Explore Plastic Surgery - Dr. Barry Eppley

Building up the nasal bridge, known as dorsal augmentation, is needed for certain types of rhinoplasty surgeries. These include secondary correction of traumatic nasal injuries and saddle nose deformities as well as in some primary ethnic rhinoplasties. Often a rebuilt or elevated dorsal line is one of the most important objectives to achieve in these rhinoplasty endeavors.

While there are numerous methods available for dorsal augmentation, the use of a graft material is needed for all of them. Cartilage is the best nasal graft material. While it takes greater effort to harvest and shape the dorsal graft using cartilage, the long-term benefits of doing so are always worth it.  At the least, there is no risk of foreign body reaction and very little absorption of the graft. Because of the size and length of the nasal dorsum, rib cartilage can always supply an adequate graft amount. (this doesn’t mean that rib is the only donor site)

When solid rib grafts are used for dorsal augmentation, they are prone to warping, deviation, and being able to feel the graft move around across the nasal bridge. As a result, using cartilage in a less structured form has become popular. Initially known as the ‘Turkish graft’ and studied and popularized here in the U.S. by Daniel, diced cartilage has become a good method of dorsal augmentation. When cartilage is cut into small segments approximately 1 mm in size and then placed in some form of a containment wrap, a moldable dorsal implant can be easily made. There is some debate as to the merits of a fascial vs. absorbable collagen wrap. Successful clinical outcomes have been obtained with either method.

Besides being easy to make out of cartilage scraps or imperfect graft pieces, a diced cartilage graft can be molded like clay.  Once placed on the dorsum, it can be shaped and held in place for one week after surgery with an external splint. The graft is still slightly malleable in the first couple of weeks after surgery. Therefore, if some irregularities are seen early in the first few weeks after surgery, the dorsal graft can be pressed and molded to improve its shape.

Diced cartilage grafts have been shown to be heal together into a solid piece of cartilage without loss of volume. It is able to be revised, reshaped, and easily identified during further surgeries if necessary. In my Indianapolis plastic surgery practice, I have used this technique for over five years and find that the results are similar to pioneers of this technique sat that it is. It has been a revolutionary approach for me in dorsal augmentation, which can be a difficult rhinoplasty manuever because of graft requirements.  

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Cartilage grafting in rhinoplasty today is often an essential component of the procedure. Improving structural support of the nasal tip and internal nasal valves may require mechanical support through the use of cartilage grafts. In some patients, particularly revisional rhinoplasty patients, cartilage donor sites may have been previously used and the patient is now ‘graft-depleted’. In reality, graft depletion is usually relegated to the septum as ear and rib cartilage donor sites are always available but the plastic surgeon or patient may want to have a seconday donor site harvest.

 
A most recent article in Plastic and Reconstructive Surgery by British plastic surgeons James and Kelly writes on their successful use of polydioxanone foil in rhinoplasty surgery. Polydioxanone is one of the many biodegradable polymers that exists and has been used for many years in orbital floor fracture repair. It maintains its integrity for about 6 months and is flexible and adaptable. It comes in various thicknesses, usually .25 or .5mm is used. They performed 58 rhinoplasties in which it was implanted. (37 primary, 21 secondary rhinoplasty) It was used primarily as a columellar strut. Two complications with its use was seen (3%), one infection and the other exposure. Both resolved by non-surgical management.

