Sir: Dorsal nasal irregularities are common aesthetic deformities following primary and secondary rhinoplasty, especially in patients with thin nasal dorsal skin. The authors present a simple technique of obtaining autologous graft material, by collecting the remnants of rasped osseocartilaginous dorsum, which is used as a routine in their rhinoplasty practice. The authors prefer open rhinoplasty in all patients. After transcolumellar and infracartilaginous incisions, a distally subperichondrial and proximally subperiosteal pocket is developed over the osseocartilaginous dorsum. A nasal dorsum rasp is introduced into this space and the dorsal hump is removed by rasping alone. During rasping, tiny fragments of bone and cartilage are produced from the breakdown of osseocartilaginous dorsum (Fig. 1). These particles are collected meticulously from the surface of the rasp by drying the rasp on a piece of gauze or from the pocket with an atraumatic forceps. Aspiration of blood by the assistant is not allowed at this stage. Hemostasis is achieved by sponges, and these sponges are also preserved for collecting any particles attached on them. When all particles are gathered and dried over a piece of gauze, a solid “meatball” of osseocartilaginous graft material is obtained (Fig. 2). This graft material is placed on the osseocartilaginous dorsum just before closure of incisions, and the nose is taped and splinted.Fig. 1.: Tiny fragments of bone and cartilage are formed by rasping the nasal dorsum.Fig. 2.: These particles are gathered into a “meatball” composite graft.This technique, which was used as a routine in 562 primary open rhinoplasties between 2002 and 2008, simply eliminated postoperative dorsal nasal irregularities in our rhinoplasty practice. Prevention of dorsal irregularities that may occur even in the most experienced hands is much easier than treating them. The authors believe that in primary rhinoplasty of patients with thin dorsal nasal skin, a maneuver that adjusts the smoothness and softness of nasal dorsum should be a part of the routine. Many techniques have been suggested in attempts to prevent visible sharp edges of dorsal nasal structures, most of which involve placement of soft, smooth, pliable grafts of autologous or alloplastic origin such as fat, diced cartilage, fascia, bone chips, AlloDerm (LifeCell Corp., Branchburg, N.J.), polytetrafluoroethylene patches, silicone sheets, and Vicryl (Ethicon, Inc., Somerville, N.J.) mesh.1–4 Our technique is simply about returning the rasped osseocartilaginous hump to where it belongs. Absence of additional donor-site morbidity is a major advantage over most autologous graft options. Lower cost and avoidance of infectious complications are advantages over alloplastic materials. Prolonged edema, which is common after contouring with dermis grafts or AlloDerm, is not seen with this technique. No envelope or wrapping is necessary. The adequacy of graft material obtained with this technique may be a subject of curiosity. In our opinion, the higher level of control that is provided by rasp removal of dorsum diminishes the amount of material that is necessary to camouflage subtle irregularities in primary rhinoplasty. In cases where additional volume is desired, especially in secondary rhinoplasties, remnants of septal, conchal, or costal cartilages that are left on the table after placement of grafts can be rasped on the table and added to the meatball. DISCLOSURE Neither of the authors has a financial conflict of interest to disclose with regard to the content of this article. Aycan Kayikçioğlu, M.D. Ozan Bitik, M.D. Hacettepe University Faculty of Medicine Department of Plastic, Reconstructive, and Esthetic Surgery Ankara, Turkey
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