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Page 4 of 16 Won et al. Plast Aesthet Res 2019;6:6 I http://dx.doi.org/10.20517/2347-9264.2018.82

A B

Figure 3. Pre and postoperative 1 year frontal photograph of a 52-year-old male patient with deviation of the silicone implant (A, B). The
implant was removed together with the surrounding capsule and dorsal augmentation was performed using autogenous rib cartilage. Tip
projection and rotation was achieved using a septal extension graft

cartilage is often used to fulfill this purpose. Often conchal composite grafts are needed to correct the
deficient vestibular mucosa. A non-alloplast dorsal onlay graft that fills the dorsal defect after removal of
the previous alloplast is also preferred.

Dorsal deviation/irregularity
Residual dorsal deviation is most often caused by failure to recognize or correct the pre-existing deviation.
Improper osteotomies with or without adequate correction of the septum is the main cause. Deviation
of the dorsal graft/implant and warping of the costal cartilage graft can be other reasons. Complete
realignment employing restorative measures to straighten the bone and cartilaginous structures are
required. If residual deviation persists after adequate structural realignment, camouflage grafts need to be
applied [Figure 3].

A supratip depression or fullness after dorsal augmentation is not uncommon. Careful design of the
implant and fine adjustment with additional grafts at the supratip is often necessary during primary
rhinoplasty. Radix irregularity is more common when the radix is augmented with cartilage. To avoid this,
the radix graft should be morcelized and inserted under a layer of soft tissue. Mastoid periosteum provides
a good grafting source to smoothly elevate the radix area.

Tip problems related with septal extension graft
The recent trend of using septal extension graft for tip surgery in Asian rhinoplasty has created an array
of complications such as overly aggressive tip projection (Pinocchio nose), deviated, asymmetric tip, pain
and nasal obstruction. Aggressive tip projection using septal bone or Medpor is a common reason for tip
pain and tenderness [Figure 4]. Removing stiff materials and restoring adequate projection with autologous
cartilage is the best solution in these patients.

Inadequate midline stabilization of the septal extension graft is a common reason for tip deviation, nostril
asymmetry, and nasal obstruction due to caudal septal deviation. This can often be avoided by securely
suturing the graft to the anterior nasal spine and positioning the end into the midline in the overlapping
type of septal extension graft. In the end to end type septal extension graft, reinforcement can be achieved
with extended spreader grafts.

GRAFTING MATERIAL IN REVISION RHINOPLASTY
Revision rhinoplasty requires a large quantity of implants for grafting, supporting, and reconstruction.
We prefer autologous cartilage for revision rhinoplasty in order to avoid further infection and soft