Radix Graft Research Articles

Discussion: Introducing Saddle-Shaped Radix Graft, with a Second Look into the Classic.

Discussion: Introducing Saddle-Shaped Radix Graft, with a Second Look into the Classic.

Introducing Saddle-Shaped Radix Graft, with a Second Look into the Classic.

An enduringly stable tip graft is the key to achieve successful rhinoplasty cases. However, the intrinsic nature of rib graft warping renders major unpredictability for the long-term outcome. The objective of this study was to detail and validate the use of a radix graft design that is characterized by the dual curved surfaces and beveled margin, which consequently renders a shape similar to a saddle. Twenty-three female patients, ranging in age from 22 to 31 years, completed the study. In all cases, the saddle-shaped radix graft was applied as the essential element for enhancing radix region profile. The complications that arose were collected retrospectively. Three-dimensional stereophotogrammetric evaluations of patients were performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection, nasal length, radix height, and the radius of curvature. Postoperative analysis suggested significant improvement on the aesthetics of the radix region over time, evidenced by the significant increase of radix height (4.33 ± 1.21 mm versus 7.08 ± 1.00 mm), and the reduction of radius of curvature at nasofrontal break over the long term (22.63 ± 2.24 mm versus 13.94 ± 0.98 mm). Other postoperative evaluations, including radix height, tip projection, and nasal length, had significant improvement. The saddle-shaped radix graft effectively augments the radix area and creates an aesthetically pleasant nasofrontal break without causing the elevated radix deformity. It has the merits of anatomical compliance and flexibility when it comes to concomitantly improving the glabella-radix profile for those East Asians with extremely low radix.

Use of Mastoid Periosteum Graft in Primary and Revision Rhinoplasty.

The authors initiated the use of a mastoid periosteum graft to augment or camouflage the dorsum and radix. This report describes the techniques and treatment outcomes of mastoid periosteum grafts in primary and revision rhinoplasty. Medical records of 62 patients who underwent rhinoplasty with mastoid periosteum were reviewed retrospectively. Of these, 21 patients who participated in follow-up for more than 6months were analyzed through a comparison of pre- and postoperative photographs. Aesthetic results were scored on a scale of 0 to 4 (0 = poor, 1 = fair, 2 = moderate, 3 = good, 4 = excellent) with photographic evaluation by two independent surgeons. A mastoid periosteum graft was used in 32 primary and 30 revision cases. The graft was used to augment the radix (28 cases), dorsum (15 cases), and both radix and dorsum (19 cases). Cartilage underlay was combined with mastoid periosteum grafts in 38 patients (61.3%, 17 in radix graft, 8 in dorsal graft, and 13 in both). The aesthetic outcome score assessed in 21 patients was 2.8 on average (3.2 in primary and 2.4 in revision cases). Cartilage combined cases showed better aesthetic outcome than free graft cases (3.1 vs. 2.5, respectively). Three cases of partial graft resorption were found, but there were no major complications. Mastoid periosteum grafting is a safe and effective method to augment the radix or dorsum in primary and revision rhinoplasty. Long-term partial resorption cannot be completely excluded, which necessitates further study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Postauricular Fascia in Augmentation Rhinoplasty

Ten rhinoplasty operations performed using postauricular fascia for the purpose of augmenting the radix and dorsum of the nose were analyzed retrospectively. All the operations were performed over a 1-year period, between 2005 and 2006. The fascia of the postauricular area has been used as a source of pliable soft-tissue grafts in primary and revision rhinoplasty. It may be easily accessed using a single sulcus incision that also enables harvesting of ear cartilage grafts. Deficiency in the radix is an overlooked abnormality seen in many patients undergoing primary as well as revision rhinoplasty after aggressive hump removal. Recent trends in rhinoplasty have been to avoid the overly reduced nasal skeleton and to create a more balanced nasal surgery result. This article presents the use of the postauricular fascia as a radix graft that has been found to be simple to carry out, reliable, and long lasting. In addition, the fascia graft is useful in the camouflage of various nasal deformities in the dorsum and sidewalls. The average patient follow-up for the study was 24 months.

