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Cortical tibial bone graft for nasal augmentation: donor site short scar
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 747e754
REVIEW
Cortical tibial bone graft for nasal augmentation: donor site short scar* E. Garcı´a-Dı´ez, E. Guisantes, J. Fontdevila, M. Raigosa*, J.M. Serra-Renom Department of Plastic Surgery, Hospital Clinico, University of Barcelona, Carrer Villarreol 170, CP 08036, Barcelona, Spain Received 20 June 2007; accepted 11 August 2007
KEYWORDS Bone graft; Nasal augmentation; Tibial graft; Short scar
Summary The nose is the central part of the face and the most prominent facial feature. Augmentation rhinoplasty is one of the most exciting and arduous techniques for plastic surgeon and patient. Fourteen cases of augmentation rhinoplasty with cortical tibial bone graft are presented. An endonasal approach was used in 13 cases and an open approach in one case, with a donor site short scar (1.5 cm) in every case. The average follow up was 2 years and no significant bone resorption was observed. No remarkable complications or complications requiring surgery were noted during the follow up. The cosmetics results have been gratifying. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Augmentation rhinoplasty procedures have an important limitation in the use of bone or cartilage grafts, which have different rates of resorption over time. Reconstruction of the nasal dorsum requires a material that provides structural support and long term augmentation. Different grafting materials have been used for augmentation rhinoplasty,
such as alloplastic implants, temporalis fascia, dermofat grafts, cartilage (from septum, rib or concha) or bone (cranial bone, iliac crest, rib and olecranon).1e9 We propose the use of the tibial bone as a cortical bone graft donor site not usually described for the purpose of augmentation rhinoplasty.
* This paper was presented during the ‘Aesthetic Facial Reconstructive in Adults and Children Symposium’, Tucson, AZ, USA, 23e25 February 2007 * Corresponding author. Address: University of Barcelona, Servicio de Cirugı´a Pla ´ stica y Reparadora, Department of Plastic Surgery, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain. Tel.: þ34 665681171; fax: þ34 932275711. E-mail address: [email protected] (M. Raigosa).
Materials and methods We present a series of 14 patients who underwent augmentation rhinoplasty using cortical tibial bone graft between September 2003 and February 2005. There were six males and eight females aged between 20 and 41 years (mean age 29). Thirteen cases were treated through closed
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.08.027
748
E. Garcı´a-Dı´ez et al.
Figure 1
Preoperative marking of the donor site (left leg).
rhinoplasty incisions. One case underwent an intraoral degloving approach combined with a frontogaleal flap to wrap around the tibial graft and to ensure graft survival in a patient suffering the after effects of cocaine consumption. The causes of the nasal deformities were posttraumatic in 11 cases, congenital in two cases, and cocaine consumption in one case.
Surgical technique of graft harvesting This technique has been previously described by the authors.16 The graft is obtained by a minimal 1.5e2 cm transverse pretibial cutaneous incision placed at the upper-third of the tibial diaphysis [6 cm under anterior tibial tuberosity (ATT)]. The cranial limit of the bone osteotomy is 3 cm under the ATT and the outer limit is the tibial crest (Figure 1). The tibial crest and the tibial tuberosity are preserved. We do not use a thigh tourniquet. An anaesthetic infiltration is performed. After the skin incision, we perform a subperiosteal dissection of the bone (Figure 2). The graft shape and size are drawn out with a pencil and by means of a sagittal and oscillating saw we perform the osteotomies (Figure 3). We finally elevate the graft
Figure 2
Donor site short incision (1.5 cm).
