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Capsule Formation
Implantation of silicone will induce macrophage-related foreign-body reaction, which will surround the implant with fibrous
tissue, which is considered as the implant capsule (Fig. 5.1). Implant capsule has the following unique characteristics.
First, the presence of capsule inhibits the adhesion between the implant and the tissue surrounding it. This allows for easy
removal of the implant, if necessary. Because it is an additional layer between the implant and the skin, the added thickness
serves to minimize the implant showing through the dorsal skin (good capsule).
Second, capsular contracture, while not common, can cause upturned nasal tip or visible implant margin (Fig. 5.2). Also,
hypertrophy of capsular tissue can widen the nasal dorsum (bad capsule) (Fig. 5.3).
Fig. 5.1 Intraoperative view of capsule upon removal of silicone
implant
Fig. 5.2 Upturned nasal tip due to the capsular contracture
a
b
Fig. 5.3 Widened nasal dorsum (a) from thick hypertrophied capsule (b)
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Calcification
After a prolonged time of implantation, calcium deposition on the surface of silicone implant can lead to calcification.
Calcification is usually present on the dorsal surface of silicone implant but can also be found on the inner surface of capsule
(Fig. 5.4). Excessive calcification can manifest as visible and/or palpable irregularity of the dorsum.
Fig. 5.4 Calcification on the
surface of capsule and
silicone implant
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e-PTFE (Gore-Tex®)
Manufacturing of e-PTFE
Most widely known by its brand name Teflon, polytetrafluoroethylene (PTFE) powder is passed through two rollers, which
will create a thin membrane that is 0.01 mm in thickness. Expansion of the membrane by means of thermal and mechanical
force will form micropores in a honeycomb pattern. The product of this process is called expanded PTFE (e-PTFE).
Microscopically, the internal structure consists of nodule and fibril (Fig. 5.5). The direction of fibril coincides with the direc-
tion of expansion. The thin e-PTFE membranes are overlapped by 100–200 plies, heated and compressed, which will form
a sheet that is 1–1.5 mm in thickness. This process is called reinforcement. By stacking ten of these reinforced sheets, an
e-PTFE block can be made with a thickness of 10 mm, which is how e-PTFE is supplied as medical implants. This block of
e-PTFE implant can be carved as a nasal implant. Most recently, implant producers have begun to supply e-PTFE blocks in
nasal implant shapes (Fig. 5.6).
The “reinforcement” process is important for the mechanical integrity of the material, as a PTFE sheet created by the
expansion of a single thick layer would collapse very easily in one direction (the direction against the fibrils, akin to an
accordion).
Bidirectional expansion is technically challenging, and products made with bidirectional expansion are available from a
select few production companies.
The most widely known e-PTFE is Gore-Tex® and was introduced first as vascular prosthesis in 1972 by Soyer et al. It
was first used for facial reconstruction by Neel in 1983, and was adopted for rhinoplasty in 1989 by Rosthein and Jacobs.
a
b
c
Fig. 5.6 Products of e-PTFE. (a) Sheet type, (b) block type (GoreTex®,
W. L. Gore and Associates, USA), (c) pre-carved type (Cleoline®, L&C
Bio Co, Seoul, Korea)
Fig. 5.5 Electron microscopic findings of nodules and fibrils of
e-PTFE (Cleoline®, L&C Bio Co, Seoul, Korea)
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Microscopic Structure of e-PTFE
A e-PTFE implant is composed solely of e-PTFE without any additives. Microscopically, the nodules are connected by
fibrils. Internodal distance is 10–40 μm. The honeycomb structure formed by the nodules and fibrils forms the micropores.
The pore sizes are determined by the internodal distance. The surrounding tissue can grow into the implant through these
micropores, which limits implant mobilization. This property also decreases the capsule formation, with capsular contracture
being significantly less than that of silicone implants.
Hardness of e-PTFE
e-PTFE implants come in three hardness: soft, medium, and hard. Among various factors, pore size is the most important in
determining the hardness of e-PTFE material, with smaller pores resulting in harder material. Other factors influencing hard-
ness include the direction of expansion and nodules. Even with smaller pore sizes, implants with bidirectional expansion can
be softer than those with unidirectional expansion.
Characteristics of e-PTFE
Advantages of e-PTFE Implants Are
1. Tissue ingrowth into the pores
2. Decreased implant mobility
3. More resistance to infection
4. Lack of capsule formation, with contracture being infrequent
5. Significantly less calcification, compared to silicone implants
Disadvantages of e-PTFE Implants Are
1. Lower predictability of dorsal shape: In the past, height loss of 20% has been reported after dorsal augmentation using
e-PTFE implants. The dorsal height can decrease over 1–1.5 years of time. Contemporary e-PTFE implants are associated
with 5% decrease in dorsal height.
2. Because of tissue ingrowth and firm adhesion, implant removal is more difficult for e-PTFE implants than for silicone
implants.
The postoperative dorsal height decrease is the most significant shortcoming for e-PTFE implants, which is the reason
behind the decline in the popularity of e-PTFE dorsal implants. To address the issue of height change, manufacturers have
introduced e-PTFE implants with smaller pore size, increased fibril density, and increased pressure during lamination.
Controversial Issues on Nasal Implants
Infection
There has been a long line of controversy regarding whether silicone or e-PTFE implant is more susceptible to infection.
Generally, the risk of infection is proportional to the implant surface area. Because of this, infection rates can be presumed
to be higher for e-PTFE with the high surface area due to micropores, compared to the infection rates for silicone. In addition,
bacteria hiding from macrophage within micropores can induce chronic subclinical infection. However, ingrowth of fibro-
vascular tissue into the material presents a significant deterrence against infection. Thus, e-PTFE may be more vulnerable to
infection in the early postoperative period but may become more resilient to harboring infectious agent. For these com-
pounded reasons, it is reasonable to assume that the overall infection rates are similar between e-PTFE and silicone implants.
The choice of implant material is not the only determinant of postoperative infection. Others include the use of prophy-
lactic antibiotics, pretreatment of implant, and experience of the operator manipulating the implant. The pore of e-PTFE is
around 10–40 μm and prevents ingress of macrophages which are 30–40 μm in diameter. However, the same pores are acces-
sible to bacteria which are 0.5–1.5 μm in diameter. Any bacterium which is able to enter these pores will escape immune
surveillance. Because of this, strict observation of the aseptic principle is of utmost importance throughout the implantation
process. When strict asepsis is not observed, inexperienced surgeons can end up having to manage early, late, or subclinical
infection from e-PTFE implant.
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Naturalness of the Implanted Nose
Any and all implants can make a patient appear unnatural, with the “operated appearance” apparent to anyone. No single
implant exists that can provide a natural appearance in all patients.
It is an outdated misconception that e-PTFE implant can appear more natural than silicone implants, with minimal dorsal
skin redness. e-PTFE does not induce capsule formation, and this can lead to increasing contact and adhesion with dorsal
skin. Paradoxically, this feature of the material can make the implant contour become more conspicuous. This problem is
more common in patients with thinner dorsal skin.
Ultimately, problems such as conspicuousness of implant contour and dorsal skin redness depend more on skin thickness
and amount of tension across the skin than on the choice of implant material.
High-Density Porous Polyethylene (Medpor®)
High-density porous polyethylene (HDPP, Medpor®) is a porous facial augmentation material composed of high-density
polyethylene. A HDPP implant consists of interconnected pores in the 100–250 μm size, which promotes soft-tissue ingrowth
and neovascularization. This implant is relatively non-compressible but still retains slight degree of flexibility and malleabil-
ity. The implant does not undergo long-term resorption, with firm fixation and stability, and strong resistance to deformation
and infection. Because of these properties, the implant material is used for many applications across a wide variety of surgi-
cal disciplines.
Compared to other implants, however, the implant is more likely to extrude through the skin and mucosa. If used as septal
extension graft, the implant can induce erosion and thinning of septal cartilage (Fig. 5.7). Another disadvantage is that it is
difficult to remove.
In Asian countries, revisional rhinoplasty is performed frequently for complications of Medpor® implantation. The author
recommends against the use of this implant for rhinoplasty, especially for the septum and mobile area (nasal tip).
PDS Plate
Polydioxanone (PDS) is a biodegradable polymer, used primarily in the production of suture material. PDS plates are made
of this material, which is made into sheets between 0.15 and 0.5 mm of thickness. Most commonly, PDS plates of 0.15 mm
thickness are used for septorhinoplasty.
A PDS plate will maintain mechanical stability for 10 weeks and by 25 weeks is absorbed completely. The plates have
been used as a template to fix the septal cartilage pieces, after dividing the cartilaginous septum along the fracture lines dur-
ing extracorporeal septoplasty. The plate can also be used to assemble the small cartilage fragments to make for a larger or
longer graft complex.
Fig. 5.7 Thinned and weakened caudal
septal cartilage can be observed. The
patient had a prior operation in which the
Medpor implants were placed on both sides
of the caudal septum as a septal extension
graft, which was removed during the latest
operation
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Allograft Materials
The most commonly used allograft materials for Asian rhinoplasty are cartilage, dermis, and fascia.
Allograft Cartilage
Allograft cartilage is a processed donated costal cartilage and is referred technically as irradiated homologous costal carti-
lage (IHCC) (Fig. 5.8). The processing of donated costal cartilages is slightly different across companies. The methods used
to process the cartilages include osmotic treatment, hyperoxide oxidation, gamma irradiation, freeze-dry, lyophilization, and
demineralization. The purpose behind most of these processes is sterilization of all organisms in the cartilage. The resulting
IHCC product consists of nonviable chondrocytes and a matrix composed of collagen and proteoglycans (Fig. 5.9).
Compared to an autogenous costal cartilage graft, the IHCC has the advantage of not requiring a donor site and associated
morbidities. The disadvantages are resorption, fracture, and possibility of infection.
In the author’s experience, the total complication rate was 8% for IHCC implantation in the nose. Major complications
were fractures (0.6%), fragmentation (1.2%), resorption (1.2%), infection (1.2%), and warping. Most of these complications
occurred in cases where the IHCC was used as a septal extension graft.
Controversy exists on the topic of resorption. Chondrocytes are highly antigenic, but the matrix is considered immuno-
logically nonreactive. As the matrix isolates chondrocytes from exposure to immune cells and circulating antibodies, the
cartilage is immune privileged. Therefore, theoretically, IHCC should not have antigenicity if the perichondrium were
removed properly. However, manipulation of cartilage such as carving does result in exposure of chondrocyte at the cutting
surface, and this may lead to an immunologic reaction that is limited to the cut surface.
It is possible to have graft resorption without immune rejection. Authors have reported the use of IHCC for dorsal onlay
graft, columellar strut graft, and septal extension graft without significant resorption. Few authors have reported that IHCC
is completely resorbed by 15 years. Yet others have reported that even if the graft is resorbed, the volume is replaced by
fibrous tissue, which leads to minimal to no change in external appearance. However, resorption of structural graft, such as
septal extension graft, can lead to significant deformity. If resorption does occur, there is a wide spectrum in the degree to
which the allograft undergoes resorption (Fig. 5.10).
Because of the processing and irradiation, IHCC is more brittle compared to autogenous costal cartilage. If the graft is
fractured in multiple locations, the graft should be fragmented and cannot act as a structural graft (Fig. 5.11). To avoid frac-
ture, the surgeon must source the IHCC from a trusted company, and the graft should be sutured with minimal number of
stitches using round needle.
Fig. 5.8 Irradiated
homologous costal cartilage
(IHCC) (MegaCartilage®,
L&C Bio Co, Seoul, Korea)
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144
a
b
Fig. 5.9 IHCC consists of nonviable chondrocytes within a matrix composed of collagen and proteoglycans. (a) IHCC before implantation. (b)
Thirteen months after implantation in the nose. The nonviable chondrocytes persist within the matrix
Fig. 5.10 Multiple focal
linear shaped resorption in the
graft, with impending
fragmentation
Fig. 5.11 Fractured IHCC (right)
The author does not believe that IHCC has higher infection rate compared to other types of implants. However, IHCC
does have decreased ability to resist off infection, compared to autogenous costal cartilage. It can undergo total resorbed and
even become a nidus of infection.
Despite the possibility of resorption, IHCC is a viable option in older patients who have complete calcification of costal
cartilages and when autogenous costal cartilage graft is not available.
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Allograft Dermis
Allograft dermis is sourced from cadaveric skin, from which the epidermal layer is removed and the dermal layer is pro-
cessed to remove immunogenic cells. The resulting product is an acellular dermal matrix that contains only collagen fiber,
elastin, and proteoglycan. Upon implantation, fibroblasts migrate into the graft, which is followed by ingrowth of blood ves-
sels and nerves. Allograft dermis is available in various sizes and thicknesses. Mainly, it comes prepackaged as freeze-dried
or as hydrated products.
In Asian rhinoplasty, allograft dermis is used for focal dorsal depression, correction of tip/ala irregularities, dorsal aug-
mentation, augmentation of thin skin, coverage of conspicuous implant contour, and wrapping diced cartilage (Fig. 5.12).
Rejection is nonexistent for allograft dermis, and infection is not common. Resorption rate varies across individual
patients between 20 and 50% and occurs up to 16 months.
Allograft Fascia Lata
Processed fascia has the advantage of no donor-site morbidity.
As with other allograft materials, the fascia is treated with osmotic treatment, dehydration, gamma, and irradiation to
minimize immune rejection and remove the possibility of transmission of infectious disease. There is no accurate description
on the resorption rate for processed fascia, and the reported rates are variable across authors. The use of fascia lata allograft
is similar to that of allograft dermis.
a
b
c
d
Fig. 5.12 Various types of allograft dermis used for Asian rhinoplasty (MegaDerm®, L&C Bio Co, Seoul, Korea)
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Further Reading
1. Berghaus A, Stelter K. Alloplastic materials in rhinoplasty. Curr Opin Otolaryngol Head Neck Surg. 2006;14(4):270–7.
2. Vuyk HD, Adamson PA. Biomaterials in rhinoplasty. Clin Otolaryngol Allied Sci. 1998;23(3):209–17.
3. Conrad K, Gillman G.  A 6-year experience with the use of expanded polytetrafluoroethylene in rhinoplasty. Plast Reconstr Surg.
1998;101:1675–83.
4. Owsley TG, Taylor CO.  The use of gore-Tex for nasal augmentation: a retrospective analysis of 106 patients. Plast Reconstr Surg.
1994;94:241–50.
5. Wellisz T. Clinical experience with the Medpor porous polyethylene implant. Aesth Plast Surg. 1993;17:339–44.
6. Skouras A, Skouras G, Karypidisand D, et al. The use of Medpor alloplastic material in rhinoplasty: experience and outcomes. J Plast Reconstr
Aesthet Surg. 2012;65:35–42.
7. Kridel RW, Sturm AK. Dorsal augmentation with homologous rib. Facial Plast Surg. 2017;33(2):195–201.
8. Toriumi DM.  Choosing autologous vs irradiated homograft rib costal cartilage for grafting in rhinoplasty. JAMA Facial Plast Surg.
2017;19(3):188–9.
9. Wee JH, Mun SJ, Na WS, et al. Autologous vs irradiated homologous costal cartilage as graft material in rhinoplasty. JAMA Facial Plast Surg.
2017;19(3):183–8.
10. Jang YJ, Kim JH. Use of tutoplast-processed fascia lata as an onlay graft material for tip surgery in rhinoplasty. Otolaryngol Head Neck Surg.
2011;144:528–32.
11. Jang YJ, Wang JH, Sinha V, et al. Tutoplast-processed fascia lata for dorsal augmentation in rhinoplasty. Otolaryngol Head Neck Surg.
2007;137(1):88–92.
12. Suh MK, Lee KH, Harijan A, Kim HG, Jeong EC. Augmentation rhinoplasty with silicone implant covered with acellular dermal matrix. J
Craniofac Surg. 2017;28(2):445–8.
13. Sherris DA, Oriel BS. Human acellular dermal matrix grafts for rhinoplasty. Aesthet Surg J. 2011;31(7 Suppl):95S–100S.
14. Gryskiewicz JM, Rohrich RJ, Reagan BJ.  The use of alloderm for the correction of nasal contour deformities. Plast Reconstr Surg.
2001;107(2):561–70. discussion 571
15. Gryskiewicz JM. Waste not, want not: the use of AlloDerm in secondary rhinoplasty. Plast Reconstr Surg. 2005;116(7):1999–2004.
16. Gryskiewicz JM. Dorsal Augmentation with AlloDerm. Semin Plast Surg. 2008;22(2):90–103.
17. Dingman RO, Grabb WC. Costal cartilage homografts preserved by irradiation. Plast Reconstr Surg. 1961;28:562–7.
18. Elves MW. Newer knowledge of the immunology of bone and cartilage. Clin Orthop. 1976;120:232.
19. Bolano L, Kopta JA. The immunology of bone and cartilage transplantation. Orthopedics. 1991;14:987–96.
20. Suh MK, Ahn ES, Kim HR, Dhong ES. A 2-year follow-up of irradiated homologous costal cartilage used as a septal extension graft for the
correction of contracted nose in Asians. Ann Plast Surg. 2013;71:45–9.
21. James SE, Kelly MH. Cartilage recycling in rhinoplasty: polydioxanone foil as an absorbable biomechanical scaffold. Plast Reconstr Surg.
2008;122(1):254–60.
22. Rimmer J, Ferguson LM, Saleh HA. Versatile applications of the polydioxanone plate in rhinoplasty and septal surgery. Arch Facial Plast Surg.
2012;14(5):323–30.
23. Gerlinger I, Kárász T, Somogyvári K, et al. Extracorporal septal reconstruction with polydioxanone foil. Clin Otolaryngol. 2007;32(6):465–70.
24. Boenisch M, Nolst Trenité GJ. Reconstruction of the nasal septum using polydioxanone plate. Arch Facial Plast Surg. 2010;12(1):4–10.
25. Suh MK, Lee SJ, Kim YJ. Use of irradiated homologous costal cartilage in rhinoplasty: complications in relation to graft location. J Craniofac
Surg. 2018 Mar 8. Doi: 10.1097/SCS.0000000000004440. [Epub ahead of print].
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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Dorsal Augmentation Using
the Implants
6
Low nasal dorsum is an extremely common feature for Asian nose (Fig. 6.1). Because of this, dorsal augmentation is one of
the most frequently performed procedures in Asian rhinoplasty.
The preference for materials used in dorsal augmentation is distinctive between surgeons from Asian countries and those
from Western countries.
There is no doubt that the autogenous tissue is superior to implants in terms of complications. However, autogenous tis-
sues are disadvantageous for (1) lesser satisfaction in the aesthetic aspect, (2) donor-site morbidity, (3) decreased height or
dorsal irregularity due to graft resorption, and (4) a more complex surgical procedure. For these reasons, implants have been
and continue to be popular for dorsal augmentation in Asia. Owing to the thick soft-tissue envelope, the problem of visible
implant contour is less of a problem in Asian patients.
A high-quality implant placed in the appropriate location under the correct surgical technique minimizes the frequency of
adverse effects. For thin dorsal skin, autogenous tissues are recommended, including dermofat graft or diced cartilage
wrapped in temporal fascia. A block costal cartilage graft may result in a visible contour of the rib cartilage graft for patients
with thin skin.
Dorsal augmentation using implants can be relatively safe while yielding aesthetically satisfactory outcomes in Asian
patients with thicker nasal skin envelop.

