Mastering Advanced Rhinoplasty

394
7
Suggested Reading
Aiach G. Atlas of rhinoplasty: open and endonasal approaches. 2nd ed. St.
Louis: Quality Medical Publishing; 2003.

Chapter 7 · Primary Augmentation of the Dorsum

395
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
8
Secondary Augmentation
of the Dorsum
8.1
Surgical Principles in Secondary Saddle-Nose Deformity – 396
8.2
Case Studies – 400
8.2.1
Case 1: Overresected Dorsum Augmented with Multilayered
Allogenic Fascia Lata – 400
8.2.2
Case 2: Augmentation with Free Diced Cartilage – 403
8.2.3
Case 3: Augmentation with Free Diced Cartilage – 405
8.2.4
Case 4: Augmentation with Conchal Cartilage and
Simultaneous Reconstruction of the Lateral Crura – 408
8.2.5
Case 5: Augmentation with Conchal Cartilage – 411
8.2.6
Case 6: Augmentation with Conchal Cartilage – 412
8.2.7
Case 7: Augmentation with Conchal Cartilage – 414
8.2.8
Case 8: Augmentation of DC-F Graft from Concha,
Complex Tip Reconstruction – 416
8.2.9
Case 9: Augmentation of DC-F Graft from Concha and
Simultaneous Deprojection of the Tip – 420
8.2.10
Case 10: Augmentation with DC-F from Rib Cartilage
and Lengthening with Septal Extension Graft – 423
8.2.11
Case 11: Replacing a MedporeR Implant with a DC-F Graft – 427
8.2.12
Case 12: Augmentation with DC-F from Rib Cartilage – 430
8.2.13
Case 13: Augmentation with DC-F from Rib Cartilage – 434
8.2.14
Case 14: Dorsal Reconstruction with DC-F from Rib Cartilage – 436
8.2.15
Case 15: Dorsal Reconstruction with Solid Rib Graft Covered with DC-F – 440
8.2.16
Case 16: Augmentation with Diced Cartilage
from the Previous Rib Cartilage Graft – 444
8.2.17
Case 17: Augmentation with Diced Cartilage
from a Previous Rib Cartilage Graft – 447
8.2.18
Case 18: Augmentation with Diced Cartilage
from the Previous Rib Cartilage Graft – 453
8.2.19
Case 19: Total Septal Reconstruction with Concha Combined
with DC-F Graft from Rib Cartilage – 455
8.2.20
Case 20: Removal of Silicone Implants and Replacement of DC-F Graft – 460
8.2.21
Case 21: Removal of Silicone Implants and Replacement of DC-F Graft – 463
8.2.22
Case 22: Removal of Synthetic Implant and Replacement of
DC-F Graft – 466
8.2.23
Case 23: Enlarging the Shrunken Skin Envelope by Continuous Manual
Stretching as Prerequisite for a Successful Augmentation with 
Solid Rib Graft – 470