using a chisel (Figure 4). Skilled separation, irrigation and aspiration provide good visibility. Through this minimal incision it is possible to obtain cortical tibial bone grafts of an average size of 6 cm in length and 2 cm wide (Figures 5 and 6). We do not leave any drainage device. We create the desired shape of the graft using a contouring burr. The graft is shaped as required, reproducing the contour of a normal nasal dorsum (wider at the bridge line than in the tip, Figure 7). The caudal part of the graft is smoothed off to obtain a rounded tip. We create a posterior canal in the graft to ensure a good contact with the nasal bone (Figure 8). The bone dust is collected during the contouring process and then placed into the donor site defect together with an absorbable haemostat (Surgicel, Johnson & Johnson, USA). The donor site incision is closed with an intradermal running suture. We place a compressive dressing (no cast) on the leg for 48 h and a non-compressive dressing for 2 weeks. The leg is kept elevated for 48 h. The patient must not do any violent exercise for 2 weeks. General endotracheal anaesthesia was used in every patient but it is possible to obtain the tibial graft under local anaesthesia.
Figure 3
Osteotomies with a sagittal and oscillating saw.
Cortical tibial bone graft for nasal augmentation
Figure 4
Elevation of the cortical tibial graft with a chisel.
Surgical technique of grafting In the 13 cases of endonasal approach, an intercartilaginous approach is performed. A tunnel is dissected in the nose, subperiosteal over the bony nose and subcutaneous at the tip, creating a pocket at the dome. The tip cartilage is not resected. The graft is placed over the nasal bone. The subperiostal dissection allows a good contact between the tibial graft and the nasal bone to ensure graft ‘survival’. We use the term survival to be clearer and comprehensible even though it is well documented that little of the cortical graft osteocytes survive but are, rather, replaced by osteoinduction, osteoconduction and creeping substitution. It is possible to gain more skin for more anterior nasal projection if the subcutaneous dissection is carried out over the cheeks. No lateral osteotomies were made. The nasal osteosynthesis is performed with two screws placed transcutaneously in the nasal root. The nasal root incision is made with an 11 blade scalpel puncture to minimise the scar. The screws should be 2.0 mm in diameter, and the length of them relates to the thickness of the graft, usually between 10 and 12 mm. wider screws may fracture the graft. It is important to have a good fixation
Figure 5
749
Figure 6
The tibial bone graft before it has been contoured.
to reduce the incidence of resorption (Figures 9 and 10).7 We had nasal packing in place for 24 h and a nasal splint for 1 week.
Results Fourteen patients were operated on and the average follow up was 28 months. The results were favourable. The stay in hospital was 2 days in 13 cases (short stay surgery) and 4 days in one case (combined frontogaleal flap with tibial graft). Patients were able to walk in 2 days. Nasal radiographic control (profile) at 1 month, 6 months, 12 months and 18 months to measure changes in graft height showed no resorption of the tibial bone graft. The union between the nasal bone and the graft was stable at 12 months on radiographic control, with no displacement of the graft (Figure 11). The aesthetic results were gratifying; with good nasal projection in every case (Figures 12 and 13). The scar within the nasal skin at the site of screw insertion is inconspicuous, in the same way as happens with skin incisions during percutaneous osteotomies in standard rhinoplasty. In three cases the screws had to be removed
(Left) Cortical tibial graft (5 1.2 cm). (Right) Short donor site incision.
750
E. Garcı´a-Dı´ez et al.
Figure 7
The tibial bone graft with the desired shape.
Figure 10
Figure 8
Frontal view of the grafted nose.
Posterior canal in the graft.
because they were palpable. There were no complications of the donor site. The postoperative pain at the donor site is perfectly controlled with standard analgesics (non-steroidal anti-inflammatory drugs every 8 h). The initial sinking in the donor site fades progressively, so that it is not noticeable 2 months after the surgery. The tibial
Figure 9
Lateral view of the grafted nose.
Figure 11 Postoperative radiographic control of the graft (12 months): no displacement, no resorption of the graft.
Cortical tibial bone graft for nasal augmentation
Figure 12
751
Preoperative views (above) and postoperative views (below).
radiographic control after 1 month showed correct bone remodel (Figures 14 and 15).
