|Decision Tree (algorithm) for revision rhinoplasty |
*** NOTE: DICED RIB CARTILAGE IS NOT MEANT FOR STRUCTURAL SUPPORT. ie. spreader, lateral crura strut or batten graft. FOR THAT YOU NEED SOMETHING STRONGER LIKE SOLID PIECE OF SEPTAL, OR RIB CARTILAGE FOR THOSE NEEDING STRONG SUPPORT. EAR CARTILAGE IS USED MORE IN THE LOWER THIRD OF THE NOSE AND FOR CASES THAT DON'T REQUIRE STRONG SUPPORT. THIS IS VERY SUBJECTIVE AND WHERE SURGEONS HAVE VARYING OPINIONS ABOUT LOCATION OF HARVESTING THE GRAFT.
Some patients online have claimed that when they had costal cartilage in the columellar there smile was negatively affected. That however could be due to improper placement or size of the graft, being too wide or long. If too large of a solid graft is used in tip area, there will be increase risk of extrusion and/or skin necrosis.
Some surgeons also seem more proficient with sutures while others are more adept at grafting. ex.. An alternative for alar batten grafts is the Lateral crus pull-up. It is a suture technique in which the lateral crus is pulled up laterally and upward to the bony pyramid. The effect is twofold widening of the valve area and strengthening of the lateral wall . In some cases instead of using a Lateral crura strut graft, the cephalic lateral crus can be reorientated to give support and correct aesthetic defects. Gruber et al created an “island” of cephalic lateral crus that was slipped under the main body of the lateral crus to stiffen and straighten it. They suggest that the cephalic part of the lateral crus can act as a lateral crural strut to maintain the ala in a more caudal position Tongue in groove is another popular suture technique used to aid in correction of columellar show, a deviated caudal septum, and various tip rotation and projection problems. It is typically used in combination with other septorhinoplasty maneuve. Many surgeons utilize both grafting and complicated suture techniques during surgery for optimal cosmetic and structural results.
It can be very daunting task to figure all this out and getting opinions online like on realself.com which is a great site, demonstrates how widely surgeons opinions and approaches vary, sometimes even contradicting each other. As in the example in dorsal augmentation there are many choices (autografts; bone, solid or diced cartilage, soft tissue, homografts, alloplasts,) available to choose from as I mentioned earlier. Beware though, that in some cases the surgeons are not simply contradicting each other, but suggesting a better alternative to correct specific problem(s) for specific type of individuals. Some surgeons will use whats called superficial muscular aponeurotic system. (SMAS) graft.(more applicable and useful for those with THICK SKIN) which is an autologous soft tissue filler onlay graft, while others may use crushed cartilage for onlay graft. Some nose surgeons recommend Fascia Lata over bone grafts in dorsal augmentation because it's a heavier fascia which is better to conceal the rigidity of a bone graft. Some may suggest Lateral crural strut graft because it corrects few problems at once, like narrowing a bulbous tip, and strengthening a weakened nasal valve. A competent revision nose surgeon will be knowledgeable and able to perform many types of grafts, sutures, flaps, and other septorhinoplasty modifying techniques [I.E. Lateral crural steal (LCS) & Lateral crural overlay (LCO)/Medial crural overlay (MCO)]and know which alternative method to apply according to each individual's specific case. What they discover esp. in revision rhinoplasty during surgery may justifiably cause them to alter or add/subtract to their pre-surgical plans. A good surgeon should be prepared for worse then expected scenarios. ie. during surgery the surgeon discovers that the patient's lower cartilages need to be reshaped, repositioned, or totally replaced with new cartilage.
|This algorithm (above) reflects Dr.W.H..Beeson's preferences|
1. Your own body is best source for grafts (bone,cartilage, soft tissue). Referred to as Autografts also known as Autogeneous, Autologous grafts. Best site within your body for nose grafts, is the septum. If there isn't enough septal cartilage, then other options are; Rib, Ear, or Calvarial as mentioned above.
2. Allografts/Homografts/Homologous-irradiated(cadaver grafts) are another good source for cartilage but work better in the immobile regions of nose.Alloderm (skin cadaver graft) has high absorption rate.
3. Synthetic implants (Alloplasts) Types: Silicone, Meshed, Porous, Porous high density polyethylene (PHDPE;Medpor),Expanded polytetraflouroethylene (e-PTFE ;GoreTex). Which is preferred is debatable amongst surgeons. GoreTex seems to be best of the choices, but some like Medpor. Silicone/Silastic implant which has been used extensively in Asian rhinoplasty is losing favor due to high rates of infections and extrusions. Meshed are also not favored due to infection rates. Medpor can be a problem when needed to be removed due to it's modest porosity. Higher porosity values means it integrates more with surrounding tissue therefore more difficult to remove without causing more damage or removal of surrounding tissue. This is why GoreTex may be preferred since it has a low porosity value. Silicone has no porosity so remains separated and unfixed. It however carry's significant risk of extrusion, higher in columellar area then dorsal area, and is not meant for structural support.
4. Xenografts is from another species mostly from bovine (cattle) or porcine (pigs). Eg. Enduragen is a tough but flexible biomaterial made up of cross-linked porcine dermal collagen and its constituent elastin fibers. Its use is indicated for tissue augmentation of the head and face, and it is commercially available in flat sheets. Permacol is another type made by different manufacturer. There is risk of allergic reaction to such type of material. To my knowledge not commonly used in Nasal revision surgery.
5. Soft tissue filler is normally preferred from own body. ex. fascia grafts
6. Bone graft, like cartilage, can be used for augmentation and as a supportive structural framework for nasal tip and internal nasal valve support. Generally considered a second choice after autogenous cartilage.
Note: In every case the Surgeon has to weight the pros/cons so their may be justifiable exceptions to the above list. Important that the surgeon & patient discuss all the options which relate to the patient's circumstances.
Open Approach to nose surgery has become more popular allowing clear visual inspection, ease of access to existing structures, & allowance for implanting larger sized grafts. This could lead however to more unnecessary over grafting of the nose. Closed Approach advantages are no scarring, less dissection which is important for those who have had prior nose surgery therefore less damage to soft tissue,vascular, & innervation system of the nose, and faster healing period. More conservative methods are being employed today compared to past, where a lot of reductive surgery was performed, without taking into account supporting structure of the nose.Today astute nose surgeons are even placing grafts in some primary surgery's to avoid long term pitfalls.
- Preserved cartilage for future surgery. Primary & Revision patients should request for their surgeons to preserve cartilage that may be removed and not re-used during the surgery.
- Tissue engineering
Interesting site's to look at:
 Menger D.J., Fokkens W.J., Lohuis P.J., Ingels K.J., Nolst Trenité G.J. Reconstructive surgery of the leprosy nose: a new approach. J Plast Reconstr Aesthet Surg. 60(2):152-62, 2007
 Grafts in Nasal Surgery p.77 D.J.Menger
 Chapter 30: Revision Surgery in Otolaryngology by David Edelstein
 Gruber RP, Zhang AY, Mohebali K. Preventing alar retraction by preservation of the lateral crus. Plast Reconstr Surg. 2010;126(2):581-5