Suggested Reading – 472

396
8
8.1
Surgical Principles in Secondary
Saddle-Nose Deformity
The principles of secondary dorsal augmentation are largely
the same as those used in primary rhinoplasty. However,
owing to the previous surgical disruption of nasal soft tissues,
scar contracture and/or fibrosis may complicate or limit sec-
ondary dorsal augmentation. Frequently, wide undermining
of the soft-tissue envelope is necessary to enable adequate
dorsal augmentation. In severe cases preoperative condition-
ing of the fibrotic skin envelope with stretching exercises
and/or repeated massage is necessary to gradually loosen the
tethered
and
noncompliant
soft-tissue
envelope.
Unfortunately, the nose is poorly suited to the use of conven-
tional tissue expanders, and while self- or autoinflating
expanders may offer effective alternatives, we have no experi-
ence with these devices.
If there is minor but full-length saddle deformity, we aug-
ment the defect with allogenic fascia lata grafts (. Figs. 8.1
and 8.2). When necessary, allogenic fascia lata can be applied
up to four layers thick. If the saddling is limited to a small
area, we prefer using free diced cartilage (FDC) minced to a
paste-­like consistency to precisely fill the indentation
(. Fig. 8.3). Before the advent of FDC, a single layer of allo-
genic fascia lata was used to cover and smooth the coarsely
diced cartilage (. Fig. 8.4).
Revision of a previous dorsal augmentation with solid rib
cartilage is most often prompted by warping of the ­original
augmentation graft material (. Fig. 8.5a). There are two pos-
sible options for correcting this problem. The first is removal
of the original graft, followed by reshaping and reinsertion.
However, because the risk of deformation increases with
decreased graft thickness, this approach is not always suc-
cessful. Alternatively, the solid rib graft can be removed and
used as donor material for a DC-F graft (. Fig. 8.5b–d). This
approach completely eliminates the risk of warping because
the graft is no longer a solid implant material. Instead, the
graft becomes a malleable augmentation material that can be
digitally manipulated in situ to achieve the desired dorsal
contour. And by leaving the caudal end open, diced cartilage
can be expressed from the open end and removed with suc-
tion when the graft is too large. However, it is best to close the
transcolumellar skin incision before making final determina-
tions regarding graft size. The marginal incision can then be
used for access to remove additional graft material when nec-
essary. Once the desired shape is established, it is reinforced
with Proxi-Strips (Ethicon, Inc., Somerville, New Jersey), a
flexible adhesive tape that stretches in two directions to bet-
ter maintain the desired contour. Regardless of the augmen-
tation graft tissue of origin (e.g., rib or conchal cartilage), we
use the DC-F conversion technique for all dorsal implants in
which shape deformation has occurred.
.
. Fig. 8.1  Multilayered fascia graft
.
. Fig. 8.2  Specimen of Tutoplast fascia graft

Chapter 8 · Secondary Augmentation of the Dorsum

397
8
a
b
.
. Fig. 8.3  (a, b) Free diced cartilage of pastelike consistency
.
. Fig. 8.4  Free diced cartilage covered with allogenic fascia graft
(Tutoplast)
8.1 · Surgical Principles in Secondary Saddle-Nose Deformity

398
8
.
. Fig. 8.5  (a–d) Reconstruction of a DC-F graft from warped rib cartilage and allogenic fascia lata
a
b
c

Chapter 8 · Secondary Augmentation of the Dorsum

399
8
d
.
. Fig. 8.5  (continued)
8.1 · Surgical Principles in Secondary Saddle-Nose Deformity

400
8
8.2
Case Studies
8.2.1 Case 1: Overresected Dorsum
Augmented with Multilayered
Allogenic Fascia Lata
A 25-year-old female presented with an overresected
­dorsum seeking revision rhinoplasty. Using the closed
approach, six layers of allogenic fascia lata were applied
to the overresected dorsum (. Fig. 8.6).
a
.
. Fig. 8.6  Augmentation with allogenic fascia lata (TutoplastR). (a) Intraop procedure and result. (b–d) Front view, profile view, base view pre-op/
post-op

Chapter 8 · Secondary Augmentation of the Dorsum

401
8
b
c
.
. Fig. 8.6  (continued)
8.2 · Case Studies

402
8
d
.
. Fig. 8.6  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

403
8
8.2.2 Case 2: Augmentation with Free Diced
Cartilage
A 36-year-old female presented after previous reduction rhi-
noplasty with irregularities of the nasal dorsum, including a
slight dorsal depression and a small residual hump. A ptotic
tip was also observed. Using the open rhinoplasty approach,
dorsal exploration revealed three layers of allogenic fascia lata,
which accounted for the small dorsal hump. Consequently, the
outer layer of fascia lata was removed, ­creating a small dorsal
depression. Conchal cartilage from the right ear was then
­harvested and diced to a very fine consistency and loaded into
a tuberculin syringe. The ptotic tip was then rotated using a tip
suspension suture with an anterior sling, and after partially
closing the skin flap, finely diced ear ­cartilage was injected into
the dorsal depression via the marginal incision. Using digital
massage, smoothing of the dorsum established a satisfactory
dorsal contour, and after closure of the marginal incision, an
elastic paper tape (3 M) dressing was applied to maintain the
desired dorsal contour during initial healing (. Fig. 8.7).
a
b
.
. Fig. 8.7  (a) Dorsal
augmentation with pastelike free
diced cartilage. (b–d) Front view,
profile view, basal view pre-op/
post-op
8.2 · Case Studies