Discussion Cartilage grafts in augmentation rhinoplasty are useful for mild deformities, but autogenous bone is used if a greater augmentation is required.5 Cartilage grafts are supposed to improve contour and function and correct deformities, but they may also lead to postoperative defects. The most frequent defects are graft displacement and asymmetry,
tendency to curl (especially rib cartilage), a visible step, and under- or overcorrection.10 Advantages of cartilage are that there is no need for contact between the graft and the nasal bone for graft survival. Alloplastic implants are another alternative for nasal augmentation. Their advantages are ready availability in shapes and sizes and no donor site morbidity. These materials have a high rate of complications like extrusion, malposition, or unnatural appearance.5,11,12 Bone grafts are the best option for reconstruction of wide defects of the nose with autogenous tissue, maintaining the tip projection with minimal airway problems. Bone graft
752
E. Garcı´a-Dı´ez et al.
Figure 13
Preoperative views (above) and postoperative views (below).
provides a durable and safe reconstruction. Tissue for augmentation rhinoplasty has been obtained from cranial bone, ribs, iliac bone and olecranon. Cranial bone is probably the most used bone graft for nasal augmentation. It has numerous advantages as a donor site: it resorbs less, is an easy to hide donor site, and does not bend.4 The complication rate reported is low; however, serious complications (intracerebral haematoma, superior sagittal sinus laceration) have been reported.13,14 The use of tibial bone graft was not usually described in the literature. Tessier et al.15 published an excellent review of the use of tibial bone in the literature since 1911.
The tibial bone has been used for dorsolumber spine, pseudoarthroses of the limbs, cranial defects, mandibular reconstruction and cleft lip-cleft palate repair. Tessier described a technique with a long vertical scar at the donor site and a combined corticocancellous graft harvesting. We describe a technique of cortical graft harvesting with a donor site short transverse scar (1.5 cm). The advantages of the augmentation rhinoplasty with cortical tibial bone graft harvested with short scar are: No tendency to bend. No resorption.
Cortical tibial bone graft for nasal augmentation
Figure 14
Figure 15
753
Radiographic control of the tibial donor site on the first postoperative day.
Radiographic control of the tibial donor site 1 month postoperatively.
It is very stable over time. Minimal donor site morbidity. Inconspicuous donor site scar (1.5 cm incision). Easy and quick harvest technique. The donor and the recipient sites are in different operating fields. Short hospitalization time (no more than 2 days). Good cosmetic results. The long and flat shape of these grafts, as opposed to the calvarial or costal grafts, is excellent for creating the shape of the nasal dorsum. We do not use columellar struts like other authors5 because we think that it is not necessary to maintain tip projection when fixation screws are placed. We do not recommend a rhinoplasty open approach to avoid the problem of closing the columellar skin incision once the graft is placed. We do not remodel the tip and we do not make lateral osteotomies, to prevent the graft bone resorption,
graft extrusion and to provide more stability. If another correction is needed, it is performed in a second operation. As with all bony nasal reconstructions, the disadvantage of this technique is that the patient must accept a certain degree of rigidity and immobility in the nose. Our early experience with this short series of cases seems to show that the cortical tibial bone graft is an excellent option for augmentation rhinoplasty.
References 1. Saray A. Porcine dermal collagen (Permacol) for facial contour augmentation: preliminary report. Aesthetic Plast Surg 2003; 27:368. 2. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: dorsal onlay grafting using shaped autogenous septal cartilage. Plast Reconst Surg 1990;86:39. 3. Jackson IT, Smith J, Mixter RC. Nasal bone grafting using split skull grafts. Ann Plast Surg 1983;11:533.
