Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

554
U. Mueller-Vogt and H.G. Gassner
Increased resorption of the graft has been associ-
ated with oxycellulose, and the use of autologous
material, typically temporalis fascia, is hence
favored. Alternative material may include costal or
conchal perichondrium. The autologous fascia is
sutured to a blind-ending tube and advanced over a
1-mL syringe (Fig. 38.13 ). The tube is then inserted
into the nasal defect and fi lled with dice of carti-
lage through the 1-mL syringe. Once an adequate
volume of cartilage has been injected, the syringe
is removed and the open end of the tube is tied
with a suture. The resulting reconstruction is softer
than costal cartilage and bone and also has no
signi fi cant risk of warping [ 22, 23 ] .
Finer dorsal and supratip contour irregulari-
ties may be augmented with crushed or shaved
cartilage. We prefer the use of very fi ne shaved
cartilage. Crushed cartilage has a variable resorp-
tion rate of approximately 20–60%. Very thinly
shaved cartilage is not associated with crush
injury to the chondrocytes and thus has likely a
less signi fi cant rate of resorption.
Alloderm has also been utilized to correct
minor contour irregularities. This material is
associated with prolonged edema formation and
very low rates of resorption. Soft synthetic mate-
rials including Gore-Tex and Mersilene mesh are
also less frequently utilized because of their risk
of infection and extrusion.
Conclusions
Transplants and suture techniques are the key
tools when performing septorhinoplasty.
Autologous materials have stood the test of
time and have proven to be the best graft mate-
rial in the vast majority of cases. Rigid recon-
struction with costal cartilage or calvarium
seems to be a secondary alternative if softer
methods of reconstruction are available. The
use of suture technique may be very helpful,
but the basic principle that adequate dissection
and mobilization must be achieved before
repositioning and re fi xation of the tissue can
be reliably achieved must be respected.
References
1. Helder AH, Huizing EH (1986) Transplantation ter-
minology in nasal surgery. Rhinology 24(4):235–236
2. Homicz MR, McGowan KB, Lottman LM, Beh G,
Sah RL, Watson D (2003) A compositional analysis
of human nasal septal cartilage. Arch Facial Plast
Surg 5(1):53–58
a
b
Fig. 38.13 ( a ) Wrapped diced cartilage for saddle nose
augmentation: the prefabricated fascial sheath is inserted
into the dorsum using a guide suture. ( b ) The fascial
sheath is fi lled through the syringe with diced cartilage
fragments. Subsequently the fascial tube is closed with
the previously prepared purse string suture

555
38 Structural Grafts and Suture Techniques in Rhinoplasty
3. Westreich RW, Courtland HW, Nasser P, Jepsen K,
Lawson W (2007) De fi ning nasal cartilage elasticity:
biomechanical testing of the tripod theory based on a
cantilevered model. Arch Facial Plast Surg 9(4):
264–270
4. Kim DW, Shah AR, Toriumi DM (2006) Concentric
and eccentric carved costal cartilage: a comparison of
warping. Arch Facial Plast Surg 8(1):42–46
5. Lopez MA, Shah AR, Westine JG, O’Grady K,
Toriumi DM (2007) Analysis of the physical proper-
ties of costal cartilage in a porcine model. Arch Facial
Plast Surg 9(1):35–39
6. Shipchandler TZ (2008) Saddle nose deformity recon-
struction with a split calvarial bone L-shaped strut.
Arch Facial Plast Surg 10(5):305–311
7. Hwang K, Hwang JH, Park JH, Kim DJ, Shin YH
(2007) Experimental study of autologous cartilage,
acellular cadaveric dermis, lyophilized bovine peri-
cardium, and irradiated bovine tendon: applicabil-
ity to nasal tip plasty. J Craniofac Surg 18(3):
551–558
8. Gryskiewicz JM (2005) Waste not, want not: the use
of AlloDerm in secondary rhinoplasty. Plast Reconstr
Surg 116(6):1999–2004
9. Ham J, Miller PJ (2003) Expanded polytetra fl uo-
roethylene implants in rhinoplasty: literature review,
operative techniques, and outcome. Facial Plast Surg
19(4):331–339
10. Guyuron B, Varghai A (2003) Lengthening the nose
with a tongue-and groove technique. Plast Reconstr
Surg 111(4):1533–1539
11. Toriumi DM (1995) Caudal septal extension graft for
the correction of the retracted columella. Oper Tech
Otolaryngol Head Neck Surg 6:311–318
12. Pastorek NJ, Bustillo A, Murphy MR, Becker DG
(2005) The extended columellar strut-tip graft. Arch
Facial Plast Surg 7(3):176–184
13. Rohrich RJ, Raniere J Jr, Ha RY (2002) The alar contour
graft: correction and prevention of alar rim deformities in
rhinoplasty. Plast Reconstr Surg 109:2495–2505
14. Gunter JP, Friedman RM (1997) Lateral crural strut
graft: technique and clinical applications in rhino-
plasty. Plast Reconstr Surg 99(4):943–952
15. Gruber RP, Kryger G, Chang D (2008) The intercarti-
laginous graft for actual and potential alar retraction.
Plast Reconstr Surg 121(5):288e–296e
16. André RF, D’Souza AR, Kunst HP, Vuyk HD (2006)
Sub-alar batten grafts as treatment for nasal valve
incompetence; description of technique and functional
evaluation. Rhinology 44(2):118–122
17. Park SS (1998) The fl aring suture to augment the
repair of the dysfunctional nasal valve. Plast Reconstr
Surg 101(4):1120–1122
18. Sheen JH (1984) Spreader graft: a method of recon-
structing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73(2):230–239
19. André RF, Paun SH, Vuyk HD (2004) Endonasal
spreader graft placement as treatment for internal
nasal valve insuf fi ciency: no need to divide the upper
lateral cartilages from the septum. Arch Facial Plast
Surg 6(1):36–40
20. Clark JM, Cook TA (2002) The “butter fl y” graft in
functional secondary rhinoplasty. Laryngoscope
112(11):1917–1925
21. Swanepoel PF, Fysh R (2007) Laminated dorsal beam
graft to eliminate postoperative twisting complica-
tions. Arch Facial Plast Surg 9(4):285–289
22. Erol OO (2000) The Turkish delight: a pliable graft for
rhinoplasty. Plast Reconstr Surg 105(6):2229–2241
23. Daniel RK, Calvert JW (2004) Diced cartilage grafts
in rhinoplasty surgery. Plast Reconstr Surg 113(7):
2156–2171

557
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_39, © Springer-Verlag Berlin Heidelberg 2013
39
39.1
Introduction
Dorsal nasal contouring as well as the re fi nements
made in the bony vault is a matter of debate when
considering the selected surgical technique.
Although many methods with successful results
have been described in the literature, each method
has its own drawbacks and disadvantages in
return [ 1– 31 ] .
Nasal dorsal irregularities after rhinoplasty
can be obvious in time especially when dealing
with patients with thin dorsal skin. Therefore,
recent studies have addressed the use of different
materials to overcome the problem such as diced
cartilage, fascia, dermal grafts, fat injection,
fi llers, Alloderm, and even banked allograft tis-
sue [ 1– 31 ] . The selection of the method is rather
dependent on the preference of the surgeon; on
the other hand, certain characteristics of the
method selected may be responsible of driving
the surgeon to do so.
The following section will describe such char-
acteristics of using the FL graft for dorsal nasal
contouring.
39.2
Advantages of the Fascia
Lata Autograft
For a successful and long-lasting dorsal contour-
ing in rhinoplasty, the selected method as well as
material used should meet certain characteristics.
These characteristics are:
1. Durability: The selected material should be
indeed durable in order to obtain a long-last-
ing effect, since the used material will func-
tion as a sealer that will obviate the possible
apparent minor irregularities later on. Diced
cartilage may be considered problematic in
regarding this aspect as it is demonstrated in
several studies [ 22– 28, 31 ] . The fascia lata
graft when compared with the others is in fact
durable and provides a long-lasting effect in
return (Fig. 39.1 ) [ 31 ] .
2. Pliability: Since nasal vault is a dynamic three-
dimensional structure, the re fi nements made
should adapt well to conform the desired shape
and texture. The pliability of the material used
renders to ease its application in surgery.
Fascia lata graft is pliable and can easily be
applied over the nasal vault; moreover, it can
well be combined with cartilage graft to obtain
the desired results [ 27, 31 ] .
Fascia Lata Graft for Nasal Dorsal
Contouring in Rhinoplasty
Mehmet Veli Karaaltin
M. V. Karaaltin , M.D.
Belediye Cad. Yucel Street, Kemerlife
D: 161, Gokturk , Eyup, Istanbul , Turkey
Department of Plastic Reconstructive and Aesthetic
Surgery, Faculty of Medicine ,
Bezmialem Vakif University ,
Istanbul , Turkey
Bezmialem Vakif Universitesi,
Tip Fakültesi Hastanesi , Adnan Menderes Bulvari ,
Fatih, İstanbul 34093 , Turkey
e-mail: mkerkuk@yahoo.com

