination revealed an abnormally low nasal “starting point” resulting from a severely overresected bony dorsum, an inverted-V deformity, leftward deviation of the dorsal septum, and tip asymmetry. Intraoperatively, the left lateral crus was found to be malformed, and the right alar dome was missing. Treatment involved placement of bilateral (conchal) spreader grafts to correct middle vault pinching and to correct the dorsal septal alignment. A columellar strut graft fashioned from septal cartilage was placed for tip support, and batten grafts fashioned from septal cartilage were used to reconstruct the lateral crura. The bony dorsum was augmented using a crosshatched conchal cartilage graft (with the perichondrium still intact) covered with two layers of allogenic fascia lata (Fig. 8.9).
(a) Augmentation with conchal cartilage and simultaneous reconstruction of the lateral crura. (b–d) Front view, profile view, basal view pre-op/post-op
8.2.5 Case 5: Augmentation with Conchal Cartilage
A 24-year-old male presented for revision rhinoplasty after four previous nasal surgeries. Examination revealed an overresected nasal dorsum. Treatment involved dorsal augmentation with a multilayered conchal cartilage graft in which multiple smaller fragments were sutured to a flat, full-length segment to produce a custom-tailored onlay graft (Fig. 8.10).
Augmentation with conchal cartilage
8.2.6 Case 6: Augmentation with Conchal Cartilage
An 18-year follow-up after saddle-nose correction by reconstruction of the anterior septum with double-layered conchal graft was seen. A 35-year-old male presented with broad saddle nose and drooped bulky tip after multiple rhinoplasties. Because of the missing anterior septum, the nasolabial angle was acute.
In a closed approach technique, the surgical exploration revealed an overresection of the anterior septum. The wide nasal pyramid was narrowed by low-to-low lateral osteotomies from a sublabial approach and by transverse osteotomies through the eyebrow. To reconstruct the anterior septum and to rebuild the dorsum, both conchae were harvested from posteriorly. A double-layered sandwich graft was folded and used as a columellar strut. It was fixed to the anterior nasal spine (ANS) through a drill hole. Also the concha from the other side was transformed in a double-layered graft and used for dorsal augmentation. Residual parts of the ear cartilage were diced for camouflaging dorsal irregularities. The patient came for a follow-up visit after 18 years because of a skin tumor. Good function and form of the nose have been stable over time (Fig. 8.11).
(a–b) Double layered conchal graft. (c–d) Front view, profile view pre-op/post-op
8.2.7 Case 7: Augmentation with Conchal Cartilage
A 40-year-old female presented for reconstruction of a saddle-nose deformity resulting from previous septoplasty. Examination revealed resection of the anterior septum and severe collapse of the weakened dorsal L-strut. The unaltered bony dorsum gave the false impression of a large rhinion hump—the so-called pseudo-hump deformity. Reconstruction was performed with conchal cartilage harvested from both ears. A portion of the donor cartilage was used to create a double-layered columellar strut graft to reconstruct the missing caudal septum, while the remaining cartilage was used to create a full-length (crosshatched) dorsal onlay graft. After reducing a slight bony hump with the rasp, five layers of allogenic fascia lata were used to cover the full-length conchal graft (Fig. 8.12).
(a–c) Augmentation with conchal cartilage. Front view, profile view, base view pre-op/post-op
8.2.8 Case 8: Augmentation of DC-F Graft from Concha, Complex Tip Reconstruction
A 41-year-old female presented for revision rhinoplasty after two failed rhinoplasties abroad. Examination revealed an overprojected nasal tip and an overresected nasal dorsum. Retraction of the central columella and overprojection of the supratip were also observed. Intraoperatively, the right lateral crus was found to be partially absent, and the medial crura were malpositioned and partially resected. Treatment included deprojection of the tip with the lateral crural sliding technique (lateral crural overlap technique) on the left and placement of a (septal) batten graft to replace the missing right lateral crus. A conchal shield graft was also placed. The dorsum was augmented with a DC-F graft fashioned from conchal cartilage and allogenic fascia lata (Fig. 8.13).
(a–d) Augmentation with DC-F graft from concha. (e–g) Front view, profile view, base view pre-op/post-op
8.2.9 Case 9: Augmentation of DC-F Graft from Concha and Simultaneous Deprojection of the Tip
A 33-year-old female presented for revision surgery after rhinoplasty elsewhere. Examination revealed an overresected dorsum partially concealed by a malpositioned rib cartilage graft. The nasal pyramid was overly wide, and the nose seemed too long. Saddling of the middle vault, overprojection of the asymmetrical tip, and an overly acute nasolabial angle were also observed.
Treatment of the overprojected and underrotated tip was accomplished with a lateral crural overlap of 5 mm, coupled with columellar shortening of 2 mm. After removing the dorsal rib graft, the bony dorsum was smoothed, and the dorsum was augmented with a DC-F graft fashioned from conchal cartilage, recycled rib cartilage, and allogenic fascia lata (Fig. 8.14).
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