148
a
c
b
Fig. 6.1 Asian nose with low and short nasal dorsum. In this patient, the nasal bone is flat and low. The lower lateral cartilages are small as well
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149
Preoperative Evaluation and Planning
During the preoperative evaluation, a patient considering dorsal augmentation should be examined for the following:
1. Facial asymmetry
2. Nasal axis deviation
3. Underlying causes of any tip and nostril asymmetry
4. Dorsal skin characteristics, including texture, color, and problems such as visible veins or telangiectasia
A preexisting nasal deviation can appear worse after a dorsal augmentation. For a patient with nasal deviation, the surgeon
should evaluate whether a nasal deviation is insignificant, or if it requires a camouflage/corrective operation, during the pre-
operative visit.
Even without axis deviation, a dorsal implant may deviate to one side if there is an asymmetry in the height of the nasal
bony roof. Because of this, bony height asymmetry should be addressed with a rasp prior to the placement of an implant.
Unless the implant itself is wide, dorsal augmentation usually makes the dorsum appear narrower, and the intercanthal
distance will seem to be decreased. From the lateral view, dorsal augmentation will give the illusion of decreased protrusion
for lips and chin. Overall, the face will appear smaller.
Implant-based augmentation is not indicated for patients with very thin dorsal skin. Preexisting visible vein or dorsal skin
redness can also become worse after implant placement.
For a dorsal augmentation to appear natural, the radix and supratip area should be addressed properly. The radix should not be
too high in an Asian patient, and the supratip break should not be exaggerated. From the lateral view, female Asian patients prefer
a slight curvature to the dorsal line, whereas male Asian patients avoid the supratip break and the dorsal curvature (Fig. 6.2).
The operator should find answers to the following particular questions during the preoperative consultation:
1. How high should the dorsum be raised?
2. Should the dorsal profile be of a straight line or a curve?
3. What type of implant is necessary to obtain the operative goals?
4. What type of cartilage is necessary for tip projection?
Fig. 6.2 Among female Asian patients,
the preferred dorsal profile is one that
has a slight curvature from the dorsum
to the nasal tip. Asian men usually prefer
a straight dorsal line
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150
Implants
The most commonly used implant for Asian dorsal augmentation is silicone implants, followed by e-PTFE implants.
There are no implants without side effects. Each material has a unique set of advantages and disadvantages, which topic
is discussed extensively in Chap. 5.
Silicone implant is not associated with postoperative change in dorsal height, which is perhaps the most important advan-
tage of using this material. Capsular formation and calcification are some of its characteristics.
e-PTFE implant has micropores into which tissue ingrowth occurs. With tissue ingrowth, the implant is less likely to be
movable, and no capsular formation occurs, which makes capsular or scar tissue contracture less likely than it is with a sili-
cone implant. However, the height of an e-PTFE implant decreases by about 5–20% over time, with less reliable dorsal
height predictability. In addition, tissue ingrowth makes for a difficult implant removal.
The Choice Between Silicone and e-PTFE Implant
A controversy exists on whether silicone implants or e-PTFE implants are better suited for dorsal augmentation. The answer
to this question largely depends on the experience and preference of the operator, without a definite objective answer.
Presently, silicone implants are more widely used because of the excellent predictability in postoperative dorsal height.
Nevertheless, an e-PTFE implant is still used as an alternative, especially for the following cases: contracted nose due to
capsular contracture, hypertrophied capsule, calcification on the surface of silicone implant, weak or torn periosteum (e-PTFE
implant has higher adherence to the nasal bone or adjacent tissues, so that implants are less movable), and late spontaneous
hematoma inside the capsule surrounding a silicone implant.
Thin dorsal skin is a relative contraindication for an e-PTFE implant. Many surgeons still recommend an e-PTFE implant
to patients with thin nasal skin, under the premise that the implant does not show through the skin. However, this is an out-
dated misconception. An e-PTFE implant may force thin nasal skin to adhere tightly to the implant without any capsular
formation, which can actually make for a more conspicuous implant margin and contour.
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151
Operative Techniques
Design
While a patient is looking straight ahead, the starting and end points of an implant are marked on the dorsal midline (Fig. 6.3).
The starting point is usually marked between double- eyelid line and eyelash line. This starting point would be more cephalic for
patients with a protruding forehead, with the point marked more caudally along the dorsum for patients with flatter forehead.
The role of an implant should be limited solely to augmentation of the dorsum itself, and the nasal tip should be projected using
various tip plasty techniques. The implant is safe for augmenting the dorsal height from the radix to the supratip area (Fig. 6.4) and
should be kept out of the nasal tip. The caudal margin of the implant should pass the supratip break by 2–3 mm, with an overall
implant length between 35 and 45 mm. Long implants or L-shaped implants designed to extend into the nasal tip should not be
used, as the implant may cause thinning and redness of the tip skin or a rupture of the tip skin, resulting in implant exposure.
For patients with oblong facial shape, dorsal augmentation can make the face appear longer. In such patients, the starting
point of implant should be placed in a slightly more caudal position, and the operator should aim for a lower height
augmentation.
An Asian patient may voice a wish to have a nasal dorsum with Caucasian features (e.g., “tall”). However, the overpro-
jected nasal dorsum would not be harmonious within the face of an Asian person. In particular, overprojection of the radix
imbues an Asian face with a striking impression, usually described as “fierce” or “aggressive” within Asian culture. For this
reason, understanding what constitutes a natural dorsal profile is pertinent to Asian rhinoplasty.
In a female patient, the nasal tip should be slightly anterior to the dorsal line so as to form the natural supratip break. To
achieve this discrepancy in height, the nasal tip should be projected with cartilage graft. In male patients, the lateral profile
of the dorsum should form a straight line from the radix to the nasal tip (Fig. 6.2).
a
b
c
Fig. 6.3 Starting and ending points for dorsal implant
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152
a
e
f
b
c
d
Fig. 6.4 Four types of dorsal and tip augmentation in Asian rhinoplasty. (a) A L-shaped implant for the dorsal and tip augmentation. (b) L-shaped
implant and cartilage graft on distal tip of implant. (c) Long I-shaped implant and cartilage graft on distal tip of implant. (d) Short I-shaped implant
with cartilage graft on the dome of lower lateral cartilage. This is the most recommended technique for the Asian rhinoplasty. (e, f) Caudal end of
the implant does not extend beyond the cartilage onlay graft
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153
Approach
Dorsal augmentation can be performed via two approaches: intranasal and open approaches. Simple dorsal augmentation can
be performed through intranasal approach, while open approach is needed in cases requiring complex tip plasty. Inframarginal
incision is recommended for the intranasal approach (Fig. 6.5).
Fig. 6.5 Inframarginal incision
Operative Techniques

