nose saddle and augmentation
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Nasal augmentation and management of saddling remains the area of most challenge and controversy. In the early days, reduction was the major concern of the Joseph rhinoplasty. Recently, in the new concept of rhinoplasty, the reduction attitude has changed and the aim now is to achieve a strong, profound, defined and well oriented nose, The author means a balanced nose. Therefore, augmentation procedures are needed in almost every rhinoplasty.

Aetiologies:

  1. Postseptal surgery:
    Post SMR and septoplasty.
  2. Nasal hump over-reduction:
    Cartilagenous or bony.
  3. Fractured nasal bone:
    Depressing fractures.
  4. Ethnic congenital or genetic:
    Black and Chinese are characterized by flat, shallow nasal dorsum with wide ill- defined tip and wide nares.
  5. Post-infection:
    Septal abscess, syphilis, leprosy.

Types of Saddling Deformities:

    1. Minor deformities:
      1. Minimal supratip collapse.
      2. Minor columellar retraction.
      3. Alar collapse.
      4. Upper lateral cartilage collapse.

 

  1. Moderate to major deformities:
    1. Marked supratip collapse.
    2. Marked or massive bony bridge collapse.
    3. Bony and cartilagenous collapse or saddling (broad and flattened bony pyramid).
    4. Marked upper lateral cartilage collapse.
Fig. 11 – 1. (A) Bony collapse was corrected by double septal grafts. (B,C) Post submucous resection supratip collapse was corrected by conchal supratip grafts.

 

Fig. 11 – 2. The edge of the dorsum graft should be bevelled or trimmed in a triangular way in order to avoid step deformities and demarcation.
Fig. 11 – 3. Clinical application of grafts:
1. Columellar strut 2. Tip graft 3. Supratip graft 4. Dorsum graft
5. Nasofrontal angle graft 6. Spreader graft 7. Batten graft

 

Types of grafts:
One hundred years ago, Jacques Joseph (1865-1934) used ivory to augment the nasal dorsum and chin, this was obtained from a nearby piano factory.

Nowadays, autogenous cartilage is used more often. The author prefers autogenous cartilage, it has superior long term survival characteristics, it is available from the nose and from the ears, there is minimal infection and absorption, it is flexible and it is more natural for the anatomical structure of the nose. For more major saddling, the author uses laminated, layered and multiple conchal grafts but rarely silicon or iliac crest grafts. However, the ideal nasal grafting material is still not in existence. When it is developed, it will enhanced our rhinoplasty results. (Fig. 17 – 20)

  1. Septal cartilage graft:
    Suitable for columellar strut, tip graft, spreader graft, supratip and dorsum grafting.
  2. Auricular graft:
    Dorsum augmentation, supratip augmentation, alar graft, tip graft and upper or lower cartilage grafting.
  3. Excised cephalic portions of lateral crus:
    Suitable for lateral crura, Batten graft, upper lateral cartilage graft, nasofrontal angle, and supratip.

In the author’s experience, we have enough cartilage grafts from the nasal septum and the ear, that should be more than adequate for any major reconstruction [septum (2.5cm x 1.5cm), conchal (4.5cm x 1.5cm)]. The author has never found the need for rib grafts and rarely any reason to use any alloplastic implants such as Polymer Mesch or proplast. On occasions, the author has used silicon in Chinese and Black patients for the reconstruction of major saddling. Recently, the author, has on a few occasions used fascia lata and AlloDerm which are proving to be practical and reliable without the postoperative problems of floating and demarcation. AlloDerm seems to be promising but it is expensive.

Preparation of the graft:

  • When the graft is taken from the ear, a full aseptic technique must be applied.
  • Care should be taken in order not to destroy the septal or conchal graft.
  • Graft should be left in Povidone during the operation until it is used.
  • The edge of the graft should be bevelled or trimmed in a triangular way to avoid steps deformities or showing of the sharp edges. (Fig. 11 – 2 and Fig. 17 – 21)
  • Avoid crushing or morsilization of the graft, except the shield tip grafts in thin skinned patients. (Fig. 17 – 7)
Layered dorsum graft
                 Lengthened dorsum grafts
Dorsum and supratip graft
Fig. 11 – 4. Dorsum grafts may be layered in order to increase its bulk and length. The layered cartilages are sutured together.
  • Suture fixation of the graft is preferable but avoid too many sutures. (Fig. 17 – 21)
  • Grafts may be laminated or layered in order to increase their bulk or length for major augmentation. The layered pieces of cartilage should be stitched together. Double or triple layers of long bridge graft may be indicated. (Fig. 11 – 4)
  • Leave a small amount of soft tissue fixed with the graft, this allows for easy suturing in place.
  • Temporalis fascia may be required to cover the graft to achieve smoother surface.
  • At the end of the operation suitable mild pressure should be applied on the nose, in order to prevent dead space and keep the graft in direct contact with cartilage, bone and skin for its blood supply and survival. (Fig. 17 – 22)
  • In major augmentation avoid too much pressure on the nose by the strips or plaster, this might cause skin necrosis. The factors which predispose for skin necrosis are, the pressure applied by the cast, stretching of the skin by the bulky graft and the graft itself which acts as a barrier for the blood supply between the skin and the dorsum.
  • Plastic or x-ray sheets applied externally on the sides of the nose for seven days will help to keep the graft in the middle and avoid displacement. (Fig. 17 – 22)
  • Bilateral index finger massage applied for ten minutes, four times a day, for two months postoperatively, is highly recommended in order to maintain the bridge graft in the middle position. (Fig. 2 – 7)

Saddling and Augmentation: Clinical Applications

  1. Dorsum grafts:
    Septal or conchal or both are used to augment the nasal bridge. As previously stated, there are more than adequate autogenous septal and conchal grafts readily available for most cases, septum (2.5cm x 1.5cm), conchal (4.5cm x 2cm) and the other conchal side may be used. A short graft may be needed to augment the bony pyramid or a long graft to augment both the bony and cartilagenous pyramid. The graft may be single, doubled or even tripled as indicated. The second or third layer may be of the same length or shorter and is placed on the area where most augmentation is required. When a layered conchal graft is used it is preferred to be covered with septal strip to provide a smoother dorsum. The graft is usually stabilized by a single suture to the dorsum septum or by double suture to the apex of the dome of the alar behind the tip graft. A graft to skin pullout suture may be required to position the graft. The pullout suture is removed five days postoperative. More stabilization of the dorsum graft and supratip graft may be achieved by a plastic or x-ray sheet applied externally on the sides of the nose fixed by steri-strips for a few days. This will help to keep the graft in the middle. (Fig. 11 – 3 and Figs. 17 – 21,22)
Fig. 11 – 5. A 22-year-old patient with a broad and collapsed nose. Correction was obtained by medial and lateral osteotomies, new dome creation, suture fixation, scoring, columellar strut and tip grafts and double conchal dorsum grafts.
  1. Supratip graft:
    Septal or conchal graft used. The graft is measured to fit the cartilagenous dorsum. Double layer may be needed. The graft is positioned and established by 4/0 Dexon suture to the dorsum septum or sutured to the delivered dome cartilages just behind the tip graft. (Fig. 17 – 21)
  2. Columellar strut:
    Septal graft 2.5cm x 0.5cm is ideal. The aim is to achieve tip elevation, projection and narrowing and prevent columellar retraction and correct bifid columella.(Fig. 17 – 15)
  3. Tip graft:
    Septal or conchal. The triangular shield graft may be short, long, double or even triple. It is sutured to the caudal margin of the intermediate crura or used as an umbrella. The aim is to achieve tip definition, projection, elevation, refinement, symmetry and narrowing. Tip graft must be crushed in a thin skinned patient.(Fig. 17 – 16)
  4. Batten or alar grafts:
    Conchal or excised cephalic portion of the upper lateral cartilage are ideal. This type of graft is indicated in alar collapse, dimpling, retraction, pinching, alar asymmetry and in small or underdeveloped lateral crus in order to achieve strong, profound, defined and well oriented nasal side walls. (Fig. 8 – 30 and Fig. 17 – 23)
  5. Spreader grafts:
    Best to be a septal graft. It is very useful in crooked noses to correct the C-shaped dorsum septal deviation, by positioning and suturing the graft to the concave septal surface. Bilateral spreader grafts also correct cartilagenous dorsum narrowing and valve collapse. (Figs. 9 – 9,10 and Fig. 17 – 24)
  6. Anchor and rim grafts:
    Anchor grafts are very helpful in tip deformity associated with cleft lip. The graft will help in achieving symmetry and correct alar rim collapse and notching. Rim grafts are useful in mild rim notching. (Fig. 8 – 30 and Fig. 17 – 23)
  7. Upper lateral cartilage grafts:
    Conchal or septal grafts and excised cephalic portion of lower lateral cartilage may be used to augment depressed or lost upper lateral cartilage. This is common in trauma and revised cases.
  8. Nasofrontal angle grafts:
    Septal, conchal or excised cephalic portion of lateral crus may be used to flatten and elevate the deep nasofrontal angle. (Fig. 17 – 21)
      1. Chinese and Black.
      2. Major trauma reconstruction.
      1. Advantages:

