Nasal augmentation and management of saddling remains the area of most challenge and controversy. In the early days, reduction was the major concern of the Joseph rhinoplasty. Recently, in the new concept of rhinoplasty, the reduction attitude has changed and the aim now is to achieve a strong, profound, defined and well oriented nose, The author means a balanced nose. Therefore, augmentation procedures are needed in almost every rhinoplasty.
- Postseptal surgery:
Post SMR and septoplasty.
- Nasal hump over-reduction:
Cartilagenous or bony.
- Fractured nasal bone:
- Ethnic congenital or genetic:
Black and Chinese are characterized by flat, shallow nasal dorsum with wide ill- defined tip and wide nares.
Septal abscess, syphilis, leprosy.
Types of Saddling Deformities:
- Minor deformities:
- Minimal supratip collapse.
- Minor columellar retraction.
- Alar collapse.
- Upper lateral cartilage collapse.
- Moderate to major deformities:
- Marked supratip collapse.
- Marked or massive bony bridge collapse.
- Bony and cartilagenous collapse or saddling (broad and flattened bony pyramid).
- Marked upper lateral cartilage collapse.
|Fig. 11 – 1. (A) Bony collapse was corrected by double septal grafts. (B,C) Post submucous resection supratip collapse was corrected by conchal supratip grafts.|
|Fig. 11 – 2. The edge of the dorsum graft should be bevelled or trimmed in a triangular way in order to avoid step deformities and demarcation.|
|Fig. 11 – 3. Clinical application of grafts:
1. Columellar strut 2. Tip graft 3. Supratip graft 4. Dorsum graft
5. Nasofrontal angle graft 6. Spreader graft 7. Batten graft
Types of grafts:
One hundred years ago, Jacques Joseph (1865-1934) used ivory to augment the nasal dorsum and chin, this was obtained from a nearby piano factory.
Nowadays, autogenous cartilage is used more often. The author prefers autogenous cartilage, it has superior long term survival characteristics, it is available from the nose and from the ears, there is minimal infection and absorption, it is flexible and it is more natural for the anatomical structure of the nose. For more major saddling, the author uses laminated, layered and multiple conchal grafts but rarely silicon or iliac crest grafts. However, the ideal nasal grafting material is still not in existence. When it is developed, it will enhanced our rhinoplasty results. (Fig. 17 – 20)
- Septal cartilage graft:
Suitable for columellar strut, tip graft, spreader graft, supratip and dorsum grafting.
- Auricular graft:
Dorsum augmentation, supratip augmentation, alar graft, tip graft and upper or lower cartilage grafting.
- Excised cephalic portions of lateral crus:
Suitable for lateral crura, Batten graft, upper lateral cartilage graft, nasofrontal angle, and supratip.
In the author’s experience, we have enough cartilage grafts from the nasal septum and the ear, that should be more than adequate for any major reconstruction [septum (2.5cm x 1.5cm), conchal (4.5cm x 1.5cm)]. The author has never found the need for rib grafts and rarely any reason to use any alloplastic implants such as Polymer Mesch or proplast. On occasions, the author has used silicon in Chinese and Black patients for the reconstruction of major saddling. Recently, the author, has on a few occasions used fascia lata and AlloDerm which are proving to be practical and reliable without the postoperative problems of floating and demarcation. AlloDerm seems to be promising but it is expensive.
Preparation of the graft:
- When the graft is taken from the ear, a full aseptic technique must be applied.
- Care should be taken in order not to destroy the septal or conchal graft.
- Graft should be left in Povidone during the operation until it is used.
- The edge of the graft should be bevelled or trimmed in a triangular way to avoid steps deformities or showing of the sharp edges. (Fig. 11 – 2 and Fig. 17 – 21)
- Avoid crushing or morsilization of the graft, except the shield tip grafts in thin skinned patients. (Fig. 17 – 7)
|Layered dorsum graft|
|Lengthened dorsum grafts|
|Dorsum and supratip graft|
|Fig. 11 – 4. Dorsum grafts may be layered in order to increase its bulk and length. The layered cartilages are sutured together.|
- Suture fixation of the graft is preferable but avoid too many sutures. (Fig. 17 – 21)
- Grafts may be laminated or layered in order to increase their bulk or length for major augmentation. The layered pieces of cartilage should be stitched together. Double or triple layers of long bridge graft may be indicated. (Fig. 11 – 4)
- Leave a small amount of soft tissue fixed with the graft, this allows for easy suturing in place.
- Temporalis fascia may be required to cover the graft to achieve smoother surface.
- At the end of the operation suitable mild pressure should be applied on the nose, in order to prevent dead space and keep the graft in direct contact with cartilage, bone and skin for its blood supply and survival. (Fig. 17 – 22)
- In major augmentation avoid too much pressure on the nose by the strips or plaster, this might cause skin necrosis. The factors which predispose for skin necrosis are, the pressure applied by the cast, stretching of the skin by the bulky graft and the graft itself which acts as a barrier for the blood supply between the skin and the dorsum.
- Plastic or x-ray sheets applied externally on the sides of the nose for seven days will help to keep the graft in the middle and avoid displacement. (Fig. 17 – 22)
- Bilateral index finger massage applied for ten minutes, four times a day, for two months postoperatively, is highly recommended in order to maintain the bridge graft in the middle position. (Fig. 2 – 7)