154
Implant Carving
The operator must be equipped with implants of various shapes and heights provided by the manufacturer (Fig. 6.6). The
implant shape is not only dictated by the desired height and length of the nasal dorsum but also by the width of implant, angle
of nasofrontal slope, and curvature of the implant in the horizontal plane. Implants are available with a variety of widths,
from 8 to 12 mm, with the most commonly used width being 10 mm. The width should be determined individually, depend-
ing on the width of nasal bone.
Silicone implants are available in I-shape (“boat shape”) and L-shape (Fig. 6.7). The I-shape is mainly used for dorsal
augmentation, while the L-shape is used to simultaneously raise both the dorsum and the tip. The L-shape implants are not
recommended since the hard implant in the nasal tip can risk skin redness and thinning, with implant exposure becoming a
serious problem for this specific implant type.
An implant is carved via the following steps (Fig. 6.8):
1. The operator selects the most appropriate implant in consideration of nasal profile and the desired nasal shape for a given
patient.
2. The proximal portion of the implant is placed on the starting point marked on the nose, with the distal ending point
marked subsequently.
3. The implant is cut to the length marked by the end point. Then, the thick distal end is thinly carved.
4. The bottom of the implant is carved and trimmed to the curvature of the dorsum.
Surgeons employ a variety of techniques for carving an implant. For a novice surgeon, No. 11 blade is convenient. A
number of blades should be prepared, ready to replace a slightly dull blade, as the operator carves away.
With respect to hardness of silicone implant, soft type has advantages of better adherence to the nasal bone and decreased
mobility.
Fig. 6.6 Various shapes of the silicone implants
Fig. 6.7 I-shaped and L-shaped silicone implant
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155
a
b
c
d
e
f
Fig. 6.8 Silicone implant carving. (a) Placement of the implant at the cephalic end. (b) The implant is cut at the cephalic end. (c) Thinning of the
cephalic tip of implant. (d) Carving of the implant undersurface to match the dorsal irregularity. (e) Final shape of the implant
Operative Techniques

