Options for Grafts in a Revision Rhinoplasty with Thin Skin?

I read your concerns. Spreader grafts are usually not visible, even in thin skinned patients, and are used to correct a front-view bridge-indentation, and to improve your nasal airway. Dorsal onlay grafts to raise the height of your bridge could be visible through thin skin.

If these are your main concerns, you may consider researching an Injectable Filler procedure to see if this might be right for you. I prefer to use Silikon-1000, an off-label filler for permanent results.

Hope this helps.

Dr. Joseph

Dear firefly in Connecticut:

Undoubtedly, your situation presents a challenge.  Thin skin reveals more than thick skin.  Therefore, one of the challenges, with respect to grafting cartilage, bone, or any other material, is that the graft process, and Nature's management of it, over time, must be perfect.  Otherwise, some irregularities can be visible.  If your skin were thicker, it could obscure some minor imperfections.

Since there is some uncertainty exactly how the grafted tissue will conform and maintain shape, it is always a little risky, and if, in fact, it does not turn out perfectly, then you would be facing a third rhinoplasty.

Today, we have so many excellent filling materials that I think you should think in terms of a nonsurgical rhinoplasty.  Certainly, you have nothing to lose by trying a temporary filler first.  That makes sense because you can see the results, and if you like them, then, you do not have to have the rhinoplasty surgery. 

Secondl: you can later go to a permanent filler.  Another great feature of fillers is that you get to make the decision while sitting in the office treatment chair when you are satisfied.  Even if you may have had computer imaging before the surgeries, there is nothing like being awake and telling the surgeon what you do like and do not like while he is changing your nose.  Think about that.  It is common sense.  It is safe, predictable and, of course, the cost is far less than a revision rhinoplasty surgery.

Robert Kotler, MD, FACS
Facial Plastic Surgeon
Author, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON

Spreader grafts do not create height and should not be seen. They should only add enough width to compensate for middle vault collapse which is aesthetically  unpleasing and often a functional problem as well. If the dorsal graft is not meant to be structural as well as aesthetic then the diced cartilage in fascia technique is excellent to prevent the risk of graft edge show with contracture in thin skin.

Thin skin over the nose may not cover grafts adequately. Sometimes temporalis fascia or even alloderm or strattice may camouflage the graft.

The spreader graft from the septum should not be seen if positioned right. Or a new method utilizing the upper lateral cartilage as a spreader graft.

As for the dorsum, it depend on how much thickness you need, rib cartilage if you need a lot of dorsum, septal cartillage gives about 2mm, acellular matrix, doubled may give you up to 3-4 mm

Spreader grafts will not be seen if properly placed in thin skin individuals.  The dorsum of your nose may be corrected by placing cartilage grafts.  The grafts may be camouflaged by injecting  your own body fat as a filler over the top of the cartilage.

Properly placed spreader grafts will not be seen even in patient with thin skin. Depending on the severity of your scooped profile I would augment your profile with temporalis fascia, or fascia and diced cartilage. Another altenative to raise your bridge, which I rarely use is the injection of fillers such as Radiesse.

 I have performed Rhinoplasty and Revision Rhinoplasty for well over 20 years and I don't like or use spreader grafts.  IMO, spreader grafts, no matter what else they are meant to do, make the nasal tip and supratip area larger and as such are aesthetically incorrect.  I use a straight, silastic dorsal implant to build up the nasal bridge and conchal cartilage ear grafts when the nasal tip requires refinement or additional strength.  Both of these should work well, even with thin skin.