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

708
J. Pan and S.A. Tatum III
45.9.1 Nasal Hemangioma Surgical
Technique (Fig. 45.8 )
There is no established timeline for the surgical
treatment of nasal hemangiomas; however, most
authors would agree that early intervention around
ages 2 or 3 before the child enters school serves to
minimize any psychological trauma [ 26 ] . The
urgency or the surgery depends on the growth rate
and amount of surrounding tissue distortion.
Though there are many different surgical app-
roaches, several principles are prevalent through-
out all of them. Mainly, one needs to consider that
hemangiomas act to expand the tissue, and most
authors would recommend conservative tissue
excision. Total excision is not always necessary if
it means removing dif fi cult-to-reconstruct struc-
tures. Surface discoloration can be managed sec-
ondarily with laser treatment. Often the nasal
cartilages are not involved, and incision should
follow relaxed skin tension lines or follow along
the junction of the nasal subunits if external nasal
skin must be incised or excised [ 27 ] . Open rhino-
plasty techniques are frequently employed for
lesions that can be subcutaneously excised or
debulked. Splayed or distorted cartilages should
be sutured back to their normal positions. Excess
skin can be conservatively excised when redrap-
ing and closing the transcolumellar incision.
Conclusions
Rhinoplasty for congenital nasal deformities
remains a challenge for reconstructive surgeons.
The reconstructive surgeon needs to weigh the
balance between form and function associated
with these deformities. It is now common prac-
tice to perform primary rhinoplasty at an early
age for improved nasal symmetry without detri-
mental effects on the bony facial growth. As
techniques become more re fi ned and newer
ones are developed, we can hope to see better
results and more consistent outcomes in con-
genital nasal rhinoplasties.
References
1. Lee TS, Schwartz GM, Tatum SA (2010) Rhinoplasty
for cleft and hemangioma-related nasal deformities.
Curr Opin Otolaryngol Head Neck Surg 18(6):526–535
2. Sykes J (2000) Surgical management of the cleft lip
nasal deformity. Curr Opin Otolaryngol Head Neck
Surg 8:54–57
3. Mulliken JB (1992) Correction of the bilateral cleft
lip nasal deformity: evolution of a surgical concept.
Cleft Palate Craniofac J 29(6):540–545
4. Latham RA (1969) The septo-premaxillary liga-
ment and maxillary development. J Anat 104(Pt 3):
584–586
5. Latham RA (1970) Maxillary development and
growth: the septo-premaxillary ligament. J Anat
107(Pt 3):471–478
6. Siegel MI, Mooney MP, Eichberg JW, Gest T, Lee DR
(1992) Nasal capsule shape changes following septo-
premaxillary ligament resection in a chimpanzee ani-
mal model. Cleft Palate Craniofac J 29(2):137–142
7. Park BY, Lew DH, Lee YH (1998) A comparative
study of the lateral crus of alar cartilage in unilateral
cleft lip nasal deformity. Plast Reconstr Surg 101(4):
915–920
8. Coleman J, Sykes J (2009) Cleft lip rhinoplasty. In:
Papel I (ed) Facial plastic and reconstructive surgery.
Thieme Medical Publishing, New York
9. Friedman O, Wang TD, Milczuk HA (2010) Cleft lip
and palate. In: Steinert RF (ed) Cummings otolar-
yngology-head and neck surgery. Mosby/Elsevier,
Philadelphia
10. McComb HK, Coghlan BA (1996) Primary repair of
the unilateral cleft lip nose: completion of a longitudi-
nal study. Cleft Palate Craniofac J 33(1):23–30
11. Anderl H, Hussl H, Ninkovic M (2008) Primary
simultaneous lip and nose repair in the unilateral cleft
lip and palate. Plast Reconstr Surg 121(3):959–970
12. Sitzman TJ, Girotto JA, Marcus JR (2008) Current
surgical practices in cleft care: unilateral cleft lip
repair. Plast Reconstr Surg 121(5):261e–270e
13. Hamilton R, Graham WP 3rd, Randall P (1971) The
role of the lip adhesion procedure in cleft lip repair.
Cleft Palate J 8:1–914
Fig. 45.8 Nasal hemangioma repair utilizing open rhino-
plasty technique

709
45 Rhinoplasty for Cleft and Hemangioma-Related Deformities
14. Stal S, Chebret L, McElroy C (1998) The team
approach in the management of congenital and
acquired deformities. Clin Plast Surg 25(4):
485–491
15. Kennedy TJ, Miller SH, Tooze FM, Harding RL,
Davis TS, Graham WP 3rd (1978) The team approach
to treatment of the cleft lip and palate. Am Fam
Physician 18(1):74–84
16. Kasten EF, Schmidt SP, Zickler CF, Berner E, Damian
LA, Christian GM, Workman H, Freeman M, Farley
MD, Hicks TL (2008) Team care of the patient with
cleft lip and palate. Curr Probl Pediatr Adolesc Health
Care 38(5):138–158
17. Sykes JM, Senders CW (1990) Surgery of the cleft lip
nasal deformity. Oper Tech Otolaryngol Head Neck
Surg 1:219–224
18. Sykes JM, Senders CW, Wang TD, Cook TA (1993)
Use of the open approach for repair of secondary cleft
lip nasal deformity. Facial Plast Surg Clin North Am
1:111–126
19. Madorsky SJ, Wang TD (1999) Unilateral cleft rhino-
plasty: a review. Otolaryngol Clin North Am 32(4):
669–682
20. TerKonda RP, Sykes JM (1997) Controversies and
advances in unilateral cleft lip repair. Curr Opin
Otolaryngol Head Neck Surg 5:223–227
21. Mulliken JB (1997) Primary repair of bilateral cleft
lip and nasal deformity. In: Goergiade GS, Riefkohl
R, Levin LS (eds) Geogiade plastic and reconstructive
surgery, 3rd edn. Williams & Wilkins, Baltimore
22. Trott JA, Mohan N (1993) A preliminary report on
open tip rhinoplasty at the time of lip repair in bilat-
eral cleft lip and palate: the Alor Setar experience. Br
J Plast Surg 46(7):215–222
23. Alef M, Irwin C, Smith D, A fi fi A, Jiang S, Vecchione
L, Ford M, Decesare GE, Deleyiannis FW, Losee JE
(2009) Nasal tip complications of primary cleft lip
nasoplasty. J Craniofac Surg 20(5):1327–1333
24. Leaute-Labreze C, Dumas de la Roque E, Hubiche T,
Boralevi F, Thambo JB, Taïeb A (2008) Propranolol
for severe hemangiomas of infancy. N Engl J Med
358(24):2649–2651
25. Buckmiller LM, Munson PD, Dyamenahalli U, Dai Y,
Richter GT (2010) Propranolol for infantile heman-
giomas: early experience at a tertiary vascular anoma-
lies center. Laryngoscope 120(4):676–681
26. Batniji RK, Buckingham ED, Williams EF 3rd (2005)
An aesthetic approach to facial hemangiomas. Arch
Facial Plast Surg 7(5):301–306
27. Simic R, Vlahovic A, Subarevic V (2009) Treatment
of nasal hemangiomas. Int J Pediatr Otorhinolaryngol
73(10):1402–1406

711
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_46, © Springer-Verlag Berlin Heidelberg 2013
46
46.1
Introduction
Meticulous attention to detail is an essential trait
of the rhinoplasty surgeon. This detail-oriented
approach should extend beyond the operating
room to the proper evaluation and care of the rhi-
noplasty patient during the postoperative period.
A methodical and consistent postoperative
sequence of care can help ensure optimal results
in primary and secondary rhinoplasty.
46.2
Immediate Postoperative Care
46.2.1 Record Keeping and Surgical
Diagrams
The postoperative care of the rhinoplasty patient
should begin before the patient even emerges
from anesthesia. The rhinoplasty surgeon’s
account of his operative maneuvers is an impor-
tant part of the postoperative care. A detailed
operative report should include the type, location,
and size of the grafts utilized. It should also delin-
eate the amount of reduction or augmentation
and should include the intraoperative fi ndings.
A graphic representation of the key intraopera-
tive maneuvers is also invaluable. Together, the
operative report and graphic record provide criti-
cal information in the postoperative period, par-
ticularly in regard to complications and deformities,
should they arise. In the event that the patient
requires revision or secondary rhinoplasty, accu-
rate records will guide the surgeon in future
surgery.
46.2.2 External Splinting
Proper external splinting of the nose is a critical
aspect of preserving the surgical result. Many
methods of external nasal splinting following rhi-
noplasty have been described – aluminum, plas-
ter, Aquaplast (Smith & Nephew, Inc), and dental
compound [ 1, 2 ] . The goal of postoperative
splinting is to preserve the operative results by
securing the nasal framework during the healing
process.
The nasal dorsum should be taped from the
nasion to the supratip to help control edema and
protect the nasal skin from the splint in the imme-
diate postoperative period. The external nasal
splint should be placed below the radix and
extend to the supratip (Fig. 46.1 ). The surgeon
should avoid lateral squeezing of the splint, as
this may actually lift the soft tissue envelope and
create a dead space under the soft tissue envelope
Postoperative Care of the
Rhinoplasty Patient
C. Spencer Cochran
C. S. Cochran , M.D.
Gunter Center for Aesthetics and Cosmetic Surgery ,
8144 Walnut Hill Lane, Suite 170 , Dallas ,
TX 75231 , USA
Department of Otolaryngology – Head and Neck Surgery ,
University of Texas Southwestern Medical Center at Dallas ,
Dallas , TX , USA
e-mail: drcochran@gunter-center.com

712
C.S. Cochran
in the supratip area as the splint recoils. The splint
and tape should remain in place for roughly 7
days and is removed at the fi rst postoperative
visit. For patients with signi fi cant edema of the
soft tissue envelope, the nose can be retaped for
an additional week.
46.2.3 Septal Splinting and Intranasal
Packing
There has been much debate over the last several
decades as to the need and optimal method of
internal septal splinting. While most surgeons do
not routinely pack the nose, Guyuron found that
patients in whom nasal packing was used were
less likely to develop recurrent or residual septal
deviation and synechiae compared to patients in
whom no packing was used [ 3 ] . He later demon-
strated that septal splints provided patients with
similar improvements in nasal airway obstruction
as those treated with packing [ 4 ] . Conversely,
several studies have demonstrated that paired
silicon splints may not prevent adhesions and can
add to postoperative discomfort [ 5, 6 ] .
Nevertheless, intranasal splints are routinely
used to help maintain septal stability and prevent
intranasal adhesions following septorhinoplasty
(Fig. 46.2 ). The general consensus is that when
placed bilaterally, these splints help stabilize the
septum as the mucoperichondrium readheres and
can help prevent the formation of a septal
hematoma.
Alternatively, a septal suture can be placed
instead of packing or splints. Typically, a plain
gut suture is passed to and fro across the septum
to reapproximate the mucoperichondrial fl aps
[ 7 ] . Suturing of the fl aps can aid in the prevention
of septal hematoma formation by obliterating the
potential dead space [ 8 ] .
The bene fi ts of packing, splinting, and taping
are not without adverse reactions or complica-
tions. Contact dermatitis may result from irrita-
tion of the skin by the topical adhesives, tape, or
dorsal splint. The treatment of contact dermatitis
includes removal of the offending agent and
application of topical and potentially systemic
steroids depending on the severity of the reaction.
Fortunately, contact dermatitis usually resolves
without any permanent sequelae.
Super fi cial skin necrosis or epidermolysis can
occur secondary to excessive compression of the
skin by the taping and dressing. Even more prob-
lematic, however, is partial-thickness or full-
Fig. 46.1 ( Upper ) The nose should be taped from the
radix to the supratip. ( Lower ) External aluminum cast is
applied on top of the taping
Fig. 46.2 Use of an intranasal septal splint may have pre-
vented this intranasal synechiae in this secondary rhino-
plasty patient who presented complaining of persistent
right-sided nasal obstruction

713
46 Postoperative Care of the Rhinoplasty Patient
thickness skin necrosis, which occurs when the
blood supply of the soft tissue envelope is more
severely embarrassed. This may occur due to
erroneous dissection of the skin fl ap, injury to the
lateral nasal arteries, aggressive debulking of the
subcutaneous tissue of the tip, or prolonged com-
pression of the skin by the taping and dressing.
The treatment of minor skin necrosis should
initially be conservative. Daily wound care and
protection from the sun should be diligently exer-
cised until the wound closes by secondary inten-
tion. After maturation of the scar, dermabrasion,
fi ller substances, skin care, and laser treatment
may be helpful. In selected patients, a skin or
composite graft may be utilized to improve the
contour of the affected aesthetic unit. Fortunately,
major skin necrosis is extremely rare. In these
cases, reconstruction should be performed using
local or regional fl aps.
Toxic shock syndrome (TSS), an acute multi-
system disease, has been described following
nasal surgery with the use of both nasal packing
and intranasal splints [ 9, 10 ] . TSS is usually
caused by the release of an exotoxin, TSS toxin-
1, created by Staphylococcus aureus . Symptoms
occur early and include nausea, vomiting, rash,
fever, and hypotension. Treatment requires imme-
diate removal of the offending object, ICU admis-
sion, and supportive care.
46.3
Perioperative Medications
The rhinoplasty surgeon is often confronted with
numerous therapeutic considerations when pre-
scribing medications during the postoperative
period as well as instructing their patients on
resuming scheduled nasal medications. Thus, the
surgeon should be well versed in the available
pharmacologic armamentarium and the impact of
these medications on patient care.
46.4
Steroids
Corticosteroids are potent anti-in fl ammatory
agents that are frequently administered in the
perioperative period in a variety of plastic surgery
procedures. There is con fl icting data on the
ef fi cacy of routine systemic corticosteroid admin-
istration in rhinoplasty. Kara and Gokalan [ 11 ]
conducted a double-blind, randomized controlled
trial with placebo control to evaluate the effects
of single-dose dexamethasone use on eyelid
edema, ecchymosis, and intraoperative bleeding
with rhinoplasty. He determined that a single
dose of dexamethasone has a signi fi cant effect in
decreasing upper and lower eyelid edema and
upper eyelid ecchymosis for the fi rst 2 days, but
there was no alteration in the intraoperative blood
loss or shortening of the recovery period.
Similarly, several other authors also found that a
single 10-mg perioperative dose of dexametha-
sone was bene fi cial in decreasing periorbital
edema and ecchymosis in the early postoperative
period [ 12 ] .
Other studies have looked at additional steroid
use beyond the perioperative period. Hoffman
et al. [ 13 ] conducted a randomized, double-blind
study of intraoperative intravenous dexametha-
sone plus a 5-day postoperative course of oral
prednisone following rhinoplasty. They found
signi fi cantly less postoperative eyelid and para-
nasal edema during the fi rst 4 days after surgery
in those patients receiving steroids. Kara and
Gokalan [ 11 ] found that three doses of 8 mg dex-
amethasone (administered intraoperatively and at
24 and 48 h postoperatively) were more effective
in decreasing facial edema and ecchymosis dur-
ing the fi rst 5–7 days.
While steroids may decrease early facial
edema, their effects on nasal edema appear to be
less ef fi cacious. Berinstein et al. [ 14 ] failed to
show an improvement in postoperative nasal
edema using MRI in patients having undergone
rhinoplasty with osteotomies who received a
10-mg preoperative dose of dexamethasone.
Thus, there continues to be debate as to the long-
term bene fi t of routinely administering intraop-
erative or postoperative corticosteroids in patients
undergoing rhinoplasty as the bene fi ts subside
after the fi rst week. Therefore, the surgeon should
weight the potential bene fi ts compared to the
potential side effects of steroids when deciding
whether or not to routinely prescribe this class of
medications to his or her rhinoplasty patients.

714
C.S. Cochran
46.4.1 Antibiotics
With the rise in the incidence of antibiotic-resistant
bacteria and the widespread occurrence of both
hospital-acquired and community-acquired methi-
cillin-resistant Staphylococcus aureus (MRSA)
infections, the surgeon should be diligent in both
screening patients preoperatively for a history of
such infections and also in having a low index of
suspicion should any signs of postoperative infec-
tion arise anytime in the perioperative period.
Purulent drainage as well as any localized or dis-
crete fl uid collection should be drained and cul-
tured. Empiric oral antibiotic should be started to
cover the suspected organism until the fi nal culture
results are obtained. Currently, there are several
multi-institutional studies being conducted to
examine the incidence of MRSA infections in rhi-
noplasty and also to evaluate the optimal guidelines
for an antibiotic prophylactic regime.
Systemic antibiotics are frequently used in rhi-
noplasty, but the routine perioperative administra-
tion of antibiotics in the absence of infection is
area of debate. Randomized, controlled trials have
shown that prophylactic antibiotics are effective in
preventing certain surgical wound infections. In
his review of over 2000 various “clean” and “clean-
contaminated” surgical procedures, Classen et al.
[ 15 ] found that perioperative administration of
antibiotics within 2 h of the surgery start time was
associated with the lowest risk of surgical wound
infections. Their use in nasal surgery, however,
remains a point of controversy as there is a paucity
of available controlled studies showing a conclu-
sive bene fi t to their use.
Topical antibiotic ointment has been shown to
signi fi cantly decrease the growth of potentially
infectious nasal fl ora and of S. aureus in patients
with nasal packing [ 16 ] . In a survey of plastic sur-
geons, Perrotti [ 17 ] found that 72% of respondents
used antibiotics during or after rhinoplasty, and
there has been a 200% increase in the use of peri-
operative antibiotics in rhinoplasty between 1985
and 2000 [ 18 ] . Despite their widespread use and
apparent ef fi cacy, no clear guidelines exist in the
literature regarding antibiotic use in aesthetic sur-
gery. Frequently cited rationales for antibiotic pro-
phylaxis in rhinoplasty are the fear of TSS with the
use of intranasal splints, the clean-contaminated
nature of the surgical wound, and use of grafts.
46.4.2 Adjunctive Medications
Topical nasal saline has been used as an adjunct in
the treatment of multiple rhinologic disorders, as
well as in the postoperative care of patients undergo-
ing nasal and paranasal sinus surgery. Anecdotal evi-
dence supports the ef fi cacy of nasal saline. Although
there are a paucity of scienti fi c studies addressing
the use of nasal saline, Tomooka [ 19 ] reported a sta-
tistically signi fi cant improvement in nasal symptoms
in patients who used nasal saline irrigation. In sup-
port of this fi nding, Shone [ 20 ] demonstrated a per-
sistent decreased mucociliary clearance three weeks
following septoplasty. Overresection of intranasal
structures such as the middle or inferior turbinate
can lead to atrophy of the nasal mucosa, referred to
as atrophic rhinitis. Patients may present with subse-
quent symptoms of dryness, crusting, and nasal
obstruction. Thus, nasal saline may be a useful
adjunct in relieving postoperative stasis of secre-
tions, crusting, and patient discomfort.
Occasionally, patients may report a spontane-
ous clear watery nasal discharge. This phenome-
non most likely represents a variant of vasomotor
rhinitis caused by abnormal parasympathetic tone
to the intranasal mucosa. Topical anticholinergic
preparations, such as 0.03% ipratropium bro-
mide, act locally and are effective in decreasing
watery rhinorrhea [ 21 ] . The recommended dos-
ing regimen is two sprays in each nostril two to
three times a day as needed. Continued symp-
toms of watery nasal discharge despite appropri-
ate topical therapy should raise the concern for an
occult cerebrospinal fl uid leak.
46.5
Managing Suboptimal Results
and Deformities
46.5.1 The Pollybeak Deformity
Supratip fullness, commonly referred to as a
“pollybeak deformity,” is a common postopera-
tive complication of rhinoplasty in which the

715
46 Postoperative Care of the Rhinoplasty Patient
nasal supratip has a convex shape in relation to
the nasal dorsum. The pollybeak most often
results from either inadequate resection of the
caudal dorsal septum and upper lateral cartilages
or from overresection of these supratip structures
with subsequent scar tissue formation in the
resulting dead space.
46.5.2 Supratip Taping
Taping the supratip region to recreate the supratip
break and obliterate the dead space is a conserva-
tive means of treating the mild pollybeak defor-
mity in the immediate postoperative period. The
use of a compressive tape such as Blenderm (3 M
Minnesota Mining and Manufacturing Co.,
Minneapolis, MN) applied to the supratip area
nightly is an effective means of enhancing the
desired supratip break.
For the moderate to severe pollybeak defor-
mity, injection of triamcinolone has proven to
alleviate the deformity in some patients. Hanasono
et al. [ 22 ] recommend initial subcutaneous injec-
tion of triamcinolone 1–2 weeks after surgery.
Similarly, Guyuron [ 23 ] advocates the judicious
injection of triamcinolone in the deep subcutane-
ous tissue if taping fails after 6–8 weeks. The
injection is repeated in 4-week intervals until the
desired result is obtained. The use of such ste-
roids is not without complications or side effects.
If injected too super fi cially, dermal atrophy and
discoloration of the overlying skin can occur. It
is, therefore, crucial that the triamcinolone be
injected beneath the dermis (as opposed subcuta-
neously in the dermal layers) to prevent this
untoward complication.
46.5.3 Revision Surgery
If a supratip deformity arises secondary to an
inadequate dorsal resection, additional dorsal
septal reduction can be accomplished in the set-
ting of a revision surgery. Conversely, the supra-
tip deformity caused by an overresected dorsum
may require grafting of the caudal dorsum in the
setting of a revision or secondary rhinoplasty.
46.5.4 Deviation
Postoperative nasal deviation is a frustrating prob-
lem for both the rhinoplasty surgeon and the
patient. If managed early, correction may preclude
a second surgery. The nose may appear deviated
secondary to shifting of the nasal bones following
osteotomies, or from scar tissue contracture caus-
ing the midvault or tip to deviate. If recognized
early in the postoperative period (1 week), the
nasal bones can be manipulated under local anes-
thetic. Conversely, the patient can be instructed on
nasal massage techniques to help “train” the nose
to heal in a less deviated fashion. Localized soft
tissue swelling may masquerade as a postopera-
tive deviation, and in this case steroid injections
may alleviate a pseudodeviation.
46.5.5 Skin Changes
Telangiectasias are small super fi cial vessels of
the skin visible to the human eye and usually
measure 0.1–1.0 mm in diameter [ 24 ] . While
telangiectasias of the nose have been reported to
result from rhinoplasty [ 25– 27 ] , their incidence
following surgery is unknown. Rees [ 28 ] believes
that the majority of facial telagiectasias in patients
who have undergone cosmetic procedures were
present preoperatively and were only exacerbated
by surgery. Several others have advocated that
telangiectasias result from failure to dissect in a
subperiosteal plane on the nasal dorsum. Other
causes of nasal telangiectasias include signi fi cant
dorsal augmentation in patients with contracted
soft tissue envelopes or following alloplastic aug-
mentation with silastic or GoreTex. Whether new
or exacerbated, telangiectasias of the nasal skin
following rhinoplasty are a frustrating problem
for both the patient and the surgeon. Lasers have
proven to be an effective means of treatment, but
they are not without their drawbacks. The argon
laser carries a risk of scarring and a relatively
high risk of posttreatment pigmentary changes
[ 29 ] while the pulsed dye laser (585 and 577 nm)
has been shown to be a safe and highly effective
means of combating telangiectasias. It has a short
pulse duration (0.45 ms) that reduces the risk of

716
C.S. Cochran
severe, long-term adverse effects. However, the
pulsed dye laser often leads to vessel disruption
and visible purpura that may last for a week. The
high cost and decreased availability of this laser
limits its use.
Several studies have addressed the ef fi cacy of
IPL in treating essential telangiectasias. Raulin
et al. [ 30 ] treated 13 patients with IPL who pre-
sented with essential telangiectasias and had excel-
lent results with no side effects. Similarly, Mark
et al. [ 31 ] quantitatively evaluated the effects of
IPL on blood fl ow, telangiectasias, and erythema in
patients with rosacea-associated erythema and
telangiectasias. They found a statistically signi fi cant
decrease in the area occupied by telangiectasias,
decreased erythema, and increased blood fl ow 1
month after completing 5 treatments at 3-week
intervals. IPL treatment appears to be a valuable
adjunct to the postoperative care of the rhinoplasty
patient and a safe and viable alternative to conven-
tional laser systems and sclerotherapy for nasal
telangiectasias (Fig. 46.3 ).
Conclusions
Meticulous attention to detail in the operating
room and in the postoperative period is para-
mount to achieving success in rhinoplasty.
The early postoperative evaluation serves to
alert the surgeon to potential complications
and allows early intervention to improve sub-
optimal results.
References
1. Ahn MS, Maas CS, Monhian N (2003) A novel, com-
fortable, rapidly setting nasal splint material. Arch
Facial Plast Surg 5(2):189–192
2. Cunningham MW, Yousif NJ, Sanger JR, Gingrass RP,
Matloub HS (1984) Aquaplast for nasal splinting. Ann
Plast Surg 13(4):357–358
3. Guyuron B (1989) Is packing after septorhinoplasty
necessary? A randomized study. Plast Reconstr Surg
84(1):41–44
4. Guyuron B, Vaughan C (1995) Evaluation of stents fol-
lowing septoplasty. Aesthetic Plast Surg 19(1):75–77
Fig. 46.3 ( Left ) Preoperative nasal telangiectasias. ( Right ) Postoperative following treatment with intense pulsed light
therapy ( IPL )