156
The bottom side of an implant should be curved in, or concave, such that the surface adheres to the dorsal roof of nasal
framework. Implant migration is less likely if the surface of implant closely matches the overall contour of the dorsal roof.
The end of implant should be carved very thin. A thick end of an implant may lead to capsular contracture, which may
occasionally cause skin indentation (Fig. 6.9).
Occasionally, an operator may drill several holes into an implant to prevent implant migration (Fig. 6.10). This technique
should be avoided since it can cause dorsal skin dimpling, secondary to capsular contracture formed within the hole. The
drilled hole can lead to late spontaneous hematoma following tearing of a thread of the capsule within the hole.
The implant is carved over the nasal skin, as an approximation of the shape of the skeletal framework. However, the
uneven thickness of the connective tissue can lead to a mismatch between the carved implant and the skeletal framework.
Because of this, the implant should be placed within the pocket and re-carved until the revised implant results in the desired
shape of the dorsum.
In the past, dorsal augmentation using the e-PTFE material required carving of an e-PTFE block into the shape of a nasal
implant. However, recent introduction of e-PTFE implants in pre-carved nasal implant shapes has made unnecessary the
initial process of rough-carving the block (Fig. 5.6). The carving process of an e-PTFE implant is quite similar to that of sili-
cone implant. As with a silicone implant, an e-PTFE implant also should not be extended into the nasal tip.
a
b
c
Fig. 6.9 In this patient, the supratip groove is caused by capsular contracture around the thick implant tip
6 Dorsal Augmentation Using the Implants

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Fig. 6.10 Drilling of the implant is not
recommended
Incision
The endonasal approach would be sufficient for simple dorsal augmentation, for which infracartilaginous incision provides
adequate exposure (Fig. 6.5). The incision begins initially along the inferior margin of the medial crus, 2–3 mm inward from
the columella border of the midpoint of the columella. Near the dome area, the incision is extended laterally along the infe-
rior border of medial crus. The inferior margin of the lateral crus can be visualized by everting the alar rim inside out.
The endonasal approach is not appropriate when additional procedures are required—most commonly when tip plasty is
required during dorsal augmentation. In such cases, the dorsal space should be approached via an open rhinoplasty
incision.
Implant deviation is a product of improper creation of an implant pocket. When an operation creates an implant pocket
through a right-sided endonasal access, the radix portion of the pocket can easily deviate towards the left side. Because of
this reason, pocket dissections should be performed through incisions made in both nares.
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158
Dissection
An implant pocket refers to the dissected space to be used for implant placement, and the creation of this pocket to be as
straight and symmetric as possible is the most significant step during dorsal augmentation.
The dissection is carried out above the perichondrium in the lower lateral and upper lateral cartilages (supraperichondrial
dissection) and under the periosteum in the nasal bone area (subperiosteal dissection). Metzenbaum scissors are utilized for
the supraperichondrial dissection while preserving the maximum amount of soft tissues attached to the skin envelope.
The subperiosteal pocket is important in limiting the mobility of an implant and to reduce the visibility of the implant
contour through the skin. To gain initial access into this plane, a Joseph knife is used to cut the periosteum transversely about
1 mm above the inferior margin of the nasal bone. Then, a Joseph elevator is used to lift the periosteum. To decrease the risk
of tears, the periosteum should be elevated in small portions, bit by bit, rather than lifting large portions of periosteum at once
(Fig. 6.11). Once an operator is acquainted with this procedure, he/she might elect to forgo the knife and use only the Joseph
elevator.
Creation of symmetric implant pocket requires that the dissection be performed through both left and right sides (Fig. 6.12).
There are two main schools of thought regarding the size of an implant pocket. One opinion is that the pocket should be
the exact size of an implant, and the contrary opinion is that the pocket should be slightly larger than the actual implant. The
author recommends the slightly larger pocket size. Theoretically, snug and precisely fitting pocket can prevent shifting of an
implant. In reality, such a tight-fitting pocket does not provide any assurances in having the identical left and right dimen-
sions of a pocket. A pocket that is slightly wider than that of the implant allows room for external manipulation of a migrated
implant at a later date. The time it takes for a capsular formation to set the implant into position is 10–14 days after surgery.
An implant that deviates from the surgically set position can be repositioned within this period.
For a nasal dorsum that is not straight or uniform (for example, the nasal dorsum is skewed to one side), an inserted
implant may easily deviate from the midline if the slope of nasal dorsum has not been properly compensated by carving the
implant properly or if the nasal asymmetry has not been corrected with a camouflage technique or osteotomy.
Fig. 6.11 Periosteal elevation with step-by-step maneuver
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Fig. 6.12 Dissection and pocket formation through bilateral access. (a) Inframarginal incisions are placed bilaterally. (b–d) Dissection around the
nasal tip and over the upper lateral cartilage. (e–g) Periosteal elevation. (h) Implant insertion
a
b
c
d
Operative Techniques

160
e
f
g
h
Fig. 6.12 (continued)
6 Dorsal Augmentation Using the Implants

161
Irrigation of Pocket
Washing the inner pocket with a mix of povidone-iodine solution and an antibiotic is helpful for prevention of infection.
Pretreatment of e-PTFE Implant
An e-PTFE implant has internal pores of 25–40 μm in diameter. A bacterium is smaller than this diameter and may enter
through these pores to reside within the implant. A macrophage is larger than the pore and cannot enter to combat these
bacteria. For this reason, pretreatment is required for infection prevention. Firstly, a thorough aseptic technique and removal
of the powder residue on gloves are necessary. Secondly, a liquid mixture of povidone-iodine and antibiotics is used for
washing the implant. Simply submerging an e-PTFE implant within a solution of antibiotic does not allow infiltration of the
antiseptic agent into the pores. Thus, the antiseptic solution should be forced to flow through these pores under negative pres-
sure. To accomplish this, the author inserts an e-PTFE implant into a syringe filled with a povidone- iodine solution and an
antibiotic. In an attempt to fill these pores with this solution, the syringe plunger is pulled to create negative pressure within
the chamber (Fig. 6.13).
Fig. 6.13 Pretreatment of the e-PTFE under
negative pressure
Operative Techniques

