Reconstruction of the dorsum or bridge of the nose is one of the important areas of a good looking nose. Where it is needed for aesthetic augmentation of a congenitally flatter nose or in secondary reconstruction where the dorsum has become resected or flattened, rhinoplasty requires a graft or implant. An autogenous graft of cartilage is usually preferred if the patient will permit it.
Solid rib grafts are often used for dorsal augmentation in rhinoplasty but they can have a problem with warping, particularly at its upper end. This problem can be avoided by the use of a diced cartilage graft technique. With this cartilage grafting method, the small pieces of cartilage must be encased in some form of wrap. Originally described as using a synthetic collagen wrap (Surgicel), it is currently felt that temporalis fascia is better. Its use, however, requires a second donor harvest site in addition to that of the rib.
In the January 2016 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘Diced Cartilage Grafts in Rectus Abdominus Fascia for Nasal Dorsum Augmentation’. Over a six year period, the authors treated 109 patients with a construct of diced rib cartilage wrapped in rectus fascia harvested through the same subcostal incision. After an average 19 month followup, four patients developed an infection, three patients required a revision for overcorrection, undercorrection was seen in five patients and one patient developed a hypertrophic scar at the rib harvest site. No patients developed graft warping or an abdominal hernia.
The use of rectus abdominus fascia is a logical choice for diced rib cartilage for several reasons. First, the avoidance of two donor sites is obvious. But secondly temporalis fascia is much thinner and less stout than rectus fascia. Rectus fascia is easier to work with and more graft material can be obtained. Thirdly, there is little if any risk of creating a hernia particularly high up on the abdominal musculature.
Diced rib cartilage grafts need a containment sleeve and rectus fascia offers the most convenient method to do it. It is a technique that I have used successfully for years in dorsal augmentation rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana