Chapter 23. Upper Lateral Cartilages: Grafting Techniques
The cartilaginous portion of the dorsum contains the transition zone between the upper lateral cartilages and the midline septum. On cross section, this is not a sharp angle but a well-supported and gradual curve. With resection of the dorsal septum, collapse of the middle vault may occur as the upper lateral cartilages fall towards the septum in a more acute manner. In the absence of structurally sound upper lateral cartilages, collapse of the nasal sidewall or asymmetry can occur and require reconstruction with a cartilage graft of similar quality. Spreader grafts are indicated to reconstruct compromised dorsal aesthetic lines, open roof deformities, and nasal deviations.1
Assessment and Markings: No specific markings are necessary for planning and placement of cartilage grafts for support of the middle cartilaginous vault. The presence of a nasal deviation, open roof deformity, or compromised dorsal aesthetic outline should be identified. The grafts will ultimately lie on either side of the dorsal septum. If upper lateral cartilage collapse has caused a loss of a dorsal aesthetic line, the septal graft can be placed more dorsal on the septum to restore this lost fullness. Spreader grafts can also be fashioned to extend beyond the anterior septal angle as a septal extension graft. In this case the extension graft serves as a stable strut to which the lower lateral cartilage (tip) complex can be sutured to control nasal tip rotation and projection. Septal cartilage is the ideal material for spreader grafts; however, rib or ear cartilage can be used if septal cartilage is unavailable. The inherent warping nature of the rib cartilage may be advantageous in correcting nasal deviation.2
Approach: Approaching the upper lateral cartilages may be achieved via either a closed or an open rhinoplasty. With an open approach, a transcolumellar incision is continued superiorly and laterally along the infracartilaginous alar rim. Dissection above the lower lateral cartilages and along the midline dorsum may be extended laterally to identify the upper lateral cartilages. A clear junction between the midline septum and upper lateral cartilages is often difficult to appreciate. If the caudal septum is approached by separating the lower lateral cartilages and dissecting along the septum in a submucosal plane, the upper lateral cartilages may be identified by reflecting the mucosa closest to the dorsum.
Technique: Cartilage sufficient for structural support is harvested from the septum if it is present. This should be determined in the preoperative consult. Costal cartilage may also be used for this purpose and is favored by some. Conchal cartilage is frequently more convoluted, thinner, and softer making it less ideal for spreader grafts. However, with the introduction of the PDS flexible plate (MentorTM) as a reinforcing material, its use may be expanded in this indication.