162
Implant Insertion
The implant is introduced into the pocket through an inframarginal incision. It is important to make sure that the implant is
positioned in the center of the pocket without deviation. Insertion of a silicone implant is not difficult, but an operator should
heed the following precautions for e-PTFE implants:
Forced insertion of the implant using forceps or a clamp can lead to wrinkling or indentation. If insertion of an e-PTFE
implant is met with resistance, the operator should not force further insertion of the implant. Instead, the implant should be
pulled towards the radix using a pullout suture. The pullout technique also facilitates proper positioning of the cephalic end
of the implant to the midline.
There is no need to fix the caudal end of implant, but if the operator cannot be sure that the implant position is stable, the
distal end can be fixated to the septal angle or alar cartilage (Fig. 6.14).
Fig. 6.14 Fixation of the silicone implant to the alar
cartilage
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163
Management of Supratip Area
A depression or bulging should be avoided between the caudal end of the implant and the cartilage onlay graft.
Theoretically, female patients should have a break point in the supratip area, such that there is a slight curvature from the
dorsum to the nasal tip. A natural-looking supratip break requires two things: (1) adequate tip projection and (2) prevention
of supratip bulging. To prevent supratip bulging, the caudal end of implants should be carved to a thin taper. Supratip bulging
can be caused by inadequate tip projection, thick supratip soft tissue, or too thick of implant at the caudal end.
A supratip groove occurs due to height discrepancy between the thinly carved distal end of an implant and the onlay graft
at the tip (Fig. 6.15). The groove is relatively inconspicuous for thick nasal skin. Because of this, the supratip area should be
palpated for a hidden groove. If an operator does find a groove, the area can be bolstered using dermis or cartilage graft
(Fig. 6.16), which should be placed between the skin envelop and the caudal end of implant.
Fig. 6.15 Visible groove between the implant end
and onlay graft
Operative Techniques

164
a
b
c
d
Fig. 6.16 (a) Cartilage graft between the implant tip and cartilage onlay graft to address the supratip groove. (b) The groove is noticeable in the
supratip area. (c) Septal cartilage graft is placed atop the groove. (d) Groove has disappeared after having placed the cartilage graft
6 Dorsal Augmentation Using the Implants

165
Wound Closure
An absorbable suture material is used to repair the intranasal incision. Drain is not necessary.
Dressing
The nasal tip is stabilized using a Joseph dressing (Fig. 6.17). In addition, the author applies compression to the dorsum with
an aqua splint (Thermosplint), which helps to minimize postoperative swelling.
Fig. 6.17 Joseph dressing
Operative Techniques

166
Postoperative Care
The aqua splint and paper dressing are removed 4–5 days after surgery. For the first 2 weeks, the implant should be monitored
closely for any deviation. During this time, implant deviation can be corrected by external manipulation of the implant. If
implant deviation is discovered after 2–3 weeks, the revision should be performed in the following manner:
For deviated silicone implant, a small inframarginal incision is made on the side contralateral to implant deviation.
Unilateral capsulotomy is performed along the lateral margin of the posterior capsule by using a D-knife or a pair of scissors
(Fig. 6.18). A small additional pocket is made to allow movement of the implant into the area slightly lateral to the capsu-
lotomy site. After manipulating the implant to a midline position, the implant is stabilized with paper tape dressing and aqua
splint.
For deviated e-PTFE implant, an incision is made in the inner nose. An elevator is used to lift the implant from the upper
lateral cartilage and nasal bone. Afterwards, the implant can be moved into proper position. Figures 6.19 and 6.20 demon-
strate dorsal augmentation in male and female patients.
Fig. 6.18 Design for the unilateral capsulotomy
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167
a
d
b
e
c
f
Fig. 6.19 Dorsal augmentation using silicone
implant (3.5 mm in height) and tip projection
using conchal cartilage onlay graft (closed
approach). (a–c) Before operation. (d–f) After
operation
Postoperative Care

168
Fig. 6.20 Dorsal augmentation using silicone
implant (5.0 mm in height) and tip projection
using conchal cartilage onlay graft (closed
approach). (a–c) Before operation. (d–f) After
operation
a
d
b
e
c
f
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169
Dorsal Augmentation in Thin Skin
With aging, thinning of the nasal skin can make an implant become more conspicuous. The rule of thumb is not to use
implants in patients with thin nasal skin. If an implant is needed in patients with thin dorsal skin, however, the implant should
be thinner than the ones typically used. Covering the implant with deep temporal fascia or dermal allograft can reduce the
risk of an implant showing through the skin (Fig. 6.21).
a
b
Fig. 6.21 Implant covered with temporal fascia (a) and dermal allograft (b) (MegaDerm®, L&C Bio, Seoul, Korea)
Dorsal Augmentation in Thin Skin

170
Further Reading
1. Ahn JM. The current trend in augmentation rhinoplasty. Facial Plast Surg. 2006;22:61–9.
2. Suh MK. Dorsal augmentation with implants. In: Asian rhinoplasty. Seoul: Koonja; 2012. p. 73–102.
3. Tham C, Lai Y-L, Weng C-J, Chen Y-R. Silicone augmentation rhinoplasty in an oriental population. Ann Plast Surg. 2005;54(1):1–5.
4. Deva AK, Merten S, Chang L.  Silicone in nasal augmentation rhinoplasy: a decade of clinical experience. Plast Reconstr Surg.
1998;102(4):1230–7.
5. Godin MS, Walderman SR, Johnson CM. Nasal augmentation using Gore-Tex: a 10-year experience. Arch Facial Plast Surg. 1999;1:118–21.
6. Jung YG, et al. Ultrasonographic monitoring of implant thickness after augmentation rhinoplasty with expanded polytetrafluoroethylene. Am
J Rhinol Allergy. 2009;23:105–10.
7. Peled ZM, Warren AG, Johnston P, Yaremchuk MJ. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr Surg.
2008;121:85e–92e.
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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Dorsal Augmentation Using
Autogenous Tissue
Unlike Western nations, the material most commonly used for dorsal augmentation in aesthetic plastic surgery clinics in Asia
still is an implant. The reason is that an implant not only provides a further defined and more beautiful dorsal shape, but also
requires shorter operating time without the donor- site morbidity that is associated with autogenous tissue harvesting. Asians
have a thicker dorsal skin than Caucasians, which contributes to remarkably low incidences of implant- related complications
among Asians. Nonetheless, nasal dorsal augmentation utilizing autogenous tissue still is the ultimate goal for aesthetic
rhinoplastic surgeons, due to the fact that autologous tissue is less likely to cause implant- related complications such as
infection, dorsal skin thinning and redness, capsular contracture, implant exposure through the tip skin, or vestibular mucosa
while providing a less psychological discomfort.
No single material or graft is able to meet all the requirements of dorsal augmentation, and every material has its own
unique set of advantages and disadvantages.
Despite the routine use of implants in Asian rhinoplasty, it is important for every rhinoplasty surgeon to be familiar in the
use of autogenous tissue in dorsal augmentation for patients with very thin skin envelope or for secondary operations rising
from implant complications.
Autogenous tissues are appropriate for dorsal augmentation in the following cases:
1. Extremely thin skin on the nasal dorsum
2. Secondary operation for implant-related complication, such as dorsal skin thinning, dorsal erythema, or capsular
contracture
3. Patient preference against implant material
In East Asian patients, the most commonly used autogenous grafts are temporal fascia, dermofat, block type of costal
cartilage, and diced cartilage (Fig. 7.1).
7

172
Temporal fascia
Rib cartilage
Dermofat
Diced cartilage
Fig. 7.1 Autogenous tissues
available for dorsal
augmentation in Asians
7 Dorsal Augmentation Using Autogenous Tissue

