Rib and Fascia Vs Ear Cartilage to Fix a Scoop

There are several options available to augment a deficient nasal bridge during revision rhinoplasty.  Unfortunately, there is no consensus as to the best option.  The preference of each surgeon depends on his or her personal bias and experience.  When making a decision I would suggest getting as best informed as you can regarding all the possible options then seeking out a handful of opinions from experienced revision rhinoplasty surgeons.  Ask them why they are making their specific recommendations and ask to see standardized photos of outcomes on several patients  they have used the particular technique they are recommending, especially in patients with deformities similar to yours.  At that point you will have to decide on your own how to proceed.  Remember that the more revision surgeries your undergo, correction will become exponentially more difficult so the first revision is in some ways the only chance to get things right - subsequent revisions will likely require you to swallow some compromise regarding outcomes.

The options for augmentation of the nasal bridge fall into 3 basic groups:  1) autologous graft (autograft):  tissue taken from a donor site and transplanted to a recipient site in the same patient.  2) allogenic graft (allograft):  tissue taken from a cadaver and transferred to another patient.  Allogenic grafts need to be processed prior to transfer using chemical treatment and/or irradiation in order to sterilize them and remove any immunogenic properties.  3) synthetic implants (alloplasts):  these are non-biologic materials such as silastic (rubberized silicone), extruded polytetrafluorethylene (e-PTFE or Gore-Tex), porous polythylene (Medpore).  These implants can be either prefabricated shapes or can be custom carved for the patient at the time of surgery.  Injectable fillers such as silicone or hydroxyappatite have also been promoted

Each of the 3 groups has its own surgeon advocates as well as unique pros and cons which would require a long discussion to properly cover.  My own preference has been to use autografts (patients' own tissue) over either allografts or synthetic alloplasts.  My experience with allografts has been that they undergo significantly more resorption when compared to autografts.  Regarding alloplastic implants, there are many scientific reports describing long term extrusion rates and implant removal in 10-15% of cases.  My experience has mirrored this finding and because of this I feel it is not worth the risk to use synthetic implants.

A variety of donor sites and materials are available from around the body and can be used for dorsal augmentation of the nose:


Fascia.  This a thin but strong tissue layer covering muscle and can be taken from either the temple (deep temporalis fascia) or the thigh (fascia lata).

Solid Cartilage.  Cartilage grafts can be harvested from a) the nasal septum, b) ears or c) ribs 5 through 9.  Each of these sites has its pros and cons.  The septum is the best quality cartilage with good handling features and the least resistance to warping, however, the supply is limited and is usually not available in revision cases.  Ear cartilage does not handle as well as septal cartilage due to its fragility and inherent curvature.  The amount of available ear cartilage can be used for mild to moderate nasal dorsum deficiencies but is inadequate for severe deficiency.  Rib cartilage is available in abundant supply but suffers from possible warpage over time.  Several measures can be taken when carving rib cartilage to minimize the risk of warpage, but there is always some risk.  Rib cartilage can also be harvested with a small segment of bone attached to its upper end which ideally simulates the native nasal framework.

Diced cartilage plus fascia.  This technique has actually been around for some time but has recently seen increased popularity.  It involves dicing solid cartilage grafts into approximately 2 mm cubes and then injecting the mixture into a fabricated tube of fascia much the same as making a sausage.  The tubed diced cartilage is then inserted as an onlay onto the nasal bridge, properly sized and molded.  This technique has several advantages that have been well-documented by Nick Slenkovich, MD, in his answer to this question. 

Bone grafts.  Bone can be harvested from the skull (split calvarial grafts), the ribs or the pelvis (iliac crest grafts).  Although once quite popular they have been largely abandoned at this time due to multiple long term problems including excessive rigidity, visible outlines, breakage and a high rate of resorption.


 


Solid Rib Vs. Tubed Diced Rib Cartilage Grafts

Solid rib grafts carry the advantage of increased rigidity over tubed diced rib cartilage.  Because of this they are more useful when correcting severe deficiencies of the nasal bridge, when attempting a markedly upturned and shortened nose or when straightening a deviated nose.  Solid grafts however, must be very precisely carved with feather edges because any imperfections will be visible as irregularities or step-offs, particularly in patients with thin skin cover.  Furthermore, there is always a small risk of long term warpage as discussed above.  Tubed diced rib grafts are better suited for less severe dorsum deficiencies.  I have used them for over 6 years in 32 patients and have found them to be very reliable with good outcomes in the vast majority of patients. Three patients (9.4%) have required minor revisions to correct over-augmentation or residual asymmetry.  They are currently my 'go-to' option for augmenting the nasal dorsum in the majority of revision rhinoplasties unless the deformity is quite severe.

using your own - not irradiated cartilage - is your best choice since it is structurally sound and will not reabsorb.

diced cartilage and fascia is a good option but it lacks any support if your nose needs to be lengthened

I read your concerns. If you have trouble breathing through your nose, you may indeed require Revision Rhinoplasty Surgery. If your breathing is not an issue, you would be surprised how much improvement you could see in the appearance of your nose after a well-performed Injectable Filler treatment. My personal preference is to use Silikon-1000, an off-label filler for permanent results.

Regards from West Orange.