404
8
c
d
.
. Fig. 8.7  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

405
8
8.2.3 Case 3: Augmentation with Free
Diced Cartilage
A 36-year-old female presented with saddling of the carti-
laginous dorsum after two previous rhinoplasties.
Examination also revealed a C-shaped nasal deviation with
an oblique columella and asymmetrical nostrils. In addi-
tion to the saddle indentation, profile examination revealed
an overprojected bony vault. Using the open rhinoplasty
approach, surgical exploration revealed a previously placed
right spreader graft that was not strong enough to keep the
dorsal septum from bending. Consequently it was replaced
by an extended spreader graft fashioned from cartilage
harvested from the ninth rib. The 8.0-cm long rib speci-
men was split into several 2-mm-thick strips, and addi-
tional graft material was used to replace a warped and
weak columellar strut graft. The newly inserted strut graft
was sutured to the extended spreader graft for stabilization.
After lowering the overprojected bony dorsum with a pow-
ered cylindrical burr, the nasal pyramid was straightened
with (internal) parasagittal medial osteotomies followed by
percutaneous low-to-low lateral and transverse osteoto-
mies. The remaining rib cartilage was finely diced and
injected beneath the nasal skin flap with a tuberculin
syringe (after closure of the columellar incision) for final
contouring of the nose (. Fig. 8.8).
8.2 · Case Studies

406
8
.
. Fig. 8.8  (a) Augmentation
with free diced cartilage. (b–d)
Front view, profile view, base
view pre-op/post-op
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

407
8
d
c
.
. Fig. 8.8  (continued)
8.2 · Case Studies

408
8
8.2.4 Case 4: Augmentation with Conchal
Cartilage and Simultaneous
Reconstruction of the Lateral Crura
A 35-year-old female presented for revision rhinoplasty after
two previous nasal surgeries. Examination revealed an
abnormally low nasal “starting point” resulting from a
severely overresected bony dorsum, an inverted-V deformity,
leftward deviation of the dorsal septum, and tip asymmetry.
Intraoperatively, the left lateral crus was found to be
­malformed, and the right alar dome was missing. Treatment
involved placement of bilateral (conchal) spreader grafts to
correct middle vault pinching and to correct the dorsal septal
alignment. A columellar strut graft fashioned from septal
cartilage was placed for tip support, and batten grafts fash-
ioned from septal cartilage were used to reconstruct the lat-
eral crura. The bony dorsum was augmented using a
crosshatched conchal cartilage graft (with the perichondrium
still intact) covered with two layers of allogenic fascia lata
(. Fig. 8.9).

Chapter 8 · Secondary Augmentation of the Dorsum

409
8
.
. Fig. 8.9  (a) Augmentation with conchal cartilage and simultaneous reconstruction of the lateral crura. (b–d) Front view, profile view, basal
view pre-op/post-op
a
b
8.2 · Case Studies

410
8
d
c
.
. Fig. 8.9  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

411
8
8.2.5 Case 5: Augmentation with Conchal
Cartilage
A 24-year-old male presented for revision rhinoplasty after
four previous nasal surgeries. Examination revealed an
­overresected nasal dorsum. Treatment involved dorsal aug-
mentation with a multilayered conchal cartilage graft in
which multiple smaller fragments were sutured to a flat, full-
length segment to produce a custom-tailored onlay graft
(. Fig. 8.10).
.
. Fig. 8.10  Augmentation with conchal cartilage
8.2 · Case Studies

412
8
8.2.6 Case 6: Augmentation with Conchal
Cartilage
An 18-year follow-up after saddle-nose correction by recon-
struction of the anterior septum with double-layered conchal
graft was seen. A 35-year-old male presented with broad
saddle nose and drooped bulky tip after multiple rhinoplas-
ties. Because of the missing anterior septum, the nasolabial
angle was acute.
In a closed approach technique, the surgical explora-
tion revealed an overresection of the anterior septum. The
wide nasal pyramid was narrowed by low-to-low lateral
­osteotomies from a sublabial approach and by transverse
­osteotomies through the eyebrow. To reconstruct the ante-
rior septum and to rebuild the dorsum, both conchae were
harvested from posteriorly. A double-layered sandwich graft
was folded and used as a columellar strut. It was fixed to the
anterior nasal spine (ANS) through a drill hole. Also the con-
cha from the other side was transformed in a double-layered
graft and used for dorsal augmentation. Residual parts of
the ear cartilage were diced for camouflaging dorsal irregu-
larities. The patient came for a follow-up visit after 18 years
because of a skin tumor. Good function and form of the nose
have been stable over time (. Fig. 8.11).
.
. Fig. 8.11  (a–b) Double
layered conchal graft. (c–d) Front
view, profile view pre-op/post-op
a
c
b

