- Email: [email protected]
Irradiated costal cartilage in augmentation rhinoplasty
Operative Techniques in Otolaryngology (2007) 18, 274-283
Irradiated costal cartilage in augmentation rhinoplasty Stephen M. Weber, MD, PhD, Ted A. Cook, MD, Tom D. Wang, MD, FACS From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology and Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon. KEYWORDS Augmentation; Rhinoplasty; Nasal reconstruction; Saddle nose; Irradiated cartilage; Costal; Rib
Numerous materials are available for use in augmentation rhinoplasty. For the moderate-to-severe saddle nose deformity, we prefer use of irradiated homologous costal cartilage. This method has been effective in augmentation of the nasal dorsum as well as nasal tip modification, when septal or auricular cartilage is lacking. During the past 25 years, we have used irradiated costal cartilage at our institution via the external rhinoplasty approach for robust and versatile reconstruction of the nasal framework and esthetic nasal tip modification. This article contains a detailed discussion of the technique as well as selected illustrative cases. © 2007 Elsevier Inc. All rights reserved.
The moderate-to-severe saddle nose deformity represents a broad spectrum of disease ranging from loss of bony and cartilaginous nasal dorsum with or without loss of tip support and, in extreme cases, contraction or loss of the soft tissue envelope. These defects result from myriad etiologies, including trauma, previous surgery, autoimmune, vasculitic and infectious diseases, oncologic resection as well as congenital malformations. The unifying deformity among these diverse etiologies is the loss of dorsal and, occasionally, tip support resulting in both compromised nasal esthetics and function. Because reconstruction of the nasal soft-tissue envelope is beyond the scope of this article, the discussion will be limited to repair of the bony and cartilaginous dorsum and nasal tip modification in cases of moderate to severe saddle nose deformity. Numerous types of implants have been used to reconstitute the bony and cartilaginous nasal dorsum and to modify nasal tip esthetics. We have experienced, for more than 2 decades, success with irradiated homologous costal cartilage.1-4 Alloplastic materials, including silastic and GoreTex, have likewise been used to increase dorsal projection and width. However, alloplastic materials represent a foreign body and, as such, have greater rates of graft infection and extrusion.2,5 For this reason, their use has been largely abandoned in the United States and Europe but continues in Address reprint requests and correspondence: Tom D. Wang, MD, FACS, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology and Head and Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2007.09.008
several Asian countries. Autografts, such as autologous septal, conchal or rib cartilage, are also advocated given their biocompatibility and ready availability. Alternatively, split calvarial bone can be used for reconstruction of total nasal defects but results in a characteristically rigid nasal structure. Given these options, we prefer autologous tissue, when available and structurally adequate. However, during reconstruction of the saddle nose deformity, septal cartilage is often insufficient and conchal cartilage does not provide adequate structural support. Autologous rib cartilage is effective for the same reasons as irradiated homologous rib but adds donor site morbidity, a separate distant operative site, increased operative time, and the risk of intrathoracic complications. Irradiated costal cartilage avoids the need for a distant operative site and provides generous quantities of cartilage for rebuilding the nasal dorsum. We prefer autologous septal or conchal cartilage for tip modification but when absent, irradiated rib cartilage can be used in a similar fashion1,4 Concerns regarding use of irradiated rib cartilage have included the propensity for warping,2,6,7 resorption,2,6,7 and theoretical risk of infectious disease transmission. We have found that, with proper carving and attention to detail, warping has been rarely encountered.1-3 Resorption has not been clinically significant, although small amounts of cartilage are possibly resorbed and replaced with scar tissue. However, this has not been clinically evident or resulted in esthetic or functional compromise. Finally, there have not been any published cases of infectious disease transmission after use of irradiated costal cartilage that the authors are aware of.
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
275
Figure 1 Overoperated nose with loss of dorsal and tip support, tip ptosis, and contraction of the soft tissue envelope. (A) Preoperative and (B) 6-month postoperative frontal view. (Color version of figure is available online.)
Figure 2 Overoperated nose with loss of dorsal and tip support, tip ptosis, and contraction of the soft tissue envelope. (A) Preoperative and (B) 6-month postoperative oblique view. (Color version of figure is available online.)
276
Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 3 Overoperated nose with loss of dorsal and tip support, tip ptosis, and contraction of the soft tissue envelope. (A) Preoperative and (B) 6-month postoperative lateral view. (Color version of figure is available online.)
Technique
Figure 4 Overoperated nose with loss of dorsal and tip support, tip ptosis, and contraction of the soft tissue envelope. (A) Preoperative and (B) 6-month postoperative base view. (Color version of figure is available online.)