 
This artilce brings to my mind my historic use with LactoSorb in some select rhinoplasties. LactoSorb is a well-known biodegradable polymer with a fifteen-year history of extensive use in craniomaxillofacial surgery primarily as resorbable plates and screws. I have used it in the past in rhinoplasty as well for septal support, columellar struts and spreader grafts in cleft and trauma patients. If one is careful to have good soft tissue coverage, the complication rate will be very low and one can avoid the need for cartilage harvesting. Since I am very comfortable with cartilage harvesting from all donor sites, I have not really used it in the purely aesthetic rhinoplasty patient. But this article has given me the impetus to press forward with its use more in aesthetic rhinoplasty. It would be particularly helpful as a spreader graft and columellar strut, both areas where one should almost always get cartilage and good soft tissue coverage. While complications rates for any material will never be as low as autogenous cartilage (which is essentially zero), an acceptable rate of 1 - 3% may be a good trade-off for potential donor site concerns.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Rhinoplasty, nose-shaping surgery, is one of the most common plastic surgery procedures of the face. It can have a dramatic effect on one’s facial appearance due to the prominent position of the nose on the face. While rhinoplasty surgery has been performed for over 100 years, modern rhinoplasty techniques create noses that are more natural and can hold their shape over time.

 
Historically, rhinoplasty surgery was associated with after surgery appearances which were ‘overdone’. This type of reductive rhinoplasty produced noses that were short with up-turned tips(pugnose appearance) and with low bridges. Even if the nose did not appear this way immediately after surgery, this appearance developed months or years later. This nasal appearance was the result of removing too much of the natural structures of the nose. Taking the bridge of the nose down too low (bone and cartilage) or shortening the tip of the nose excessively (all cartilage), while immediately looking good, weakens the support of the nasal framework. Over time, as scar forms and tissues heal and contract, the nose gradually ‘falls’ and assumes an unnatural appearance. It may look too small, too upturned, or too narow and pinched at the tip.

 
The importance of maintaining as much of the support of the nose is better appreciated today. The nose is like a house, the framework must be maintained to keep the roofline intact. Contemporary rhinoplasty is more of a rearrangement of the framework structures with only small removals of cartilage or bone. In this way, the nasal dorsum (line along the bridge to the tip) remains smooth but at a good height, the end of the nose is lifted but not too high, and and the nasal tip is narrowed but is not made into a single point.

 
Besides less cartilage and bone removal, the natural rhinoplasty makes use of adding support through cartilage grafts as necessary. Supporting the nasal tip through columellar strut grafts, small hand-carved grafts for better tip definition, spreader cartilage grafts to the middle vault to improve breathing, and adding height at the very top of the nose where it joins the forehead (radix) with small crushed cartilage grafts are some of the ways to help build and strengthen the framework of the nose. These cartilage grafts are usually acquired from the septum of the nose (which may be simultaneously straightened) or from the back of the ear.

 
Natural rhinoplasty techniques are a combination of preserving critical nasal tissues, skillfully rearranging the different zones of the nose, and the three-dimensional eye to visualize how to get to the final nasal result. It is usually best done through an ‘open approach’ with a resultant indetectable scar across the columella. (strip of skin between the nostrils) Natural noses fit each patient’s face more proportionately and never have that ‘operated’ appearance. While tedious to perform, I find the long-term results rewarding and the need for secondary revisional surgery reduced.

 
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

One of the three main areas to modify in a rhinoplasty is the nasal tip. The nasal tip is a very elegant structure that has a remarkable amount of anatomical detail from its size, shape, and symmetry of both halves to its amount of projection and its relationship to the nostril and nasal base. The open approach to a rhinoplasty, which is now the standard approach to most rhinoplasties today, has made changing the nasal tip much easier and more reliable than ever before.

Part of the modifications of many nasal tips during rhinoplasty involves the use of cartilage grafts. Cartilage grafts in the nasal tip are extremely effective at controlling the amount of nasal projection as well as the defining points of the tip. These cartilage grafts are usually harvested from your own septum, which may be part of the rhinoplastic procedure if you are having internal nasal surgery as well to improve your breathing. If you don’t have enough septum to use as a donor site, then the concha (bowl) of the ear is the next available site. The cartilage grafts are shaped with a scalpel to create the shape of the tip and its amount of projection, and then they are sutured in place. This is usually done as the final part of the rhinoplasty operation.

While cartilage grafts are used on the bridge of the nose as well in some cases (too build up the bridge), their use in the nasal tip is more common. In the nasal tip, the size of the cartilage graft is much smaller and its shaping and positioning more detailed.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis