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Archive for the ‘rhinoplasty’ Category

Compressed Diced Cartilage Grafting in Rhinoplasty

Thursday, December 14th, 2017

 

Cartilage grafting in rhinoplasty is an essential part of aesthetic nasal augmentation. It is traditionally used as an onlay method, using single layer or stacked grafts. While effective for some cases, it requires straight grafts that can be shaped with smooth edging.  This does not always fit, however, every defect and straight grafts can be hard to find. This has led to the contemporary use of diced cartilage grafting which allows an injectable graft though syringes that can be molded intraoperatively.

The use of diced cubes of cartilage in rhinoplasty is associated with using a containment method. This has been either temporal fascia, the product Surgicel or thin allogeneic dermis. There is great debate about which wrap for diced cartilage is best. But the debate is now switching to whether any containment method is really needed at all.

In the November 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Injection of Compressed Diced Cartilage in the Correction of Secondary and Primary Rhinoplasty: A New Technique with 12 Years’ Experience’. In this paper the authors reviewed their decade plus experience in over 3,000 patients of which over 2,300 were primary procedures and almost 800 were secondary rhinoplasties. Diced cartilage was injected using a special syringe design which compresses the cartilage into a malleable cylindrical-shaped mass. They report a 98% graft take, creating a smooth external surface contour. Less than 1% (21 patients) had partial resorption of the injected grafts. They were treated by secondary injection. Over 1% (36 patients) had over correction which was treated one years later by rasping when the graft was completely consolidated.

This paper offers an extensive clinical experience with using compressed diced cartilage grafting. By compressing the graft it becomes easier to place as well as is composed of pure cartilage. This accounts for its high take that would be comparable to solid cartilage grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study- Hump Reduction Rhinoplasty

Tuesday, December 12th, 2017

 

Background: The surgical reduction of a nasal hump is one of the oldest techniques in rhinoplasty. It has been done since the nasal reshaping procedure was introduced and, historically, defines what a rhinoplasty was. It has long been recognized that a raised or convex profile to the dorsum of the nose is not an aesthetically desirous nasal feature for most people. In addition it can he perceived as an ethnic nasal feature and in trying o achieve better nasal shape its removal can also make the nose more ethnically neutral.

The upper third of the nose is commonly known as the bridge. While often perceived as being bony in composition, it is really a combination of bone (nasal bones) and cartilage. (septum and upper lateral cartilages) This becomes apparent when a hump is present and its removal is requested. Taking down a dorsal hump on the nose always requires removal of both bone and cartilage of which cartilage usually makes up the greatest percentage of the hump.

The standard goal in most hump reduction is to change the profile of the nose to a straight line. This linear dorsal profile is most commonly accepted and is one that optimally maintains nasal airway function. But it is not the only dorsal profile that is requested. Some females may want a more concave dorsal profile while some men may want to maintain a bit of convexity to it or the semblance of a small dorsal hump.

Case Study: This young female had several features of her nose that she wanted changed for a slimmer more feminine nose. One was the long dorsal hump that covered the entire distance of her nasal profile.

Under general anesthesia an open rhinoplasty was done to completely remove the nasal hump to a straight nasal profile as well as thin out the tip and give it a slight upturn.

Because most hump reductions are usually not done in isolation, an open rhinoplasty approach is most commonly used. This is the most assured approach for a smooth dorsal line that is optimally reduced.

Highlights:

1) The presence of a hump on the nose is the most common reason patients seek rhinoplasty surgery.

2) A straight dorsal line is the most desirous shape that those with a hump reduction seek.

3) Hump reduction consists of both bone and cartilage removal for which ‘rasping’ alone is not an adequate treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Dorsal Line Modifications in Rhinoplasty

Tuesday, November 28th, 2017

 

The shape of the nose is as varied amongst people as the weather is on any one day around the world. While not quite as distinct as a fingerprint, one’s nose shape is fairly unique in each individual. But despite this tremendous diversity in appearance, there are certain nasal shapes that many patients strive to achieve regardless of what their natural nose looks like. This creates a real challenge for any rhinoplasty surgeon in trying to achieve patient expectations.