717
46 Postoperative Care of the Rhinoplasty Patient
5. Cook JA, Murrant NJ, Evans KL, Lavelle RJ (1992)
Intranasal splints and their effects on intranasal adhe-
sions
and
septal
stability.
Clin
Otolaryngol
17(1):24–27
6. Malki D, Quine SM, P fl eiderer AG (1999) Nasal
splints, revisited. J Laryngol Otol 113(8):725–727
7. Gottschalk GH (1978) An improved septoplasty: the
microsurgical suture technique. Ann Plast Surg
1(1):30–33
8. Orlandi RR, Lanza D (2004) Is nasal packing neces-
sary
following
endoscopic
sinus
surgery?
Laryngoscope 114(9):1541–1544
9. Jacobson JA, Kasworm EM (1986) Toxic shock syn-
drome after nasal surgery. Case reports and analysis
of risk factors. Arch Otolaryngol Head Neck Surg
112(3):329–332
10. Wagner R, Toback JM (1986) Toxic shock syndrome
following septoplasty using plastic septal splints.
Laryngoscope 96(6):609–610
11. Kara CO, Gokalan I (1999) Effects of single-dose steroid
usage on edema, ecchymosis, and intraoperative bleeding
in rhinoplasty. Plast Reconstr Surg 104(7):2213–2218
12. Grif fi es WS, Kennedy K, Gasser C, Frankhauser C,
Taylor R (1989) Steroids in rhinoplasty. Laryngoscope
99(11):1161–1164
13. Hoffman DF, Cook TA, Quatela VC, Wang TD,
Brownrigg PJ, Brummet RE (1991) Steroids and rhi-
noplasty. A double-blind study. Arch Otolaryngol
Head Neck Surg 117(9):990–993
14. Berinstein TH, Bane SM, Cupp CL, DeMarco JK,
Hunsaker DH (1998) Steroid use in rhinoplasty: an
objective assessment of postoperative edema. Ear
Nose Throat J 77(1):40–43
15. Classen DC, Evans RS, Pestotnik SL, Horn SD,
Menlove RL, Burke JP (1992) The timing of prophy-
lactic administration of antibiotics and the risk of sur-
gical-wound infection. N Eng J Med 26(5):281–286
16. Bandhauer F, Buhl D, Grossenbacher R (2002)
Antibiotic prophylaxis in rhinosurgery. Am J Rhinol
16(3):135–139
17. Perrotti JA, Castor SA, Perez PC, Zins JE (2002)
Antibiotic use in aesthetic surgery: a national survey
and
literature
review.
Plast
Reconstr
Surg
109(5):1685–1693
18. Lyle WG, Outlaw K, Krizek TJ, Koss N, Payne WG,
Robson MC (2001) Prophylactic antibiotics in plastic
surgery: trends of use over 25 years of an evolving
specialty. Aesthetic Surg J 23:117
19. Tomooka LT, Murphy C, Davidson TM (2000)
Clinical study and literature review of nasal irrigation.
Laryngoscope 110(7):1189–1193
20. Shone GR, Yardley MP, Knight LC (1990) Mucociliary
function in the early weeks after nasal surgery.
Rhinology 28(4):265–268
21. Cochran CS, Marple BF (2004) Rhinologic pharma-
cotherapy in rhinoplasty. Facial Plast Surg Clin North
Am 12(4):415–424
22. Hanasono MM, Kridel RW, Pastorek NJ, Glasgold
MJ, Koch RJ (2002) Correction of the soft tissue pol-
lybeak using triamcinalone injection. Arch Facial
Plast Surg 4(1):26–30
23. Guyuron B, DeLuca L, Lash R (2000) Supratip
deformity: a closer look. Plast Reconstr Surg 105(3):
1140
24. Goldman MP, Bennet RG (1987) Treatment of telang-
iectasia: a review. J Am Acad Dermatol 17(2 Pt 1):
167–182
25. Padovan IF, Jugo SB (1991) The complications of
external rhinoplasty. Ear Nose Throat J 70(7):
454–456
26. Dicken CH (1990) Argon laser treatment of the red
nose. J Dermatol Surg Oncol 16(1):33–36
27. Noe JM, Finely J, Rosen S, Arndt KA (1981)
Postrhinoplasty “red nose”: differential diagnosis and
treatment by laser. Plast Reconstr Surg 67(5):
661–664
28. Rees TD (1998) Point and counterpoint, parts x, xi,
and xii. In: Rees TD, Baker DC, Tabbal N (eds)
Rhinoplasty problems and controversies – a discus-
sion with the experts. Mosby, St. Louis, p 368
29. Scheepers JH, Quaba AA (1994) Clinical experience
in the treatment of the “red nose” using the fl ashlamp-
pumped pulsed dye laser. Aesthetic Plast Surg
18(1):57–60
30. Raulin C, Weiss RA, Schonermark MP (1997)
Treatment of essential telangiectasias with an intense
pulsed light source (PhotoDerm VL). Dermatol Surg
23(10):941–946
31. Mark KA, Sparacio RM, Voigt A, Marenus K, Sarnoff
DS (2003) Objective and quantitative improvement of
rosacea-associated erythema after intense pulsed light
treatment. Dermatol Surg 29(6):600–603

Part V
Fillers

721
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_47, © Springer-Verlag Berlin Heidelberg 2013
47
47.1
Introduction
There are many procedures described in the
medical literature in order to correct volume
defects in rhinoplasty, such as the osseous or car-
tilaginous autologous graft, the lyophilized bone,
or synthetic materials, but all of them, at a higher
or lesser level, can show some nondesired effects,
such as the reabsorption, intolerance, granulomas,
visualization of the graft edges, or the migra-
tion of the implant [ 1– 6 ] . With the idea of trying
to avoid the nondesired effects, we provide you
with our protocol for the correction of the dorsum
nasi defects by using other techniques, especially
with the use of a dermic regeneration template
(Integra™).
When the osseous dorsum nasi defects or the
nasofrontal angle needs a moderate augmenta-
tion, the author uses demineralized bone matrix
activated with platelet growth factors (PGF).
When it is necessary to correct more important
defects of the osseous dorsum nasi that need a
higher volume of correction, or defects that affect
not only the osseous dorsum but also the carti-
laginous one, the demineralized bone matrix with
PGF is not the best way to follow for two reasons:
the fi rst one is that it is not possible to obtain a
big increase in volume, and the second one is that
an osseous bed is needed in order to be placed
and start the process of osseous regeneration. For
these reasons, in these cases, we prefer to use the
dermic regeneration template of an only sheet
(Integra™), which allows us to have a constant
regeneration of autologous dermic tissue of the
suitable thickness [ 7, 8 ] , obtaining excellent
results, above all in post-traumatic cases and sec-
ondary rhinoplasties.
The dermal regeneration template is a porous
matrix of glycosaminoglycans and collagen,
which provides us with a three-dimensional struc-
ture necessary for the cellular invasion and growth,
which function is to stimulate the organism in the
creation of autologous dermis. Although it is a
synthetic material, it is completely absorbed in
4–6 months [ 9 ] , and it is replaced totally by the
own patient’s tissue. It has an easy handling and
versatility because it can be folded on its own and
the size and shape of the implant can be designed
as wished.
The proposed surgical treatment, as an alter-
native to the use of other grafts for the restoration
of the defects of the dorsum nasi in the augmen-
tation rhinoplasty, is the use of the dermic regen-
eration template, as the material for increasing
volumes, improving the contours, and hiding the
Use of Integra™ in Rhinoplasty
Jorge Planas
J. Planas , M.D.
Clinica Planas , Pere de Montcada, 16, 08034
Barcelona , Spain
e-mail: jorge@clinica-planas.com

722
J. Planas
aesthetic defects. This material can be grafted
under the cutaneous tegument without complica-
tions, and it keeps achieving its objective, the
same as it is placed on the damaged tissue as a
coating in case of burns or tissue lost [ 10– 12 ] .
If the author does not want to give volume,
just some more thickness to the entire nasal con-
tour (in cases of very thin skins to avoid that the
osteocartilaginous structure could be seen exces-
sively), either dermis regeneration template
(Integra™) or a cellular dermis (Alloderm™) is
used and placed it all over the dorsum nasi.
47.2
Technique
The use of the dermal regeneration template has
already succeeded in other areas of the body in
plastic surgery, such as the correction of cranial
osseous defects [ 7 ] .
The author used dermal regeneration template
(Integra™) as an only technique or as an additional
one to the rhinoplasty is of 56 patients. An informed
consent was obtained from all the patients to use
Integra™, and all other options of different materi-
als were explained to them as well.
Fifty- fi ve patients had been operated on under
general anesthesia and only one with local anesthe-
sia: There were 32 open rhinoplasties and 24 closed
ones. Two of them were post-traumatic cases, 18
secondary rhinoplasties, and 36 primary ones.
The complete dorsum nasi was increased in 41
cases, and a partial increase was carried out in 13
cases. In two cases, the area of the right upper
lateral cartilage was also fi lled, and in one case,
both upper lateral cartilages were fi lled. The
author has used only one layer in all the cases,
except in 10 patients that we have folded the sheet
in order to obtain two layers; in 5 patients, the
sheet was folded more times so as to get three
layers; and in one patient, we folded the sheet in
four layers.
All patients had a dermal regeneration tem-
plate of one sheet used, having removed previ-
ously the super fi cial silicone layer, since this
works as an epidermis when it is used as an injury
cover. The layer size used is of 5 × 5 cm, and its
design is handled according to the area to be
fi lled, cutting out the necessary amount, having
the possibility of folding the material on its own
as needed, in order to obtain the desired result in
each case. It is better to carry the abovementioned
design out before removing the super fi cial coat of
silicone because the trimming is made easier.
Once it is designed, it should be left to soak in
saline solution for a few minutes before its place-
ment. Then, the silicone coat is removed because
its function is not necessary and it could work as
a foreign body (Fig. 47.1 ).
It is important to place the layer carefully
in order to have it well spread all over the area
to be treated, avoiding the folds and, therefore,
some possible irregularities of contour later.
The template placement can be performed as
a unique technique or associated to a complete
rhinoplasty.
Depending on the maneuvers associated to
the performed technique, a tamponade will be
placed, as well as a plastic splint, if necessary.
None of the patients needed a secondary revi-
sion after augmentation with dermic regeneration
template.
The dermal regeneration template (Integra™)
achieved very good results in patients with dor-
sum nasi defects, such as saddle nose deformi-
ties, overresected dorsum, or traumatic noses
(Figs. 47.2 , 47.5 , and 47.6 ), and dorsum asym-
metries (Figs. 47.3 and 47.4 ). It is mandatory to
have a solid base where to place the dermic regen-
eration template. In cases where there is an
absence of a solid base, we prefer to use autolo-
gous osseous or cartilaginous grafts.
47.3
Cases
Representative cases are presented and examples
of surgical indications from regarding the use of
the dermal regeneration template (Integra™) in
rhinoplasty.

