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Abstract
Keywords
rhinoplasty
dorsal augmentation
revision rhinoplasty
Understanding the nuanced practices and grafting options of dorsal augmentation will
improve outcomes and results in rhinoplasty. To better understand the practices of
dorsal augmentation among our colleagues. To review the current literature regarding
the indications, safety proles, and outcomes of different materials used in dorsal
augmentation. A PubMed search was performed to capture current articles containing
reviews or large series regarding the safety and efcacy of various grafting materials
used for dorsal augmentation. Of the many options available, autologous cartilage
grafts maintain widespread use for dorsal augmentation and other techniques in
rhinoplasty. Homologous cartilage grafts, namely irradiated rib, are a preferred
alternative. Irradiated costal cartilage has been shown to have low complication rates
and is unique in its abundance of supply, particularly in the revision rhinoplasty.
Alloplastic implants, particularly silicone, are prevalent in Asian countries where they
are a popular rst-line choice. ePTFE has a favorable complication prole in primary
rhinoplasty; however, caution is recommended when using ePTFE in revision cases.
Porous polyethylene has a higher risk of associated complications than the other
alloplastic implants listed, and therefore should be considered thoughtfully. Although
cartilage is often the preferred graft for dorsal augmentation, there are many other
autogenous, homologous, and alloplastic materials that have been shown to be safe and
effective choices when applied in the proper setting.
Methods
A brief six-question survey was created and dispersed via email to the current attending and fellow members of the
DOI http://dx.doi.org/
10.1055/s-0035-1555616.
ISSN 0736-6825.
Malone, Pearlman
Results
Of the 1,300 surveys dispersed, 290 responses were received
for a survey response rate of 22%. Responses were collected
over a 2-month period from August through September of
2013. The data were analyzed anonymously and independently using the Survey Monkey Web site and data analyzer.
Our survey showed that approximately one-third (32%) of
our participants have a surgical practice in which rhinoplasty
represents more than half of their overall case volume.
Approximately one-fourth (23%) of our responders reported
that more than half of their rhinoplasty cases are revision or
secondary surgeries (Fig. 1).
Primary Rhinoplasty
An overwhelming majority of responders (93%) report that
they perform dorsal augmentation in less than 25% of primary
rhinoplasties. For the surgeons who perform dorsal augmentation in the majority of their primary cases, 83% reported
that rhinoplasty represented less than half of their overall
surgical case volume.
Our ndings are consistent with current literature advocating septal cartilage as the graft of choice for primary cases,
with 70% of surgeons indicating so in our survey. Alloplastic
implants were the rst-line choice in primary cases for 11% of
responders; ePTFE being the most popular alloplast (8%),
followed by silicone (3%), and porous polyethylene (<1%).
Diced cartilage wrapped in fascia is the autogenous graft of
choice for 8% of responders. Costochondral grafting (both
autologous and cadaveric) was the rst choice for 6% of
surgeons (autologous rib 4%, cadaveric rib 2%) in primary
cases.
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Discussion
This brief survey reveals the widespread practices of dorsal
augmentation among rhinoplasty surgeons. Proper and safe
management of the nasal dorsum is imperative to achieving
desirable aesthetic outcomes, and must be considered on an
individual basis. Mastering techniques in dorsal augmentation require advanced skill and a large armamentarium of
knowledge about different options in grafts and implants.
We conducted a literature review on the various types of
materials used in dorsal augmentation, and the historical
complication rates associated with each. An ideal graft is one
that is readily available, biocompatible, inexpensive, harvested with low donor site morbidity, and bearing a low
complication rate.1 The current literature reports separately
on the use of autogenous, homologous, and alloplastic grafts
for dorsal augmentation. We present a concise article to
compare all types of grafting material together, with their
associated successes and failures, as well as the patient
population for which each is most suitable (Table 1).213
This survey did not query surgeons on rhinoplasty approach
as it was considered extraneous to the aims of this study.
Whereas an open versus closed rhinoplasty approach can
alter tip shape and projection, it is not considered to affect the
outcome of dorsal augmentation. However, we acknowledge
that this is an unlikely but potential confounding issue with
our data. This study focused on the unique issues related to
varying graft materials in dorsal augmentation.
Autologous Grafts
Autologous grafts are considered by many to be the most
desirable material for grafting in rhinoplasty.1,14,15 Autologous grafts offer clear advantages of low rates of infection or
graft extrusion and favorable patient acceptance. However,
the well-known disadvantages of autologous grafts include
availability of graft volume, irregular shape, absorption,
donor site morbidity, and aesthetic resultsall of which
may prohibit use in revision or more extensive cases.16,17
Autologous cartilage is the preferred grafting material for
dorsal augmentation as shown in our survey, and has been
widely documented as a successful technique in the literature.16 Autologous cartilage is sourced from the nasal septum,
conchal bowl, costal cartilage, and lateral crura of the lower
lateral cartilages. Cartilage grafts can be used en bloc or diced
and wrapped in autogenous temporalis fascia or other biocompatible materials such as Surgicel18 (Ethicon, Inc., Somerville, NJ). When using diced cartilage techniques, the senior
author prefers encasement with temporalis fascia versus
surgical and other biocompatible materials available. Surgicel
wrapped cartilage is also referred to as a Turkish Delight18
based on the original authors publication and heritage. The
complication rates of autologous cartilage are infection (1.5
5%), implant migration (112.5%), graft resorption (0.55%),
and warping (2.55%).2,1842 There are no reported cases of
graft exposure. Particular care must be taken in cases of
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Malone, Pearlman
Graft material
Cases
Follow-up
Complication rate
33
18 y
56
114 y
Exposure 3.6%
Resorption 1.8%
Displaced 1.8%
Removal 1.8%
Kridel et al4
20,1
4 d24 y
Alloderm
15
624 mo
None
Silicone
1,079
N/A
Infection 2.6%
Removed 2.6%
Cosmesis 2.96%
Tham et al7
Silicone
355
3 mo3 y
Infection 5.3%
Extrusion 2.8%
Cosmesis 7.8%
Wang et al8
Silicone
27
2y
Conrad et al9
Gore-Tex
264
1217 mo
10
Gore-Tex
309
5 mo10 y
Infection 3.2%
Removed 3.2%
Cosmesis 0.32%
Jin et al11
Gore-Tex
853
18 mo
Infection 2.1%
Removed 2.2%
Cosmesis 1.9%
Chen et al12
Medpor
32
25 mo
Infection 6.25%
Removed 6.25%
Romo et al13
Medpor
187
642 mo
Infection 2.6%
Removed 2.6%
Cervelli et al
Jackson et al5
Lam and Kim
Godin et al
Homologous Grafts
Irradiated rib has gained widespread popularity with a
particular advantage in secondary or revision rhinoplasty,
where autologous cartilage may be scant or inadequate for
use. Irradiated rib has unique benets for use in augmentation of the nasal dorsum in that it is an abundant resource to
provide ample grafting material while reducing operative
time and donor site morbidity as compared with harvesting
autologous costal cartilage. Reported complications of irradiated rib include infection (0.877.4%), resorption (17.4%),
displacement (0.35.9%), warping (114.8%), and graft exposure (3.6%).3,4346 Human acellular dermal matrix grafts,
AlloDerm, is an alternative homologous graft. Used either
alone or in conjunction with other graft materials, Alloderm is
incorporated into surrounding tissue and therefore may cover
small contour irregularities. Resorption, has been shown to be
between 20% and 30%, occurring within the rst year postop.43
Facial Plastic Surgery
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Alloplastic Implants
Alloplastic implants are well studied and in widespread use,
and are particularly favored in Asian countries for augmentation in rhinoplasty. The reported complications associated
with silicone implants include extrusion (2.13.7%), infection
(3.7%), and displacement (3%). There were also reports of graft
dislocation; however, there are no published rates of this
complication.48,37,47,48
Expanded polytetrauoroethylene (Gore-Tex, Implantech,
Inc., Ventura, CA) has also been used with good results in
augmentation rhinoplasty, alone and in combination with
autologous cartilage grafts. Complications observed with
ePTFE include extrusion (1%) and infection (3.2%). Of note,
the published literature notes a higher complication rate with
ePTFE use in cases of revision surgery, thereby heeding
special attention and care to this subset of patients.37
Porous polyethylene (Medpor; Porex Surgical, Inc. Newnan, GA) is also used in dorsal augmentation rhinoplasty;
however, the reported complication rates of porous polyethylene are somewhat higher than the other alloplastic choices.
Porous polyethylene was shown to extrude from 3.1% to 10.7%
of the time, and infection rates run from 1 to
6.25%.2,3,30,43,45,49 Some surgeons also nd that with
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Malone, Pearlman
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