The short nose – grafts & donor cartilage
Donor Sources of Cartilage
Donor cartilage can be obtained from a number of sites. The most preferable is the septum. This often provides a nice batten or spreader graft. The second choice is the concha or auricular cartilage from one or both ears. A third choice is cartilage from a rib.
In obtaining a batten graft from the concha or ear, a posterior approach is preferred by Dr. Sam Rizk to hide the scar and expose the convex concha. A piece of cartilage measuring 3cmx2cm is removed. It is more than adequate in size. Dr. Rizk points out that plans should be made in advance in revision rhinoplasty with a short nose to harvest ear cartilage and the patient should be aware of this in advance so there are no surprises. Sometimes, if a composite graft is needed with the ear cartilage skin, this can be done as well. Sometimes this is needed if there is contracture of the area between the upper lateral-lower lateral cartilage regions. If rib cartilage needs to be used, then this has to be planned ahead of time as well and patient well informed.
Batten graft or caudal septal extension graft
The batten graft is used to lengthen the septum by attaching to it and pushing the tip cartilages in a caudal direction. Sometimes batten grafts are used for tip projection or to correct collapses of the external nasal valve. The septal extension graft is a form of batten graft to lengthen the nose. Dr. Sam Rizk has used the concept of a batten graft by using an extended spreader graft such that it pushes the tip cartilages caudally. The size of the batten may vary individually and it can be taken from a site such as the concha in which case it will not be straight but the bend in it is not necessarily a problem. The bend can be scored multiply or by a long score. The batten is then applied to the septum and sutured to it with interrupted sutures. If the batten has a stiff and a flexible portion, then the flexible portion should be against the septum and the stiff portion should be inferiorly. The batten position can be adjusted accordingly if more projection is needed or if more lengthening is needed in the posterior part of the caudal septum. The batten is often sutured to the septal dorsal strut or in the dorsal-caudal junction of the strut and is placed between the lower lateral cartilages in a pocket. Sometimes it can also be sutured to the lower lateral cartilages. The batten can lengthen the nose by as much as 1cm. It is necessary to do this without tension and Dr. Sam Rizk emphasizes the need for a good superior and lateral release of the mucoperichondrial flap. With the batten graft in place, the lengthening of the nose is immediately apparent. If for some reason the skin flap is not closing without tension, it is essential according to Dr. Sam Rizk, a NYC nose job or New York City rhinoplasty surgeon, to undermine more and release better to achieve closure without tension. Tension closures may cause pressure on the skin and may lead to skin necrosis, a complication that needs to be prevented if possible. The tension on the skin would constrict the blood supply to the nasal tip and lead to skin necrosis and infection.
Additional Maneuvers to lengthen the nose
There are a few other techniques that are used for short noses that can be used in addition to the above. These include derotating the tip cartilages and adding a dorsal graft. This can add even further length. Also a tip graft of the shield type also can add some length to the nose. Dr. Sam Rizk also recommends doing a transfixion incision which lengthens and deprojects the nasal tip. A natural NYC nose job created by Dr. Sam Rizk takes into account the length of the nose. An overly short nose is not a natural nose. The length of the nose varies between men and women. The length of the nose affects the nasolabial angle and an ideal angle for a female is between 95-100 degrees. An ideal angle for a male is 90-95 degrees.