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Augmentation rhinoplasty

BY SOTIRIOS FOUTSIZOGLOU

hinoplasty refers to a must possess a thorough knowledge procedure in plastic of nasal anatomy and ideal facial in which the structure of the aesthetic proportions. The Rnose is changed by adding or must also be familiar with all types removing or , grafting of material and the current tissue from another part of the body, techniques and methods to correct or implanting synthetic material to nasal deformities. This article addresses alter the shape (and function) of the augmentation of the nose based on a nose. Nasal surgery can be performed unique method developed by Mr Tim to correct functional problems (e.g. Leontsinis (Consultant ENT and Facial improvement in airway function Plastic Surgeon) using rib cartilage without changes in nasal contour) or in conjunction with commercially purely for cosmesis. However, the most available bovine pericardium common scenario involves a patient (Tutopatch®). seeking both functional and cosmetic nasal enhancement. After all, a Cosmetic rhinoplasty misshapen nose is often associated with Cosmetic alteration to the nose may corresponding functional abnormalities be undertaken for a variety of different such as a deviated septum. indications. The commonest practice Figure 2: Wegener’s granulomatosis Despite the fact that rhinoplasty is is to carry out a reduction rhinoplasty the most common facial, and overall to reshape the nose and to make it the third most common, operation smaller. The patient usually wants the Augmentation rhinoplasty, however, in aesthetic among removal of a nasal hump or a more is performed when the individual has both men and women, it is one of the refined nasal tip. This will often make too little tissue to provide an attractive most technically difficult surgical the nose look smaller because bone or shape to the nose. The nose also usually procedures requiring a high level of cartilage has been removed. Hence the lacks support and may appear ‘floppy’ expertise and experience. To obtain term ‘reduction rhinoplasty’ is used to with some compromise of breathing as aesthetically pleasing results, ensure describe the procedure. An example well. The cause of this type of deformity patient satisfaction, and minimise of reduction rhinoplasty and profile may be congenital or due to an accident complications, the rhinoplasty surgeon realignment is shown in Figure 1. or even the result of previous nasal surgery. The latter occurs if there has been over-reduction of the dorsum or tip from a previous rhinoplasty or if too much septal cartilage has been removed with a previous . Previous over-reduction of the bony dorsum will give the nose a so-called ‘ski slope’ appearance. If too much cartilage from the septum has been removed due to an overzealous septoplasty, the deformity that may ensue is that of a . In this instance the loss of cartilage causes collapse of the area immediately above the tip, which causes an over- rotated tip and a shortened nose with a ‘piggy’ look. Medical conditions such as Wegener’s granulomatosis may also result in this problem, due to septal collapse. An example of Wegener’s is shown in Figure 2. Another reason for collapse of the septum is use, Figure 1: Reduction rhinoplasty which causes septal perforation.

pmfa news JUNE/JULY 2016 | | VOL 3 NO 5 | www.pmfanews.com FEATURE

Augmentation rhinoplasty is therefore carried out to correct the Table 1: Material used in augmentation rhinoplasty. cosmetic deformities that result from Autografts / own tissue Septal cartilage either previous over-reduction of the nose or nasal collapse due to the cartilage reasons discussed above. Rib Bone (e.g. outer table cranial bone, Materials used in nasal reconstruction iliac bone) Throughout the 20th century, various alloplastic materials – as well as autologous grafts – were used Homografts or Allografts / Human cadaver rib cartilage for nasal reconstruction. In 1907, same species (Tutoplast) Jacques Joseph described the use of autologous cartilage inserted as a free Xenografts / different Porcine graft through an endonasal incision species Bovine pericardium (Tutopatch) [1]. In 1941, Peer described the ability of autologous septal and auricular cartilage to resist resorption [2]. Alloplasts Silastic (silicone) Over the ensuing decades, a variety Gortex (ePTFE) of grafts for augmentation of the Injectable fillers (e.g. hyaluronic dorsum and tip have been described. In 1979, Tardy described 2000 cases acid, CaHA, Aquamid) of dorsal augmentation performed by using autograft cartilage (septum, pinna and rib), with low resorption and began using tip grafting to project the nasal augmentation. Figures 4 and rates, which subsequently nasal tip in the early 70s [4]. First single 5 demonstrate augmentation using became standard practice for primary grafts were used followed, a few years septal cartilage. augmentation rhinoplasty [3]. In recent later, by multiple layered grafts of solid, The alternative method is rib decades, in addition to the traditional scored, or morselised cartilage. Over cartilage, which can be used in the autograft dorsal augmentation, a vast the years tip grafting with autograft dorsum or to reconstruct the septum array of alloplasts, xenografts and material, such as septal or auricular (Figure 6). Rib cartilage is often a allografts for nasal augmentation has cartilage, has proven to be a reliable, good choice in the dorsum but some also been described (Table 1). As for tip stable method to improve tip projection patients may refuse to allow their own enhancement Jack Sheen and others and definition, and to camouflage rib to be used because of perceived irregularities. morbidity and scarring. In that case The prevailing view is that permanent another option would be the use of alloplasts (foreign material) are human cadaver rib cartilage, available undesirable. The safest option is always commercially as Tutoplast-processed to use natural material, preferably costal cartilage [TPCC] which is one the patient’s own tissue. However of the safest and strongest allograft one’s own cartilage is not always fit options available [5]. Tutoplast® is a for purpose and may also be either patented, scientific and technology insufficient in amount or difficult to based process of virally inactivating, harvest. Our personal view is that bone preserving and sterilising human should never be used for augmentation. tissue for transplantation. Ear cartilage is not always suitable, all over the world have used Tutoplast especially in the dorsum above the allografts for over 30 years. More than level of the rhinion (i.e. the point where one million patients have received the cartilage and bone meet on the Tutoplast tissues without a single dorsum). The skin is thin above this known or documented case of disease area, so the graft is easily seen if it is not transmission [1]. In augmentation well camouflaged. Ear cartilage may rhinoplasty, particularly in revision distort with time, so that an initially surgery where the availability of good result may worsen later especially sufficient autologous cartilage becomes in the aforementioned area of the nose. more of an issue, TPCC may be used as In primary rhinoplasty the first an alternative to autologous cartilage choice for an autograft is septal as it eliminates the need for cartilage cartilage, often crushed to prevent it harvesting and is not associated with from being visible through the skin. donor site morbidity and scarring or Figure 3 demonstrates the appearance additional operation time. In addition of septal cartilage after it has been TPCC retains most of the general Figure 3: Crushed septal cartilage. crushed in preparation for use in characteristics of autologous cartilage.

pmfa news JUNE/JULY 2016 | | VOL 3 NO 5 | www.pmfanews.com FEATURE

Figure 4a: Before augmentation with septal cartilage. Figure 4b: Crushed cartilage placed externally. Figure 4c: Appearance after augmentation.

Figure 5: Septal cartilage augmentation (Left – pre augmentation and right – post augmentation). Figure 6: Rib cartilage immediately after harvesting and shown after balanced cross- sectional carving.

Nasal augmentation with the so that it assumes a more natural Other implants use of Tutopatch and less ‘hard’ appearance. Once The use of silicone and other permanent Our preference for augmentation of the desired length and thickness of graft materials in the nose is generally the dorsum is to use rib cartilage. the Tutopatch envelope containing not advocated. These tend to be Although it is possible to obtain rib fragments has been created the unreliable and the rate of extrusion and a very good result with rib cartilage composite graft can be inserted via other complications is too high to make that has been carved appropriately a closed or an open approach and such grafts a viable and safe option. and then placed in position without placed as a single layer onto the Injectable hyaluronic acid or CaHA fixation, Mr Leontsinis’ usual practice nasal dorsum. No fixing is required fillers are suitable for augmentation is now to use a different method other than a nasal splint which needs of minor defects. They offer a good of preparation of such grafts. The to be worn for at least seven days. alternative to revision surgery when carved rib graft has the potential to Tutopatch is a solvent-dehydrated there is only a small area to be filled out. be visible through the skin and also gamma irradiated preserved bovine The patient should be made aware of has the potential to warp. The latter pericardium surgical mesh. The the fact that repeat injections are likely may cause the nose to look deviated, Tutopatch implant consists of to be necessary to maintain the result. although this occurs only in a minority collagenous with Generally, fillers are not suitable in the of such grafts (Figure 7). Symmetrical three dimensional intertwined fibre. nasal tip and their use is best confined carving of the harvested rib can Therefore, it has a multidirectional to the dorsum, where they should be minimise warping. Warping usually mechanical strength and can be fixed injected just above the periosteum or occurs early, so it might be evident regardless of the direction of the graft. perichondrium. even during surgery. In such instances Collagenous connective tissue with this can be corrected immediately. multidirectional fibres retains the Conclusion If the graft warps later on, however, mechanical strength and elasticity of The key to success in nasal revision surgery might be indicated. the native tissue, while providing the augmentation is to correctly analyse Mr Leontsinis’ method is to chop up basic formulative structure to support the cause of the deformity and then to the rib, using the resulting shavings to replacement by new endogenous choose the simplest effective option to augment the nose. The shavings can tissue resulting in a smoother and correct the defect. This may involve the be wrapped in fascia or commercially more natural result. Commercially use of one or more grafts as discussed available bovine perichondrium available human cadaver rib (TPCC) above, preferably using natural tissue (Tutopatch), which helps to disguise offers an alternative to harvesting the and sometimes with the assistance of a the graft and allows it to be moulded patient’s own rib as discussed earlier. dermal filler for minor refinements.

pmfa news JUNE/JULY 2016 | | VOL 3 NO 5 | www.pmfanews.com FEATURE

Table 3: Advantages and disadvantages of dermal fillers in nasal augmentation. Advantages Disadvantages Can be used in both Non-permanent congenital and acquired nasal defect Satisfactory cosmetic Limited range of application enhancement Can be used in conjunction Skin or thinning with rhinoplasty surgery Minimally invasive Cannot correct functional problems Less expensive Not recommended for nasal tip Figure 7: Conchal graft distortion and subsequent correction using autograft rib cartilage. Safer Cannot be used when nasal

Table 2: Most common complications associated with TPCC. reduction is required Complication Rate Less complications Partial resorption 17% Potential for reversibility Warping 9% Minimal downtime Graft fracture 3% Quick treatment Visible graft contour 3% Only topical anaesthesia 0% required

References Acknowledgement: 1. Joseph J. Contributions to Rhinoplasty. Berl Klin With thanks to Mr Tim Leontsinis, Consultant ENT and Wahnschr 1907;46:470. Facial Plastic Surgeon, City Hospitals Sunderland NHS Dr Sotirios 2. Chu EA. Augmentation Rhinoplasty. . Foundation Trust. Foutsizoglou, medscape.com/article/881443-overview. March 2009 Cosmetic Surgeon and Founder 3. Tardy ME, Denney J, Fritsch MH. The versatile cartilage of SFMedica, London, UK. autograft in reconstruction of the nose and . E: [email protected] Laryngoscope 1979; 95: 523-33. 4. Sheen JH. Achieving more nasal tip projection by the use of a small autogenous or septal cartilage graft. Reconstr Surg 1975;56:35-40. 5. Hyung MS. Processed costal cartilage homograft in Declaration of competing interests: rhinoplasty. The Asian Medical Center Experience. None declared. Arch Otolaryngol Head Neck Surg 2008; 134(5).

pmfa news JUNE/JULY 2016 | | VOL 3 NO 5 | www.pmfanews.com