Dorsal Augmentation Rhinoplasty Research Articles

Dorsal Augmentation in Rhinoplasty: A Survey and Review.

Understanding the nuanced practices and grafting options of dorsal augmentation will improve outcomes and results in rhinoplasty. To better understand the practices of dorsal augmentation among our colleagues. To review the current literature regarding the indications, safety profiles, and outcomes of different materials used in dorsal augmentation. A PubMed search was performed to capture current articles containing reviews or large series regarding the safety and efficacy of various grafting materials used for dorsal augmentation. Of the many options available, autologous cartilage grafts maintain widespread use for dorsal augmentation and other techniques in rhinoplasty. Homologous cartilage grafts, namely irradiated rib, are a preferred alternative. Irradiated costal cartilage has been shown to have low complication rates and is unique in its abundance of supply, particularly in the revision rhinoplasty. Alloplastic implants, particularly silicone, are prevalent in Asian countries where they are a popular first-line choice. ePTFE has a favorable complication profile in primary rhinoplasty; however, caution is recommended when using ePTFE in revision cases. Porous polyethylene has a higher risk of associated complications than the other alloplastic implants listed, and therefore should be considered thoughtfully. Although cartilage is often the preferred graft for dorsal augmentation, there are many other autogenous, homologous, and alloplastic materials that have been shown to be safe and effective choices when applied in the proper setting.

Cultured chondrocyte and porcine cartilage-derived substance (PCS) construct as a possible dorsal augmentation material in rhinoplasty: A preliminary animal study

As there is no single ideal material for dorsal augmentation in rhinoplasty, there has been a continuing need for the development of improved materials. Therefore, we aimed to evaluate the outcome of using a novel tissue-engineered construct composed of autologous chondrocytes cultured with a porcine cartilage-derived substance (PCS) scaffold as an augmentation material in rhinoplasty. A scaffold derived from decellularized and powdered porcine articular cartilage was prepared. The rabbit articular cartilage was used as the source of homologous chondrocytes, which were expanded and cultured with the PCS scaffold for 7 weeks. The chondrocyte-PCS constructs were then surgically implanted on the nasal dorsum of six rabbits. Four and eight weeks after implantation, the gross morphology, radiologic images, and histologic features of the site of implant were analyzed. The rabbits showed no signs of postoperative inflammation and infection. The degree of dorsal augmentation was maintained during the 8-week postoperative observation period. Postoperative histologic examinations showed chondrocyte proliferation without an inflammatory response. However, neo-cartilage formation from the constructs was not confirmed. The biocompatibility and structural features of tissue-engineered chondrocyte-PCS constructs indicate their potential as candidate dorsal augmentation material for use in rhinoplasty.

Clinical effectiveness and safety of collagen sheet for dorsal augmentation in rhinoplasty.

In Asian rhinoplasty, dorsal augmentation often requires the use of alloplastic materials because sufficient amounts of autograft are difficult to harvest. Given considerations of aesthetics, costs, and the characteristics of the oriental nose, silicone or Gore-Tex is commonly used when augmenting the nasal dorsum to a great extent. Such materials can often result in postoperative complications and foreign-body sensations. Moreover, extrusion or visualization of the implant may occur because of thinning of the skin over time. Permacol collagen implants are specifically indicated for soft tissue reinforcement and repair of the head and face in plastic and reconstructive surgery. The handling versatility of the flexible collagen sheet allows it to be layered over itself until the requisite thickness and desired shape are obtained. A total of 50 patients who underwent nasal augmentation rhinoplasty between December 2007 and May 2011 were observed for at least 24 months. Depending on the nasal dorsum, we layered the collagen sheet up to a maximum of 4 times and we have not seen any case of severe resorption or overcorrection in the nasal configuration. Collagen implant material is safe for use in select rhinoplasty patients because of its low complication rate, as shown in our series. It could therefore be considered as a useful alternative when reconstruction is problematic because of the low quality or lack of available autologous grafts.