Given the ability to assess the distorted anatomy of the saddle nose deformity in 3 dimensions, to determine the extent of residual nasal structural support, and the ability to precisely place and suture graft material, we prefer the external rhinoplasty approach. In cases of saddle nose deformity with concurrent lack of tip definition, we advocate use of septal or conchal cartilage for creation of tip grafts and columella strut. Unfortunately, this tissue is unavailable in most cases. Although autologous costal cartilage can be obtained from the synchondrosis of the sixth, seventh, and eighth ribs as described by Tardy and coworkers,8 use of irradiated homologous costal cartilage avoids the morbidity, need for a distant surgical site and risk of autologous rib cartilage harvest. Recent studies have demonstrated no significant difference in the rate of warping between fresh costal cartilage and irradiated rib.6 In that article, Adams and coworkers described a phenomenon that has been observed clinically after fresh and irradiated rib rhinoplasty—warping is a dynamic phenomenon that continues long after reconstruction. Thus, every precaution must be taken to minimize the risk of warping during preparation of the rib graft material. Whether fresh autologous rib or irradiated homologous rib is used, perichondrium is removed from the rib cartilage to minimize the risk of warping. Likewise, the principle of balanced cross-sections is respected while carving costal cartilage to minimize the risk of graft warping.9 Further, close observation, sequential carving and subtle modification of the rib cartilage during the operative procedure can reveal the tendency for the cartilage to warp in a given
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
Figure 5 Intraoperative images of patient shown in Figures 1-5 demonstrating complete loss of dorsal and tip support after the removal of globule of unknown injectable material over nasal dorsum and tip (A). Intraoperative view after the reconstruction with articulated irradiated rib graft and tip graft demonstrating improved dorsal and tip support, tip projection and tip esthetics (B). (Color version of figure is available online.)
direction and allow compensation for this predilection. When alternative sources of autologous cartilage are unavailable, costal cartilage is carved and shaped to create tip grafts. However, when using costal cartilage, care and attention must be directed to creating smooth edges that will result in an esthetically pleasing tip. In the case of isolated saddle deformities, the dorsal onlay graft is shaped to recapitulate missing dorsal structural support. This tends to require an elliptical shape, narrowed at both the cephalic and caudal extent. Similarly, the dorsal deficiency requires a graft with an elliptical surface articulating with the residual nasal dorsum to fill the defect with a flat dorsal surface to maintain the appearance of a straight, flat dorsum. The deep aspect of this graft is also typically fashioned with a hollowed groove that articulates with the residual dorsum and helps secure the graft in place, preventing graft migration and mobility.3 Finally, this graft is ideally placed within a subperiosteal pocket over the bony dorsum to provide an additional point of fixation. Residual lower lateral cartilage, when present, should be positioned and imbricated caudal to the dorsal graft to optimize nasal tip esthetics. Patients with existing lower lateral and caudal septal cartilage, the nasal tip can be addressed by traditional meth-
277
Figure 6 Intraoperative base view of patient shown in Figures 1-4 demonstrating irradiated rib cartilage graft consisting of dorsal graft and articulated columella strut (A). Rib cartilage also was used to create a tip graft to further improve tip esthetics (B). (Color version of figure is available online.)
ods including dome modification, interdomal suturing, columella strut, “tongue-in-groove” technique and tip grafting methods as noted above. In the unfortunate patient requiring tip modification with insufficient septal or conchal cartilage, the rib cartilage can be fashioned to address deformities of both the dorsum and nasal tip. In this case, a longer dorsal graft is fashioned that extends to the inferior tip lobule. The
Figure 7 Base view demonstrating radix mass 20-years after primary rhinoplasty. (Color version of figure is available online.)
278
Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 8 Frontal projection demonstrating radix mass 20-years after primary rhinoplasty (A) and 1.5-year postoperative view (B) after reconstruction with irradiated rib dorsal graft. (Color version of figure is available online.)
Figure 9 Right lateral view demonstrating radix mass 20-years after primary rhinoplasty (A) and 1.5-year postoperative view (B) after reconstruction with irradiated rib dorsal graft. (Color version of figure is available online.)
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
279
Figure 10 Base view demonstrating radix mass 20 years after primary rhinoplasty (A) and 1.5-year postoperative view (B) after reconstruction with irradiated rib dorsal graft. (Color version of figure is available online.)
caudal aspect of this graft is shaped to resemble a tip graft. To add further refinement, individual tip defining points can be carved from costal cartilage and suture-secured to the caudal aspect of this graft under direct vision.4 In our experience these tip defining point grafts are typically positioned 2-4 mm from the caudal-most aspect of the dorsal graft but individual modification is essential for optimal outcomes. These cases also require shaping the dorsal graft to properly articulate with native lower lateral cartilage when
present. This requires graft narrowing caudally or the incorporation of a convexity on the surface of the graft to allow close approximation without deformation of residual lower lateral cartilage. A columella strut is placed in a “snug” pocket overlying the nasal spine. An additional element of fixation can be achieved with precise suturing to secure the columella strut to the spine. This not only serves to create tip support but allows an additional point of fixation for the dorsal graft. The dorsal graft itself is fashioned with a small recessed hole that allows articulation with
Figure 11 Intraoperative photo demonstrating mersilene mesh encased within abscess capsule that corresponded with radix mass (A). Intraoperative left lateral view demonstrating significant radix depression after removal of infected implant (B). (Color version of figure is available online.)