But one aspect of nasal shape that is the least controversial and can be argued to be the most straightforward to change is the of the dorsal line. Viewed primarily in the side view the dorsal line of the nose is the profile shape from the top of the nose down to the tip along the skin. It can only have have three different profiles, straight, convex or concave. While the dorsal line does have aesthetic considerations in the front view, these do not have quite the significance as how it appears in the profile and oblique facial views.

The dorsal line is affected by the height of the nasal bones and the septum and can appear convex with a hump or concave with a saddle nose. In general a straight dorsal line is the safest aesthetic shape and would be considered one primary goal in many rhinoplasty surgeries. It is also considered the functionally safest nasal shape as it prevents collapse of the middle vault and potential nasal airway insufficiency.

The dorsal line is also considered gender neutral, being that a straight-line shape is desired by both men and women. But this is not always the case. In some women who seek a ‘cuter’ or definitely a strong feminine nose, a more concave dorsal line profile is preferred. It is the antithesis for treating a larger dorsal hump or a hook nose. Changing the dorsal line to this profile is particularly useful in transgender male to female rhinoplasty where ‘overdoing’ the dorsal line reduction helps create a more feminine appearance. As it turns out I have yet to have a male who wants anything other than a straight dorsal line and some may even prefer the maintenance of a residual dorsal hump or convexity.

In the older female nose where some tip dropping may have occurred, rotating the tip upward and lowering the dorsal line, can have a rejuvenating facial effect.

Determine before surgery what type of dorsal line profile a patients wants is one of the most straightforward imaging changes to make. Its impact affects the entire rhinoplasty result and is usually one of the top three types of changes a patient wants to surgically make to their nose.

Dr. Barry Eppley

Indianapolis, Indiana

Case Report – The Combined Rhinoplasty Lip Lift Procedure

Sunday, November 5th, 2017

 

Background: Reshaping of the central part of the face is done by changes to the nose and lips. Whether through a rhinoplasty or various lip augmentations or lifts, the shape of these two midline facial structures have a major influence on one’s appearance whether it is seen from the front or side views.

Rhinoplasty and lp enhancement procedures are not surprisingly requested and done during the same surgery. Normally combining changes to the nose and lips does not pose any adverse risks. The one exception is when an open rhinoplasty and a subnasal lip lift are desired. The proximity of the incisions needed for these operations raises concerns about whether the columellar skin between them would survive if done together. This is a well known debate and surgeons have opinions on both concomitant and staging the procedures.

Case Study: This young female wanted to change the shape of her nose to get rid of her small hump and narrow the tip. In addition she wanted a fuller upper lip and to decrease the vertical skin distance between the nose and the upper lip.

Under general anesthesia an open rhinoplasty was done to reduce the hump, narrow the tip and perform nasal osteotomies. No septal work done including shortening of the caudal septum or separation of the medial footplates. Once the nose was closed a subnasal lip lift was performed removing 4mms of skin at the central lip position.

After surgery she suffered no vascular compromise of the intervening skin segment between the incisions of the open rhinoplasty and the subnasal lip lift.  Her aesthetic outcomes were acceptable with a more shapely nose, a shorter nose-lip distance and a fuller central upper lip.

If these two procedures are going to be performed together, maximal preservation of the vascular inflow to the lower columellar skin must be preserved. This requires non-disruption of the tissues that are on the backside of the columella, the septal mucosa and the anterior nasal spine area. This will be adequate for skin survival even with high and low skin incisions on its front surface. If a more extensive septorhinoplasty is to be performed then a subnasal lip lift should not be performed at the same time.

The alternative approach to a combined rhinoplasty lip lift procedure is to use just one incision at the base of the columella. This creates a longer superiorly-based skin flap but as long as excess tension is not placed on the tip skin due to increased projection this should not be a problem. This does, however, potentially create a downward tension the nasal tip which is avoided when a skin segment is maintained between them.

Highlights:

  1. 1) An open rhinoplasty uses a mid-columellar incision.
  2. 2) A subnasal lip lift uses an incision that crosses the base of the columella
  3. 3) Combining open rhinoplasty and a subnasal lip lift requires an appreciation for the integrity of the blood supply to the intervening columellar skin segment.

Dr. Barry Eppley

Indianapolis, Indiana

Combining Open Rhinoplasty and Subnasal Lip Lift

Thursday, November 2nd, 2017

 

Patients desiring changes to the nose and reshaping of the upper lip are common. Nose changes are done by a variety of rhinoplasty techniques and lip changes accomplished by augmentations or surgical lifts. One of these uplifting lip procedures is the well known subnasal lip lift. Because it is done by an excision of tissue along the base of the nose, there has always been concerns about whether it should be performed with an open rhinoplasty or done separately.

When a rhinoplasty and a subnasal lip lift are done together, this traditionally places two incisions placed fairly close together. (one at the mid-columellar location and the other at the base of the columella. This potentially runs the risk of skin necrosis in the intervening small skin segment which exists between these two incisions. While I have personally never seen it, I know surgeons who have. That potential risk depends on what type of rhinoplasty is being done and how much dissection, if any, is done along the caudal septum and the anterior nasal spine. Even if no vascular compromise occurs, this operative combination results in two columellar incision whether it is done together or staged.

In the October 2017 issue of JAMA Facial Plastic Surgery Journal, a Surgical Pearl was published entitled ‘Combining Rhinoplasty with Upper Lip Lift Using a Single Line Incision’. In this paper the author describes his technique for combining two ‘nasal’ operations using a V-shaped incision located in the posterior third of the columella. This incision line then connects with the subnasal incision line. In the nasal sill area the flap extends about 3mms into the nose and then goes along the nasal alar crease laterally. The author describes a subnasal issue resection down to the anterior nasal spine and muscle plication sutures out laterally.

The use of a single base columellar incision location makes sense when the two procedures are combined. This certainly avoids any skin necrosis concerns but also potentially creates traction on nasal tip work due to the downward pull of the elevated upper lift. This would account for support sutures placed through the caudal septum to the central lip segment as well as muscle plication out laterally to prevent downward traction on the nose .

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Injectable Diced Rib Graft Rhinoplasty

Sunday, October 29th, 2017

 

Cartilage grafting to the nose is most commonly done using anatomically convenient graft sites. This usually means the septum which offers straight graft dimensions or the ear which offer curved or shaped grafts. For many traditional rhinoplasty surgeries these graft sites are sufficient both in size and shape.

But in rhinoplasties that require larger amounts of augmentation, almost always that of the dorm, facial graft sites are too small in volume and do not have the right shape. This is where rib graft harvesting does into play if one wants avoid an implant or a cadaveric cartilage source.

While rib grafts in rhinoplasty offer plenty of volume, they usually have some shape issues. Occasionally a rib graft may actually be harvested that is straight or it can be carved to be straight. But rib graft carving must take into consideration the perichondrial lining and the ever present risk of postoperative warping.

A well known technique of avoiding rib graft warping in rhinoplasty is to change it from a solid graft to a particulated one. By dicing the rib graft into very small pieces or cubes and containing it in some form of a wrap, a very moldable cartilage graft is obtained. The debate in the use of diced rib grafts is whether it should be wrapped in autologous fascia, a very thin piece of allogeneic dermis or a bovine collagen mesh wrap (Surgicel) There is no standard consensus on the ideal wrap material.

Another method to place the diced rib cartilage graft is to not wrap it at all. The placement/containment method is a small syringe from which it can be injected. This requires a precise soft tissue pocket over the dorsum and can be done through either an open or closed rhinoplasty. The diced graft is injected and then digitally molded into the desired shape. Tapes and a metal splint are placed over it to help maintain its shape.