        1. Augmentation of tip and bridge at the same time in a single manoeuvre.
        2. Easy and quick to insert. The procedure takes about fifteen minutes under local anaesthetic. (Fig. 17 – 22)
    1. Silicon implants:
      Indication:

Disadvantages:

    1. Early or delayed rejection.
    2. Infection:
      The fibrous capsule formed around the implant acts as a barrier to infection. Therefore, treatment with antibiotics is justified when the implant site becomes infected, as it is possible to heal without removing the implant.
    3. Line of demarcation:
      The fibrous capsule formed around the implant, may contract the surrounding skin and outline the implant. This may be cosmetically unacceptable as the implant will be visible under the skin.
    4. Implant mobility (free floating):
      The implant may be moved from side to side by patient’s fingers. This may concern the patient.

Saddling and Augmentation: Complications of Grafting

  1. Infections:
    The main enemy of grafting is infection. If it happens, the graft will be destroyed and revision may be required later. Therefore, aseptic technique and prophylactic antibiotics are vital.
  2. Absorption:
    Absorption of cartilage autografts are extremely rare in the tip and supratip region. In rare situations, absorption is noticed in autogenous cartilage covering the bony nasal dorsum. On this occasion the patient comes back to the clinic saying that his nose is looking smaller than it was soon after operation. In this situation, a strip of autogenous auricular graft is inserted into a precise pocket, it will elevate the dorsum.

    This is usually done as an out patient under local anaesthetic and takes no more than ten minutes. On rare situations, when there is no more autogenous septal or conchal graft available, an irradiated homograft can be used and if absorbed, repeated in the future as necessary.
    1. Graft displacement:
      To avoid early graft displacement, the graft should be positioned accurately during operation, stitched if necessary to adjacent dorsum, septum or alar cartilage. External steri-strips and plaster are used for one week to keep the bridge graft in the middle followed by instructed bilateral index finger massage. The massage is done by applying gentle pressure with two fingers on the sides of the nose equally on each side of the grafts for ten minutes to maintain the graft in the middle. This is repeated three to four times a day for two months (Fig. 2 – 6). Late displacement may occur six to twelve months postoperatively due to uncontrolled wound contraction and healing. In this situation, under local anaesthesia, undermining and repositioning of the graft is indicated.
    2. Graft movement and mobility:
      The patient may complain that he can mobilize the graft with his fingers. If the graft is in the middle and in the right position, the patient is reassured.
    3. Line of demarcation:
      The sharp edges of the graft may show through the skin or step deformity may be formed. Therefore, bevelling of the graft edges and triangular trimming along the edge of the dorsum and tip grafts are highly indicated to reduce this problem.
    4. Skin necrosis:
      This very rare complication is reported in major augmentation when bony graft or multiple layered cartilage graft are used with pressure dressing. The bulky graft will stretch the dorsum skin, the graft acts a barrier for the blood supply and with application of pressure dressing strips and tight plaster of paris, necrosis of the skin may occur.
      The main alarming sign is that the patient will complain of severe pain on the nose early in the postoperative period. The dressing and the plaster should be immediately removed and the skin on the nose inspected. If there is necrosis, or bluish discolouration, the graft should be removed and changed to a smaller one with application of local and systemic antibiotics.
Fig. 11 – 7. Post traumatic saddling and wide tip. Augmentation rhinoplasty was performed. Lateral and medial osteotomies, dorsum septal graft, new dome creation, suture fixation, scoring, columellar strut and tip grafts.

 

Saddling and Augmentation: Before and After

Fig. 11 – 8. A 23-year-old man, who desired aesthetic improvement. Dorsum augmentation was achieved by septal graft. Tip refinement obtained by new dome creation, scoring, suture fixation, columellar strut and tip graft.

Fig. 11 – 9. Postrhinoplasty bony collapse. Correction was achieved by double conchal grafts.

 

Refrences
Saddling and Augmentation
 

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