173
Radix Augmentation with Temporal Fascia
The temporal fascia is generally used to wrap diced cartilage or cover a block cartilage graft. It is also utilized for the purpose
of concealing a visible underlying osseocartilaginous framework in patients with thin skin. And a fascia graft by itself may
be used for dorsal augmentation. The amount of harvest from the temporal fascia is limited, and post-graft resorption is rela-
tively high, making it restricted to carry out whole dorsal augmentation in Asians with a low dorsum. Thus, the temporal
fascia is largely used for radix augmentation or correction of focal irregularities or depression of the dorsum.
Operative Techniques
Harvest of Temporal Fascia
The anatomy of temporal fascia is described extensively in Chap. 4. The graft is harvested between the temporal crest and
the auricle (Fig. 7.2). The operative details for deep temporal fascia harvest are described in Chap. 4 (Fig. 4.32).
Fig. 7.2 Incision for accessing the temporal fascia
Radix Augmentation with Temporal Fascia

174
a
b
c
Fig. 7.3 Radix augmentation using the rolled deep temporal fascia. (a) Harvested deep temporal fascia. (b) The fascia is rolled like a roll cake.
(c) The rolled fascia is placed in the radix area
Augmentation Technique
After harvesting the temporal fascia graft, the fascia graft is rolled to have a preferred volume (height) in a desired length,
similar to a roll cake (Fig. 7.3). The fascia will contain a lot of interstitial fluid, which should be squeezed out of the tissue
prior to rolling the fascia. This will minimize the overestimation of graft volume. The graft volume should be greater than
the amount desired for augmentation to account for postoperative resorption.
Visibility, infection, or skin redness is nil (0%) with temporal fascia graft, and the revision rate secondary to long- term
complications is very low. Nevertheless, the high resorption rate is the main disadvantage. Considering the minimal resorp-
tion rate of 30% or more, overcorrection of at least 30% is required. Figure 7.4 shows an example of radix augmentation
using a temporal fascia graft.
7 Dorsal Augmentation Using Autogenous Tissue

175
a
d
b
e
c
f
Fig. 7.4 Radix augmentation using the
rolled temporal fascia. (a–c) This male
patient has a low radix, and supratip
depression due to saddle nose deformity.
(d–f) Three months after radix
augmentation surgery using the rolled
temporal fascia, conchal cartilage graft
on the supratip area and tip projection
with columella strut graft using the
conchal cartilage
Radix Augmentation with Temporal Fascia

176
Dorsal Augmentation with Dermofat
Dermofat graft has been used for the correction of facial volume deficiency since long ago.
The dermofat graft incorporates both the dermis and the underlying subcutaneous fat tissue. A graft composed solely of
subcutaneous fat tissue may have poor survival rate, depending on the donor site. A dermal graft would avoid this problem
of survivability but does not provide enough graft volume needed for dorsal augmentation. In contrast, dermofat graft pro-
vides adequate tissue volume through the fat tissue, to which the blood supply is provided by the subdermal vascular plexus
and is associated with lower rates of resorption. Because of this, dermofat graft is the most commonly used autologous tissue
for dorsal augmentation in East Asian countries. In particular, dermofat graft can be most safely applied to the thinned dorsal
skin after the removal of illegally injected foreign liquid material to the dorsum, which was rather common in Asia.
Operative Technique
Harvest Procedures
A graft is harvested from one side of the buttock close to the intergluteal crease. The medial margin of the graft is located
about 2–3 mm lateral to the crease (Fig. 7.5). The design of dermofat should incorporate larger-than-needed dimensions to
account for the contracture. For the purpose of dorsal augmentation, the author harvests the dermofat that is 60 mm long,
10–12 mm wide, and 6–10 mm deep. The skin is incised using a No. 15 blade without exposing the subcutaneous fat. The
dermis is de-epithelized by peeling off the epidermis using a No. 10 blade. After de-epithelization, the dermal incision is
carried down into the subcutaneous tissue. Once the incision is at an adequate depth, the whole graft is elevated en bloc.
a
b
c
d
Fig. 7.5 Harvesting the dermofat graft. (a) Graft is harvested from one side of the buttock close to the intergluteal crease. (b) After the skin inci-
sion along the designed line, de-epithelization is performed. (c) The dermis and fat layer are harvested. (d) Wound closure
7 Dorsal Augmentation Using Autogenous Tissue

177
Dorsal Augmentation Technique
Unlike silicone implants, dermofat grafts are placed in the supraperichondrial and supraperiosteal planes.
The superior end of silicone implant is usually placed at the height of upper eyelash line or the supratarsal fold. Dermofat
graft should be placed a bit more cephalically than this upper point. For most patients, the author finds the midpoint between the
supratarsal crease and the eyebrow to be appropriate (Fig. 7.6). This will tend to result in a natural augmentation of the radix
upon partial resorption of the dermofat. Inferiorly, the caudal end point of dermofat should reach all the way to the nasal tip.
Prior to insertion, the dermofat should be trimmed to appropriate width and shape. Usually, a graft width of 10 mm is
appropriate, but this should be tailored to the width of each individual nose. Akin to the shape of silicone implants, the der-
mofat should be contoured such that the floor is wider and the roof is narrower (Fig. 7.7). Regarding the orientation of der-
mofat, the conventional practice is to place the dermis side up and subcutaneous down within the graft pocket—the idea
being the proximity of the de-epithelized dermis to the nasal skin allowing neovascularization and increasing graft survival.
In practice, however, the author thinks that the orientation of dermofat placement does not affect the survivability, or resorp-
tion, of the graft. Additionally, placing the graft such that the fat layer is on top facilitates the shaping the graft more easily.
For fixation, the cephalic end of dermofat graft is secured using a pullout suture between the eyebrows. At the caudal end,
a
b
Fig. 7.7 Trimming the dermofat graft. (a) Trimming the fat portion of the graft. (b) The graft’s shape resembles that of the implant, whose roof
side is narrower than the bottom side
Fig. 7.6 Starting point of the dermofat graft is
approximately the midpoint between the double-
eyelid crease and eyebrow
Dorsal Augmentation with Dermofat

178
a
c
b
Fig. 7.8 Fixation of the dermofat graft. (a, b) A pullout suture is used to fix the cephalic end of the graft to the area between the eyebrows. (c) The
caudal end of the graft is fixed to the septal angle or dome of the lower lateral cartilage by using an absorbable suture
the graft is fixated to the septal angle or the dome of lower lateral cartilage using a 5-0 PDS suture (Fig. 7.8). The pullout
suture is removed a week after the operation.
The dermofat graft can undergo partial resorption up to 18 months after the operation. The resorption rate increases with
the amount of fat tissue. Some authors reported as much as 70% resorption rate. Other authors reported that 25–30% of
overcorrection would be sufficient, but an approximately 40–60% or higher resorption rate is generally considered to be
average. Thus, overcorrection should be performed in consideration of this resorption rate. Surgeons must also consider the
patient’s psychological uneasiness towards unnatural height and shape, secondary to overcorrection, in the early period after
surgery. Such a decision is made after a discussion with the patient before surgery, but usually an overcorrection of 30–40%
is appropriate. However, resorption rate varies widely across individuals and cannot be predicted in an accurate manner.
Resorption occurs until approximately 16 months after surgery, but there is not much change thereafter (Fig. 7.9). In most
cases, an unsatisfactory dorsal height is shown due to the high absorption rate, necessitating an additional procedure such as
fat injection (Fig. 7.10).
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179
a
d
b
e
c
f
Fig. 7.9 Pre- and postoperative views of dorsal
augmentation using the dermofat graft. (a–c)
Preoperative view. (d–f) Three years after
dermofat grafting for the dorsum and conchal
cartilage onlay grafting for the tip projection
Dorsal Augmentation with Dermofat