Chapter 8 · Secondary Augmentation of the Dorsum

413
8
d
.
. Fig. 8.11  (continued)
8.2 · Case Studies

414
8
8.2.7 Case 7: Augmentation with Conchal
Cartilage
A 40-year-old female presented for reconstruction of a saddle-­
nose
deformity
resulting
from
previous
septoplasty.
Examination revealed resection of the anterior septum and
severe collapse of the weakened dorsal L-strut. The unaltered
bony dorsum gave the false impression of a large rhinion
hump—the so-called pseudo-hump deformity. Reconstruction
was performed with conchal cartilage harvested from both
ears. A portion of the donor cartilage was used to create a dou-
ble-layered columellar strut graft to reconstruct the missing
caudal septum, while the remaining cartilage was used to create
a full-length (crosshatched) dorsal onlay graft. After reducing a
slight bony hump with the rasp, five layers of allogenic fascia
lata were used to cover the full-length conchal graft (. Fig. 8.12).
.
. Fig. 8.12  (a–c)
Augmentation with conchal
cartilage. Front view, profile
view, base view pre-op/post-op
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

415
8
c
.
. Fig. 8.12  (continued)
8.2 · Case Studies

416
8
8.2.8 Case 8: Augmentation of DC-F Graft
from Concha, Complex Tip
Reconstruction
A 41-year-old female presented for revision rhinoplasty
after two failed rhinoplasties abroad. Examination revealed
an overprojected nasal tip and an overresected nasal dor-
sum. Retraction of the central columella and overprojection
of the supratip were also observed. Intraoperatively, the
right lateral crus was found to be partially absent, and the
medial crura were malpositioned and partially resected.
Treatment included deprojection of the tip with the lateral
crural sliding technique (lateral crural overlap technique)
on the left and placement of a (septal) batten graft to replace
the missing right lateral crus. A conchal shield graft was
also placed. The dorsum was augmented with a DC-F graft
fashioned from conchal cartilage and allogenic fascia lata
(. Fig. 8.13).
.
. Fig. 8.13  (a–d)
Augmentation with DC-F graft
from concha. (e–g) Front view,
profile view, base view pre-op/
post-op
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

417
8
c
d
.
. Fig. 8.13  (continued)
8.2 · Case Studies

418
8
e
f
.
. Fig. 8.13  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

419
8
g
.
. Fig. 8.13  (continued)
8.2 · Case Studies

420
8
8.2.9 Case 9: Augmentation of DC-F Graft
from Concha and Simultaneous
Deprojection of the Tip
A 33-year-old female presented for revision surgery after rhi-
noplasty elsewhere. Examination revealed an overresected
dorsum partially concealed by a malpositioned rib cartilage
graft. The nasal pyramid was overly wide, and the nose
seemed too long. Saddling of the middle vault, ­overprojection
of the asymmetrical tip, and an overly acute nasolabial angle
were also observed.
Treatment of the overprojected and underrotated tip was
accomplished with a lateral crural overlap of 5 mm, coupled
with columellar shortening of 2 mm. After removing the dor-
sal rib graft, the bony dorsum was smoothed, and the dorsum
was augmented with a DC-F graft fashioned from conchal
cartilage, recycled rib cartilage, and allogenic fascia lata
(. Fig. 8.14).
.
. Fig. 8.14  (a–g) Dorsal
augmentation with DC-F graft
and simultaneous deprojection of
the tip. (e–g) Front view, profile
view, base view pre-op/post-op
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

