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Guide To Nasal Grafts

tatler magazine 2013

Tatler Magazine (2013) - Top Rhinoplasty Surgeon in NYC/New York

What is a graft and when are grafts indicated in rhinoplasty surgery?
A graft is either a piece of cartilage, cartilage and skin (composite graft), or soft tissue (as in temporalis fascia) used in rhinoplasty to either support lost tissue from a previous rhinoplasty to correct collapsing areas or are used in primary rhinoplasty to create more definition in the nose in ethnic or thick skin patients. Grafts can also be used in primary rhinoplasty to support weak cartilages and prevent them from collapsing or to make the nose look straighter (spreader and camouflage grafts).

What is the purpose of obtaining temporalis facia?
The temporalis fascia is a piece of flat soft tissue graft  obtained from the area above the ear from a small scar within the hair and is used to thicken thin skin to make irregularities or grafts less visible. It can be used to thicken the skin on its own without using cartilage grafts or it can be used with cartilage grafts to soften the edges. Alloderm is a soft tissue graft used as an alternative to temporalis fascia but is obtained from a tissue bank.

Where are most  grafts obtained from?
Grafts imply the material is natural and are obtained either from the patient or a tissue bank (as in rib or costal cartilage grafts or alloderm). If obtained from the patient, cartilage grafts are  either obtained from the septum (parting wall between right and left side of nose), or from the patient's own ears. A graft should be distinguished from an implant because  an implant is synthetic material.

I am afraid grafts will make my nose larger?
This is a myth and is not the case.  Grafts create definition in the nasal tip to make the nose prettier. Now, grafts may be used on purpose to make the bridge or dorsum larger as in African American Rhinoplasty or Asian Rhinoplasty where the bridge is flat.

What is the goal of using grafts in rhinoplasty?
The goal of grafts in rhinoplasty is to use them selectively to achieve specific goals such as creating definition in thick skin noses, making a nose appear straighter, correcting a collapse or indentation in the nose, providing tip support to prevent the nose from drooping or correcting a saddled (scooped) or pinched nose in revision rhinoplasty.

How are grafts placed in the nose?
Grafts are placed with either the open (external) rhinoplasty approach or the endonasal (internal) rhinoplasty approach.

rhinoplasty - before/after - case 1 - front view rhinoplasty - before/after - case 1 - side view

43 yo female with a severe saddle deformity and absence of septal cartilage to use for reconstruction underwent reconstructive rhinoplasty to correct saddle nose deformity using banked rib cartilage and temporalis fascia (soft tissue obtained from above the ear). The bony bump was reduced, the nose was straightened, and the cartilaginous saddle collapse was built up. The rib cartilage was sculpted using Dr. Sam Rizk's specialized microsurgical powered instruments to obtain a smooth result instead of the typical method using the surgical knife.

rhinoplasty - before/after - case 2 - front view rhinoplasty - before/after - case 2 - front view

44 year old female patient who underwent endonasal rhinoplasty to correct a collapse of the left nose secondary to an injury which also created a crooked nose to the right. Patient wanted also more tip refinement and a very subtle profile reduction. Patient had rhinoplasty endonasally in 3d with multiple nasal cartilage graft placement on the left side to correct the collapse as well as a conservative profile reduction and tip refinement. The grafts were harvested from the patient's own nasal septum.

What is the best source of grafts?
As grafts are mostly composed of cartilage, the nasal septum is the best source of good cartilage. The second best source is the ear. The last alternative if both septum and ear cartilage is not available is banked rib cartilage. Dr. Rizk does not believe it is necessary to harvest rib grafts from the patient's own rib as banked rib works just as well and does not involve the significant risks of entering the patient's chest region. Many studies have compared use of banked rib versus patient's own rib and have found no difference. If a strong piece of cartilage is needed, either banked rib or septum are the best but if a softer cartilage is needed, then ear is the best source.

What are the various named grafts used in rhinoplasty and what are they used for?
The following are some of the more common grafts Dr. Rizk uses but this list is  by no means complete. Some grafts used have no name.

  • Composite Graft - composed of skin and cartilage and obtained from the ear. Used to correct a retracted nostril.
  • Shield Graft - used in the nasal tip to provide definition and some support.
  • Columellar strut - used in the tip to provide support to a weak tip.
  • Tip Onlay Graft - used in the nasal tip to provide definition and projection. The ear (conchal) cartilage makes a good tip onlay graft.
  • Camouflage Graft - a type of onlay graft used to correct a collapsed or indented area anywhere in the nose.
  • Caudal Extension Graft - used to make a short nose longer
  • Dorsal Augmentation Graft - used to correct a saddle nose deformity (scooped nose).
  • Spreader Graft - used to widen a middle vault collapse and to correct an inverted V deformity. They are placed between the upper lateral cartilage and septum.
  • Alar Batten Graft - used to support the external nasal valve and goes lateral to the lower lateral cartilages to correct a "pinched nasal tip"-used frequently in revision rhinoplasty. Helps prevent collapse of ala when breathing in.
  • Plumping Grafts - a graft placed at the nasolabial angle and is used to augment or improve a retracted columella. This graft can make the nose appear shorter.
  • Radix Graft - a graft placed in the angle between nose and forehead (nasofrontal angle) to change the angle and make it look less deep. This makes nose appear longer. Dr. Rizk likes to crush this graft made of cartilage to make it less visible and places it deep in the nasofrontal area under the muscle.
  • Alar Rim Graft - graft placed along the edge of the nostrils to also improve a pinched tip appearance or a retracted nostril. Dr. Rizk prefers to use soft ear (conchal) cartilage or septal cartilage for this graft.

What are the risks of using grafts and how does Dr. Rizk decrease these risks?
Grafts can sometimes, although rarely, move, or become visible or absorb. All grafts will absorb or settle slightly with time even if the graft is obtained from the patient's own body.

To decrease graft visibility, Dr Rizk developed a technique to sculpt and smooth the graft edges with a powered sanding tool, rather than use the surgical knife. Dr. Rizk believes that a rounded edge in a cartilage is less visible than an angled edge. The surgical knife creates angled edges, whereas the powered sanding tools used by Dr. Rizk (see article in Plastic Surgery Practice journal in the media section of this website) create more rounded and less visible edges.

Also Dr. Rizk places grafts deep under the muscular layer of the nose to provide enough cushion and coverage. If the patient has thin skin, Dr. Rizk will add either temporalis fascia or Alloderm over the graft to thicken the skin.