Nasal Tip Projection: Asymmetries after Rhinoplasty

Background: Nasal tip projection has been defined as the distance along a perpendicular line from the vertical facial plane to the most anterior projecting point of the nasal tip. The tripod concept, although an oversimplification of nasal tip dynamics, highlights the intimate relationship between projection and rotation. Aim: The aim of the study was to evaluate the rate of nasal tip irregularities after the medial crura overlay procedure, and following the Tripoid concept. Methods: We completed a retrospective review of patients who have been admitted at ENT Clinic, Skopje from the period of 2008-2012. Operative technique rhinoplasty was prepared in 36 patients. Procedures included full-transfixion incision, release of tension septum, lateral crural overlay (LCO), dome truncation, medial crural overlay (MCO), and combinations of them. We reviewed major and minor secondary revision procedures that patients underwent, postoperative complications, and any functional complaints. Results: Of the remaining 36 patients: one (2.5%) required minor revision of dorsal irregularities, 3 (3.0%) required tip revision, 33 patients (93.3%) were satisfied without qualification, 3 patients (3.5%) were not satisfied and wont for revision surgery. Three patients (2.5%) underwent radix grafts. 5 (13.3%) of the patients had had previous rhinoplasty performed by another physicians. Seven patients (18.3%) were classified as having tension nose. One patient had postoperative epistaxis, and there were no cases of postoperative functional complaints. Conclusion: Our revision rate of 4.2% for tip irregularity and our finding that no patients had postoperative functional complaints allows us to feel confident that this algorithmic paradigm can be used to accomplish tip deprojection in almost any circumstance.

Radix Grafts in Cosmetic Rhinoplasty

We describe our experience with radix augmentation during cosmetic rhinoplasty over an 8-year period using both autologous and synthetic grafts and provide insight into maximizing success. We discuss various surgical considerations, including patient selection, graft materials, and dealing with complications. We focus on our operative technique and provide patient examples.

Radix Grafts in Cosmetic Rhinoplasty

We describe our experience with radix augmentation during cosmetic rhinoplasty over an 8-year period using both autologous and synthetic grafts and provide insight into maximizing success. We discu...

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

Complete or a partial sheet of deep temporal fascial graft as a radix graft for radix augmentation

Autogenous fascia, including the temporalis fascia, has a particular role in rhinoplasty as radix and dorsal onlay grafts. The main purpose of this study is to achieve desired appearance of facial harmony using either a complete or partial sheet of deep temporal fascia as a radix graft in the patients with required permanent radix augmentation. This is a prospective study of 15 patients who referred to Gandi Day Clinic, Tehran, Iran, between 2005 and 2006 and underwent rhinoplasty including nasal radix augmentation using deep temporalis fascia through external rhinoplasty approach. The patients with hump noses had low radix and required radix augmentation. Full sheet facial graft was used in 13 patients. Partial sheet facial graft was used in two patients. As a donor site problem, minor hematoma was observed in one patient. Temporary hair loss in incision line was another problem which were seen in five. As for the recipient site, no infection, persistent erythema of nasal skin extrusion, visibility, displacement of graft materials or irregularity of graft contour were observed postoperatively. Resorption rate was approximately 30% for grafted fascia. Using fascia grafts in radix point, the revision rate was minimal. In order to augment the radix, if 4mm augmentation is needed, it should be considered that full sheet fascia graft alone would be insufficient. If more than 4mm of augmentation is needed, 30% overcorrection would manage well the permanent radix augmentation without any problem.

