research-article2014
AESXXX10.1177/1090820X14535078Aesthetic Surgery JournalAs’adi et al
IBUTION
TR
AL CON
ON
ERN
INT ATI
535078
Rhinoplasty
Rib Diced Cartilage–Fascia Grafting in Dorsal
Nasal Reconstruction: A Randomized Clinical
Trial of Wrapping With Rectus Muscle Fascia
vs Deep Temporal Fascia
Aesthetic Surgery Journal
2014, Vol. 34(6) NP21­–NP31
© 2014 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
http://www​.sagepub.com/
journalsPermissions.nav
DOI: 10.1177/1090820X14535078
www.aestheticsurgeryjournal.com
Kamran As’adi, MD; Seyed Hamid Salehi, MD; and
Saeed Shoar, MD
Abstract
Background: Rib cartilage is an abundant source for cartilage grafts when significant dorsal nasal augmentation or structural support is indicated.
Diced cartilage wrapped in fascia was developed to counteract warping, visibility, and displacement of rib cartilage as a dorsal solid graft. The technique
for wrapping diced cartilage has evolved during the past several years.
Objectives: The authors compared 2 distinct fascial sleeves for wrapping rib diced cartilage in the treatment of patients who required major dorsal
nasal augmentation.
Methods: Thirty-six patients who planned to undergo major dorsal nasal reconstruction with diced costal rib cartilage were assigned randomly to 1 of 2
groups: the intervention group, which received grafts wrapped with rectus muscle fascia from the rib cartilage harvesting site, or the control group, which
received deep temporal fascia harvested separately. Outcomes were compared between the groups.
Results: Patients in the intervention group had significantly shorter operating times, significantly higher average satisfaction scores, and significantly
shorter postoperative hospital stays than did patients in the control group.
Conclusions: Harvesting rectus muscle fascia for wrapping diced rib cartilage is a feasible and reliable technique in dorsal nasal reconstruction surgery.
It is associated with favorable outcomes and a high level of patient satisfaction.
Level of Evidence: 4
Keywords
diced cartilage, wrapping, rectus muscle fascia, deep temporal fascia, nasal augmentation
Accepted for publication December 6, 2013.
Rib cartilage in the reconstruction of complex rhinoplasty
deformities represents an abundant source of autologous
cartilage for grafting.1-3 However, solid grafts with autologous costal cartilage have been associated with warping and
disfigurement, and the limited availability of long, straight
cartilage grafts for major dorsal nasal reconstruction presents a challenge.4,5 Diced cartilage, which has gained popularity in the past decade, provides a dorsal graft option with
greater flexibility in shape and size, without the risk of
warping or resorption.4,5 Because diced cartilage grafts are
prone to palpability, visibility, and uncontrolled dispersion
of cartilage fragments, diced cartilage should be enclosed
Dr As’adi is an assistant professor in the Department of Plastic and
Reconstructive Surgery at St Fatima Hospital, and Dr Salehi is an
assistant professor in the Department of Surgery at Motahari Burn
Hospital, Iran University of Medical Sciences, Tehran, Iran. Dr Shoar
is a research associate in the Department of Surgery at Shariati
Hospital, Tehran University of Medical Sciences, Tehran, Iran.
Corresponding Author:
Dr Kamran As’adi, Department of Plastic and Reconstructive
Surgery, St Fatima Hospital, Iran University of Medical Sciences,
Suite 2, Afra Tower, Khashayar Park, Africa Blvd, Tehran,
1915683913, Iran.
E-mail: [email protected]
NP22
Aesthetic Surgery Journal 34(6)
Figure 1. (A) A nearly straight 45-mm section of the seventh costal cartilage was harvested from this 28-year-old man
through a 3-cm incision. The bruised edges of the incision, caused by traction of instruments, were debrided before closure.