Dorsal Nasal Augmentation With “Open Sandwich” Graft Consisting of Conchal Cartilage and Retroauricular Fascia

Augmenting the nasal dorsum with conchal grafts can cause visible irregularities over time due to the morphological qualities of that material. This study describes the senior authors' technique of dorsal nasal augmentation with chondrofascial "open sandwich" grafts consisting of pieces of conchal cartilage and retroauricular fascia. The authors assess the efficiency and reliability of this graft in nasal dorsal augmentation. The authors retrospectively reviewed the cases of 19 patients who underwent dorsal augmentation rhinoplasty with chondrofascial grafts. Both cartilage and fascia were harvested through the same incision in the retroauricular sulcus. The conchal graft was cut in 2 to 4 pieces and slightly crushed with tissue forceps. The pieces of cartilage were arranged and fixed to the fascia in different patterns according to the nasal dorsum contour. The follow-up period ranged from 12 to 35 months in 16 patients who qualified for inclusion in the final data. The maximal thickness of the chondrofascial graft was 4.5 mm. There were no major complications in the recipient area, except 1 case of undercorrection. There were 2 complications in the donor area. In 1 case, a hematoma was treated conservatively. In another case, a strip of skin necrosis in the conchal area occurred and was treated by excision and direct suture with satisfactory resolution. The autologous chondrofascial graft is appropriate for slight to mild dorsal nasal augmentation. The method, as with most rhinoplasty techniques, requires careful and judicious preoperative examination, planning, and execution. The postoperative scar is inconspicuous and the donor site morbidity is minimal.

The Usefulness of the Endonasal Incisional Approach for the Treatment of Nasal Bone Fracture

BackgroundAmong all facial fractures, nasal bone fractures are the most common, and they have been reduced by closed reduction (CR) for a long time. But several authors have reported suboptimal results when using CR, and the best method of nasal bone reduction is still being debated. We have found that indirect open reduction (IOR) through an endonasal incisional approach is a useful method for more accurate reduction of the nasal bone.MethodsA retrospective chart review was performed of 356 patients who underwent reduction of a nasal bone fracture in our department from January, 2006, to July, 2011. We treated 263 patients with IOR. We assessed patients' and doctors' satisfaction with surgical outcomes after IOR or CR. We evaluated the frequency of nasal bleeding owing to mucosal injury, and followed the surgical outcomes of patients who had simultaneous dorsal augmentation rhinoplasty.ResultsAccording to the analysis of the satisfaction scores, both patients and doctors were significantly more satisfied in the IOR group than the CR group (P<0.05). Mucosal injury with nasal bleeding occurred much less in the IOR group (5.3%) than the CR group (12.9%). Dorsal augmentation rhinoplasty with IOR was performed simultaneously in 34 cases. Most of them (31/34) showed satisfaction with the outcomes.ConclusionsIOR enables surgeons to manipulate the bony fragment directly through the endonasal incisional approach. However, we propose that CR is the proper technique for patients under 16 and for those with comminuted nasal bone fractures because submucosal dissection in IOR can damage the growth or circulation of nasal bone.

Correction des ensellures nasales par greffons cartilagineux selon la technique DC-F

Cartilage and bone graft are customarily used for dorsal augmentation in rhinoplasty. Daniel and Calvert described an original technique in 2004, using diced cartilage grafts wrapped in temporal fascia (DC-F). We describe the technical procedure used to correct severe nasal saddles with stable results. Diced cartilage grafts wrapped in temporal fascia is an interesting alternative in rhinoplasty with dorsal augmentation: this composite graft is malleable and can be used whatever the quality of the recipient site. It remains malleable postoperatively.

Use of Silicone Sizers in Implantation of Porous Polyethylene Nasal Dorsal Implants in Asians

Introduction. A new technique of implantation of high-density porous polyethylene nasal dorsal implants in Asians is described in this paper. Silicone sizers, which have smooth surfaces, were used to facilitate implantation of porous polyethylene implants in Asian patients. Materials and Methods. Twenty-three patients of Asian descent underwent dorsal augmentation rhinoplasty with open technique using high-density porous polyethylene implants. In all cases, silicone sizers were used to facilitate implantations of high-density porous polyethylene nasal dorsal implants. Patient selection criteria exclude patients with history of cocaine use, history of nasal or sinus disorders, previous nasal surgery, deviated septum, poor cartilage support, and thin skin. Results. No bleeding, infection, rejection, displacement, or extrusion was noted. One implant was removed because of a patient's dissatisfaction with the resulting tip height. Conclusion. The use of silicone sizers to facilitate implantations of high-density porous polyethylene nasal dorsal implants was safe and efficacious.