723
47 Use of Integra™ in Rhinoplasty
a
c
d
b
Fig. 47.1 ( a – d ) After removing the silicone layer, the necessary amount is designed and cut out, having the option of
folding the material on its own as needed, and then placed it in the area to be fi lled

724
J. Planas
Case 1 (Fig. 47.2 )
This 40-year-old female patient had a contused
trauma in childhood with a bone fracture that
caused a depression of the dorsum nasi. She also
presented with respiratory functional alteration.
When physically examined, she showed a saddle
nose deformity in the dorsum nasi, as well as
septal deviation toward the left. The surgical
treatment consisted of an open rhinoseptoplasty,
with turbinectomy and head resection of the right
inferior concha, columella strut, interdomal
suture of both alar cartilages, lateral and medial
osteotomies, placement of four layers of Integra™
folded among them on the osteocartilaginous
dorsum, and a graft of auricular cartilage of 0.5 ×
0.5 cm in the supratip-break area in order to give
more consistency to the area.
a
b
Fig. 47.2 ( a ) Preoperative patient with a saddle nose and a marked supratip break due to a traumatism. ( b ) Twenty-
seven months postoperative after open rhinoseptoplasty with the placement of four layers of Integra™

725
47 Use of Integra™ in Rhinoplasty
Case 2 (Fig. 47.3 )
This 53-year-old female patient had antecedent
rhinoplasty with depression in the dorsum nasi.
At the examination, an excess of resection of the
osseocartilaginous dorsum was noticed as well as
a deviation of the dorsum nasi. The proposed
corrective surgery was performed through a
closed rhinoplasty, rasping the small monticulus
in the osseous dorsum nasi, left unilateral osteot-
omy to correct deviation, resection of the excess
of lower lateral cartilage, and placement of
Integra™ folded over its own in two sheets in all
the extension of the dorsum nasi.
Fig. 47.3 ( a ) Preoperative patient with an excess resection in the dorsum due to a previous surgery. ( b ) Fifteen days post-
operative following the use of Integra™ folded in two sheets in the dorsum nasi. ( c ) Twenty-four months postoperative
a
b
c

726
J. Planas
Case 3 (Fig. 47.4 )
This 31-year-old female patient had previous rhi-
noplasty. She wished to have improvement of the
dorsum nasi, with no respiratory dif fi culty. She
showed a depression of the dorsum nasi and the
region corresponding to the right upper lateral
cartilage. An open rhinoseptoplasty was per-
formed, with the placement of a layer of Integra™
folded on its own, in two sheets, in the osteocar-
tilaginous dorsum, and one sheet in the right
upper lateral cartilage.
a
b
Fig. 47.4 ( a ) Preoperative patient with sequelae of a pre-
vious rhinoplasty in dorsum and right upper lateral carti-
lage. ( b ) Twenty-two months postoperative after use of
two sheets of Integra™ in the dorsum nasi and one in the
depression of the area of the right upper lateral cartilage

727
47 Use of Integra™ in Rhinoplasty
Case 4 (Fig. 47.5 )
This 44-year-old male patient had prior record of
nasal trauma in his childhood and sequelae of
rhinoplasty. At the examination, he showed
respiratory dif fi culty, deformity of the dorsum
nasi with a visible edge of the costal cartilage
graft from the previous rhinoplasty, a very marked
supratip break, minimum depression in the right
upper lateral cartilage, and a large synechia
between the nasal septum and the lower concha
in the right nasal nostril. A rhinoseptoplasty was
performed, with a bridle resection, costal graft
edge resection, osteotomies, and a folded sheet
of Integra™ in a double layer in the whole dor-
sum nasi area.
a
b
Fig. 47.5 ( a ) Preoperative 33-year-old female patient
with a record of sequelae of rhinoplasty. ( b ) Twenty-four
months after an open rhinoplasty. First, the existing
fi brosis was removed and then the tip reconstruction with
a columella strut and a Peck graft. Also performed was
dorsal reconstruction with Permacol™ (porcine dermis),
which reabsorbed in a few months, and lyophilized bone
was placed, which also reabsorbed eventually. Finally,
Integra™ was used for the same purpose

728
J. Planas
Case 5 (Fig. 47.6 )
This 33-year-old female patient had sequelae of
prior rhinoplasty. An open rhinoplasty was per-
formed. First, the existing fi brosis was removed,
and then, the tip reconstruction with a columella
strut and a Peck graft was carried out. We also did
a dorsal reconstruction with Permacol™ (porcine
dermis), which reabsorbed in a few months. Next,
a lyophilized bone, which also reabsorbed even-
tually, was placed. Finally, Integra™ was used
for the same purpose.
a
b
Fig. 47.6 ( a ) Preoperative patient with sequelae of a previous rhinoplasty. ( b ) Twenty-two months postoperative fol-
lowing tip reconstruction and three layers of Integra™ used to fi ll the dorsum deformity

729
47 Use of Integra™ in Rhinoplasty
47.4
Discussion
The use of the dermal regeneration template
(Integra™) as a fi ller in primary or secondary rhi-
noplasties can be done successfully, whenever
the material is handled properly. In the author’s
protocol for the correction of the dorsum nasi
defects, demineralized bone matrix activated with
platelet growth factors (PGF) is used only when
the osseous dorsum nasi or the nasofrontal angle
needs moderate augmentation.
When it is necessary to correct more impor-
tant defects of the osseous dorsum nasi that need
a higher volume of correction, or defects that
affect not only the osseous dorsum but also the
cartilaginous one, the demineralized bone matrix
with PGF is not the best way to be followed. This
is for two reasons: (1) It is not possible to obtain
a big increase in volume, and (2) an osseous bed
is needed for its placement and the consequent
process of osseous regeneration. For these rea-
sons and in these cases, we prefer to use the der-
mic regeneration template of an only sheet
(Integra™), which allows us to have a constant
regeneration of autologous dermic tissue of suit-
able thickness.
The thickness of the Integra™ sheet is 2 mm and
does not increase after being placed in saline solu-
tion because it already comes wet. According to our
experience, we have used it up to a maximum of
four times folded, and there has been no case of
resorption or overcorrected defect. Therefore,
Integra™ can be used for correcting defects in
between 8- and 2-mm height or thickness.
Nevertheless, in the cases in which an impor-
tant amount of volume is required, the use of
other materials should be considered, such as the
autologous osseous graft, since the dermal regen-
eration template is useful to raise only up to
8-mm height, if it is always placed on a solid
base. In case of more important defects or the
lack of a solid base to place it, due to a complete
absence of the cartilaginous or osseous dorsum,
we do believe that it would be better to use the
autologous osseous graft or the costal cartilage
one in order to solve the problem.
If increased volume is desired and just some
more thickness to the entire nasal contour (in
cases of very thin skins, to avoid that the osteo-
cartilaginous structure could be seen in excess),
either dermal regeneration template (Integra™)
or a cellular dermis (Alloderm™) is used and
placed all over the dorsum nasi.
Cellular dermis (Alloderm™) has different
sizes. The most suitable Alloderm™ sheet for
rhinoplasty is that of 2 × 4 mm. This sheet has a
thickness between 0.17 and 0.99 mm. So, to
obtain the same thickness of just one layer of
Integra™, several layers of Alloderm™ will be
needed, but with the inconvenience that its
manipulation makes the correct and homoge-
neous placement dif fi cult inside the nose.
Alloderm™ can provide a maximum dorsal
augmentation of 3 mm and has a partial absorp-
tion from 10% to 30% of the volume [ 13, 14 ] ,
especially over the dorsum in thin-skinned
patients. It should be noted that even though
Alloderm™ is dermis, it is still a foreign material
because it is a cadaver dermal graft. That is why
today it is only used in cases where the only need
is to create a thicker cover/coat of the nose, with
just one layer of Alloderm™.
The big advantage between Integra™ and the
rest of options (Alloderm™, fascia lata allografts,
etc.) is that Integra™ is the only material com-
pletely reabsorbed and replaced by autologous
tissue because it regenerates the patient’s own
dermis.
Dermal autologous grafts also have a range of
reabsorption [ 15, 16 ] , not the diced cartilage
wrapped in Surgicel [ 17 ] or in fascia [ 18 ] that has
none reabsorption as con fi rmed histologically [ 19 ] ,
but they have the disadvantage of the donor-site scar
and the visibility and junctional step-offs [ 18 ] .
The technique is simple, and the tridimen-
sional matrix of the dermic regeneration template
is completely reabsorbed and replaced by autolo-
gous dermis. It also avoids behaving as a foreign
body and stops the possibility of granulomas
[ 11 ] . The period of hospitalization using this
technique has been lower than the one needed
using autologous osseous grafts. The technique
also shortens the operative time signi fi cantly by
eliminating graft harvest.
The patients avoid the scars in the donor area
in order to obtain the osseous or cartilaginous

730
J. Planas
graft, and they also have an easier and less pain-
ful postoperative period.
There is a natural feel to the implant, and it is
impossible to have implant migration.
The results with the dermal regeneration tem-
plate achieve stable results with a 27-month fol-
low-up. The results are stable in terms of
reabsorption because the material used is com-
pletely reabsorbed in a maximum of 6 months
and it is replaced totally by the own patient’s tis-
sue. Only long-lasting edema could vary the fi nal
results; that is why even the results after a follow-
up of more than 2 years are encouraging.
It has already been demonstrated that the
thickness obtained with the same material in
other indications keeps steady, as the medical lit-
erature shows [ 12, 20 ] , such as in cranial osseous
defects or in the treatment of injuries and burns.
It is an advantage over other techniques (autolo-
gous or lyophilized bone) in which really exist a
certain level of long-term reabsorption. Any sec-
ondary revision was needed after augmentation
with dermal regeneration template. The cost of
Integra™ is something to be considered before
planning the surgery, and the number of layers
needed will affect directly the fi nal cost of the
product used.
Conclusion
The dermis regeneration template (Integra™)
is an alternative fi ller to be considered in rhi-
noplasty, mainly in those cases with important
defects in the dorsum nasi due to traumatism
or secondary rhinoplasties. We point out to the
fact that Integra™ has an easy handling and
versatility. It can be folded in several layers on
its own. However, it is mandatory that the tem-
plate is not too compressed in the implanted
bed because it can collapse the porous matrix,
avoiding the fi broblast migration necessary to
create neodermis [ 7 ] .
It is a simple technique that reduces the hospi-
talization period and avoids the postsurgical
complications, such as the morbidity of the donor
area, migration, visibility, reabsorption, and reac-
tion to a foreign body. Patient satisfaction has
been very high and steady in all patients.
References
1. Jackson IT, Smith J, Mixter RC (1983) Nasal bone
grafting using split skull grafts. Ann Plast Surg 11(6):
533–540
2. Inanli S, Sari M, Baylancicek S (2007) The use of
expanded polytetra fl uoroethylene (Gore-Tex) in rhi-
noplasty. Aesthetic Plast Surg 31(4):345–348
3. Bottini DJ, Gentile P, Donfrancesco A, Fiumara L,
Cervelli V (2008) Augmentation rhinoplasty with
autologous grafts. Aesthetic Plast Surg 32(1):136–142
4. Tosun Z, Karabekmez FE, Keskin M, Duymaz A,
Savaci N (2008) Allogenous cartilage graft versus
autogenous cartilage graft in augmentation rhino-
plasty: a decade of clinical experience. Aesthetic Plast
Surg 32(2):252–260
5. Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey
A (2007) Dorsal nasal augmentation with rib cartilage
graft: long-term results and patient satisfaction.
J Craniofac Surg 18(6):1457–1462
6. Clark RP, Wong G, Johnson LM, Hagge RJ, Ciminello
F, Lee J, Stone KI, Clark IA (2009) Nasal dorsal aug-
mentation with freeze-dried allograft bone. Plast
Reconstr Surg 124(4):1312–1325
7. Gómez Morell PA, Paolo Domenech R (2007) Uso del
regenerador dérmico Integra como material de relleno
para el tratamiento de defectos del contorno corporal.
Cir Plast Iberolatinoam 33(3):195–200
8. Stern R, McPherson M, Pharm D, Longaker T (1990)
Histologic study of arti fi cial skin used in the treatment
of full-thickness thermal injury. J Burn Care Rehabil
11(1):7–13
9. Hembach D, Luterman A, Burke J (1988) Arti fi cial
dermis for major burns, a multi-center randomized
clinical trial. Ann Surg 208:313
10. Dantzer E, Queruel P, Salier L (2001) Integra, a new
surgical alternative for the treatment of massive burns.
Clinical assessment of acute surgery and reconstructive
surgery on 39 cases. Ann Chir Plast Esthet 46:173–189
11. Moiemen N, Vlachou E, Staiano J (2006)
Reconstructive surgery with Integra dermal regenera-
tion template: histologic study, clinical evaluation
and current practice. Plast Reconstr Surg 117:
160s–174s
12. Sheridan R, Hegarty M, Tompkins R, Burke J (1994)
Arti fi cial skin in massive burns-results to ten years.
Eur J Plast Surg 17:91–93
13. Gryskiewicz JM, Rohrich RJ, Reagan BJ (2001) The
use of alloderm for the correction of nasal contour
deformities. Plast Reconstr Surg 107(2):561–570
14. Gryskiewicz JM, Not W, Not W (2005) The use of
AlloDerm in secondary rhinoplasty. Plast Reconstr
Surg 116(7):1999–2004
15. Karaaltin MV, Orhan KS, Demirel T (2009) Fascia
lata graft for nasal dorsal contouring in rhinoplasty.
J Plast Reconstr Aesthet Surg 62(10):1255–1260
16. Erdogan B, Tuncel A, Adanali G, Deren O, Ayhan M
(2003) Augmentation rhinoplasty with dermal graft and

