605
40 Augmentation Rhinoplasty
Fascia graft
b
Fascia graft
Fig. 40.12 (continued)
606
J. Guerrerosantos
c
Fig. 40.12 (continued)
607
40 Augmentation Rhinoplasty
Case 7
This 43-year-old female patient presented with
a nasal hump (Fig. 40.13 ). This was treated
with the Skoog technique that consists of
removing the nasal hump and then remodels
it and returns it to the nasal dorsum. She also
had the modulated hump covered with fascia.
A very satisfactory result was obtained as seen
1 year later.
Fig. 40.13 ( a ) This 43-year-old female patient presented
with a nasal hump. ( b ) Outline of the technique of Skoog
and the modeled hump covered with fascia. ( c ) One year
after performing the Skoog technique that consists of
removing the nasal hump and then remodeling it and
returning it to the nasal dorsum. She also had the modu-
lated hump covered with fascia
a
608
J. Guerrerosantos
Reshaped hump
covered by
fascia graft
Two layer
Tip graft
Fascia graft
b
Fig. 40.13 (continued)
609
40 Augmentation Rhinoplasty
c
Fig. 40.13 (continued)
610
J. Guerrerosantos
40.4
Rolled Fascia Graft
To improve the depressed nasal defect, the authors
have used rolled fascia grafts without cartilage
and obtained acceptable aesthetically results
(Fig. 40.14 ). The technique consists on making a
deep undermining of the skin and of the subcuta-
neous tissue and then rasping the nasal dorsum
and then to apply the rolled fascia graft. To avoid
deviations of the fascia graft, it is very important
to avoid wide undermining of the skin and of the
subcutaneous tissue.
Case 8
This 47-year-old patient presented with depressed
nasal dorsum (Fig. 40.15 ). The technique that was
performed was of the open tip without incision in
the columella and preparing the cavity carefully
performing the rasping of the nasal dorsum and
then the introduction of the winding fascia graft.
Also performed were preseptal cartilage graft and
another cartilage graft in the nasal tip. The
18-month postoperative result after the rhinoplasty
was very satisfactory.
Fig. 40.14 ( a and b ) Rolled fascia graft
a
b
611
40 Augmentation Rhinoplasty
Fig. 40.15 ( a ) Preoperative 47-year-old patient who presented with depressed nasal dorsum. ( b ) Drawing of the treatment.
( c ) After rhinoplasty with rolled fascia graft
a
612
J. Guerrerosantos
b
Rasping the
dorsum
Open tip
approach
Fascia graft
Tip cartilage
graft
Per-septal
caretilage graft
Fig. 40.15 (continued)
613
40 Augmentation Rhinoplasty
c
Fig. 40.15 (continued)
614
J. Guerrerosantos
Case 9
This 38-year-old patient presented with depressed
radix, hump of the nasal dorsum, fallen nasal tip, and
retraction of the columella (Fig. 40.16 ). Resection of
the nasal hump was performed with the radix and
the nasal dorsum increased using fascia rolled
graft, cartilage graft in the nasal tip, and sutures of
the inferior portion of the cartilages of the colu-
mella. The result 8 months later was satisfactory.
Fig. 40.16 ( a ) Preoperative 38-year-old patient who pre-
sented with depressed radix, hump of the nasal dorsum,
fallen nasal tip, and retraction of the columella. ( b ) Outline
of the treatment. ( c ) Eight months after resection of the
nasal hump was performed with the radix and the nasal
dorsum increased using fascia rolled graft, cartilage graft
in the nasal tip, and sutures of the inferior portion of the
cartilages of the columella
a
615
40 Augmentation Rhinoplasty
Rolled
fascia
graft
TIP
cartilage
graft
Attached
lower
medial
crura
b
Fig. 40.16 (continued)
616
J. Guerrerosantos
c
Fig. 40.16 (continued)
617
40 Augmentation Rhinoplasty
40.4.1 Fascia Grafts
On occasions, patients who present with depres-
sions located in some area of the nasal contour, as
a consequence either of a trauma or a previous
surgery, a good solution is to introduce a strip of
fascia graft.
Case 10
This 22-year-old female patient had a rhinoplasty,
and she developed as a sequel a depression in the
lateral nasal dorsum, behind the left nasal alar
(Fig. 40.17 ). To reconstruct the defect, deep tem-
poral fascia graft was used. The fascia graft was
introduced by an intranasal incision. The result
1 year later was excellent.
The deep temporal fascia grafts can also be
used as spreaders.