(B) A piece of harvested rib cartilage, which was to be used to construct diced cartilage–fascia grafts, was cut into 0.5- to
1-mm cubes on a silicone block with no. 11 blades in preparation for the diced cartilage–fascia construct. The remaining
cartilage was used as a structural graft.
appropriately. Wrapping the diced cartilage in fascia also
improves its efficacy when major augmentation is required.4
Enclosures for diced cartilage in dorsal nasal augmentation have included Surgicel (Ethicon LLC, San Lorenzo,
Puerto Rico),6 deep temporal fascia,7,8 and AlloDerm9 (LifeCell
Corp, Bridgewater, New Jersey), but each has limitations:
Surgicel-related cartilage resorption, the distinct harvesting
site of the deep temporal fascia from the cartilage donor, and
the cost and cartilage resorption of AlloDerm (respectively).
Due to the high morbidity and complication rates associated
with these limitations,7-9 the utility of these materials as graft
enclosures has been challenged.
We conducted a randomized clinical trial to determine
whether rectus muscle fascia, a potential option because of
its close proximity to the harvest site for rib cartilage, can
serve as a fascial sleeve to enclose diced rib cartilage during major dorsal nasal augmentation. Outcomes for dorsal
nasal augmentation with diced cartilage wrapped in deep
temporal fascia (conventional technique) were compared
with outcomes for diced cartilage wrapped in rectus muscle fascia.
Methods
Study Design
A prospective randomized clinical trial was designed to
evaluate the outcome of dorsal nasal reconstruction with
diced rib cartilage wrapped in 2 types of autologous fascia.
Two groups were compared: the intervention group, which
was treated with diced rib cartilage wrapped in rectus
muscle fascia obtained from the site of harvested rib cartilage, and the control group, which received diced rib cartilage wrapped in deep temporal fascia. The study was
approved by the institutional review board of St Fatima
Hospital in Tehran, Iran. All surgical procedures were performed by the senior author (K.A.).
Patients
Between September 2010 and October 2012, 36 consecutive
rhinoplasty patients who required rib cartilage grafting for
dorsal nasal reconstruction were enrolled in this study.
Eligible participants were required to have insufficient septal
cartilage, thus requiring an abundant source of cartilage for
dorsal augmentation. Patients older than 55 years and those
with radiologic evidence of cartilaginous rib ossification were
excluded from the study. Patients were informed of the advantages and risks of the procedure and the necessity for grafting
with fascial-wrapped rib cartilage. Written informed consent
was provided by each patient. Information gathered preoperatively included demographic data, medical conditions, and
precise measurements of nasal dorsum defects. Standard
photographs also were obtained, from which anthropometric
analysis was performed.
Randomization and Blinding
Before surgery, patients were randomly assigned to 1 of 2
equally sized groups via a computer-generated randomization system. The patients and nurses who later evaluated
postoperative outcomes were blinded to study group
assignment (double-blind design). However, because all
procedures were performed by the same surgeon (K.A.), it
was not possible to blind the surgeon to study group
assignment.
Surgical Techniques
Harvesting of Rib Cartilage
After assessing the grafting requirement, the surgeon
determined the harvest site; the fifth, sixth, and seventh
cartilaginous ribs were most frequently selected. The ribharvesting technique was similar to that described by
Cochran and Gunter3 (Figure 1). Through a 3- to 4-cm
As’adi et alNP23
Figure 2. (A) Harvesting of rectus muscle fascia from a 28-year-old woman was performed as a second surgical step through
the same incision made for harvesting costal cartilage. (B) The quadrangular strip of rectus muscle fascia graft harvested from
the patient.
incision just above the inframammary fold in women and
directly over the selected rib in men, the skin, subcutaneous, fascial, and muscle layers were transected until the
selected rib was exposed. A central longitudinal perichondrial incision was made along the length of the cartilaginous rib, and 2 vertical cuts were made at the most
lateral and medial parts of the rib. Two perichondrial
flaps, based on the superior and inferior rib borders, were
elevated to the deep surface of the rib. After adequate
release and transection of the lateral and medial ends, a
3- to 5-cm segment of rib cartilage was harvested, depending on the need for augmentation and/or structural support. The wound was irrigated, and pleural integrity was
verified.
After harvesting of the rib cartilage only (control group)
or the rib cartilage plus rectus muscle fascia (intervention
group), the perichondrium and muscles were reapproximated and the wound was closed layer by layer. Similar to
the technique described by Daniel and Calvert,8 the harvested cartilage was placed in antibiotic saline solution,
diced into 0.5- to 1-mm cubes on a silicone block with no.
