Augmentation Rhinoplasty Treatment & Management

Updated: Nov 16, 2015
  • Author: Eugene A Chu, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Preoperative Details

The 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.

Table. Advantages and Disadvantages of Graft Materials (Open Table in a new window)

 

Advantages

Disadvantages

Septum

Easy harvest

Present in the surgical field (no separate donor-site morbidity)

Straight (good for certain purposes, such as a columellar strut)

May be deficient

Straight (less desirable as batten graft)

Auricle

Easy harvest

Relatively abundant

Curved nature ideal for certain purposes

Separate donor site

Curved (less desirable for some purposes)

Rib

Large volume (abundant, even for significant augmentation)

Distant donor site (2-team approach possible)

Reliable

Donor-site morbidity

Warping possible

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Intraoperative Details

Graft 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 should 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 with removal of 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.

The following steps can be taken to limit the amount of warping: (1) remove perichondrium completely, (2) symmetric carving of the costal cartilage from the straightest rib segment, (3) use only the core part of the rib discarding the peripheral pieces, and (4) soak the prepared segment in saline for 10-minutes to identify any acute warping before implantation. For dorsal grafts, the senior author utilizes the lower floating rib and harvests a graft that is approximately 2/3 bone and 1/3 cartilage and has found that this has greatly decreased the likelihood of warping. The use of a pain pump, such as the On-Q pain pump (VQ OrthoCare, Irvine, CA) allows costal grafts to be performed on an outpatient basis.

Recipient site preparation

A critical point is the preservation of an adequate soft-tissue envelope during preparation of 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.

Alternatively, percutaneous K-wires can be placed to secure the graft to the radix and are removed in the office3-weeks post-operatively. In the authors’ experience utilizing this technique over the last 10 years, all costal bone grafts have had stable bony fusion.

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.

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Postoperative Details

The 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.

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Follow-up

Splints 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.

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Complications

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 allografts. 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.

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Outcome and Prognosis

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.

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Future and Controversies

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.

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