Fig. 40.17 ( a ) Preoperative 22-year-old female patient
submitted to a rhinoplasty and she developed as a sequel a
depression in the lateral nasal dorsum, behind the left
nasal alar. ( b ) Outline of the depressed area and the graft
of deep temporal fascia that was utilized to correct the
depression. ( c ) One year after the application of the fascia
graft
a
618
J. Guerrerosantos
Lateral
depression
b
Fig. 40.17 (continued)
619
40 Augmentation Rhinoplasty
c
Fig. 40.17 (continued)
620
J. Guerrerosantos
Case 11
This 42-year-old female patient presented ini-
tially with a moderate deformity (Fig. 40.18 ).
She was subjected to rhinoplasty in which fascia
grafts were utilized like spreaders. The patient
1 year after the surgery showed a very good
result.
a
621
40 Augmentation Rhinoplasty
Fig. 40.18 ( a ) The fascia grafts to be used as spreaders. ( b ) Preoperative 42-year-old patient with moderate deformity.
( c ) One year after rhinoplasty using facial graft as spreader
b
Fig. 40.18 (continued)
622
J. Guerrerosantos
c
Fig. 40.18 (continued)
623
40 Augmentation Rhinoplasty
Case 12
This 35-year-old patient presented with depressed
radix, moderate hump of the nasal dorsum, and lack
of projection of the nasal tip (Fig. 40.19 ). As
treatment in the rhinoplasty, fascia graft was utilized
to augment the radix, extirpation of the nasal hump,
grafts of deep temporal fascia as spreaders, and a
cartilage graft in the nasal tip. The aesthetic result
was excellent 1 year after the rhinoplasty.
Fig. 40.19 ( a ) Preoperative 35-year-old patient presented
with depressed radix, moderate hump of the nasal dorsum,
and lack of projection of the nasal tip. ( b ) Outline of the treat-
ment using fascia graft to improve the contour of the radix
and as a spreaders and cartilage graft in the nasal tip. ( c ) One
year after rhinoplasty with fascia graft to augment the radix,
extirpation of the nasal hump, grafts of deep temporal fascia
as spreaders, and a cartilage graft in the nasal tip
a
624
J. Guerrerosantos
Radix
fascia
graft
b
Spreader
fascia
graft
Tip
cartilage
graft
Fig. 40.19 (continued)
625
40 Augmentation Rhinoplasty
c
Fig. 40.19 (continued)
626
J. Guerrerosantos
Case 13
This 26-year-old patient presented with nasal
hump in the area of the cartilage of the nasal sep-
tum and also had depressed radix (Fig. 40.20 ). The
rhinoplasty consisted of extirpation of the excess
of dorsal cartilage, and from this cartilage, a prese-
ptal cartilage graft was made, and to augment the
radix, deep temporal fascia was utilized. The result
1 year later shows aesthetic improvement.
Fig. 40.20 ( a ) This preoperative 26-year-old patient pre-
sented with nasal hump in the area of the cartilage of the
nasal septum and also had depressed radix 1 year before
rhinoplasty. ( b ) Outline of the treatment. (1). Extirpation
of the excess of dorsal cartilage. (2). Application of the
fascia graft in the radix and the preseptal cartilage graft.
( c ) One year after rhinoplasty that consisted of extirpation
of the excess of dorsal cartilage, and from this cartilage, a
preseptal cartilage graft was made, and to augment the
radix, deep temporal fascia was utilized
a
627
40 Augmentation Rhinoplasty
Cartilage
to be
removed
Fascia
graft
Pre-septal
cartilage
graft
b
c
Fig. 40.20 (continued)
628
J. Guerrerosantos
Case 14
This 27-year-old patient presented with dorsal
hump, depressed radix, and lack of de fi nition of the
nasal tip (Fig. 40.21 ). Rhinoplasty was performed
with reduction of the hump, fascia graft in the radix,
and cartilage in the tip and preseptal. The result
1 year later was satisfactory.
a
b
c
Fig. 40.21 ( a ) Preoperative 27-year-old patient that pre-
sented with dorsal hump, depressed radix, and lack of
de fi nition of the nasal tip. ( b ) Outline of the treatment. ( c )
One year following rhinoplasty was performed with
reduction of the hump, fascia graft in the radix, and carti-
lage in the tip and preseptal
629
40 Augmentation Rhinoplasty
Case 15
This 55-year-old patient presented with thick
skin nose, retracted columella, fallen nasal tip,
nasal hump, and depressed radix (Fig. 40.22 ).
Rhinoplasty was performed with fascia graft in
the radix, correction of the nasal hump, presep-
tal cartilage graft, and another in the nasal tip.
The result 1 year later showed a great aesthetic
improvement in the nose.
a
Fig. 40.22 ( a ) Preoperative 55-year-old patient who pre-
sented with thick skin nose, retracted columella, fallen
nasal tip, nasal hump, and depressed radix. ( b ) Outline of
the treatment. ( c ) One year after rhinoplasty with fascia
graft in the radix, correction of the nasal hump, preseptal
cartilage graft, and another in the nasal tip
630
J. Guerrerosantos
Fascia
graft
TIP cartilage
graft
Preseptal cartilage
graft
b
c
Fig. 40.22 (continued)
631
40 Augmentation Rhinoplasty
Case 16
This 45-year-old patient presented with thin skin
and subcutaneous tissue, with bulbous nasal tip,
due to the hypertrophy and rigidity of the carti-
lages of the nasal tip and nasal alae (Fig. 40.23 ).
Extirpation of the excess of the cartilages was
performed with Sheen cartilage graft in the tip,
and the cartilages of the tip and the alae were
covered with fascia. The aesthetic correction was
successful as you can see in the patient 1 year
after rhinoplasty.
Fig. 40.23 ( a ) Preoperative 45-year-old patient presented
with thin skin and subcutaneous tissue, with bulbous nasal
tip, due to the hypertrophy and rigidity of the cartilages of
the nasal tip and nasal alae. ( b ) Sheen type cartilage was
placed in the tip, and the cartilage of the tip and the alae
were covered with fascia. ( c ) One year after surgery shows
a favorable aesthetic result
a
632
J. Guerrerosantos
Cartilage
to be
removed
Fascia graft
over cartilages
TIP cartilage
graft
b
Fig. 40.23 (continued)
633
40 Augmentation Rhinoplasty
c
Fig. 40.23 (continued)
634
J. Guerrerosantos
40.5
Fragmented Cartilage Graft
Covered with Fascia in Primary
Rhinoplasty
Erol [ 6 ] report the use of the fragmented carti-
lage graft covered with Surgicel. The author [ 7 ]
has always preferred to use autologous grafts
covered with deep temporal fascia instead of
covering the fragmented cartilage graft with
Surgicel. After several clinical cases treated in
the Jalisco Plastic Surgery Institute with success,
the author decided that this technique had very
good and natural appearance. Daniel [ 8, 9 ]
reports this procedure covering also the cartilage
fragments with fascia.
40.6
Surgical Technique
Cartilage graft is harvested from the auricular
concha and then is fragmented and then is cov-
ered with a strip of deep temporal fascia. A suture
is placed with absorbable material forming a roll.
Then the combined graft is introduced in a deep
cavity on the nasal dorsum. The combined graft
is modeled externally, and then the nasal splint is
applied over the nasal dorsum carefully. The
nasal splint is retires 1 week later, and Micropore
is placed for some days.
With this procedure, the author has obtained
an aesthetically and very de fi ned nasal dorsum
with very modeled aesthetic corrections of the
deviated nose to augment and to model the radix
with good results (Fig. 40.24 ).
Case 17
This 24-year-old patient presented with moderate
deviation of the nasal dorsum and hypertrophy of
the cartilages of the nasal tip and alae (Fig. 40.25 ).
Aesthetic rhinoplasty was performed placing
fragments of cartilage graft covered with fascia
in the radix and in the nasal dorsum and also
aesthetic correction of the tip and nasal alae.
The patient 1 year later showed the correction
of the nasal deviation and aesthetic improvement
in the tip and the nasal alae.
Fig. 40.24 ( a ) Fragmentation of the cartilage graft and the placement over strip of temporal deep fascia. ( b )
Preoperative. ( c ) Postoperative after placement of the combined fascia and cartilage graft in the nasal dorsum
Lateral
dorsal
depresion
a
Spreader
cartilage
graft
Tip
caretilage
graft
635
40 Augmentation Rhinoplasty
b
c
Fig. 40.24 (continued)
636
J. Guerrerosantos
a
Fig. 40.25 ( a ) Preoperative patient showing nasal devia-
tion and hypertrophy of the cartilages of the tip and the
nasal alae. ( b ) Outline of the placement of the combined
fragmented cartilage graft and fascia graft in the radix and
nasal dorsum and also cartilage graft in the nasal tip. ( c )
The patient 1 year after the rhinoplasty
637
40 Augmentation Rhinoplasty
Right middle
vault collapse
b
Spreader ear
cartilage graft
Tip cartilage
graft
Spreader ear
cratilage graft
Tip cartilage
graft
Fig. 40.25 (continued)
638
J. Guerrerosantos
c
Fig. 40.25 (continued)
639
40 Augmentation Rhinoplasty
Case 18
This 28-year-old patient presented with depressed
radix, moderate nasal hump, fallen nasal tip, sharp
nasolabial angle, wide nasal pore, and retracted
chin (Fig. 40.26 ). The treatment performed
included radix augmentation with fascia and car-
tilage graft, partial resection of the superior and
anterior nasal septum, preseptal cartilage graft,
and neck liposuction. The patient 16 months after
the aesthetic surgery showed a good aesthetic
result.
