Asian Facial Cosmetic Surgery

DORSAL AUGMENTATION USING IMPLANTS
205
A
B
Figure 20-5
Jung’s forceps facilitate the placement of soft e-PTFE. A and B, After the insertion,
the implant is fixed with a 26-gauge needle that penetrates through the nasal skin;
the forceps are then withdrawn. C, Preoperative view. D, Postoperative view.
C
D

AUGMENTATION RHINOPLASTY WITH AUTOGRAFT/ALLOPLASTY COMBINATION
206
a
d
c
b
c
d
Marginal incision
Transcolumellar incision
Figure 20-6
Incisions for the endonasal approach: intercartilagenous (a),
transcartilagenous (b), marginal (c), and rim (d).
Figure 20-7
Marginal and transcolumellar incisions in the open rhinoplasty approach.

DORSAL AUGMENTATION USING IMPLANTS
207
A
Figure 20-8
An approach through one nostril may lead to preferential dissection into the contralateral side. Incisions on both sides ensures pocket symmetry (A).
B and C, Postoperative views demonstrate deviated noses.
B
C

AUGMENTATION RHINOPLASTY WITH AUTOGRAFT/ALLOPLASTY COMBINATION
208
A
B
A
B
Figure 20-9
A, A patient with an obliterated nasofrontal angle. B,The nasal bone
was reduced through a glabellar incision.
Figure 20-10
A, Jung’s forceps. The tip of the instrument has a narrow slit through which a
26-gauge percutaneous needle is introduced and fixes the implant. The implant then
remains in place as the forceps are removed (B).

DORSAL AUGMENTATION USING IMPLANTS
209
References
1. Yun YS, Choi JC, Jung DH, et al: External nasal appearance
preferred by Koreans: photo analysis, J Rhinol 5(2):103-107,
1998.
2. Daniel RK: The radix. In Daniel RK, ed: Rhinoplasty,
Newport Beach, 1993, Little, Brown, pp 677-704 .
3. Gunter JP: Facial analysis for the rhinopalsty patient.
Proceedings of the 14th Dallas Rhinoplasty Symposium,
Dallas, Feb 28 to Mar 3, 1997. Dallas, TX, 1997,
Southwestern, pp 45-55.
4. Jung DH, Jung YK, Lee WW, et al: A study on grafts
materials in augmentation rhinoplasty, Korean J Otolaryngol
39(2): 250-257, 1996.
5. Tardy ME: Rhinoplasty. In Cummings CW, Fredrickson JM,
Harker LA, eds:. Otolaryngology head and neck surgery, ed 2,
Baltimore, 1992, Mosby, pp 807-856.
6. Jung DH, Lim JH, Kim TM, et al: New forceps for insertion
of implants in augmentation rhinoplasty, Korean J
Otolaryngol 44:936-939, 2001.
A
B
Figure 20-11
The tip projection and supratip break should be preserved after dorsal augmentation. The tip should be 1 to 2 mm higher (anterior) than the
nasal dorsum.

211
Revision rhinoplasty in the Asian patient is unique because
of its use of alloplastic implants. The procedure is often
associated with deficiency of structural support, scar
formation of the soft tissue, and lack of available cartilage
grafting material. Revision rhinoplasty is best performed
after wound healing and scar maturation have been
completed, generally 6 to 12 months after the surgery.
Grotting and Rorich have advocated waiting as long as 2
years when a third revision surgery is indicated.1 However,
it is prudent to revise the nose if a significant problem
occurs, such as warping of the implant or a serious
aesthetic concern. The septal or auricular cartilages may be
unavailable when the complications occurred after the
previous use of the cartilage. Tragal cartilage, dermofat, or
alloplasts such as Gore-TexTM (W.L. Gore & Associates,
Inc., Newark, NJ) may be used instead. If a large amount of
graft is needed, costal cartilage or calvarial bone can be
used.2
Because the dermal graft’s absorption rate is 50% to 70%, it
is used only in the correction of severe adhesions second-
ary to the removal of paraffin or trauma. The absorption
rate of the costal cartilage is less than 10%. An internal
stress exists within the cartilage graft, which can lead to
warping (Figure 21-1).3 To minimize this effect, the
straighter portion of the graft should be used and all four
sides of the graft should be deeply scored (Figure 21-2).
The seventh rib is straighter, thicker, longer, and situated in
the abdominal wall, which lowers the risk of pneumo-
thorax. The choice of rigid outer cortex also influences the
degree of warping. Despite the surgeon’s best efforts to
choose a proper graft, warping occurs in approximately
3% to 5% of all cases. Calavarial bone is a poor grafting
candidate. It is difficult to carve, hard in consistency, and
gives an unnatural appearance, and its resorption is uneven.
Revision Augmentation
Rhinoplasty
Dong Hak Jung
Infection
Infection associated with grafts is often successfully treated
with saline irrigations through an endonasal approach and
intravenous (IV) antibiotics. If the infection persists
despite these measures, the graft should be removed.
Reoperation is postponed for 6 to 12 months. Once an
infection develops in the nose with an implant, it rarely
21
A
B
C
D
Figure 21-1
A similar amount of the perichondrium or outer cortex should be preserved or
eliminated to lessen warping. Shaded areas represent removal of pericondrium and
outer cortex.

REVISION AUGMENTATION RHINOPLASTY
212
responds to IV antibiotics. If there is no sign of improve-
ment after 5 days of IV antibiotics, immediate removal is
indicated to prevent further progression. If the patient
insists on immediate reoperation, autologous material
should be used to prevent reinfection (Figure 21-3). Never-
theless the patient should be informed of the possibility of
reinfection despite the use of autologous grafts.
Skin Color Change
The nasal tip skin may turn red or white when the pressure
from the implant is excessive (Figure 21-4). The height of
the implant is reduced to decrease the tension, and the
implant should be covered with a biologic material such
as dermis or acellular dermis (Alloderm, Life Cell,
Branchburg, N.J.). The implant may be replaced with the
cartilage. To protect thinned “shiny” skin, either the
auricular cartilage with perichondrium is used or the
cartilage graft is wrapped with dermis or fascia.
Implant Migration
Endonasal approach through one nostril may result in a
pocket that deviates toward the opposite side. To ensure
symmetry, the author attempts to dissect the pocket in the
nasal root area, intentionally deviating toward the same
side of the incision. Alternatively, the pocket is developed
through bilateral intranasal incisions. In addition, the
pocket should be just large enough to allow implant
insertion. The recipient pocket should be slightly larger for
the softer Gore-TexTM implant than that for the silicone
implant. Unlike the silicone implant, Gore-Tex may
bend without an adequate space. The silicone implant
induces a capsule formation, and displacement of the
implant may occur when the capsule contracts excessively.
When a displaced silicone implant is replaced with another
Figure 21-2
A straighter portion of the cartilage should be used. In addition, all four sides of the
graft should be scored.
Figure 21-3
A, Autologous graft replacement for infected nose with silicone transplant. B,
Redness and swelling due to an infected silicone implant. C, Postoperative view.
A
B
C

IMPLANT MIGRATION
213
A
B
Figure 21-4
A,The silicone implant is found immediately beneath the skin. B, A shield graft composed of septal and auricular cartilages is in place.
A
B
Figure 21-5
A, Preoperative view of supratip depression. B, GoreTex implant.
Continued