558
M.V. Karaaltin
3. Adequacy: The temporal fascia has been
described as a camou fl age material in previ-
ous textbooks [ 12, 17 ] . Yet the adequacy in
the thickness of the temporal fascia remains
debatable. The author has demonstrated the
superiority of the FL over the temporal fas-
cia by measuring the thickness under the light
power microscopy with using the microscopic
measuring system. Ten specimens were col-
lected, and data were analyzed (Table 39.1 ).
Results have shown that FL is about two times
thicker than the temporal fascia. This fact ren-
ders FL to be a more reliable camou fl age graft
material in terms of adequate thickness [ 31 ]
(Figs. 39.2 and 39.3 ).
4. Pathogenicity: Although banked allograft
material has been successfully used for nasal
dorsal contouring, the possibility of carrying
pathogens such as prions or virions renders
the procedure to be debatable. Several studies
have shown the transmissibility of the allograft
material for infectious agents (this has been
shown even in a nitrogen tank!) [ 32– 36 ] . On
the other hand, such material is more prone to
local infections postoperatively; therefore,
besides the donor site morbidity, autografts
remain the main tissue resource for nasal sur-
gery precisely.
39.3
Indications and Strategy
in Patient Selection
The patient’s selection and planning for surgery
indeed con fi nes a huge list of checkpoints. Yet this
technique may be considered a good solution for
troublesome irregularities that might be apparent
over the nasal tip and nasal vault. The following
are the indications for FL usage in rhinoplasty:
1. Thin nasal dorsal skin with sparse subcutane-
ous tissue
2. Rocker-type deformity generated during surgery
3. Irregularities in the nasal vault due to trauma
4. As a camou fl age graft in secondary procedures
5. Augmentation of the nasal dorsum
6. Combination of FL graft with costal cartilage
graft for better re fi nements
7. Combination of FL graft with on-lay cartilage
grafts used in the tip region
39.4
Surgical Technique in
Harvesting and Application
of FL Graft
Although the idea of harvesting a fascia lata graft
from a patient willing to have a rhinoplasty might
be frustrating, indeed taking into consideration
Table 39.1 The thickness of FL graft plotted versus the
thickness of temporal fascia using the light microscope
(hematoxylin-eosin, ×10)
Fascia lata
thickness (mm)
Temporal fascia
thickness (mm)
3.91
1.92
4.3
1.90
3.89
1.93
4.10
1.87
3.9
1.65
3.88
1.80
4.12
1.60
mm millimeters
Fig. 39.1 Patient operated on for nasal trauma due to a
vehicle accident that was operated on for nasal deformity
2 years previously. The forceps point out the vital FL graft
over the nasal dorsum

559
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
certain pitfalls and with little experience, the
method may take only a few minutes while leav-
ing a 3–5-mm scar at the donor site in return.
Several textbooks describe the surgical algorithm
of a rhinoplasty in terms of primary and second-
ary intervention [ 12, 17 ] . As re fi nements of the
nasal dorsum take its place in the end of the sur-
gery, the author advises to do the procedure as the
fi nal step.
In describing the surgical technique, a 2-cm
horizontal incision is made over the lateral thigh
in a midline 15–20 cm proximal to the insertion
of FL at the lateral side of the knee. After blunt
dissection of the skin over the fascia, two paral-
lel incisions in the fascia are made taking into
consideration the width and length of the graft.
Afterward, using the Metzenbaum scissors, the
fascia is cut longitudinally so that the graft is
harvested in a rectangular fashion. Actually,
there is no restriction in the shape designed, but
it seems that the rectangular form fi ts the best
over the nasal dorsum (Fig. 39.4 ).
Fig. 39.2 The cross section
of FL graft under the light
microscope (hematoxylin and
eosin, ×10 magni fi cation)
Fig. 39.3 The cross section
of temporal fascia graft
under the light microscope
(hematoxylin and eosin, ×10
magni fi cation)

560
M.V. Karaaltin
After harvesting, the graft is prepared for
application. An absorbable suture is applied at
four quadrants of the graft, and a 21-gauge nee-
dle is inserted through the nasal skin at each
cephalic corner (Fig. 39.5 ). Each suture is
inserted through the needle hole and slowly
pulled out from the skin while the graft is placed
in the subcutaneous pocket. Both sutures are
tensed and manipulated (i.e., like a puppet) so
that the graft spreads evenly over the nasal dor-
sum (Fig. 39.6 ). Afterward, the free suture
edges are fi xed to the frontoglabellar region
using the steri-strips. All other steps are pre-
ceded as in a regular rhinoplasty including the
preferred casting method.
39.5
The Donor Site Closure
In the beginning, I use to close the donor site
in the usual manner, i.e., with a regular sub-
dermal closure using 4/0 absorbable suture
and a continuous subcuticle using 5/0 nonab-
sorbable suture for the skin. But with gaining
experience, I started to plan the incision in an
oblique fashion to create an elliptic wound that
can be closed with a 5/0 PDS suture using the
purse-string method (Fig. 39.7 ). In return, this
technique gave the opportunity to leave a bet-
ter quality scar no more than 3–5 mm in length
(Fig. 39.8 ).
Fig. 39.4 The harvested FL graft in a rectangular
fashion
a
b
c
Fig. 39.5 ( a ) The graft is placed over the nasal dorsum,
and the skin is marked at two points in the cephalic edge.
( b , c ) An absorbable suture is sutured on each edge of the
graft. A 21-G ( green ) needle is introduced into nasal skin
marked at two cephalic quadrants, and the suture needles
are inserted to the edge of the needle and pulled out

561
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
After wound closure, I usually wrap the thigh
with a compressive bandage and recommend it
for at least 24 h. This provides a protective cover
that prevents the possibility of seroma formation
especially when the patient ambulates. Later on,
the bandage is changed with applying steri-strips
over the suture line for the following 1 week.
Fig. 39.6 The two sutures are pulled equally (i.e., like a
puppet) to spread the graft evenly over the nasal dorsum
Fig. 39.7 The donor scar closed in the purse-string
fashion
Fig. 39.8 The donor scar appearance after 1 month
postoperatively

562
M.V. Karaaltin
Fig. 39.9 ( a ) Preoperative 26-year-old male
patient complaining of dif fi culty in breathing
and was concerned about the shape of his
nose. ( b ) Intraoperatively, the upper lateral
cartilages were long and weak. Lateral
osteotomies were not indicated. Despite
bilateral spreader grafts, inverted V deformity
persisted. Twenty- fi ve months postoperative
after FL graft was placed horizontally over
nasal dorsum to correct the deformity
a
39.6
The Use of FL Graft in Primary
Rhinoplasty
Case 1
A 26-year-old male patient complained of
dif fi culty in breathing and was concerned about
the shape of his nose (Fig. 39.9 ). Clinical exam-
ination revealed that the patient had a minor
dorsal hump, lateral nasal wall collapse, natural
inverted V deformity, narrow bony vault, and
thin nasal skin. Intraoperatively, the upper lat-
eral cartilages were long and weak. Lateral
osteotomies were not indicated. Despite apply-
ing bilateral spreader grafts, inverted V defor-
mity persisted. FL graft was placed horizontally
over nasal dorsum to correct the evident
deformity.

563
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
b
Fig. 39.9 (continued)

564
M.V. Karaaltin
Case 2
A 28-year-old female patient suffered of an
asymmetry of nasal dorsum and nasal tip (Fig.
39.10 ). Clinical examination revealed that the
patient had a collapse at the right upper lateral
cartilage, narrow bony vault, and an asym-
metric nasal tip with thin parchment like nasal
skin. Intraoperatively, bilateral spreader grafts,
interdomal suturing, and application of FL
graft horizontally over the nasal dorsum were
performed.
Fig. 39.10 ( a ) Preoperative 28-year-old female patient
complaining of asymmetry of nasal dorsum and nasal tip.
( b ) Intraoperatively, bilateral spreader grafts, interdomal
suturing, and application of FL graft horizontally over the
nasal dorsum were performed. ( c ) Thirty-six months
postoperative
a
b

565
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
c
Fig. 39.10 (continued)

566
M.V. Karaaltin
Case 3
A 21-year-old female patient complained of having
a nasal trauma during her childhood. The patient
had a crooked nose with a thin dorsal nasal skin
(Fig. 39.11 ). Total septal correction with minor
hump resection was performed; an FL graft was
used for dorsal camou fl age.
a
Fig. 39.11 ( a ) Preoperative 21-year-old female patient
complained of having nasal trauma during her childhood.
( b ) Twenty-two months following total septal correction
with minor hump resection. An FL graft was used for dor-
sal re fi nement

567
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
b
Fig. 39.11 (continued)

568
M.V. Karaaltin
Case 4
A 23-year-old male patient complained of having
nasal trauma 3 years previously. The patient suf-
fered dif fi culty in breathing with a tension narrow
nose and S-type deviated septum. Nasal vault
was irregular, and nasal skin was obviously thin
(Fig. 39.12 ). A corrective septorhinoplasty with
bilateral spreader graft application was performed;
an FL graft was used for dorsal contouring.
a
Fig. 39.12 ( a ) Preoperative 23-year-old male patient com-
plained of having a nasal trauma 3 years ago. ( b ) Twenty-one
months following corrective septorhinoplasty with bilateral
spreader graft application was performed; an FL graft was
used for dorsal countering

569
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
b
Fig. 39.12 (continued)

570
M.V. Karaaltin
39.7
The Use of FL Graft in
Previously Operated Patients
Case 5
A 22-year-old female patient was previously
operated for her nasal deformity twice. The
patient complained of a wide nasal root with a
right deviation in the nasal vault (Fig. 39.13 ).
Intraoperatively, a septorhinoplasty with minimal
dorsal rasping was performed; an FL graft was
applied over the dorsum for a better re fi nement
and camou fl age.
a
Fig. 39.13 ( a ) Preoperative 22-year-old female patient
was previously operated on for her nasal deformity. ( b )
Eighteen months after a septoplasty with minimal dorsal
rasping was performed and an FL graft was applied over
the dorsum for a better re fi nement

571
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
b
Fig. 39.13 (continued)

