WHERE IS MATERIAL NEEDED FOR RHINOPLASTY OBTAINED FROM?
In rhinoplasty, grafts and implants are used to augment, reshape, or provide structural support to the nose. They can be sourced from the patient’s own body (autologous) or be synthetic. Here’s a detailed overview of the various grafts and implants used in rhinoplasty:
AUTOLOGOUS GRAFTS
These are derived from the patient’s own tissues, reducing the risk of allergic reactions or rejection.
SEPTAL CARTILAGE
This is the most commonly used graft material in primary rhinoplasty. It’s harvested from the nasal septum and is ideal due to its strength, flexibility, and versatility.
EAR CARTILAGE
Typically sourced from the conchal bowl of the ear, it’s softer than septal cartilage and is often used for subtle refinements, especially in the nasal tip.
RIB CARTILAGE
Used in cases requiring significant augmentation or when other sources of autologous cartilage are depleted. It provides a large volume and is robust, but there’s a risk of warping over time.
TEMPORALIS FASCIA
This is soft tissue harvested from the lining of the temporalis muscle in temple region and can be used to wrap other grafts or as a soft tissue filler in the nose.
RECTUS ABDOMINIS FASCIA
This is soft tissue harvested from the covering of the rectus abdominis muscle in the abdominal/chest region and can be used to wrap other grafts or as a soft tissue filler in the nose.
BONE
Occasionally, bone grafts (often from the skull or rib) might be used, especially in cases of significant dorsal augmentation.
SEPTAL CARTILAGE
Septal cartilage is one of the most commonly used graft materials in rhinoplasty. It’s harvested from the nasal septum, the structure that divides the two nostrils. Here’s a detailed look at the use of septal cartilage grafts in rhinoplasty:
ADVANTAGES OF SEPTAL CARTILAGE GRAFTS
BIOCOMPATIBILITY
Since septal cartilage is harvested from the patient’s own body, it is biocompatible. This means that the body recognizes it as its own tissue, reducing the risk of complications such as graft rejection or allergic reactions.
STRUCTURAL INTEGRITY
Septal cartilage possesses a combination of rigidity and flexibility, making it an ideal material for structural support and reshaping in rhinoplasty. It maintains its shape over time, ensuring the longevity of the surgical outcome.
IDEAL CONSISTENCY
Septal cartilage has a firm yet flexible consistency, making it suitable for various modifications in rhinoplasty.
READILY AVAILABLE
For most patients, especially those undergoing primary rhinoplasty, septal cartilage is available and can be harvested without creating a visible external scar. Septal cartilage is Dr Sandeep’s first port of call for cartilage graft harvest in rhinoplasty.
LOW RESORPTION RATE
Septal cartilage grafts tend to maintain their shape and volume over time, with a lower rate of resorption compared to some other graft materials.
APPLICATIONS OF SEPTAL CARTILAGE GRAFTS IN RHINOPLASTY
DORSAL ONLAY GRAFTS
These grafts are used to correct a saddle nose deformity or to augment a flat nasal bridge. The graft is carved to the desired shape and placed along the nasal dorsum. Based on the current scientific evidence Dr Sandeep prefers to use Diced cartilage with fibrin glue for dorsal augmentation as this technique leads to long lasting natural looking results without the risk of cartilage graft warping.
TIP GRAFTS
meticulously carved and placed in the tip region to achieve the desired aesthetic.
SPREADERS GRAFTS
These are thin, rectangular grafts placed between the septum and the upper lateral cartilages. They play a crucial role in:
- Rectifying internal valve collapse, which can cause breathing difficulties.
- Straightening a crooked nose.
- Preventing an “inverted V” deformity post-surgery.
COLUMELLAR STRUT GRAFTS
This graft provides support to the columella, ensuring that the nasal tip remains elevated and doesn’t droop post-surgery. It’s a foundational graft that can influence the rotation and projection of the nasal tip.
ALAR BATTEN GRAFTS
Positioned in the soft tissue of the nostrils, these grafts combat external nasal valve collapse, a common cause of nasal obstruction.
RIM GRAFTS
Positioned in the soft tissue of the nostrils, along the alar rim, these grafts combat external nasal valve collapse, a common cause of nasal obstruction.
SHIELD GRAFTS
Shaped like a shield, these grafts are placed over the nasal tip, providing definition, projection, and a slight upward tilt.
HARVESTING CONSIDERATIONS
When extracting septal cartilage, Dr Sandeep ensures that enough cartilage remains to maintain the structural integrity of the septum. This careful approach minimizes potential complications like a deviated septum, saddle nose or a septal perforation.
POST-SURGICAL EVOLUTION
Over time, the septal cartilage graft integrates with the surrounding tissues, becoming a part of the nasal structure. While there’s a minor risk of graft warping or resorption, in most cases, the graft remains stable, ensuring the longevity of the rhinoplasty results.
CONSIDERATIONS AND LIMITATIONS
LIMITED QUANTITY
There’s a finite amount of septal cartilage available. In revision rhinoplasty cases or after previous septoplasty, there might be insufficient or no septal cartilage left for grafting.
DONOR SITE MORBIDITY
Harvesting septal cartilage might lead to complications like septal perforation or nasal septum instability, although these are rare with experienced surgeons.
CONCLUSION
Septal cartilage is a versatile and preferred graft material in rhinoplasty due to its favourable properties and the ease of harvest. Its use can address a variety of nasal deformities, providing both aesthetic and functional improvements. The decision to use septal cartilage, other autologous materials, or synthetic grafts will depend on the specific needs of the patient, the surgeon’s assessment, and the desired outcome. Proper surgical technique and post-operative care are crucial to optimize results and minimize potential complications.
EAR CARTILAGE HARVEST
Using ear cartilage in rhinoplasty is a common technique, especially when there’s a need for additional cartilage to achieve the desired nasal shape or to provide structural support. Here’s a more detailed look at its application and considerations:
WHY EAR CARTILAGE?
AVAILABILITY
The ear provides an easily accessible source of cartilage.
FLEXIBILITY
Ear cartilage is relatively soft and flexible, making it suitable for certain areas of the nose, especially the tip.
SHAPE
The shape and curvature of the ear cartilage makes it particularly suitable for tip grafting and for creating replacement grafts for alar cartilage.
MINIMAL DONOR SITE MORBIDITY
Harvesting cartilage from the ear typically results in minimal visible scarring and deformity.
WHEN IS EAR CARTILAGE USED IN RHINOPLASTY?
TIP REFINEMENT
Due to its flexibility, ear cartilage is often used to refine the nasal tip, providing better definition or projection.
DORSAL AUGMENTATION
For patients with a flat nasal bridge, ear cartilage can be used to build up the dorsum, although its flexibility might make it less ideal than other sources (like rib cartilage) for significant augmentation.
ALAR CARTILAGE RECONSTRUCTION
The shape and curvature of the ear cartilage makes it particularly suitable in patients who require extensive alar reconstruction for revision rhinoplasty or for nasal reconstruction following resection of nose cancers.
ALAR RIM GRAFTS
Ear cartilage can be used to support the nostrils, preventing them from collapsing during inhalation or to correct alar retraction.
ADVANTAGE OF USING EAR CARTILAGE GRAFT
LESS INVASIVE
Harvesting ear cartilage is less invasive than obtaining rib cartilage.
REDUCED SCARRING
The incisions made behind the ear to harvest cartilage usually heal well and are hidden from view.
NATURAL FEEL
Ear cartilage tends to integrate well and feels natural in the nose.
LIMITATIONS OF USING EAR CARTILAGE GRAFT
LIMITED QUANTITY
There’s only a limited amount of cartilage available from the ear, which might not be sufficient for extensive nasal reconstructions.
NOT AS STRONG
Ear cartilage isn’t as robust or rigid as cartilage from other sources, like the rib or septum. This can be both an advantage (for areas like the nasal tip) and a limitation (for major structural support).
PROCEDURE
- Anaesthesia: The procedure can be performed under local anaesthesia, sedation, or general anaesthesia, depending on the patient’s preference and the extent of the primary surgery.
- Site Selection: The conchal bowl, which is the central, concave part of the external ear, is the most common site for harvesting cartilage. This area provides a good amount of cartilage while preserving the ear’s natural shape. In reconstructive surgery the cartilage may be harvested along with a part of the skin (composite graft) from other parts of the ear.
- Incision: A posterior (behind the ear) approach is typically used by Dr Sandeep to hide the incision scar. The incision is usually made in the crease behind the ear to access the conchal cartilage. Rarely an anterior approach where incisions are made at the periphery of the conchal bowl, in areas where the scars are well camouflaged may be used.
- Cartilage Harvest: Once the incision is made, the skin is elevated to expose the cartilage. The desired amount of cartilage is carefully removed. Dr Sandeep ensures that enough cartilage remains to preserve the ear’s natural shape and support. If additional cartilage or soft tissue is needed, Dr Sandeep might also harvest the surrounding perichondrium or skin.
- Closure: After the cartilage is harvested, the incision is closed using sutures. These might be dissolvable or may need removal at a follow-up appointment. A dressing or bandage is applied to protect the site and minimize swelling.
- Postoperative Care: Patients are usually given pain relievers to manage any discomfort. It’s essential to keep the area clean and dry to prevent infections. Swelling, bruising, and mild pain are common but usually subside within a few days. The patient is advised to avoid sleeping on the operated ear for a few weeks. A follow-up appointment is scheduled to monitor the healing process, remove non-dissolvable sutures, and address any concerns.
POTENTIAL RISKS AND COMPLICATIONS
- As with any graft, there is a risk of graft displacement, or resorption over time.
- Altered Ear Shape: Removing cartilage might cause a change in the shape or contour of the ear, especially if a significant amount is harvested.
- Pain and Discomfort: The ear may be sore or painful for several days to weeks after the procedure.
- Hematoma or Seroma Formation: Blood or fluid might accumulate at the harvest site, leading to swelling and discomfort.
- Infection: As with any surgical procedure, there’s a risk of infection at the incision or harvest site.
- Numbness or Altered Sensation: The ear might feel numb or have altered sensation due to nerve disturbances during the procedure. This is usually temporary but can be permanent in rare cases.
- Delayed Wound Healing: The incision site may take longer to heal in some individuals, especially if there’s tension on the wound or if an infection develops.
- Stiffness: The ear might feel stiffer due to the removal of cartilage and subsequent healing.
- Asymmetry: The ears might appear asymmetrical if the cartilage removal is more pronounced on one side.
- Skin Discoloration: There might be temporary or permanent skin discoloration at the harvest site.
- Keloid or Hypertrophic Scarring: Some individuals, especially those with a predisposition, might develop thick, raised scars.
- Necrosis: Rarely, the skin overlying the harvest site might not receive adequate blood supply and could undergo necrosis or tissue death.
RIB CARTILAGE HARVEST
Using rib cartilage in rhinoplasty is a well-established technique, especially when a significant amount of cartilage is required or when previous surgeries have depleted the native nasal cartilage. Here’s a detailed look at its application, advantages, and considerations:
WHY IS RIB CARTILAGE USED FOR RHINOPLASTY?
VOLUME
The rib provides a substantial amount of cartilage, making it suitable for major reconstructions.
STRENGTH
Rib cartilage is robust and can offer significant structural support, especially for patients who need major modifications or revisions to augment the nasal dorsum, reconstruct the nasal septum, increase nasal length, and tip projection.
VERSATILITY
It can be carved and shaped to fit various parts of the nose.
WHEN IS RIB CARTILAGE USED IN RHINOPLASTY?
MAJOR RECONSTRUCTIONS
For patients who need significant nasal reshaping or support.
REVISION RHINOPLASTY
In cases where previous surgeries have used up or damaged the patient’s nasal cartilage.
DORSAL AUGMENTATION
To build up the nasal bridge, especially in patients with flat or saddle-nose deformities.
TIP RECONSTRUCTION
To provide support and projection to the nasal tip.
WHAT ARE THE ADVANTAGES OF USING RIB CARTILAGE IN RHINOPLASTY?
ABUNDANCE
Provides a large amount of cartilage, suitable for extensive reconstructions.
DURABILITY
Offers long-lasting results due to its strength and resilience.
NATURAL
Being autologous (from the same individual), it reduces the risk of allergic reactions or rejection compared to synthetic implants.
WHAT ARE THE LIMITATIONS & CONSIDERATIONS IN USING RIB CARTILAGE IN RHINOPLASTY?
DONOR SITE MORBIDITY
Harvesting rib cartilage requires an additional incision at the chest, which may lead to scarring, discomfort, and a longer recovery time.
WARPING
Rib cartilage has a tendency to change shape or warp over time, which can affect the outcome of the rhinoplasty. Dr Sandeep uses some advanced techniques to minimize the effect of rib cartilage warping, however despite this there is always a risk that warping may alter the rhinoplasty results.
RESORPTION
Over time, some of the rib cartilage might get absorbed by the body, potentially altering the rhinoplasty results.
WHAT IS THE PROCEDURE FOR HARVESTING RIB CARTILAGE?
Typically, cartilage is harvested from the 6th, 7th, or 8th rib. An incision is made over the desired rib, the overlying muscle is dissected, and a segment of cartilage is carefully removed. The incision is then sutured closed, and a dressing is applied.
WHAT ARE THE POTENTIAL RISKS AND COMPLICATIONS OF USING RIB CARTILAGE FOR RHINOPLASTY?
- Chest Scarring: The incision on the chest leads to visible scarring. In women the incision is placed in the fold under the breast so that it is less conspicuous.
- Chest Discomfort: Some patients report discomfort or a sensation of tightness in the chest for a few days after the procedure.
- Pneumothorax: A rare but potentially serious complication may occur where air enters the space between the lung and chest wall during rib harvest, leading to lung collapse. This is a risk whenever the chest wall is breached. Should this rare complication occur a chest tube is used to reinflate the lung, this will require you to stay in the hospital for longer than the usual overnight stay.
While rib cartilage offers a valuable resource for rhinoplasty, especially in challenging cases, it’s essential for patients to be informed about the potential risks and benefits. The decision to use rib cartilage is typically based on the individual patient’s needs, the extent of the changes desired, and the surgeon’s assessment and expertise.
In conclusion, the choice of graft or implant in rhinoplasty depends on the specific needs of the patient, the surgeon’s preference, and the desired outcome. Each material has its advantages and potential complications. Proper surgical technique, thorough pre-operative assessment, and diligent post-operative care can help optimize results and minimize risks. The choice of cartilage source—whether from the ear, septum, or rib—depends on the individual patient’s needs, the extent of the changes desired, and Dr Sandeep’s assessment.
AUTOLOGOUS FASCIA
Autologous fascia is fascia (covering of muscle) derived from the patient’s own body, particularly the temporalis fascia (from the temple region) and rectus abdominis fascia (upper abdomen), is a valuable grafting material used in various surgical procedures, including rhinoplasty. Here’s a detailed look at the use of autologous fascia in rhinoplasty:
ADVANTAGES OF AUTOLOGOUS FASCIA IN RHINOPLASTY
BIOCOMPATIBILITY
Since it’s derived from the patient’s own body, there’s a minimal risk of allergic reactions or graft rejection.
NO FOREIGN BODY REACTION
Unlike synthetic materials, autologous fascia is less likely to cause a foreign body reaction.
VERSATILITY
Fascia is thin and pliable, making it suitable for various applications in rhinoplasty.
NATURAL FEEL
Being a natural tissue, it integrates well and feels natural post-operatively.
LOW RESORPTION RATE
While some resorption can occur, the fascia generally retains its volume and shape over time.
APPLICATIONS OF AUTOLOGOUS FASCIA IN RHINOPLASTY
CAMOUFLAGING IRREGULARITIES
Fascia can be used to smooth out irregularities or transitions in the nasal contour, especially after dorsal hump reduction or graft placement.
TIP REFINEMENT
It can be used to soften and refine the nasal tip, especially if there’s a concern about visible graft edges or irregularities.
GRAFT WRAPPING
Fascia can be used to wrap other grafts, such as cartilage grafts, to reduce the risk of graft visibility or palpability through the skin.
DORSAL AUGMENTATION
While less common, multiple layers of fascia can be used for subtle dorsal and radix augmentation, especially in revision cases where there’s a need for soft, malleable augmentation.
HARVESTING CONSIDERATIONS
The temporalis fascia is typically harvested through a small incision within the hair-bearing scalp, which means the resultant scar is well-concealed. The procedure adds some time to the surgery but is generally associated with minimal discomfort post-operatively. Rectus abdominis fascia is harvested through the same incision used to harvest the rib cartilage.
DISADVANTAGES OR LIMITATIONS
DONOR SITE MORBIDITY
While generally minimal, there’s a potential for pain, hematoma, or scarring at the donor site.
LIMITED VOLUME
The amount of fascia that can be harvested is limited, so it might not be suitable for procedures requiring significant volume or bulk.
POTENTIAL RESORPTION
Over time, some resorption or thinning of the fascia might occur, potentially affecting the surgical outcome.
CONCLUSION
Autologous fascia offers a biocompatible and versatile grafting option in rhinoplasty. Its ability to provide a smooth contour and camouflage underlying structures makes it particularly valuable in achieving refined and natural-looking results.
HOMOGRAFTS
Homografts, also known as allografts, are grafts taken from one individual and implanted into another individual of the same species. In the context of rhinoplasty, homografts are tissues derived from human donors, which are processed to ensure their safety and then used in nasal reconstruction. They are a good alternative for patients who are not keen on grafts harvested from their own body. Here’s a detailed look at the use of homografts in rhinoplasty:
TYPES OF HOMOGRAFTS USED IN RHINOPLASTY
RIB CARTILAGE
Processed rib cartilage from donors can be used for major reconstructions, especially when a significant amount of cartilage is needed.
DERMAL GRAFTS
Acellular Dermal Matrix (e.g., AlloDerm): This is processed human skin devoid of cells. It can be used to wrap other grafts, provide soft tissue augmentation, or as an interposition graft in certain cases.
ADVANTAGES OF HOMOGRAFTS
NO DONOR SITE MORBIDITY
Since the graft is not taken from the patient, there’s no additional surgical site or associated complications.
AVAILABILITY
Since the graft is not taken from the patient, there’s no additional surgical site or associated complications.
SAFETY
Properly processed homografts are sterilized to eliminate potential pathogens, reducing the risk of disease transmission.
DISADVANTAGES AND CONSIDERATIONS
- Integration and Resorption: Homografts might not integrate as well as autografts (grafts from the patient’s own body). There’s also a potential risk of graft resorption over time.
- Rejection: While rare, there’s a possibility of an immune response against the graft.
- Limited Lifespan: Over time, the graft might degrade or become absorbed by the body, potentially altering the results of the rhinoplasty.
- Cost: Processed homograft materials can be more expensive than using the patient’s own tissues.
CONCLUSION
Homografts offer a valuable alternative to autografts in rhinoplasty, especially when there’s a need to avoid additional surgical sites or when autologous tissue is limited. The choice between using homografts, autografts, or other materials will depend on the specific needs of the patient, the surgeon’s assessment, and the desired outcome.
SYNTHETIC IMPLANTS
Synthetic implants in rhinoplasty, often referred to as alloplastic implants, are man-made materials used to augment or reshape the nose. They offer an alternative to autologous grafts (those derived from the patient’s own body). The commonly used implants are:
SILICONE
A popular implant material, especially in some Asian countries, for dorsal augmentation. While it’s easy to insert and shape, there’s a risk of extrusion, movement, and infection. This is particularly so when a L shaped implant is used.
GORE-TEX (POLYTETRAFLUOROETHYLENE OR PTFE)
This is a synthetic material that’s been used for dorsal augmentation. It’s more porous than silicone, allowing for tissue ingrowth.
MEDPOR (POROUS POLYETHYLENE)
This implant allows for tissue integration due to its porous nature. It’s used for dorsal augmentation but can be challenging to remove due to tissue ingrowth.
Here’s a breakdown of the advantages and disadvantages of using synthetic implants in rhinoplasty:
ADVANTAGES OF SYNTHETIC IMPLANTS
READILY AVAILABLE
Unlike autologous grafts, which require harvesting from the patient, synthetic implants are readily available in various sizes and shapes.
NO DONOR SITE MORBIDITY
Since there’s no need to harvest tissue from another part of the patient’s body, there’s no risk of complications or scars at a donor site.
CONSISTENT QUALITY
Synthetic implants are manufactured to meet specific standards, ensuring consistent quality and performance.
SHAPE AND SIZE VARIETY
They come in a variety of shapes and sizes, allowing for customization to the patient’s needs.
STABILITY
Some synthetic materials can offer long-term stability without significant resorption, which can sometimes occur with autologous grafts.
DISADVANTAGES OF SYNTHETIC IMPLANTS
- Foreign Body Reaction: Being foreign materials, there’s a risk of the body rejecting the implant or forming a capsule around it, which can alter the desired results.
- Infection: Synthetic implants can sometimes become a nidus for infection, which might require removal of the implant.
- Extrusion: Over time, the implant may push through the skin, especially if it’s placed in a region with thin skin, like the nasal tip.
- Migration: Implants can sometimes move from their original position, leading to asymmetry or an undesired shape.
- Palpability: Especially in areas with thin skin, the implant might be felt or even seen beneath the skin.
- Long-term Complications: While some patients may have synthetic implants for years without issues, others might experience complications or dissatisfaction over time, necessitating revision surgery.
- Limitations in Natural Feel: Synthetic implants might not feel as natural as autologous grafts, which can be a concern for some patients.
CONCLUSION
The decision to use synthetic implants or autologous grafts in rhinoplasty will depend on the specific needs and desires of the patient, the surgeon’s assessment, and the intended outcome. While synthetic implants offer certain advantages, especially in terms of availability and avoiding donor site morbidity, they come with their own set of potential complications. Proper surgical technique, thorough pre-operative assessment, and diligent post-operative care are essential to optimize results and minimize risks.
ANIMAL GRAFTS
Also known as xenografts, these are derived from animal tissues and can be used in various medical procedures, including rhinoplasty. In the context of rhinoplasty, xenografts are less commonly used than autografts (from the patient’s own body) or allografts (from another human), but they do have specific applications. Here’s an overview of the use of animal grafts in rhinoplasty:
TYPES OF XENOGRAFTS USED IN RHINOPLASTY
PORCINE (PIG) DERMAL COLLAGEN
Processed and sterilized pig skin can be used as a soft tissue filler or to wrap other grafts. Dr Sandeep will confirm with you that you do not have any religious of other objection to use of these grafts.
BOVINE (COW) DERMAL COLLAGEN
Like porcine grafts, bovine-derived grafts can be used as soft tissue fillers or structural supports.
ADVANTAGES OF XENOGRAFTS
NO DONOR SITE MORBIDITY
Since the graft is not taken from the patient, there’s no additional surgical site or associated complications.
AVAILABILITY
Xenografts can be readily available, eliminating the need for an additional procedure to harvest the patient’s own tissue.
SAFETY
Properly processed xenografts are sterilized to eliminate potential pathogens.
DISADVANTAGES AND CONSIDERATIONS
- Integration and Resorption: Xenografts might not integrate as well as autografts or allografts. There’s also a potential risk of graft resorption over time.
- Immune Response: There’s a higher possibility of an immune response or rejection with xenografts compared to autografts or allografts.
- Limited Lifespan: Over time, the graft might degrade or become absorbed by the body, potentially altering the results of the rhinoplasty.
- Ethical and Religious Concerns: Some patients might have ethical or religious objections to the use of animal-derived materials in their bodies.