Atlas of Asian Rhinoplasty (Volume 3) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Incision, Approach, and Perioperative
Medications and Instructions
3
Incision and Approach for the Rhinoplasty
An incision is an opening made in the skin or mucosa that provides the operator an access to certain bony and cartilage
structures of the nose. An approach is a surgical method performed to arrive at or expose a certain nasal structure, includes
the dissection, and may require a combination of several incisions.
A variety of incisions and approaches are used for rhinoplasty. Each incision and approach has a unique set of advantages
and disadvantages, and as such no single approach can allow the wide variety of rhinoplasty techniques to be performed. An
experienced operator should be familiar with the spectrum of incisions and approaches, and be able to use the access that is
most appropriate for a given situation. Approaches for the rhinoplasty include closed approach (endonasal approach) and
open approach.
Endonasal Approach
The intranasal incisions used for endonasal approach include inframarginal incision, intracartilaginous incision, intercarti-
laginous incision, and transfixion incision (Fig. 3.1).
a
b
c
d
Fig. 3.1 Incision for endonasal approach. (a) Inframarginal incision, (b) intracartilaginous incision, (c) intercartilaginous incision, (d) transfixion
incision

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a
b
c
Fig. 3.2 Inframarginal incision. (a) The incision starts 2–3 mm inside from the columellar border and extends cephalically along the caudal mar-
gin of the medial crus. (b) Avoiding the soft triangle, the incision curves outward at the domal area. (c) Incision extends laterally along the caudal
margin of lateral crus
Inframarginal Incision
The inframarginal incision is the most commonly performed rhinoplasty incision. The incision begins just inside of the mid-
point of columella and continues along the caudal margin of the medial crus of the lower lateral cartilage towards the dome.
Near the dome, the incision is extended laterally along the caudal margin of the lateral crus (Fig. 3.2). With outward retrac-
tion of the alar rim, the caudal margin of lateral crus can be observed as the line between the areas with and without vibrissae.
The margin is located deeper more laterally. The inframarginal incision should be placed deeper within the nostril than the
alar rim itself. The incision should never be made along the alar rim to avoid inadvertent changes to the shape of the
nostril.
For accurate suture technique on the lower lateral cartilage, the inframarginal incision should be made for both sides.
Even without cartilage workup, bilateral incision and dissection can allow for symmetric pocket formation for a dorsal aug-
mentation or simple cartilage onlay graft.
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Intercartilaginous Incision
The intercartilaginous incision is made in the vestibular skin between the upper lateral cartilage and lower lateral cartilage.
This incision provides access to the cartilaginous and bony dorsum, and allows retrograde undermining of the lobule
(Fig. 3.3). The ala is retracted in a lateral and cephalic direction with a double-skin hook, while the middle finger of the
retracting hand is used to provide counterpressure and expose the valve area. After identifying the caudal margin of upper
lateral cartilage, a No. 11 or 15 blade is used to make the incision along the caudal margin of the cartilage and then towards
the valve angle.
This incision is used for operations in the nasal dorsum (e.g., hump reduction).
In order to minimize the risk of nasal valve injury, the incision should be made 1–2 mm inferior to the limen vestibuli.
Intracartilaginous Incision
Intracartilaginous incision passes through the lateral crus of the lower lateral cartilage. This incision is caudal to the nasal
valve, and thus decreases the risk of nasal obstruction (i.e., avoids scar contracture of the valve observed after an intercarti-
laginous incision). This incision is useful for partial resection of the cephalic portion of the lateral crus. In most cases, the
incision is made 6–8 mm cephalic to the caudal margin of lateral crus. The author does not recommend the use of this inci-
sion because the cartilage incision may not be symmetric and because the lateral crura are asymmetric most of the time.
a
b
c
d
Fig. 3.3 Intercartilaginous incision
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Transfixion Incision
Transfixion incision is an incision of the membranous septum overlying the caudal end of the cartilaginous septum. It can
also be called caudal septal incision. This incision provides access to the septum, premaxilla and anterior nasal spine, and
floor of the nasal cavity.
Complete transfixion incision is an incision made through both sides of the membranous septum; thus, it is a through- and-
through incision made at the caudal end of the septal cartilage. A subperichondrial dissection can be carried out on both sides
of the septum through this incision (Fig. 3.4).
A hemitransfixion incision is performed for septal operations, where the incision is made through one side of the mem-
branous septum. One side of the membranous septum is incised, through which both sides of the mucoperichondrium are
elevated. A right-handed surgeon makes this incision on the right side of the septum.
Fig. 3.4 Transfixion incision
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Fig. 3.5 Open rhinoplasty
incision
Open Approach
Open rhinoplasty requires an external incision on the columella and an intranasal incision along the inframarginal border.
The columellar incision has several variations including inverted-V incision, stair-step incision, and columellar base V
incision. Of these, the inverted-V incision and stair-step incision are widely used (Fig. 3.5). The author prefers inverted-V
incision because it appears to result in less noticeable scars with little chance of scar contracture.
The incision is made at the narrowest point of the columella, which is usually the midportion. This incision area is usually
where the underlying cartilage is closest to the skin, which minimizes the chance of depressed scar. If the incision is placed
too posteriorly in the columella, the resulting scar will be long, and the chance of the scar indentation is higher because the
skin is not so closely supported by the underlying cartilage structures.
A No. 11 blade is used to make the inverted-V portion, and a No. 15 blade is used for the transverse incision on the colu-
mella. The incision should be kept perpendicular to the skin surface. The incision is continued towards the alar dome area
along the caudal margin of the medial crus. At the dome area, this incision goes further along the caudal margin of the lateral
crus, which is the inframarginal incision (Fig. 3.6). The caudal margin of lower lateral cartilage can be visualized and
exposed by the placement of skin hook along the alar rim and eversion of the ala using the index and middle fingers of the
hand holding the retractor. The inframarginal incision can be difficult to perform if the nostril is small or if the caudal margin
of lower lateral cartilage cannot be visualized easily. In such cases, the inframarginal incision can be delayed until after the
elevation of the columellar flap.
The dissection using the Metzenbaum scissors or angled Converse scissors is performed to elevate the columellar portion
of the flap and proceeded further cephalically to expose the dome and lateral crura of the lower lateral cartilages. The dissec-
tion is carried out along the relatively avascular plane just superficial to the perichondrium. If flap elevation is performed by
detaching the perichondrium from the cartilage, the lower lateral cartilage can become fragile, which is to be avoided. In
patients with thin skin, the dissection should try to leave as much of the soft tissue for the skin flap.
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a
b
c
d
e
f
Fig. 3.6 Operative procedures of open rhinoplasty incision. (a) Inverted-V incision at the columella. (b) Incision along the caudal margin of the
medial crus. (c, d) The incision is extended laterally along the caudal margin of lateral crura. (e, f) Dissection through the supraperichondrial plane
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In patients with bulbous tip and thick skin, the skin flap is elevated while leaving a portion of the fibrofatty tissue with the
dome and lateral crura of lower lateral cartilages. The fibrofatty tissue attached to the lower lateral cartilages can later be
trimmed for tip volume reduction. However, the author prefers to leave the fibrofatty tissue not on the cartilage but on the
side of skin flap. The rationale is that leaving the fibrofatty tissue with the skin flap and the debulking procedure to be per-
formed as the last step in the operation after having exposed the lower lateral cartilage and completed the cartilage workup
allow for more accurate removal of soft tissue. This also minimizes the postoperative edema in the nasal tip. Of course, this
choice is up to the experience and preference of individual surgeons. To preserve the blood supply to the nasal tip, excessive
debulking should be avoided in the nasal tip area.
The dissection is continued further along the nasal dorsum using the Metzenbaum scissors. Supraperichondrial dissection
is carried above the upper lateral cartilage area. For the nasal bone area, the dissection is deep to the periosteum. Materials
used for dorsal augmentation (e.g., nasal implant, block costal cartilage graft, or diced cartilage wrapped in fascia) should be
placed in the subperiosteal plane. The reason for this is because the periosteum minimizes the visibility and mobility of the
implant or cartilage graft. Also, intact periosteum tends to minimize the visibility of irregularities after hump reduction and
medial osteotomy.
The periosteum is elevated using the Joseph elevator. Once the caudal periosteum is elevated, Aufricht retractor is used to
suspend the periosteum-skin flap. The dissection should be continued with the periosteum under direct visualization, to avoid
periosteal tearing. The blood vessels through tiny foramen on the nasal bone that supply the skin flap will be transected dur-
ing the periosteal elevation (Fig. 3.7). Bleeding from these vessels will stop spontaneously, but the vessels should be coagu-
lated prior to transection, whenever possible, to minimize the delayed bleeding, hematoma, and bruise.
skin envelope
perforating
vessel
nasal bone
Fig. 3.7 Perforating vessel
coming through a small
foramen in the nasal bone
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Selection of the Incision and Approach
The choice between the endonasal approach and the open approach depends on the surgeon preference and experience, as
well as a given patient’s clinical problem and operative goals. In most patients, the columellar scar of open rhinoplasty does
not pose a significant problem in most patients.
The author uses the open approach in 70% of primary rhinoplasty and 90% of secondary rhinoplasty.
Endonasal Approach
The endonasal approach allows for dorsal augmentation, hump reduction, osteotomy, and tip plasty.
Advantages of the Endonasal Approach
1. Possibly faster than the open approach
2. Does not leave external scar
3. Less edema in the nasal tip
4. No loss of tip support
5. Readily accepted by patients who are sensitive about scars
Disadvantages of the Endonasal Approach
1. Limited exposure and visualization in small nostrils, which is common among Asians.
2. Depending on the operator, there is a wide variation in the operative area accessible by endonasal approach.
3. In patients with abundant soft tissue, thick nasal tip skin, and small lower lateral cartilage, tip plasty is extremely difficult
to perform via endonasal approach. The outcomes are usually inferior to those from open approach.
Candidates
The endonasal approach is ideal for a patient with thin skin, sparse subcutaneous tissue, adequate-sized nostril, and firm
strong lower lateral cartilages. In Asian rhinoplasty, the approach is commonly used for tip projection, dorsal augmentation,
mild long-nose correction, and mild alar retraction correction. Endonasal approach provides limited access for bulbous tip
with thick skin and abundant soft tissue, short nose, and deviated nose. For such cases, the open approach is recommended.
Open Approach
Advantages of the Open Approach
1. Better exposure of the structures
2. More accurate placement of grafts and sutures
3. Scar revision and contracture release are easier in secondary rhinoplasty
4. Allows for excellent hemostasis with minimal risk for hematoma
5. More accurate intraoperative inspection of deformed structures
6. Teaching value
Disadvantages of the Open Approach
1. Columella scar:
The scar is inconspicuous in most situations. Problematic scars can be addressed by laser or simple scar revision.
2. Operative time is longer initially. However, experienced surgeons will notice less of a difference between open and endo-
nasal approaches.
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3. Open approach can lead to a longer lasting tip edema.
4. On rare occasions, open approach can result in necrosis of the columella or nasal tip. This is extremely rare in Asian
patients, especially if the removal of the subcutaneous tissue in the tip area is not excessive.
Candidates
1. Short nose with upturned tip
2. Deviated nose
3. Bulbous tip with thick soft tissue
4. Asymmetric tip and nostril
5. Low or short tip with very small lower lateral cartilages
6. Secondary operation for nasal tip, for which endonasal approach cannot adequately expose the lower lateral cartilages
7. Secondary operation for contracted nose
8. Mid-vault deformities
9. Removal of injected foreign material
Preoperative Preparation and Anesthesia
Two weeks prior to an operation, patients should be instructed to stop taking NSAIDs, aspirin, anticoagulant, herb medica-
tion, and vitamin E. Medications to be taken even on the day of operation include antihypertension medications, DM medica-
tion, and thyroid hormone. Patients should be NPO for 4 h prior to IV sedation and 8 h prior to general anesthesia. Patients
with high levels of anxiety can be given anxiolytic drugs prior to an operation.
Preoperative imaging (e.g., photographs and X-ray) should be hung in the operating room.
Excessive nasal hair (vibrissae) should be trimmed with nasal hair trimmer or with curved iris scissors. The internal nose
and the whole face are prepped with povidone-iodine solution.
Lubrication of the eye with ophthalmic ointment is important for prevention of corneal injuries.
The author performs most rhinoplasty procedures under intravenous sedation. General anesthesia is reserved for occa-
sional patients for operations taking up more than 5 h, male patients requiring costal cartilage harvest, or other extraneous
circumstances. Commonly used agents for intravenous sedation include a combination of midazolam, ketamine, propofol,
and fentanyl. Under the care of an anesthesiologist, the patient should be monitored for blood pressure, EKG, pulse oxym-
etry, and other appropriate vital signs.
Upon proper IV sedation, the operative area is infiltrated with local anesthetic. An equal mixture of 2% lidocaine and
0.5% bupivacaine mixed with 1:100,000 epinephrine is used for this purpose. The bupivacaine is included for longer duration
of action. With general anesthesia, the longer acting local anesthetic is not needed.
Pre- and Intraoperative Medication
There is a controversy regarding routine use of prophylactic antibiotics for aesthetic rhinoplasty, and no guideline exists
on the type of coverage required. According to a few meta- analyses, antibiotic prophylaxis is associated with significant
decrease in postoperative infection for contaminated rhinoplasty and septoplasty. In clinical practice, the use of prophylactic
antibiotics has increased over time. The author also uses prophylactic IV antibiotics. The normal flora within nasal cavity
consists of gram-positive bacteria such as S. epidermidis and S. aureus, and proper prophylaxis against these agents can
be provided by the first-generation cephalosporins. However, patients who work in healthcare environment are frequently
exposed to pseudomonas and enterobacter and should be given ciprofloxacin.
To minimize postoperative edema and ecchymosis, 10 mg of IV dexamethasone can be administered, barring any contra-
indication. The steroid also helps with the postoperative nausea as well.
It is extremely important to minimize bleeding during rhinoplasty. Postoperative hematoma and swelling affect the post-
operative result in a significant way. In Asian patients with thick skin and soft tissue, bleeding and edema can be worse in
comparison to patients with thinner skin. Severe bleeding and edema can lead to post-rhinoplasty fibrosis, which is especially
problematic for bulbous tip correction. To minimize bleeding, 500 mg of IV tranexamic acid can be infused prior to incision
Preoperative Preparation and Anesthesia

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with additional 500 mg infusion during the operation. Tranexamic acid is contraindicated in patients who take anticoagulants
or who have a history of vascular thromboembolism.
Another agent used to decrease intraoperative bleeding is desmopressin (DDAVP), which is a synthetic analogue of the
antidiuretic hormone L-arginine vasopressin. It is known to increase tissue plasminogen activator and endothelial factor VIII,
both of which increase coagulation activity and decrease aPTT and BT. The medication can be used for coagulation disorders
such as von Willebrand factor deficiency but can be useful in minimizing intraoperative bleeding in patients who have taken
aspirin or NSAIDs. Desmopressin also reduces intraoperative bleeding in patients with normal coagulation profile.
Guyuron et al. have advocated the use of desmopressin in maxillofacial surgery and treatment of epistaxis. These authors
have recommended the dose to be 0.3 μg/kg, to be given at least 20 min before the desired effect. Palaia et al. have reported
decreases in microhematoma for patients undergoing face-lift. Gruber et al. have also reported routine use of desmopressin
for minimizing postoperative ecchymosis and edema. These authors reported administration of a smaller dose (0.1 μg/kg)
with up to two additional as-needed bolus at 20-min intervals thereafter, which is the protocol the author follows.
For the operator, the use of desmopressin is followed by a significant decrease in the amount of intraoperative bleeding,
which can decrease the operation time and stress on the part of the operator. However, further research is needed on whether
the dry intraoperative field afforded by hemostatic medication leads to decreased postoperative ecchymosis and edema.
Possible side effects of desmopressin include cutaneous vasodilation (facial flushing, tingling, headache, warmth feeling,
tachycardia). It is possible for elderly patients to experience dilutional hyponatremia, but this is relatively rare unless the
patient has an excessive amount of water intake. Desmopressin has few side effects. Regardlessly, the medication is contra-
indicated in patients with unstable coronary artery disease and observation is required in elderly.
Another method of minimizing intraoperative bleeding and edema is ensuring a proper control of blood pressure such that
the systolic pressure does not exceed too much beyond 120 mmHg. Cold gauze placed atop the nose can be helpful in pro-
moting vasoconstriction in the vicinity of the operative field.
Postoperative Medications and Instructions
Postoperative medications include antibiotics and pain medications. Depending on the case, patients may benefit from anti-
nausea drugs, tranzamine and montelukast.
Whether postoperative prophylactic antibiotics is needed and for how long are up to debate. Some authors have reported
that a single dose of preoperative administration is adequate and that longer term prophylaxis is of no benefit. The author is
of the opinion that postoperative antibiotic makes sense in Asian rhinoplasty, where the operation is on a clean contaminated
wound and frequently requires the use of implant. Normally, the author prescribed 3–5 days of oral ciprofloxacin.
It is not uncommon for a patient to experience postoperative nausea as a side effect of anesthesia as well as cathartic effect
of swallowed blood. Nausea can elevate systemic blood pressure, which can cause delayed nasal bleeding and increased
edema. Because of this, complaints regarding nausea should be considered with more weight. After making sure that the
nauseated patient is adequately hydrated, the nausea can be treated with 10 mg of IV metoclopramide. A more serious nausea
and vomiting can be managed with IV ondansetron, which is a serotonin 5-HT3 receptor antagonist. Oral antiemetic can be
prescribed depending on the patient’s ability to take oral medication.
Oral tranzamine is not always prescribed. However, patients at higher risk for postoperative bleeding can be given a daily
dose of 3 g for 2–5 days.
In severe cases of postoperative edema in the first couple of days, IV or IM dexamethasone can be helpful in decreasing
the edema. Short-term oral prednisolone is also thought to be effect in this effort.
The leukotriene inhibitor, montelukast, can be prescribed for prevention of fibrosis and contraction of the nose after tip
plasty in patients with thick skin and soft tissue, and for patients with a lot of scar tissue or contracted nose. The dose for
montelukast is 10 mg daily for 2–3 months.
The inflammatory cytokine leukotriene induces inflammation and contraction of smooth muscle cells, and increases neutrophils
and influx of lymphocytes by promoting increased vascular permeability. This inflammatory mechanism is known to be important
in the pathology of asthma and capsular contracture. The use of montelukast to minimize capsular contracture has been reported
widely in the breast augmentation literature, and is considered to be a routine medication for breast augmentation using implant.
Montelukast after rhinoplasty is not widely reported, but the author feels that there is a need for scar tissue and contracture prophy-
laxis after correction of contracted nose, rhinoplasty in thick-skinned nasal tip, and revisional surgery for thick capsule. Possible
side effects of the medication include headache, cough, abdominal pain, dyspepsia, increased liver enzyme, and hepatitis.
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Topical application of vitamin K cream may reduce the severity of a bruise, particularly in the early postoperative
days.
Postoperative edema tends to increase for the first 2–3 days. To minimize this, patients should be instructed to apply cold
compress to the eyes and the cheek area and to elevate the head of the bed for a week. About 80% of edema should have
subsided by 2 weeks, and about 5% of edema should remain at 2 months. The remaining bit of edema/swelling will take 6–12
months to completely resolve.
Intraoperative bleeding and edema are more severe in Asian patients with thicker skin, compared to Caucasian patients
with thinner skin. The edema can induce fibrosis and tends to worsen the operative outcome. As such, the operator must
make a concerted effort to minimize the intraoperative factors responsible for the edema while maximizing the use of all
available means to decrease the ongoing edema in the postoperative period. If the nasal tip edema is severe, the patient
should be instructed to apply compressive tape to the nasal tip and to keep the nose compressed for 2 months following the
operation (Fig. 3.8). Injection of triamcinolone in the nasal tip can also be helpful in minimizing edema in the area.
Triamcinolone is injected in the edematous area causing supratip bulge after 1–2 weeks (0.1–0.3 cc per injection of 10 mg/
mL concentration). The injection is made in the subcutaneous plane, and should not be made in the dermis nor in the
cartilage.
Leisurely walks are permissible at 2 days after an operation. However, patients should be instructed to avoid running or
engaging in strenuous activity for the first month after surgery. This is to minimize the risk of exercise-induced edema in the
nose. In addition, patients should understand that traveling to hot climate or use of hot sauna can increase edema, and that
such activities should be avoided for about a month. The same caution also applies to salty diet and to alcohol and tobacco.
Patients may wear glasses while wearing a splint over the dorsum, but should resort to contact lenses for a month following
disuse of the splint.
Patient should avoid UV light until the bruise has subsided and apply sunblock for outdoor activities.
a
b
Fig. 3.8 Dressing to decrease the tip edema. (a) Taping for the edema around the tip. (b) Taping for the supratip bulging
Preoperative Preparation and Anesthesia