This injectable rhinoplasty technique allows for rapid tissue ingrowth into the diced cartilage graft. Within a few weeks it becomes very firm and maintains its shape. My and other clinical experiences show that significant graft resorption does not occur.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Refining Rhinoplasty

Sunday, October 15th, 2017

 

Background: The popularity of rhinoplasty is a combination of the prominence of the nose on the face and the successful outcomes possible from the procedure. It is hard to know the exact gender distribution that undergoes this type of facial surgery but it seems like more females than males have the surgery.

While the nose shapes in women are highly variable, there are common features of the nose that they wish to change. Almost first and foremost is that of the nasal hump or bump. At the least women prefer a straight dorsal line and some even prefer more of a saddle nose or swoop their dorsal profile. The second feature is that of the nasal tip. A wide or drooping nasal tip is not a flattering nasal shape in a female. 

Recovery from rhinoplasty its highly influenced by the thickness of the nasal skin. The thinner the skin is, the less swelling of the nose after surgery that will occur…and the sooner the final result is realized. The percentage of female noses that have thinner skin than men is not precisely known but it seems that it is so. The young thin Caucasian female that comes in for a rhinoplasty often has thinner nasal skin.

Case Study: This young female in her mid-20s presented for rhinoplasty. Her two basic nasal dislikes were the small hump and the wideness of the nasal tip. She had fairly thin nasal skin.

Under general anesthesia, she had an open rhinoplasty in which the nasal hump was reduced to a straight dorsal line and osteotomies done to make a less nasal base beneath the hump. In addition, the nasal tip was narrowed by a cephalic trim and transdomal sutures.

Her 3 month results show a smooth dorsal line and a more narrow tip. The nasal bridge still remains sensitive as expected as bony healing takes much longer for complete healing.

Highlights:

  1. Many women seek nose reshaping changes that are for refinement of small disproportionate features.
  2. Small hump reductions and nasal tip narrowing are two common nasal reshaping requests.
  3. Females with thin skinned noses respond quickly to nasal reshaping surgery that only takes a few months to see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cranial Bone Graft Rhinoplasty

Sunday, September 17th, 2017

 

Background: Rhinoplasty surgery often entails the need for grafts. Most commonly cartilage grafts from the septum or ear are used as the volume needs are low and it is helpful to have a convenient and anatomically close harvest site. But major nasal reconstruction may need much larger graft volumes for which the rib offers a near limitless amount.

But in some nasal reconstruction cases where other craniofacial work is being performed, the most convenient donor site is one in which it is already open…the skull. Split-thickness cranial bone grafts have a long history of use in facial reconstruction including for reconstruction of the nose.

In reality, cranial bone is not the best graft for use in the nose because it is rigid and has to be made straight by either burring or controlled bending through partial osteotomy cuts.  One must also be careful that it does not put a lot of pressure on the nasal tip skin to prevent soft tissue breakdown. But if careful graft shaping is done, as well as bone fixation if needed, successful outcomes can be obtained with its use.

Case Study: This young female has been involved in a motor vehicle accident and sustained multiple craniofacial fractures of the forehead and midface. While these fractures underwent primary repair she remained with numerous residual brow bone, orbital and nasal deformities.

Under general anesthesia she had her original coronal scalp incision reopened for exposure and cranial grafts harvested to rebuild the frontal sinus and right orbital floor. Medial canthoplasties were also performed from this approach to improve her traumatic telecanthus. Her nasal dorsal had been impacted inward giving her a saddle nose appearance. A long 4 cm cranial bone graft was harvested and reshaped to be straight by partial thickness osteotomies and sutures. The dorsal bone graft was secured by screw fixation at the frontonasal junction. It was combined with a septal columellar strut graft through an open rhinoplasty approach to ensure adequate nasal tip projection.

A satisfactory nasal profile was achieved with good tip projection. The bone grafts has maintained its volume and structural integrity at a there year followup.

Cranial bone is not a primary source for nasal reconstruction grafting due to the limitations of its rigid structure. But if open access to the skull is already present for other procedures, it can make be used successfully.