The Angry Face Syndrome

The Angry Face Syndrome

Frequently Used Grafts in Korean Rhinoplasty: Nomenclature and Definitions

Background and ObjectivesZZNo definite concepts or nomenclature have yet been established in Korean for a number of different grafts used frequently in Korean rhinoplasty. The aims of this study were to define indications and usages of grafts frequently used in Korean rhinoplasty and to suggest appropriate Korean nomenclatures for these grafts. Materials and MethodZZWe prepared diagrams and explanations for the grafts frequently used in rhinoplasty in Korea and suggested Korean nomenclature that were considered the most appropriate. We carried out a survey on the rhinoplasty experts in order to reach a consensus on the nomenclature. We also reviewed recent Korean articles on rhinoplasty to investigate how names of each graft had been translated into Korean nomenclature. ResultsZZWe classified grafts according to anatomical locations; the nasal dorsum, the nasal tip, the alar region, and the alar base. Grafts of the nasal dorsum included radix graft, dorsal onlay graft, dorsal sidewall onlay graft, and spreader graft. Grafts of the nasal tip were the columellar strut, shield graft, buttress graft, cap graft, and septal extension graft. The alar batten graft, alar rim graft, composite alar rim graft, lateral crural onlay graft, and lateral crural strut graft belonged to grafts of the alar region. Grafts of the alar base included the columellar plumping graft, premaxillary graft, and alar base graft. The names of all these grafts were translated into Korean. ConclusionZZWe set definitions, indications, and usages of each graft, and suggested the most appropriate Korean nomenclature. We hope that this nomenclature can be widely accepted and used in future papers and books on Korean rhinoplasty. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:412-8 Key WordsZZRhinoplasty·Graft·Nomenclature·Definition·Korean.

Diced cartilage grafts in rhinoplasty surgery.

The use of diced cartilage grafts in rhinoplasty surgery was recently revived by Erol with the publication of his technique for "Turkish delight" grafts (i.e., diced cartilage grafts wrapped in Surgicel). The present study details the authors' experience with 50 consecutive diced cartilage grafts used in three configurations during a prospective study of 50 primary and secondary aesthetic rhinoplasty procedures performed by the senior author (Daniel). Part I consists of 22 diced cartilage grafts wrapped in Surgicel and placed in the radix (n = 14), radix/upper dorsum (n = 4), and full-length dorsum (n = 4). All grafts were performed adhering meticulously to Erol's technique without modification. This portion of the study was halted abruptly at 4 months because of the unexpected absorption and clinical failure of all diced cartilage grafts wrapped in Surgicel. Subsequently, five patients had revision surgery, and biopsy specimens were taken at the prior grafting site and analyzed histologically. After this clinical failure, part II of the study began, consisting of 20 patients who had diced cartilage grafts wrapped in fascia. The range of applications was comparable: radix (n = 12), radix/dorsum (n = 3), and full-length dorsum (n = 5). Because of our prior practice of overcorrecting by 20 percent with diced cartilage grafts wrapped in Surgicel, we had excessive amounts of material in six of our initial diced cartilage wrapped in fascia radix grafts, but no subsequent grafts. The overcorrections were easily reduced at 6 weeks to 11 months postoperatively using a pituitary rongeur under local anesthesia, and the material was sent for histologic analysis. Minimum 1-year follow-up of all 20 cases has shown maintenance of the grafts without evidence of absorption. Part III of this study comprised eight patients who had diced cartilage grafts without a fascial covering placed throughout the nose, including on the sides of osseocartilaginous rib grafts to the dorsum. At 14 months, there was no evidence that any of these grafts had been absorbed. Histologic analysis of the biopsy specimens from the diced cartilage grafts wrapped in Surgicel showed evidence of fibrosis and lymphocytic infiltrates with small amounts of Surgicel visible on birefringent microscopy. Remnants of cartilage were present but were metabolically inactive on the basis of negative glial fibrillary acidic protein staining. Control specimens of fresh septal cartilage and banked septal cartilage were remarkably similar to each other and demonstrated normal cartilage architecture and cellular activity. The diced cartilage grafts wrapped in fascia showed coalescence of the diced cartilage into a single cartilage mass, with viable cartilage cells and normal metabolic activity on the basis of glial fibrillary acidic protein staining. All of the diced cartilage grafts wrapped in Surgicel absorbed and failed to correct the clinical problem for which they were performed. All of the diced cartilage grafts wrapped in fascia and pure diced cartilage grafts did correct the clinical deformities and appear to have survived completely. The diced cartilage grafts wrapped in fascia placed along the dorsum were distinctly palpable throughout the postoperative period, as was one prior case with a 6-year follow-up. The authors' clinical experience confirms the experimental studies of Yilmaz et al. that question the use of Surgicel for wrapping diced cartilage grafts in clinical rhinoplasty surgery.

The radix graft in cosmetic rhinoplasty.

Experience with rhinoplasty over time has shown that a detailed anatomic analysis of the nose is an essential first step in achieving a successful outcome. Failure to recognize a particular anatomic point preoperatively will often lead to a less than ideal long-term result. Deficiency in the radix is a commonly overlooked abnormality that may be found both in patients undergoing primary rhinoplasty and patients undergoing revision rhinoplasty after an overzealous bony hump removal. Whereas surgeons previously reduced the nasal dorsum down to the level of the radix on a routine basis, recent emphasis on a strong natural profile has focused attention on anatomic deficiency in the radix region. We describe a simple technique for treatment of the deep nasofrontal angle and present patient examples. Autologous cartilage grafts may be fashioned into a "radix graft" and reliably used to augment the region either with a precise pocket approach or without when a precise pocket is not possible, achieving a natural aesthetic result.

Lengthening the short nose.

Correction of the aesthetically short nose is one of the most challenging problems in facial plastic surgery. We discuss several techniques aimed at the correction of this problem and propose an algorithm based on the desired effect of the lengthening procedure on tip rotation. Five principal techniques for nasal lengthening are discussed, with figures and cases to illustrate the concepts: (1) the flying buttress graft, which is made up of a single or paired spreader grafts secured to a columellar strut; (2) caudal septal grafts and (3) tip grafts of various shapes; (4) radix grafts placed to elevate the nasion; and (5) interposition grafts placed between the upper and lower lateral cartilages. When the tip is overrotated, small to moderate gains in nasal length may be achieved by a triangular-shaped caudal septal graft or a shield graft that is backed by wedge grafts near the tip. More substantial lengthening and derotation can be achieved by the flying buttress technique or by interposition cartilage or composite grafting between the upper and lower lateral cartilages. With a nasal tip that is adequately rotated or underrotated, nasal lengthening can be achieved by a rectangular-shaped caudal septal graft or by a full-length shield graft. An onlay graft to augment the radix and elevate the nasion to a higher point on the dorsum can be used alone or in combination with a tip or septal graft.

Radix Grafting to Maintain Dorsal Height

Over the past 25 years, the trend for rhinoplasty has been toward higher dorsums. This emphasis on the more aesthetically prominent nose has led to examination of augmenting the radix to achieve this higher dorsum. Traditionally, augmentation of the radix has been limited to those cases where the radix is disproportionately low. While it is true that augmentation due to low radix disproportion is the major criterion for radix grafts, radix augmentation may benefit many patients who do not fit into that category. It is well known that the dorsum will rise after lateral osteotomies and nasal bone infracture. Without reduction this can create a hump. Integrity of the dorsal projection achieved with the infracture can be maintained by implementation of the radix graft procedure which overcomes the appearance of a dorsal hump. A retrospective review of 52 patients who underwent radix grafting was performed. Some were augmented due to low radix disproportion and some were augmented to maintain the aesthetic line of the higher dorsal projection. This review examined the following criteria: type of cartilage graft used; cartilage morselization; cartilage tiering, complications; and, revisions of radix graft implants. This study examines the use of radix grafting in those instances where a high profile cannot be otherwise achieved. A broader utility of radix grafting is encouraged to maintain dorsal height in aesthetic rhinoplasty.