REVISION AUGMENTATION RHINOPLASTY
214
implant after a pocket correction, a new capsule displaces
the implant to the previous position.4 Creation of a new
pocket and use of a different material may prevent
recurring implant migration. On the bony nasal dorsum,
subperiosteal dissection minimizes implant migration.
Correction of the migrated implant due to the presence of
the nasal hump or deviated nose should be done only after
the underlying problem is corrected.
Contour Deficiency
Patient dissatisfaction may arise not only from an un-
expected surgical outcome but also if the surgeon mis-
understands the patient’s desires. A thorough preoperative
discussion with the patient is essential to prevent an
unhappy outcome. Dorsal irregularity may develop as a
result of inadequate implant carving. A minor irregularity
can be corrected with a small segment of Gore-Tex
(Figure 21-5). A short nose with excessive cephalic rotation
of the tip as a result of an overzealous attempt to increase
the projection is corrected with extended spreader grafts
(Figure 21-6). Columellar deviation and asymmetry of
the nostrils are corrected with multiple Z-plasty and
columellar modifications (Figure 21-7).
The columellar defect secondary to use of the external
rhinoplasty approach is reconstructed with bilateral
vestibular flaps (Figure 21-8). Columellar deviation is a
result of misalignment between the columellar and the
columellar strut. The deviation can be corrected with
realignment of the strut and the columellae and fixated by
allowing a compensatory deviation toward the opposite
side (Figure 21-9). Columellar deviation may be the
result of an excessively long L-shaped silicone implant. It
is corrected by removing the implant and building a
columellar strut with cartilage graft–enhanced tips (Figure
21-10). The “postsurgical” look caused by an implant with
sharp and pointy edges can be corrected with a more pre-
cise carving and placement of the implant (Figure 21-11).
To achieve an ideal, curvilinear brow-tip aesthetic line on
the frontal view, the implant should be made broad at the
nasal root and narrow toward the tip. An overly projected,
“Pinocchio-type” nose is unattractive. The graft position-
C
D
Figure 21-5, cont’d
C, Preoperative view. D, Postoperative view.

PARAFFIN OR LIQUID SILICONE
215
ing should be adjusted to obtain a well-defined double
break (Figure 21-12). An overly narrowed nasal tip due to
previous dome-binding sutures should be broadened with
grafting (Figure 21-13). Appropriate nasal tip width is
guided by the two light reflexes from each dome region.
Paraffin or Liquid Silicone
Injected material is best removed in an en-bloc fashion for
the maximal elimination of the foreign body (Figure 21-14).
At times, injected material is too close to the skin, which
Figure 21-6
A shortened, overly rotated nose is corrected with extended spreader grafts. A, Operative view. B, Pre-revision view. C, Post-revision view.
B
C
A

REVISION AUGMENTATION RHINOPLASTY
216
prevents complete removal. In such cases, the tissue mixed
with foreign material is shaved off in layers. However, care
should be taken to avoid excessive thinning of the skin and
perforation (Figure 21-15).
The skin becomes thin and uneven, and the nose
looses projection. Augmentation with a dermal graft from
the buttock area and Gore-Tex may be added under the
dermal graft if needed. Skin thinning may result in a
A
A
B
B
C
C
Figure 21-7
A, Postoperative columellar deviation and scarring. B, Multiple Z-plasty.
C, Postoperative view.
Figure 21-8
A, Cicatrical columellar deformity. B and C, Bilateral vestibular flaps.

PARAFFIN OR LIQUID SILICONE
217
A
B
C
D
Figure 21-9
A, Columellar deviation due to a malposition of the columellar strut. B, Its correction. C, Preoperative view. D, Postoperative view.
A
B
Figure 21-10
A, Tip deviation secondary to placement of a L-shaped silicone implant. B, Removal of the silicone implant.
Continued

REVISION AUGMENTATION RHINOPLASTY
218
C
D
E
F
Figure 21-10, cont’d
C, Removed implant. D, Premaxillary bony erosion on a computed-tomography scan secondary to the implant. E, Placement of a strut carved from costal cartilage.
F, Basal view.
Continued

PARAFFIN OR LIQUID SILICONE
219
Figure 21-10, cont’d
G, Preoperative view. H, Postoperative view.
G
H
A
B
Figure 21-11
The “stick-like”postsurgical look caused by the placement of a straight implant without tapered edges. A, Preoperative frontal view. B, Postoperative frontal
view.
Continued

REVISION AUGMENTATION RHINOPLASTY
220
pinched appearance, which tends to improve with time
(Figure 21-16). If the skin change persists for more than
6 to 12 months, a corrective procedure is necessary and
should include the placement of a dermal graft or acellular
dermis (e.g., AlloDerm) under the skin.
Saddle Nose Deformity
The saddle nose deformity secondary to a septal defect
may be reconstructed with costal cartilage grafting (Figure
21-17). Augmentation rhinoplasty cannot be performed
without proper septal support. Complications during
costal cartilage harvesting include pneumothorax and
excessive scarring. When realized, pneumothorax should
be treated immediately with a chest tube, approximation
under positive pressure with ambu bagging, or both.
Excessive scarring is managed with direct steroid injection.
C
D
Figure 21-11, cont’d
The “stick-like”postsurgical look caused by the placement of a straight implant without tapered edges. C, Preoperative lateral view. D,
Postoperative lateral view.

SADDLE NOSE DEFORMITY
221
A
B
Figure 21-12
An augmented tip with silicone appears too sharp and unnatural. A, Preoperative view. B, Postoperative view.
A
B
Figure 21-13
Correction of an overly narrowed tip. A, Intraoperative view of dome binding suture from previous surgery. B, Augmented dome with a cartilage graft.
Continued

REVISION AUGMENTATION RHINOPLASTY
222
Figure 21-13, cont’d
Correction of an overly narrowed tip. C, Preoperative view. D, Postoperative view.
C
D
A
B
Figure 21-14
A, Removed paraffin. B, e-PTFE wrapped in a dermofat graft.
Continued

223
C
D
Figure 21-14, cont’d
C, Preoperative view. D, Postoperative view.
Figure 21-15
Perforated skin during the removal of paraffin.

REVISION AUGMENTATION RHINOPLASTY
224
A
B
C
D
Figure 21-16
Paraffin removal. A, Preoperative view. B, 2-week postoperative view shows “pinched”nasal skin. C, 6-month postoperative view shows spontaneous
improvement. D, 14-month postoperative view shows almost complete resolution.

SADDLE NOSE DEFORMITY
225
Figure 21-17
Septal and dorsal reconstruction with costal cartilage graft. A, Costal cartilage carved for the septal repair. B, Placement of cartilage into the septal pocket. C, Carved costal
cartilage for nasal augmentation. D, Shield graft to the tip.
Continued
A
B
C
D

REVISION AUGMENTATION RHINOPLASTY
226
Figure 21-17, cont’d
Septal and dorsal reconstruction with costal cartilage graft. E, Preoperative frontal view. F, Postoperative frontal view. G, Preoperative lateral view.
H, Postoperative lateral view.
E
F
G
H

SADDLE NOSE DEFORMITY
227
References
1. Rorich RJ: Harvesting cartilage grafts in rhinoplasty.
Proceedings of the 14th Dallas Rhinoplasty Symposium,
Dallas, Feb 28 to Mar 3, 1997. Dallas, TX, 1997,
Southwestern, pp 305-310.
2. Jung DH, Jung YK, Lee WW, et al: A study on grafts
materials in augmentation rhinoplasty, Korean J Otolaryngol
39(2): 250-257, 1996.
3. Gibson T, Davis WB: The distortion of autogenous cartilage
grafts: its cause and prevention, Br J Plast Surg 10:257, 1958.
4. Min YG, Jung PS: Rhinoplasty, Korean J Otolaryngol
36(3): 443-449, 1993.

