- Dorsum grafts:
Septal or conchal or both are used to augment the nasal bridge. As previously stated, there are more than adequate autogenous septal and conchal grafts readily available for most cases, septum (2.5cm x 1.5cm), conchal (4.5cm x 2cm) and the other conchal side may be used. A short graft may be needed to augment the bony pyramid or a long graft to augment both the bony and cartilagenous pyramid. The graft may be single, doubled or even tripled as indicated. The second or third layer may be of the same length or shorter and is placed on the area where most augmentation is required. When a layered conchal graft is used it is preferred to be covered with septal strip to provide a smoother dorsum. The graft is usually stabilized by a single suture to the dorsum septum or by double suture to the apex of the dome of the alar behind the tip graft. A graft to skin pullout suture may be required to position the graft. The pullout suture is removed five days postoperative. More stabilization of the dorsum graft and supratip graft may be achieved by a plastic or x-ray sheet applied externally on the sides of the nose fixed by steri-strips for a few days. This will help to keep the graft in the middle. (Fig. 11 – 3 and Figs. 17 – 21,22)
|Fig. 11 – 5. A 22-year-old patient with a broad and collapsed nose. Correction was obtained by medial and lateral osteotomies, new dome creation, suture fixation, scoring, columellar strut and tip grafts and double conchal dorsum grafts.|
- Supratip graft:
Septal or conchal graft used. The graft is measured to fit the cartilagenous dorsum. Double layer may be needed. The graft is positioned and established by 4/0 Dexon suture to the dorsum septum or sutured to the delivered dome cartilages just behind the tip graft. (Fig. 17 – 21)
- Columellar strut:
Septal graft 2.5cm x 0.5cm is ideal. The aim is to achieve tip elevation, projection and narrowing and prevent columellar retraction and correct bifid columella.(Fig. 17 – 15)
- Tip graft:
Septal or conchal. The triangular shield graft may be short, long, double or even triple. It is sutured to the caudal margin of the intermediate crura or used as an umbrella. The aim is to achieve tip definition, projection, elevation, refinement, symmetry and narrowing. Tip graft must be crushed in a thin skinned patient.(Fig. 17 – 16)
- Batten or alar grafts:
Conchal or excised cephalic portion of the upper lateral cartilage are ideal. This type of graft is indicated in alar collapse, dimpling, retraction, pinching, alar asymmetry and in small or underdeveloped lateral crus in order to achieve strong, profound, defined and well oriented nasal side walls. (Fig. 8 – 30 and Fig. 17 – 23)
- Spreader grafts:
Best to be a septal graft. It is very useful in crooked noses to correct the C-shaped dorsum septal deviation, by positioning and suturing the graft to the concave septal surface. Bilateral spreader grafts also correct cartilagenous dorsum narrowing and valve collapse. (Figs. 9 – 9,10 and Fig. 17 – 24)
- Anchor and rim grafts:
Anchor grafts are very helpful in tip deformity associated with cleft lip. The graft will help in achieving symmetry and correct alar rim collapse and notching. Rim grafts are useful in mild rim notching. (Fig. 8 – 30 and Fig. 17 – 23)
- Upper lateral cartilage grafts:
Conchal or septal grafts and excised cephalic portion of lower lateral cartilage may be used to augment depressed or lost upper lateral cartilage. This is common in trauma and revised cases.
- Nasofrontal angle grafts:
Septal, conchal or excised cephalic portion of lateral crus may be used to flatten and elevate the deep nasofrontal angle. (Fig. 17 – 21)
- Chinese and Black.
- Major trauma reconstruction.
- Augmentation of tip and bridge at the same time in a single manoeuvre.
- Easy and quick to insert. The procedure takes about fifteen minutes under local anaesthetic. (Fig. 17 – 22)
- Silicon implants:
- Early or delayed rejection.
The fibrous capsule formed around the implant acts as a barrier to infection. Therefore, treatment with antibiotics is justified when the implant site becomes infected, as it is possible to heal without removing the implant.
- Line of demarcation:
The fibrous capsule formed around the implant, may contract the surrounding skin and outline the implant. This may be cosmetically unacceptable as the implant will be visible under the skin.
- Implant mobility (free floating):
The implant may be moved from side to side by patient’s fingers. This may concern the patient.