Page 47 - Read Online

Page 2 of 9 Wu et al. Plast Aesthet Res 2019;6:5 I http://dx.doi.org/10.20517/2347-9264.2018.74

rhinoplasty, no such criterion standard yet exists for dorsal augmentation. In the ongoing pursuit of the
optimal technique for augmenting the dorsum during primary and revision rhinoplasty, surgeons have
continuously sought to increase precision, safety, and permanence.

The history of dorsal augmentation during rhinoplasty emulates in many ways the progression of
increasingly higher standards of care in medicine driven by technological advances and rapidly evolving
therapies. Early attempts were decidedly crude, with a wide assortment of everyday materials including
[1]
ivory and jade used to increase the height of the nose. Through the years surgeons have attempted to
[2-4]
improve outcomes by utilizing a variety of autologous and alloplastic materials, including: cartilage, bone ,
[16]
[5]
[13]
fascia diced cartilage and fascia [6-9] , silicone [10-12] , medpore , polytetrafluorethylene [14,15] , supramid ,
[17]
[18]
[19]
proplast , vicryl , and mersilene . All with mixed results.
While many contemporary surgeons favor autologous grafts in an onlay configuration for mild to moderate
amounts of dorsal augmentations [2,10,20] , cases demanding a larger volume of graft materials have prompted
surgeons to explore alloplastic (silicone, Goretex, etc.) and homoplastic (irradiated costal cartilage) options
in addition to autologous options given the ease of obtaining grafts, and the absence of any donor site
morbidity [2-5] . However, a primary downside of these grafts has proven to be the relatively high risk of
complications compared to autologous graft techniques, driving other surgeons to pursue this avenue more
intently.

The use of diced cartilage in dorsal augmentation has been periodically documented in the English-
language literature as early as 1943 by Peer, in 1951 by Cottle, and in 1968 by Burian, though it did not
[8]
gain wide-spread acceptance at the time [21-23] . Guerrerosantos revisited this concept in the 1990s , refining
the technique by wrapping fragmented cartilage in fascia, while Erol brought a larger audience with his
[24]
description of wrapping diced cartilage in Surgicel in 2000 , then Daniel subsequently brought a renewed
[6,7]
interested in wrapping diced cartilage in fascia . Modifications of the concept of using diced cartilage
as the building block for dorsal augmentation have been variously described, primarily adding assorted
tissue adhesives to ease shaping of the graft, altering the material wrapping the cartilage, or foregoing
an encasement altogether [9,25-30] . The manifold existing descriptions in the literature notwithstanding, a
systematic approach refining the surgical technique to achieve greater precision and consistency using diced
cartilage with fascia has not been previously delineated.

Diced cartilage with fascia represents a potentially ideal graft for dorsal augmentation as it makes use of the
lower complication rates associated with autologous grafts, while also providing a graft that has the ability
to recreate dorsal aesthetic lines in a natural and predictable manner. The usage of diced cartilage has been
variously described in the literature, with consistently satisfactory results reported. Herein, we present our
experience, with patients undergoing dorsal augmentation during rhinoplasty, using an updated method of
diced cartilage wrapped in fascia.

SURGICAL TECHNIQUE
Proper surgical planning and preparation for dorsal augmentation begins with the consultation and pre-
operative visit, wherein the nasal anatomy should be thoroughly assessed, and the aesthetic goals of surgery
defined, with particular attention directed at the dorsum, established with the patient.

The primary consideration with regards to the pre-operative nasal anatomy is the shape and integrity of
the platform created by the confluence of the upper lateral cartilages along the dorsal septum. The presence
of significant contour irregularities such as a dorsal hump or inverted-V deformities, indicate the need for
proper preparation and modification of the dorsum to support a diced cartilage wrapped in fascia (DCF)