Correction of Overresection With Non-Rib Cartilage Wrapped in Fascia

The Problem

Primary rhinoplasty typically has no grafting issues because grafting material is abundantly present. However, in secondary cases with overresection, providing adequate material for grafting has been an issue of concern. Sufficient cartilage is necessary to provide form and function. Cartilages are the most critical grafting materials in secondary rhinoplasty.

A graft is considered ideal when it is available and biocompatible, and when it has the least donor site morbidity with no risk of infection or extrusion. Homografts and alloplasts have a high risk of infection, inflammation, and protrusion. On the other hand, some autografts have considerable donor site morbidity. Advances in facial plastic surgery led to the use of special techniques to decrease donor site morbidity for autografts, while increasing the success rate of grafting and reducing complications. Minimally invasive procedures and the use of an endoscope with a magnified view help us to harvest sufficient graft material with the least morbidity.

The Background

The cartilage may be harvested from the septum alone or as a combination of the septum and ear. It is almost always possible to provide adequate support for structural and camouflage purposes from these two non-rib sources. The donor sites are in a close operative field, and the technique has very low morbidity if it is done meticulously. Temporalis fascia could be readily harvested from the same region. Diced cartilage can be wrapped in an alloplastic or homograft material. However, the foreign body reaction to such materials causes an inflammatory response with more resorption of the diced cartilage.

Generally, the long-term advantages of autografts outweigh the problems of the donor site morbidity. With increased experience and minimally invasive techniques, donor site morbidity has decreased dramatically, and the patient can be discharged just a few hours after surgery when a non-rib cartilage graft wrapped in the fascia is used.

The first choice for grafting material, which can also be used in revision cases, is residual septal cartilage. The remaining parts of the septal cartilage are a reliable source for preparing spreader grafts. However, for more grafting, enough cartilage material may not be available to provide other structural grafts such as septal extension and alar strut grafts. In such cases, I propose using a perpendicular plate of the ethmoid as a septal extension graft. It works well in this region and can be fixed using multiple holes created in it. Two advantages of thin perpendicular plate grafts for septal extension are a straighter, narrower septum.

Ear cartilage is an abundant source of cartilage graft material. It is the best cartilage for lower lateral cartilage (LLC) structural grafts. Its natural curvature can be tailored to fit for better aesthetic and functional results. It can also be used as spreader grafts, soft triangle grafts, alar rim grafts, and alar batten grafts. The residual auricular and septal cartilages are diced to less than 1-mm particles, inserted into the insulin syringe and wrapped in the fascia temporalis for correction of an overresected dorsum.