11 blades, and packed into the cylinder of a 1-mL syringe.
Harvesting of Rectus Muscle Fascia (Intervention
Group)
The skin, subcutaneous, and superficial fascia were incised
down to the rectus muscle fascia through the same incision
used to harvest the rib cartilage. A quadrangular strip of
rectus muscle fascia was marked to an appropriate graft
size (4 × 2-3 cm). An incision was made with a no. 15
blade to beneath the rectus muscle fascia. With meticulous
dissection over the rectus muscle and countertraction on
elevated fascia, the fascia was easily separated from the
muscle through a bloodless dissection. The harvested fascia was placed in saline- and antibiotic-soaked gauze
(Figure 2).
Harvesting of Deep Temporal Fascia (Control Group)
A curved 3-cm temporal incision was made above the root
of the helix and 2 to 3 cm behind the anterior hairline. The
incision was placed parallel to hair follicles to avoid the
risk of alopecia. The superficial temporal fascia was incised
down to the glistening white surface of deep temporal fascia. A 4-cm × 2- to 3-cm strip of deep temporal fascia was
harvested and placed in saline- and antibiotic-soaked
gauze.
Fascial-Wrapped Diced Cartilage: Construction and
Placement Over Dorsum
The nasal dorsum was accessed through an open rhinoplasty approach and transcolumellar incision. The extent
of the defect area over the nasal dorsum was precisely
determined as the recipient site of the graft.
As described by Daniel and Calvert,8 harvested fascia
(rectus muscle fascia and deep temporal fascia) was
wrapped around a 1-mL syringe filled with diced cartilage
micrografts and secured with a running 5-0 Monocryl
suture (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio). The
fascial-wrapped diced cartilage was constructed on the
back table, without the injection technique (Figure 3).
The constructed graft was placed in the defect area, and
overcorrection was avoided. Fixation was achieved at the
cephalic end by transcutaneous pullout nasofrontal sutures
and at the caudal end to the anterior septal angle. As a
final step, digital manipulation allowed further refinement
to obtain a desirable shape and dorsal height (Figure 4).
Outcome Assessments
Dorsal nasal augmentation was assessed with dimensional
measurements from soft-tissue surface landmarks (nasion
and rhinion soft tissue), and anthropometric measurements were obtained from standardized preoperative and
NP24
Aesthetic Surgery Journal 34(6)
Figure 3. (A) Diced rib cartilage was packed into the cylinder of a 1-mL syringe. Harvested rectus muscle fascia was wrapped
around the syringe and secured with a running suture of Monocryl 5-0. (B) Length and (C) height of the construct of diced rib
cartilage and rectus muscle fascia.
Figure 4. Intraoperative view shows the placement of
a diced cartilage–fascia construct over the previously
determined defect of nasal dorsum in a 21-year-old woman.
A nasofrontal pullout suture was used as a guide and a
cranial point of fixation of the construct. The caudal end of
the construct was fixed to the anterior septal angle.
postoperative photographs of the patient’s profile (Image J
1.41 image processing software; US National Institutes of
Health, Bethesda, Maryland). Preoperative radix height
and dorsal nasal height were measured using soft-tissue
landmarks and compared with net postoperative changes.
Radix height was defined as the measurement from the
medial canthus to the nasion. Dorsal nasal height was
defined as the height of the nasal dorsum at the rhinion
level and was measured from the point at which the medial
canthus intersected the alar facial crease.10
A comparative review of pre- and postoperative photographs was performed by 2 independent plastic surgeons.
For both the intervention group and the control group, outcomes of dorsal augmentation were scored on a Likert
scale from 0 (least desirable) to 10 (most desirable). Patient
satisfaction with surgical outcome was assessed at the
1-month postoperative visit. Patients were asked to score
their satisfaction on a visual analog scale from 0 (least satisfied) to 10 (most satisfied).
Statistical Analysis
Data were analyzed with SPSS statistical software (SPSS,
Inc, an IBM Company, Chicago, Illinois). Continuous and
categorical data were analyzed by t test and χ2 test, respectively. In addition, the Mann-Whitney test was applied to
compare anthropometric indices between the study groups.