280
Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 12 Frontal projection of 50-year-old male with posttraumatic nasal deformity preop (A) and 18 years status-post (B) external augmentation rhinoplasty with irradiated costal cartilage. (Color version of figure is available online.)
Figure 13 Lateral view of a 50-year-old man with posttraumatic nasal deformity preop (A) and 18 years status-post (B) external augmentation rhinoplasty with irradiated costal cartilage. (Color version of figure is available online.)
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
281
Figure 14 Oblique view of a 50-year-old man with posttraumatic nasal deformity preop (A) and 18 years status-post (B) external augmentation rhinoplasty with irradiated costal cartilage. (Color version of figure is available online.)
the columella strut. In these cases, the strut is fashioned slightly longer to allow direct articulation with the dorsal graft. Further, suturing of the lower lateral cartilages to the strut in a tongue-in-groove fashion supports the tip and prevents prolapse of the medial crura into the nasal airway. After achievement of satisfactory contour and stabilization of the articulating dorsal graft/columella strut complex, all external rhinoplasty incisions are closed and a dorsal nasal splint applied to minimize edema and further stabilize the articulated rib cartilage graft during initial healing.
revealed a total lack of tip and dorsal support with complete collapse of the nasal tip (Figure 5A). Irradiated rib cartilage was used to reconstruct both the nasal dorsum and tip using a dorsal graft suture-secured to a columella strut (Figures 5B and 6). The columella strut articulated with a depression fashioned into the dorsal graft and was further reinforced with suture. Given the lack of septal cartilage, irradiated rib was also used to fashion a tip graft (Figure 6B) to further enhance tip esthetics. This approach resulted in improved dorsal width and contour, tip projection and tip esthetics (Figures 1B-4B and 5B).
Case 2
Case presentations Case 1 A 55-year-old woman presented after multiple previous rhinoplasties, including injection of an unknown material over the nasal dorsum. She had evidence of poor tip support, tip ptosis, and leftward deflection as well as contraction of the soft-tissue envelope (Figures 1A, 2, 3 and 4A). The presumed site of injected material was palpable over the dorsum as an amorphous, globular mass. An external rhinoplasty approach was undertaken given the patient’s multiply-operated history and the unknown nature and amount of injectable material over the nasal dorsum. Exposure and removal of this material
A 38-year-old black woman presented 20 years after primary rhinoplasty at another institution. During the year before presentation, she had noted a slowly enlarging mass over the right nasion (Figures 7, 8A, 9, and 10A). This region was firm, nontender and without discharge, but the patient found it to be cosmetically unacceptable. Exposure via the external rhinoplasty approach revealed a mature inflammatory rind surrounding an abscess cavity containing mersilene mesh situated over the nasion (Figure 11A). Both the mesh and abscess capsule were removed completely, resulting in significant radix depression (Figure 11B). Irradiated rib cartilage was used to fashion a dorsal cartilage graft, which resulted in reconstitution of dorsal/radix height and repair of the radix deformity (Figures 8B, 9 and 10B).
282
Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 15 Base view of a 50-year-old man with posttraumatic nasal deformity preoperatively (A) and 18 years status-post (B) external augmentation rhinoplasty with irradiated costal cartilage. (Color version of figure is available online.)
Case 3 A 50-year-old white male presented for functional rhinoplasty many years after developing a posttraumatic nasal deformity and airway obstruction. Preoperative evaluation revealed significant loss of dorsal and tip support (Figures 12A, 13 , 14, and 15A). During 18 years of follow-up, this patient exhibited robust nasal reconstruction and no evidence of resorption or warping (Figures 12B-15B) of the irradiated costal cartilage graft material with good nasal airway function.