229
Augmentation Rhinoplasty
with Autologous Cartilage
Grafting
Dean M. Toriumi
Surgery in the Asian patient requires unique attention to
an aesthetic ideal that is distinctly different from that of the
Caucasian patient. These aesthetic ideals have progressed
during the past decade and demonstrate a shift toward a
natural yet refined look. The anatomy of the Asian nose
requires unique surgical techniques to achieve the desired
contours. The Asian nose frequently lacks sufficient struc-
tural support to provide a refined look to the nasal tip and
dorsum. The lower lateral cartilages tend to be weak and
do not provide a good foundation for a structurally sound
nasal tip structure. Thick nasal tip skin and abundant sub-
cutaneous tissue blunt the nasal contour. The introduction
of the structure approach to rhinoplasty has enabled the
surgeon to provide Asian patients with increased tip
projection and definition as well as higher dorsums.
To increase support and provide improved refinement,
many surgeons have relied on alloplastic implants that can
establish excellent support and augmentation. Most
patients who have received alloplastic implants do well
over their lifetime. However, problems such as thinning of
the skin over the implant, extrusion, infection, displace-
ment, and chronic pain can be seen in patients with
alloplastic nasal implants.1,2 Many acceptable alloplastic
materials can be used for nasal augmentation, such as
Silastic, Gore-TexTM (W.L. Gore & Associates, Newark,
DE), and Med-Pore (Porex Surgical, Inc., Fairburn, GA).3,4
Silastic is relatively inexpensive, is the most commonly
used alloplastic implant worldwide, and has a reasonable
success rate.5,6 Commonly used L-shaped dorsocolumellar
implants can effectively increase tip projection and dorsal
height. However, these implants tend to create a
22
foreshortened nose because they are unable to preserve
nasal length. Additionally, the genu of the implant can
create a pressure point on the nasal tip skin and lead to
thinning and potential extrusion. The author prefers to use
autologous grafting materials for nasal augmentation. The
materials used by the author for augmentation of the Asian
nose include septal cartilage, auricular cartilage, and costal
cartilage. In this chapter, the use of autologous cartilage
grafting for augmentation and structural grafting of the
Asian nose is discussed.
Principles of Structural Grafting
In most patients who require augmentation rhinoplasty,
augmentation of the nasal dorsum and nasal tip is
necessary. An increase in tip projection will usually provide
an improvement in tip definition and also act to narrow the
nasal base. By increasing tip and dorsal projection, the
surgeon is better able to control the width of the nose.
Projection into thick skin will provide more favorable
redraping and a more refined look on the frontal view. This
standard principle of projecting into a thick skin soft tissue
envelope is basic to making Asian noses look more refined.
Patient Selection
Patient selection requires an in-depth discussion between
the patient and the surgeon. Most Asian patients who
are in good health and have realistic expectations are
candidates for augmentation rhinoplasty. Some patients

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
230
may have unrealistic expectations and would not be good
candidates for augmentation rhinoplasty. Patients with
autoimmune disorders that could affect their cartilage (e.g.,
relapsing polychondritis) or those with calcified rib (i.e.,
patients more than 55 years old) cartilage may not be
candidates for major augmentation using costal cartilage.
Consultation
The time spent with the patient in consultation is critical to
determining whether the patient is a good candidate for
surgery. Computer imaging is critical when augmentation
rhinoplasty in the Asian patient is planned. Cartilage
grafting is very powerful and will allow the surgeon to
make major changes in nasal contour. It is critical that the
surgeon and patient clearly understand the planned
outcome. Parameters such as the position of the radix,
height of the dorsum, degree of tip projection and rotation,
attitude of the nasolabial angle, and width of the nasal base
can all be communicated using computer imaging. The
surgeon must perform the imaging in the office and be sure
to only show realistic images; otherwise the patient may be
disappointed postoperatively.
If costal cartilage grafting is planned, the patient should
also be counseled regarding the postoperative changes seen
in the nose. If costal cartilage grafting is used in the nasal
tip, then the patient’s nose will likely be stiffer and less
pliable. If tip projection is increased with an extended
columellar strut, the patient’s upper lip posture may be
slightly different and the smile could be altered until the
edema and swelling decreases, and the soft tissues
accomodate the cartilage grafts.
During the consultation the patient must also be informed
of options for augmentation rhinoplasty. The surgeon can
discuss the use of autologous or alloplastic materials and
the pro and cons of each material. If the use of autologous
costal cartilage is discussed, the surgeon should inform the
patient of the possibility of cartilage warping, deformity,
and other related complications. The patient should also
be informed of the incisions used for cartilage harvesting
and nasal augmentation. Augmentation rhinoplasty with
autologous cartilage is more complex and requires a longer
duration of surgery as compared with augmentation with
alloplastic implants. Augmentation with costal cartilage is
by far the most complex and has a higher potential for
complications if it is not executed properly.
Anesthesia
The anesthesia typically used for augmentation rhinoplasty
is a general anesthetic with orotracheal intubation. The
orotracheal intubation allows the surgeon to protect the
airway and carefully monitor the patient’s oxygenation.
The author uses 1% lidocaine with 1:100,000 epinephrine
for the local anesthetic injections. The harvesting site and
the nose and septum are injected with a maximum of
15 mL of local anesthetic. Most of the author’s patients
undergo the external rhinoplasty approach with injections
down the columella, over the tip, along the marginal
incisions, and over the dorsum. If osteotomies are planned,
an additional injection is made bilaterally along the lateral
osteotomy sites. The local anesthetic should be allowed to
work for at least 10 minutes before the surgery begins.
Instruments and Supplies
The following items are used:
1. Standard rhinoplasty instruments
2. Freer elevator
3. Converse or Wilmer scissors
4. Bipolar cautery
5. 5-0 polydiaoxane (PDS) suture
6. 6-0 Monacryl suture
7. 5-0 clear nylon suture
8. 5-0 fast-absorbing gut suture
9. 4-0 plain gut on a straight septal needle
10. Dental rolls
Procedure
Autologous Grafting Material
The type of grafting material chosen for the augmentation
rhinoplasty depends on the degree of augmentation and
desires of the patient. Septal cartilage may be adequate in
Asian patients who require a mild to moderate degree of
dorsal augmentation. The septal cartilage can be harvested
through either an intranasal approach or the external
rhinoplasty approach after dissection is made between the
medial crura. If the patient requires primarily tip and
dorsal work with no changes to the premaxilla or
columella, then the surgeon can harvest the septal cartilage
through a Killian incision. If the patient needs premaxillary
augmentation or a major change in the status of the nasal
base, then the surgeon can harvest the septal cartilage

PROCEDURE
231
through the external rhinoplasty approach after dissecting
between the medial crura and raising the bilateral muco-
perichondrial flaps. If septal cartilage is inadequate, then
the surgeon can opt to use auricular or costal cartilage. In
patients who need a minor degree of dorsal augmentation
(i.e., less than 3 mm), the author usually uses septal
cartilage, auricular cartilage, or both for augmentation. In
patients with sufficient septal or auricular cartilage, a
double layer of cartilage can be used to provide more than
3 mm of augmentation. If the patient needs more than
5 mm of dorsal augmentation, then the author usually
harvests costal cartilage for the dorsal contouring.
Generally, the author uses costal cartilagee for structural
grafting in patients who require premaxillary augmenta-
tion or lengthening of the nose.
Auricular Cartilage Harvesting
When auricular cartilage is harvested for augmentation,
the postauricular approach provides excellent exposure of
the conchal cartilage with minimal if any change in ear
shape. The incision is placed 3 to 4 mm lateral to the
postauricular crease on the back of the concha and is
difficult to identify postoperatively (Figure 22-1, A). Local
anesthetic (1% lidocaine with 1:100,000 epinephrine) is
injected into the postauricular surface of the ear and
allowed to take effect for 10 minutes. The postauricular
incision is made down to cartilage, and the skin is dissected
from the back of the conchal bowl. After the lateral extent
of excision at the vertical aspect of the conchal bowl is
identified, the concha is incised and a 27-gauge needle is
passed through the anterior side of the ear (see Figure
22-1, B). The needle can also be used to identify the
inferior and superior extent of the cartilage excision.
Ideally, the vertical component of the conchal bowl and the
cartilage just medial to the antitragus and the inferior crus
should be preserved. The incision is made through the
cartilage, preserving the perichondrium on the anterior
surface of the conchal bowl (see Figure 22-1, C). The
surgeon must be careful to dissect the full thickness of skin
and perichondrium from the anterior surface of the concha
because this skin is thin and can be compromised (see
Figure 22-1, D). The cavum and cymba cartilage is
harvested with some soft tissue on the posterior surface of
the graft (see Figure 22-1, E). This soft tissue can be peeled
from the cartilage and used to help camouflage tip grafts.
After the cartilage is removed, hemostasis is attained. The
surgeon should be careful while cauterizing the skin that is
elevated off the concha because excessive cautery to this
skin can result in necrosis. The postauricular incision is
closed with subcutaneous 5-0 PDS sutures and a running
5-0 fast-absorbing catgut suture. Then a bolster fashioned
from a cotton dental roll is placed in the conchal bowl with
a smaller piece of cotton behind the ear and sutured into
place with a 3-0 nylon through-and-hrough suture. The
suture is tied snugly but not tightly (see Figure 22-1, F).
Costal Cartilage Harvesting
During costal cartilage harvesting, the chest can be
palpated to determine the preferred rib for the proposed
augmentation. In most cases the sixth costal cartilage,
seventh costal cartilage, or both is harvested. The author
harvests from the right chest and typically makes the
incision at the inferior aspect of the right breast, which is
usually over the sixth rib (Figure 22-2). The incision is
usually 3 cm in length and is easily hidden beneath a
brassiere. In male patients, the incision is made over the
desired rib as determined by palpation. After making the
incision, dissection is performed through the breast tissue
down to the muscle fascia. After incising the muscle fascia,
a natural dehiscence in the muscle can be located and
separated with a hemostat (Figure 22-3, A). Then the
desired costal cartilage is identified, and a cotton dissector
is used to clear soft tissue. Incisions are made in the
perichondrium near the periphery of the rib, leaving a 5- to
10-mm strip of perichondrium on the anterior surface of
the cartilage. Careful dissection of the perichondrium is
performed around the circumference of the rib remaining
in the distinctive plane below the perichondrium and
against the smooth surface of the cartilage (see Figure
22-3, B). This plane is similar to the plane noted during
septoplasty. Special care is taken to avoid violating the
perichondrium on the undersurface of the rib because this
could result in damage to the pleura, which lies deep to the
perichondrium. After the perichondrium is elevated off the
rib, the cartilage is incised just medial to the osteochondral
junction. A medial incision is made at the designated
length needed for the patient’s augmentation. In some
cases, the seventh rib may meet at a confluence with the
eighth rib, requiring careful division of the confluence
before rib removal. At this point the remainder of the
perichondrium is dissected from the undersurface of the
costal cartilage and removed from the donor site (see
Figure 22-3, C). In most patients the author harvests a rib
that is 5 to 7 cm in length. If the costal cartilage is used for

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
232
A
B
C
D
E
F
Figure 22-1
A, Postauricular incision used for harvesting ear cartilage. B, A 27-gauge needle is placed through the ear along the vertical component of the conchal bowl to indicate the
lateral extent of cartilage excision. C,The cartilage is carefully incised so as to not violate the skin and perichondrium on the anterior surface of the conchal cartilage.
D, Converse scissors are used to dissect the perichondrium and skin off the anterior surface of the conchal cartilage. E,The cavum and cymba cartilage is harvested, leaving soft
tissue on the posterior surface of the graft. F,The postauricular incision is closed, and cotton dental rolls are placed on the anterior and posterior surface of the concha to preserve
normal conchal contour.

PROCEDURE
233
dorsal augmentation alone, some patients may need only
5 cm of length. It is helpful to have additional cartilage for
other grafts such as struts, battens, and tip grafts. If an
extended columellar strut is needed, then an adjacent rib
may need to be harvested.
Once the rib is harvested, the sharp edges of the medial
and lateral margins of the costal cartilage at the donor site
should be beveled to round off the corners and avoid
visible or palpable edges. Before closure, irrigation solution
is placed into the harvest site and a Valsalva maneuver is
performed. If no bubbles are noted, a pleural leak is not
likely. If a defect is noted, a red rubber catheter can be
placed into the defect and the wound closed over the
catheter. Then the chest can be expanded and the catheter
removed. The uncut margins of the muscle are closed very
tightly with 4-0 PDS sutures to create a splinting effect on
the surgical site. This significantly decreases postoperative
pain. The subcutaneous tissues and skin are closed with
5-0 PDS sutures and 5-0 nylon, respectively.
Before the costal cartilage is carved, the strip of
perichondrium intentionally left on the graft is carefully
stripped from the cartilage and saved for tip camouflage.
When carving the costal cartilage, it is imperative that the
dorsal graft be carved from the central core of the rib
(Figure 22-4). This maneuver creates more symmetric
forces on the periphery of the rib and reduce the risk of
warping.7,8 To accomplish this, four strips are taken from
each quadrant of the graft, leaving a central core with fewer
unbalanced stresses (see Figure 22-4, A). The larger strips
tend to warp toward the periphery because of the
unbalanced forces (see Figure 22-4, B). Sequential carving
of the graft is then performed, taking some of the periphery
and allowing the rib to soak in antibiotic saline solution for
about 20 minutes between carvings (see Figure 22-4, C).
The graft can be examined for any tendency toward warp-
ing after it has finished soaking in the solution. If some
curvature is noted, then the graft is carved on the concave
side to help release some of the deforming forces. When
a series of multiple carving and whittling maneuvers are
performed at various times throughout the entire surgery,
the surgeon can feel more comfortable that the rib will not
warp after it is implanted in the patient (see Figure 22-4,
D). If warping is to occur, the surgeon can frequently see
some warpage within the first 20 to 30 minutes of carving.
Figure 22-2
The incision on the inferior aspect of the right breast typically lies over the sixth rib. To ensue proper placement, the rib can be palpated before the incision is made.

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
234
Symmetric and balanced carving is also important for
columellar struts and spreader grafts. The likelihood of
warping is more prominent with the dorsal graft because
it is one of the least stabilized cartilage grafts used in
augmentation rhinoplasty.
Augmentation Rhinoplasty
The augmentation rhinoplasty can be executed with an
endonasal or external rhinoplasty approach. The author
prefers to use the external rhinoplasty approach because
most patients will have tip work done as well. In the
external rhinoplasty approach, an inverted-V incision is
made midway up the columella (Figure 22-5, A). It is always
better to err on the lower side of the columella because a
high scar will be much easier to visualize. After the incision
is executed, the columellar flap is carefully elevated off the
medial crura. Then three-point countertraction, with two
small and one large double-prong hooks, is used to aid in
dissection of the domes (see Figure 22-5, B). Dissection
over the middle vault should be immediately adjacent
to the middle vault cartilages. Then the periosteum is
elevated off the nasal bones with a Joseph periosteal
elevator. In the Asian patient it is very important to limit
the upper extent of the pocket to prevent a high radix or
A
B
C
Figure 22-3
A, After the fascia is incised over the muscle, the muscle fibers are carefully separated and not cut. B,The perichondrium is carefully dissected around the circumference of the
rib so as to not violate the perichondrium on the undersurface of the rib. A strip of perichondrium is left on the outer surface of the cartilage. This perichondrium is used to
camouflage tip grafts. C,The segment of costal cartilage is removed after medial and lateral incisions in the costal cartilage are made.