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Dressings
External Dressing
To minimize postoperative edema and bleeding and to stabilize the intranasal implant and cartilage frame, paper tape or
Steri-Strips are applied on the soft tissue of nasal dorsum and around the tip. The tape is applied first in the supratip area and
then onto the radix and the rest of dorsum. If the nasal tip requires buttressing, the Joseph dressing is appropriate in stabiliz-
ing the nasal tip (Fig. 3.9). Application of thermoplastic splint decreases hematoma and edema and protects the bony seg-
a
b
c
e
d
Fig. 3.9 Joseph dressing
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a
b
Fig. 3.10 Aqua splint
ments after osteotomy (Fig. 3.10). The splint should be maintained for 5–7 days. The splint should not be applied with
excessive compression, which could cause necrosis or epithelial injury in the supratip skin.
Splint or paper tape should be removed by the insertion of a blunt stylet between the skin and the tape. The stylet tip
should be moved from side to side in a gentle manner so as not to distract the skin away from the underlying framework.
Dressings

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Intranasal Dressing
Intranasal packing or splinting is required for osteotomy, septal surgery, septal cartilage harvest, and turbinate surgery.
For simple prevention of septal hematoma after cartilage harvest, septal mucoperichondrial suture may be adequate, espe-
cially if the bleeding is not severe. This can be accomplished with 1–2 quilting sutures or a continuous mattress suture, using
absorbable suture materials.
For the following situations, intranasal packing or splint is recommended:
1. Possibility of septal bleeding
2. Deviated septal correction or extensive septal reconstruction
3. After turbinate surgery
4. The need to support an osteotomized bony segment from within the cavity
Intranasal packing and splinting serve the following purposes:
1. To prevent the septal hematoma and to decrease the septal edema
2. To maintain the straightened septum by the septal surgery in the midline position
3. To support the osteotomized nasal bone
4. To minimize the crusts on the surface of the turbinate after turbinate surgery
5. To prevent the synechiae between the septum and turbinate
Intranasal packing is most commonly performed using Merocel® (Fig. 3.11). Among various products, one can use the
packing containing a patent air passage. The packing material is usually removed after 2 days. However, packing material
can be distressingly uncomfortable for obstruction of nasal air passage, and intranasal splint has become preferable over
packing for this reason.
Intranasal splints are a pair of soft silicone splint, which is lubricated with antibiotic ointment and inserted next to each
side of the septal mucoperichondrium. One or two through- and- through mattress sutures are used to loosely fixate the sili-
cone splints to each other (Fig. 3.12). Depending on the type, splints are removed between 2 and 7 days after operation. If
the splint is required for a longer duration, the patient should be managed more actively to avoid the formation of crust and
mucus plugs. Streptococcus and Staphylococcus bacteria are a normal flora in the nasal cavity, but foreign body can allow
these organisms to multiply uncheck in the nasal space at the risk of toxic shock syndrome. With packing or intranasal splint,
patients should be receiving antibiotics to prevent toxic shock syndrome and should be cautioned to watch out for signs and
symptoms such as fever, dizziness, headache, vomiting, diarrhea, and rash.
After septal surgery and turbinate surgery, septal mucosal tearing can increase the risk of synechiae between the septum
and turbinate. In the presence of such tearing, the thin silicone sheet is placed between the opposing raw surfaces. The sheet
is left in place for 2–3 weeks while the mucosa heals. The suture is removed at about 10 days, and the splint is changed regu-
larly after that to prevent infection.
Fig. 3.11 Intranasal packing
Fig. 3.12 Silicone sheet
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Further Reading
1. Totonchi A, Eshraghi Y, Beck D, et al. Von Willebrand disease: screening, diagnosis, and management. Aesthe Surg J. 2008;28(2):189–94.
2. Guyuron B, Vaughan C, Schlecter B. The role of DDAVP (desmopressin) in orthognathic surgery. Ann Plast Surg. 1996;37(5):516–9.
3. Faber C, Larson K, Amirlak B, Guyuron B. Use of desmopressin for unremitting epistaxis following septorhinoplasty and turbinectomy. Plast
Reconstr Surg. 2011;128(6):728e–32e.
4. Gruber RP, Garza RM, Cho GJ. Nasal bone osteotomies with nonpowered tools. Clin Plast Surg. 2016;43(1):73–83.
5. DiMichele DM, Hathaway WE. Use of DDAVP in inherited and acquired platelet dysfunction. Am J Hematol. 1990;33:39–45.
6. Palaia DA, Rosenberg MH, Ronanno PC. The use of DDAVP desmopressin reduces the incidence of microhematomas after faciopalsty. Ann
Plast Surg. 2001;46:463–6.
7. Rohrich RJ, Adams WP, Gunter JP. Postoperative management of the rhinoplasty patient. Dallas rhinoplasty. 3rd ed. St. Louis: QMP/CRC
Press; 2014. p. 133–46.
8. Georgiou I, Farber N, Mendes D, et al. The role of antibiotics in rhinoplasty and septoplasty: a literature review. Rhinology. 2008;46:267–70.
9. Ariyan S, Martin J, Lal A, Cheng D, et al. Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based
consensus conference statement from the American Association of Plastic Surgeons. Plast Reconstr Surg. 2015;135(6):1723–39.
10. Lyle WG, Outlaw K, Krizek TJ, et al. Prophylactic antibiotics in plastic surgery: trends of use over 25 years of an evolving specialty. Aesthet
Surg J. 2003;23(3):177–83.
11. González-Castro J, Lighthall JG. Antibiotic use in facial plastic surgery. Facial Plast Surg Clin North Am. 2016;24(3):347–56.
12. Clayton JL, Bazakas A, Lee CN, Hultman CS, et al. Once is not enough: withholding postoperative prophylactic antibiotics in prosthetic breast
reconstruction is associated with an increased risk of infection. Plast Reconstr Surg. 2012;130(3):495–502.
13. Phillips BT, Halvorson EG. Antibiotic prophylaxis following implant-based breast reconstruction: what is the evidence? Plast Reconstr Surg.
2016;138(4):751–7.
14. Andrews PJ, East CA, Jayaraj SM, et al. Prophylactic vs postoperative antibiotic use in complex septorhinoplasty surgery: a prospective, ran-
domized, single-blind trial comparing efficacy. Arch Facial Plast Surg. 2006;8(2):84–7.
15. Graf R, Ascenço AS, Freitas Rda S, et  al. Prevention of capsular contracture using leukotriene antagonists. Plast Reconstr Surg.
2015;136(5):592e–6e.
16. Reid RR, Greve SD, Casas LA. The effect of zafirlukast (Accolate) on early capsular contracture in the primary augmentation patient: a pilot
study. Aesthet Surg J. 2005;25:26–30.
17. Gurlek A, Fariz A, Aydogan H, Ersoz-Ozturk A, et al. Effects of different corticosteroids on edema and ecchymosis in open rhinoplasty.
Aesthet Plast Surg. 2006;30:150–4.
18. Gruber RP, Zeidler KR, Berkowitz RL. Desmopressin as a hemostatic agent to provide a dry intraoperative field in rhinoplasty. Plast Reconstr
Surg. 2015;135:1337–40.
19. Eftekharian HR, Rajabzadeh Z. The efficacy of preoperative oral tranexamic acid on intraoperative bleeding during rhinoplasty. J Craniofac
Surg. 2016;27(1):97–100.
Further Reading