421
8
c
d
e
.
. Fig. 8.14  (continued)
8.2 · Case Studies

422
8
f
g
.
. Fig. 8.14  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

423
8
8.2.10  Case 10: Augmentation with DC-F
from Rib Cartilage and Lengthening
with Septal Extension Graft
A 31-year-old female presented with a ski-loop nose after
overresection of the dorsum during previous surgery. The
nasolabial angle was 125°. The bony pyramid was deviated to
the left. Both alae showed deep impression, and the left one
had additional notching. Using an open approach technique,
surgical exploration revealed that both the dorsum and the
anterior septum had been overresected. There was a huge
open roof on both sides. A big septal transplant consisting of
cartilage and thin bone was harvested and used as a septal
extension graft. The bone was perforated with multiple holes
and used as a splint to fix the septal extension graft to the
residual parts of the anterior septum.
After straightening the nasal pyramid by percutaneously
low-to-low lateral and transverse osteotomies (parasagittal
medial osteotomies were not necessary because of the huge
open roofs), the upper border of the upper lateral cartilage
(ULC) was sutured to the dorsal septum as spreader flaps,
accepting an increase of the saddling.
The ninth rib was harvested and cut into small strips.
From these, two lateral crural struts grafts were fabricated to
support the weak lateral crura. Then the lateral parts of the
lower lateral cartilages (LLC) were transposed to correct the
retraction.
The rest of the cartilage was diced finely and put into a
tube of deep temporalis fasciae, sutured over a tuberculin
syringe. Only the cranial end was closed, and then the
DC-F was placed with two guiding sutures. After suturing
back the nasal skin, the final shape was molded, the excess
of cartilage was sucked out, and the transition areas from
the graft to the dorsum were smoothed with free diced
cartilage (. Fig. 8.15).
8.2 · Case Studies

424
8
.
. Fig. 8.15  (a–c) Augmentation with DC-F from rib cartilage and lengthening with septal extension graft. Enforcing the lateral crura with under
batten grafts from rib cartilage (lateral crural strut grafts). (c–e) Front view, profile view, base view pre-op/post-op
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

425
8
c
d
.
. Fig. 8.15  (continued)
8.2 · Case Studies

426
8
e
.
. Fig. 8.15  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

427
8
8.2.11  Case 11: Replacing a MedporeR
Implant with a DC-F Graft
A 29-year-old female with an overly short nose presented for
evaluation 5 years after reduction rhinoplasty performed
elsewhere. Examination revealed acute erythema of the dor-
sum. A review of the operative report revealed that inadver-
tent overresection of the dorsum was treated primarily with
MedporeR implant placement. A threatened extrusion was
also observed at the glabella with thinning and erythema of
the overlying skin.
To avoid extrusion, we elected to treat the patient emer-
gently and we removed the MedporeR implant through an
open rhinoplasty approach. Although there were no signs of
an acute purulent infection, a chronic foreign body-type reac-
tion with diffuse granulation tissue was observed. Removal of
the implant also revealed a very irregular dorsum and explo-
ration of the septum revealed prior removal of the central sec-
tion. The tip framework was also severely damaged.
In light of the severe skeletal damage, we opted for an
immediate reconstruction. Autologous rib cartilage was
­harvested and cut into 1.5 mm thick strips. The strips were
then used as extended spreader grafts and fixed to the previ-
ously placed columellar strut graft. The strut graft had been
cranially overrotated from scar contracture and was there-
fore counter-rotated using the extended spreader grafts. The
medial crural remnants were then sutured to the reposi-
tioned columellar strut graft for support. Lateral crural bat-
ten grafts fashioned from rib cartilage were also used to
replace missing segments of the lateral crura, and the tip was
further contoured with placement of a shield graft.
Dorsal reconstruction was achieved with a DC-F graft.
However, owing to the preexisting inflammation, the fascial
sleeve was fashioned from vascularized autologous tempora-
lis fascia rather than from allogenic fascia lata. Using the
explanted MedporeR implant as a template, the DC-F sleeve
was fabricated from temporalis fascia and filled with finely
diced residual rib cartilage. The DC-F graft was positioned
using percutaneous guiding sutures placed at both medial
eyebrows and secured with interrupted sutures to the under-
lying ULCs. Final refinement of the dorsum was achieved
with the application of free diced cartilage (. Fig. 8.16).
.
. Fig. 8.16  (a) Destroyed tip framework, MedporeR implant in situ (leftside). (b) Extended spreader grafts from rib cartilage, DC-F graft using
MedporeR implant as a template. (c) Alloplastic dorsal implant threatening extrusion with acute erythema and thinning of the overlying glabellar
skin. (d–f) Front, profile, and base views before and 8 months postoperative
a
b
8.2 · Case Studies

428
8
c
d
.
. Fig. 8.16  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

429
8
e
f
.
. Fig. 8.16  (continued)
8.2 · Case Studies

430
8
8.2.12  Case 12: Augmentation with DC-F
from Rib Cartilage
A 31-year-old female presented after two previous surgeries
with an overresected dorsum and a broad deviated nose. The
columella was asymmetrical and oblique, so that the nostrils
were asymmetrical as well. The ANS was dislocated to the
right. Endoscopic view showed a septal perforation of 23 mm
in diameter that extended up the roof of the nose.
An open approach was performed, but the transection of the
columella was not done via the old scar, which had been placed at
the base but at the most narrow part of the columella. Surgical
exploration revealed destruction of the LLC and camouflaging
by bended rib grafts, which were not contoured. Only a small
part of the anterior and dorsal septum was left. The caudal sep-
tum was strengthened by a sandwich graft from the concha,
which was shaped asymmetrically at its base to balance the dislo-
cated ANS. The medial crura were missing. The rib grafts were
removed but could not be used for reconstruction of the
LLC. Therefore, the ninth rib was harvested and cut into 1.5-mm-
thick strips. These were fixed to the columellar strut from
­conchal cartilage, thinned in the dome area for better bending
and easier shaping by sutures, and then fixed to the lateral crura.
The nasal pyramid was narrowed and straightened by
parasagittal median osteotomies and percutaneously low-to-­
low lateral and transverse osteotomies. The dorsum was
reconstructed by a DC-F from the fine diced residual rib car-
tilage and allogenic fascia (. Fig. 8.17).

Chapter 8 · Secondary Augmentation of the Dorsum

431
8
.
. Fig. 8.17  (a–b) Augmentation with DC-F from rib cartilage. (c–e) Front view, profile view, base view pre-op/post-op
a
b
8.2 · Case Studies

432
8
c
d
.
. Fig. 8.17  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

433
8
e
.
. Fig. 8.17  (continued)
8.2 · Case Studies

434
8
8.2.13  Case 13: Augmentation with DC-F
from Rib Cartilage
A 24-year-old male presented with a very wide and overre-
sected dorsum after two previous rhinoplasties. The tip was
round and bulky, and the distance between the tip defining
points was widened. The supratip area showed a fullness.
After using the open approach, the intraoperative explor-
ing showed multiple grafts on top of the domes, which were
removed. The residual septum was deviated to the left and
blocked the airway. The deformed parts were resected, and
the septum was shortened at its base und fixed to the ANS
after perforating it. From the resected cartilage, two extended
spreader grafts were harvested and sutured in position to
­stabilize the framework. The wide deviated nasal pyramid
was straightened and narrowed by percutaneous low-to-low
lateral and transverse osteotomies.
From the resected septal part, a strong columellar strut
could be cut and brought into position. By inverted ­suspension
sutures, the whole tip-columella complex was shifted down-
ward. The previously cut medial crura were fixed to the strut.
For reconstruction of the dorsum, we resected the 10th
and 11th ribs, diced this cartilage, and built a DC-F from
allogenic fascia lata. In the end a double-layered onlay graft
from allogenic fascia was put on the tip to obtain a good con-
tour (. Fig. 8.18).
.
. Fig. 8.18 
(a) Augmentation
with DC-F from rib cartilage.
(b–d) Front view, profile view,
base view pre-op/post-op
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

435
8
c
d
.
. Fig. 8.18  (continued)
8.2 · Case Studies

436
8
8.2.14  Case 14: Dorsal Reconstruction
with DC-F from Rib Cartilage
Technique: Removal of infected Mersilene mesh used for
dorsal augmentation and secondary dorsal reconstruction
using an autologous DC-F graft.
After six previous nasal surgeries, a 50-year-old female
presented with purulent infection of the nasal dorsum. All the
prior surgeries had been done abroad in different countries.
Ten years earlier, Mersilene mesh was used for ­augmentation
of the nasal dorsum. Nine years later, a different surgeon who
did not know that Mersilene mesh had been implanted was
consulted to perform a revision surgery. Following the revi-
sion surgery, the Mersilene mesh became infected, but the
second surgeon declined to remove the infected implant
because he did not feel responsible for the problem. The sur-
geon who had originally implanted the Mersilene mesh also
declined to treat the patient because the infection had started
only after additional surgery by another doctor.
During surgical exploration, it became clear that the
entire nasal framework had been augmented with Mersilene
mesh. All of the mesh was subsequently removed, resulting
in a flat nose with inadequate projection of both the nasal tip
and nasal dorsum. Bacterial cultures of the explanted
Mersilene revealed a multiresistant organism (Escherichia
coli with extended spectrum beta-lactamases [ESBL]).
Antimicrobial coverage was selected according to the pre-
vailing antibiogram, and the patient was treated with
­intravenous piperacillin and tazobactam combined with
local wound care.
After 3 months (and confirmation by three consecutive
negative nasal swabs), the infection had resolved, and recon-
structive surgery was undertaken. The tenth rib was har-
vested from the right chest wall and the right conchal bowl
was also harvested. Additionally, a 5- × 3-cm piece of deep
temporalis fascia was harvested from beneath the right tem-
poral scalp. The temporalis fascia was used to create a “sleeve”
of fascia to encase finely diced cartilage to construct a DC-F
augmentation graft. After dissecting the membranous sep-
tum with the open rhinoplasty approach, the previously
placed columellar strut graft was removed and replaced with
a double-layered sandwich graft fashioned from conchal car-
tilage. The conchal graft was implanted into the columella
using a guiding suture through the philtrum, and the former
strut graft was recycled to create a nonintegrated shield graft
to stretch the scarred and thickened nasal skin.
To narrow the overly wide nasal pyramid, percutaneous
low-to-low lateral and transverse osteotomies were first per-
formed. Then the overfilled DC-F graft was sutured shut at
the cephalic end but left open distally. Two guiding sutures
were placed at the cephalic end and used to guide the DC-F
into position over the nasal dorsum. After partial skin flap
closure, the final graft shape was created by applying external
digital pressure and suctioning the excess diced cartilage
from beneath the skin flap until the desired contour was
achieved (. Fig. 8.19).

Chapter 8 · Secondary Augmentation of the Dorsum

437
8
.
. Fig. 8.19  (a–d) Dorsal
reconstruction with DC-F from
rib cartilage after removing of
infected Mersilene mesh. (e–g)
Front view, profile view, base
view pre-op/post-op
a
b
8.2 · Case Studies

438
8
c
d
e
.
. Fig. 8.19  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

439
8
f
g
.
. Fig. 8.19  (continued)
8.2 · Case Studies

440
8
8.2.15  Case 15: Dorsal Reconstruction
with Solid Rib Graft Covered
with DC-F
An 18-year-old male presented with a severe saddle-nose
deformity and a large septal perforation measuring
20 × 30 mm located close to the nasal roof. According to the
previous operative report, a two-flap technique was used in a
failed attempt to close a central septal perforation. Mucosa
was harvested from beneath the upper lateral cartilages bilat-
erally, and in addition to recurrence and enlargement of the
original septal perforation, the denuded cartilage resulted in
saddle collapse of the nasal dorsum. Moreover, there was
inadequate residual space within the dorsal soft tissues to
permit augmentation of the saddle deformity. Hence, closure
of the septal perforation was first undertaken.
Perforation repair was achieved by elevating mucosa off the
upper lateral cartilages and advancing mucosal flaps inferiorly
to partially eliminate the perforation. This, in turn, created a
pocket to accommodate placement of a dorsal augmentation
graft. Autologous deep temporalis fascia was first used to line
the mucosal pocket, which was used to secure a solid rib carti-
lage graft. The solid rib construct was then covered with a DC-F
graft fashioned from diced rib cartilage and additional deep
temporalis fascia. One-year follow-­up revealed good dorsal con-
tour and persistent closure of the septal perforation (. Fig. 8.20).
.
. Fig. 8.20  (a–e) Dorsal
reconstruction with solid rib graft
covered with DC-F after closing
the septal perforation close to the
roof. (f–h) Front view, profile view,
base view pre-op/post-op
a
Deep temporalis fascia
used to fill the dead space
after closing the perforation
and to prepare a DCF
b

Chapter 8 · Secondary Augmentation of the Dorsum

441
8
e
c
d
Septal perforation
Pre op
Post op
.
. Fig. 8.20  (continued)
8.2 · Case Studies

442
8
f
g
.
. Fig. 8.20  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum