The main enemy of grafting is infection. If it happens, the graft will be destroyed and revision may be required later. Therefore, aseptic technique and prophylactic antibiotics are vital.
Absorption of cartilage autografts are extremely rare in the tip and supratip region. In rare situations, absorption is noticed in autogenous cartilage covering the bony nasal dorsum. On this occasion the patient comes back to the clinic saying that his nose is looking smaller than it was soon after operation. In this situation, a strip of autogenous auricular graft is inserted into a precise pocket, it will elevate the dorsum.
- This is usually done as an out patient under local anaesthetic and takes no more than ten minutes. On rare situations, when there is no more autogenous septal or conchal graft available, an irradiated homograft can be used and if absorbed, repeated in the future as necessary.
- Graft displacement:
To avoid early graft displacement, the graft should be positioned accurately during operation, stitched if necessary to adjacent dorsum, septum or alar cartilage. External steri-strips and plaster are used for one week to keep the bridge graft in the middle followed by instructed bilateral index finger massage. The massage is done by applying gentle pressure with two fingers on the sides of the nose equally on each side of the grafts for ten minutes to maintain the graft in the middle. This is repeated three to four times a day for two months (Fig. 2 – 6). Late displacement may occur six to twelve months postoperatively due to uncontrolled wound contraction and healing. In this situation, under local anaesthesia, undermining and repositioning of the graft is indicated.
- Graft movement and mobility:
The patient may complain that he can mobilize the graft with his fingers. If the graft is in the middle and in the right position, the patient is reassured.
- Line of demarcation:
The sharp edges of the graft may show through the skin or step deformity may be formed. Therefore, bevelling of the graft edges and triangular trimming along the edge of the dorsum and tip grafts are highly indicated to reduce this problem.
- Skin necrosis:
This very rare complication is reported in major augmentation when bony graft or multiple layered cartilage graft are used with pressure dressing. The bulky graft will stretch the dorsum skin, the graft acts a barrier for the blood supply and with application of pressure dressing strips and tight plaster of paris, necrosis of the skin may occur.
The main alarming sign is that the patient will complain of severe pain on the nose early in the postoperative period. The dressing and the plaster should be immediately removed and the skin on the nose inspected. If there is necrosis, or bluish discolouration, the graft should be removed and changed to a smaller one with application of local and systemic antibiotics.
- Graft displacement:
|Fig. 11 – 7. Post traumatic saddling and wide tip. Augmentation rhinoplasty was performed. Lateral and medial osteotomies, dorsum septal graft, new dome creation, suture fixation, scoring, columellar strut and tip grafts.|