PROCEDURE
235
nasal starting point. Typically the upper extent of the
dorsal pocket should be at or below the midpupillary line
in Asian patients (Figure 22-6). The upper limit to the
pocket can always be advanced higher if necessary when
the graft is placed into its final position. When dorsal
augmentation is planned, lateral dissection is also limited,
and dissection over the nasal bones is limited to a narrow
midline tunnel that will aid in stabilizing the dorsal graft.
At this point the surgeon must decide how to stabilize the
base of the nose. If the patient has good tip support, an
acceptable nasolabial angle, appropriate rotation, and a
normal alar/columellar relationship, then a columellar
strut can be placed between the medial crura to stabilize
the nasal base (Figure 22-7).9 In this case, a pocket is
dissected between the medial crura, stopping short of the
nasal spine. It is important to leave a cushion of soft tissue
under such a strut to prevent it from clicking over the nasal
spine.10 The columellar strut typically measures 8 to 14 mm
in length, 3 to 4 mm in width, and 1 to 2 mm in thickness.
The strut is placed in the pocket and sutured with a 4-0
plain gut mattress suture on a straight septal needle that
passes through vestibular skin, medial crura, and graft.
Such a graft will have minimal permanent effect on tip
position but will provide some degree of tip support.
If the patient has poor tip support, an acute nasolabial
angle, poor tip position (dependent tip or a tendency
toward overrotation), or an abnormal alar columellar
relationship, then the surgeon can use a caudal extension
graft.11 A caudal extension graft is a segment of cartilage
that typically overlaps the caudal septum and is sutured
with at least three 5-0 clear nylon sutures (Figure 22-8).
The caudal extension graft should be overlapped so that
the caudal margin of the graft is in the midline without a
tilt. This requires careful assessment of different overlap-
ping configurations to determine which provides the best
A
B
C
D
Figure 22-4
Costal cartilage dorsal grafts should be carved from the central core of the costal
cartilage to decrease the chance of warping. A, Initially, cartilage can be carved from
each quadrant of the costal cartilage to expose the central core. With excision of the
four quadrants, significant cartilage strips are created that can be used for other
cartilage grafting. B,The strips taken from the periphery will tend to warp toward
the periphery. C,The central core of the cartilage can then be carved into a dorsal
graft in a sequential fashion. D,The dorsal graft made with balanced carving is less
likely to warp postoperatively.
A
B
Figure 22-5
External rhinoplasty approach. A, Note that the incision is made midway between
the top of the nostril and the base of the nose in an inverted-V fashion. B, Three-
point countertraction with two prong hooks retracting the columellar flap, nostril
margin, and vestibule under the domes.

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
236
orientation. The back margin of the caudal extension graft
that overlaps the caudal septum must not block the airway
or create fullness along the floor of the nose. If the caudal
margin of the graft is off the midline, then the tip will be
off the midline. After the graft is fixated, the medial crura
can be positioned on the caudal extension graft to set
appropriate tip rotation, tip projection, and alar columellar
relationships. The shape and attitude of the caudal
extension graft depend on the desired changes. If the
patient has an acute nasolabial angle and requires rotation,
then the graft should be longer along the inferior margin to
promote blunting of the nasolabial angle and rotation of
the tip (Figure 22-9, A and B). If the patient has a tendency
toward overrotation, then the graft can be contoured so
that it is longer along the superior margin to counterrotate
the tip (Figure 22-10). Most Asian patients need projection
without increased rotation, so they more frequently
require a caudal extension graft that is longer along the
superior margin. If major nasal lengthening is required,
spreader grafts can be extended beyond the existing caudal
septum to stabilize the superior margin of the extension
graft (Figure 22–10D). The extended spreader grafts will
create a more stable tip position. If the tip needs support
with little change in position, the graft can be more
rectangular in shape. Once the caudal extension graft is
sutured into position, the medial crura can be sutured to
A
B
Figure 22-6
A,The dorsal pocket should be dissected to a level at or below the midpupillary line in Asian patients. Red line indicates midpupillary line. B, Joseph periosteal
elevator used to elevate subperiosteal pockets to the level of the midpupillary line.
Figure 22-7
The columellar strut is sutured in place. The graft is fixed
between the medial crura and provides tip support.

PROCEDURE
237
the caudal margin of the extension graft with a 4-0 plain
gut suture on a straight septal needle. If symmetrical
alignment is noted, then a 5-0 clear nylon suture is placed
along the internal surface of the medial crura and then
through the caudal margin of the extension graft (Figure
22-11). This suture must be placed symmetrically to
prevent the creation of tip asymmetry.
If major tip support is needed because of previous surgery
or a significant deficiency in the premaxilla (e.g., retruded
premaxilla or dependant nasal tip), then the patient may
need an extended columellar strut with or without a pre-
maxillary graft. An extended columellar strut is fashioned
from costal cartilage because it must be very strong and
long enough to extend from the premaxilla to the final
dome position. In this case the medial crura are dissected
apart down to the premaxilla, and the strut is fixed to
the periosteum around the nasal spine. This can be
accomplished with several different methods. One method
involves placing two thin wafers of cartilage on opposite
sides of the base of the strut. Then the strut can be
stabilized over the spine with sutures; the wafers of
cartilage ensure the strut does not shift off the midline
(Figure 22-12). Another option is to flare the width of the
strut at its base and create a groove that will accept the
nasal spine (Figure 22-13). This maneuver may require that
the spine be burred down to a more pointed contour.
Another option is to place a premaxillary graft over the
nasal spine and then fixate the strut into a groove in the
premaxillary graft. The premaxillary graft also has a groove
or notch on its inferior border that can be fixed over the
nasal spine. This creates a very stable midline premaxillary
graft and extended columellar strut. Use of the pre-
maxillary graft provides the greatest degree of premaxillary
augmentation. This combination is ideal for the patient
with deficient premaxilla, an underprojected nose, and an
acute nasolabial angle. Whichever method is used, it is
important to ensure that the extended columellar strut is
fixed in the midline with sutures. Any tilting of the graft
will result in tilting of the columella and nasal base.
After the extended columellar strut is fixed into position,
the medial crura can be moved and fixed anteriorly on the
strut to increase tip projection and create a more obtuse
nasolabial angle. This maneuver also tends to increase tip
rotation. If tip rotation is unwarranted, then the medial
crura can be sutured to the strut in a neutral position, or
the strut can be fixed to the dorsal graft in an integrated
fashion. If additional support is required to minimize the
tilting of the strut, extended spreader grafts can be sutured
to the superior margin of the extended columellar strut.
The surgeon should also use a 5-0 clear nylon suture on
the internal surface of the medial crura and through the
extended columellar strut to create a more stable
reconstruction.
Nasal Tip Lobule Management
At this time, the tip contour can be set with a number of
different tip techniques. In the patient with thin to
medium-thick skin and adequate tip projection, dome
sutures can be used to slightly increase tip projection and
tip definition. The author prefers to use two separate 5-0
clear nylon dome sutures that are placed through each
dome and cinched down to create narrowing.
Most Asian patients have thick skin and need tip definition
and tip projection. Therefore the author frequently places
a tip graft and sutures it to the caudal margin of the medial
crura and domes. Most tip grafts are shaped like a shield
and are thicker at the leading edge and thin at the base. The
edges are beveled, and the leading edge is rounded to
provide a smooth tip contour. The tip graft should have a
slight curvature to allow for a double break in the tip
lobule. The tip graft should be positioned so that it projects
2 to 3 mm above the existing dome structure and fixed
with at least four 6-0 Monacryl sutures (Ethicon, Inc.,
Somerville, NJ). After a tip graft is placed, the leading
edge of the graft must be camouflaged. This can be
Figure 22-8
Caudal extension graft. The graft overlaps the caudal septum and extends caudally to
provide the desired effect. The graft should overlap in a manner that allows the
caudal margin of the graft to sit in the midline.

