You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > RECONSTRUCTIVE SURGERY Rhinoplasty, AugmentationArticle Last Updated: Oct 3, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Patrick Byrne, MD, Assistant Professor, Department of Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Johns Hopkins University Patrick Byrne is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, and American College of Surgeons Coauthor(s): Peter Hilger, MD, Professor, Department of Otolaryngology, University of Minnesota Medical School Editors: Richard V Smith, MD, Director of Clinical Affairs, Associate Professor, Department of Otolaryngology, Division of Head and Neck Surgery, Einstein College of Medicine, Montefiore Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dean Toriumi, MD, Department of Otolaryngology, Associate Professor, University of Illinois Medical Center; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: nose surgery, nose job, plastic surgery of the nose, nasal surgery, nasal reconstruction, nose reconstruction, nose augmentation, nasal augmentation INTRODUCTIONSection 2 of 11
  Rhinoplasty may require the addition of material to augment the nose. Augmentation is necessary for both aesthetic and functional indications. Functional reasons for augmentation include providing structural support for areas deficient of material, such as the upper or lower lateral cartilages. Augmentation may also be required for aesthetic reasons. Typically, augmentation rhinoplasty is performed to increase the projection of the nasal dorsum on the profile view. The nasal tip may also be augmented. In addition, grafts may be placed to camouflage irregularities of the bony dorsum and of the upper or lower lateral cartilages. A number of materials are available to the rhinoplastic surgeon to augment the nose. These include alloplasts (synthetic implants), homologous materials (obtained from cadavers), or autologous implants (harvested from the patient's own tissue). Each has advantages and disadvantages; these are discussed in this article. History of the ProcedureThroughout the 19th century, various alloplastic materials were used for nasal reconstruction, and autologous bone was used most commonly. In 1907, Jacques Joseph described the use of autologous cartilage inserted as a free graft through an endonasal incision. In 1941, Peer described the resistance to resorption of autologous septal and auricular cartilage. Over the ensuing decades, a vast variety of grafts for augmentation of the dorsum and tip have been described. In 1985, Tardy described 2000 cases of augmentation rhinoplasty performed by using cartilage (septum, pinna, and rib), with low resorption and complication rates. In recent decades, a vast array of alloplasts for nasal augmentation has been described. ProblemThe most common deformities requiring augmentation include a lack of projection of the dorsum and/or tip. Augmentation may also be required to fill defects or camouflage irregularities of the nasal sidewalls. Nasal valve collapse is among the more common functional deficits requiring augmentation. This collapse may be treated with a number of cartilage grafts, including alar batten grafts and spreader grafts. The indications for augmentation are multiple and include congenital defects, posttraumatic defects, and postsurgical defects due to excessive reduction rhinoplasty. One of the decisions to be made when one considers augmentation in such situations involves the choice of graft material to augment the nose. The many choices may appear to equal the number of rhinoplasty surgeons. The literature is replete with widely divergent views of the usefulness and reliability of the available graft materials—alloplastic, homologous, or autologous. This article reviews the advantages and disadvantages of the more commonly used graft materials. The characteristics of the ideal graft material for augmentation rhinoplasty include the following:
Many surgeons prefer to use autologous tissue whenever possible, and some evidence suggests a lower incidence of infection when the patient's own tissue is used. Autologous materials have the potential to be incorporated into the host bed tissue, offering stability, as well as resistance to infection and extrusion over time. Autologous materials are also believed to have the unique ability to adapt to the host bed. Thus, a graft consisting of cartilage tends to fix well to cartilage, and bone tends to fix well to bone. Autologous materials used include cartilage and bone; examples include septal, auricular, and rib cartilages and ossified rib, respectively. One of the advantages of septal cartilage is the ease of harvest from the surgical field. The septal cartilage tends to be well suited for augmentation because it retains its shape well with minimal warping. The disadvantage is that enough septal cartilage is not often available for moderate-to-severe augmentation in patients who have undergone previous septorhinoplasty. This lack is due to resection of septal cartilage at the time of previous surgery or the resorption of the cartilage over time as a result of trauma. In some cases, the amount of augmentation material required simply exceeds the available cartilage despite the presence of normal amounts of septum. Auricular cartilage is easily harvested and generally plentiful for mild-to-moderate augmentation. However, auricular cartilage has a greater tendency to warp, as well as to crack, with efforts to soften or crush the edges. This donor cartilage can also be difficult to use in persons who need a straight graft (eg, columellar strut). When inadequate amounts of septal and auricular cartilage are available for the augmentation necessary, a rib graft is an excellent choice. One of the advantages of rib grafts is the plentiful supply. However, rib grafts have a tendency to warp, and, in older patients, the rib may have undergone significant ossification. Symmetric concentric carving of the costal cartilage decreases the incidence of warping. Another way to prevent warping is to insert a Kirschner wire (K-wire) through the graft. Autologous bone may also be used. Bone from the iliac crest, calvaria, rib, tibia, and ulna have been used. The advantages include the abundant bone available and its resistance to warping. Some believe that endochondral bone sources, such as the rib, iliac crest, and tibia, have greater resorption rates than those of membranous bone such as calvaria. In addition, the donor sites typically have some morbidity, and the graft has a greater tendency to feel unnatural, with sharp edges occasionally showing through as the skin retracts over time. Use of bone for augmentation in the lower third of the nose appears particularly unnatural because of its rigidity. Other autologous materials have been used. Use of the temporalis fascia, either alone or wrapped around cartilage to soften the edges, has been advocated. Use of the pericranium for smaller defects has also been described. Homologous grafting essentially refers to irradiated rib. This is advantageous because of the large amount of material available for significant augmentation without donor-site morbidity. Resorption, warping, and infection can occur as with other materials. Some concern about the possible transmission of infectious disease exists. For many patients and physicians, this concern makes the choice of this material unappealing. The most commonly used allograft materials include silicone, polytetrafluoroethylene, and porous polyethylene. Alloplastic materials have numerous advantages. They are readily available with an unlimited supply, they are easy to fashion into the desired shape, they resist warping and resorption, and they have no donor-site morbidity. For these reasons, alloplastic implants have many proponents. However, alloplastic implants have been noted to have higher rates of infection and extrusion. Infection of the implant may leave the patient with permanent damage to the overlying skin. Caution is advised in the use of synthetic implants in revisions and in situations in which a communication with the nasal cavity (eg, septal perforation) is present (see Contraindications). In these cases, the poorer vascularity, thinner soft-tissue envelope, and potential for contamination significantly increase the risks of infection and extrusion with alloplastic implantation. The upper third of the nose, with less mobility of the soft tissue and less proximity to the nasal lumen, may be somewhat safer for the introduction of synthetic implants. Some patients note skin changes (eg, erythema) with the introduction of synthetic implants. Porous polyethylene is somewhat unique because an ingrowth of tissue may develop, and this makes it more stable and less likely to become infected. EtiologyA person with a congenital defect (uncommon) may have a relative lack of cartilage or bony structure. Some persons may have agenesis of 1 or more components of the bony and/or cartilaginous structure of the nose. Defects due to trauma and iatrogenic causes are more common. These defects result from a crushing injury to the structures of the nose or from septal hematoma, resulting in necrosis of the septum with subsequent collapse of support of the dorsum. If such injuries occur at an early age, they can cause scarring, which limits subsequent growth of the nose. Iatrogenic causes of defects include excessive removal of bone and cartilage at the time of rhinoplasty. These can result in a relative lack of projection and severe saddle-nose deformities. Rarely, infectious and inflammatory conditions such as relapsing polychondritis or Wegener granulomatosis can destroy the support structures of the nose. Finally, neoplasms, including skin cancers that erode through the skin to disrupt the underlying structures, can require a reconstructive procedure and augmentation. ClinicalAugmentation rhinoplasty may be indicated for functional concerns, aesthetic concerns, or both. The internal and external nasal valves affect nasal airway obstruction. Collapse of these areas in either a static or dynamic fashion often require the introduction of graft material to provide needed support of the nasal sidewalls. Patients who present for augmentation rhinoplasty may or may not be consciously aware of the need for augmentation. The desire for augmentation is particularly strong those patients with saddle-nose deformity or other such dramatic deficits. In other individuals, an asymmetry of the profile may produce a pseudohump, and the patient may believe that reduction is necessary. In such persons, careful nasal analysis reveals the need for augmentation to bring the dimensions of the nose into harmony with the rest of the face. These principles should be demonstrated to the patient to gain his or her acceptance of the surgical plan. Careful history taking to determine the nature of the problem is crucial to proper surgical planning. This process should include an inquiry about previous trauma or surgery and symptoms of nasal obstruction, as well as a clear discussion of the patient's objectives. On physical examination, the aesthetic value of the nasal dorsum must be critically evaluated. The frontal view is examined. Two slightly curved, divergent lines that extend from the medial supraciliary ridges to the tip-defining points outline the brow-tip aesthetic line of the dorsum. Alternatively, the authors and many others believe that a slightly wider dorsum should also be demonstrated in the middle third, with cephalic and caudal tapering, because this is a more natural appearance. The aesthetics of the profile must be analyzed critically. No single ideal profile exists, because each individual has his or her own tastes and priorities. However, some rules pertaining to the desirable components of a theoretic ideal are important in guiding the decision-making process of the surgeon. The concepts involved in the ideal profile are as follows:
The physical examination must include an assessment of the internal nasal anatomy, any septal deviations or perforation, and the position and quality of the upper and lower lateral cartilages. The upper lateral cartilages may be displaced into a vertical position, abutting the septum. This is often observed as an inverted V deformity on frontal view, where the upper lateral cartilages have collapsed inferomedially. This appearance may also be caused by overresection of the bony dorsum with inadequate medialization of the nasal bones. On rare occasions, the upper lateral cartilages may actually become disarticulated from the nasal bones. Simple augmentation in a person with such a deformity without addressing the collapse in this region (eg, with spreader grafts) invariably leads to disappointing functional results in such patients who have nasal obstruction. The nasal bones must be palpated. The patient with short nasal bones (in which the bony pyramid is less than one third the distance from the nasofrontal angle to the septal angle) often has a narrow upper vault and bilateral concavities of the cartilaginous vault. Osteotomies may further impede the airway in such individuals, and spreader grafts often are required. A dorsal onlay graft may be necessary to widen the nose to improve the aesthetic result. INDICATIONSSection 3 of 11
Augmentation of the dorsum is not commonly required at primary rhinoplasty. The indications include the following:
To analyze the need for this augmentation, one may draw an imaginary line from just above the nasofrontal angle to the tip defining point. The dorsum of a woman should lie parallel and as far as 2 mm posterior to this line. If the dorsum is separated from this line by more than 2 mm, dorsal augmentation should be considered. The nasion should lie at the level of the supratarsal crease. If it is below this level, augmentation may be performed to raise the nasion. Other than dorsal augmentation, additional indications for augmentation of the nose exist. Functional improvement of nasal valve collapse is achieved with spreader or alar batten cartilage grafts. Asymmetries of the nasal tip may be corrected with cartilage grafts. RELEVANT ANATOMYSection 4 of 11
The anatomy of the nose must be understood in detail to perform rhinoplasty safely and effectively, and augmentation is no exception. Some particular points of the anatomy warrant emphasis. The nasal airway is narrowest at the internal nasal valve, which consists of the region where the caudal end of the upper lateral cartilage meets the septum medially and the anterior end of the inferior turbinate laterally. Many patients requiring augmentation have undergone extensive surgery or trauma, and nasal obstruction is often present. This obstruction may narrow the middle vault by a number of mechanisms, including overresection of the dorsum or of the lateral crura, excessive narrowing with osteotomies, and loss of the naturally occurring increased width of the dorsal septum once excised. The traumatized or resected nasal bones may have resulted in destabilization of the upper lateral cartilages, resulting in inward collapse of the upper lateral cartilages, which are displaced to lie vertically, abutting the septum. The surgical plan should address this collapse. This may be accomplished with spreader grafts or onlay grafts placed in such a way as to spring open the nasal valve. The soft tissue envelope of the nose may limit the amount of improvement in projection. Many such patients have significant scarring, resulting in not only inflexibility of the soft tissues covering the structures of the nose but also a relative lack of vestibular lining. Overrotation of the tip in such patients is not uncommon. Examination including palpation can reveal this in the office. Such patients may require composite grafts to provide greater vestibular lining in addition to augmentation of the dorsum or tip. CONTRAINDICATIONSSection 5 of 11