731
47 Use of Integra™ in Rhinoplasty
review of the literature. Plast Reconstr Surg 111(6):
2060–2068
17. Erol OO (2000) The Turkish delight: a pliable graft for
rhinoplasty. Plast Reconstr Surg 105(6):2229–2241
18. Daniel RK (2008) Diced cartilage grafts in rhino-
plasty surgery: current techniques and applications.
Plast Reconstr Surg 122(6):1883–1891
19. Calvert JW, Brenner KB, Da Costa-Iyer M, Evans
GRD, Daniel RK (2006) Histological analysis of
human diced cartilage grafts. Plast Reconstr Surg
118:230
20. Palao R, Gómez P, Huguet P (2003) Burned breast
reconstructive surgery with Integra dermal regenera-
tion template. Br J Plast Surg 56:252

733
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_48, © Springer-Verlag Berlin Heidelberg 2013
48
48.1 Introduction
In recent years, clinicians are facing an increasing
number of patients wishing to achieve an aesthetic
improvement of nasal shape without having to
undergo surgical rhinoplasty. Although surgical
rhinoplasty must be the primary indication in any
patient seeking aesthetic improvement of the
nose, the ability to smooth out irregularities or
contour deformities and asymmetries with an
injectable material holds great appeal due to
apparent simplicity. The ability to fi x a deformity
with local or no anesthesia, less fi nancial expense,
and no downtime is an appealing advantage. The
great majority of treatments the author has wit-
nessed include or are based on using permanent
or semipermanent fi llers injected to the dorsum,
tip, and columela. Regarding semipermanent
fi llers, clinicians have an acceptable degree of
safety pending on an even and complete resorp-
tion, but still clinicians must face some potential
complications [ 1, 2 ] . The patient must forego a
permanent result unless he or she has repeat
injections on a regular basis, and in the event that
the patient fi nally wishes to undergo a standard
surgical rhinoplasty, clinicians must wait for the
complete resorption of the implant until surgical
planning can be done with con fi dence. The use of
permanent fi llers in the nose poses additional
risks of severe adverse reactions, skin necrosis,
and extrusion and addition of the almost com-
plete dif fi culty in a thorough evacuation of the
fi ller and the obvious dif fi culties in eventual sur-
gical planning.
The author will discuss his experience in non-
surgical rhinoplasty using autologous fat grafting
instead of injectable fi llers in patients that refused
primary or secondary surgical rhinoplasties. It will
be discussed as well the combination of open or
closed rhinoplasty with fat grafting to paranasal
regions to get equal or better results than with car-
tilage grafts or solid prosthesis in same regions.
48.2
Author’s Experience
From April 2007, the author has performed 51
procedures in 48 patients with a maximum fol-
low-up of 18 months and a mean follow-up of
8 months. In 23 patients, nasal lipoimplants were
done as the unique method of improving nasal
aesthetics whether it was previously operated or
not (Fig. 48.1 , 48.2 , and 48.3 ). In these cases,
patients always refused a standard rhinoplasty
although they all were informed and advised
about the differences in fi nal results, limitations,
and aesthetic improvements that each technique
Fat Grafting to the Nose
Juan Monreal
J. Monreal , M.D.
Plastic, Reconstructive and Aesthetic Surgery,
San Rafael Hospital , Serrano, 207-1º , 28016 ,
Madrid , Spain
Plastic, Reconstructive and Aesthetic Surgery,
San Rafael Hospital ,
Madrid , Spain
e-mail: juanmonreal@me.com

734
J. Monreal
a
b
Fig. 48.1 ( a ) Preoperative view of a patient after a previous rhinoplasty performed by another surgeon. ( b ) Postoperative
view at 6 months of nasal lipoimplant and touch-up procedure to improve dorsal and tip contours

735
48 Fat Grafting to the Nose
a
c
b
d
Fig. 48.2 ( a ) Preoperative. ( b ) Postoperative at 2 weeks. ( c ) Six-month postoperative. ( d ) Fourteen months after nasal
lipoimplant to improve tip and dorsum contours

736
J. Monreal
a
c
b
Fig. 48.3 ( a ) Preoperative. ( b ) Five-month postoperative. ( c ) Twelve months after performing nasal lipoimplant to
correct slight dorsal deviation and pinching of the tip

737
48 Fat Grafting to the Nose
can provide. All patients were informed and
acknowledged these limitations when comparing
lipoimplant with a surgical rhinoplasty.
The remaining 25 patients underwent nasal lipo-
implants as a complement to surgical rhinoplasty
(open or closed) with the aim of reshaping bony
dorsum, radix, glabella, or premaxillary region
(Fig. 48.4 ). Traditionally, patients presenting
with short nasal bones, frontal recession, or
premaxillary retrusion have been treated with
a
b
Fig. 48.4 ( a ) Preoperative. ( b ) Twelve-month postoperative following a combination of open rhinoplasty and lipoim-
plant to premaxillary area to improve facial pro fi le and nasal base proportions

738
J. Monreal
cartilage grafts or solid prosthesis during rhino-
plasties to supplement de fi cient bone in this area.
In this study, fat grafts were used instead of carti-
lage or prosthesis to supplement de fi cient bone to
assess their ef fi cacy.
Nasal reshaping performed only with lipoim-
plants is done under local anesthesia, using
3–12 mL of fat harvested from lower abdomen or
inner thighs. All lipoimplants performed in com-
bination with rhinoplasties were done under gen-
eral anesthesia, using 6–12 mL of fat harvested
from the same areas. Due to severe postrhino-
plasty deformities, three patients needed an addi-
tional procedure to re fi ne the fi nal result
(Fig. 48.5 ).
Follow-ups were scheduled at 7 days, 15 days,
3 months, 6 months, and 12 months although
unfortunately it was not easy to get patients back
Fig. 48.5 ( a , b ) Preoperative. ( c , d ) Postoperative nasal lipoimplant to improve irregularities of a previous rhinoplasty.
( e , f ) Note the excellent smooth contours after 6 months

739
48 Fat Grafting to the Nose
in the of fi ce from the sixth postoperative month.
Basic analysis including changes in volume and
shape, aesthetic improvement, and patient satis-
faction was performed by comparing preopera-
tive and postoperative photographic controls.
48.3
Nasal Danger Zones
and Technical Details
The arterial supply of the nose is derived from the
ophthalmic artery and facial artery (Fig. 48.6 ).
The ophthalmic artery arises from the internal
carotid, just as that vessel is emerging from the
cavernous sinus. The central retinal artery is the
fi rst and one of the smaller branches of the oph-
thalmic artery. The ophthalmic artery terminates
in two branches, the supratrochlear artery and the
dorsal nasal artery. The dorsal nasal artery
emerges from the orbit above the medial palpe-
bral ligament and divides into two branches: the
fi rst one crosses the root of the nose and anasto-
moses with the angular artery and the other runs
along the dorsum of the nose supplying its outer
surface in its route towards the nasal tip and anas-
tomoses with its fellow artery of the opposite side
and with the lateral nasal branch of the facial
artery.
The lateral nasal artery is derived from the
facial artery as that vessel ascends along the side
of the nose. It supplies the ala and dorsum of the
nose, anastomosing with its fellow, with the sep-
tal and alar branches, with the dorsal nasal branch
of the ophthalmic, and with the infraorbital
branch of the internal maxillary. Finally, the colu-
mellar artery, a branch of the superior labial
artery, runs up the columella, ending and anasto-
mosing in the tip with branches of the lateral
nasal artery.
From this anatomical review, clinicians can
obtain the main conclusions. The proximal blood
supply of the nose has direct and short connec-
tions with the internal carotid and retinal arteries.
This means that embolization of this network
during injection in the area of the dorsum, radix,
or glabella can cause a variety of disastrous con-
sequences such us blindness or brain infraction
[ 1, 3 ] . The distal blood supply, mainly at the tip
and in alar regions, can be affected by emboliza-
tion, causing a variety of ischemic phenomena.
Thus, it is of outmost importance to follow the
same strict principles when performing fat graft-
ing to the nose as in any other facial region if one
wishes to avoid serious complications. The use of
blunt-tip cannulas whenever possible reduces the
chance of perforating the arterial wall and thus
cannulating the arterial lumen. Applying soft
pressure to the plunger of the syringe will aid to
deposit the smallest fat fragments possible and to
reduce as well the chance of propelling the fat
through arterial lumen in the event it is cannu-
lated. Unfortunately, fat grafting to the nose in
some previously operated patients is more chal-
lenging due to two main reasons: First, blood
supply architecture is usually distorted and tissue
planes less identi fi able, and second, fat grafting
Fig. 48.6 Main arterial supply of the nose and danger
zones regarding fat injection ( blue arrows ). STA supratro-
chlear artery, DNA dorsal nasal artery, AA angular artery,
IOA infraorbital artery, LNA lateral nasal artery, LA supe-
rior labial artery, FA facial artery

740
J. Monreal
through blunt-tip cannulas can be dif fi cult due to
severe soft tissue scarring and adherence, partic-
ularly over the nasal dorsum. In these cases, fat
grafting is performed with 18-gauge needles.
Fat grafting to the nose does not differ so much
from the technique used in other body areas, as
reported previously [ 4– 6 ] including the treatment
of perinasal areas such as the premaxillary region
[ 6 ] . The technique consists basically of atrau-
matic harvesting under local anesthesia of fat
fragments using a 3-mm multi-ori fi ce cannula
(Fig. 48.7 ) attached to 10-mL syringes. This kind
of cannula allows harvesting of 2–3-mm fat frag-
ments with ease. Usually, it is not necessary to
obtain more than 12 mL of fat ready for injection
to treat the whole nose and perinasal areas. This
usually means that clinicians need to harvest at
least 24 mL of lipoaspirate due to the loss of tis-
sue during washing and decanting process.
Harvested fat is washed with Ringer lactate and
allowed to decant for 20 min. Once decanted, fat
can be cautiously passed to smaller syringes of 1
or 2.5 mL for easily handling. Fat is injected rou-
tinely in a retrograde manner using 1.2–1.4-mm
blunt-tip cannulas and applying very gentle pres-
sure on the plunger. The author is using conven-
tional 18-gauge needles only when dealing with
highly adherent or fi brous tissues in the nasal
dorsum of previously operated patients. There is
no need to use conventional sharp needles in pri-
mary cases as they pose an additional risk of
intravascular injection with disastrous conse-
quences. In any case, the clinician must have in
mind all danger zones and vascular territories of
the nose to prevent an unwanted intravascular
injection. Special care must be taken when deal-
ing with supratip and glabellar region introduc-
ing cannula or needle from the tip as these
approaches are most at risk.
The clinician can take advantage of two main
tissue planes when injecting fat in the nose. Sub-
SMAS plane is present along the entire nasal dor-
sum, and it has continuity with radix and glabella.
Subcutaneous plane is also useful in the dorsum
and is the only plane the clinician will fi nd over
the tip and lateral crura of lower lateral cartilages.
In secondary cases, clinicians should be cautious
as probably clinicians will not fi nd these planes
with ease, and different degrees of fi brosis will
impair cannula advancement and fat placement.
Clinicians are asked to always evaluate and
remember the vascular anatomy of the patient’s
nose and glabellar area to avoid severe complica-
tions such as intravascular injection of fat.
Unlike other body and face areas where the
usual approach is to create a three-dimensional
mesh, the soft tissues of the nose do not allow this
approach. This is the reason why clinicians need
to be cautious when performing fat injection,
both in quantity and location. Due to the relative
small caliber of cannulas and needles used in
nasal fat grafting, clinicians can choose whatever
access point they need; however, it is preferable
to avoid entering the nasal skin directly or near
the principal arterial trunks of the nose. The
author usually performs fat grafting to the nose
under regional block of the nose, avoiding direct
in fi ltration of nasal tissues to avoid any distortion
of pro fi le. Once the procedure is fi nished, the
author routinely does not use any splint or tape to
immobilize nasal tissues.
Those nasal lipomplants performed in combi-
nation with rhinoplasties were done, following
the same principles described once the rhino-
plasty was fi nished and all wounds closed. The
glabellar region, radix, or premaxillary regions
were treated individually if de fi cient to improve
fi nal nasal pro fi le. The glabella and radix were
approached from the middle frontal region 1 cm
Fig. 48.7 Cannulas used by the author since 1998 to per-
form atraumatic harvest of 2–3-mm fat fragments

741
48 Fat Grafting to the Nose
above eyebrows, and the premaxillary region [ 6 ]
was approached from nasolabial fold 2 cm, lat-
eral to nasal ala. Unlike the technique described
by Cardenas and Carvajal [ 7 ] , the author does not
place fat parcels in dorsal nasal skin of these
patients, but only in the radix, glabella, and piri-
form aperture with the aim of adding volume if
de fi cient to further enhance nasal pro fi le and pro-
portions. Final nasal dressings and splinting were
done as usual at the end of the rhinoplasty.
The follow-up visits and photographic con-
trols were scheduled at 24 h, 7 days, 15 days,
3 months, and 12 months to evaluate improve-
ment and stability in results. In those nasal lipom-
plants
performed
in
combination
with
rhinoplasties, dorsal splint was removed at 7 days,
and follow-up visits were scheduled at the same
time intervals.
After 24 h, nasal swelling was of mild degree
with nearly complete absence of ecchymosis in
primary cases; patients were happy to recover
daily activities and daily work in a fairly short
period of time. Lipoimplants performed in previ-
ously operated patients showed a little bit more
swelling and ecchymosis than primary cases.
When combined with rhinoplasties, the degree of
swelling and ecchymosis was equivalent to cases
performed without associated lipoimplantation
except in the glabellar area. Grafted fat volume
slowly decreased over the fi rst 15 days after treat-
ment and until the fi rst month but showed a high
degree of stability thereafter. After 4–5 months,
neither patient showed changes in contour or
volume. The fi nal graft take percentage was
dif fi cult to calculate due to small volumes used,
but based on photographic controls, it was esti-
mated to be about 60% in secondary cases and
75% in primary cases. Patient satisfaction was
good to high in 80% of cases, particularly in cases
of postrhinoplasty deformities. Only three
patients were disappointed, expecting more pro-
found changes from this technique. Only four
patients presenting with severe postrhinoplasty
deformities needed a touch-up procedure to add
volume to an originally highly depressed and
adhered dorsal skin and to two under projected
and scarred tips that could not receive all fat vol-
ume required in the fi rst procedure. Swelling
improvement in combined cases does not differ
so much from rhinoplasty cases where no lipoim-
plantation was done.
Besides pure modeling capabilities, fat grafts
offer proven biological bene fi ts in scarred, pig-
mented, and other skin disorders. It was not the
purpose of this study to evaluate the biological
improvements provided by fat grafting to the
nose. Nonetheless, the improvements in skin
quality particularly in pigmentations, adherences,
and texture have been witnessed by the author
and were more evident after treating secondary
cases (Fig. 48.3 ). It will be necessary to conduct
speci fi c studies to objectively evaluate and mea-
sure these fi ndings.
There were no complications or untoward
results that required additional treatment or sur-
gical interventions. Only in one combined case
where there was a minimal displacement of the
grafted fat in the radix that was probably caused
during the nasal splinting and was easily treated
without major consequences. None of the patients
have experimented signi fi cant changes in body
weight during follow-up, so the impact of body
weight changes in fat graft behavior could not be
evaluated. Patients that complained about func-
tional or obstructive airway problems were
informed about the inef fi cacy of fat grafting to
correct the symptoms. No new symptoms of air-
way obstruction or worsening of previous were
noticed in any patient.
48.4
Discussion
The tendency of patients to seek minimally inva-
sive cosmetic treatments also reaches nasal
aesthetics. Nonsurgical rhinoplasty, also called
medical rhinoplasty, has been performed tradi-
tionally using permanent or semipermanent inject-
able fi llers [ 2 ] . With semipermanent fi llers, the
patient must forego a permanent result unless he
or she has repeat injections on a regular basis.
With the use of permanent fi llers, it may be impos-
sible or fairly dif fi cult to remove the implant com-
pletely or to safely make a surgical plan in the
event that the patient desires an eventual surgical
rhinoplasty. In either case, complications arising

742
J. Monreal
from the use of injectable fi llers are already
known. Some disastrous complications reported
in the literature include blindness and strokes [ 3 ]
or other local complications such as intolerance,
granulomas, extrusion, or a subtotal necrosis tip
or nasal ala.
Fat grafting to the nose must not be consid-
ered as a risk-free technique as potential compli-
cations can be devastating. The use of fat grafting
removes certain side effects fi ller-dependent like
the need for repeating treatments in the long term,
intolerance, or rejection to foreign material, or
the dif fi culty of planning in the event that a
patient needs or wants an eventual surgical rhino-
plasty. Embolization of arterial nasal network is a
technique-dependent complication that can occur
with fat grafting and with other injectable fi llers
as well, and it has been well documented previ-
ously [ 3 ] , so every plastic surgeon dealing with
this technique must have a thorough knowledge
of the nasal arterial network and soft tissue anat-
omy to prevent its occurrence. In this sense, arte-
rial embolization of angular or dorsal nasal artery
in a cranial direction (via tip approach) will cause
immediate pain, blindness, or stroke, whereas
arterial embolization of dorsal nasal artery or lat-
eral nasal artery in a caudal direction (via glabel-
lar, radix, or lateral alar approach) will cause
necrosis of soft tissues of variable degree. Using
a proper technique that includes injection with
blunt cannulas whenever possible, very gentle
pressure applied on the syringe plunger and
placement of fat parcels in a retrograde manner
are mandatory when performing nasal fat
grafting.
It is essential to understand that true nasal
modeling is obtained through improving archi-
tectural elements of bone and cartilage, leaving
soft tissues to adapt to changes and draw the fi nal
result. Autologous fat grafting applied to nasal
aesthetics works opposite by altering only soft
tissues to mask architectural imbalances or irreg-
ularities except when it is used in combination
with rhinoplasty to supplement de fi cient bone in
radix, glabella, and premaxillary region. In this
later case, fat grafting worked with the same
ef fi cacy as cartilage grafts or solid prosthesis in
the same locations. Obviously, clinicians will
face patients with bone or cartilage architectures
unable to be camou fl aged by fat grafts such as,
for example, a coarse boxy tip, an over projected
tip, or a tension nose. For these reasons, autolo-
gous fat grafting to the nose is an indication only
in some selected nasal deformities of patients
that refuse rhinoplasty as the primary choice and
understand clearly the limitations in the fi nal
results. Based on the biological improvements
that the author has observed in secondary cases,
fat grafting to the nose could be the fi rst choice in
some selected cases in which a high degree of
scarring or adherence could jeopardize dissection
or blood supply during open or closed rhino-
plasty. Fat grafts have demonstrated the ability to
release tightly adherent skin in such a way that
provides better conditions and makes secondary
surgical rhinoplasty safer.
Some other authors have previously reported
their personal experiences with fat grafting to the
nose [ 7– 10 ] . Cárdenas and Carvajal [ 7 ] reported
the use of lipoinjection of the nasal dorsum in
combination with open rhinoplasties to obtain
smooth dorsal contours with good results.
Coleman [ 8 ] gives a thoroughly description of his
nasal fat grafting technique in his last book and
Marketa Duskova [ 10 ] et al. report their experi-
ence in cleft nose re fi nement.
Conclusions
Surgical rhinoplasty must be the primary indi-
cation for any patients seeking aesthetic
improvement of the nose. Fillers or fat grafting
is not a substitute for an adequate surgical
technique and will never provide better results.
Nonetheless, autologous fat grafting also
reveals itself as the fi rst line nonsurgical alter-
native to modeling nasal shape and pro fi le in
primary and secondary cases of patients that
refuse surgical rhinoplasties and admit limita-
tion in results. Clinicians will be able to treat
the whole aesthetic nasal and paranasal units
or treat aesthetic subunits individually as
needed. It is also possible to combine surgical
rhinoplasty with lipoimplants in dorsum, radix,
glabella, or premaxillary area to improve vol-
ume and shape in these areas without the need
of using cartilage grafts or solid prosthesis.

743
48 Fat Grafting to the Nose
This kind of approach to nasal remodeling is
an easy, safe, and reliable procedure that lacks
serious complications, side effects, or untoward
results if properly done. However, this is tech-
nically demanding in order to obtain good
results and to avoid serious complications.
Unlike permanent injectable fi llers, autologous
fat grafts do not pose any risk or dif fi culties in
planning or performing an eventual rhinoplasty
throughout the patient lifetime.
References
1. Winslow CP (2009) The management of dermal fi ller
complications. Facial Plast Surg 25(2):124–128
2. Humphrey CD, Arkins JP, Dayan SH (2009) Soft tissue
fi llers in the nose. Aesthet Surg J 29(6):477–484,
Erratum in: Aesthet Surg J 2010;30(1):119
3. Egido JA, Arroyo R, Marcos A, Jiménez-Alfaro I
(1993) Middle cerebral artery embolism and unilat-
eral visual loss after autologous fat injection into the
glabellar area. Stroke 24(4):615–616
4. Monreal J (2003) Fat tissue as a permanent implant:
new instruments and re fi nements. Aesthet Surg J
23:213–216
5. Monreal J (2005) Instrumental alternativo en los injer-
tos de grasa autóloga. Cir Plast Iberlatinamer
31(2):137–146
6. Monreal J (2008) Injerto de grasa en fosa piriforme.
Revista de la AECEP 8:27–30
7. Cárdenas JC, Jenny Carvajal J (2007) Re fi nement of
rhinoplasty with lipoinjection. Aesthetic Plast Surg
31(5):501–505
8. Coleman SR (2009) Fat injection. From fi lling to
regeneration. Quality Medical Publishing, Inc., St.
Louis, pp 423–447
9. Ellenbogen R (2000) Fat transfer: current use in prac-
tice. Clin Plast Surg 27(4):545–556
10. Marketa Duskova M, Kristen M (2004) Augmentation
by autologous adipose tissue in cleft lip and nose.
Final esthetic touches in clefts: part I. J Craniofac
Surg 15(3):478–481

745
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_49, © Springer-Verlag Berlin Heidelberg 2013
49
49.1
Introduction
Nasal augmentation using silicone implant has a
long legacy of safety in Asia [ 1 ] , especially in Far
Eastern countries such as Korea, Japan, and China.
Although a variety of alloplastic materials are
available and have been used for nasal augmenta-
tion, silicone implant has been chosen in Asian
rhinoplasty as alloplastic implant most frequently
because of its nontoxicity, chemical stability, non-
immunogenicity, simplicity of use, excellent bio-
compatibility, and comparatively low product
price [ 2, 3 ] . The objective of Asian rhinoplasty is
often augmentation, for both the depressed dor-
sum and the receded tip so that silicone implants
may be divided into I (for the dorsum only) and L
(for dorsum and tip) shapes traditionally. However,
most of Asian patients prefer L-shaped implants
to accentuate the nasal tip and augment the nasal
dorsum simultaneously.
When the patient’s nasal tip skin is thin and/or
the columellar portion of the implant is too pro-
nounced, application of L-shaped implant to nasal
augmentation may lead to unnatural look and, in
some cases, serious complication of extrusion. To
overcome this obstacle, the author developed a
simple technique of using the orbital fat pad instead
of the auricular cartilage as a cushion between the
silicone implant and the overlying nasal tip skin.
Additionally, the orbital fat graft can be applied to
augmentation of a deep radix, camou fl age of minor
contour irregularities, and smoothness of the dor-
sal contour when in combination with silicone
implant. The aesthetic results and patient’s satis-
faction to the combined use of orbital fat may
prove to be superior to the results of single use of
implant in augmentation rhinoplasty.
49.2
Surgical Technique
Generally, the designed incision line, approxi-
mately 3–5 mm, is marked on each upper eyelid
5–6 mm above the ciliary margin at the level of
the pupil. A solution of 2% lidocaine with
1:100,000 epinephrine is used for local anesthe-
sia. Just 0.2 mL of anesthetic with a 30-gauge
insulin needle per side is in fi ltrated below the
incision line in the subcutaneous plane. At least
10 min are needed to achieve anesthesia and
maximal hemostasis. An incision is then made on
the marked line with no. 11 scalpel blade or a
CO 2 laser through both the skin and the orbicu-
laris oculi muscle. The orbicularis muscle is
divided with fi ne tenotomy scissors in a spread-
ing manner until the orbital septum with underly-
ing orbital fat is exposed. The orbital septum is
then picked up with fi ne-toothed forceps, and a
small window is created with the scissors. The
preneurotic adipose tissue of the middle fat com-
ponent is gently pulled out through the septal
Orbital Fat Pad for Nasal Tip
Augmentation in Far Eastern
Rhinoplasty
Young Kyoon Kim
Y. K. Kim , M.D.
5050 Clinic , #408 Megaplus, 541-1 Sangdong ,
Wonmigu, Bucheon 420-030 , South Korea
e-mail: clinic5050@hotmail.com