Discussion Herein, we discuss our preferred technique of augmentation rhinoplasty to address moderate-to-severe saddle nose deformity. We have found the use of irradiated costal cartilage to be quite versatile and robust with respect to reconstruction of these defects. In cases in which autologous septal or conchal cartilage are missing or inadequate, this material can also be used for tip modification. We have found that this method provides reconstitution of the nasal cartilaginous and bony scaffold but also allows precise esthetic refinement of both the dorsum and nasal tip. In our experience, this approach can be performed effectively in concert with traditional tip modification maneuvers. The result is a versatile technique that allows recreation of dorsal height, contour and esthetic tip modification. Alternative grafting materials are available but often represent suboptimal reconstructive materials relative to costal cartilage. Alloplastic materials carry a high risk of infection and eventual extrusion.5 Although their use has been largely abandoned in the United States and Europe, we frequently see patients with extruding silastic implants that have immigrated to the United States. We have had much success in primary reconstruction of these infected alloplastic implants with irradiated rib grafts.2 In these cases, patients are pretreated with 2 weeks of antibiotics and then undergo removal of the infected graft material and concurrent reconstruction with articulated rib grafts. In addition to precluding a second surgery, this approach avoids the in-
terval unreconstructed cosmetic deformity between infected graft removal and definitive reconstruction which typically ranges between 3 and 6 months. In our experience, none of the rib grafts became infected.2 However, other authors have published their experience with infected rib grafts and have noted salvage of these grafts with antibiotic therapy and/ or incision and drainage.10 In our experience, warping of the irradiated rib graft has been rare (⬍2%).1-3 Further, in all cases of graft warping1-3 or fracture,3 the graft was replaced with another irradiated rib graft of similar proportions without recurrent warping. In the 2 most thoroughly evaluated cases,1 both warped rib grafts had evidence of residual rib cortex on a single side of the graft likely predisposing these grafts to long-term failure. Replacement with properly carved irradiated rib cartilage grafts was successful in both cases. In these cases requiring graft replacement, there was minimal evidence of resorption with persistence of carving marks at up to 2 years after rhinoplasty, suggesting minimal, if any, resorption. Concerns regarding rib cartilage graft resorption have been widely discussed. Welling and coworkers7 described very high rates of rib cartilage graft resorption. However, this study included rib cartilage grafts used in a variety of locations in the head and neck. We have found that placement of rib grafts for nasal reconstruction has resulted in much lower rates of resorption. This is likely due to the fact that this location avoids repetitive contraction of the facial mimetic musculature and is much less frequently traumatized than subsites such as the auricle. The patient depicted in Figures 12-15 has no clinical evidence of cartilage resorption or warping 18 years after augmentation rhinoplasty with irradiated costal cartilage to reconstruct a posttraumatic nasal deformity. Throughout our experience with irradiated rib cartilage for reconstruction of the saddle nose deformity, we have adhered to several guiding principles. All perichondrium must be removed from the rib graft. The straightest portion of the donor rib is used for fashioning the dorsal graft and columella strut. The rib cortex is removed, and all attempts are made to use the most central portion of the rib donor tissue. Balanced carving of the rib cartilage is used to reduce the risk of warping. Finally, given the evidence that the
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
majority of warping occurs within the first hour of carving,6 rib grafts are carved and soaked in saline to allow maneuvers to counteract the tendency of the graft to warp before implantation. Further, elucidation of the intrinsic warping tendency allows preferential placement of the cartilage to minimize the potential cosmetic and functional impact of postoperative alteration in graft shape. After creation of the dorsal graft and columella strut with the aforementioned principles in mind, the dorsal graft must be securely positioned. This involves placement in a subperiosteal pocket over the nasal bony dorsum. Further, firm articulation with the columella strut is required. Occasionally, this necessitates fashioning of a columella strut of greater length than typically needed. This can also be suture secured with Prolene or other permanent monofilament suture. Further, a snug tunnel must be created to retain the columella strut to avoid mobility of the graft and potential for cartilage resorption. Early in our experience occasional graft displacement occurred that required revision under local anesthesia.3 Finally, when residual lower lateral cartilage is available, the dorsal graft is fashioned to allow imbrication of the residual lower lateral cartilage caudal to the graft to maintain optimal tip esthetics. In conclusion, we feel that this technique of saddle nose repair provides not only effective re-establishment of the nasal dorsal support but facilitates esthetic modification of the nasal tip as well.
283
References 1. Burke AJ, Wang TD, Cook TA: Irradiated homograft rib cartilage in facial reconstruction. Arch Facial Plast Surg 6:334-341, 2004 2. Clark JM, Cook TA: Immediate reconstruction of extruded alloplastic nasal implants with irradiated homograft costal cartilage. Laryngoscope 112:968-974, 2002 3. Murakami CS, Cook TA, Guida RA: Nasal reconstruction with articulated irradiated rib cartilage. Arch Otolaryngol Head Neck Surg 117:327-330, 1991; discussion 31 4. Wang TD: Aesthetic structural nasal augmentation. Op Tech Otolaryngol 1:234-238, 1990 5. Lovice DB, Mingrone MD, Toriumi DM: Grafts amd implants in rhinoplasty and nasal reconstruction. Otolaryngol Clin North Am 32: 113-141, 1999 6. Adams WP Jr, Rohrich RJ, Gunter JP, et al: The rate of warping in irradiated and nonirradiated homograft rib cartilage: A controlled comparison and clinical implications. Plast Reconstr Surg 103:265-270, 1999 7. Welling DB, Maves MD, Schuller DE, et al: Irradiated homologous cartilage grafts. Long-term results. Arch Otolaryngol Head Neck Surg 114:291-295, 1988 8. Tardy ME Jr, Denneny J 3rd, Fritsch MH: The versatile cartilage autograft in reconstruction of the nose and face. Laryngoscope 95:523533, 1985 9. Gibson T, Davis WB: The distortion of autogenous cartilage grafts: Its cause and prevention. Br J Plast Surg 10:257-274, 1957 10. Kridel RW, Konior RJ: Irradiated cartilage grafts in the nose. A preliminary report. Arch Otolaryngol Head Neck Surg 119:24-30, 1993; discussion 30-31
Irradiated costal cartilage in augmentation rhinoplasty Stephen M. Weber, MD, PhD, Ted A. Cook, MD, Tom D. Wang, MD, FACS From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology and Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon. KEYWORDS Augmentation; Rhinoplasty; Nasal reconstruction; Saddle nose; Irradiated cartilage; Costal; Rib
Numerous materials are available for use in augmentation rhinoplasty. For the moderate-to-severe saddle nose deformity, we prefer use of irradiated homologous costal cartilage. This method has been effective in augmentation of the nasal dorsum as well as nasal tip modification, when septal or auricular cartilage is lacking. During the past 25 years, we have used irradiated costal cartilage at our institution via the external rhinoplasty approach for robust and versatile reconstruction of the nasal framework and esthetic nasal tip modification. This article contains a detailed discussion of the technique as well as selected illustrative cases. © 2007 Elsevier Inc. All rights reserved.
The moderate-to-severe saddle nose deformity represents a broad spectrum of disease ranging from loss of bony and cartilaginous nasal dorsum with or without loss of tip support and, in extreme cases, contraction or loss of the soft tissue envelope. These defects result from myriad etiologies, including trauma, previous surgery, autoimmune, vasculitic and infectious diseases, oncologic resection as well as congenital malformations. The unifying deformity among these diverse etiologies is the loss of dorsal and, occasionally, tip support resulting in both compromised nasal esthetics and function. Because reconstruction of the nasal soft-tissue envelope is beyond the scope of this article, the discussion will be limited to repair of the bony and cartilaginous dorsum and nasal tip modification in cases of moderate to severe saddle nose deformity. Numerous types of implants have been used to reconstitute the bony and cartilaginous nasal dorsum and to modify nasal tip esthetics. We have experienced, for more than 2 decades, success with irradiated homologous costal cartilage.1-4 Alloplastic materials, including silastic and GoreTex, have likewise been used to increase dorsal projection and width. However, alloplastic materials represent a foreign body and, as such, have greater rates of graft infection and extrusion.2,5 For this reason, their use has been largely abandoned in the United States and Europe but continues in Address reprint requests and correspondence: Tom D. Wang, MD, FACS, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology and Head and Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2007.09.008
several Asian countries. Autografts, such as autologous septal, conchal or rib cartilage, are also advocated given their biocompatibility and ready availability. Alternatively, split calvarial bone can be used for reconstruction of total nasal defects but results in a characteristically rigid nasal structure. Given these options, we prefer autologous tissue, when available and structurally adequate. However, during reconstruction of the saddle nose deformity, septal cartilage is often insufficient and conchal cartilage does not provide adequate structural support. Autologous rib cartilage is effective for the same reasons as irradiated homologous rib but adds donor site morbidity, a separate distant operative site, increased operative time, and the risk of intrathoracic complications. Irradiated costal cartilage avoids the need for a distant operative site and provides generous quantities of cartilage for rebuilding the nasal dorsum. We prefer autologous septal or conchal cartilage for tip modification but when absent, irradiated rib cartilage can be used in a similar fashion1,4 Concerns regarding use of irradiated rib cartilage have included the propensity for warping,2,6,7 resorption,2,6,7 and theoretical risk of infectious disease transmission. We have found that, with proper carving and attention to detail, warping has been rarely encountered.1-3 Resorption has not been clinically significant, although small amounts of cartilage are possibly resorbed and replaced with scar tissue. However, this has not been clinically evident or resulted in esthetic or functional compromise. Finally, there have not been any published cases of infectious disease transmission after use of irradiated costal cartilage that the authors are aware of.
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
275
Figure 1 Overoperated nose with loss of dorsal and tip support, tip ptosis, and contraction of the soft tissue envelope. (A) Preoperative and (B) 6-month postoperative frontal view. (Color version of figure is available online.)
Figure 2 Overoperated nose with loss of dorsal and tip support, tip ptosis, and contraction of the soft tissue envelope. (A) Preoperative and (B) 6-month postoperative oblique view. (Color version of figure is available online.)
276
Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 3 Overoperated nose with loss of dorsal and tip support, tip ptosis, and contraction of the soft tissue envelope. (A) Preoperative and (B) 6-month postoperative lateral view. (Color version of figure is available online.)
Technique
Figure 4 Overoperated nose with loss of dorsal and tip support, tip ptosis, and contraction of the soft tissue envelope. (A) Preoperative and (B) 6-month postoperative base view. (Color version of figure is available online.)
Given the ability to assess the distorted anatomy of the saddle nose deformity in 3 dimensions, to determine the extent of residual nasal structural support, and the ability to precisely place and suture graft material, we prefer the external rhinoplasty approach. In cases of saddle nose deformity with concurrent lack of tip definition, we advocate use of septal or conchal cartilage for creation of tip grafts and columella strut. Unfortunately, this tissue is unavailable in most cases. Although autologous costal cartilage can be obtained from the synchondrosis of the sixth, seventh, and eighth ribs as described by Tardy and coworkers,8 use of irradiated homologous costal cartilage avoids the morbidity, need for a distant surgical site and risk of autologous rib cartilage harvest. Recent studies have demonstrated no significant difference in the rate of warping between fresh costal cartilage and irradiated rib.6 In that article, Adams and coworkers described a phenomenon that has been observed clinically after fresh and irradiated rib rhinoplasty—warping is a dynamic phenomenon that continues long after reconstruction. Thus, every precaution must be taken to minimize the risk of warping during preparation of the rib graft material. Whether fresh autologous rib or irradiated homologous rib is used, perichondrium is removed from the rib cartilage to minimize the risk of warping. Likewise, the principle of balanced cross-sections is respected while carving costal cartilage to minimize the risk of graft warping.9 Further, close observation, sequential carving and subtle modification of the rib cartilage during the operative procedure can reveal the tendency for the cartilage to warp in a given
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
Figure 5 Intraoperative images of patient shown in Figures 1-5 demonstrating complete loss of dorsal and tip support after the removal of globule of unknown injectable material over nasal dorsum and tip (A). Intraoperative view after the reconstruction with articulated irradiated rib graft and tip graft demonstrating improved dorsal and tip support, tip projection and tip esthetics (B). (Color version of figure is available online.)
direction and allow compensation for this predilection. When alternative sources of autologous cartilage are unavailable, costal cartilage is carved and shaped to create tip grafts. However, when using costal cartilage, care and attention must be directed to creating smooth edges that will result in an esthetically pleasing tip. In the case of isolated saddle deformities, the dorsal onlay graft is shaped to recapitulate missing dorsal structural support. This tends to require an elliptical shape, narrowed at both the cephalic and caudal extent. Similarly, the dorsal deficiency requires a graft with an elliptical surface articulating with the residual nasal dorsum to fill the defect with a flat dorsal surface to maintain the appearance of a straight, flat dorsum. The deep aspect of this graft is also typically fashioned with a hollowed groove that articulates with the residual dorsum and helps secure the graft in place, preventing graft migration and mobility.3 Finally, this graft is ideally placed within a subperiosteal pocket over the bony dorsum to provide an additional point of fixation. Residual lower lateral cartilage, when present, should be positioned and imbricated caudal to the dorsal graft to optimize nasal tip esthetics. Patients with existing lower lateral and caudal septal cartilage, the nasal tip can be addressed by traditional meth-
277
Figure 6 Intraoperative base view of patient shown in Figures 1-4 demonstrating irradiated rib cartilage graft consisting of dorsal graft and articulated columella strut (A). Rib cartilage also was used to create a tip graft to further improve tip esthetics (B). (Color version of figure is available online.)
ods including dome modification, interdomal suturing, columella strut, “tongue-in-groove” technique and tip grafting methods as noted above. In the unfortunate patient requiring tip modification with insufficient septal or conchal cartilage, the rib cartilage can be fashioned to address deformities of both the dorsum and nasal tip. In this case, a longer dorsal graft is fashioned that extends to the inferior tip lobule. The
Figure 7 Base view demonstrating radix mass 20-years after primary rhinoplasty. (Color version of figure is available online.)
278
Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 8 Frontal projection demonstrating radix mass 20-years after primary rhinoplasty (A) and 1.5-year postoperative view (B) after reconstruction with irradiated rib dorsal graft. (Color version of figure is available online.)
Figure 9 Right lateral view demonstrating radix mass 20-years after primary rhinoplasty (A) and 1.5-year postoperative view (B) after reconstruction with irradiated rib dorsal graft. (Color version of figure is available online.)
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
279
Figure 10 Base view demonstrating radix mass 20 years after primary rhinoplasty (A) and 1.5-year postoperative view (B) after reconstruction with irradiated rib dorsal graft. (Color version of figure is available online.)
caudal aspect of this graft is shaped to resemble a tip graft. To add further refinement, individual tip defining points can be carved from costal cartilage and suture-secured to the caudal aspect of this graft under direct vision.4 In our experience these tip defining point grafts are typically positioned 2-4 mm from the caudal-most aspect of the dorsal graft but individual modification is essential for optimal outcomes. These cases also require shaping the dorsal graft to properly articulate with native lower lateral cartilage when
present. This requires graft narrowing caudally or the incorporation of a convexity on the surface of the graft to allow close approximation without deformation of residual lower lateral cartilage. A columella strut is placed in a “snug” pocket overlying the nasal spine. An additional element of fixation can be achieved with precise suturing to secure the columella strut to the spine. This not only serves to create tip support but allows an additional point of fixation for the dorsal graft. The dorsal graft itself is fashioned with a small recessed hole that allows articulation with
Figure 11 Intraoperative photo demonstrating mersilene mesh encased within abscess capsule that corresponded with radix mass (A). Intraoperative left lateral view demonstrating significant radix depression after removal of infected implant (B). (Color version of figure is available online.)
