A e s t h . Plast. S u r g .

1 0 : 2 1 - 2 5 , 1986

Aesthetic _ Plasuc Surgery

9 1986Springer-Verlag New York Inc.

Tip Graft from the Cartilaginous Dorsum in Rhinoplasty

Jose Garcia-Velasco, M.D., F.A.C.S. and Manuel Garcia-Velasco, M.D., F.R.C.S.(C) Mexico City, Mexico

Abstract. A cartilage graft from the cartilaginous hump

can be used in primary rhinoplasty for nasal tip projection. This technique has now been used for two years without complications in 35 patients with similar nose deformities, which included an inadequately projected tip and a high dorsal line. These grafts have proved to be another easy way to get an adequate tip projection in primary rhinoplasty.
Key words: Rhinoplasty - - Cartilage - - Graft - - Tip

To get an adequate nasal tip projection, the advantages of cartilage grafts in primary rhinoplasty, are well known. The use of these grafts have been widely popularized by several authors [1, 4, 5, 6]. Jack Sheen is one of the most enthusiastic promoters in the use of these grafts. He describes in his book, Aesthetic Rhinoplasty [7], a deformity called tip inadequately projected (TIP). in it he also mentions that a cartilage graft can be used to produce a well-projected nasal tip. In Mexico, the so-called Mestizo nose, shows several problems as perfectly described by Monasterio and Olmedo [3]. They provide solutions for the correction of this nasal shape and procedures to get a satisfactory final result. The characteristics of this kind of noses can be classified among the TIP deformity group described by Sheen. Frequently, this deformity includes a high dorsal line with a hump mainly formed of cartiPaper presented at The Annual Meeting of the American Society for Anesthetic Plastic Surgery, in Los Angeles, California, April, 1983 Address reprint requests to Jose Garcia-Velasco, M.D., Camino Sta. Teresa 1055-209 Mexico City, Mexico 10700

lage from the septum in conjunction with the upper lateral cartilages. In Skoog's rhinoplasty technique [8], a big piece of the osteocartilaginous hump is resected in one block and reapplied once it has been reshaped and reduced in size, obtaining a better profile line. Based on this type of hump resection in block, but conservatively resected, it is possible to obtain a quadrangular piece, mainly of cartilage. This piece, if properly shaped, can be used as a graft for the nasal tip. In this article, we are reporting on our experience with the use of grafts obtained from the cartilaginous vault, for projection of difficult nose tips in primary rhinoplasty. Thirty-five patients, selected with similar characteristics, were operated on between N o v e m b e r 1980 and September 1982. The most important defect in all o f these patients was a poorly projected tip or a tip with a bad definition and a predominantly cartilaginous high hump. A conservative rhinoplasty was performed on each patient [2]. The osteocartilaginous hump was resected in one piece with the use of a No. 11 blade. At this stage the cartilaginous portion of the upper lateral cartilage was removed. We finished the resection with a chisel, removing a very small part of bone. This specimen was cleaned of small amounts of attached soft tissue and at the same time taking care to preserve the perichondrium. The bony portion was detached and any possible residue of nasal mucosa was eliminated from its under surface. A supramucosal resection of the hump is recommended in big noses. Following this, a proper graft for each case was designed. In most cases a triangular-shaped graft can be tailored to measure 2 cm by 8 to 10 mm on its base (Fig. 1). Its upper surface has a little convexity, avoiding the shape edges of the

22

Tip Graft from the Dorsum

Fig. 1. (A,B) Osteocartilaginous hump resected in block.

A
' .4

Fig. 2. The usual specimen that is obtained. The central septal projection can be seen.

Fig. 3. Schematic representation of graft preparation and insertion.

J. Garcia-Velasco and M. Garcia-Velasco

23

Fig. 4. (A,B) Graft placed in nasal tip. The septal central projection lies securely between the medial crura of the alar cartilages.

Fig. 5. (A) Preoperative left profile of a 23-year-old female with a cartilaginous hump and a short columnella. (B) Postoperative left profile. (C) Postoperative oblique profile.

Fig. 6. (A,B) Preoperative and postoperative front views.

24

Tip Graft from the Dorsum

Fig. 7. (A,B) Preoperative and postoperative front views.

Fig. 8. (A,B) Preoperative and postoperative right profile.

graft. The undersurface has a central projection (Fig. 2) that corresponds to the septum. This projection can be preserved to facilitate graft fixation. The graft was applied in the nasal tip in the usual way, through a marginal incision (Fig. 3). The pocket formed to contain the graft can have a groove between the medial crura of the alar cartilages where the undersurface edge of the graft can lie. This edge rests on the groove, secures the position of the graft, and avoids any displacement (Fig. 4). The postoperative results have been very satisfactory, as far as the rhinoplasty is concerned. The graft has not had any displacement in any case; there has also been no reabsorption, probably because the perichondrium attached to the surface ensures the survival of the graft, and finally the shape and projection of the tip has been very adequate in all cases (Figs. 5-8).

Discussion and Conclusions A well-projected nasal tip can be obtained, in some nasal deformities; with cartilaginous grafts, as is evidenced with this group of selected patients. Furthermore, the use of part of the cartilaginous hump as a graft demonstrated the following advantages: 1. It is not necessary to touch or modify other structures such as the nasal septum or the concha of the ear. 2. It saves time. There will not be an extra surgical stage because the hump resection is a necessary step in conventional rhinoplasty. 3. The graft has perichondrium on its anterior surface, which ensures its survival. 4. The graft shape helps its adequate placement. Its edges are slightly convex avoiding abrupt demarcation. The presence of the septal projection on the back surface places the graft between the medial

J. Garcia-Velasco and M. Garcia-Velasco

25 3. Ortiz Monasterio F, Olmedo A: Rhinoplasty on the Mestizo nose. Clin Plast Surg 4:89, 1977 4. Ortiz Monasterio F, Olmedo A Ortiz Oscoy: The use of cartilage grafts in primary aesthetic rhinoplasty. Plast Reconstr Surg 67:597, 1981 5. Peck GC: The onlay graft for nasal tip projection. Plast Reconstr Surg 71:27, 1983 6. Sheen JH: Achieving more nasal tip projection by the use of a small autogenous bone or cartilage graft. Plast Reconstr Surg 56:35, 1975 7. Sheen JH: Aesthetic Rhinoplasty. St. Louis: C.V. Mosby, 1978 8. Skoog T: A method of hump reduction in rhinoplasty. Arch Otolaryng 83:283, 1966

crura of the alar cartilages. This septal projection avoids future displacement and malposition.

References

1. Falces E, Gorney M: Use of ear cartilage grafts for nasal tip reconstruction. Plast Reconstr Surg 50:147, 1972 2. Garcia-Velasco J, Rivera JF, Garcia-Velasco M: A conservative approach to rhinoplasty. Aesth Plast Surg 3:119, 1979