Rib and Fascia Vs Ear Cartilage to Fix a Scoop

What is the "Best" option for augmenting the nose?

You will not get agreement amongst surgeons to this question! With that caveat out of the way, I'll give you the opinion that I've held for more than 5 years: Diced Cartilage (your own cartilage) Wrapped in Fascia (your own fascia) is "the best" tissue or material available when a significant augmentation of the back of the nose is needed.

Advantages of Diced-Cartilage Grafts Wrapped in Fascia:


It becomes completely integrated into your body, therefore it will not have a risk of becoming encapsulated or infected in the future like an implant can.

When your own cartilage and fascia are used (instead of cadaver tissue), the chances of resorption of the tissue is the very lowest.

Because the cartilage is diced into tiny pieces and wrapped in a soft wrapper of fascia, it is the least likely graft to have it's edges become visible through the skin over time as our tissue age and our skin thins.

This graft technique is "mold-able" to a small degree even at one week after surgery, where minor adjustments can simply molded through the skin and your splint can then be replaced to protect the nose during healing for the 2nd week.


Some Disadvantages:


Probably the biggest disadvantage is time. It takes time to harvest fascia using a small incision behind the ear and time harvest and prepare the cartilage (which can come from either the nose, ear or rib).

It is not rigid enough for cases where a very large augmentation of the nose is needed.


Hope this helps!

Nick Slenkovich, MD FACS

 

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.

Using ear cartilage or rib may be equally effective in correcting your nasal concerns.  Different surgeons have different preferences regarding their choice of donor material.  Some surgeons would argue that using your own rib is better than cadaver rib as well.  The important question is how much cartilage is needed and is ear going to provide enough grafting material as well as how experienced your surgeon is in performing a complicated revision procedure. 

Septal, ear and rib cartilage are all good sources of cartilage. Depending on the specific use some times may be better than others given their size and strength.

Some surgeons like to use a diced cartialge wrapped in fascia technique for augmenting the dorsum. I prefer using a patient's own cartilage that I then carve.

Fixing an upturned tip often requires strong, straight cartilage. The septum or ear are usually the best sources of cartilage for this purpose.
 

A scooped out bridge of the nose is always best treated with patient’s own cartilage.  Nasal and septal cartilages are the best choice, but in the event of a cartilage depleted nose, ear cartilage is the second best choice.  Rib cartilage is the third best choice.  Another alternative is a small silastic implant which can be inserted as a synthetic implant if no cartilage is available.  Radiated donor cartilage tends to have resorption problems and is not consistent. 

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.

There are many different ways to s"skin a cat"  If you have a scooped nose, often a rib cartilage graft will offer the most cartilage to augment it.  I am not a big fan of diced cartilage.

None of the above, IMHO.  For over 20 years, of performing Rhinoplasty and Revision Rhinoplasty, I prefer to use materials that are reliable and predictable in Revision Rhinoplasty because the worst thing that can happen is the material placed begins to reabsorb.  Rib cartilage, bone, and folded ear cartilage for nasal bridge augmentation can and does absorb..unevely after a number of years.

I like ear cartilage for nasal tip grafts because it's soft enough to look natural and strong enough to give shape and support to the nasal tip.  For the nasal bridge, I prefer a straight (not L-shaped) silastic nasal implant which does not absorb.

I suggest septal, ear, or rib cartilage grafts to lengthen your nose, fix your collapsed valves,and correect  the "scoop". Diced cartilage wrapped in fascia is an excellent technique to augment the dorsum.