Expanded Polytetrafluoroethylene as Dorsal Augmentation Material in Rhinoplasty on Southeast Asian Noses

Objective To describe the outcomes of dorsal augmentation rhinoplasty with expanded polytetrafluoroethylene (ePTFE) implants in Southeast Asian patients from the Philippines. Methods Retrospective ...

Expanded Polytetrafluoroethylene as Dorsal Augmentation Material in Rhinoplasty on Southeast Asian Noses

To describe the outcomes of dorsal augmentation rhinoplasty with expanded polytetrafluoroethylene (ePTFE) implants in Southeast Asian patients from the Philippines. Retrospective review of 1054 patients. Of the 1054 patients, 90.61% were women and 9.39% were men. One thousand eight patients (95.64%) underwent primary rhinoplasty; 46 (4.36%), secondary or revision rhinoplasty. One thousand thirty (97.72%) had desirable and 24 (2.28%) had undesirable outcomes. The most common undesirable outcome was implant deviation (1.04%), followed by a visible ePTFE implant (0.47%). Implant infection occurred in 0.38% of the patients, and 0.38% of the patients were not satisfied with their aesthetic outcome because of the presence of a high nasal bridge. We find ePTFE to be an excellent synthetic material with proven outcomes for augmenting the dorsum in rhinoplasty of the Southeast Asian patient. However, prudent use of this material is warranted to avoid undesirable outcomes.

Diced Cartilage Versus Solid Grafts in Rhinoplasty

The use of diced cartilage grafts in reconstructive surgery was first described by Peer [1] in 1943. A number of additional reports describing diced cartilage have followed since then, but the technique has never achieved widespread use. In recent years, however, an interest in using diced cartilage for rhinoplasty procedures has resurfaced. As aesthetic and reconstructive surgeons revisit this technique, it is important that we critically assess the various materials, approaches, and indications applied by clinicians using diced-cartilage augmentation. The use of diced cartilage rather than a solid piece of cartilage graft is an attractive concept because it offers greater flexibility, carries a minimal risk of warping, and obviates the need for a long and straight cartilage graft donor site. Diced cartilage also may be particularly advantageous by enabling the use of residual septum in cases of secondary and revision rhinoplasty or by proving to be a more effective method for delivering conchal cartilage that as a single piece may be inadequate. To prevent problems of palpability and visibility of diced grafts, surgeons have described the use of autogenous, synthetic, or alloplastic wraps to camouflage the cartilage construct. A great deal of controversy currently exists about the various techniques that have been advocated, and the optimal substance or scaffold for delivering diced cartilage has yet to be determined. In 2000, Erol [2] introduced the concept of a ‘‘Turkish Delight,’’ whereby diced cartilage wrapped in Surgicel was used as an adjunct to rhinoplasty. The report by Erol describes the use of Surgicel-wrapped diced cartilage in more than 2,000 rhinoplasty cases, with successful longterm follow-up evaluation. On the other hand, others have had far less success using this approach during rhinoplasty. Daniel and Calvert [3] reported their experience using Surgicel-wrapped diced cartilage for 22 patients involving 14 radix grafts, 4 upper dorsum grafts, and 4 full-length grafts. In all cases, this technique failed to correct the problem due to complete resorption by about 3 months. As a result, Daniel and Calvert abandoned Surgicel and instead used fascia to wrap diced cartilage. In contrast, this patient cohort of fascia-wrapped diced cartilage (n = 20) did not demonstrate any notable resorption but rather required removal of excess amounts of cartilage in one-third of patients due to overcorrection for anticipated volume loss. A recent follow-up article of 79 patients with diced cartilage and fascia demonstrated adequate results at 1to 2-year follow-up evaluations [4]. In this article titled A Novel Autologous Scaffold for Diced Cartilage Grafts in Dorsal Augmentation Rhinoplasty, Bullocks et al. present an innovative approach to rhinoplasty using diced cartilage combined with autologous tissue glue (ATG: platelet-rich plasma ? fibrin glue). The authors report the use of ATG-diced cartilage constructs for 68 rhinoplasty patients requiring dorsal augmentation. During a mean follow-up period of 15 months, no major complications (extrusion, displacement, or infections) were reported, but 11 patients did experience an erythematous reaction lasting 1–4 weeks. The authors report maintenance of dorsal height in all cases, but this was not objectively studied. We believe Bullocks et al. should be congratulated for their work. If diced cartilage is a preferred method of reconstruction, these authors have introduced a novel technique for delivering diced cartilage that may minimize negative factors (i.e., elevated costs, additional donor sites, N. Tabbal (&) O. M. Tepper 521 Park Avenue, New York, NY 10065-8140, USA e-mail: mail@tabbal.us

A Novel Autologous Scaffold for Diced-cartilage Grafts in Dorsal Augmentation Rhinoplasty

Diced-cartilage grafts have been used for dorsal nasal augmentation for several years with good results. However, compounds such as Surgicel and temporalis fascia used as a wrap have inherent problems associated with them, predominantly inflammation and graft resorption. An autologous carrier could provide stabilization of cartilage grafts while avoiding the complications seen with earlier techniques. In our patients, a malleable construct was used for dorsal nasal augmentation in which autologous diced-cartilage grafts were stabilized with autologous tissue glue (ATG) created from platelet-rich plasma (platelet gel) and platelet-poor plasma (fibrin glue). A prospective analysis of 68 patients, who underwent dorsal nasal augmentation utilizing ATG and diced-cartilage grafts between 2005 and 2008, were included in the study. Although there was notable maintenance of the dorsal height, no complications occurred that required explantation over a mean follow-up of 15months. The use of ATG to stabilize diced-cartilage grafts is a safe, reliable technique for dorsal nasal augmentation. The platelet gel provides growth factors while the fibrin glue creates a scaffold that allows stabilization and diffusion of nutrients to the cartilage graft.

Use of Tutoplast‐Processed Fascia Lata as an Onlay Graft Material for Tip Surgery in Rhinoplasty

Tutoplast-processed fascia lata (TPFL) is a commercially available homograft that has been successfully used as human graft tissue for dorsal augmentation in rhinoplasty. The present study evaluated the use of TPFL as an onlay tip graft material in rhinoplasty. Case series with chart review. Academic tertiary care medical center. The study involved a retrospective analysis of rhinoplasty cases using TPFL as a tip onlay graft. The study included 82 patients (46 men and 36 women) who underwent tip surgery using TPFL from February 2006 to June 2008. By comparing facial photographs before and after the operation, 2 independent rhinoplastic surgeons assessed outcomes of 8 months postoperative time as being excellent, fair, or poor. Using the pre- and postoperative profile view, anthropometric measurements were also made. The 82 subjects included 71 primary and 11 revision patients. TPFL was used as a tip onlay graft in final tip modification. Postoperative assessment found that only 6 (7%) patients had excellent results, 51 (62%) had fair results, and 25 (31%) had poor results. Pre- and postoperative anthropometric measurements showed the technique resulted in an overall increased nasal tip projection postoperatively (0.56 ± 0.09 vs 0.60 ± 0.08; P < .05). However, the overall nasolabial angle was not changed after surgery (91.35 ± 10.36° vs 93.05 ± 8.3°; P = .08). No patient experienced infection, visible graft contour, or migration. TPFL was not that satisfactory in terms of aesthetic outcome when used as a tip onlay graft material in rhinoplasty patients.

Are Polytetrafluoroethylene (Gore-Tex) Implants an Alternative Material for Nasal Dorsal Augmentation in Asians?

Augmentation rhinoplasty is a relatively common procedure in Korea. Alloplastic materials such as silicone, supramid mesh, Proplast, Mersiline, Medpor, and hydroxyapatite are frequently used for dorsal augmentation. Alloplastic implants have advantages, such as ready availability and no donor-site morbidity, but are associated with higher infection and extrusion rates than are autogenous materials. Although polytetrafluoroethylene (Gore-Tex) implants have recently been introduced, such implants are yet to be established as an alternative for nasal augmentation because of a lack of relevant reports. From March 1998 to March 2007, we operated on 873 nasal dorsum augmentation patients using hard-type Gore-Tex implants. The patients were all of Korean ethnicity. There were 826 female and 47 male patients and aged ranging from 18 to 57 years (mean, 24 y). The Gore-Tex implant thicknesses were 3.1 to 4.9 mm (used in 59% of cases), 2 to 3 mm (8%), or 5 to 6 mm (33%). The Gore-Tex implants were used only for dorsal augmentation, whereas conchal or septal cartilage was used for nasal tip plasty. Of the total of 873 patients, 257 received long-term follow-up (mean follow-up, 34 mo). Apart from 34 patients with revision, no patient reported dissatisfaction, and there were no reports of problems with nasal contour, implant migration, or resorption of the implant material. The overall complication rate was 3.8%. Of the 257 long-term follow-up patients, 34 (13.5%) required revision. Four of these patients involved minor complications that were managed conservatively, whereas 30 patients required implant removal and revision procedures. These 30 cases included irregularity, infection, deviation, unfavorable dorsum height, and apparent implant silhouette, in addition to obvious supratip deformity. A review of the literature revealed that Gore-Tex implants seemed to have a lower implant removal rate than silicone implants. However, the overall complication rates seemed to be similar when Gore-Tex and silicone implants were used for nasal dorsum augmentation in Asian patients. We found that Gore-Tex implants were effective and safe for use in primary and revision rhinoplasty in Asians. Gore-Tex implants seem to have an overall complication rate similar to that of silicone implants. Thus, Gore-Tex can be considered as an alternative material for dorsal augmentation rhinoplasty but turned out not to have definite advantages over the silicone implants.

Combined use of crushed cartilage and processed fascia lata for dorsal augmentation in rhinoplasty for Asians

Autologous dorsal nasal grafts have limitations including limited tissue availability, additional surgery time, donor site morbidity, a visible graft contour, and postoperative distortions and deformities owing to displacement and warping. This report describes our experience using combined Tutoplast-processed fascia lata (TPFL) and crushed cartilage for dorsal augmentation and contouring in rhinoplasty. A retrospective clinical chart review. The study involved a total of 113 patients (68 male, 45 female), who underwent crushed cartilage-TPFL grafting to the nasal dorsum. Patient satisfaction was evaluated using a questionnaire. Photographs and postoperative histories were reviewed to assess complications including graft resorption, graft infection, warping, extrusion, irregularity, and postoperative deformity. Different autologous grafts were used in combination with TPFL: septal cartilage in 70 cases (61.9%), septal cartilage and ethmoid bone in 17 cases (15.0%), costal cartilage in 15 cases (13.3%), and septal and conchal cartilage in 11 cases (9.7%). Of the 101 patients who responded to the questionnaire, 85.1% were satisfied with the surgical outcome. Complications were encountered in four patients (3.5%), comprising overcorrected dorsal augmentation in two patients, graft resorption in one patient, and dorsal irregularity in one patient. Eight patients (7.1%) required revision rhinoplasty due to dissatisfaction with the nasal tip shape (n = 6), graft resorption (n = 1) and overcorrected dorsal augmentation (n = 1). The combined use of crushed cartilage and TPFL appears to be a useful technique for dorsal augmentation and contouring. This technique provides favorable and predictable outcomes in rhinoplasty. Laryngoscope, 2009.

The use of expanded polytetrafluoroethylene (e-PTFE) implants in rhinoplasty

Nasal dorsal augmentation in rhinoplasty using synthetic implants remains an intensely controversial surgical practice. The authors describe their experience with expanded polytetrafluoroethylene (e-PTFE) sheeting as an implant material in rhinoplasty. A review of the literature and detailed descriptions of techniques for creating synthetic dorsal implants are offered. Alloplastic implants are powerful tools which may be used by the thoughtful surgeon in carefully selected patients to achieve nasal dorsal augmentation. Nasal dorsal augmentation in rhinoplasty using synthetic implants remains an intensely controversial surgical practice. The authors describe their experience with expanded polytetrafluoroethylene (e-PTFE) sheeting as an implant material in rhinoplasty. A review of the literature and detailed descriptions of techniques for creating synthetic dorsal implants are offered. Alloplastic implants are powerful tools which may be used by the thoughtful surgeon in carefully selected patients to achieve nasal dorsal augmentation.

Dorsal Augmentation Rhinoplasty with Irradiated Homograft Costal Cartilage

Augmentation of the nasal framework requires a working knowledge of nasal and facial anatomy, as well as the principles of facial proportion and balance. Dorsal augmentation rhinoplasty is a valuable means of improving nasal appearance in patients with a low and/or concave nasal dorsum, obtuse nasofrontal angle, and low radix. It frequently is combined with other techniques, including columellar strut grafting, nasal tip grafting, and tip suturing, as dorsal deficiencies are often associated with poor tip projection and support and a shortened columella. Our experience with dorsal augmentation rhinoplasty, including the use of irradiated homograft costal cartilage for grafting in 56 surgeries, is described. A high level of patient satisfaction with a low percentage of complications has been seen.

Fred L. Hackney, M.D., D.D.S., and Joseph M. Gryskiewicz, M.D., F.A.C.S.

I want to thank Dr. Fred L. Hackney and Dr. Joseph M. Gryskiewicz for responding to the challenge of being guest editors for this issue of Seminars in Plastic Surgery dedicated to dorsal augmentation in rhinoplasty. I would also like to thank the contributing authors for sharing their knowledge and experience in the field of dorsal augmentation. After graduating from the University of Alabama Medical School, Dr. Hackney completed training first in oral and maxillofacial surgery and then in plastic surgery, graduating from the University of Texas at Southwestern program in Dallas. Since that time, he has developed an extensive experience in rhinoplasty and contributed much to our understanding of this difficult operation. Dr. Hackney is also a noted author, a respected lecturer, and a member of numerous professional organizations. He is coauthor of several chapters in prominent plastic surgery textbooks including Dallas Rhinoplasty, Surgery by the Masters. He is also a member of the Clinical Faculty of the Department of Plastic and Reconstructive Surgery, University of Texas Southwestern Medical Center. Perhaps most importantly, though, he was the senior resident during my plastic surgery training and always the steady confident voice in the midst of my frequent confusion. For this I will be forever indebted to him. Dr. Gryskiewicz graduated from the University of Minnesota Medical School in 1978. His postgraduate medical training included 7 years at the University of Wisconsin Hospital and Clinics in general and plastic and reconstructive surgery. Dr. Gryskiewicz also completed a hand surgery rotation at Northwestern University in Chicago. Dr. Gryskiewicz is an international speaker on nose surgery and has published numerous articles on that topic in medical journals. He is also a guest reviewer for Aesthetic Surgery Journal and Journal of Plastic and Reconstructive Surgery and is an active board member in the rhinoplasty society. Although he has extensive training in all aspects of cosmetic and plastic surgery, Dr. Gryskiewicz's special medical interests are breast augmentation, nasal surgery, facial plastic surgery, and body contouring. He is a clinical professor at the University of Minnesota Cleft Palate Clinics School of Dentistry and also maintains a private practice in Edina and Burnsville, Minnesota.

Use of silicone sheets for dorsal augmentation in rhinoplasty for Asian noses

Conclusion. While the complication rate for silicone sheets was similar to that reported for silicone rubber, there are several advantages to the use of silicone sheets for correcting minor dorsal irregularities. Therefore, silicone sheets can be used as a versatile graft material for dorsal augmentation in rhinoplasty. Objectives. Silicone implants mostly in the form of prefabricated silicone rubber remain the most commonly used materials for nasal augmentation in Asians. The present study analyzed the use of silicone sheets rather than silicone rubber for nasal dorsal augmentation rhinoplasty. Materials and methods. Data from 27 patients who underwent dorsal augmentation with silicone sheets between April 2003 and July 2005 were retrospectively reviewed. Results. All patients received silicone sheets to augment the nasal dorsum and/or radix. Twenty-four patients had satisfactory outcomes. One patient (3.7%) complained the implant was too visible, one experienced infection, and one experienced endonasal extrusion of the implant. All three cases were readily managed by implant removal and administration of antibiotics.