746
Y.K. Kim
defect and the orbital fat with fi brous capsule is
transected by electrocautery (Fig. 49.1 ) and the
closure suture of the incision is made. In select
cases, the orbital fat can be obtained indirectly
during excisional upper blepharoplasty. The
orbital fat pads should be harvested bilaterally for
symmetry. The harvested ones are preserved in
saline until grafting.
The designed marginal incision line is marked
on the right (or left) nostril, and local anesthetic
is then in fi ltrated along the marginal incision line,
around the right (or left) lobule, and along the
midline of the nose. Until local anesthesia is
achieved, padding the orbital fat graft over the
silicone implant is prepared. Various sized
L-shaped implants are purchased and retained in
general inventory so that the proper size can be
obtained swiftly. Accordingly, little additional
trimming is made, if necessary. The orbital fat
graft is stabilized on the distal tip of the silicone
implant with dissolvable suture (Fig. 49.2 ). The
implant combined with orbital fat graft is soaked
in a gentamicin antibiotic solution for a while.
The marginal incision is made with no. 11
scalpel blade on the incision line marked along
the domed region. A sharp Metzenbaum scissors
is inserted through the marginal incision to dis-
sect the lobule, columella, and dorsum up to the
rhinion. Great care should be taken to make cer-
tain the implant is in the exact area to be aug-
mented. And, in order to stabilize the proximal
portion of the silicone implant in the radix area,
dissecting the nasal bone area should be made
subperiosteally. The implant is then guided via
the marginal incision into the created pocket, and
symmetry should be con fi rmed by visual inspec-
tion and palpation. The distal portion of the sili-
cone implant covered with orbital fat graft should
be stabilized in accordance with the nasal tip.
The marginal incision is closed. Adhesive tape
and nasal splints are applied – both of which are
removed the following day.
49.3
Discussion
The objective of Asian rhinoplasty includes aug-
mentation of the nasal dorsum in conjunction
with enhancement and re fi nement of lobular
con fi guration. The nasal tip of Asian nose, espe-
cially Far Eastern nose, is usually low, and the
lower lateral cartilages are small and weak. When
compared with Caucasian noses, the typical
Asian nose appears to be relatively small and fl at
and has poor tip de fi nition [ 4 ] . However, most of
Asian patients prefer more accentuated nasal tip,
and L-shaped implants have been in vogue for
quite some time now, which provide dorsal and
tip augmentation. However, overzealous augmen-
tation of the nasal tip using more accentuated
L-shaped silicone should be condemned because
the overlying skin of the implant may lead to
complications. When L-shaped implant is used to
nasal augmentation, if the patient’s nasal tip skin
is thin and/or the columellar portion of the implant
is too pronounced, it may exhibit the proclivity
for unnatural look and, in some cases, serious
Fig. 49.1 The orbital fat is teased out with fi ne-toothed
forceps through the skin incision and the septal window
Fig. 49.2 The orbital fat graft is stabilized on the distal
tip of the silicone implant with dissolvable suture

747
49 Orbital Fat Pad for Nasal Tip Augmentation in Far Eastern Rhinoplasty
complications such as thinning of the nasal tip
skin, pressure necrosis, and resultant contracture
or extrusion of the silicone implant [ 5 ] . Extrusion
is signi fi cantly in fl uenced by an undue silicone
implant and the character of the overlying skin-
soft tissue envelope(S-STE) of the nasal tip. The
S-STE of Asian nose is thick, and the softer ver-
sions of Silastic that have emerged yield a natural
contour to the nasal pro fi le and resilience to the
nasal tip [ 6 ] . However, overaugmentation of the
nasal tip using an excessively thick and/or more
accentuated L-shaped silicone implant has been
implicated in the most common cause of implant
extrusion. Relatedly, a thin S-STE or pressure
necrosis of the nasal tip skin owing to continuous
tension over L-shaped silicone implant can also
cause a greater risk of extrusion. Therefore, the
surgeon should be conservative in selection of
implant shape and size, remembering that subtle
enhancement of the nasal dorsal contour often
produces substantial aesthetic bene fi t (Figs. 49.3
and 49.4 ), even when performing augmentation
with I-shaped silicone. According to this concept,
the author introduced a modi fi ed I-shaped sili-
cone implant (named “Bird”) and its carving skill
in the literature [ 7 ] .
However, when L-shaped silicone implant is
needed to use for nasal augmentation, the preven-
tive surgical modalities reducing serious compli-
cations should be considered. There has been
unanimous agreement on the advantage of autog-
enous tissue graft over an alloplastic material for
the nasal augmentation. Some surgeons have
advocated the use of cartilage grafts to enhance
tip projection in nasal augmentation [ 8, 9 ] . And it
is well known that the auricular cartilage graft is
also used for preventing postoperative complica-
tions of the nasal tip skin. For this reason, the use
a
b
Fig. 49.3 ( a ) Preoperative. ( b ) Postoperative view after nasal augmentation using “Bird” silicone implant combined
with the orbital fat pad

748
Y.K. Kim
of the auricular cartilage has recently become
popular in Far East. Auricular cartilage can be
used as an onlay graft placed over both domes
when performing silicone dorsal graft [ 10 ] .
However, in some cases, the main disadvantage
of this auricular cartilage graft is that it has the
propensity to warp and occasionally causes visi-
ble dorsal irregularities over time, due to its
intrinsic memory and/or overlying thin skin. To
overcome this obstacle, the author has used the
orbital fat graft, instead of the auricular cartilage
graft, available to cushion the distal tip portion of
the silicone implant under the overlying nasal tip
skin. The author believes that the orbital fat pad is
acceptable for preventing thinning of the nasal tip
skin and extrusion of the silicone implant in care-
fully select cases under the concept of its cushion
effect, buffering mechanical pressure being
exerted on the skin by the L-shaped undue sili-
cone implant. The orbital fat pad is attached over
the distal tip of the silicone implant, and then the
silicone implant combined with fat graft is
inserted subcutaneously over the nasal dorsum
and both domes. Of course, any kind of fat tissue
(i.e., abdominal fat) can be used as padding over
the silicone implant and acts as an excellent
camou fl age graft. However, according to differ-
ent authors, the survival rate of common fat graft
may vary from 30% to 50% [ 11– 14 ] . The author
believes that the orbital fat graft is superior to the
a
b
Fig. 49.4 ( a ) Preoperative. ( b ) Postoperative view after nasal augmentation using “Bird” silicone implant combined
with the orbital fat pad. This case took the additional upper blepharoplasty and chin augmentation on site

749
49 Orbital Fat Pad for Nasal Tip Augmentation in Far Eastern Rhinoplasty
conventional fat graft in both the graft take rate
and quality of the tissue because the orbital fat
has more dense cells than body fat and the fat pad
is well encapsulated with fi brous tissue. These
characteristics are considered to affect the take
and durability of the graft [ 15 ] .
When performing the nasal augmentation
using silicone implant, in addition to augment the
nasal dorsum, the orbital fat graft padding over
the silicone implant can provide a dual advantage
of preventing the extrusion of silicone and
enhancing the nasal tip contouring (Figs. 49.5
and 49.6 ). Also the orbital fat is incorporated into
the surrounding tissue and does not develop
unsightly irregularities of the nasal tip over time.
The orbital fat graft can be combined with
I-shaped silicone implants including “Bird”
implant. Additionally, this technique employs the
orbital fat pad placed over the proximal portion
of the silicone implant to augment a deep radix
(Fig. 49.7 ). The orbital fat graft can also be
applied to camou fl age of minor contour irregu-
larities and smoothness of the dorsal contour.
When inserting the combined implant inside the
dissected pocket, the Waikiki forceps (Fig. 49.8 )
can be used for guiding and protecting the implant
complex. The Waikiki forceps has a widened
tong resembling a pelican’s beak so that the
implant with fat pad can be protected from its
folding and knuckling when passing upward
a
b
Fig. 49.5 ( a ) Preoperative. ( b ) Postoperative after upper
blepharoplasty and nasal augmentation using L-shaped
silicone implant combined with the orbital fat pad. This
case took the additional upper blepharoplasty and chin
augmentation on site

750
Y.K. Kim
through the dissected pocket. It is available espe-
cially in case of using Gore-Tex implant instead
of silicone (Figs. 49.9 and 49.10 ).
The aesthetic results and patient’s satisfaction
to the combined use of orbital fat may prove to be
superior to the results of single use of implant in
augmentation rhinoplasty. The main disadvantage
of the author’s technique is the necessity of inci-
sion of the upper eyelids to harvest the orbital fat,
b
a
Fig. 49.6 ( a ) Preoperative. ( b ) Postoperative after upper blepharoplasty and nasal augmentation using L-shaped sili-
cone implant combined with the orbital fat pad. This case took an additional chin augmentation on site
Fig. 49.7 The orbital fat pad placed over the proximal
portion of the silicone implant in addition to distal por-
tion. The fat graft can be applied to augment a deep radix
simultaneously, if necessary
Fig. 49.8 The Waikiki forceps devised by the author in
2003. It has a widened tong resembling a pelican’s beak

751
49 Orbital Fat Pad for Nasal Tip Augmentation in Far Eastern Rhinoplasty
even though the incision line is very small. Another
disadvantage is that the fat volume obtained is
variable in cases so that this technique should be
applied to select patients. The harvesting of orbital
fat should be approached with thorough consider-
ation of a case’s individual circumstances.
References
1. Deva AK, Merten S, Chang L (1998) Silicone in nasal
augmentation rhinoplasty: a decade of clinical experi-
ence. Plast Reconstr Surg 102(4):1230–1237
2. Smith EM Jr (2000) Silicone: its chemistry and bio-
compatibility. In: Terino EO, Flowers RS (eds) The art
of alloplastic facial contouring. Mosby, St. Louis, pp
243–249
3. Jung DH, Kim BR, Choi JY, Rho YS, Park HJ, Han
WW (2007) Gross pathologic analysis of long- term
silicone implants inserted into the human body for aug-
mentation rhinoplasty: 221 revision cases. Plast
Reconstr Surg 120(7):1997
4. Jang YJ, Yu MS (2010) Rhinoplasty for the Asian nose.
Facial Plast Surg 26(2):93–101
5. Jung DH, Moon HJ, Choi SH, Lam SM (2004)
Secondary rhinoplasty of the Asian nose: correction of
the contracted nose. Aesthetic Plast Surg 28(1):1–7
6. McCurdy JA (2002) The Asian nose: augmentation
rhinoplasty with L-shaped silicone implants. Facial
Plast Surg 18(4):245–252
7. Lam SM, Kim YK (2003) Augmentation rhinoplasty
of the Asian nose with the “Bird” silicone implant. Ann
Plast Surg 51(3):249–256
8. Jin HR, Won TB (2009) Nasal augmentation in Asians
using autogenous cartilage. Otolaryngol Head Neck
Surg 140(4):526–530
9. Matsunaga RS (1996) Augmentation rhinoplasty of
Asian noses. Facial Plast Surg Clin North Am 4:75–85
Fig. 49.9 The Waikiki
forceps biting a combined
implant. It protects the
implant’s folding and
knuckling when passing
upward through the dissected
pocket. It is available
especially in case of using
Gore-Tex implant instead of
silicone
Fig. 49.10 The proximal end of the implant is temporarily
fi xed on the radix by the syringe needle passing through a
hole of the Waikiki forceps. The forceps is released and
pulled out, and the combine implant is left and placed over
the dorsum. The columellar strut of the implant is then coaxed
into the columellar portion of the pocket with a forceps

