In the old days of purely “reductive” Closed Rhinoplasty, Plastic Surgeons would do an entire Rhinoplasty in about half an hour, by simply removing cartilage, removing bone and thereby narrowing and shrinking the nose. The results were often great in the first few months, to even the first few years, but with the passage of time, shrink-wrapping of the skin and soft tissue envelope, and the unpredictable nature of scar tissue contracture, would end up distorting many of these noses. Pinched tips, alar notching and retraction, collapsed nasal bridges and some of the telltale signs of a “bad” nose job were unavoidable.
With the pendulum swing from the predominantly closed Rhinoplasty to the open structure Rhinoplasty, more grafts and more sutures (stitches) entered the tool belt of the Rhinoplasty Surgeon. The use of more conservative reductive maneuvers replaced aggressive, reckless, excisions. (For example, judicious narrowing of the lateral segment of the Lower Lateral Cartilages replaced the complete amputation of this segment: “Cephalic Trim” vs. “Complete Strip”). Rearrangement of tissue and reshaping of tissue, with sutures, as well as addition of support grafts, replaced simply removing tissue. Cartilage grafts, soft tissue grafts, and suture manipulations, have developed significantly over the last ten to fifteen years. We have learned which sutures are safe and which sutures should be avoided due to their higher risk of infection or extrusion.
The knowledge gained as result of open structure Rhinoplasty has spilled over into the closed Rhinoplasty technique in order to achieve more predictable, and stable, long lasting result. The skillful Rhinoplasty surgeon should be able to achieve great results with either open Rhinoplasty (External Rhinoplasty) or closed Rhinoplasty (Endonasal Rhinoplasty). While the open Rhinoplasty is the approach of choice for total nasal reconstruction in severely deformed Revision Rhinoplasty cases, as well as complex Primary Rhinoplasty cases, the closed Rhinoplasty remains an excellent approach and an art that is becoming extinct, due to its teaching complexity, and steep learning curve. Both are great approaches and both approaches can be done well or done poorly. These are merely tools in a plastic surgeon’s hands and the nose job results depend on how well the tools are used!
GRAFTS IN RHINOPLASTY:
Columellar Strut Grafts: About a 4mm x 2cm cartilage graft that sits between the medial crura of the Lower Lateral Cartilages (LLC) and provides support to the tip. Sizes can vary. May be sutured in open Rhinoplasty or placed into a precise pocket in closed Rhinoplasty. Positioning and shape can affect rotation of the tip and projection as well as shape of columella. Very strong columellar struts can be fashioned from rib cartilage to allow building of the tip in revision Rhinoplasty or in significantly short & under-projected noses such as Asian Rhinoplasty.
Plumping Grafts: Pieces of cartilage placed at the naso-labial junction, usually beneath a columellar strut to “open up” the naso-labial angle in patients with ptotic (droopy nasal tips)
Pre-maxillary Grafts: Larger sheet of cartilage or fascia or implants placed at the naso-labial junction as the foundation for the base of the nose, in patients with severely under developed pre-maxillas. Usually used in Hispanic or Indian Rhinoplasty patients.
Shield Type Tip Grafts: Cartilage grafts in various shapes, widths, and lengths (typically resembling a medieval armored shield) placed over the medial crura of the Lower Lateral Lartilages (LLC) extending to the domes or even above. Used to modify the tip and create new and better “tip defining points.” Can be used to increase projection if the graft extends above the domes of the LLC. Can be used to create a more refined and narrow tip. Can be used in a layered or stacked manner to de-rotate the tip in short, upturned noses and to lengthen the nose. Edges must be beveled to prevent showing through the skin. Must be used in extreme care in thin skin Rhinoplasty patients. Very commonly used in thick skin Rhinoplasty patients to create better tip definition. Secured with sutures in open or “closed-delivery Rhinoplasty;” or placed in a precise pocket in “closed-non-delivery Rhinoplasty.”
Cap Grafts: Small oval shaped grafts placed over the domes of the lower lateral cartilages or placed over the upper portion of shield type tip grafts for added projection or length to the tip
Blocking Grafts: Small oval shaped cartilage grafts placed on the back part of the upper portion of an extended shield type tip graft to add support and prevent the upper end of the shield graft from bending backward. Used in cases where extended shield grafts are used above the lower lateral cartilage domes for added projection and length.
Alar Batten Grafts: Large oval shaped cartilage grafts placed over or under the lateral portion of the lower lateral cartilages and extending to above the pyriform aperture bone. Used to support the lateral ala (nostrils) and prevent pinching or collapse. Can be used for cosmetic purposes but often used for functional purposes to prevent dynamic alar collapse during forceful inspiration.
Alar Strut Grafts: Rectangular cartilage grafts placed above or below the lateral segment of the lower lateral cartilages to provide shape and support. Often used for replacement or reconstruction of the LLC’s in revision Rhinoplasty when the LLC’s have been over aggressively excised. Also used to bend a convex lateral LLC into a more favorable straight segment to reduce bulbosity of the tip.
Rim Grafts: These are usually 2mm x 1.5cm cartilage grafts placed at the alar (nostril) rims to provide support and prevent pinching or collapse in Rhinoplasty patients with thin nostril skin. May be used to correct minimally retracted alar margins. These may flare the nostrils on base view.
Composite Grafts: Usually cartilage grafts harvested from the ears with the skin remaining attached to the cartilage. These are used to correct vestibular stenosis as well as correct moderate to severely retracted or notched alar margins.
Spreader Grafts: These are usually 4mm x 2-3cm cartilage grafts placed between the upper lateral cartilages and the dorsal septum. Very useful grafts in prevention of some post-operative Rhinoplasty deformities as well as correction during revision Rhinoplasty. Sutured into place in open rhinoplasty or placed into a precise pocket in closed rhinoplasty. Cosmetically spreader grafts can be used to:
- Help straighten a crooked nose
- Open a pinched middle vault and fix an “hour glass shaped” nose
- Help de-rotate an over rotated nose when used as a D.A.R.T.
- Lengthen a short nose when extended beyond the caudal septum
- Prevent “inverted V deformities” post Rhinoplasty
- Create nice “brow-tip aesthetic lines”
- Functionally spreader grafts may improve breathing by opening the internal valve area between the dorsal septum and the upper lateral cartilages.
- These grafts can create noses that look too wide from front view
Onlay Grafts: Cartilage or fascia grafts placed over the middle vault, or dorsum to add bulk, width, or height. Can be crushed or morselized cartilage. Not “functional” grafts usually but mostly cosmetic.
Radix Grafts: Cartilage, diced cartilage, or fascia grafts placed at the radix to increase the height of the radix and the “nasal starting point.” These grafts may show their edges in thin skinned Rhinoplasty patients.
Caudal Septal Extension Grafts: Very useful and powerful grafts placed to increase the length of the septum and nose. Used in ethnic patients with short noses or in Revision Rhinoplasty cases. Usually this graft is taken from rib cartilage but thick septum or double layer ear cartilages can also be used.
Lateral Wall Grafts: Cartilage grafts to replace over aggressively reduced Upper Lateral Cartilages in Revision Rhinoplasty.
Temporalis Fascia Graft: Soft tissue graft used in patient with very thin skin to help camouflage and create a smoother nose. Can be used at the tip, dorsum or radix. Alloderm, which is a cadaveric a-cellular dermal graft, can also be used as an easier, but more expensive alternative.
GRAFT MATERIAL IN RHINOPLASTY:
Septal cartilage: A large portion of the Septal Quadrangular Cartilage can be harvested and used during Rhinoplasty. “An L-strut” must be left to support the nose. This L-strut must be at least 1.5cm in width to support the bridge and tip. The remainder of the cartilage can be removed and used for Rhinoplasty. In Revision Rhinoplasty, this cartilage is often missing and unavailable, as it may have been used during the previous Rhinoplasty surgeries. Septal perforation (hole) is a risk of septal cartilage harvest or septoplasty. This cartilage is often missing and destroyed in patients who have been struck to the nose very hard (boxers) as well as patients with history of Cocaine abuse or autoimmune diseases.
“Cartilage is to a Rhinoplasty Surgeon what wood is to a carpenter.”
Most Rhinoplasties require some form of cartilage grafts – from minimal use to extensive use. Typically septal cartilage is the first choice of cartilage for most Facial Plastic Surgeons while many Plastic Surgeons prefer ear cartilage due to lack of comfort and training in operating inside the nose.
Septal bone: A portion of the perpendicular plate of the Ethmoid bone, at the back-top end of the septum, can be used for graft material although not ideal.
Ear (Auricular) cartilage: A greatly versatile source of cartilage for grafts. Incisions can be placed in front or behind the ear(s). Cartilage can be harvested from various parts of the ear and used in Rhinoplasty and Revision Rhinoplasty. Under skillful hands, no major cosmetic deficits should be noticed with the ears after surgery.
Ear composite graft: Powerful grafts taken from the ear including cartilage and its overlying attached skin. Used to correct “soft tissue triangle defects” as well as retracted nostrils and vestibular stenosis. Very technically challenging grafts to place and do not always survive.
Post Auricular Fascia: Soft tissue taken from behind the ear to help camouflage areas, in thin skinned Rhinoplasty patients.
Temporalis Fascia: Strong soft tissue layer covering the Temporalis Muscle, used to camouflage areas in Rhinoplasty patients with thin skin. It can also be used to augment the radix. Alloderm can substitute for Temporalis fascia.
Rib (Costal) Cartilage: Large, strong cartilages harvested from the ribs 5,6,8,9,or 10. Used when abundant cartilage and building material is needed in Rhinoplasty or Revision Rhinoplasty. Often used to build up the bridge or lengthen the tip. Frozen or Irradiated cadaver rib may also be used. When carved properly concentrically, these cartilages have a minimal risk of warping.
Bone: Bone from the ribs, skull, scapula or hips can be used in major reconstructive cases.
IMPLANT & ALLOPLASTIC GRAFTS USED IN RHINOPLASTY
Mersilene Mesh: Permanent implant that resembles “cheese cloth.” Often used in general surgery to fix hernias. Can be layered and used nicely as a chin implant. Not a good option in the nose due to risk of acute or delayed infection but some plastic surgeons do use this in the nose.
Gore-Tex (PTFE): Permanent white leathery soft plastic implants. Comes in sheets or in pre-formed strut type implants. Not a first option in the nose due to risk of acute or delayed infection but used commonly by many plastic surgeons.
Silastic (Silicone): Pre-made implants in different shapes and sizes. Very commonly used for Asian Rhinoplasty. Not a good option in the nose due to risk of acute or delayed infection as well as shifting and extrusion.
Medpor: Pre-made implants in different shapes and sizes. Very commonly used for Asian Rhinoplasty. Not a good option in the nose due to risk of acute or delayed infection as well as shifting. Very difficult to remove once it’s been in place for a few weeks. May also extrude through the nasal skin, leaving bad scars.
Surgicel: Cellulose sheets used for hemostasis. Used abroad for radix grafts as a “Turkish Delight” which is diced cartilage wrapped in Surgicel. Temporalis Fascia is a much better alternative.
SUTURE MATERIAL IN RHINOPLASTY:
Vicryl: An absorbable braided suture that can be used in Rhinoplasty but not the best choice. It can cause inflammation, infection, or extrusion (spitting of the suture).
Monocryl: A fantastic mono-filament (non-braided) absorbable suture that can be used in Rhinoplasty. Often used in a 5.0 size for dome defining sutures.
PDS: A fantastic mono-filament (non-braided) absorbable suture that can be used in Rhinoplasty. Often used in a 5.0 size as dome defining sutures, or 6.0 for securing tip grafts. Takes a few weeks to months longer than Monocryl to absorb.
Plain Gut & Fast Absorbing Gut: Quickly absorbing sutures used in Rhinoplasty to close internal incisions. Fast Absorbing Gut dissolves quicker than Plain Gut but the two are very similar. Used in 3.0, 4.0, 5.0 and 6.0 sizes.
Chromic and Mild Chromic: Quickly absorbing sutures used in Rhinoplasty to close internal incisions. Alternative to Gut.
Prolene: Permanent mono-filament suture that can be used in certain areas of the nose during Rhinoplasty. It is often unnecessary and can be substituted with PDS. The suture is not removed if used internally.
Nylon: Permanent mono-filament suture that is often used in a 6.0 or 7.0 size to close external Rhinoplasty columella incisions. The suture is removed in 3-7 days if used externally.
Ethibond: Permanent braided Polyester suture used by some Plastic Surgeons in Rhinoplasty. High risk of infection and post Rhinoplasty problems.
SUTURE TECHNIQUES IN RHINOPLASTY:
Single Dome Stitch: Mattress type stitch placed at the dome of the Lower Lateral Cartilage to bend the dome into the desired, more defined shape. The suture material most commonly used are 5.0 PDS, 5.0 Monocryl, 5.0 Clear Prolene, or 5.0 Clear Nylon. May cause alar retraction.
Double Dome Stitch: Mattress or simple type stitch placed between the two domes of the two Lower Lateral Cartilages to bring them together and create more symmetry and support. Plastic Surgeons must be careful to avoid cinching the suture down too tight to prevent a “uni-tip” appearance.
Alar Spanning Stitch: Simple type stitch placed between the cephalic, lateral aspects of the Lower Lateral Cartilages to reduce tip convexity. Must be used carefully as it can create significant alar rim retraction.
Wright Stitch: Suture placed to correct a deviated caudal septum. It essentially pulls the deviated septum to the other side of the anterior nasal spine and secures it there
Septal-Columellar Stitch: Suture placed to position the tip in relationship to the rest of the nose by placing a suture from the caudal septum to the columella. It is also used in “Tongue-In-Groove” maneuvers to suspend a “hanging columella” and shorten the nose.
- There are many other stitches used in Rhinoplasty to attach grafts or bend and manipulate cartilages. There are also other less commonly used grafts and suture materials in Rhinoplasty and Revision Rhinoplasty that can be used in certain situations. Your Rhinoplasty Surgeon should be familiar and comfortable with multiple grafts and sutures in order to have all the necessary tools to achieve the best possible Rhinoplasty results.