BSAPS Journal

Introduction

The history of dorsal augmentation during rhinoplasty emulates in many ways the progression of increasingly higher standards of care in medicine, driven by technological advances and rapidly evolving therapies. Early attempts were decidedly crude, with a wide assortment of everyday materials including ivory¹ and jade used to increase the height of the nose. Though the years, surgeons have attempted to improve outcomes by utilizing a variety of autologous and alloplastic materials, including cartilage, bone^2-4, fascia, diced cartilage silicone, polytetrafluorethylene, and various type of incisions have also been used. All with mixed results⁵.

When many contemporary surgeons favor autologous grafts in an onlay configuration for mild to moderate amounts of dorsal augmentations^2,6,10 on demand a larger volume of graft materials have prompted surgeons to explore alloplastic (silicone, Gorertex, etc.) and homoplastic (irradiated costal cartilage) options. The use of Artifisial implants can obviate the need for donor site incision and its morbidity^2-5.

However, a primary downside of artificial implants can be a relatively high risk of complications compared to autologous graft techniques, driving some surgeons to pursue this avenue.

The use of diced cartilage in dorsal augmentation has been periodically documented in the English literature as early as 1943 by Peer, in 1951 by Cottle, and in 1968 by Burian, though it did not gain widespread acceptance at the time.^6-7 Guerrerosantos revisited this concept in the 1990s⁸, refining the technique by wrapping fragmented cartilage in fascia, while Erol brought a larger audience with his description of wrapping diced cartilage in Surgicel in 2000⁹. Daniel subsequently brought a renewed interested in wrapping diced cartilage in fascia^6,7. Modifications of the concept of using diced cartilage as the building block for dorsal augmentation have been variously described, primarily adding assorted tissue adhesives to ease shaping of the graft, altering the material wrapping the cartilage or foregoing an encasement altogether^9,10,11. The manifold existing descriptions in the literature notwithstanding, a systematic approach refining the surgical technique to achieve greater precision and consistency using diced cartilage with fascia has not been previously delineated.

Diced cartilage with facial harvest in a same incision represents a potentially ideal graft for dorsal augmentation, as it makes use of the lower complication rates associated with autologous grafts, while also providing a graft that has the ability to recreate dorsal aesthetic lines in a natural and predictable manner. The usage of diced cartilage has been variously described in the literature, with consistently satisfactory result. Herein, we present our early experience, with patients undergoing dorsal augmentation during rhinoplasty using an updated method of diced cartilage wrapped in fascia using a single incision at donor site.

Figure 3: Before and after Microdiced Cartilage Fascia Augmentation Rhinoplasty -front view.

Materials & Methods

Total of 3 patient were operated for nasal dorsal augmentation, during a period of 4 months from October 2019 to January 2020. All 3 patients were female; age range was 22 to 31 years.

Procedure

After proper assessment and under general anesthesia, conchal cartilage was harvested from the auricle using vertical incision posteriorly. After harvesting, the end of the inc1s1on was extended upward and backward into the scalp in a zigzag manner. Retroauricular fascia was then harvested. The length and width of the harvested fascia depended on the dimention of the cartilage graft. Hemeostasis was ensured with diathermy. Closure was attained by 4/0 vicryl. By open rhinoplasty method dorsal tunnel was dissected along the midline. Lower alar cartilages (LAC) were trimmed and fibrofatty tissue debulking from the tip was done as required. The Conchal cartilage was sliced into microdices using a sharp blade. (Figure 1) The retroauricular fascia was spreadout onto a wooden board and pinned at four comers. The microdiced cartilage was aligned vertically and the fascia wrapped around it. (Figure 2) The facial margins were than sutured by 4/0 vicryl. This diced cartilage fascia graft was then gently inserted in the dorsal tunnel. Necessary moulding was done to attain the desired shape. The LACs were apposed in the midline again using 4/0 vicryl. Would closure was done with 6/0 prolene and 4/0 vicryl. Light nasal pack and malleable external splint was applied.

Results

The results of all 3 patients were satisfactory and no complications were encountered. Since the follow-up period was small, further floow up is required for assessment of long-term results. (Figure 3)

Discussion

Given         the      contemporary         focus       of minimizing complications and creating a sustainable result, many rhinoplasty surgeons have moved towards exclusively using autologous grafts during dorsal augmentation. Diced cartilage fascia techniques have proven fascinating due to its relative pliability, wide availability of materials needed for the construct, and the perceived forgiving nature with regards to contour irregularities12.

Diced cartilage fascia techniques for doral augmentation in rhinoplasty and revision rhinoplasty have been variously utilized and described for over half a century. Although producing satisfactory result in many cases, at the same time has received criticism for creating a ''sausage-like'' appearance or an otherwise unnatural look to the dorsum. The term is broadly descriptive and there remains a wide-range of ways to execute it13,14,15.

Contour irregularities as well as multiple incisions made for harvesting tissue remain the most common reason for surgeon and patient dissatisfaction after dorsal augmentation using diced cartilage with fascia. Sub-optimal contours may manifest in the from of convexities and concavities, over or under augmentation, deviation, asymmetries, and unnatural dorsal anesthetic lines.16,17,30. Conservative management of minor contour irregularities with nasal scar (especially within the first month following surgery), and directed injections of kenalog and 5-fluorourecil for scar management will successfully address many of the irregularities observed in the early post-operative period18,19,20. Persistent contour irregularities beyond post-operative edema due to coalesced diced cartilage will infrequently warrant revision surgery.