572
M.V. Karaaltin
Case 6
A 29-year-old female patient with a characteris-
tic thin nasal skin has been operated twice previ-
ously due to a primary nasal deformity. In the
second operation, conchal cartilage from the right
ear was used to correct the resulted deformities,
but the patient was unsatis fi ed about the result.
On examination, an overt nasal dome distortion
with obvious alar notching was found, and in
addition, a depression in the supratip region was
present (Fig. 39.14 ). The operative plan aimed to
correct the irregularities in the nasal tip region by
using costal cartilage. In exploration, both alar
cartilages were found overresected, and the rem-
nants were insuf fi cient. Both medial crus carti-
lages were previously injured and asymmetric.
The dome region was distorted. Costal cartilages
were used to reconstruct both alar cartilages with
alar batten and alar rim graft, the strut graft for tip
projection, dorsal on-lay graft for restoring the
supratip region, bilateral spreader graft for inter-
nal valve competence, and on-lay FL graft in the
nasal tip region.
a
Fig. 39.14 ( a ) Preoperative 29-year-old female patient
with a characteristic thin nasal skin that has been operated
on twice previously due to a primary nasal deformity. ( b 1)
Intraoperative showing the deformed lateral crus of the
alar cartilages. ( b 2) Costal cartilage graft used to recon-
struct the alar and domal region. ( b 3) On-lay FL graft
applied over the nasal tip and dorsum, respectively. ( c )
Fourteen months postoperative

573
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
Fig. 39.14 (continued)

574
M.V. Karaaltin
b
Fig. 39.14 (continued)

575
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
c
Fig. 39.14 (continued)

576
M.V. Karaaltin
39.8
The Use of FL Graft in Saddle
Nose Deformity
Case 7
A 25-year-old female patient was operated twice
previously in an attempt to correct her primary
nasal deformity. The patient had a severe septal
deviation, saddle nose deformity with a nasal tip
distortion, and valve incompetence (Fig. 39.15 ).
The surgical correction included the use of a
combination of costal buttress graft and FL graft
for saddle nose deformity, bilateral spreader
graft for internal valve restoration, strut graft for
restoring the tip projection, and bilateral alar rim
and batten graft for restoring the alar region.
a

577
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
b
Fig. 39.15 (continued)
Fig. 39.15 ( a ) Preoperative 25-year-old female patient
who was operated on twice previously in an attempt to
correct her primary nasal deformity. ( b ) Twenty-three
months postoperative after the use of a combination of
costal buttress graft and FL graft for saddle nose
deformity

578
M.V. Karaaltin
Case 8
A 21-year-old female patient suffering of severe
nasal deformity had been operated three times for
breathing problems. On examination, the patient
had a saddle nose deformity, bilateral alar fl aring,
and loss of tip projection in addition to bilateral
nasal valve insuf fi ciency (Fig. 39.16 ). The surgical
correction included the use of a combination of
costal buttress graft and FL graft for dorsal aug-
mentation, bilateral spreader graft for internal valve
restoration, strut graft for restoring the tip projec-
tion, bilateral alar rim and batten graft for restoring
the lower alar region, and columellar strut graft and
on-lay tip graft for correcting tip projection com-
bined with FL graft over the nasal tip.
Fig. 39.16 ( a ) Preoperative 21-year-old female patient
with severe nasal deformity. Surgical correction included
the use of a combination of costal buttress graft and FL
graft for dorsal augmentation, bilateral spreader graft for
internal valve restoration, strut graft for restoring the tip
projection, bilateral alar rim and batten graft for restoring
the lower alar region, and columellar strut graft and on-
lay tip graft for correcting tip projection combined with
FL graft over the nasal tip. ( b 1) The black arrows point
out the FL grafts combined with the costal grafts. ( b 2)
Alar reconstruction. ( b 3) Tip graft used for dome
de fi nition. ( c ) Fourteen months postoperative
a

579
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
c
b
Fig. 39.16 (continued)

580
M.V. Karaaltin
39.9
The Application of FL Graft
in a Comminuted
Nasoethmoidal Fracture
This section represents the idea of using an FL graft
in covering the possible irregularities in a complex
nasoethmoidal fracture. After applying the rigid
fi xation over the bony segments (Fig. 39.17 ) [ 21 ] ,
an FL graft was introduced from the open lacera-
tion and evenly spread, fi xed with four absorbable
sutures over the fractured fragments (Fig. 39.18 ).
The aim was to prevent the possible irregulari-
ties that might appear at the nasal radix in the late
postoperative period; moreover, it acted like a seal
that prevented the adhesion of the insulted scar that
might lead to unfavorable mark (Fig. 39.19 ).
Fig. 39.17 The comminuted nasoethmoidal fracture
repaired with rigid fi xation
a
b
Fig. 39.18 ( a ) The FL graft harvested for covering the
glabellar region as an on-lay graft. ( b ) The FL graft fi xed
over the radix

581
39 Fascia Lata Graft for Nasal Dorsal Contouring in Rhinoplasty
b
c
a
Fig. 39.19 Six month’s postoperative view. ( a ): Frontal
view, ( b ) and ( c ): Right and left four-quadrant views
showing the contour in the naso-frontal region