180
a
e
d
c
b
f
Fig. 7.10 The case shows significantly
high resorption of dermofat graft on the
dorsum. (a–c) Preoperative views. (d–f)
Graft resorption is observed 7 months after
surgery. Therefore, fat injection was
performed on the dorsum. (g–i) Resorption
is still observed, especially in the supratip
area, even at the second attempt of fat
injection 6 months after surgery. Then,
additional allograft dermis graft was
performed on the dorsum. (j–l) One month
after allograft dermis graft
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181
g
k
j
i
h
l
Fig. 7.10 (continued)
Dorsal Augmentation with Dermofat

182
Indications for Dermofat Graft
Despite the relatively high rates of resorption, dermofat graft allows for a natural shape of augmented dorsum. Compared to
cartilage grafts, skin thinning and redness are less common with dermofat graft. Furthermore, the graft does not share the
complications of implants such as implant contour showing through the skin, inflammation, or infection. Therefore, dermofat
graft is appropriate for the following situations:
1. Patients with very thin dorsal skin of nose in whom silicone implants may become conspicuous or cause dorsal skin
redness.
2. Patients who are apprehensive about silicone or Goretex implant.
3. Patients who wish for a natural nasal profile with mild augmentation.
4. Secondary rhinoplasty for skin thinning or redness from implant material.
5. After removal of injected materials (e.g., liquid silicone), the dorsal skin may be extremely thin with irregular texture. In
such cases, implants or cartilage grafts can show through the thin skin, and dermofat graft would be more appropriate. It
is possible to use a combination of implant and dermofat. In such cases, the dermofat is interposed between the implant
and the dorsal skin.
6. Skin wrinkling after removal of high implant can be addressed by dermofat graft.
7. Correction of minor depression or irregularity in the dorsum, ala, or tip.
Vertically Oriented Folded Dermal Graft Technique
Dermofat graft undergoes resorption in both dermal layer and fat layer, but this resorption is greater in the fat layer. To retain
the maximum amount of dorsal augmentation, the thickness of dermal layer should be maximized while minimizing the
thickness of the fat layer. Some authors reported cases of dermal graft for dorsal augmentation. Nevertheless, there are dif-
ficulties in the correction of very low dorsum of Asians, due to limitations in human dermal thickness. KH Kim et al. reported
a method of dorsal augmentation by folding two layers that had been collected from the dermal layers of the buttocks.
However, the technique which enables much higher dorsal augmentation is a vertically oriented folded dermal graft tech-
nique which was firstly presented by Cho IC et al.
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183
Design on the Donor Site
With the patient in prone position, the graft is designed in the sacrococcygeal area as shown in Fig. 7.11. The inferior end
point of graft is located 2 cm superior to the coccyx. The superior portion of the graft design can be altered depending on
how much of the radix is to be raised (Fig. 7.12). The cephalic portion of the graft needs to be wider for greater augmentation
of the radix area.
a
b
Fig. 7.11 Design of the vertically oriented folded dermal graft. The graft is located at the midline of the sacrococcygeal area, and the caudal end
of the graft is located 2 cm above the coccyx. The length of the graft is 6 cm, while the width of the cephalic area is 3–4 cm and that of the caudal
area is 1.6–1.8 cm
Fig. 7.12 Adjustment of the
cephalic width of the graft.
The higher the radix height
one desires, the wider the
width of the cephalic area of
the graft should be designed
Dorsal Augmentation with Dermofat

184
a
b
c
e
d
f
Fig. 7.13 Harvesting of the vertically oriented folded dermal graft. (a) Incision is made, along the incision line, into the half-thickness depth of the
dermis. (b) The epidermal layer has been peeled off from the dermal layer. (c) A deeper dermis incision is made to reach a part of subcutaneous fat
layer. (d) The appearance of the buttocks after the dermis and fat layers has been harvested. (e) Closure of the subcutaneous layer. (f) Skin closure
Infiltration of Local Anesthetics
Local anesthetic is infiltrated along the incision design. Inside the graft area, shallow infiltration can alter the dermal thick-
ness. Using a long spinal needle, the anesthetic is infiltrated in the deep subcutaneous fat or the deep fascia.
Harvest of the Graft
Regarding the graft harvesting method, the graft harvest begins with incision through half the thickness of dermis as seen in
Fig. 7.13. Then, de-epithelization is performed. Thereafter, the incision is carried into the subcutaneous fat layer. The graft
is elevated while incorporating a minimal amount of the fat into the graft.
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185
Wound Closure
The donor site should be closed without undermining the skin to minimize the risk of necrosis in the wound margin. The
dermal layer is closed using No. 3-0 Vicryl sutures, and the skin is closed using No. 3-0 nylon sutures. Drains are not
necessary.
Fabrication of the Harvested Graft
The graft fabrication uses multiple sutures to fold the graft such that it becomes more compact horizontally and provides
maximal height.
The harvested graft is fixated to a thick paper plate with a pin on each end. A portion of the subcutaneous fat is trimmed
to leave minimal amount of fat such that the combined thickness of the dermis and fat ends up around 4 mm (Fig. 7.14). A
straight line is drawn along the central axis of the graft, with two offset lines on either side. The graft is folded in half along
the central line by placing five 6-0 nylon sutures through the offset lines. The folded edges are brought together in four places
using 5-0 nylon sutures, and this becomes the graft base. Next, the graft is made more compact by the use of multiple outer
vertical or horizontal sutures (5-0 nylon). If bulging of the graft’s base occurs due to these sutures, the base is trimmed until
it is flat. Next, the outer circular sutures are placed using 5-0 nylon. At this point, the graft should stand vertically on its base
as shown in Fig. 7.14h. The final height of the fabricated graft should be around 10–12 mm.
a
b
c
d
Fig. 7.14 17 Fabrication of a graft. (a) A harvested graft containing minimal fat. (b) Marking for five inner sutures. (c) Five inner sutures were
placed using a No. 6-0 nylon suture. (d) Four base sutures were placed using a No. 5-0 nylon suture. (e) Multiple outer horizontal sutures were
placed using a No. 5-0 nylon suture. (f) The graft base was trimmed to remove the bulging after outer horizontal sutures. (g) The outer circular
sutures were placed. (h) The graft is erected in a vertical orientation after all the sutures have been placed
Dorsal Augmentation with Dermofat

186
g
h
e
f
Fig. 7.14 (continued)
7 Dorsal Augmentation Using Autogenous Tissue