Aesthetic structural nasal augmentation

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AESTHETIC STRUCTURAL NASAL AUGMENTATION TOM D. WANG, MD

This article addresses the author's preferred technique in the reconstruction of moderate and severe saddle nasal deformities. The prevailing concept is the provision of adequate structural support for the overlying nasal soft tissue coverage for an aesthetically pleasing outcome. All reconstructive efforts are undertaken via the external rhinoplasty approach. Detailed descriptions of the individual steps involved in the reconstructive sequence are included. Representative patient cases are included to demonstrate the versatility of techniques. KEY WORDS: Nasal reconstruction/saddle nose deformity/dorsal augmentation/open approach/tip graft.

Implants have long been used for correction of both acquired and congenital contour deformities of the nose. A saddle-nose deformity involves depression of the bony and cartilaginous nasal dorsum. When both the nasal dorsum and the nasal tip are depressed, a flattened or platyrrhine nasal deformity exists. Etiologic factors in these deformities include trauma, infection, autoimmune process, neoplastic disease, and congenital malformation. Numerous reconstructive materials and methods have been described for correction of these contour deformities.' These include a variety of synthetic and autogenous materials used to improve dorsal and tip projection. However, relatively little attention has been devoted to the creation of an aesthetic and refined nasal tip in the context of these reconstructive efforts. Understandably, the primary goal in these reconstructions is to restore normal nasal contour. However, with the evolution and refinement of the structural concept in aesthetic rhinoplasty, we believe it is now possible to not only adequately reconstruct the nasal contour, but to also achieve an aesthetic and refined nasal tip in the process. In effect, an attempt is being made to bring the reconstructive effort into the realm of the aesthetic. The nasal tip has long been noted to be the sin:fle most important determining factor of a refined nose. Essential landmarks characterizing a refined tip include bilateral projecting domes framed by superior and inferior points of differentiation from the remainder of the nose. The tip graft as originally described by Sheen and Sheerr' and modified and refined by Johnson and Toriumi," under appropriate circumstances is able to recreate the topographic contours of a refined nasal tip. This article presents a technique using carved costal cartilage to augment and provide aesthetic refinement of

From the Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN. Address reprint requests to Tom D. Wang, MD, Department of Otorhinolaryngology, Mayo Clinic, 200 First St Southwest, Rochester, MN 55905. © 1990 by W.B. Saunders Company. 1043·1810/9010104-0019$05.0010

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the nose. Costal cartilage is favored in this type of reconstruction over various other types of implants. In many instances, the amount of material required to adequately reconstruct the deformity precludes the sole use of conchal or septal cartilage. Cartilage has the advantage over bone, both calvarial and iliac, in that it is easy to carve and manipulate.P In addition, it is able to restore the natural springiness of the normal nose. Bone grafts are rigid and 'subject to fracture and resorption." Synthetic materials are not used for dorsal augmentation because of their high tendency for extrusion. 1,5

TECHNIQUE Costal cartilage is our preferred material in reconstructions where large quantities of cartilage are required. When available, septal cartilage or conchal cartilage is preferred for creation of the tip-defining structural support. Otherwise, these structures are carved from costal cartilage as well. Autogenous cartilage can be harvested from the confluence of the sixth, seventh, and eighth ribs as described by Tardy et aI.5 Irradiated homologous cartilage can also be used, avoiding the morbidity associated with harvesting autogenous material.v" The cartilage is cut and carved according to the principle of balanced cross-sections to prevent warping and curling." If a tip graft is needed, the posterior septal cartilage is the preferred region from which this is obtained. The carving of the tip graft is meticulously performed to prevent any sharp edges and to allow for smooth blending with the remainder of the tip structural supports." When septal or conchal cartilage is not available, the same carving principles are applied to costal cartilage for tip grafting. An external rhinoplasty approach is used to allow exposure of the pathology.!'' In addition, this approach facilitates precise placement and suturing of the cartilaginous support structures. In the presence of adequate lower lateral cartilages with good tip support, such as a saddle-nose type deformity, only the dorsum is augmented. The nasal tip is refined separately using shield tip grafts. The costal cartilage

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 4 (DEC), 1990: PP 234·238

graft in these instances is carved to recreate a straight dorsal profile. The dorsal configuration of the graft is a tapered one, being narrow cephalically and caudally and slightly wider in the middle. The undersurface of the graft is carved to exactly fit the contour -distortion of the nasal defect. Typically, this involves a convex configuration on profile and a slight cavity in cross-section (Figs 1-3). This configuration not only allows for a good fit of the implant over the existing nasal dorsum, but also helps to minimize shifting secondarily (Fig 4). The dorsal graft is then placed either cephalic or posterior to the lower lateral cartilages (Fig 5). Every effort should be made to enhance graft stability through accurate coaptation of the carved undersurface. Reduction and refinement of the dorsum to achieve the desired profile may be accomplished at this point. The creation of adequate tip projection and aesthetic tip-definition is then carried out as one would in an aesthetic rhinoplasty procedure.' This may involve bilateral cephalic trims of the lower lateral cartilages along with dome divisions, and suturing the cut ends of the cartilage to reconstitute the intact lateral crural strip. A shield tip graft is carved to provide the essential landmarks of a refined tip. 2 To prevent displacement and rotation of the graft, prolene sutures are used to secure it to the lower lateral cartilages (Fig 6). We also routinely place a columellar strut between the medial crura to enhance tip structural support. After all of the grafts have been secured, the external rhinoplasty incision is closed. A dorsal nasal splint is placed to enhance graft stability during healing. In the platyrrhine situation with inadequate lower lateral cartilages to support tip projection, one large dorsal graft is carved to both augment the nasal dorsum and provide tip reconstruction. The dorsal graft is carved to extend to the region of the inferior tip lobule in a tapered fashion to resemble the contour of a tip graft (Fig 7). The two tip-defining points are carved separately and then inserted in a notch along the distal portion of the dorsal graft. The tip-defining graft is sutured with prolene directly onto the dorsal graft for stability. The placement of the dorsal graft is dependent on the desired final rotation and projection of the nasal tip. In our hands, this is typically 2 to 4 mm from the distal-most portion of the dorsal graft. The undersurface consistency of the distal portion of the dorsal graft requires special attention to avoid inferior and lateral displacement of the existing lower lateral cartilages. In most instances, this requires a convexity on the undersurface region to prevent displacement. Additionally, the lower lateral cartilages may need to be divided at the domes and perhaps trimmed to some degree. A columellar strut is always used to prevent downward tilting of the dorsal graft. The medial crura of the lower lateral cartilages are sutured to this strut to further minimize its displacement into the nasal vestibule and cause airway obstruction. The columellar strut is carved slightly longer than is usually necessary to provide support for the dorsal graft and projection beyond the domes of the lower lateral cartilages. This strut is tunneled downward towards the nasal spine and can actually be splayed distally to straddle the spine. Adequate stabilization along the spine with suturing prevents strut displacement. The junction between the strut and the dorsal graft is further stabilized by carving a recessed hole on the undersurface of the dorsal graft (Fig 8). In addition, the strut may be sutured to the graft itself. Otherwise, the dorsal graft is carved in an identical fashion cephalically to match the contour of TOM D. WANG

FIGURE 1. Dorsal view of graft tapered at both ends.

FIGURE 2. Convex configuration of graft on profile.

FIGURE 3. Cross-sectional appearance of graft.

FIGURE 4. Insertion of graft via the external approach onto nasal dorsum.

FIGURE 5. Graft placement posterior to lower lateral cartilages.

FIGURE 6. Shield tip graft sutured to lower lateral cartilages.

FIGURE 7. Appearance of dorsal augmentation graft with tip-defining points sutured in place. Note length of columellar strut.

FIGURE 8. Caudal undersurface of dorsal graft with recessed hole for articulation with columellar strut.

the nasal dorsal depression. Once in place, this graft will provide not only nasal dorsal augmentation, but also improve nasal tip definition. The external rhinoplasty incision is then closed and a dorsal nasal splint applied.

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CASE PRESENTATION CASE ONE A 33-year-old woman sustained a severe communited fracture of her nasal ethmoid complex, with extensive soft tissue laceration of the nasal dorsum and tip. She exhibited significant nasal dorsal flattening, with loss of tip projection due to damage to the lower lateral cartilages. Other injuries sustained include right medial canthal rounding. Her repair was performed via an external rhinoplasty approach. Due to the severity of the injury,

FIGURE 12. Intraoperative dorsal augmentation via external approach. (A) Pre-graft insertion, right oblique. (B) Post-graft insertion, right oblique.

FIGlJRE 13. (A) Pre-graft insertion, right profile. (B) Post-graft insertion, right profile.

FIGURE 9. Post-traumatic nasal flattening with loss of tip projection requiring large dorsal graft with incorporated tip defining points for reconstruction. (A) Preoperative, anteroposterior view. (8) One-year postoperative, anteroposterior view.

a large costal cartilage graft was needed to augment the dorsum and reconstruct the nasal tip (Fig 9A, B). This was supported by a columellar strut sutured to the medial crura of the lower lateral cartilages. This strut articulated with the dorsal implant via a carved notch on the undersurface and was additionally sutured to the dorsal implant for greater stability. The patient showed significantly improved definition of the dorsum and tip subunits of the nose following the reconstruction (Figs 10 and 11).

CASE TWO

A FIGURE 10. (A) Preoperative, right oblique. (B) Postoperative, right oblique.

A 31-year-old woman sustained a fracture of the nasal dorsum in a motor vehicle accident. One year following the injury, she presented with saddling of the dorsum. However, her lower lateral cartilages appeared intact with adequate structural support. Her reconstruction involved an external rhinoplasty approach with a carved piece of costal cartilage graft (Fig 12A, B). The graft was carved to conform to the contour of the existing nasal dorsum to ensure stability following placement (Fig 13A, B). The nasal tip was refined with bilateral cephalic trims followed by placement of a tip graft. This helped to improve both the projection and definition of her nasal tip. A 2-year postoperative result is shown (Figs 14, 15, and 16).

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DISCUSSION A

FIGURE 11. (A) Preoperative, left oblique. (B) Postoperative, left oblique.

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This article presented a technique of nasal augmentation and reconstruction that has evolved through a synthesis of previous reconstructive techniques coupled with cur-

AESTHETIC STRUCTURAL NASAL AUGMENTATION

FIGURE 14. Saddle-nose deformity following motor vehicle

accident. (A) Preoperative, right oblique. (B) Two years postoperative, right oblique.

FIGURE 15. (A) Preoperative, left oblique. (B) Postoperative,

left oblique.

FIGURE 16. (A) Preoperative, right profile. (B) Postoperative,

right profile. rent thinking on structural aesthetic rhinoplasty. The aim of this technique is to not only augment the dorsum and maintain tip projection, but also recreate a more elegant and refined nasal tip in the process. As facial plastic and reconstructive surgeons, our goal is to try to recreate normal form and function while achieving an aesthetically pleasing result. The nasal tip represents the single most important determinant of a refined nose. The technique presented, incorporating either tip graft or separate tip-defining points, allows the surgeon to control projection, rotation, and tip-definition. It is through this greater degree of control that improved aesthetics can be achieved with major nasal reconstructions.

TOM D. WANG

FIGURE 17. Large dorsal reconstructive graft with

incorporated tip-defining points used in aging nose reconstruction. (A) Pre-graft insertion. (B) Appearance at final closure.

FIGURE 18.

Non-Caucasian rhinoplasty using a single large dorsal augmentation graft with incorporated tip-defining points. (A) Pre-insertion of graft. (B) Appearance at final closure. This reconstructive technique was first used in 1987 for the patient presented in Case one. This is our preferred method of reconstruction in those cases requiring significant augmentation. Cases of patients included in this category include post-traumatic and post-rhinoplasty saddle deformities, as well as the aging nose (Fig 17A, B) and non-Caucasian rhinoplasty (Fig 18A, B). In addition, this same cartilaginous structural framework has been used in conjunction with midline forehead flaps in total nasal reconstruction.l! Known complications of dorsal augmentation and nasal reconstruction reported in the literature include: skin necrosis, graft extrusion, graft displacement, graft warping along with bleeding, infection, and nasal airway obstruction. Fortunately, we have not experienced any of these complications thus far in our series. Both autogenous rib cartilage and irradiated homograft costal cartilages are used for reconstruction. Although it has been reported that irradiated homograft cartilage undergoes resorption over time, 8 our experience with this material seems to indicate that contour appears to be preserved despite cartilaginous resorption. This probably occurs through the replacement of cartilage with fibrous scar tissue. As such, it has not been a significant problem in our patients. In conclusion, we feel

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that this technique not only corrects the nasal dorsal deformity and improves tip projection, but also recreates the natural aesthetic features of the nose.

6. 7.

REFERENCES 1. Converse JM: Reconstructive Plastic Surgery. Vol 2, (ed 2) Philadelphia, PA, W.B. Saunders, 1977 2. Sheen JH, Sheen AP: Aesthetic Rhinoplasty. (Ed 2) St Louis, MO, CV Mosby, 1987 3. Sheen JH, Sheen AP: Aesthetic Rhinoplasty. St Louis, MO, CV Mosby, 1978 4. Johnson CM, Toriumi OM: Open Structure Rhinoplasty. Philadelphia, PA, W.B. Saunders, 1990 5. Tardy ME, Denneny J, Firtsch MH: The versatile cartilage autograft

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8.

9. 10. 11.

in reconstruction of the nose and face. Laryngoscope 95:523-533, 1985 Zhou LY, Chang TS: Correction of complicated saddlenose: Report of 63 cases. Eur J Plast Surg 9:52-56, 1986 Schuller DE, Bardach J, Krause CJ: Irradiated homologous costal cartilage for facial contour restoration. Arch Otolaryngol Head Neck Surg 103:12-16, 1977 Welling DB, Maves MD, Schuller DE, et al: Irradiated homologous cartilage grafts: Long-term results. Arch Otolaryngol Head Neck Surg 114:291-295, 1988 Gibson T, Davis WB: The distortion of autogenous cartilage grafts: Its cause and prevention. Br J Plast Surg 10:247-259, 1957 Anderson JR, Ries WR: Rhinoplasty: Emphasizing the External Approach. New York, NY, Thieme, Inc, 1986 Burget GC, Menick FJ: Nasal reconstruction: Seeking a fourth dimension. Plast Reconstr Surg 78:145-157, 1986

AESTHETIC STRUCTURAL NASAL AUGMENTATION