Autogenous Dorsal Reconstruction: Maximizing the Utility of Diced Cartilage and Fascia

Abstract

The problem of reconstructing the dorsum of the nose is complex and a source of frustration for both patients and surgeons. Dorsal deficiencies due to various etiologies and the need for dorsal contouring cause the plastic surgeon to look to time-honored techniques such as osseocartilaginous rib grafts while also searching for other options that may be less technically challenging and have the benefit of temporal success. Diced cartilage wrapped with deep temporal fascia is just such a method to achieve reliable dorsal reconstructions. The various ways to use diced cartilage and deep temporal fascia are discussed. Dorsal nasal reconstruction continues to present one of the greatest challenges in rhinoplasty surgery. As with all aspects of medicine and surgery, favorable treatment outcomes mandate a correct diagnosis beforehand. Although seemingly pedestrian, proper preoperative diagnoses are frequently overlooked by the operating surgeon. Improper diagnoses beget improper treatments with unfavorable results. This generates an unhappy patient and an even unhappier surgeon; both wondering where it all went wrong. Prior to choosing a method for dorsal reconstruction , the surgeon should focus in on a thorough history, paying specific attention to trauma, nasal allergies, airway obstruction, and previous nasal and craniomaxillo-facial surgery. Equally essential is a complete head and neck examination. This includes a speculum examination of the internal anatomy of the nose. Important structures that are frequently overlooked include the palate, the nasal sidewall, the turbinates, and the dynamic function of the nasal valves. Inspection of the support structures of the nose helps delineate their individual relation to the dorsum. Evaluation of the skin is also paramount to understanding how grafts will or will not show over the long-term. Proper forethought will help the surgeon to forecast the effect that altering the septum and nasal bones can have on the overall nasal shape and function. The difficulties with dorsal reconstruction seem to stem from attempting to correct multiple problems with a single graft. Traditionally, osseocartilaginous rib grafts using a variety of fixation methods have been the gold standard for major dorsal reconstruction. Cantilev-ered bone grafts, another common method for dorsal reconstruction, produce excellent results when well executed. However, we have found these methods to be technically challenging and temporally disappointing. Intraoperative and 6-month postoperative results are frequently acceptable. However, graft warping and twisting over time seem to be the rule rather than the