582
M.V. Karaaltin
Conclusions
For the surgeon, a rhinoplasty can be consid-
ered as the craftsman masterpiece, which car-
ries the details of the hard work and efforts,
scented with the surgical philosophy in order
to achieve the desired result; therefore, fi nal
touches can be regarded as the most important
steps to give the de fi nition of the aesthetic
lines in the nasal structure.
Several methods and materials have been
described for the fi nal re fi nements in nose
surgery, but still autografts remain the main
resource and gold standard for nasal surgery.
Because of its physical and biological char-
acteristics, fascia lata graft can be considered
as one of the good choices. Moreover, it may
be considered as a perfect seal for covering
the unwilling bias. Allografts can be pre-
ferred in some instance to avoid the donor
site morbidity, yet the high possibility for
infection, lack of vitality, and the risk of
rejection and exposure renders the procedure
to be unfavorable.
Recent studies regarding stem cell therapy,
adult mesenchymal stem cells, smart tissue
scaffolds, and tissue engineering [ 37 ] may
give the opportunity to provide us with the
vital material that can replace the current tech-
niques. Generating cartilage, fat, and fascia
blocks from a punch biopsy may sound futur-
istic; however, it may be available in the clini-
cal practice for such purposes soon.
References
1. Erol O (2000) The Turkish delight: applicable graft for
rhinoplasty. Plast Reconstr Surg 105(6):2229–2241;
discussion 2242–2243
2. Baker TM, Courtiss EH (1994) Temporalis fascia
grafts in open secondary rhinoplasty. Plast Reconstr
Surg 93(4):802–810
3. Erdogan B, Tuncel A, Adanali G, Deren O, Ayhan M (2003)
Augmentation rhinoplasty with dermal graft and review of
literature. Plast Reconstr Surg 111(6):2060–2068
4. Jackson IT, Yavuzer R (2001) Alloderm for dorsal
nasal irregularities. Plast Reconstr Surg 107(2):553–
558; discussion 559–560
5. Gryskiewicz JM, Rohrich RJ, Reagan BJ, Schwartz
BM (2001) The use of AlloDerm for the correction of
the nasal counters deformities. Plast Reconstr Surg
107(2):561–570; discussion 571
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sue in plastic surgery. Cell Tissue Bank 4(2–4):
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Tutoplast-processed fascia lata for dorsal augmentation
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the nose. Plast Reconstr Surg 63(3):377–382
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mentation rhinoplasty techniques for the correction of
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plasty dorsal on lay grafts using shaped autogenous
septal cartilage. Plast Reconstr Surg 86(1):39–45
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DOI 10.1007/978-3-642-28053-5_40, © Springer-Verlag Berlin Heidelberg 2013
40
40.1
Introduction
To perform aesthetic corrections in the nose, the
plastic surgeon usually makes surgical maneuvers
in occasions reducing the contour and volume of
the nasal tissues, especially the bone and the car-
tilage, but in occasions either in primary or sec-
ondary rhinoplasty, the surgeon should increase
contour and nasal volume.
To augment the nasal dorsum in the 1950s and
1960s, the bone graft was utilized, but due to the
partial absorption of the bone grafts that caused
the aesthetic aspect of the nasal dorsum, it was
not the ideal. In the last years, the author used
cartilage and fascia grafts, utilizing diverse pro-
cedures to be described in this chapter.
40.2
Cartilage Grafts in Rhinoplasty
Some of the surgeons that initially reported the
advantages of the use of the cartilage grafts in
rhinoplasty were Stark and Frileck [ 1 ] , Ortiz
Monasterio et al. [ 2 ] , Sheen [ 3 ] , and Gunter [ 4 ] .
They mentioned the advantages achieved with
the use of cartilaginous grafts.
Cartilage grafts can be obtained either from
the nasal septum, of the ear concha, or from the
rib (Fig. 40.1 ). Initially the author utilized strip
cartilage grafts in the nasal dorsum. The results
were good, but in people with thin skin and sub-
cutaneous tissue, borders of the cartilage graft
were notorious 16 months after having done the
rhinoplasty since the postoperative edema disap-
peared. To solve this problem, the cartilage grafts
were covered with the fascia grafts that were har-
vested from the deep temporal fascia, and it sur-
vives the super fi cial temporal fascia since it is
thin and disappears months later. To obtain carti-
lage grafts from the ear, the ear concha is extir-
pated completely. In occasions, the author uses
cartilage of the concha of one side, and in cases
of exaggerated nasal depression, cartilage from
both sides is utilized.
Then to make the straight cartilage grafts, the
following maneuver is performed (Fig. 40.2 ):
Lines are drawn to give rightness to the graft and
to make straight cuts. After making the cuts, the
cartilage graft has the tendency to curve. From
each concha cartilage, two or three strips are
obtained, and to avoid that they become curved,
we do lateral cuts so that the cartilage loses this
way the memory. The cavity in the nasal dorsum
where we introduce the cartilage grafts should be
deep narrow and straight line being calculated that
they are of the exact measures to receive the carti-
lage grafts when being introduced (Fig. 40.3 ). The
undermining of the cavity in the nasal dorsum is
made with a portaagujas 4 mm in width (Fig. 40.4 )
and rasps of the cartilage and the bone of the nose
Augmentation Rhinoplasty
Jose Guerrerosantos
J. Guerrerosantos , M.D.
Garibaldi # 1793, Colonia Ladron de Guevara ,
Guadalajara, Jalisco 44680 , Mexico
e-mail: guerrerosantos@megared.net.mx