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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Harvest of Autogenous Tissues
This chapter discusses harvest techniques of autogenous cartilages and soft tissues used in Asian rhinoplasty, which include
auricular cartilage, septal cartilage, costal cartilage, dermofat, and temporal fascia.
Auricular Cartilage
For rhinoplasty in Caucasian patients, septal cartilage is the most desired source of cartilage graft. This is because the carti-
lage exists within the operative field and because a significant amount of cartilage is available for harvest. Another reason is
that much of rhinoplasty is actually septorhinoplasty.
However, auricular cartilage finds a larger repertoire of application in Asian patients with small septal cartilage. Unlike
small septal cartilage, the auricle provides cartilage graft of adequate length. The auricular cartilage is an elastic cartilage
with adequate strength. The natural curvature of the cartilage allows for highly anatomic grafts in the alar rim or the dome.
Straight strut is possible when two layers of auricular grafts are used.
Histologically, the auricular cartilage is the most similar graft to lower lateral cartilages, with both cartilages being the
fibroelastic type. The auricular cartilage is also similar to the lower lateral cartilages in both shape and macro-texture.
Conchal cartilage is most commonly used for tip onlay graft and shield graft. It is also seldom used for derotation graft, colu-
mellar strut graft, and lateral crural onlay graft.
The advantages of auricular cartilage are that it is easy to harvest, with low donor-site morbidity. Large cartilage graft can
be harvested from both the cymba concha and cavum concha (Fig. 4.1).
Cartilage of cavum concha is thicker than that of cymba concha and can yield widely round graft. It is commonly used for
tip onlay graft and shield graft. In comparison, the cartilage of cymba concha can be longer with a more oval shape, and is
more appropriate for columella strut graft, alar rim graft, and derotation graft.
The right ear may be preferable as the donor site for a right-handed surgeon. However, the patient should be given the first
word over the choice of donor site.
Location of Incision
The conchal cartilage can be harvested through either anterior or posterior approach (Fig. 4.2). The incision location can vary
according to surgeon preference, but posterior approach yields an inconspicuous scar. The anterior approach affords easier
access to the cartilage, and larger amount of graft can be harvested, but can leave a visible scar in rare cases.
For anterior approach, the incision should be located 2 mm medial to the crus of antihelix for the scar to be less visible
and to avoid ear deformity. For posterior approach, the incision should be placed 2–3 mm anterior to the sulcus.
4

104
Fig. 4.1 Donor site of conchal cartilage harvest. Conchal cartilage can be harvested from both cavum concha and cymba concha. However, crus
of helix should be preserved for the prevention of ear deformity
a
b
Fig. 4.2 Incision for the conchal cartilage harvest. (a) Anterior approach. (b) Posterior approach
4 Harvest of Autogenous Tissues

105
Injection of Local Anesthetic
Local anesthetic mixed with 1:100,000 epinephrine is injected using a 1 mL syringe with 30-guage needle. For harvested
cartilage to have its perichondrium incorporated on the graft, the following should be observed: First, the needle end should
be placed in the subcutaneous plane between the perichondrium and the skin. Second, the bevel of needle end should be
pointed towards the skin. Otherwise, inadvertent hydrodissection of the subperichondrial plane will take place, perichon-
drium being detached from the cartilage.
The inclusion of perichondrium increases the overall volume of the cartilage graft, as well as increases the stability of the
graft. However, it is important to note that leaving behind perichondrium allows for formation of new cartilage at the donor
site. The author incorporates a single layer of perichondrium for non-supporting grafts such as tip onlay graft and shield graft
and both layers of perichondrium for structural grafts such as columella strut graft and derotation graft.
When the perichondrium is not incorporated into the graft, the local injection should be used to hydrodissect the plane
between the perichondrium and the cartilage.
Harvest of Cartilage
To avoid auricular deformity, the crura of helix and antihelix need to be preserved during graft harvest.
The anterior approach provides ready access to the cartilage to be harvested and direct visualization of the structures to
be preserved in the donor site. The incision should be placed 2–3 mm medial to the crus of antihelix, preserving anti-helical
margin (Fig. 4.3). Upon elevation of the skin flap, the cartilage is cut to the desired dimension. For columellar strut graft or
derotation graft, the cymba concha needs to be harvested in its entire length.
With the posterior approach, it is difficult to delineate the portions of auricular cartilage to be harvested from that to be
preserved (Fig. 4.4). The area of conchal cartilage to be harvested is marked on the anterior surface of the ear. The corre-
sponding outline is recreated on the posterior surface of the ear by piercing the full thickness of the concha with a 25-guage
needle along the lateral line of the marked area, in a medial-to-lateral direction. From the posterior side, the gentian violet
ink is applied to the needle tip. The cartilage itself will then be marked as the needle is withdrawn. The posterior skin is
incised slightly lateral to the ear sulcus, and the skin flap is elevated. At least one layer of the perichondrium should be incor-
porated into the graft. Both layers should be incorporated for derotation graft. Once the cartilage to be harvested is adequately
exposed, the lateral margin of the cartilage marked with gentian violet is incised, and the dissection is carried down between
the cartilage and the anterior skin.
Once the cartilage is harvested, the donor site should be examined with meticulous attention to any potential source of
bleeding, to minimize the risk of auricular hematoma. Compression dressing must be applied to the donor site (Fig. 4.5). Ear
mold should be used 2–3 months for significant sizes of cartilage harvest (Fig. 4.6). It should be worn at all times in the first
month, and worn in the evenings the second month.
Auricular Cartilage

106
a
b
c
d
g
e
f
Fig. 4.3 Anterior approach for the harvest of cymba conchal cartilage. (a, b) The incision is placed 2–3 mm medial to the crus of antihelix. (c)
The skin flap is elevated. (d) Incision on the cartilage. (e, f) Cartilage of maximum size is harvested. (g) Primary repair of the wound
4 Harvest of Autogenous Tissues

107
a
b
c
e
d
f
Fig. 4.4 Posterior approach for the harvest of cymba conchal cartilage. (a) The conchal fossa is outlined. (b) The skin incision is placed 2–3 mm
anterior to the sulcus. (c, d) Along the lateral line, a 25-gauge needle is used to pierce the full thickness of the ear. Gentian violet ink is applied to
the needle tip and withdrawn, by which the cartilage is marked. (e) Upon skin incision, the lateral margin of cartilage is incised along the margin
marked by the needle. (f) The graft is harvested to the desired size
Auricular Cartilage

108
Fig. 4.6 Ear mold after cartilage harvest
Fig. 4.5 Tie over compression
dressing for cavum conchal cartilage
harvest through posterior approach
4 Harvest of Autogenous Tissues

109
Complications of Auricular Cartilage Harvest
Complications of auricular cartilage harvest include hematoma, auricular deformity, visible scar, and hypertrophic scar.
Prevention of auricular hematoma requires meticulous hemostasis and compression dressing. If an auricular hematoma
does develop, a small portion of the closed wound should be opened, through which the hematoma should be delivered out
of the cavity. Any active bleeding should be stopped through re-exploration of the wound. If a hematoma is not completely
removed from the wound cavity, the remnant portion could undergo fibrotic change and induce a cauliflower ear deformity.
To avoid auricular shape deformity, the cartilage harvest should not invade into the tragus, antitragus, root, and crus of
helix. A mold should be used after harvesting a large cartilage graft to avoid conchal collapse (Fig. 4.7).
Hypertrophic scar and keloid are an uncommon occurrence after auricular cartilage harvest (Fig. 4.8). The first treatment
option is intralesional injection of triamcinolone.
Fig. 4.7 Collapsed cymba
concha after cartilage harvest
a
b
Fig. 4.8 Keloid and
hypertrophic scar formation
after conchal cartilage harvest
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110
Septal Cartilage
Septal cartilage is a hyaline cartilage. It is located within the operative field for rhinoplasty. The cartilage is relatively rigid
and planar without significant curvature. A relatively large graft can be obtained, which allows for a wide variety of applica-
tions, including dorsal onlay graft, columellar strut graft, spreader graft, and septal extension graft.
Injection of Local Anesthetic
The local injection for septal cartilage harvest serves not only the purpose of local anesthetic but also the mucoperichondrial
hydrodissection. Using a dental syringe, a mixture containing 2% lidocaine and 1:100,000 epinephrine is injected into the
submucoperichondrial plane (Fig. 4.9). The injection is started at the caudal septum and advanced in the cephalic direction.
The local anesthetic must be injected deep to the mucoperichondrium, and the operator must visually confirm this by simul-
taneous elevation and blanching of the septal mucosa. Except for caudal septum and the floor side, most of the mucoperi-
chondrium flap should be elevated solely with hydrodissection. For this, the needle bevel of the dental syringe should be in
contact with the cartilage surface during the injection.
a
b
Fig. 4.9 Injection of local anesthetic to the septum. Lidocaine mixed with 1:100,000 epinephrine is injected to the septum. The injection starts
from the caudal septum and proceeds cephalically. The operator should try to hydrodissect and elevate the mucoperichondrium from the cartilage
through this local injection
4 Harvest of Autogenous Tissues

111
Approaches
The septal cartilage can be harvested by four approaches (Fig. 4.10): Killian approach, transfixion incision approach, dorsal
approach, and medial crural (intercrural) approach.
Transfixion approach and Killian approach are endonasal approaches, whereas dorsal approach and medial crural approach
are approaches via open rhinoplasty incision.
transfixion
approach
Killian approach
dorsal
approach
intercrural
approach
a
b
Fig. 4.10 Approaches to the nasal septum. (a) Endonasal approach includes the Killian approach and transfixion approach. (b) Open approach
includes dorsal approach and medial crural (intercrural) approach
Septal Cartilage

112
a
b
c
d
e
f
Fig. 4.11 Harvest of the septal cartilage through Killian incision. (a, b) The vertical incision is made a few millimeters cephalad to the caudal
septum. (c) The mucoperichondrial is elevated on the right side. (d) A No. 5 blade is used to score a half-thickness incision on the septal cartilage,
10–15 mm posterior to the caudal septum. (e) D-knife is inserted through that half-thickness cartilage incision and severs the remaining thickness
of septal cartilage, entering the contralateral submucoperichondrial plane. (f) The mucoperichondrium is elevated on the contralateral side. (g)
Septal cartilage of adequate size is harvested
Killian Approach
This is an approach to the nasal septum through an incision made 2–5 mm cephalad to the caudal margin of the cartilaginous
septum. The exact location of this access can vary across operators and depending on septal deformity. The operative steps
are as follows (Fig. 4.11).
4 Harvest of Autogenous Tissues

113
A No. 15 blade is used to make a vertical incision at a 2–5 mm cephalic offset from the caudal septum. Each operator will
have a preferred side to open the mucoperichondrium. However, the concave side of the septum offers the easier mucoperi-
chondrial dissection.
The vertical incision incorporates the perichondrium and exposes the cartilage. The operator should take care not to
continue the incision into the cartilage layer. From the incision, the mucoperichondrium is elevated in the cephalic direction
using a Freer or Cottle elevator. The dissection space can be secured under direct visualization, either by retracting the
mucoperichondrial flap with a double hook or by insertion of the blade of a medium speculum between the cartilage and
the flap.
Because of the narrow field of vision, the mucosa might tear at the end of the incision under traction. To avoid this, the
incision can be prophylactically extended to the vestibular floor. In this case, the dissection should be advanced carefully
because the floor-side flap strongly adheres to the maxillary crest.
Once flap elevation is completed on the initial side, the contralateral mucoperichondrium is lifted. To gain access to the
contralateral plane, a No. 15 blade is used to place a half- thickness incision into the cartilage at about 10–15 mm posterior
to the caudal septal margin. Then, a D-knife with blunt edge is inserted into the cartilage incision to complete the incision
through the complete thickness of cartilage, which will provide the submucoperichondrial plane on the other side. The con-
tralateral mucoperichondrium is elevated from the septum using a Freer elevator.
Once the mucoperichondrium is elevated on both sides, the septal cartilage is further manipulated for harvest. On the
caudal side, the cartilage is already divided with a 10–15 mm strut left in place. In the dorsal area, the cartilage is divided
using a sharp Metzenbaum scissors while leaving a 10–15 mm strut. Using a Freer elevator, the floor and cephalic cartilagi-
nous septum is dislocated from the cartilage-bony junction.
Upon harvesting the cartilage graft, the incision can be closed with Vicryl suture or left open.
Transfixion Incision Approach
Transfixion incision is made through both sides of the membranous septum. This approach is useful for correction of caudal
septal deviation.
The mucoperichondrial incision follows the caudal margin of septum, from septal angle to the nasal spine. Upon incision
and elevation of mucoperichondrial flaps, a cartilage of desired size can be harvested, with simultaneous correction of caudal
septal deviation.
Fig. 4.11 (continued)
g
Septal Cartilage

114
Hemitransfixion Incision
This incision is made on one side of membranous septum, and both layers of mucoperichondrium are elevated through this
single incision (Fig. 4.12).
e
f
a
b
c
d
Fig. 4.12 Hemitransfixion incision approach. (a, b) A vertical incision is made along the caudal margin of the septum on the right side. (c) The
mucoperichondrium is elevated. (d, e) The contralateral mucoperichondrium is elevated. (f) Septal cartilage is harvested
4 Harvest of Autogenous Tissues

115
Dorsal Approach
The dorsal approach is performed via the open rhinoplasty incision. The approach begins at the septal angle and advances
between the dorsal border of septum and upper lateral cartilages.
This approach does not dissect between the medial crura of lower lateral cartilages and the caudal septum and does not
injure the tip-supporting soft tissue. Also, the approach provides an excellent exposure of the septal cartilage. If access to the
caudal septum is not needed, this approach is highly recommended for an open rhinoplasty that requires just septal cartilage
graft. The operative sequence is as follows (Fig. 4.13).
While applying caudal traction to the lower lateral cartilages, the septal angle is exposed. The dissection begins in the cau-
dal and dorsal portion of the septum, and the mucoperichondrial elevation is advanced in the cephalic direction. At the starting
point, the perichondrium is tightly adherent to the cartilage and should be elevated with care. In the cephalic area, the peri-
chondrium is more easily elevated. The mucoperichondrial flap is elevated in the cephalic direction along the dorsal border of
septum, and the upper lateral cartilage is detached from the dorsal septum. After this step, the mucoperichondrium is elevated
in areas of less adhesion (areas 1, 2, and 3 in Fig. 4.14). Subsequently, the dissection is carried in the caudal direction, where
the mucoperichondrium is more densely adherent (area 4 in Fig. 4.14). This approach minimizes the risk of mucosal tearing.
The dorsal approach is useful for repeat harvest of septal cartilage in patients with prior history of septal cartilage harvest
and in those cases where bony septum requires manipulation. This is because the approach avoids prior areas of dissection
(Fig. 4.15).
a
b
c
d
Fig. 4.13 Dorsal approach for the septal cartilage harvest. (a) Lower lateral cartilage is pulled caudally to expose the septal angle. (b)
Mucoperichondrial elevation starts from the caudal dorsal septum and continues cephalically. (c) Upper lateral cartilages are detached from the
dorsa septum, and mucoperichondrial flap elevation is continued cephalically and towards the mid-septum and posterior septum. (d) The flap on
the left side elevated in the same manner
Septal Cartilage

116
Fig. 4.15 The dorsal approach is useful for providing access to the posterior septum in patients with prior history of septal surgery
Fig. 4.14 Sequence of mucoperichondrial flap elevation
4 Harvest of Autogenous Tissues

117
c
d
a
b
Fig. 4.16 Medial crural approach (intercrural approach)
Medial Crural Approach (Intercrural Approach)
The medial crural approach provides access to the septum through the membranous septum and between the medial crura of
lower lateral cartilages (Fig. 4.16).
This approach disrupts the soft-tissue attachment between the medial crura, and the resulting weakened nasal tip support
can induce tip drooping. As such, the approach should be limited to procedures such as short-nose correction, retracted colu-
mella correction, and long-nose correction with resection of caudal septum or membranous septum. To minimize the poten-
tial for tip drooping, the medial crural footplate attachment to the septum should be preserved as much as technically
possible.
Septal Cartilage

118
General Tips for Flap Elevation
1. Between the two mucoperichondrial flaps, it is important to start the elevation process on the easier side to minimize
mucosal tearing (e.g., the flap on the concave surface or the side without any septal deformity) and to elevate the contra-
lateral side afterwards. If one side of the mucoperichondrium is elevated without any tearing, there is no reason to fear
flap tearing on the contralateral side because septal perforation is only a problem when mucosal perforations exist at the
same septal location in both flaps.
2. Primary closure with suture is a terrible idea for repairing a mucosal injury and can lead to additional tearing. It is impor-
tant to understand that (1) a unilateral tearing does not require repair and (2) even a bilateral tearing is highly unlikely to
lead to permanent septal perforation if the tearing on each side does not overlap. If the tearing is bilateral and overlapping,
the risk for septal perforation is high. In such cases, the mucosa tearing should be kept separate from each other by the
interposition of a septal cartilage, an ethmoid bony segment, or a PDS plate. Silicone sheets should be applied on both
sides for 2–3 weeks, while the mucosal defect is healed.
3. If a flap is torn during dissection, then the dissection should take a detour into an area of less adhesion and better plane.
Cartilage Harvest
The quadrangular cartilage connects to the perpendicular plate and vomer in the end-to-end fashion and becomes easily
disarticulated. However, it is connected to the maxillary crest in a tongue-and-groove articulation, and the cartilage is more
difficult to separate from the bone in this area.
Firstly, make a curved L-shaped incision on the cartilage at the transition points between the dorsal and caudal L-strut
(Fig. 4.17). The L-incision is extended in the cephalic and caudal direction, using a sharp Metzenbaum scissors. Quadrangular
cartilage can be easily separated from the perpendicular plate and vomer by gentle detachment pressure using the D-knife or
septal elevator. The cartilage should also be dislocated from the tongue-on-groove junction with maxillary crest using the
same instruments. The cartilage graft is then free to be lifted out of the space. The use of swivel knife for septal harvest is not
recommended because a portion of the septal cartilage may be left behind, which is highly undesirable for Asian patients
with smaller supply of septal donor graft. The knife is especially wasteful for the posterocephalic portion of septum where
the cartilage joins with vomer. Complete harvest of this septal portion is important for obtaining a thick and long septal car-
tilage graft (Fig. 4.18).
The septal cartilage should be harvested such that 10–15 mm of cartilage is left intact on the dorsal and caudal margins,
to prevent the formation of saddle nose. If possible, it is important to leave 12–15 mm of dorsal septal cartilage. L-strut of
inadequate width may appear to provide enough support during the operation but will result in sinking of cartilaginous dor-
sum over time. Or saddle nose deformity may form after a minor trauma to the dorsum. Because of this, the amount of septal
cartilage available for a safe harvest is severely limited in Asian patients.
4 Harvest of Autogenous Tissues

119
a
b
c
Fig. 4.17 Harvest of septal cartilage. (a) A curved L-shaped incision is made on the cartilage at the transition points between the dorsal and caudal
L-strut. (b) The L-incision is extended in cephalic and caudal direction, using a sharp Metzenbaum scissors. (c) Quadrangular cartilage is separated
from the perpendicular plate, vomer, and maxillary crest
Fig. 4.18 A thick, long septal graft can be obtained
by incorporating the posterocephalic portion of
the septum
Septal Cartilage

120
Harvest of Septal-Ethmoid Segment
For small septal cartilages, it is possible to increase the graft size by the incorporation of the ethmoid bone into the graft
(Fig. 4.19). Leaving the L-strut, the mid-septal cartilage is detached from the maxillary crest and vomer. The resulting carti-
lage is attached only to the perpendicular plate of ethmoid. The graft is freed by cutting the ethmoid bone using a septal
scissor or an osteotome. The author does not recommend the use of this graft, as the resulting septal-ethmoid graft often has
an angulation at the cartilage-bony junction and can lead to septal collapse.
Intranasal Packing and Splinting
Upon septal cartilage harvest, the following three measures should be considered to minimize septal hematoma.
Septal mucoperichondrial suture may be adequate in preventing septal hematoma if the bleeding is not severe. This can
be accomplished using 1–2 quilting sutures or a continuous mattress suture, with absorbable suture material.
a
b
Fig. 4.19 Harvest of osseocartilaginous graft
4 Harvest of Autogenous Tissues

121
However, intranasal packing or splint is necessary for the following situations:
1. High likelihood of septal bleeding
2. Deviated septal correction or extensive septal reconstruction
3. After turbinate surgery
4. The need to support a bony segment after an osteotomy
First, the potential space between the perichondrial layers can be controlled using quilting sutures or continuous mattress
suture. If the risk of bleeding is low after a septal cartilage harvest, the mucoperichondrial suture may be enough in prevent-
ing hematoma formation while avoiding the discomfort associated with the use of splints or packing.
Second, intranasal splint should be employed if the likelihood of bleeding is high or if the layers need more compression
for structural reasons (Fig. 3.12). Soft silicone sheet is introduced into each nasal cavity and is loosely fixated to the septal
mucoperichondrium using a mattress suture. The sheet can be removed between 2 and 7 days after operation. For simple
septal cartilage harvest, 2 days are sufficient. However, the splint should remain in place up to a week after a septal deviation
correction or extensive septal surgery.
Third, intranasal packing can induce significant respiratory discomfort in patients and is not used as much (Fig. 3.11).
However, it may be necessary to support bony segment after an osteotomy. When using either intranasal splint or packing,
the patient should be prescribed an appropriate antibiotic coverage to prevent toxic shock syndrome.
Complications of Septal Cartilage Harvest
If the dorsal and caudal L-struts do not have enough width, the mid-vault collapse can lead to saddle nose deformity. This
complication does not present itself during or immediately after an operation but develops over several months to several
years. In Asian patients, it is common to obtain septal cartilage grafts which are significantly smaller than is needed for the
purpose of harvest. In such cases, it is tempting to obtain a larger graft by leaving a smaller L-strut. Under no circumstances
should the operator leave less than 10–12 mm of L-strut. Because of this, a surgeon who is versed in Asian rhinoplasty should
have various techniques and approaches to answer the problem of inadequate small septal cartilage.
Other complications of septal cartilage harvest include septal hematoma, septal perforation, septal infection, and mucosal
synechiae.
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122
Costal Cartilage
Costal cartilage is a hyaline cartilage. It is abundant and can yield many grafts over multiple operations. It undergoes little
resorption and can be harvested along with the rib bone. The costal cartilage is useful for secondary operations, in which the
septal or auricular cartilage is either insufficient or missing from a previous operation. The disadvantages of costal cartilages
are graft warping, significant rigidity, necessity of chest wall scar, and longer operative time.
Anatomy of the Rib Cartilage
The first to seventh rib bones are connected directly to the sternum, and are therefore considered true rib bones (Fig. 4.20).
The eighth to tenth pairs of ribs connect to the sternum indirectly via the costal cartilages of the superior ribs, and are con-
sidered as false rib. The costal cartilages for sixth and seventh ribs are connected to each other. The 11th and 12th rib bones
do not connect at all with the sternum and are called floating rib.
During rib cartilage harvest, the muscles encountered include the external oblique muscle and rectus abdominis muscle,
with the occasional pectoralis major muscle (Fig. 4.21). The sixth and seventh rib cartilages are located below external
oblique muscle and rectus abdominis muscle.
6th rib
7th rib
10th rib
Fig. 4.20 Anatomy of costal cartilage
pectoralis
major m.
serratus
anterior m.
external
oblique m.
rectus
abdominis m.
Fig. 4.21 Muscles of chest wall and upper abdomen
4 Harvest of Autogenous Tissues

123
Fig. 4.23 Total ossification of the costal cartilages
Preoperative Evaluation
Preoperative consultation should evaluate for history of augmentation mammoplasty, previous costal cartilage harvest, and
chest wall trauma. Chest X-ray is mandatory for elucidation of old fracture of costal cartilage and bone and either the calci-
fication or the ossification of the costal cartilage. A patient’s age is important. Calcification of costal cartilages begins around
mid-30s and becomes a more frequent finding in older patients. In addition to calcification, the cartilage is more brittle in
elderly patients (Fig. 4.22). Complete calcification or ossification of the costal cartilages can occur even in younger patients.
Because of this, X-ray of the rib cage should always be inspected prior to the chest incision (Fig. 4.23).
Fig. 4.22 Calcified costal cartilage
Costal Cartilage

124
Design
The costal cartilage can be harvested for fifth to ninth ribs, with sixth and seventh ribs being the most common donor sites.
If the need for cartilage graft is small, the floating rib cartilage may provide grafts of sufficient size (Fig. 4.24). The rib car-
tilage is usually harvested from the right chest wall. The right chest wall is easier to approach for an operator, and the post-
operative pain of right chest wall is more easily distinguishable from angina of cardiovascular origin.
Harvest of the Fifth, Sixth, and Seventh Rib Cartilages
The incision will vary according to the rib cartilage to be harvested, patient’s gender, required amount of the cartilage, and
length of incision.
[Female]
In female patients, the incision can be hidden in the inframammary fold (IMF). However, this is not always possible in Asian
patients, as most patients do not have large enough of breast volume to hide the scar in a definite IMF.
The incision is designed by drawing a vertical line down from the nipple to the IMF. The beginning point of incision is
drawn 1 cm medial to this intersection point and is extended for 3 cm further medially (Fig. 4.24a). This incision is useful
for approaching the fifth and sixth rib cartilages and is even possible to access the seventh rib in some cases.
Longer cartilage grafts (5–6 cm) can be obtained from seventh, eighth, and ninth ribs, but these cartilages are not acces-
sible from the IMF incision. As such, the incision should be made directly over the cartilage to be harvested. At this level,
there is a density of connective tissue between the rib and the parietal pleura, which makes cartilage harvest less likely to
cause pneumothorax, compared to superior rib cartilages. This makes for easier harvest even for the novice surgeon. Unlike
septal extension graft, costal cartilage graft used for dorsal augmentation requires long straight grafts. The sixth rib is less
than ideal for its curved shape, whereas the seventh rib cartilage is the most preferred for its length and the straightness.
Osseocartilaginous grafts are most commonly obtained from eighth or ninth rib.
In patients with a history of breast augmentation through IMF incision, the preexisting IMF scar can be utilized for carti-
lage harvest. In such cases, the operator should watch out for malposition or rupture of breast implant. Although the IMF scar
is closer to the sixth rib, the cartilage should be harvested from the seventh or eighth rib to protect the breast implant.
[Male]
In male patients, the skin incision can be made directly over the sixth or seventh rib cartilage. The length of incision will vary
according to graft size and operator experience, but this commonly falls between 2 and 4 cm. In Asian patients, hypertrophic
scar forms easily over the chest wall, and long incisions can be very conspicuous. However, extremely short incision provides
limited vision of the cartilage and can increase the risk of vessel injury or pneumothorax. Also, inadequate incisions can lead
to formation of hypertrophic scar from excessive retraction and maceration of the wound.
Fig. 4.24 Incisions for costal cartilage harvest. (a) The fifth and
sixth costal cartilages are possible through an inframammary
incision. (b, c) The seventh to tenth rib cartilages can be harvested
via direct incisions over the respective cartilage to be harvested
4 Harvest of Autogenous Tissues

125
Harvest of Free-Floating Rib (11th, 12th Rib)
Free-floating ribs are not connected to the sternum. Because cartilages on these ribs are small, the incision does not need to
be larger than 1.5 cm. The graft can be harvested from the costochondral junction to the tip of the floating rib, or it can be
harvested in the opposite direction from the tip to the junction. The location of the incision will depend on harvest
direction.
Operative Procedures
Anesthesia
Harvesting the costal cartilage is possible under intravenous sedation and local infiltration of an anesthetic agent. However,
rhinoplasty involving the costal cartilage takes considerable operating time. General anesthesia, with which both the operator
and the patient are comfortable, is highly recommended.
Local Anesthetic Infiltration
Prior to local infiltration, a 25-gauge needle is used to locate the costochondral (osseocartilaginous) junction and also to
evaluate for calcification of the rib cartilage. The needle is inserted into the costal cartilage and moved in all directions. If the
calcification is severe, the cartilage should be harvested from a different rib. There is a wide variability in the amount of
calcification across the costal cartilages within a patient, and it is quite common that the other rib is less calcified even though
one rib is severely calcified.
The incision line and the operation field are adequately injected with 1% lidocaine mixed with 1:200,000 epinephrine. All
layers including the subcutaneous tissues, muscles, and perichondria are injected to minimize intraoperative bleeding.
Incision and Dissection
Incisions on the skin and subcutaneous tissues expose the superficial fascia (Scarpa’s fascia) of the abdomen. Incisions
of the fascia expose the abdominal muscles. Depending on the incision location, the operator encounters the external
oblique muscle, the rectus abdominis muscle, and often the pectoralis major muscle. The most ideal approach to the
costal cartilage is the approach between the rectus abdominis and external oblique muscle without cutting the muscle
fibers. However, this is not always possible. When the operator has to pass through the muscle, splitting the muscle
fibers, rather than cutting, is recommended to reduce intraoperative bleeding and postoperative pain, and to ease the
muscle repair. The tissues covering the costal cartilage are sufficiently dissected to expose the perichondrium of the
costal cartilage fully and to identify the costochondral junction. The costochondral junction is visually confirmed in
most cases, but the operator may need to stick a needle into the junction for any ambiguity. Once the junction is identi-
fied, the operator should stick a fine needle into the cartilage in several points to find the presence and extent of
calcification.
Harvest of the Cartilage
A cross-shaped (H-shaped) incision is made in the perichondrium of the costal cartilage to be harvested (Fig. 4.25). This
perichondrial incision is extended to the costochondral junction laterally and the costosternal junction medially, along the
midline of the anterior surface of the costal cartilage. Lateral and medial junction areas of the cartilage also should have an
H-shaped incision. If the perichondrial incision is too shallow, the perichondrium does not peel off easily. A Freer elevator is
used to carefully lift the perichondrium from the anterior surface of the costal cartilage towards cephalic and caudal margin
of the cartilage, and also towards lateral and medial junction.
The perichondrium adheres to the cartilage denser and tighter at medial and lateral ends, which can lead to easy tearing
of the perichondrium. Every precaution should be taken since a perichondrial tear, especially the posterior perichondrial tear,
can lead to pleural injury. Elevation of the anterior perichondrium is followed by posterior perichondrial elevation, which
should begin in the costochondral junction area. The operator must take particular care not to injure the perichondrium and
pleura, since the initial dissection of posterior perichondrium is performed under poor visualizations. Most pleural injury and
pneumothorax develop during this process.
The perichondrium elevation begins in the cephalic and caudal margins of the costal cartilage, and then proceeds
towards the posterior direction. After elevation of the posterior perichondrium of the costochondral junction, a protector
is inserted in the area between the posterior surface of the cartilage and the elevated posterior perichondrium. Then, a
scalpel blade is used to cut and split the costochondral junction. The junction should not be cut through the full thickness.
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126
a
b
c
d
e
f
Fig. 4.25 Harvesting the costal cartilage. (a) A cross-shaped incision is made on the perichondrium of the lateral costochondral junction and
medial chondrosternal junction. (b) The perichondrium is elevated from the anterior and posterior surfaces of the costochondral junction. (c) A
protector is inserted between the posterior surface of the cartilage and the elevated perichondrium. This protects the perichondrium and pleura.
Then, a scalpel blade is used to cut about 3/4 thickness of the costochondral junction. (d, e) A blunt elevator is inserted into the gap created by the
incision, and the elevator is twisted to fracture the posterior 1/4 thickness of the costochondral junction that has not been cut yet. This completes
splitting of the cartilage. (f) While lifting the cut face, the posterior perichondrium is dissected and the posterior surface of the costal cartilage is
medially elevated. (g, h) The cartilage is cut slightly lateral to the chondrosternal junction for harvesting. (i) Posterior perichondrium seems intact,
without tearing after cartilage harvesting. (j) Harvested costal cartilage (seventh rib). (k) Valsalva maneuver demonstrates no air leakage
4 Harvest of Autogenous Tissues

127
g
h
i
k
j
Fig. 4.25 (continued)
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128
Instead, the costochondral junction should be cut ¾ of the way through, followed by the insertion of a blunt elevator into
the gap created by the initial cut. Then, the elevator is twisted to induce a fracture to the posterior 1/4 of the costochondral
junction. This approach is safer compared to that made by a full-thickness cut with a scalpel blade. While lifting up the
cut surface, the posterior perichondrial dissection proceeds medially. The cartilage is cut at the costosternal junction or
slightly lateral to the costosternal junction, depending on the length required. The anterior perichondrium can be har-
vested, as required. During the procedure, utmost care should be taken to prevent neurovascular bundle and pleural
injuries.
Because the costal cartilages are conjoined from eighth to tenth ribs, the cartilage to be harvested needs to be separated
from other costal cartilages.
For harvesting from the tip of floating ribs, it is easier to harvest the whole cartilage without a separate dissection of the
perichondrium. In contrast, floating ribs need to be harvested with the same technique used for sixth–eighth costal cartilages
if the harvest begins at the costochondral junction.
Valsalva Maneuver
After filling the operating field with an antibiotic solution before wound closure, the anesthesiologist is requested to perform
the Valsalva maneuver to inflate the lung maximally. The operating field is carefully checked for air bubbles, to evaluate for
potential pleural injury.
Wound Closure
The perichondrium needs not be repaired, but the author usually repairs it with an absorbable suture material. The muscle,
Scarpa’s fascia, subcutaneous, and skin layers are closed in succession. The muscle should be repaired as a full layer. In the
event of a severe skin maceration due to excessive retraction, the skin margin should be excised and repaired to help reduce
hypertrophic scar formation. Drain is not needed, and compression dressing is required for a single day.
Complications of Costal Cartilage Harvest
Complications of costal cartilage harvest include pneumothorax, hemothorax, seroma, hematoma, graft fracture, and chest
wall scar.
Complications
Pneumothorax
The major donor-site complication is pneumothorax from a pleural injury. The most important thing to prevent this serious
complication is avoiding the perichondrial tearing at the cephalic and caudal borders and the posterior side of the costal
cartilage. If a parietal pleural injury occurs without lung parenchymal injury, a rubber catheter is inserted into the pleural
cavity through the injured pleural area. The catheter is then connected to a wall suction to maintain a negative pressure, fol-
lowed by wound closure. While the lungs are fully expanded by the anesthesiologist, the rubber catheter is removed and the
final skin suture is placed, upon which waterproof dressing is applied. A pleural repair is not necessary. This procedure alone
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129
largely removes air from the pleural space, obviating a chest tube insertion. If possible, an upright chest X-ray is performed
using a portable X-ray in an operating room later.
Postoperative X-ray imaging may reveal micropneumothorax, due to an unrecognized pleural injury during surgery. Such
small pneumothoraxes may spontaneously resolve with high O2 therapy, but the patient should be consulted with a
physician.
Seroma and Hematoma
Hematoma or seroma is not common after costal cartilage harvest, and drains are not needed. In obese patients, vacuum drain
can be used as required. Postoperative seroma or hematoma can be addressed by aspiration of the fluid and compression of
the wound. A seroma will require repeat aspirations.
Graft Fracture
Generally graft fracture is not common for costal cartilage harvest, but can occur for brittle rib cartilage from calcification
(Fig. 4.26).
Scar
Incisions on the chest wall can frequently result in hypertrophic scar or keloid, and patients should be counseled on this fact
prior to an operation.
Fig. 4.26 This costal cartilage graft was inadvertently fractured
during the harvest
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130
Dermofat
A dermofat graft consists of de-epithelized dermis and subcutaneous fat and can be used to correct volume deficits or dorsal
irregularities.
Depending on the donor site, a graft composed solely of subcutaneous fat tissue may have poor survival rate. A dermal
graft avoids the problem of survivability but does not provide adequate graft volume needed for dorsal augmentation. In
contrast, dermofat graft provides 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. Between the fat and dermal layers, the fat tissue
undergoes significantly more resorption. For this reason, it is important to secure the maximal thickness of dermal layer.
Dermofat graft is indicated for the following situations: for dorsal augmentation in patients with thin skin; for soft- tissue
padding to the thin nasal tip skin; for correction of irregularities of the nasal dorsum, lobule, or ala; for correction of dorsal
skin redness from an implant; for tissue enhancement after removal of injected foreign material; and for immediate dorsal
augmentation after an infection.
Harvest Technique of Dermofat Graft
The dermis is thicker in the sacrococcygeal area than anywhere else in the body. In addition, the subdermal fat layer is rela-
tively dense. These anatomic properties of the sacrococcygeal soft tissue create for an excellent source of dermofat graft.
This is also one of the most covered areas of the body, and postoperative scars are very inconspicuous. 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. 4.27). The dermofat will undergo shrinkage immediately upon harvest. Thus, the design of dermofat
a
b
c
d
Fig. 4.27 Harvesting the dermofat graft. (a) Graft is harvested from one side of the buttock close to the intergluteal crease. (b) Upon skin incision,
the flap is de-epithelized. (c) The dermis and fat layer are harvested. (d) Wound closure
4 Harvest of Autogenous Tissues

131
should incorporate larger-than-needed dimensions to compensate for this shrinkage. 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. From an aesthetic standpoint, a
caudal-most incision would hide the scar in the intergluteal cleft. However, the perianal dermis does not have the desired
properties for a graft, and a donor site that is too close to the anus creates for an unhygienic wound and can even result in
anal fistula. To avoid such problems, the author designs the lowermost point of the incision at least 3 cm above the mucocu-
taneous junction of the anus.
Prior to incision, the skin is injected with a local anesthetic containing a mixture of epinephrine and lidocaine. The skin
is incised using a No. 15 blade without exposing the subcutaneous fat. The dermis is de-epithelized by peeling off the epi-
dermis using a No. 10 blade. Incomplete removal of epidermis should be avoided as it can result in epidermal cyst at the graft
site. Upon complete 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.
Harvest of Folded Dermal Graft
Harvest technique for the vertically oriented folded dermal graft for dorsal augmentation is described in detail in Chap. 7.
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132
Temporal Fascia
The fasciae, consisting of fibroblast, collagen fiber, and elastic fiber, can be harvested from various parts of the human body.
The fasciae used for rhinoplasty are the fascia lata and temporal fascia. The fascia lata may be used to reduce cartilage visibil-
ity or smooth out dorsal irregularities by covering up the cartilage graft on the nasal dorsum. This author prefers the temporal
fascia since (1) the operation field for the donor site and rhinoplasty is the same, (2) the harvest procedure is easy, and (3) it
has remarkably low donor-site morbidity.
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. A fascia graft by itself
may be used for dorsal augmentation.
Anatomy of Temporal Fascia
The soft-tissue envelope over the skull consists of skin, subcutaneous layer, galea aponeurosis, subgaleal loose areolar tissue,
and periosteum (Fig. 4.28).
The temporal fascia is the thick, strong fascia covering the temporalis muscle and is composed of two layers: superficial
and deep layers (Fig. 4.29). Superficial temporal fascia is a supra-zygomatic extension of SMAS and continues anteriorly as
the frontalis muscle and superiorly as galea aponeurosis. It covers nearly the entire lateral side of the skull. The deep tempo-
ral fascia is continuous with the periosteum of the skull and covers exactly the temporalis muscle, with a dimension of
10 × 12 cm. Superficial and deep temporal fasciae are histologically same tissues but are different in thickness. For rhino-
plasty, the thicker deep temporal fascia is preferred.
During temporal fascia harvest, the superficial temporal artery and vein are encountered.
Superficial temporal artery comes from the preauricular region, and passes over the posterior root of the zygomatic pro-
cess, about 1 cm in front of the tragus. This artery runs within the superficial temporal fascia, and branches into frontal
branch and parietal branch, mostly above the zygomatic arch (Fig. 4.30). The vein runs superficial to the artery.
epidermis
dermis
subcutaneous
tissue
galea
subgaleal space
pericranium
skull
Fig. 4.28 The soft-tissue envelope over the cranium includes skin, subcutaneous layer, galea aponeurosis, subgaleal loose areolar tissue, and
periosteum
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133
superficial temporal
fascia
deep temporal
fascia
Fig. 4.29 Temporal fascia is composed of superficial and
deep layers
Fig. 4.30 Superficial temporal vessels
frontal branch of
superficial temporal a.
parietal branch of
superficial temporal a.
superior auricular
a.
zygomatico-orbital
a.
Temporal Fascia

134
Operative Technique
Temporal fascia can be harvested under local anesthesia and is harvested between the temporal crest and superior root of ear
helix (Fig. 4.31).
A 3–4 cm skin incision is made 1 cm anterior and 3 cm superior to the superior root of ear helix (Fig. 4.32). The incision
is carried down through the subcutaneous tissue. To minimize the damage to hair follicles, the wound edges should be
retracted using either narrow-faced retractors or hook retractors while applying the minimal amount of force necessary to
maintain surgical access. When using the electrocautery for hemostasis, the electrode tip should be kept away from hair fol-
licle, as too much heat can lead to alopecia along the incision scar. Arising from the external carotid artery, the superficial
temporal artery and vein travel anterior to the ear where the artery can be palpated with relative ease. The artery runs deep to
the superficial temporal fascia, whereas the vein runs superficial to the artery. The operator should take care not to inadver-
tently injure these vessels but can ligate them as needed.
Upon opening and retracting the superficial temporal fascia, the glistening membrane observed is the deep temporal fas-
cia. The deep fascia is incised and separated from the temporal muscle. An even thickness of the deep fascia can be harvested
if the temporal muscle can be separated from the fascia.
It is essential to harvest the fascia as large as possible, up to 5 × 4 cm fascia. An even thickness of the deep fascia can be
harvested, if the temporal muscle can be separated from the fascia.
Hematoma formation is possible after temporal fascia harvest, which should be prevented by diligence in hemostasis and
by compression dressing above the donor site. Drains are unnecessary in most cases.
Fig. 4.31 The temporal fascia is harvested between the temporal
crest and superior root of ear helix
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Fig. 4.32 Operative procedures for harvesting the deep temporal fascia. (a) A 3 cm vertical incision is made between the temporal crest and
superior root of ear helix while avoiding injury to the superficial temporal vessels. (b) The deep temporal fascia is exposed after careful dissection.
(c) The suprafascial dissection should be extended wide enough to expose the fascia as much as possible. (d) The deep temporal fascia is exposed.
(e) Elevation of the deep temporal fascia. (f) The harvested deep temporal fascia. (g) Wound approximation using a No. 4-0 Vicryl suture. (h) The
skin is closed using a stapler
a
b
c
d
e
f
g
h
Temporal Fascia

136
Further Reading
1. Kim DW, Shah AR, Toriumi DM.  Concentric and eccentric carved costal cartilage: a comparison of warping. Arch Fac Plast Surg.
2006;8(1):42–6.
2. Wormald PJ, Alun-Jones T. Anatomy of the temporalis fascia. J Laryngol Otol. 1991;105(7):522–4.
3. Toriumi DM.  Dorsal augmentation using autologous costal cartilage or microfat-infused soft tissue augmentation. Facial Plast Surg.
2017;33(2):162–78.
4. Letourneau A, Daniel RK. The superficial musculoaponeurotic system of the nose. Plast Reconstr Surg. 1988;82(1):48–57.
5. Hwang K, Kim DJ, Lee IJ. An anatomic comparison of the skin of five donor sites for dermal fat graft. Aesth Plast Surg. 2001;46(3):327–31.
4 Harvest of Autogenous Tissues