Rebuilding dorsum - planning for worst outcome.

Question

After a disastrous primary where my surgeon literally hacked off my bridge and my radix, I am looking to undergo a rebuild which thus entails the use of an onlay graft composed of coastal cartilage. The aim is to rebuild my nasion and entire dorsum. Now can temporal fascia be used to mask irregularities? Worst case scenario, the warping of coastal cartilage occurs. Theoretically speaking, could temporal fascia mask any indication of warping that it wouldn't be visible to human eye?

Alejandro Nogueira, MD · Answer

One one side it is true temporal fascia, especially the SUPERFICIAL (the deep one or temporal muscle fascia is a gliding surface and provide scarce camouflage) hides ALL the nasal irregularities and conceals the presence of a new entire or en-bloc dorsum build with onlay graft. But it will never hide or diminish the graft if it warps, which is not an irregularity or an edge visibility but a true structural deformity.Rib grafting DOES NOT warb... if properly harvested and tailored; the key is harvesting the core of the rib cartilage, the outer layers do indeed warp and using them is a sign of poor knowledge and experience, only the core of the rib is valid to use on the nose, do beware of this pitfall and be sure your surgeon knows about this,

P. Daniel Ward, MD · Answer

I would recommend that the perichondrium from the rib graft be used. It is essentially the same tissue as temporalis fascia, but since the rib is being exposed anyway, there is no reason for another incision on the. Key to be made. Just use some of the rib perichondrium. It works great and we use it all the time for masking irregularities.

Samuel Lin, MD, FACS · Answer

It would really depend on the physical examination- indeed there are several techniques available using fascia and cartilage from the rib either as a single piece or as smaller pieces

Myriam Loyo, MD · Answer

Let's talk about dorsum augmentation (aka. rebuilding the bridge of the nose)Rib can be a great option for dorsal augmentation. Cartilage coming from the rib is long enough that it can build a bridge of the nose in its entire length. It is also thick enough to provide significant augmentation (as opposed to thinner septum for example). The risks of using rib are that the cartilage can bend (called warping) and that you can have irregularities. We have technical maneuvers to minimize the risk of warping but it still happens. For example, only the center of the rib is used and the edges discarded as the edges have more risk of bending. If cartilage warps, a thin layer of fascia will not be able to hide it. Fascia can hide small irregularities but it will not hide if the whole piece curves. You have an option of using your own rib or donated rib. Some people think donated rib has a higher risk of being reabsorbed.Another good option is diced cartilage wrapped in fascia from tissue from your temple. The cartilage can come from the ear or even the outside edges for the rib. It is diced into little pieces and wrapped in fascia to make the shape of the dorsum need. It is almost like a burrito wrap with cartilage inside. It has the advantage of being able to use smaller pieces of cartilage and less likely to show any of the edges of the graft. But in a few very thin skin people if they press on their skin they can see the implant (for thin skin individuals you always have the risk of irregularities showing under the skin).The final option is to use a synthetic implant (also called allograft). I tend to stay away from synthetic material in the nose because it can get infected and extrude (even years after it is implanted). But it can be nice to have a preformed implant with the perfect shape that is very smooth.I hope this long explanation give you some useful information. Pluses and minuses to each approach.Good luck!

Shervin Naderi, MD, FACS · Answer

Hi.  First off Temporalis Fascia or Alloderm can be used in patients with thin skin to soften the edges of bone and cartilage but will not mask cartilage warping issues.  Frankly there is no perfect dorsal onlay graft material or technique.  They all have pluses and minuses.  Anywhere from Silicone or Medpore implants to costal (rib) cartilage to diced cartilage wrapped in fascia and on and on they all can work out great or not so great.  Obviously surgeons' skill and technique can improve outcome but there is no guarantee due to the variety of healing variables in a nose job.  In fact often the best and more predictable "dorsal augmentation" technique is a non-surgical rhinoplasty with Restylane.  Yes it has to be repeated but the results for the bridge are much more smooth, natural and ADJUSTABLE!

Victor Chung, MD · Answer

Rhinoplasty is a surgery to improve the shape of the nose for breathing or appearance.Rib (costal) cartilage can be used to build up the bridge of the nose. I use the rib's perichondrium (soft tissue) to cover the augmentation graft. It can be harvested at the same time as the rib. It's thicker than temporalis fascia. It camouflages the transition and edges of the augmentation graft. Knowing how to carve the dorsal augmentation graft is the key to less warping. Go with a surgeon who understands these rib cartilage concepts for safe and happy result. Safety comes first.

Rebuilding dorsum - planning for worst outcome.

Answers (6)

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