Are grafts necessary in rhinoplasty? Cartilage flaps with cartilage-saving rhinoplasty concept

Overview

Cartilage grafts are routine in rhinoplasty, but each graft must be harvested. The authors asked whether the tissue already in the nose could do the same jobs: the upper lateral cartilages turned in as flaps in place of spreader grafts, the upper strip of the tip cartilages slid over the lower part in place of alar struts, and the tip supported by tucking the tip cartilages onto the septum rather than trimming it.

Sections of note

• 147 patients, open rhinoplasty, January 2010 to May 2012; mean operative time 73 minutes (range 44 to 120).
• After dorsal bone and septal reduction, upper lateral cartilage segments were preserved and turned inward as flaps replacing spreader grafts.
• Cranial parts of the lower lateral cartilages were not excised but slid over the caudal part, replacing alar strut grafts.
• Caudal septum not excised; tip supported by tongue-in-groove displacement of the lower lateral cartilages.
• Mean follow-up 19.6 months (6 to 30).
• All but 12 patients satisfied or completely satisfied.
• Secondary procedures: 4 for one-sided inverted-V (spreader grafts added), 3 for supratip deformity, 2 for extra tip definition, 2 for bone asymmetry, 1 for hanging columella.
• Level of evidence IV.

What it means for a patient

• In most patients the nose's own cartilage provided enough support without a separate harvest from the septum, ear or rib.
• About 8% needed a second procedure, and in 4 the flaps did not hold the middle vault open on one side.
• The tongue-in-groove tip support only works when the septum's lower edge needs shortening anyway.

Why this paper matters

It is an early, large series of the cartilage-saving philosophy that feeds into preservation rhinoplasty, with honest reporting of where flaps fell short. No comparison with grafted patients was made.

Terms

• Cartilage flap: a piece of cartilage repositioned while still attached, rather than removed and replaced.
• Spreader graft: a cartilage strip placed beside the septum to hold the middle vault open.
• Alar strut graft: a cartilage strip placed under the tip cartilage's side arm to support it.
• Tongue-in-groove: setting the medial crura into a pocket on the caudal septum and suturing them there.
• Inverted-V deformity: a visible V-shaped shadow where the nasal bones end, from the upper lateral cartilages falling inward.
• Supratip deformity: a bulge on the bridge just above the tip after rhinoplasty.