Statistical significance was defined as P < .05.
As’adi et alNP25
Table 1. Patient Demographics, Indication for Surgery, and Graft Size
Intervention Group (n = 18)
Age, mean ± SD, y
35.4 ± 2.6
Control Group (n = 18)
34.8 ± 3
Sex, No. (%)
P Value
.80
NS
Male
Female
7 (38.9)
6 (33.3)
11 (61.1)
12 (66.7)
Indication for surgery, No. (%)
NS
Cleft lip/nose
2 (11.1)
1 (5.5)
Posttraumatic
5 (27.7)
7 (38.8)
11 (61.1)
10 (55.5)
Length
19 ± 3.6
20.2 ± 3
.60
Width
7.2 ± 2.4
7.6 ± 2.1
.70
Height
6 ± 1.4
5.8 ± 0.9
.50
Intervention Group (n = 18)
Control Group (n = 18)
P Value
1 (5.5)
0
NS
Intraoperative bleeding, No. (%)
0
0
NS
Operating time, mean ± SD, min
15.6 ± 3.5
30 ± 4.6
<.0001
Cosmetic
Size of diced cartilage–fascia graft, mean ± SD, mm
Abbreviations: NS, difference not statistically significant; SD, standard deviation.
Table 2. Intraoperative Events and Operating Time
Pleural tears/pneumothorax, No. (%)
Abbreviations: NS, difference not statistically significant; SD, standard deviation.
Results
Eighteen patients (the intervention group) were treated
with diced cartilage wrapped in rectus muscle fascia, and
18 (the control group) were treated with diced cartilage
wrapped in deep temporal fascia. No patient was lost to
follow-up, and the median follow-up time was 12 months
(range, 10-20 months). Patient demographics, indication
for surgery, and graft size did not differ significantly
between the study groups (P > .05). Twenty-three patients
(63.9%) were women, and 13 (36.1%) were men. The
mean age was 35.2 ± 2.7 years (range, 19-42 years).
Cosmetic rhinoplasty was the most common indication
(58.3%) for surgery (Table 1).
Intraoperative events and operating times are listed in
Table 2. Operating time (± standard deviation) for harvesting
rib cartilage and fascia was significantly lower for the intervention group (15.6 ± 3.5 minutes vs 30 ± 4.6 minutes for
the control group; P < .0001). Pneumothorax occurred in 1
patient in the intervention group, during harvesting of rib cartilage. No other significant differences in intraoperative
adverse events were observed between the groups (P > .05).
Aesthetic outcomes are listed in Table 3. Asymmetry
occurred in 1 patient (5.5%) in the intervention group. The
2 major anthropometric indices—net alterations of radix
height and dorsal nasal height—did not differ significantly
between the groups (P > .05). Rates of other aestheticrelated events, such as visibility and step-off, were similar
for the groups (Table 3).
One case (5.5%) of surgical site infection occurred in
the control group and resolved with appropriate antibiotic
treatment. One patient from each group (5.5% of each
group) required revision surgery.
A case of mild junctional step-off at the radix occurred
in the intervention group, which was easily managed
with injection of Juvéderm (Allergan, Inc, Irvine,
California) performed as an outpatient procedure. One
case of pleural tear and air leak during rib harvesting,
also in the intervention group, was managed by intraoperative lung expansion and water-tight closure of the
chest wall incision. One patient in the intervention group
and 2 patients in the control group had palpable dorsal
grafts, without any visibility or contour deformity. No
cases of resorption were noted.
NP26
Aesthetic Surgery Journal 34(6)
Table 3. Postoperative Aesthetic Outcomes
Intervention Group (n = 18)
Control Group (n = 18)
10.2 ± 1.7
9.6 ± 1.9
3.6 ± 0.9
3.3 ± 1.1
16.7 ± 2.4
17.3 ± 2.1
Postoperative net change
6.8 ± 1.3
7.4 ± 1.6
Visibility/palpability, No. (%)
1 (5.5)
2 (11.1)
Dorsal asymmetry, No. (%)
1 (5.5)
0
1 (5.5)
0
0
1 (5.5)
Radix height, mean ± SD, mm
Preoperative
Postoperative net change
Dorsal nasal height, mean ± SD, mm
Preoperative
Step-off, No. (%)
Radix
Supratip
Abbreviation: SD, standard deviation.