Fig. 40.26 ( a ) This 28-year-old patient presented with
depressed radix, moderate nasal hump, fallen nasal tip,
sharp nasolabial angle, wide nasal pore, and retracted
chin. ( b ) Outline of the rhinoplasty of the case. ( c ) The
treatment performed included radix augmentation with
fascia and cartilage graft, partial resection of the superior
and anterior nasal septum, preseptal cartilage graft, and
neck liposuction
a
640
J. Guerrerosantos
Crushed cartilage
wripped with
fascia graft
Tip caretilage
graft
Chin implant
b
Fig. 40.26 (continued)
641
40 Augmentation Rhinoplasty
c
Fig. 40.26 (continued)
642
J. Guerrerosantos
Case 19
This 24-year-old patient had depressed radix,
dorsal hump, tip nasal fall, and elongated nose
(Fig. 40.27 ). Radix augmentation was performed
with fascia and cartilage graft, rasping of the
nasal dorsum, resection of a superior and anterior
portion of the nasal septum, cartilage graft in the
nasal tip, and chin augmentation with fat grafts.
The result 1 year later was very satisfactory.
Fig. 40.27 ( a ) This 24-year-old patient had depressed radix,
dorsal hump, tip nasal fall, and elongated nose. ( b ) Outline of
the rhinoplasty with radix augmentation with fascia and car-
tilage graft and additional procedures. ( c ) Radix augmenta-
tion was performed with fascia and cartilage graft, rasping of
the nasal dorsum, resection of a superior and anterior portion
of the nasal septum, cartilage graft in the nasal tip, and chin
augmentation with fat grafts
a
643
40 Augmentation Rhinoplasty
Tip cartilage graft
Crushed cartilage
wripped with fascia graft
b
Fig. 40.27 (continued)
c
644
J. Guerrerosantos
40.7
Fragmented Cartilage
Graft Covered with Fascia
in Secondary Rhinoplasty
The indications to use this procedure in second-
ary rhinoplasty are:
1. To correct deformed nasal dorsum after carti-
lage graft applied in primary rhinoplasty
2. To correct depressed nasal dorsum by exces-
sive resection of cartilage and bone
3. To correct irregularities in the nasal dorsum
40.8
Cases of Deformed Nasal
Dorsum After the Application
of Cartilage Graft in a Very
Super fi cial Cavity
Case 20
This patient had prior augmentation rhinoplasty
with cartilage graft, and the surgeon applied
cartilage graft in a very super fi cial and wide nasal
cavity (Fig. 40.28 ). The technique to correct this
deformity
consists
on
carrying
out
the
following:
1. Removal the cartilage applied previously from
the nasal dorsum.
2. After having extracted the cartilage graft, it
was fragmented and covered with fascia strip,
enrolled, and then introduced in the cavity that
is made in the nasal dorsum, trying to make it
deep, then the intranasal incision is sutured,
the combined graft is modeled with manual
external maneuvers, and the fi rst nasal splint is
placed with Micropore and plaster.
a
b
Fig. 40.28 ( a ) The patient previously had augmentation
rhinoplasty with deviated and deformed cartilage that was
applied super fi cially. ( b ) Postoperative after having the
cartilage graft extracted, fragmented, and covered with
fascia strip, enrolled, and then introduced in the cavity
that was made in the nasal dorsum, trying to make it deep.
The intranasal incision was sutured, and the combined
graft was modeled with manual external maneuvers
645
40 Augmentation Rhinoplasty
Case 21
This 49-year-old patient had another surgeon
apply cartilage graft in the nasal dorsum in a very
super fi cial cavity that caused cartilage graft to be
very noticeable (Fig. 40.29 ). The treatment con-
sisted on performing the already described sec-
ondary rhinoplasty. The result 1 year later was
very satisfactory with aesthetic nasal dorsum
without irregularities.
Fig. 40.29 ( a ) This 49-year-old patient had another sur-
geon apply cartilage graft in the nasal dorsum in a very
super fi cial cavity that caused cartilage graft to be very
noticeable (40. 29a). ( b ) Outline of the secondary aug-
mentation rhinoplasty. ( c ) The patient had secondary rhi-
noplasty with extraction of the cartilage graft that was
fragmented and cover with fascia strip, enrolled, and then
introduced in the cavity that was made in the nasal dor-
sum, trying to make it deep, then the intranasal incision
was sutured, and the combined graft was modeled with
manual external maneuvers with favorable aesthetic
result
a
Removed
superficially
placed and
noticeable
onlay dorsal
cartilage
graf t
Crushed
Wrapped
Cylineder
comblned
graft
b
646
J. Guerrerosantos
c
Fig. 40.29 (continued)
647
40 Augmentation Rhinoplasty
40.9
Patients with Depressed Nasal
Dorsum for Excessive
Resection of Cartilage and
Bone in Primary Rhinoplasty
In the decades of 1950s and 1960s, the author
(FSF) corrected many cases with this deformity.
Case 22
This 22-year-old patient was subjected to primary
rhinoplasty by another surgeon who extirpated
an exaggerated quantity of bone and cartilage
from the nasal dorsum. The patient had depressed
radix and nasal dorsum, supratip and valvular
collapse, exaggerated rising of the nasal tip, and
sharp nasolabial angle (Fig. 40.30 ). The treat-
ment included placement of fragmented cartilage
graft covered by fascia, vascular plasty, and nar-
rowing of the central crura in the columella
suturing the lower portio of the cartilages. The
result 18 months later showed a great improve-
ment, and the result 4 years later was very
satisfactory.
a
Fig. 40.30 ( a ) This 22-year-old patient was subjected to
primary rhinoplasty by another surgeon who extirpated an
exaggerated quantity of bone and cartilage from the nasal
dorsum. The patient had depressed radix and nasal dor-
sum, supratip and valvular collapse, exaggerated rising of
the nasal tip, and sharp nasolabial angle. ( b ) The treat-
ment includes augmentation of the radix and of the nasal
dorsum with fragmented cartilage covered with fascia and
also other ancillary procedures. ( c ) The patient 1 year and
half later showed an excellent result with the increase of
the radix and of the nasal dorsum. ( d ) The patient 4 years
after the secondary augmentation rhinoplasty
648
J. Guerrerosantos
Chooped cartilage
wrapped with
fascia
Narrowing the
lower medial
crura with suture
b
c
Fig. 40.30 (continued)
649
40 Augmentation Rhinoplasty
d
Fig. 40.30 (continued)
650
J. Guerrerosantos
Case 23
This 40-year-old patient had three previous rhino-
plasties by surgeons who are not plastic surgeons.
The patient had a very depressed radix and supra-
tip and valvular collapse (Fig. 40.31 ). Treatment
was performed in two surgical stages. In the fi rst
stage, valvular collapse was corrected liberating
the valvular retraction, and skin and cartilage grafts
from the posterior area of the ear were applied
intranasal in the wound located in the area that was
developed when removing the scar of the valvular
collapse. Good healing of the graft was obtained
and improved the nasal breathing in the patient.
Ten months later, a second surgical stage was made
with placement of fragmented cartilage and fascia
grafts to augment the radix, correction of the
supratip removing cartilage excess, application of
cartilage spreaders, and cartilage graft in the nasal
tip. The result 2 years later shows the correction of
the sequels of the previous rhinoplasties and an
aesthetic improvement in the nose.
651
40 Augmentation Rhinoplasty
Fig. 40.31 ( a ) This 40-year-old patient had a very
depressed radix and supratip and valvular collapse as a
consequence of three previous rhinoplasties. ( b ) In the
fi rst surgical corrective stage, the valvular retraction was
liberated, and a skin and cartilage graft was applied. ( c ) In
the second surgical stage, fragmented cartilage covered
with fascia was used to augment the radix. Correction of
the supratip, cartilage spreaders, and a cartilage graft
placed in the nasal tip were performed. ( d ) Two years
after corrective surgery
a
652
J. Guerrerosantos
Depressed
Radix
Supratip
Collapsed
valve
Cutting bands
of scars in
vestibular stenosis
Internal defect
Composite ear graft
(cartilage plus skin)
b
Fig. 40.31 (continued)
653
40 Augmentation Rhinoplasty
Severe
depressed radx
Supratip
Crushed cartilage graft
wrapped with
temporalis fascia
Cartilage spreader
graft from the ear concha
Three-tier tip
cartilage graft
Cartilage spreader
graft from the ear
concha
Three-tier
tip cartilage
grast
Crushed
cartilage
graft
wrapped
with
temporalis
fascia
c
Fig. 40.31 (continued)
654
J. Guerrerosantos
d
Fig. 40.31 (continued)