752
Y.K. Kim
10. Ahn JM, Honrado C, Horn C (2004) Combined sili-
cone and cartilage implants: augmentation rhinoplasty
in Asian patients. Arch Facial Plast Surg 6(2):
120–123
11. Hoerl HW, Feller AM (2001) Autologous fat volume
retention evaluation by magnetic resonance imaging.
In: Shiffman MA (ed) Autologous fat transplantation.
Marcel Dekker, New York, pp 39–41
12. Peer LA (1969) Transplantation of fat. In: Transplantation
of tissue. Williams & Wilkins, Baltimore, pp 165–244
13. Saunders MC, Keller JT, Dunsker SB, May fi eld FH
(1981) Survival of autologous fat grafts in humans
and in mice. Connect Tissue Res 8(2):85–91
14. Coleman SR (1995) Longterm survival of fat trans-
plants: controlled demonstrations. Aesthetic Plast
Surg 19(5):421–521
15. Erol ÖO (2000) Facial autologous soft-tissue contour-
ing by adjunction of tissue cocktail injection (micro-
graft and minigraft mixture of dermis, fascia, and fat).
Plast Reconstr Surg 106(6):1375–1387

753
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_50, © Springer-Verlag Berlin Heidelberg 2013
50
50.1
Introduction
Rhinoplasty surgeons often wish to implant graft
materials into the nose, to either augment the tip
or nasal dorsum or to camou fl age irregularities of
the bony dorsum or the upper and lower lateral
cartilages. A range of both autologous and non-
autologous grafts are available. Autologous carti-
lage is usually thought of as the ideal graft, but
there are times when it is not readily available in
the nose or its use is undesirable (e.g. in autoim-
mune conditions). A wide range of non- autologous
materials provide alternatives in such cases,
including Silastic, Gore-Tex and a growing num-
ber of biological products. Permacol™ was intro-
duced for hernia repair and soft tissue damage but
has been used increasingly in a wide range of soft
tissue reconstructive procedures. The authors
describe how and when Permacol is used in
rhinoplasty.
The ideal graft material for augmentation
should be readily available in the required vol-
ume and economical. It should provide volume
replacement that is stable over time; it should be
easy to shape and should maintain the structural
integrity of the nose. It must be biocompatible
and should not cause discolouration of the over-
lying skin, become infected or extruded. It must
not permit transmission of infective agents to the
recipient. The authors believe that Permacol
offers all of these properties.
Permacol™ is a sheet of acellular cross-linked
porcine dermal collagen and its constituent elas-
tin fi bres. It was been approved for surgical soft
tissue repair in Europe in 1998. It is soft and
moist and is claimed to be non-allergenic, non-
toxic and devoid of foreign body response
(unpublished data, Tissue Science Laboratories
Plc). It is pliable but provides structural integrity
while being invisible and impalpable when placed
below the dermis. The material is easy to fashion
and suture. The manufacturing process produces
a graft that is resistant to collagenase and is steril-
ized by gamma irradiation. The material comes
in a variety of dimensions, with variable thick-
ness ranging from 0.5 to 1.5 mm. The current
cost of a single unit of 5 × 5 cm Permacol with
0.5-mm thickness is £240.
Autogenous grafts require increased operative
time for harvesting and have morbidity and poten-
tial for complications resulting from this. There is
a need to slightly overcorrect the deformity to
allow for resorption of cartilaginous grafts. These
problems are avoided using Permacol, which, as
Permacol in Augmentation
Rhinoplasty
Claire Hopkins and David Roberts
C. Hopkins , M.D., FRCS (ORL-HNS), DM (*)
Carmay, Chels fi eld Lane , Orpington , BR6 7RR , UK
Rhinological Unit, ENT Department ,
Guy’s and St. Thomas’ Hospital ,
Great Maze Pond , London , SEI 9RT , UK
e-mail: clairehopkins@yahoo.com
D. Roberts , FRCS (ORL-HNS)
Rhinological Unit, ENT Department ,
Guy’s and St. Thomas’ Hospital ,
Great Maze Pond , London , SEI 9RT , UK
e-mail: dr@hsnc.co.uk

754
C. Hopkins and D. Roberts
an ‘off-the-shelf’ product, is readily available and
has been shown not to degrade while allowing
vascularisation and integration with host collagen
[ 1 ] . This biocompatibility reduces the infection
and extrusion rates found with other synthetic
materials (Fig. 50.1 ) [ 2 ] . The graft is sterilized,
thus reducing infection risks. Importantly, unlike
bovine products, there is no risk of transmission
of prion infection.
Permacol has been used widely in abdominal
and gynaecological surgery since its introduction,
but use in surgery to the face has been less widely
reported. Saray [ 3 ] reported some success with
usage of Permacol for facial contour augmenta-
tion, and Benito-Ruiz et al. [ 4 ] has published a
successful reconstruction of the lip using Permacol.
Fu et al. [ 5 ] has published a single case report, and
Pitkin et al. [ 2 ] have used Permacol in over 45 rhi-
noplasty patients and have reported good results
with just two complications, of which only one
required the removal of the graft. They found that
the infection rate with Permacol is lower than
Gore-Tex (4–5.4%) and silicone (removal inci-
dence 9.8%) and that Permacol provides excellent
cosmetic results [ 2 ] . Thinakarajan and Srinivasan
[ 6 ] reported the use of Permacol augmentation in
12 patients with a minimum of 12 months follow-
up, of whom 11 had successful outcomes, but in 1
patient the Permacol extruded at 2 months.
There are a number of other biocompatible
grafts available. Results of augmentation rhino-
plasty using AlloDerm (acellular dermis) have
been reported, but partial resorption rates of up to
67% have been described [ 7 ] . Surgisis (acellular
pig intestinal mucosa) is being used in some cen-
tres, especially in the USA. There are no com-
parative studies available. In a recent systematic
review, there is surprisingly little difference
between the various grafts in terms of complica-
tion rates, including infection and extrusion rates,
in the published literature. However, outcomes,
both in terms of objective measures and patient-
reported outcomes, are too infrequently reported
(only 35% of published series) to allow meta-
analysis [ 8 ] .
50.2
Surgical Techniques
Permacol comes in a variety of sizes, and between
0.5- and 1.5-mm thickness may be used, depend-
ing upon indication and volume of augmentation
required. The authors most frequently use 3 × 3 cm
and 0.5-mm thickness.
Grafts may be sited by an open or closed rhino-
plasty approach, depending on other cosmetic or
functional indications. One dose of intravenous
antibiotic is administered perioperatively. At the
end of the procedure, Plaster of Paris is applied
over a layer of SteriStrips, and the patient is given
5 days of oral co-amoxiclav (providing there is no
penicillin allergy). The dressing is removed
1 week following surgery, and the patient is reas-
sessed at 3 and 12 months postoperatively.
50.3
Long Dorsal Onlay Graft
for Contouring: Highlighting
Dorsal Aesthetic Line
Permacol is ideal to place over the dorsum to
smooth out any irregularities. While these are
often invisible in the early postoperative period,
as the skin thins with age, they may become
Fig. 50.1 Permacol biocompatibility reduces the infection
and extrusion rates found with other synthetic materials

755
50 Permacol in Augmentation Rhinoplasty
apparent many years after the procedure. Some
surgeons advocate draping a layer of Permacol
over the dorsum and down the lateral wall of the
nose. In contrast, the authors have been using a
strip of Permacol over the dorsum and have found
that this restores the dorsal aesthetic line
(Fig. 50.2 ).
50.4
Use of Permacol to Camou fl age
Tip Irregularities
A small graft of Permacol (Fig. 50.3 ) can be used
to camou fl age irregularities at the tip. This patient
underwent an open rhinoplasty, with intradomal
suturing and placement of a Permacol shield graft
Fig. 50.2 ( Upper ) Preoperative patient. ( Lower ) Postoperative following revision rhinoplasty with dorsal onlay of
Permacol camou fl aging dorsal irregularities under thin skin and restoring dorsal aesthetic lines

756
C. Hopkins and D. Roberts
50.5
Dorsal Augmentation
with Rolled Permacol
‘Sausage’
When a greater volume of augmentation is
desired, the authors use a rolled Permacol graft
– the ‘sausage roll rhinoplasty’. The graft is made
from rolled 5 × 5 cm Permacol, the ‘sausage roll’.
Sheets, 0.5 mm thick, are used as a standard, but
this can be tailored to the volume of augmenta-
tion required (Fig. 50.4 ). The roll is fl attened and
secured with two or three 5/0 Monocryl sutures,
depending on length, trimmed lengthwise to size.
It is important to bevel the edges of the layers,
particularly at the cephalic end, to prevent a ridge
at the top of the implant. The surgery is techni-
cally simple – the graft is easy to shape and trim
to the required size and volume and can be
Fig. 50.3 ( Upper ) Preoperative patient. ( Lower ) Postoperative open rhinoplasty with intradomal suturing and place-
ment of a Permacol shield graft

757
50 Permacol in Augmentation Rhinoplasty
a
b
c
Fig. 50.4 ( a ) 5 × 5 cm sheets
of Permacol. ( b ) Rolled
Permacol. ( c ) Permacol
‘sausage’ being positioned via
closed approach

758
C. Hopkins and D. Roberts
Fig. 50.5 ( Left ) Preoperative. ( Right ) Postoperative after Permacol ‘sausage’ used to correct depressed dorsum after
naso-ethmoid fracture
positioned via open or closed approaches. It feels
smooth and soft under the skin and recreates
pleasing dorsal aesthetic lines.
The technique would be easily reproduced in
the hands of any competent rhinoplasty surgeon.
Both patient morbidity and operative time have
been reduced by the use of an ‘off-the-shelf’
product. Grafting has been combined with osteot-
omies, tip suturing and other techniques thought
necessary.
Prior to using the ‘sausage roll’, when larger
volume augmentation is required, the authors
had used layered Permacol; similarly, use of
layered AlloDerm grafts have also been
described [ 6 ] . We had been unable to achieve
suf fi cient volume augmentation in this manner
without the additional use of autologous carti-
lage. Auricular cartilage may be rolled, but the
resulting contour is often irregular. Furthermore,
the patients who require greatest volume replace-
ment frequently lack suf fi cient donor cartilage
or are at risk of underlying in fl ammatory condi-
tions attacking cartilaginous grafts. Rib and cal-
varial bone grafts may be used when more
structural support is required, particularly when
associated with an over-rotated tip. However,
there is considerable donor site morbidity, and
the resulting graft may undergo late distortion
and warping.
The use of rolled grafts in rhinoplasty surgery
has been previously described. Erol published his
technique for ‘Turkish delight’ grafts – diced car-
tilage grafts wrapped in rolled Surgice [ 9 ] .
However, Daniel [ 10 ] report unexpected reab-
sorption of all these Surgicel-wrapped grafts such
that they were immediately abandoned. They do
report good long-term results using a modi fi ed
technique of diced cartilage wrapped in tempora-
lis fascia, but this still involves some donor site
morbidity and a need to harvest both cartilage
and fascia. The rolled appearance of these grafts
was the inspiration for the ‘sausage roll’.
The authors have used rolled Permacol in ten
patients with a minimum of 12 months follow-
up, with no extrusions or loss of volume
(Figs. 50.5 , 50.6 , 50.7 , 50.8 , and 50.9 ).

759
50 Permacol in Augmentation Rhinoplasty
50.6
Permacol with Concurrent
Cartilaginous Graft
One of the most useful applications of
Permacol is in conjunction with cartilaginous
grafts, where a layer of Permacol helps to pre-
vent warping and visible irregularities, par-
ticularly beneath thin skin. In this case
(Fig. 50.10 ), the saddle was corrected with a
caudal extension graft and supratip graft, and
the tip was resuspended.
50.7
Permacol Grafts in Patients
with Wegener’s Syndrome
A diagnosis of vasculitis had been made in six
patients in whom Permacol was used, although all
was thought be quiescent prior to surgery
Fig. 50.6 ( Upper ) Preoperative. ( Lower ) Postoperative following Permacol ‘sausage’ used to correct depressed dorsum
after naso-ethmoid fracture

760
C. Hopkins and D. Roberts
Fig. 50.8 ( Upper ) Preoperative. ( Lower ) Postoperative after Permacol ‘sausage’ sited via open approach in conjunc-
tion with domal sutures in revision rhinoplasty. Derotation of tip achieved without additional grafts
Fig. 50.7 ( Left ) Preoperative. ( Right ) Postoperative after Permacol ‘sausage’ used to augment over-resected, irregular
dorsum insertion

761
50 Permacol in Augmentation Rhinoplasty
Fig. 50.8 (continued)
Fig. 50.9 ( Upper ) Preoperative. ( Lower ) Postoperative following dorsal augmentation with Permacol and cap graft to
correct over-resected dorsum and lower laterals