754 4. Jackson IT, Choi HY, Clay R, et al. Long-term follow-up of cranial bone graft in dorsal nasal augmentation. Plast Reconstr Surg 1998;102:1869. 5. Karacaoglan N, Ata Uysal O. Use of iliac bone graft for saddle nose deformity. Auris Nasus Larynx 1998;25:49. 6. Sarukawa S, Sugawara Y, Harii K. Cephalometric long-term follow-up of nasal augmentation using iliac bone graft. J Cranio Maxill Surg 2004;32:233. 7. Judith MG, Thomas P, Chad AP, et al. Long-term outcome of autogenous rib graft nasal reconstruction. Plast Reconstr Surg 2001;108:1895. 8. Hodgkinson DJ. The olecranon bone graft for nasal augmentation. Aesthetic Plast Surg 1992;16:129. 9. Bernd R, Neu MD. Segmental bone and cartilage reconstruction of major nasal dorsal defects. Plast Reconstr Surg 2000;106:160. 10. Aiach G. Atlas of Rhinoplasty. Open and Endonasal Approaches. St Louis, Missouri: Quality Medical Publishing, Inc.; 2003. 11. Antia N, Daver B, Keswani M. Prefabricated silicone nasal implants. Plast Reconstr Surg 1973;52:264.
E. Garcı´a-Dı´ez et al. 12. C ¸ elik M, Haliloglu T, Baycin N. Bone chips and diced cartilage: an anatomically adopted graft for the nasal dorsum. Aesthetic Plast Surg 2004;28:8. 13. Cannella DM, Hopkins LN. Superior sagittal sinus laceration complicating an autogenous calvarial bone graft harvest, case report. J Oral Maxillofac Surg 1990;48:741. 14. Young VL, Schuster RH, Harris LW. Intracerebral hematoma complicating split calvarial bone graft harvesting. Plast Reconstr Surg 1990;86:763. 15. Tessier P, Kawamoto H, Matthews D, et al. Taking tibial grafts in the diaphysis and upper epiphysis e Tools and techniques: a 650-case experience in maxillofacial and craniofacial surgery. Plast Reconstr Surg 2005;116:47S. 16. Fontdevila J, Martı´-Page ´s C, Garcı´a-Dı´ez E, et al. Augmentation rhinoplasty using tibial bone graft. In: Proceedings of the Aesthetic facial reconstruction in adults and children Symposium; 2006 February 23e25. Tucson, AZ. Arlington Heights, IL: American Society of Plastic Surgeons/Plastic Surgery Educational Foundation; 2006.
REVIEW
Cortical tibial bone graft for nasal augmentation: donor site short scar* E. Garcı´a-Dı´ez, E. Guisantes, J. Fontdevila, M. Raigosa*, J.M. Serra-Renom Department of Plastic Surgery, Hospital Clinico, University of Barcelona, Carrer Villarreol 170, CP 08036, Barcelona, Spain Received 20 June 2007; accepted 11 August 2007
KEYWORDS Bone graft; Nasal augmentation; Tibial graft; Short scar
Summary The nose is the central part of the face and the most prominent facial feature. Augmentation rhinoplasty is one of the most exciting and arduous techniques for plastic surgeon and patient. Fourteen cases of augmentation rhinoplasty with cortical tibial bone graft are presented. An endonasal approach was used in 13 cases and an open approach in one case, with a donor site short scar (1.5 cm) in every case. The average follow up was 2 years and no significant bone resorption was observed. No remarkable complications or complications requiring surgery were noted during the follow up. The cosmetics results have been gratifying. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Augmentation rhinoplasty procedures have an important limitation in the use of bone or cartilage grafts, which have different rates of resorption over time. Reconstruction of the nasal dorsum requires a material that provides structural support and long term augmentation. Different grafting materials have been used for augmentation rhinoplasty,
such as alloplastic implants, temporalis fascia, dermofat grafts, cartilage (from septum, rib or concha) or bone (cranial bone, iliac crest, rib and olecranon).1e9 We propose the use of the tibial bone as a cortical bone graft donor site not usually described for the purpose of augmentation rhinoplasty.
* This paper was presented during the ‘Aesthetic Facial Reconstructive in Adults and Children Symposium’, Tucson, AZ, USA, 23e25 February 2007 * Corresponding author. Address: University of Barcelona, Servicio de Cirugı´a Pla ´ stica y Reparadora, Department of Plastic Surgery, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain. Tel.: þ34 665681171; fax: þ34 932275711. E-mail address: [email protected] (M. Raigosa).
Materials and methods We present a series of 14 patients who underwent augmentation rhinoplasty using cortical tibial bone graft between September 2003 and February 2005. There were six males and eight females aged between 20 and 41 years (mean age 29). Thirteen cases were treated through closed
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.08.027
748
E. Garcı´a-Dı´ez et al.
Figure 1
Preoperative marking of the donor site (left leg).
rhinoplasty incisions. One case underwent an intraoral degloving approach combined with a frontogaleal flap to wrap around the tibial graft and to ensure graft survival in a patient suffering the after effects of cocaine consumption. The causes of the nasal deformities were posttraumatic in 11 cases, congenital in two cases, and cocaine consumption in one case.
Surgical technique of graft harvesting This technique has been previously described by the authors.16 The graft is obtained by a minimal 1.5e2 cm transverse pretibial cutaneous incision placed at the upper-third of the tibial diaphysis [6 cm under anterior tibial tuberosity (ATT)]. The cranial limit of the bone osteotomy is 3 cm under the ATT and the outer limit is the tibial crest (Figure 1). The tibial crest and the tibial tuberosity are preserved. We do not use a thigh tourniquet. An anaesthetic infiltration is performed. After the skin incision, we perform a subperiosteal dissection of the bone (Figure 2). The graft shape and size are drawn out with a pencil and by means of a sagittal and oscillating saw we perform the osteotomies (Figure 3). We finally elevate the graft
Figure 2
Donor site short incision (1.5 cm).
using a chisel (Figure 4). Skilled separation, irrigation and aspiration provide good visibility. Through this minimal incision it is possible to obtain cortical tibial bone grafts of an average size of 6 cm in length and 2 cm wide (Figures 5 and 6). We do not leave any drainage device. We create the desired shape of the graft using a contouring burr. The graft is shaped as required, reproducing the contour of a normal nasal dorsum (wider at the bridge line than in the tip, Figure 7). The caudal part of the graft is smoothed off to obtain a rounded tip. We create a posterior canal in the graft to ensure a good contact with the nasal bone (Figure 8). The bone dust is collected during the contouring process and then placed into the donor site defect together with an absorbable haemostat (Surgicel, Johnson & Johnson, USA). The donor site incision is closed with an intradermal running suture. We place a compressive dressing (no cast) on the leg for 48 h and a non-compressive dressing for 2 weeks. The leg is kept elevated for 48 h. The patient must not do any violent exercise for 2 weeks. General endotracheal anaesthesia was used in every patient but it is possible to obtain the tibial graft under local anaesthesia.
Figure 3
Osteotomies with a sagittal and oscillating saw.
Cortical tibial bone graft for nasal augmentation
Figure 4
Elevation of the cortical tibial graft with a chisel.
Surgical technique of grafting In the 13 cases of endonasal approach, an intercartilaginous approach is performed. A tunnel is dissected in the nose, subperiosteal over the bony nose and subcutaneous at the tip, creating a pocket at the dome. The tip cartilage is not resected. The graft is placed over the nasal bone. The subperiostal dissection allows a good contact between the tibial graft and the nasal bone to ensure graft ‘survival’. We use the term survival to be clearer and comprehensible even though it is well documented that little of the cortical graft osteocytes survive but are, rather, replaced by osteoinduction, osteoconduction and creeping substitution. It is possible to gain more skin for more anterior nasal projection if the subcutaneous dissection is carried out over the cheeks. No lateral osteotomies were made. The nasal osteosynthesis is performed with two screws placed transcutaneously in the nasal root. The nasal root incision is made with an 11 blade scalpel puncture to minimise the scar. The screws should be 2.0 mm in diameter, and the length of them relates to the thickness of the graft, usually between 10 and 12 mm. wider screws may fracture the graft. It is important to have a good fixation
Figure 5
749
Figure 6
The tibial bone graft before it has been contoured.
to reduce the incidence of resorption (Figures 9 and 10).7 We had nasal packing in place for 24 h and a nasal splint for 1 week.