Highlights:

  1. Cranial bone is one secondary option for dorsal grafting in rhinoplasty.
  2. The curved nature of cranial bone requires graft bending techniques for a straight dorm.
  3. A dorsal bone graft often needs to be combined with a columellar strut for an L-shaped nasal reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Free Diced Cartilage Grafts in Rhinoplasty

Thursday, September 7th, 2017

 

The use of cartilage grafts in the nose is common and is the most frequently used tissue graft in the nose. This is not surprising given that 2/3s of the nose is made up of cartilage. Harvesting adequate cartilage for use in rhinoplasty can be done from a variety of sites from the septum, ear or ribs. Donor quantity is not usually a problem but getting a good graft shape for its nasal purpose is often the challenge.

Cartilages grafts in the nose have several basic structural demands. Most commonly they need to be straight with some rigidity such as in use as a columellar strut, alar batten grafts etc. The most demanding structural requirement in the nose for cartilage is in dorsal augmentation. Not only is the most graft volume needed for this use but it must be straight and not change shape after surgery.  Rib grafts often are ideal in volume for dorsal augmentation but such grafts are rarely straight and are prone to postoperative warping. This has led to their use as a diced cartilage construct, usually wrapped in fascia or Surgicel as a containment method.

In the September 2017 issue of the journal Plastic and Reconstructive Surgery an article entitled ‘Free Diced Cartilage: A New Application of Diced Cartilage Grafts in Primary and Secondary Rhinoplasty’. In this paper the authors looked at the use of free (injectable) diced cartilage grafts to augment the nasal dorsum in 446 patients over a one year period. In the majority of the patients (73%) free diced cartilage was the only dorsal augmentation method used. In the remainder of the patients it was either combined with fascial wraps or done exclusively with fascial wrapping of the grafts. The study period was under one year (average 7 months). Revision rates for dorsal irregularities were 25% collectively with the free diced grafts along having a 5% revision rate.

Having used diced cartilage for years for variety of dorsal augmentations, it is not surprising that others have engaged in its use. This is the largest series to date with revision rates as a non-wrapped graft construct that would rival any solid cartilage graft used in rhinoplasty. There is always the concern of how smooth the dorsal augmentation would be and whether some graft resorption would occur. The contour irregularities are the reason for the revisions which may be a reflection of either uneven graft settling or some resorption.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Batten Rib Graft Rhinoplasty

Saturday, September 2nd, 2017

 

The use of cartilage grafts in rhinoplasty are done for a wide variety of reasons. While all cartilage grafts add support, some of these effects are to improve the shape of the nose while others are to improve its breathing function. Of all cartilage graft placements, the nasal tip is the most common area in which they are used.

Cartilage grafts in the lower third of the nose are most frequently placed in the central tip area. Whether it is a columellar strut graft or a wide variety of tip augmentation/shaping grafts, increasing tip projection and/or support is critical to resist the potentially displacing effects of the overlying skin.

But the side walls of the nasal tip, or lateral alar regions, can occasionally need cartilage grafts as well. The lateral alar cartilages are responsible for keeping the nostrils more open for breathing and play a critical role in the shape of the nostrils as well. Extending from the tip down to the nasal base they encompass almost the full length of the nostrils like a spanning bridge. Weak lateral alar cartilages can result in their collapse when breathing in. This can often occur after a rhinoplasty when too much cartilage has been taken due to an aggressive cephalic trim.

Support to the lateral alar can be done with cartilage, known as batten grafts. As the name implies a batten graft provides support to either help the collapsed lateral alar cartilages be brought back out as in a secondary rhinoplasty or as a preventative maneuver to prevent potential collapse after surgery in a primary rhinoplasty. The most common batten grafts comes from the septum since it is straight and fairly strong. But when a rib graft is being harvested anyway, it can be cut into thin batten grafts that are even stronger than that from the septum. The stiffness of these grafts is best done in noses with thicker skin.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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