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
238
A
B
C
Figure 22-9
Caudal extension graft. A, Patient with an acute nasolabial angle and in need of tip rotation. B, In this case, the caudal extension graft should be longer along the inferior margin
and shorter along the superior border to push out the nasolabial angle and rotate the nasal tip. C,The graft is sutured to the caudal septum in an overlapping orientation. Special
care is taken to ensure the caudal margin is in the midline. The medial crura are sutured to the caudal margin of the extension graft.

239
A
B
C
Figure 22-10
Caudal extension graft. A, Patient with a foreshortened nose with too much rotation. B, Correction requires a caudal extension graft that is longer along the superior margin of
the graft and shorter along the base of the graft. This will act to counterrotate the nasal tip and increase nasal length. C,The graft is sutured to the caudal margin of the nasal
septum in an overlapping orientation. The medial crura are fixed to the caudal margin of the extension graft. D, Extended spreader grafts used to stabilize superior margin of
caudal extension grafts. This extension graft will help provide a stable increase in nasal length.
D

240
accomplished by placing a buttress graft behind the
leading edge of the tip graft. The buttress graft helps
prevent the tip graft from rotating cephalically and also
helps create a transition from tip graft to existing domes
(Figure 22-14).10
If the tip graft projects more than 3 mm above the existing
domes, then lateral crural grafts should be sutured to the
posterior surface of the tip graft at an oblique angle of
approximately 45 degrees (Figure 22-15).10 These grafts
provide a continuous transition from tip graft to existing
lateral crura and help prevent graft visibility. Lateral crural
grafts should be relatively flat to avoid creating any tip
bulbosity. The lateral crural grafts can then be sutured to
the surface of existing lateral crura with 6-0 Monacryl
suture. The lateral crural grafts must be strong enough to
support the tip graft and prevent it from rotating cephal-
ically after the skin is closed over the tip graft. Prevention
of this cephalic rotation is particularly important in Asian
rhinoplasty. The surgeon must always be aware of the
skin closure by periodically pulling the skin over the tip
structures to assess tension on the closure of the columellar
incision. If excessive tension is placed on the columellar
closure, the surgeon incurs the risk of deformity, visible
grafts, or skin necrosis.
After the tip graft is placed, the leading edge of the graft
can be further camouflaged by suturing a sheet of the thick
Figure 22-11
After it is sutured into position, the nasal tip should be located in the midline and
show good symmetry to the nasal tip structures.
Figure 22-12
Extended columellar strut carved from costal cartilage. A,The extended columellar strut is placed over the nasal spine and fixated in the midline. Two thin cartilage grafts
straddle the nasal spine and prevent the extended strut from shifting off the midline. B, Other thin cartilage grafts can be used to stabilize the upper aspect of the graft.
A
B

PROCEDURE
241
perichondrium taken from the harvested rib to the leading
edge of the tip graft with 6-0 Monacryl suture. This tissue
is excellent for camouflaging the tip graft, minimizing the
chances of graft visibility, and preserving a round tip
appearance that is ideal for the Asian patient.
Dorsal Augmentation
At this time the tip projection is set, and now the dorsal
height can be set to complement the tip projection. When
a dorsal graft is carved, it should maintain a canoe shape:
narrower and thinner at the ends of the graft. This general
shape provides a more favorable hourglass shape to the
dorsum on frontal view. If auricular cartilage is used, the
surgeon can carve a graft in the proper shape and then
bevel the edges. Auricular cartilage must be carved very
carefully to prevent graft visibility. If necessary, a second
layer of auricular cartilage can be used to double the
thickness (Figure 22-16). In this case, the graft still must be
carefully beveled and all the edges refined. The graft can
then be placed into the pocket on the dorsum and fixated
with sutures to the upper lateral cartilages. Careful
palpation of the graft on the dorsum will help determine
whether it is midline and symmetric. Auricular cartilage
tends to curl at the margins, which could create deformity.
Fortunately the thicker skin of the Asian patient will help to
hide these irregularities (Figure 22-17). If septal cartilage is
available, the auricular cartilage can be placed under the
septal cartilage. The septal cartilage will help camouflage
the auricular cartilage and aid in preventing deformity.
If costal cartilage is used, the sequential carving method
should progressively move toward a canoe-shaped graft
that is narrower at the ends with rounded edges (Figure
22-18). The undersurface of the graft should be slightly flat
to accommodate the native dorsum. The graft should fit
tightly into the subperiosteal pocket over the nasal dorsum.
The upper end of the pocket for the graft should be
dissected so that the upper margin of the graft is at or
lower than the midpupil level in the Asian patient. If the
graft is placed too high on the radix it can create an
unusual look. The dorsal graft should be observed for any
tendency to bend. Ideally, the dorsal graft should have a
slight tendency to bend, creating a concave and convex
surface. The convex surface should face superior. With this
orientation, the tension of the skin envelope will help to
counteract any tendency for the graft to bend. If the dorsal
graft does not bend, it will tend to create a slight dorsal
convexity. Observation of the graft for at least 1 hour is
Figure 22-13
Extended columellar strut. A, Extended columellar strut with a notch in its base, allowing the strut to be lodged over the inferior aspect of the caudal septum and nasal spine
and minimizing any shifting of the strut. B, Note how the notch in the strut accommodates the posterior caudal septum.
(Continued)
A
B

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
242
critical to identify tendencies of the cartilage to bend, and
to make appropriate adjustments. The graft can then be
placed into the pocket and suture fixated with 5-0 PDS
suture to the upper lateral cartilages and to the midline
septum near the anterior septal angle. This three-point
fixation helps stabilize the graft in the midline. If the pocket
over the dorsum is tight, then the graft should be fixed at
four points because the tight pocket on the dorsum will
stabilize the upper end of the graft.
In patients who require counterrotation of the nasal tip or
major stabilization of the tip, the dorsal graft can be
integrated with the extended columellar strut through a
notch carved into the caudal aspect of the dorsal graft. This
notch accepts the strut and creates a continuous cartilagin-
ous support structure that extends from the nasofrontal
angle to the nasal spine (Figure 22-19). The integrated
columellar strut dorsal graft is ideal for patients who need
major augmentation and counterrotation of the nasal tip or
nasal lengthening. In most patients, it is preferable to keep
the dorsal graft separate from the strut to allow for more
independent positioning of the dorsal graft.
Closing the Nose
Closing the columellar incision frequently requires
placement of a midline 6-0 PDS subcutaneous suture to
relieve tension of the superficial skin closure. If a 6-0 PDS
suture does not enable closure of the columellar incision,
Figure 22-13 —cont’d
Extended columellar strut. C, The strut is fixed to the periosteum around the nasal spine and also to the posterior aspect of the nasal septum. Splinting grafts can be used to fix
the upper margin of the graft in the midline.
C