Results Fourteen patients were operated on and the average follow up was 28 months. The results were favourable. The stay in hospital was 2 days in 13 cases (short stay surgery) and 4 days in one case (combined frontogaleal flap with tibial graft). Patients were able to walk in 2 days. Nasal radiographic control (profile) at 1 month, 6 months, 12 months and 18 months to measure changes in graft height showed no resorption of the tibial bone graft. The union between the nasal bone and the graft was stable at 12 months on radiographic control, with no displacement of the graft (Figure 11). The aesthetic results were gratifying; with good nasal projection in every case (Figures 12 and 13). The scar within the nasal skin at the site of screw insertion is inconspicuous, in the same way as happens with skin incisions during percutaneous osteotomies in standard rhinoplasty. In three cases the screws had to be removed
(Left) Cortical tibial graft (5 1.2 cm). (Right) Short donor site incision.
750
E. Garcı´a-Dı´ez et al.
Figure 7
The tibial bone graft with the desired shape.
Figure 10
Figure 8
Frontal view of the grafted nose.
Posterior canal in the graft.
because they were palpable. There were no complications of the donor site. The postoperative pain at the donor site is perfectly controlled with standard analgesics (non-steroidal anti-inflammatory drugs every 8 h). The initial sinking in the donor site fades progressively, so that it is not noticeable 2 months after the surgery. The tibial
Figure 9
Lateral view of the grafted nose.
Figure 11 Postoperative radiographic control of the graft (12 months): no displacement, no resorption of the graft.
Cortical tibial bone graft for nasal augmentation
Figure 12
751
Preoperative views (above) and postoperative views (below).
radiographic control after 1 month showed correct bone remodel (Figures 14 and 15).
Discussion Cartilage grafts in augmentation rhinoplasty are useful for mild deformities, but autogenous bone is used if a greater augmentation is required.5 Cartilage grafts are supposed to improve contour and function and correct deformities, but they may also lead to postoperative defects. The most frequent defects are graft displacement and asymmetry,
tendency to curl (especially rib cartilage), a visible step, and under- or overcorrection.10 Advantages of cartilage are that there is no need for contact between the graft and the nasal bone for graft survival. Alloplastic implants are another alternative for nasal augmentation. Their advantages are ready availability in shapes and sizes and no donor site morbidity. These materials have a high rate of complications like extrusion, malposition, or unnatural appearance.5,11,12 Bone grafts are the best option for reconstruction of wide defects of the nose with autogenous tissue, maintaining the tip projection with minimal airway problems. Bone graft
752
E. Garcı´a-Dı´ez et al.
Figure 13
Preoperative views (above) and postoperative views (below).
provides a durable and safe reconstruction. Tissue for augmentation rhinoplasty has been obtained from cranial bone, ribs, iliac bone and olecranon. Cranial bone is probably the most used bone graft for nasal augmentation. It has numerous advantages as a donor site: it resorbs less, is an easy to hide donor site, and does not bend.4 The complication rate reported is low; however, serious complications (intracerebral haematoma, superior sagittal sinus laceration) have been reported.13,14 The use of tibial bone graft was not usually described in the literature. Tessier et al.15 published an excellent review of the use of tibial bone in the literature since 1911.
The tibial bone has been used for dorsolumber spine, pseudoarthroses of the limbs, cranial defects, mandibular reconstruction and cleft lip-cleft palate repair. Tessier described a technique with a long vertical scar at the donor site and a combined corticocancellous graft harvesting. We describe a technique of cortical graft harvesting with a donor site short transverse scar (1.5 cm). The advantages of the augmentation rhinoplasty with cortical tibial bone graft harvested with short scar are: No tendency to bend. No resorption.
Cortical tibial bone graft for nasal augmentation
Figure 14
Figure 15
753
Radiographic control of the tibial donor site on the first postoperative day.
Radiographic control of the tibial donor site 1 month postoperatively.
It is very stable over time. Minimal donor site morbidity. Inconspicuous donor site scar (1.5 cm incision). Easy and quick harvest technique. The donor and the recipient sites are in different operating fields. Short hospitalization time (no more than 2 days). Good cosmetic results. The long and flat shape of these grafts, as opposed to the calvarial or costal grafts, is excellent for creating the shape of the nasal dorsum. We do not use columellar struts like other authors5 because we think that it is not necessary to maintain tip projection when fixation screws are placed. We do not recommend a rhinoplasty open approach to avoid the problem of closing the columellar skin incision once the graft is placed. We do not remodel the tip and we do not make lateral osteotomies, to prevent the graft bone resorption,
graft extrusion and to provide more stability. If another correction is needed, it is performed in a second operation. As with all bony nasal reconstructions, the disadvantage of this technique is that the patient must accept a certain degree of rigidity and immobility in the nose. Our early experience with this short series of cases seems to show that the cortical tibial bone graft is an excellent option for augmentation rhinoplasty.
References 1. Saray A. Porcine dermal collagen (Permacol) for facial contour augmentation: preliminary report. Aesthetic Plast Surg 2003; 27:368. 2. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: dorsal onlay grafting using shaped autogenous septal cartilage. Plast Reconst Surg 1990;86:39. 3. Jackson IT, Smith J, Mixter RC. Nasal bone grafting using split skull grafts. Ann Plast Surg 1983;11:533.
754 4. Jackson IT, Choi HY, Clay R, et al. Long-term follow-up of cranial bone graft in dorsal nasal augmentation. Plast Reconstr Surg 1998;102:1869. 5. Karacaoglan N, Ata Uysal O. Use of iliac bone graft for saddle nose deformity. Auris Nasus Larynx 1998;25:49. 6. Sarukawa S, Sugawara Y, Harii K. Cephalometric long-term follow-up of nasal augmentation using iliac bone graft. J Cranio Maxill Surg 2004;32:233. 7. Judith MG, Thomas P, Chad AP, et al. Long-term outcome of autogenous rib graft nasal reconstruction. Plast Reconstr Surg 2001;108:1895. 8. Hodgkinson DJ. The olecranon bone graft for nasal augmentation. Aesthetic Plast Surg 1992;16:129. 9. Bernd R, Neu MD. Segmental bone and cartilage reconstruction of major nasal dorsal defects. Plast Reconstr Surg 2000;106:160. 10. Aiach G. Atlas of Rhinoplasty. Open and Endonasal Approaches. St Louis, Missouri: Quality Medical Publishing, Inc.; 2003. 11. Antia N, Daver B, Keswani M. Prefabricated silicone nasal implants. Plast Reconstr Surg 1973;52:264.
E. Garcı´a-Dı´ez et al. 12. C ¸ elik M, Haliloglu T, Baycin N. Bone chips and diced cartilage: an anatomically adopted graft for the nasal dorsum. Aesthetic Plast Surg 2004;28:8. 13. Cannella DM, Hopkins LN. Superior sagittal sinus laceration complicating an autogenous calvarial bone graft harvest, case report. J Oral Maxillofac Surg 1990;48:741. 14. Young VL, Schuster RH, Harris LW. Intracerebral hematoma complicating split calvarial bone graft harvesting. Plast Reconstr Surg 1990;86:763. 15. Tessier P, Kawamoto H, Matthews D, et al. Taking tibial grafts in the diaphysis and upper epiphysis e Tools and techniques: a 650-case experience in maxillofacial and craniofacial surgery. Plast Reconstr Surg 2005;116:47S. 16. Fontdevila J, Martı´-Page ´s C, Garcı´a-Dı´ez E, et al. Augmentation rhinoplasty using tibial bone graft. In: Proceedings of the Aesthetic facial reconstruction in adults and children Symposium; 2006 February 23e25. Tucson, AZ. Arlington Heights, IL: American Society of Plastic Surgeons/Plastic Surgery Educational Foundation; 2006.