Table 4. Postoperative Clinical Outcomes
Intervention Group (n = 18)
Control Group (n = 18)
P Value
0
1 (5.5)
NS
Revision surgery, No. (%)
1 (5.5)
1 (5.5)
NS
Patient satisfaction score, mean ± SD
8.4 ± 3.1
5.3 ± 2.7
<.0001
Surgical team evaluation score, mean ± SD
6.2 ± 3.6
4.7 ± 2.4
.025
Postoperative hospital stay, mean ± SD, h
16.2 ± 5.8
25.6 ± 6.4
<.0001
Infection, No. (%)
Patient satisfaction was scored on a scale of 0 (least satisfied) to 10 (most satisfied). Surgical outcomes were scored on a scale of 0 (least desirable) to 10 (most desirable). Postoperative
hospital stay was defined as the time from patient entry to the surgical ward until hospital discharge. Abbreviations: NS, difference not statistically significant; SD, standard deviation.
Mean patient satisfaction rates were significantly higher
for the intervention group (8.4 ± 3.1 vs 5.3 ± 2.7 for the
control group; P < .0001), likely due to the single surgical
site, lower level of pain, and diminished donor-site morbidity. The mean postoperative hospital stay (time from
patient entry into the surgical ward until hospital discharge) was significantly shorter for the intervention group
(16.2 ± 5.8 hours vs 25.6 ± 6.4 hours for the control
group; P < .0001). Postoperative clinical outcomes are
summarized in Table 4. Representative pre- and postoperative photographs from patients in the intervention group
are shown in Figures 5 and 6.
Discussion
The ideal reconstructive technique for nasal dorsum
defects is still evolving. Rib cartilage continues to be the
preferred grafting material for complex rhinoplasty deformities when a considerable amount of cartilage is required
for dorsal augmentation and/or robust structural integrity.
Despite improvements in harvesting and processing of rib
cartilage (such as internal stabilization and central and
balanced cross-sectional carving), the primary challenges
of solid rib cartilage remain: visibility, abnormal contouring, and warping.3,4,11 Wrapping diced rib cartilage in
Surgicel,6 autologous fascia,7,8,12 or Alloderm9 addresses
these limitations by providing a pliable dorsal graft with
minimal visibility and a smooth transition between dorsum and lateral nasal subunits, without the risk of warping. With the increased popularity of diced cartilage for
dorsal nasal augmentation, there has been greater focus on
wrapping methods that enclose the cartilaginous fragments and homogenously stabilize them inside the area of
defect.13,14
Erol6 reported successful outcomes with Surgicel as a
sleeve for diced cartilage grafts for rhinoplasty, which
obviated an additional harvest site for autologous tissue,
increased collagen content, and suppressed the generation
capacity of cartilage cells without affecting viability.15,16
However, due to the high rate of cartilage resorption, the
As’adi et alNP27
Figure 5. (A, C, E, G) This 18-year-old woman presented with a low-set dorsum, wide middle vault, and a poorly defined
nasal tip with thick skin. She had nasal trauma during childhood, which resulted in deficient septal support. (B, D, F, H)
Twenty-six months after dorsal nasal augmentation with diced rib cartilage wrapped in rectus muscle fascia and placement
of additional structural grafts derived from the harvested sixth costal cartilage (columellar strut graft, lateral crural strut graft,
and tip graft). Nasal base stabilization and improved tip definition were achieved.
NP28
Aesthetic Surgery Journal 34(6)
Figure 5. (continued) (A, C, E, G) This 18-year-old woman presented with a low-set dorsum, wide middle vault, and a poorly
defined nasal tip with thick skin. She had nasal trauma during childhood, which resulted in deficient septal support. (B, D, F,
H) Twenty-six months after dorsal nasal augmentation with diced rib cartilage wrapped in rectus muscle fascia and placement
of additional structural grafts derived from the harvested sixth costal cartilage (columellar strut graft, lateral crural strut graft,
and tip graft). Nasal base stabilization and improved tip definition were achieved.