586
J. Guerrerosantos
with instruments 3 mm in width (Fig. 40.5 ). If one
makes a wide cavity, the cartilage graft is curved,
and therefore, the nasal dorsum will be deviated. It
is calculated that the quantity of cartilage strips
that are used to obtain an aesthetic result in occa-
sions with a single strip is enough, but in other
occasions, two or three strips are needed. If several
strips are utilized, they are united with sutures of
absorbable material.
The fascia graft [ 5 ] is taken from the temporal
region (Fig. 40.5 ), making an incision of 3-cm
length, and always inclining the bistoury laterally
for not damaging the pilous follicles and this way
to avoid an alopecic area.
After dissecting the super fi cial temporal fascia
in the deep temporal fascia, incisions are made to
obtain the graft of deep temporal fascia of the
appropriate dimension to cover the cartilaginous
graft. The fascia is fi xed to the cartilage with
absorbable suture. The combined graft is placed
in the nasal dorsum carefully (Fig. 40.6 ).
This procedure is made to increase the volume
and the contour of the nasal dorsum, in patients that
have made primary rhinoplasty in which the sur-
geon extirpated excess of cartilaginous and bony
tissues, but there are also cases in which nasal dor-
sum is depressed congenitally without previous
rhinoplasty. I will show some cases of this type.
Fig. 40.1 Cartilage grafts
harvest from the nasal
septum before being
introduced to the nasal
dorsum
Fig. 40.2 Cartilage
graft taken from the ear
concha
Fig. 40.3 ( a ) Cutting cartilage to shape. ( b ) Cleaning cartilage. ( Right ) Final cartilage cut to shape. ( c ) cuts in cartilage
for bending

587
40 Augmentation Rhinoplasty
a
b
Cartilage
Fascia
Perichondrium
c

588
J. Guerrerosantos
a
b
c
Fig. 40.4 ( a ) Extent of undermining. ( b ) Spreading a pocket over the cartilage. ( c ) Area to place cartilage
Fig. 40.5 Rasping of the bone and cartilage of the
septum is made with instrument 3 mm wide

589
40 Augmentation Rhinoplasty
Fig. 40.6 ( a ) Outline of the placement of cartilage grafts
covered with fascia. ( b ) After having made the incision in
the temporal region, the deep temporal fascia is harvested.
The super fi cial fascia is avoided to use since this is
absorbed and does not have rigidity. ( c ) Outlines of the
harvesting of the deep temporal fascia graft and the suture
of the donor area. ( d ) Outline of the placement of the car-
tilage graft in rhinoplasty covered with fascia with osteot-
omy and without osteotomy. ( e ) Outlines when only fascia
grafts are placed
Fascia
Cartilage
Fascia
Cartilage
a

590
J. Guerrerosantos
b
c
Fig. 40.6 (continued)

591
40 Augmentation Rhinoplasty
Cartilage
Cartilage
Fascia
Fascia
Fascia
Fascia
Bone
Bone
d
e
Fig. 40.6 (continued)

592
J. Guerrerosantos
Case 1
This 25-year-old female patient requested aes-
thetic rhinoplasty, and on examination, she was
noted to have congenital depressed nasal dorsum
(Fig. 40.7 ). Aesthetic rhinoplasty was performed
with nasal dorsum augmentation using cartilage
and fascia grafts, cartilage graft in the nasal tip,
and preseptal cartilage graft. The aesthetic result
was very acceptable 10 years later.
a
Fig. 40.7 ( a ) Preoperative 25-year-old patient with con-
genitally depressed nasal dorsum. ( b ) Ten years postop-
erative following nasal dorsum augmentation using
cartilage and fascia grafts, cartilage graft in the nasal tip,
and preseptal cartilage graft

593
40 Augmentation Rhinoplasty
b
Fig. 40.7 (continued)

594
J. Guerrerosantos
Case 2
This 18-year-old female patient had congenital
depression of the nasal dorsum (Fig. 40.8 ).
Aesthetic rhinoplasty was performed with nasal
dorsum augmentation with cartilage and fascia
grafts. An acceptable result was obtained in her
nasal dorsum as is observed 1 year later.
a
Fig. 40.8 ( a ) Preoperative patient with congenital depression of the nasal dorsum. ( b ) One year after nasal dorsum
augmentation with cartilage and fascia graft

595
40 Augmentation Rhinoplasty
b
Fig. 40.8 (continued)

596
J. Guerrerosantos
Case 3
This 22-year-old patient with depressed nasal dor-
sum, wide nasal tip, wide nasal pores, and hyper-
trophic nasal alae requested aesthetic rhinoplasty
(Fig. 40.9 ). Rhinoplasty was performed with nasal
dorsum augmentation using fascia and cartilage
grafts, thinning the cartilages of the tip and of the
alar, Sheen cartilage graft in the nasal tip, reduc-
tion of the width of the nasal pores, and thinning
of the nasal wings. The patient 1 year later showed
a good result with aesthetic improvement.
Cartilage
facial graft
a
b

597
40 Augmentation Rhinoplasty
Fig. 40.9 ( a ) Preoperative patient with depressed nasal
dorsum, wide nasal tip, wide nasal pores, and hypertro-
phic nasal alae. ( b ) Outline of the treatment of the patient
with nasal dorsum augmentation using fascia and carti-
lage grafts, thinning the cartilages of the tip and of the
alar, Sheen cartilage graft in the nasal tip, reduction of the
width of the nasal pores, and thinning of the nasal wings.
( c ) One year after rhinoplasty
C
Fig. 40.9 (continued)

598
J. Guerrerosantos
Case 4
This 42-year-old patient, who had been submitted
to aesthetic rhinoplasty in the 1950s, presented
with a very depressed nasal dorsum and retracted
nasal tip (Fig. 40.10 ). A secondary rhinoplasty was
performed applying cartilage graft and deep tem-
poral fascia in the dorsum, tip nasal cartilage graft,
and preseptal cartilage graft. The result 1 year after
the secondary rhinoplasty was excellent.
Fig. 40.10 ( a ) Preoperative 42-year-old female who had
been submitted to aesthetic rhinoplasty in the 1950s pre-
sented with a very depressed nasal dorsum and retracted
nasal tip. ( b ) Outline of the surgical procedure utilized. ( c )
One year after secondary rhinoplasty was performed
applying cartilage graft and deep temporal fascia in the
dorsum, tip nasal cartilage graft, and preseptal cartilage
graft
Dorsal
Fascia-Cartilage
Graft
a
b
Tip Cartilage
Graft
Neck Suctioned

599
40 Augmentation Rhinoplasty
c
Fig. 40.10 (continued)

600
J. Guerrerosantos
40.3
Many Ways of Using Fascia
Graft in Aesthetic Rhinoplasty
Fascia grafts can be used in various ways in aes-
thetic rhinoplasty including radix augmentation,
nasal dorsal augmentation, and as a spreader graft
to improve the nasal tip in cases in which hyper-
trophy of the cartilages of the tip and alae deforms
these areas to augment the paranasal area com-
bined with cartilage. Some cases with thin skin
and subcutaneous tissue develop mild nasal dor-
sum depression in which the use of fascia grafts
gives excellent aesthetic results.
Case 5
This 24-year-old female patient presented with a
moderate depression of the nasal dorsum
(Fig. 40.11 ). Aesthetic rhinoplasty was performed
by rasping the bone and cartilage of the nasal dor-
sum and applying fascia graft on the dorsum.
Also cartilage grafts were applied on the nasal
tip and preseptal taken from the auricular concha.
One year later, the patient showed a remarkable
aesthetic improvement.

601
40 Augmentation Rhinoplasty
Fig. 40.11 ( a ) Preoperative 24-year-old male patient
presented with a moderate depression of the nasal dor-
sum. ( b ) Surgical treatment using fascia graft on nasal
dorsum and preseptal and tip cartilage grafts. ( c ) One year
postoperative following rasping the bone and cartilage of
the nasal dorsum and applying fascia graft on the dorsum.
Also cartilage grafts were applied on the nasal tip and pre-
septal taken from the auricular concha
a

602
J. Guerrerosantos
Rasping the
dorsum
b
Fig. 40.11 (continued)

603
40 Augmentation Rhinoplasty
c
Fig. 40.11 (continued)

604
J. Guerrerosantos
Case 6
This 26-year-old female patient, besides wanting
aesthetic improvement in her nose, presented with
nasal deviation and thin skin and subcutaneous
tissue (Fig. 40.12 ). Aesthetic rhinoplasty was per-
formed with fascia graft on the nasal dorsum and
septum plasty to correct nasal deviation. The patient
18 months after rhinoplasty showed an excellent
result with the combined surgical procedure.
Fig. 40.12 ( a ) Preoperative 26-year-old female patient
wanting aesthetic improvement in her nose. She had nasal
deviation and thin skin and subcutaneous tissue. ( b )
Application of fascia graft on the nasal dorsum and sep-
tum plasty. ( c ) Eighteen months postoperative after fascia
graft on the nasal dorsum and septum plasty to correct
nasal deviation
a