Conclusion

This updated diced cartilage fascia technique with a single incision eliminates an aditional donar site incisions and morbidity. It can enhance precision to create more predictable and consistently beautiful results^23,24. A further attention on precision approach for practicing the DCF graft may result in even improved outcomes for future patients^25,26,27.

1. Deneck HJ, Meyer R. Plastic Surgery of the Head and Neck. NewYork: Springer-Verlag; 1967. p. 148. 2. Burian F. The Plastic Surgery Atlas. New York: Macmillan; 1968. 3. Daniel RK, Calvert JW. Diced cartilage in rhinoplas-ty surgery. Plast Reconstr Surg 2004;113:2156-2171. 4. Guerrerosantos J. Rhinoplasty: the "Taco" graft. Plast Reconstr Surg 2006. In press. 5. Wilflingseder P. Cranioplasties by means of diced cartilage and split rib grafts. Minerva Chir 1983;38:837-843. 6. Velidedeoglu H, Demir Z, Sahin U, Kurtay A, Ero! 00. Block and Surgicel-wrapped diced solvent-preserved costal cartilage homograft application for nasal augmentation. Plast Reconstr Surg 2005;115:2081-93; discussion 2094-7 [Daniel RK]. 7. Erol 00. The Turkish Delight: a pliable graft for rhi-noplasty. Plast Reconstr Surg 2000;105:2229-2241. 8.Daniel RK. Rhinoplasty-An Atlas of Surgical Tech-niques. New York: Springer; 2002. 9. Calvert JW, et al. Diced cartilage grafts: a histologi-cal analysis. Plast Reconstr Surg 2006. In press.. Vilar-Sancho B. An old story: an ivory nasal implant. Aes-thetic Plast Surg 1987;11:157-61. 10. Krause CJ. Augmentation rhinoplasty. Otolaryngol Clin North Am 1975;8:743-52. 11. Wheeler ES, Kawamoto HK, Zarem HA. Bone grafts for nasal reconstruction. Plast Reconstr Surg 1982;69:9-18. 12. Romo T 3rd, Jablonski RD. Nasal reconstruction using split calvarial grafts. Otolaryngol Head Neck Surg 1992;107:622-30. DOIPubMed 13. Leaf N. SMAS autografts for the nasal dorsum. Plast Reconstr Surg 1996;97:1249-52. DOIPubMed 14. Daniel RK. Rhinoplasty: an atlas of surgical tech-niques. New York: Springer; 2002. pp. 11-2. 15. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg 2004;113:2156-71. PubMed 16. Guerrerosantos J, Trabanino C, Guerrerosantos F. Multifragmented cartilage wrapped with fascia in aug-mentation rhinoplasty. Plast Reconstr Surg 2006;117:804-12; discussion 13-6. 17. Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg 2016;137:43-51. DOIPubMed 18. Regnault P. Nasal augmentation in the problem nose. Aesthetic Plast Surg 1987;11:l-5. DOI 19. Khoo BC. Augmentation rhinoplasty in the orien-tals. Plast Reconstr Surg 1964;34:81-8. PubMed 20. Beekhuis GJ. Silastic alar-columellar prosthesis in conjunction with rhinoplasty. Arch Otolaryngol 1982;108:429-32. DOIPubMed 21. Wellisz T. Clinical experience with the Medpor po-rous polyethylene implant. Aesthetic Plast Surg 1993;17:339-44. DOIPubMed 22. Godin MS, Waldman SR, Johnson CM Jr. The use of expanded polytetrafluoroethylene (Gore-Tex) in rhinoplasty. A 6-year experience. Arch Otolaryngol Head Neck Surg 1995;121:1131-6. DOIPubMed 23. Queen TA, Palmer FR 3rd. Gore-tex for nasal aug-mentation: a recent series and a review of the literature. Ann Otol Rhinol Laryngol 1995;104:850-2. DOIPub-Med 24. Adams JS. Grafts and implants in nasal and chin augmentation. A rational approach to material selec-tion. Otolaryngol Clin North Am 1987;20:913-30. PubMed 25. Juraha LZ. Experience with alternative material for nasal augmentation. Aesthetic Plast Surg 1992;16:133-40. DOI 26. Gilmore J. Use of vicryl mesh in prevention of postrhinoplasty dorsal irregularities. Ann Plast Surg 1989;22:105-7. DOIPubMed 27. Fanous N. Mersilene tip implants in rhinoplasty: a review of 98 cases. Plast Reconstr Surg 1991;87:662-71. discussion 72-3 PubMed 28. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: dorsal onlay grafting using shaped autogenous septa! cartilage. Plast Reconstr Surg 1990;86:39-45. DOIPubMed 29. Peer LA. Diced cartilage grafts: new method for re-pair of skull defects, mastoid fistula and other deformi-ties. Arch Otolaryngol 1943;38:156-65. DOI 30. Cottle MH. Nasal surgery in children. Eye Ear Nose Throat Mon 1951;30:32-8.