POSTOPERATIVE CARE
243
then there is likely too much tension on the closure. After
the subcutaneous suture is placed, the skin can be closed
with 7-0 vertical mattress sutures. The septal flaps can be
approximated with a running 4-0 plain gut quilting
suture that acts to eliminate the dead space between the
septal flaps and minimize the chances of hematoma
formation.
Postoperative Care
Postoperatively the patient is given a 2-week regimen of
a broad-spectrum antibiotic. The sutures are typically
removed on the seventh postoperative day. The nasal
cavity should be cleared of crusts, and the patient can
irrigate the nose with saline solution.
The nasal cast is removed on the seventh postoperative
day, and the position of the dorsal graft is examined care-
A
B
Figure 22-14
Tip graft with buttress graft. The shield graft is supported from behind with a buttress
graft that spans the posterior edge of the graft with the existing domes.
Note how the buttress graft is angled to meet the domes.
Figure 22-15
Tip graft with lateral crural grafts. Note how the lateral crural grafts create a
continuous transition of cartilage from the edges of the tip graft to the existing lateral
crura. The grafts also support the tip graft to prevent cephalic rotation.
Figure 22-16
Double-layer dorsal graft using a piece of septal cartilage with two pieces of
auricular cartilage under the septal cartilage. The septal cartilage is more regular in
contour and helps camouflage the auricular cartilage.

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
244
A
B
C
D
Figure 22-17
This patient underwent placement of a double-layer dorsal graft made from a layer of septal cartilage and a layer of auricular
cartilage. The graft was used to provide a conservative elevation in the dorsal height. Note how the nose appears narrower on the
frontal view with the increase in dorsal height. A, C, E, and G, Preoperative views. B, D, F, and H, Postoperative views.
(Continued)

POSTOPERATIVE CARE
245
fully. If the dorsal graft has shifted off the midline, then the
patient is instructed to perform nasal exercises to move the
dorsal graft back to the midline. The patients should push
on the graft on the side of the deviation to manage the
slight deviation of the graft. Such exercises can be very
effective in centering a slightly asymmetric dorsal graft.
Warping or major deviations may require revision surgery.
The patient is instructed to sleep with the head elevated on
two or more pillows to help decrease nasal tip edema. The
patient is also requested to avoid eating salty foods, which
can increase nasal tip edema. Patients tend to have an
increase in edema when they are overheated or perspire.
The avoidance of exercise for approximately 1 month will
help minimize postoperative edema.
If the patient experiences postoperative supratip edema
that does not resolve after 4 to 6 weeks, then the surgeon
can request that the patient tape the supratip at night.
This usually helps create the desired supratip contour.
On rare occasions the patient may need an injection of
triamcinolone acetonide (Kenalog, 10 mg/ml).
The
E
F
G
H
Figure 22-17—cont’d
This patient underwent placement of a double-layer dorsal graft made from a layer of septal cartilage and a layer of auricular cartilage. The graft was used to provide a
conservative elevation in the dorsal height. Note how the nose appears narrower on the frontal view with the increase in dorsal height.

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
246
injection volume should be less than 2 ml, and it should be
injected deep to the dermis of the skin to prevent the risk
of subdermal atrophy.
Recovery
After augmentation rhinoplasty, the patient’s nose will heal
over an extended period of time. The patient’s nose begins
to look relatively better after 6 weeks and will continue to
improve over the course of many years. The patient’s nose
will be approximately 50% healed at 1 year postoperatively,
with the remainder to the healing occurring over the
lifetime of the patient. Therefore the appearance of the
patient’s nose will likely improve after the first year, with
improved definition and less edema.
Outcome
In the author’s experience, autologous grafting materials
used with structure rhinoplasty techniques have worked
well in the Asian patient. The grafts provide a stable
augmentation that resists infection and trauma. The
patients tolerate the costal cartilage harvesting procedure
well and can return home on the same day as the surgery,
with mild to moderate chest pain. In the author’s patient
population, the incidence of warping has been relatively
low and is likely the result of the time spent carving the
dorsal grafts using balanced carving principles. The
cartilage does not resorb over time, an outcome that is
supported by the literature.12 The author’s patients have
B
A
Figure 22-18
Costal cartilage dorsal graft. A, Note how the dorsal graft is canoe shaped and is
narrower at the superior and inferior ends of the graft. B, The graft also is thinner at
the cephalic edge. The dorsal graft also has a slight tendency to curve or bend with
the convexity oriented upward.
Figure 22-19
Integrated columellar strut dorsal graft. Note how the columellar strut is integrated
into a notch in the caudal end of the dorsal graft. This type of configuration allows
excellent control of nasal length.

OUTCOME
247
been happy with the aesthetic results. The functional
results have also been very good because of the minimal
excision of supportive tissues and the focus on adding
structure to the nose. In fact, most of the author’s patients
breathe better after surgery.
The techniques chosen for the augmentation procedure
depend primarily on the desire and needs of the patient.
Most patients do well with moderate degrees of augmenta-
tion using septal and auricular cartilage struts and dorsal
grafts. Other patients require a more complex operation
that may call for autologous costal cartilage augmentation
with an extended strut and costal cartilage dorsal graft
(Figures 22-20 and 22-21). The surgeon must be able to
design the surgery that is most appropriate for the patient
based on the discussions made during the consultation.
Figure 22-20
This patient underwent previous augmentation rhinoplasty using a Silastic implant. The implant eroded into the nasal tip skin, leaving a scar and thinned nasal tip skin. A,Two
pieces of costal cartilage were harvested to provide enough cartilage for an extended columellar strut and a dorsal graft. B, An extended columellar strut was integrated into a
notch in the premaxillary graft to provide correction of the deficient premaxilla and to increase tip projection. The notch in the bottom of the premaxillary graft allows the graft to
be fixed over the nasal spine. C, The premaxillary graft and extended columellar strut were fixed into position, and the medial crura were sutured to the extended columellar
strut. D, A tip graft and lateral crural grafts were used to provide additional tip projection and also to prevent excessive rotation of the tip graft.
A
B
C
D

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
248
Figure 22-20—cont’d
This patient underwent previous augmentation rhinoplasty using a Silastic implant. The implant eroded into the nasal tip skin, leaving
a scar and thinned nasal tip skin. E, Note how the lateral crural grafts are obliquely oriented. F, A carefully carved dorsal graft provided
the appropriate degree of dorsal augmentation. G, I, K, and M, Preoperative views. H, J, L, and N, Postoperative views.
(Continued)
E
F
G
H

COMPLICATIONS
249
Figure 22-20—cont’d
I
J
K
L

AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
250
M
N
A
B
Figure 22-20—cont’d
Figure 22-21
This patient underwent previous rhinoplasty, leaving her with a short, upturned nose. She desired a more
natural-appearing nose with less rotation. Correction required a costal cartilage extension graft with two
extended spreader grafts. The caudal extension graft was longer on the superior margin to lengthen the
nose. Lateral crural strut grafts were used to counter-rotate the nasal tip. The nasal dorsum was augmented
with a septal cartilage dorsal graft (A, C, E, G, preoperative photographs; B, D, F, H, postoperative
photographs).
(Continued)

COMPLICATIONS
251
Complications
Potential complications include those related to the harvest-
ing of the grafting material and those related to the
augmentation rhinoplasty. Potential complications of the
auricular cartilage harvest include pain, bleeding, infection,
change in ear shape, dehiscence of the incision, visible scar
or keloid formation, and skin necrosis over the conchal
bowl. Potential complications of harvesting costal cartilage
include pain, bleeding, infection, chest scar, deformity of
the rib cage, pneumothorax, or pneumonia. These compli-
cations can be prevented if the surgeon is careful and
precise in the execution of the harvesting procedure.
Potential complications of the augmentation rhinoplasty
include visible graft, displaced or warped graft, infection,
bleeding, excessive augmentation, or other deformities. The
most common complications noted after costal cartilage
grafting are slight nasal asymmetries that frequently
improved with postoperative nasal exercises. Most com-
C
D
Figure 22-21—cont’d
E
F

5. Deva AK, Marten S, Chang L: Silicone in nasal
augmentation rhinoplasty: a decade of clinical experience,
Plast Reconstr Surg 102:1230-1237, 1998.
6. Lam SM, Kim YK: Augmentation rhinoplasty of the Asian
nose with the “Bird” silicone implant, Ann Plast Surg
51:249-252, 2002.
7. Fry H: Nasal skeletal trauma and the interlocked stresses of
the nasal septal cartilage, Br J Plast Surg 20(2):146-158,
1967.
8. Gibson T, Davis WB: The distortion of autologous cartilage
grafts: its cause and prevention, Br J Plast Surg 10:257,
1958.
9. Johnson CM, Toriumi DM: Open structure rhinoplasty,
Philadelphia, 1989, Saunders.
10. Toriumi DM: Structure approach in rhinoplasty, Facial
Plast Surg Clin N Amer 13:93-113, 2005.
11. Toriumi DM: Caudal extension graft for correction of the
retracted columella, Op Tech Otolaryngol Head Neck Surg
6:311-318, 1995.
12. Horton CE, Matthews MS: Nasal reconstruction with
autogenous rib cartilage: a 43-year follow-up, Plast Reconstr
Surg 89:131-135, 1992.
Recommended Reading
1. Toriumi DM, Becker DG: Rhinoplasty dissection manual,
Philadelphia, 1999, Lippincott.
plications can be prevented by adherence to the patient’s
desires, careful execution of the techniques and close
postoperative follow-up.
These more complex reconstructions require tremendous
attention to detail. If the surgeon is not willing to take the
time to create near perfection in all of the steps in such
cases, then the less-involved augmentation using onlay
grafts of auricular and septal cartilage is a safer choice. Of
course, the surgeon who chooses not to use autologous
materials has the option of using an alloplastic implant.
References
1. Pak MW, Chan ES, van Hasselt CA: Late complications of
nasal augmentation using silicone implants, J Laryngol Otol
112:1074-1077, 1998.
2. Parker Porter J: Grafts in rhinoplasty: alloplastic versus
autogenous, Arch Otolaryngol Head Neck Surg 126;558-561,
2000.
3. Godin MS, Waldman SR, Johnson CM: Nasal augmentation
using Gore-Tex: a 10-year experience, Arch Facial Plast
Surg 1:118-121, 1999.
4. Romo T, Sclafani AP, Sabini P: Use of porous high-density
polyethylene in revision rhinoplasty and in the platyrrhine
nose, Aesthetic Plast Surg 22:211-221, 1998.
AUGMENTATION RHINOPLASTY WITH CARTILAGE GRAFT
252
Figure 22-21—cont’d
G
H

253
Nasal bone graft is used infrequently in cosmetic rhino-
plasty. However, it is an alternative to a cartilage graft or an
alloplastic nasal augmentation when the patient refuses
alloplastic augmentation and requires a large augmenta-
tion. If the patient is reluctant to have a lower chest
wall scar or has a propensity for keloid or hypertrophic
scarring, a rib cartilage graft may not be a suitable option.
An ear or nasal septal cartilage graft often is not sufficient
in amount to augment the low nasal bridge. The deformed
nose secondary to previous trauma may require a non-
alloplastic augmentation because of its diminished
capillary blood flow that may lead to implant extrusion. A
bone graft may provide the necessary structural support
for those patients with skeletal deficiency. Resorption of
the bone graft remains a significant problem.1-6
Consultation
The patient should be thoroughly informed of the
more common alternative procedures. A bone graft is
recommended only after other options, such as an
alloplastic implant or cartilage graft, are not feasible. The
patient should also be educated regarding the possibility of
resorption of the bone graft. Calvarial bone grafts are
preferable because they are associated with less visible
scarring and less postoperative pain and disability than are
iliac bone grafts (Figure 23-1, A and B).
Preoperative Preparation
The patient is advised to shampoo the hair with antiseptic
soap the night before and the morning of the surgery. Pro-
phylactic intravenous antibiotics are given preoperatively.
Augmentation Rhinoplasty
with Bone Graft
Jung I. Park
Anesthesia
Although the surgery can be performed under local or
monitored anesthesia care (MAC), general anesthesia is
preferred for the bone graft harvesting.
Mastoid Bone Graft Harvesting
A solution of 0.5% lidocaine with epinephrine is infiltrated
into the mastoid cortex. After sterile prepping and draping,
an incision is made deep to the periosteum in the post-
auricular sulcus in its entire length. The mastoid peri-
osteum is elevated to the posterior limit of the mastoid
bone. The tendinous attachments should be cleanly
detached with a periosteal elevator. The area of the bone to
be harvested is then marked with a marking pen. The
upper limit of the bone harvesting may extend upward
toward the temporal bone to harvest extra length, if
necessary. The skull bone at the transition area between
the temple and the mastoid bone is still fairly thick and will
allow bone harvesting. The skull bone just outside the
marking is then drilled with a medium-sized cutting burr
to develop a groove around the marking. The groove is
deepened either until the mastoid air cells are encountered
or it is 5 mm deep. The mastoid air cells may be exposed
and included in the harvested bone in the patient with a
well-pneumatized mastoid. Exposed mastoid air cells
encapsulate without causing a significant problem. The
cortex is then shaved off using a heavy, slightly curved
chisel, starting from the temple side to prevent accidental
entrance into the cranial cavity (Figure 23-2, A). The air
cells are drilled until all the mucous membrane is
completely eliminated. The bone is then carved as desired
(see Figure 23-2, B).
23

AUGMENTATION RHINOPLASTY WITH BONE GRAFT
254
Figure 23-1
A, Iliac bone graft. B, Bone graft secured in place with a temporary external suture fixation.
Figure 23-2
A, Mastoid bone graft. B, Carving bone graft with a chisel.
A
B
A
B

NASAL BONE GRAFTING
255
Skull Bone Graft Harvesting
The reader should refer to the description in Chapter 31,
“Premaxillary Augmentation with Bone Graft” (Figure 23-3).3-5
Nasal Bone Grafting
Supplementary local anesthesia is infiltrated using 0.5%
lidocaine with epinephrine solution. Depending on the
need for tip modification, an external or vestibular incision
is made. The goal of a symmetric pocket is just as important
as in the alloplastic implantation. The dissection plane is
immediately above the perichondrium of the upper lateral
cartilage and the subperiosteal space over the nasal bone.
The subperiosteal dissection should be done meticulously
so that the periosteum is preserved. The pocket should be
just wide enough to allow insertion of the bone graft. The
graft should be 20% larger than the anticipated augmenta-
tion to compensate for future bone resorption (Figure
23-4). Despite the need for overaugmentation, an aesthetic
(albeit larger) contour is a crucial achievement. The
columellar graft may be inserted into the columellar
pocket. However, tip projection is better achieved with a
cartilage graft when possible.
A
B
Figure 23-3
Skull bone graft.
Figure 23-4
A, Preoperative view. B, Postoperative view. Nasal bridge was overaugmented with the expectation of graft resorption.