Goals/Purpose:
Among autologous materials used for the mild dorsal augmentation, the conchal cartilage has been the most favorite graft for many years. However, achieving a smooth dorsum is very difficult with auricular cartilage due to its inherent natural concavities and convexities. Even scored, crushed or trimmed and used as one piece to cover the entire dorsum, the conchal graft can cause irregularities over time.
The purpose of this article is to present our experience in dorsal nasal augmentation using a smooth, flat and pliable composite graft consisted of lightly crushed fragments of conchal cartilage and retroauricular fascia.
Methods/Technique:
A composite graft consisted of conchal cartilage and retroauricular fascia was used for dorsal nasal augmentation in sixteen patients. Among them, three were primary and thirteen secondary rhinoplasties. An open approach was used in twelve cases and a closed approach in the remaining four cases. The follow up ranged from 5 to 25 months. The indication for augmentation was concavity and irregularities of the nasal dorsum. All patients exhibited a dorsal deficiency of 3 to 5 mm.
The conchal graft and retroauricular fascia were harvested through the same incision in the retroauricular groove from the site the patient doesn't sleep on. First, a rectangle-shaped retroauricular fascia was harvested with a dimension of maximum 2.5/ 4.5 cm and with a thickness of approximately 1.5 mm.
Depending of its variable architecture, the conchal graft was used as one piece or cut in either two or three fragments according to its curvatures to obtain most straight fragments, which were slightly crushed and beveled with Adson forceps to soften and flatten them.
The cartilage fragments were placed and fixed to the retroauricular fascia and to each other with 6/0 PDS sutures. The number and shape of the pieces of cartilage were selected according to the deficiencies present on the nasal dorsum. The nasal dorsum was undermined as necessary, taking care not to undermine too much in order to avoid postoperative deviations of the graft. The nasal bones were rasped to create an adequate recipient place for the graft. The composite graft was placed on the nasal dorsum in the sub-SMAS pocket with the fascia facing upwards. Adjustments to the final position and form of the graft were carried out with the graft taken out, trimmed and replaced. The graft was fixed cephalically with two pull-out 4/0 non-absorbable sutures and caudally to the septum and upper lateral cartilages with separate 6/0 PDS sutures. The pull-out sutures were removed on the fourth postoperative day. Overcorrection was avoided. In all cases the composite graft was used for aesthetic purpose only after a stable nasal framework was ensured and functional disorders were solved.Other aspects of rhinoplasty were performed where indicated.The nasal splint was used in all cases and removed on postoperative day nine. Broad spectrum antibiotic prophylaxis was used intraoperatively and 5 days after surgery.
Fig. 1 Primary mild saddle nose deformity. Preoperative profile view
Fig. 2 Primary mild saddle nose deformity. Postperative profile view after dorsal nasal augmentation with composite graft
Fig. 3 Primary mild saddle nose deformity. Preoperative frontal view
Fig. 4 Primary mild saddle nose deformity. Postoperative frontal view after dorsal nasal augmentation with composite graft
Fig. 5 Diagram of composite graft insetted to the dorsum. Blue line represents fragments of the concha, red line - retroauricular fascia.
Fig. 6 Diagram of the composite graft consisted of retroauricular fascia and three fragments of conchal cartilages.
Results/Complications:
All 16 patients were followed for 2 years. The follow-up revealed no case of infection, hematoma, seroma, resorption or displacement of the graft. There were no complications in the donor area, excepting one hematoma that was treated conservatively. Satisfactory aesthetic result was achieved in all patients, except one. There were one case of initial undercorrection of the nasal dorsum, but the patient refused secondary augmentation.The maximal thickness of the combined graft was to 4,5 mm. No contour changes were noted after one year.
Conclusion:
The autologus graft described herein consists of two to four fragments of the conchal cartilage and retroauricular fascia. This composite graft is appropriate for slight to mild dorsal nasal augmentation, but not for structural support. Both components of the composite grafts are harvested through the same incision in the retroauricular groove. The postoperative scar is inconspicious and the donor site morbidity is minimal. The method of augmentation allows balancing all three parts of the dorsum by placing fragments of the concha on the fascia in different manners depending on the initial dorsum contour. Fragments of other cartilages could be added to the graft to thick it. The retroauricular fascia placed upwards masks any contour irregularities that might be present due to the cartilage underneath, especially in patient with a thin skin. It also permits to smooth transition between the dorsum and the lateral nasal walls.