Nasal Augmentation Research Articles

Cortical Tibial Bone Graft for Nasal Augmentation

This study sought to determine the efficacy of cortical tibial bone graft for nasal augmentation. Nine cases of augmentation rhinoplasty with cortical tibial bone graft are presented. This prospective study evaluated the postoperative results of nine patients who underwent augmentation rhinoplasty using cortical tibial bone graft. There were six males and three females aged between 21 and 36years (mean age 29). All the nine cases were treated through closed rhinoplasty incisions. Nine patients were operated on and the average follow up was 18months. The results were favorable. The aesthetic results were gratifying; with good nasal projection in every case without any significant postoperative effects or complications requiring surgery were noted during the follow up. The findings of this study support the use of cortical tibial bone graft for nasal augmentation although further studies with more sample size are required.

Technical considerations and morbidity in outer table calvarial bone graft harvesting

Introduction: Calvarium is valued for craniomaxillofacial reconstruction because of the proximity of the donor site to the recipient site, reasonable resistance to resorbtion, suitable geometry, and ability to be rigidly fixated. Although intracranial injury is a possibility, careful harvesting techniques minimize donor site morbidity. They can be used as onlay or interpositional grafts and for continuity defects due to their distinctive properties. The aim of this paper is to compare different surgical approaches and their implications on postoperative outcomes/morbidity for calvarial graft harvesting used for pre-prosthetic, articular eminence and nasal augmentation. 8 patients were evaluated in this study.

Diced Cartilage Grafts Wrapped in AlloDerm for Dorsal Nasal Augmentation

Dorsal nasal augmentation is commonly performed for various aesthetic deficiencies and/or reconstructive defects such as the saddle nose deformity. However, the optimal technique for volume augmentation has yet to be identified. The senior author (F.P.) has since developed a new modified technique using wrapped diced cartilage within an AlloDerm. This novel construct provides the plastic surgeon a smooth, convenient, pliable option with similar operative times as compared with other popular techniques. In summary, this technique has been proven to be successful in achieving attractive, safe, and acceptable outcomes in nasal dorsal configuration and overall patient satisfaction.

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.

Gore-Tex Nasal Augmentation

Gore-Tex Nasal Augmentation

In Search of Suitable Indications for Homografts and Allografts in Nasal Augmentation

In Search of Suitable Indications for Homografts and Allografts in Nasal Augmentation

Osseocartilaginous Rib Graft Rhinoplasty

To assess the long-term stability of osseocartilaginous dorsal onlay rib grafts used for augmentation rhinoplasty. Patients who had rib grafts used for augmentation rhinoplasty from 2000 through 2009 were assessed for graft viability, graft mobility, graft warping, maintenance of dorsal projection, functional airway status, need for revision surgery, and donor site morbidity. A retrospective cohort study using telephone follow-up was conducted. A total of 58 rib graft rhinoplasties were performed in the 10-year review period, 39 of which used dorsal onlay grafts. The mean duration of clinical follow-up was 24 months, and the median duration of clinical follow-up was 16 months. Thirty-three of 33 osseocartilaginous onlay grafts (100%) and 5 of 6 cartilaginous onlay grafts (83%) were viable, rigid, and had maintained dorsal projection at last follow-up. None of the grafts warped. Twenty-nine of 33 patients receiving osseocartilaginous onlay grafts (88%) and 5 of 6 patients receiving cartilaginous onlay grafts (83%) had persisting relief of their nasal obstruction. Twelve of the 39 patients (30%) had revision surgery, mostly performed for minor cosmetic revision. Osseocartilaginous onlay rib grafts provide an ideal scaffold for dorsal nasal augmentation and restoration of nasal airway in patients with collapse of the nasal framework due to a saddle deformity, history of trauma, or history of multiple septorhinoplasties. The graft has excellent viability, lacks potential for long-term warping, achieves bony fusion to the nasal bones, and allows surgical molding of the cartilaginous tip.

Reply

Sir: In response to the letter entitled “Onlay Bone Autografts in Nasal Augmentation: Ileum versus Calvaria,” we would like to review some of the advantages and disadvantages associated with the use of iliac crest and calvarial bone for augmentation rhinoplasty. The use of iliac crest and calvarial bone grafts has been described in the literature. Some recent studies show satisfactory cosmetic and functional results with a low incidence of donor-site morbidity.1–4 However, it is important to note that most studies show that calvarial bone (membranous) retains its size and form to a significantly greater extent than those of endochondral origin such as ilium, both as an inlay and as an onlay.5–8 This remained true with or without the application of guided bone regeneration.9 With regard to donor-site morbidity, some studies show that iliac crest harvesting leads to moderate morbidity, with complications including fracture, gait disturbance, persistent pain, hernias, fat embolism, and sensory disturbance,10–12 although other studies claim acceptable aesthetic results with no long-term sequelae.11,13 Reviews of the literature have shown severe complications to be rare but certainly worth considering when determining donor sites.14 Calvarial bone grafts are typically obtained by means of split harvesting from the temporoparietal region. This technique has been shown to be tolerated by patients, with minimal or no postoperative discomfort. Severe complications are exceedingly rare with split calvarial grafts but include dural and central nervous system injury and hematoma and are more likely with full-thickness harvests.15 Autologous cartilage grafts (of septal and auricular type) remain the preferred grafts for rhinoplasty and nasal reconstruction.15–17 Split calvarial bone has emerged as a preferred bone graft in the recent nasal reconstruction literature because of its superior strength, lower resorption rate, and lower donor-site morbidity. However, each patient and reconstructive situation must be considered individually, with the advantages and disadvantages of each graft and harvest risks kept in mind. Ali Sajjadian, M.D. Nima Naghshineh, M.D., M.Sc. Roee Rubinstein, M.D. Newport Beach, Calif.

Interpositional Cartilage Grafts to Improve Vertical Length of the Face

Most plastic surgeons in the past used bone grafts for nasal augmentation and for augmentation of the middle third of the face, and we, in our service, also used bone grafts at that time. Later, however, most plastic surgeons changed, and cartilage grafts are now the favorite material for rhinoplasty. For many years, we used cartilage grafts in rhinoplasty, and we now report the use of cartilage grafts to augment the length of the middle third of the face. We performed an osteotomy Le Fort I and harvest cartilage grafts from the costal region; then, we placed cartilage grafts between the upper portion and the lower portion of the maxilla to augment the vertical dimension of the middle third of the face. Results in our patients were excellent. Instead of bone grafts, cartilage grafts can be used as a good alternative to augment the vertical dimension of the maxilla.

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.

Fixation of nasal bone grafts with interosseous wire: our technique

The use of interosseous wire to fix bone grafts is well known. Herein, we describe a technique for fixation of an iliac crest bone graft for nasal augmentation, using a stainless steel wire. A hole in the cancellous part of the graft guides the wire exactly into a groove in the cortical part, preventing slippage and ensuring rigid fixation. The wire is then threaded through a hollow spinal needle passed underneath the skin envelope; this avoids a dorsal incision and thus minimises scarring, reduces the risk of graft exposure and improves the aesthetic result. This technique has two distinct advantages: prevention of wire slippage and avoidance of a dorsal nasal incision. The described method uses an interosseous wire for rigid bone graft fixation, without a dorsal incision. This prevents wire slippage; it also achieves a good cosmetic result by improving the nasal contour via a cantilever effect which raises the nasal tip.

Nasal Dorsal Augmentation with Freeze-Dried Allograft Bone

Background: Properly prepared freeze-dried bone has been used with impunity by orthopedic surgeons since 1992 without a single report of disease transmission. The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. Methods: Freeze-dried human cortical bone was obtained from DCI Donor Services, Nashville, Tennessee. Standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention were followed. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography. Vascularization and incorporation of new bone elements within the grafts were demonstrated by using fluorine-18 sodium fluoride positron emission tomographic/computed tomographic scanning. Results: The average persistence of projection in 18 patients was 87 percent at 6 months. Thereafter, 10 patients showed 100 percent maintenance of projection at 12 to 36 months. Vascularization and incorporation of new bone elements within the grafts were demonstrated by using fluorine-18 sodium fluoride positron emission tomographic/computed tomographic scanning in four patients. Conclusions: The initial loss of 13 percent of projection is most likely attributable to resolution of early surgical edema. The authors postulate that there are two pathways based on whether the recipient bed allows vascular access to the graft. The revascularization or inductive pathway involves stem cell conversion to eventual osteoblasts. The scar bed barrier or noninductive pathway involves the preservation of the graft as an unchanged alloimplant. This report is the first of a series that will include a 5-year and a 10-year follow-up.

Analysis of Nasal Periosteum and Nasofrontal Suture with Clinical Implications for Dorsal Nasal Augmentation

Subperiosteal placement of nasal implants has been performed widely for dorsal nasal augmentation in Asia. The authors introduced anatomical and biomechanical studies to investigate the influence of the periosteum on the subperiosteal technique. Nasal periosteum on 20 cadavers was investigated by hematoxylin and eosin staining and biomechanical methods. Nasal profiles (n = 160) and motility testing (n = 1317) were used to analyze patients who underwent augmentation rhinoplasty between 2003 and 2008. An alternative high-split subperiosteal technique was developed for higher placement of the nasal implant. In the cadaver study, the authors discovered that the periosteum and bone were bound together by Sharpey's fibers below the nasion (1.3 +/- 0.6 mm) that penetrated into the nasofrontal suture. The nasal periosteum above the nasofrontal suture (1.77 +/- 0.19 mm) was thicker than the one below the suture (0.83 +/- 0.15 mm) (p < 0.001). Men had relatively thicker periosteum (1.41 +/- 0.49 mm) compared with women (1.18 +/- 0.5 mm), and the difference was statistically significant (p < 0.001). Motility testing for clinical cases revealed that there was a higher percentage of the mobilized implant in women than in men (p = 0.042). When the subperiosteal technique was compared with the subcutaneous technique, analysis of the Poisson ratio for the periosteum (0.33 +/- 0.02) indicated greater strength than in the subcutaneous tissue (0.45 +/- 0.02). The alternative high-split subperiosteal technique significantly shortened the radix-to-glabella distance, increased the radix height, and made the nasofrontal angle more obtuse than the conventional subperiosteal technique (p < 0.001, p < 0.001, and p = 0.02, respectively). Analysis of the nasal periosteum provided scientific support for using the subperiosteal technique in dorsal nasal augmentation.

Surgical Management of Binder’s Syndrome: Lessons Learned

Maxillonasal dysplasia, commonly known as Binder's syndrome, is unmistakably characterized by midfacial hypoplasia and a retruded flat nose. The condition is variably expressed, and reconstruction must be tailored to the individual. Controversy still exists over the optimal age for surgery and the ideal treatment strategy. In a review of 24 patients with Binder's syndrome treated at the Chang Gung Craniofacial Centre over a period of 17 years, the authors examine the evolution of their experience treating patients with this condition. Maxillary osteotomies were rarely required and were reserved only for patients with severe and symptomatic class 3 malocclusion. Effective augmentation of the skeletal deficiencies in the midface was achieved with onlay bone or cartilage grafts. Nasal augmentation was performed with bone or cartilage grafts to the dorsum, columella, and tip. Cartilage is preferred over bone as graft material because it retains its volume and is less prone to resorption. Silastic implants can be a useful adjunct to cartilage in cases for which donor availability is limited. To minimize the risk of infection and extrusion, however, silastic implants are always limited to the nasal dorsum and always used in conjunction with cartilage grafts to the columella and tip. The authors prefer to defer surgery until midfacial growth is nearly complete, when the patient is in his or her mid-teenage years. Earlier surgery is indicated if the condition presents a significant psychological strain to the patient. In such cases, a silastic nasal implant can be used as a temporary corrective measure.

Injection rhinoplasty: non‐surgical nasal augmentation and correction of post‐rhinoplasty contour asymmetries with hyaluronic acid: how we do it

Injection rhinoplasty: non‐surgical nasal augmentation and correction of post‐rhinoplasty contour asymmetries with hyaluronic acid: how we do it

Sandwich technique in nasal dorsal augmentation

Tutoplast fascia lata (TFL) has been used as an onlay graft for nasal dorsal augmentation in open approach rhinoplasty; however, insertion of layers of moist TFL in the closed approach is technically challenging. We have presented a "sandwich" technique which facilitates graft insertion in a closed approach rhinoplasty. The available autologous graft (cartilage or perpendicular plate of ethmoid) is sandwiched and secured between layers of TFL (sandwich technique) prior to insertion of the graft for nasal dorsal augmentation in a closed rhinoplasty approach. All our cases of nasal dorsal augmentation were reviewed in a 2year period. Eight cases of nasal dorsal augmentation in secondary rhinoplasty through a closed approach were reviewed. The ease of insertion and the subsequent manipulation of the graft were noted in all the cases. Good aesthetic results have been noticed in all the cases after an average of 14months follow-up. The sandwich technique ensures ease of the graft insertion and the subsequent manipulation in a closed approach secondary rhinoplasty for dorsal augmentation.