As’adi et alNP29
Figure 6. (A, C, E) This 32-year-old woman, who had undergone 2 previous rhinoplasty procedures, presented with a
foreshortened nose from overresection of the nasal dorsum and a rotated nasal tip. (B, D, F) Sixteen months after corrective
rhinoplasty, which included harvest of the sixth costal cartilage for dorsal augmentation with a construct of diced rib cartilage
and rectus muscle fascia plus additional structural grafts (septal extension, extended spreader graft, and shield graft for
structural support and lengthening of the nose).
NP30
Aesthetic Surgery Journal 34(6)
Figure 6. (continued) (A, C, E) This 32-year-old woman, who had undergone 2 previous rhinoplasty procedures, presented
with a foreshortened nose from overresection of the nasal dorsum and a rotated nasal tip. (B, D, F) Sixteen months after
corrective rhinoplasty, which included harvest of the sixth costal cartilage for dorsal augmentation with a construct of diced
rib cartilage and rectus muscle fascia plus additional structural grafts (septal extension, extended spreader graft, and shield
graft for structural support and lengthening of the nose).
longevity of results attained with Surgicel-wrapped cartilage has been questioned.8 Autologous fascia, which has
optimal tensile strength and good tissue integration,
became a preferred material for enclosing diced cartilage.7,8,17 Daniel4 used deep temporal fascia to wrap cartilage for major dorsal nasal augmentation; this construct
provided a stable dorsal nasal graft with no evidence of
cartilage absorption. Guerrerosantos et al14 reported excellent long-lasting aesthetic results in augmentation rhinoplasty with fascial-wrapped multifragmented cartilage
obtained from ear concha. However, additional donor-site
morbidity remained a potential drawback. Despite newer
techniques with autologous fascia as an enclosure for
diced cartilage, harvesting fascia from a location other
than the costal cartilage donor site (eg, the temporal area)
is a demanding technique that may increase morbidity.
Regardless of the type of autologous fascia, all patients
in our study had optimal long-term outcomes with no significant change from the initial postoperative degree of
dorsal augmentation. The diced rib cartilage fascia construct provided a stable dorsal nasal graft and durable
outcomes.
To our knowledge, this is the first comparative analysis of
outcomes for fascial grafting with diced rib cartilage vs rectus
muscle in dorsal nasal reconstruction. Our results showed
that rectus muscle fascia is a feasible option for enclosing
diced cartilage. Although the rates of intraoperative events
and postoperative complications were similar for the 2 types
of fascial grafts, rectus muscle fascia grafts were associated
with reduced operating time and shorter hospital stays (vs
traditional grafts), and they eliminated the need for an additional autologous donor site for the fascial sleeve. In addition,
patients were significantly more satisfied with the newer
technique, likely because of the single donor site (minimizing
morbidity and scarring) and the potential for a less painful
recovery. As autologous tissues, the rectus muscle fascia and
deep temporal fascia share similar histologic characteristics;
they are comparable in tensile strength, tissue incorporation
As’adi et alNP31
capability, and scaffolding effects. Deep temporal fascia is
more elastic than rectus muscle fascia, but we experienced no
technical difficulty when wrapping with rectus muscle fascia
(Figure 3). The poor dimensional stability of deep temporal
fascia as a free graft and its tendency to shrink more than the
fascia lata have been reported.18 Because of the gross similarity of the rectus muscle fascia and the fascia lata, rectus muscle fascia grafts may undergo less contraction and shrinkage
than deep temporal fascia grafts. With respect to dorsal nasal
and radix augmentation, there was no significant difference
in long-term absorption of the diced cartilage–fascia constructs between our study groups. Further investigation of the
dimensional stability and contraction of the rectus muscle
fascia as a free graft is recommended.
Relative to the traditional approach, the benefits of the
newer technique include reductions in operating time and
hospital stay. The advantages of temporal fascia are maintained while donor-site morbidity is reduced. Moreover,
surgical outcomes are more favorable, patient satisfaction
is greater, and the risk of alopecia (which may occur when
harvesting deep temporal fascia) is eliminated.
Revision surgery was needed for only 2 of our patients
(1 in each study group.) The patient in the intervention
group experienced a supratip step-off deformity that
required revision surgery for placement of a cartilage graft.
The patient in the control group had nasal asymmetry;
during revision surgery, lateral displacement of the diced
cartilage–fascia construct was observed.
Our small randomized controlled trial will pave the way
for additional studies of the utility of rectus muscle fascia
for wrapping diced cartilage. Future research in larger
study populations is warranted to permit thorough investigation of the pros and cons of this technique. Moreover, it
will be important to evaluate clinical and aesthetic outcomes in a more quantitative manner. A head-to-head
comparison of our technique with the Surgicel technique
also may provide valuable information.
Conclusions
Harvesting rectus muscle fascia is a feasible and reliable
technique for dorsal nasal reconstruction surgery that
requires wrapped diced rib cartilage. Using the same donor
site for harvesting and augmentation is associated with
favorable clinical and aesthetic outcomes.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
References
1.Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey A.
Dorsal nasal augmentation with rib cartilage graft: longterm results and patient satisfaction. J Craniofac Surg.
2007;18(6):1457-1462.
2. Cervelli V, Bottini DJ, Gentile P, et al. Reconstruction of
the nasal dorsum with autologous rib cartilage. Ann Plast
Surg. 2006;56(3):256-262.
3.Cochran CS, Gunter JP. Secondary rhinoplasty and the
use of autogenous rib cartilage grafts. Clin Plast Surg.
2010;37(2):371-382.
4.Daniel RK. Rhinoplasty: dorsal grafts and the designer
dorsum. Clin Plast Surg. 2010;37(2):293-300.
5. Tabbal N, Tepper OM. Diced cartilage versus solid grafts
in rhinoplasty. Aesthetic Plast Surg. 2011;35(4):580-581.
6.Erol OO. The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr Surg. 2000;105(6):2229-2243.
7.Daniel RK. Diced cartilage grafts in rhinoplasty surgery:
current techniques and applications. Plast Reconstr Surg.
2008;122(6):1883-1891.
8. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty
surgery. Plast Reconstr Surg. 2004;113(7):2156-2171.
9.Gordon CR, Alghoul M, Goldberg JS, Habal MB, Papay F.
Diced cartilage grafts wrapped in AlloDerm for dorsal nasal
augmentation. J Craniofac Surg. 2011;22(4):1196-1199.
10. McKinney P, Sweis I. A clinical definition of an ideal nasal
radix. Plast Reconstr Surg. 2002;109(4):1416-1420.
11.Farkas JP, Lee MR, Lakianhi C, Rohrich RJ. Effects of
carving plane, level of harvest, and oppositional suturing techniques on costal cartilage warping. Plast Reconstr
Surg. 2013;132(2):319-325.
12.Calvert J, Brenner K. Autogenous dorsal reconstruction:
maximizing the utility of diced cartilage and fascia. Semin
Plast Surg. 2008;22(2):110-119.
13. Harel M, Margulis A. Dorsal augmentation with diced cartilage enclosed with temporal fascia in secondary endonasal rhinoplasty. Aesthetic Surg J. 2013;33(6):809-816.
14.Guerrerosantos J, Trabanino C, Guerrerosantos F. Multifragmented cartilage wrapped with fascia in augmentation
rhinoplasty. Plast Reconstr Surg. 2006;117(3):804-816.
15. Yilmaz S, Ercocen AR, Can Z, Yenidunya S, Edali N, Yormuk
E. Viability of diced, crushed cartilage grafts and the effects
of Surgicel (oxidized regenerated cellulose) on cartilage
grafts. Plast Reconstr Surg. 2001;108(4):1054-1062.
16. Erol OO, Gundogan H. Diced cartilage grafts in rhinoplasty
surgery. Plast Reconstr Surg. 15 2005;116(4):1169-1173.
17.Kelly MH, Bulstrode NW, Waterhouse N. Versatility of
diced cartilage-fascia grafts in dorsal nasal augmentation.
Plast Reconstr Surg. 2007;120(6):1654-1659.
18.Indorewala S. Dimensional stability of free fascia grafts:
clinical application. Laryngoscope. 2005;115(2):278-282.