280
Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 12 Frontal projection of 50-year-old male with posttraumatic nasal deformity preop (A) and 18 years status-post (B) external augmentation rhinoplasty with irradiated costal cartilage. (Color version of figure is available online.)
Figure 13 Lateral view of a 50-year-old man with posttraumatic nasal deformity preop (A) and 18 years status-post (B) external augmentation rhinoplasty with irradiated costal cartilage. (Color version of figure is available online.)
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
281
Figure 14 Oblique view of a 50-year-old man with posttraumatic nasal deformity preop (A) and 18 years status-post (B) external augmentation rhinoplasty with irradiated costal cartilage. (Color version of figure is available online.)
the columella strut. In these cases, the strut is fashioned slightly longer to allow direct articulation with the dorsal graft. Further, suturing of the lower lateral cartilages to the strut in a tongue-in-groove fashion supports the tip and prevents prolapse of the medial crura into the nasal airway. After achievement of satisfactory contour and stabilization of the articulating dorsal graft/columella strut complex, all external rhinoplasty incisions are closed and a dorsal nasal splint applied to minimize edema and further stabilize the articulated rib cartilage graft during initial healing.
revealed a total lack of tip and dorsal support with complete collapse of the nasal tip (Figure 5A). Irradiated rib cartilage was used to reconstruct both the nasal dorsum and tip using a dorsal graft suture-secured to a columella strut (Figures 5B and 6). The columella strut articulated with a depression fashioned into the dorsal graft and was further reinforced with suture. Given the lack of septal cartilage, irradiated rib was also used to fashion a tip graft (Figure 6B) to further enhance tip esthetics. This approach resulted in improved dorsal width and contour, tip projection and tip esthetics (Figures 1B-4B and 5B).
Case 2
Case presentations Case 1 A 55-year-old woman presented after multiple previous rhinoplasties, including injection of an unknown material over the nasal dorsum. She had evidence of poor tip support, tip ptosis, and leftward deflection as well as contraction of the soft-tissue envelope (Figures 1A, 2, 3 and 4A). The presumed site of injected material was palpable over the dorsum as an amorphous, globular mass. An external rhinoplasty approach was undertaken given the patient’s multiply-operated history and the unknown nature and amount of injectable material over the nasal dorsum. Exposure and removal of this material
A 38-year-old black woman presented 20 years after primary rhinoplasty at another institution. During the year before presentation, she had noted a slowly enlarging mass over the right nasion (Figures 7, 8A, 9, and 10A). This region was firm, nontender and without discharge, but the patient found it to be cosmetically unacceptable. Exposure via the external rhinoplasty approach revealed a mature inflammatory rind surrounding an abscess cavity containing mersilene mesh situated over the nasion (Figure 11A). Both the mesh and abscess capsule were removed completely, resulting in significant radix depression (Figure 11B). Irradiated rib cartilage was used to fashion a dorsal cartilage graft, which resulted in reconstitution of dorsal/radix height and repair of the radix deformity (Figures 8B, 9 and 10B).
282
Operative Techniques in Otolaryngology, Vol 18, No 4, December 2007
Figure 15 Base view of a 50-year-old man with posttraumatic nasal deformity preoperatively (A) and 18 years status-post (B) external augmentation rhinoplasty with irradiated costal cartilage. (Color version of figure is available online.)
Case 3 A 50-year-old white male presented for functional rhinoplasty many years after developing a posttraumatic nasal deformity and airway obstruction. Preoperative evaluation revealed significant loss of dorsal and tip support (Figures 12A, 13 , 14, and 15A). During 18 years of follow-up, this patient exhibited robust nasal reconstruction and no evidence of resorption or warping (Figures 12B-15B) of the irradiated costal cartilage graft material with good nasal airway function.
Discussion Herein, we discuss our preferred technique of augmentation rhinoplasty to address moderate-to-severe saddle nose deformity. We have found the use of irradiated costal cartilage to be quite versatile and robust with respect to reconstruction of these defects. In cases in which autologous septal or conchal cartilage are missing or inadequate, this material can also be used for tip modification. We have found that this method provides reconstitution of the nasal cartilaginous and bony scaffold but also allows precise esthetic refinement of both the dorsum and nasal tip. In our experience, this approach can be performed effectively in concert with traditional tip modification maneuvers. The result is a versatile technique that allows recreation of dorsal height, contour and esthetic tip modification. Alternative grafting materials are available but often represent suboptimal reconstructive materials relative to costal cartilage. Alloplastic materials carry a high risk of infection and eventual extrusion.5 Although their use has been largely abandoned in the United States and Europe, we frequently see patients with extruding silastic implants that have immigrated to the United States. We have had much success in primary reconstruction of these infected alloplastic implants with irradiated rib grafts.2 In these cases, patients are pretreated with 2 weeks of antibiotics and then undergo removal of the infected graft material and concurrent reconstruction with articulated rib grafts. In addition to precluding a second surgery, this approach avoids the in-
terval unreconstructed cosmetic deformity between infected graft removal and definitive reconstruction which typically ranges between 3 and 6 months. In our experience, none of the rib grafts became infected.2 However, other authors have published their experience with infected rib grafts and have noted salvage of these grafts with antibiotic therapy and/ or incision and drainage.10 In our experience, warping of the irradiated rib graft has been rare (⬍2%).1-3 Further, in all cases of graft warping1-3 or fracture,3 the graft was replaced with another irradiated rib graft of similar proportions without recurrent warping. In the 2 most thoroughly evaluated cases,1 both warped rib grafts had evidence of residual rib cortex on a single side of the graft likely predisposing these grafts to long-term failure. Replacement with properly carved irradiated rib cartilage grafts was successful in both cases. In these cases requiring graft replacement, there was minimal evidence of resorption with persistence of carving marks at up to 2 years after rhinoplasty, suggesting minimal, if any, resorption. Concerns regarding rib cartilage graft resorption have been widely discussed. Welling and coworkers7 described very high rates of rib cartilage graft resorption. However, this study included rib cartilage grafts used in a variety of locations in the head and neck. We have found that placement of rib grafts for nasal reconstruction has resulted in much lower rates of resorption. This is likely due to the fact that this location avoids repetitive contraction of the facial mimetic musculature and is much less frequently traumatized than subsites such as the auricle. The patient depicted in Figures 12-15 has no clinical evidence of cartilage resorption or warping 18 years after augmentation rhinoplasty with irradiated costal cartilage to reconstruct a posttraumatic nasal deformity. Throughout our experience with irradiated rib cartilage for reconstruction of the saddle nose deformity, we have adhered to several guiding principles. All perichondrium must be removed from the rib graft. The straightest portion of the donor rib is used for fashioning the dorsal graft and columella strut. The rib cortex is removed, and all attempts are made to use the most central portion of the rib donor tissue. Balanced carving of the rib cartilage is used to reduce the risk of warping. Finally, given the evidence that the
Weber et al
Irradiated Costal Cartilage in Augmentation Rhinoplasty
majority of warping occurs within the first hour of carving,6 rib grafts are carved and soaked in saline to allow maneuvers to counteract the tendency of the graft to warp before implantation. Further, elucidation of the intrinsic warping tendency allows preferential placement of the cartilage to minimize the potential cosmetic and functional impact of postoperative alteration in graft shape. After creation of the dorsal graft and columella strut with the aforementioned principles in mind, the dorsal graft must be securely positioned. This involves placement in a subperiosteal pocket over the nasal bony dorsum. Further, firm articulation with the columella strut is required. Occasionally, this necessitates fashioning of a columella strut of greater length than typically needed. This can also be suture secured with Prolene or other permanent monofilament suture. Further, a snug tunnel must be created to retain the columella strut to avoid mobility of the graft and potential for cartilage resorption. Early in our experience occasional graft displacement occurred that required revision under local anesthesia.3 Finally, when residual lower lateral cartilage is available, the dorsal graft is fashioned to allow imbrication of the residual lower lateral cartilage caudal to the graft to maintain optimal tip esthetics. In conclusion, we feel that this technique of saddle nose repair provides not only effective re-establishment of the nasal dorsal support but facilitates esthetic modification of the nasal tip as well.
283
References 1. Burke AJ, Wang TD, Cook TA: Irradiated homograft rib cartilage in facial reconstruction. Arch Facial Plast Surg 6:334-341, 2004 2. Clark JM, Cook TA: Immediate reconstruction of extruded alloplastic nasal implants with irradiated homograft costal cartilage. Laryngoscope 112:968-974, 2002 3. Murakami CS, Cook TA, Guida RA: Nasal reconstruction with articulated irradiated rib cartilage. Arch Otolaryngol Head Neck Surg 117:327-330, 1991; discussion 31 4. Wang TD: Aesthetic structural nasal augmentation. Op Tech Otolaryngol 1:234-238, 1990 5. Lovice DB, Mingrone MD, Toriumi DM: Grafts amd implants in rhinoplasty and nasal reconstruction. Otolaryngol Clin North Am 32: 113-141, 1999 6. Adams WP Jr, Rohrich RJ, Gunter JP, et al: The rate of warping in irradiated and nonirradiated homograft rib cartilage: A controlled comparison and clinical implications. Plast Reconstr Surg 103:265-270, 1999 7. Welling DB, Maves MD, Schuller DE, et al: Irradiated homologous cartilage grafts. Long-term results. Arch Otolaryngol Head Neck Surg 114:291-295, 1988 8. Tardy ME Jr, Denneny J 3rd, Fritsch MH: The versatile cartilage autograft in reconstruction of the nose and face. Laryngoscope 95:523533, 1985 9. Gibson T, Davis WB: The distortion of autogenous cartilage grafts: Its cause and prevention. Br J Plast Surg 10:257-274, 1957 10. Kridel RW, Konior RJ: Irradiated cartilage grafts in the nose. A preliminary report. Arch Otolaryngol Head Neck Surg 119:24-30, 1993; discussion 30-31