Nasal Reconstruction for Maxillonasal Dysplasia

Maxillonasal dysplasia, Binder type (Binder syndrome and nasomaxillary hypoplasia), is a spectrum of deficient nasomaxillary osteocartilaginous framework, deficient nasal soft tissues, and a short columella. The correction of these deformities is challenging, and results are often disappointing. Tissue expansion with multiple bone grafts for nasal augmentation from childhood has been advocated as a means to address the constricted soft tissues. However, bone grafts in children have been associated with unpredictable growth and resorption. Agreeing with the principle of serial nasal augmentation that commences in childhood, we used alloplastic material for tissue expansion followed by definitive reconstructive rhinoplasty at the completion of growth and orthognathic surgery as required. Definitive rhinoplasty mainly used a 1-piece costochondral graft cantilevered to the frontal bone. Thirty-one patients over a period of 27 years were reviewed. The patients were divided into 2 groups based on the age of presentation, namely, prepubertal and postpubertal. The prepubertal group underwent serial tissue expansion of the constricted nasal envelope with customized silicone implants and final reconstruction by costochondral rhinoplasty at the end of puberty. The postpubertal group underwent 1-stage costochondral rhinoplasty. The definitive rhinoplasty used a cantilevered 1-piece costochondral graft retaining the dorsal periosteum that was dowelled into the frontal sinus wall. In the prepubertal group (n = 20), 41 silicone implants were placed in the childhood years for tissue expansion of the nasal envelope. One patient developed implant infection, and another required replacement after extrusion. Long-term follow-up showed minimal resorption of the costochondral graft in the pre-expanded prepubertal group and minimal to moderate graft resorption in the postpubertal group. Successful treatment of maxillonasal dysplasia is dependent on the following: an understanding of the underlying pathologic anatomy, namely, that of the constricted nasal tissues, serial tissue expansion of the nasal envelope in childhood, and definitive costochondral rhinoplasty at the end of growth. Early tissue expansion with the placement of alloplastic silicone implants effectively stretches the constricted nasal soft tissues in Binder syndrome to limit graft resorption after definitive nasal reconstruction with costochondral rib grafts. There is a possible role for similar tissue expansion in the postpubertal patient with alloplastic material before costochondral grafting if the soft tissues are inadequate. Long-term resorption of cantilevered, 1-piece, periosteum-covered costochondral grafts was minimal.

Autologous Bone Grafting with Adjunctive Use of Acellular Dermal Matrix for Alveolar Cleft Defects: Early Outcomes

Background and Purpose Alveolar bone grafting remains the standard for alveolar cleft repair. Compromised oral and/or nasal closure may impede healing and result in graft failure or persistent fistulae. Incorporating acellular dermal matrix into these repairs may protect the bone graft during mucosal healing by providing an additional layer of soft tissue coverage. Methods A retrospective review of alveolar bone grafts undertaken at our cleft–craniofacial center from 2005 to 2007 was performed. The use of acellular dermal matrix for nasal and/or oral lining augmentation was determined. A minimum 3 months’ follow-up was required for inclusion. Outcomes included (1) mucosal disruption, (2) time to complete mucosal healing, (3) bone graft exposure, (4) postoperative bone graft incorporation using the Chelsea scale, and (5) canine eruption through the graft site. Results In total, 35 patients were included. Of those, 15 patients (four girls, 11 boys; seven Veau III, eight Veau IV) received acellular dermal matrix for mucosal augmentation (five nasal, one oral, nine nasal and oral lining). Average age at surgery was 10 years (range, 9 to 16 years). Average follow-up was 23 months (range, 3 to 35 months). Mucosal disruption occurred in 20% of the acellular group and in 30% of the control group ( p = nonsignificant). Complete mucosal healing was achieved at an average of 4 weeks (range, 1 to 14 weeks) in the acellular dermal matrix group versus 4 weeks (range, 2 to 11 weeks) in the control group ( p = nonsignificant). Exposure of bone graft occurred in 0% of the acellular dermal matrix group and in 30% of the control group ( p = .016). The Chelsea scale demonstrated no significant radiographic difference in postoperative bone graft incorporation between the acellular dermal matrix and control groups. Canine eruption through the graft site was similar for both groups. Conclusions These data support the conclusions that using acellular dermal matrix to augment nasal/oral mucosal lining in alveolar bone grafts (1) does not increase mucosal disruption or time to complete healing, (2) prevents postoperative bone graft exposure, and (3) appears to have no negative effect on postoperative bone graft incorporation or canine eruption through the graft site.

Perspectives on the Evolution of Rhinoplasty

Perspectives on the Evolution of Rhinoplasty

Mastoid Bone as a New Graft Material in Rhinoplasty

The management of certain nasal deformities, especially after prior rhinoplasty, may require grafting material. In this study we describe the use of mastoid bone as a viable and low morbidity autologous graft. Mastoid bone was used for nasal augmentation, smoothing dorsal nasal irregularities, or augmentation of radix. Candidates for mastoid bone graft were patients undergoing primary rhinoplasty suffering from low radix or saddle nose deformity and candidates for secondary rhinoplasty suffering from prior overresection of the osteocartilaginous structures. Fifty-six patients met the study criteria. Eighteen patients underwent secondary rhinoplasty and suffered from prior overresection of osteocartilaginous structures and 38 patients underwent primary rhinoplasty. Of these, 18 patients had a low radix and 20 patients had a saddle nose deformity. Follow-up was 6-49 months (mean, 23 months). All cases resulted in an augmented straightened nasal dorsum, increased tip projection, and adjusted radix. There were no cases of graft infection. In two cases the graft was displaced requiring revision. The amount of graft absorption even after 2 years follow-up was acceptable. There were no donor site complications. The mastoid bone graft provides adequate autologous bone in most cases of primary or revision rhinoplasty. The donor site carries low morbidity and a well camouflaged scar. It is easily accessible especially for the otolaryngologist who is accustomed to operating on the mastoid bone.