Relative contraindications exist for the type of implant used. Alloplasts such as polytetrafluoroethylene and silicone have a greater risk of infection and extrusion when previous surgery has been performed, as it often has been in these patients. In addition, any communication of the pocket for the graft and the internal nose increases the risk of infection, and one may consider the implantation of synthetic materials more hazardous in such instances. Graft material needs enough rigidity to support the surrounding soft tissues, which, for example, prevents the use of polytetrafluoroethylene in the lower third of the nose. WORKUPSection 6 of 11
Imaging Studies
TREATMENTSection 7 of 11
Surgical therapyThe patient must have a clear understanding of the realistic goals of the operation. He or she must be informed of the potential risks, as well as the pros and cons of taking the graft material from the available donor sites. The patient must have the opportunity to make an informed decision about the planned procedure and about the type of graft material is to be used. The patient must also understand the importance of accepting compromises. For example, meeting the preconsultation aesthetic ideals of the patient and still achieving a functionally competent nose may not be possible. Preoperative detailsThe patient must have a clear understanding of the realistic goals of the operation. He or she must be informed of the potential risks, as well as the pros and cons of taking the graft material from the available donor sites. The patient must have the opportunity to make an informed decision about the planned procedure and about the type of graft material is to be used. The patient must also understand the importance of accepting compromises. For example, meeting the preconsultation aesthetic ideals of the patient and still achieving a functionally competent nose may not be possible. Advantages and Disadvantages of Graft Materials
Intraoperative detailsGraft harvest Septum: In patients without extensive removal of septal cartilage in the past, abundant quadrangular cartilage is apt to be available for harvest. This cartilage may be harvested with impunity, as long as enough remains to provide adequate support to the nose. Maintaining 1.5 cm of the dorsal and caudal septum may be sufficient. An intact L-shaped septal strut is necessary to provide support to the lower two thirds of the nose. Auricle: Auricular cartilage grafts may be harvested from either a posterior incision or an anterior incision. As long as the antihelical fold is preserved, the form of the auricle is not significantly altered by the removal of even the entire cavum conchae and cymba conchae complex. Maintaining the vertical component of the conchal bowl is advised to preserve lateral ear projection. Hydraulic dissection of the subcutaneous plane with the injection of local anesthetic aids in the ease of harvest. Composite grafts may be harvested by carefully maintaining the required amount of attached skin to the cartilage. This anterior skin is more adherent, although some surgeons prefer to harvest composite grafts from a posterior incision. Rib: The confluence of the sixth and seventh ribs and the confluence of the 9th and 11th ribs have been used successfully for grafting. Care is taken to avoid entrance into the intrapleural space. Symmetric carving of the costal cartilage helps avoid warping of the graft. Recipient site preparation A critical point is the preservation of an adequate soft-tissue envelope in preparing the pocket for implantation of the graft. The dissection should be performed deep to the subdermal plexus, which not only preserves an adequate thickness of overlying soft tissue but also minimizes subsequent fibrosis and unpredictable healing. If possible, make every attempt to perform the operation without excessively disrupting the nasal mucosa. In endonasal procedures, a precise pocket is created to prevent migration of the graft. For open procedures, fixation of the graft with suture is required. In cases of bony augmentation (rib or calvaria), exposure of the bony dorsum allows bone-to-bone contact and adequate fixation of the graft. Graft preparation Meticulous contouring and appropriate sizing of the graft are critical to ensure a successful outcome. The preservation of a small amount of soft tissue attached to the graft may aid in fixation of cartilage grafts; however, bone-to-bone contact is necessary for fixation of bone grafts. The edges must be beveled to prevent undue visibility of the edges through the skin. In addition, the edges can be further diminished by gently morselizing them with the Brown-Adson forceps. Excessive crushing is to be avoided because it may cause warping and eventual resorption of the graft. Several pieces of the graft material may be stacked and sutured together with polydioxanone suture (PDS) to increase the dimensions of the implant. When possible, fixation of graft with 5-0 or 6-0 PDS is performed. In rib grafts, if an undesirable curvature is present, the graft may be straightened with a K-wire passing through the graft. Graft implantation Radix: The placement of a graft to the radix to correct an overly deep nasofrontal angle can restore a high, strong profile. The graft also produces the appearance of lengthening the nose. A precise pocket is produced deep to the procerus muscle, and the graft is placed. Often, the recipient bed is too large, and the graft should be fixed by placing an absorbable suture through the graft and bringing it out through the skin. It is fixed at this point with a Steri-Strip for several days. Nasal dorsum: If an endonasal approach is chosen and if the recipient pocket can be created precisely, the graft may be introduced without the need for fixation. Otherwise, fixation is necessary. Multiple options can be used to stabilize the graft. If possible, multiple point fixation is performed. PDS may be used to stabilize the graft to the underlying cartilages. In addition, sutures passed through the skin and left in place for several days are helpful. For larger dorsal reconstructions such as those requiring rib grafts, fixation is important. Lag screws, miniplates, or circumferential passage of 26-gauge wire or suture is necessary. The wire or suture technique may be performed by passing a Keith needle through the bony nasal pyramid underneath the graft and by passing wire or suture through this and over the graft. In addition, suturing of the upper lateral cartilages to the dorsal graft helps support the airway. Postoperative detailsThe immediate postoperative care is the same as that for primary rhinoplasty. Patients are instructed to leave any splints or tape undisturbed for 1 week. Head elevation is encouraged in the immediate postoperative period. The gentle application of ice the first day minimizes swelling and ecchymosis. The avoidance of strenuous activity is advised for the first week. Particular care to avoid any manipulation of the nose, including nose blowing, is stressed for the first week. Eyeglasses are not rested on the bridge of the nose but possibly taped to the forehead. Follow-upSplints and tape may be removed 1 week after surgery. The patient is monitored closely for the first several weeks and months. At times, areas of soft tissue swelling may respond well to local steroid injections. COMPLICATIONSSection 8 of 11
Complications and adverse outcomes occur in augmentation rhinoplasties. A certain percentage of patients inevitably require future procedures to achieve a desirable result. This should be clearly explained to the patient before surgery. A particularly relevant adverse outcome of augmentation rhinoplasty is warping and resorption of the grafts, especially with homografts. Asymmetries can occur, despite ideal alignment of the tissues during surgery. These result from asymmetric resorption, warping, and the formation of scar tissue and can occur as long as several months after surgery. An inadequacy or overabundance of the augmented area may become apparent postoperatively. Obviously, this circumstance is best prevented with careful measurements and technique. However, some patients may require revision to achieve a better outcome. Infection may occur. The infection may cause extrusion of the implant. Removal is then necessary, particularly with alloplasts. Changes may occur in the skin overlying the graft material. These include persistent erythema, telangiectasias, and contour irregularities due to dermal or subdermal fibrosis. OUTCOME AND PROGNOSISSection 9 of 11
The patient should be counseled about the possibility of revision rhinoplasty, which is required in about 10% of cases. As discussed, some patients experience resorption or warping of the graft material. Less commonly, excessive augmentation is performed, and future revision is required. With proper adherence to sound surgical principles and the judicious use of augmentation techniques, most patients enjoy a satisfactory result, both aesthetically and functionally. FUTURE AND CONTROVERSIESSection 10 of 11
The future certainly holds new possibilities for every area of facial plastic surgery. New alloplastic materials may prove to be safer and more reliable in the nose. Tissue engineering probably will allow tremendous advances in the potential for restorative rhinoplasty. The future may allow the laboratory production of an abundant supply of cartilage from the patient's own tissue. This material might then be shaped in vitro to the desired configuration. REFERENCESSection 11 of 11
Rhinoplasty, Augmentation excerpt Article Last Updated: Oct 3, 2006 |
