The Dual-Plane Diced Cartilage Concept for Nasal Augmentation in Ethnic Rhinoplasty

Overview

The dual-plane concept places diced cartilage in both the sub-SMAS layer, just beneath the fibrous sheet under the skin, and the subperiosteal layer, beneath the covering of the bone. The authors argue this enlarges the interfacing tissue area, improving graft survival and smoothing the junction between the two thirds of the bridge. All patients were first time rhinoplasties treated between May 2021 and May 2023.

Sections of note

• Design: case series, 54 patients, all primary rhinoplasties. Level of evidence therapeutic IV.
• Approach: endonasal in 33 patients and open in 21.
• Graft material: costal cartilage, wrapped in rectus fascia.
• Patients were monitored for complications at 1, 3, 6 and 12 months. Average follow up 17.3 months.
• Results were documented photographically and rated by two blinded plastic surgeons at one year.
• Ratings: 1 unsatisfactory, 1 average, 2 satisfactory, 24 very satisfactory, 26 outstanding.
• No complications occurred, including no graft resorption, infection or skin circulation problems on the bridge.
• Stated rationale: enlarging the interfacing tissue area improves augmentation outcomes and graft viability.

What it means for a patient

• Diced cartilage grafts shrink over time, and this technique aims to improve survival by spreading the graft across two layers with more contact tissue.
• Splitting the graft between layers is also intended to smooth the junction where bone meets cartilage, a common site of visible irregularity.
• No resorption at an average 17 months is notable, though shrinkage typically develops over longer periods.
• Limits: 54 patients, no comparison group against single plane placement, and outcomes rated on a five point scale by two surgeons rather than by patients.

Why this paper matters

Diced cartilage is the standard material for building up a low bridge, and unpredictable shrinkage is its recognized weakness. Placing it across two planes is a mechanistic proposal about why grafts survive. Whether volume holds beyond 17 months, and whether two planes outperform one, is untested.

Terms

• Diced cartilage: cartilage cut into tiny pieces so it can be molded like a paste.
• SMAS: the superficial musculoaponeurotic system, a fibrous layer beneath the skin.
• Subperiosteal: beneath the membrane covering bone.
• Radix: the root of the nose, the area between the eyes.
• Rectus fascia: the connective tissue sheet covering the abdominal muscle, used to wrap grafts.
• Resorption: gradual absorption and loss of graft volume by the body.