A New Technique to Correct Saddle Nose Deformity After Failure of Diced Cartilage Grafts: Diced Cartilage Flap — Suleyman Tas PubMed

I N N O V A T I V E T E C H N I Q U E S CRANIOFACIAL/MAXILLOFACIAL A New Technique to Correct Saddle Nose Deformity in Failure of Diced Cartilage Grafts: Diced Cartilage Flap Su¨leyman Tas¸1 Received: 15 January 2015 / Accepted: 26 June 2015 / Published online: 11 July 2015 /C211Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015 Abstract Background To correct saddle nose deformity, diced car- tilage grafts have been commonly used over the past decade. However, following the correction of saddle nose deformity with diced cartilage graft, some problems like graft absorp- tion or displacement may occur, which require revision surgery. Here, a new technique is presented for correcting saddle nose deformity when diced cartilage graft fails. Methods Twelve cases were admitted to my clinic with complaints of nasal dorsal irregularity and depressions, asking for tertiary rhinoplasty. Seven (four women and three men) of these patients, who had a gap smaller than 1 cm in the lower 1/3rd of nasal dorsum, were selected for the described technique. After the nasal dorsum is under- mined through the supra-perichondrial and subperiosteal plane, the diced cartilage island attached to the nasal dorsal skin is released distally until the island can be transposed to the tip area. This island attached to the nasal dorsal skin proximally, is formed as a flap and moved caudally as an advancement flap and sutured to the posterior of the dome area. The patients were followed for minimum 1 year (12–20 months) with intervals of 3 months. Results All the patients and also the surgeon were satis- fied with the results. No complications such as resorption of the grafts were observed in any of the cases. Conclusion This is an alternative, new, practical tech- nique for correcting saddle nose deformity in the lower 1/3 of the nasal dorsum, in which the diced cartilage graft technique has failed to correct. In addition, tip projection and upward rotation can be achieved with this technique. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to 46 Authors www.springer.com/00266. Keywords Cartilage /C1Diced /C1Flap /C1Nose /C1Rhinoplasty /C1 Saddle Introduction Despite the fact that rhinoplasty is one of the most common esthetic procedures in the world, we still encounter a considerable number of secondary and tertiary rhinoplasty patients in our practice [ 1]. If the problem of secondary rhinoplasty patients is under-resection, it can be simply solved by resection of the excessive tissues. However, the most common problems in secondary rhinoplasty cases are over-resection or destruction of the osteocartilaginous structures which is called saddle nose deformity (SND) and needs to be reconstructed by graft materials [ 2]. The use of diced cartilage grafts (DCG) has become popular for dorsal reconstruction over the past decade [ 1– 4]. However, it is well known that DCG may be displaced or absorbed over time, which is the reason for revision surgeries. Currently, in these revision surgeries, graft materials with/without surgicel or fascia are commonly used [ 4, 5]. Here, the author describes a diced cartilage flap (DCF) technique as a new way to correct the SND in the lower third of the dorsum that had previously been corrected with DCG. & Su¨leyman Tas¸ drsuleymantas@live.com 1 Department of Plastic, Reconstructive and Aesthetic Surgery, R.T.E. University Training & Research Hospital, 53100 Rize, Turkey 123 Aesth Plast Surg (2015) 39:764–770 DOI 10.1007/s00266-015-0530-8

Materials and Methods In total, 12 cases were admitted to my clinic for tertiary rhinoplasty with complaints of nasal dorsal irregularity and depressions. The chart of the patients is summarized in Table 1. From their history and documentation, it was seen that all of them underwent a primary rhinoplasty in other centers, which resulted in over-resection and secondary rhinoplasty in yet other centers for the correction of the deformity with DCG. The exclusion criteria were defor- mities affecting the proximal 2/3 of the nose or a gap larger than 1 cm in distal 1/3 of the nose. Seven of the patients (four women and three men), who had a gap smaller than 1 cm in the lower 1/3rd of the nasal dorsum, were selected for the aforementioned technique (DCF). The reason for the gap was absorption in six of seven patients and dis- placement in one patient. Patient records revealed that in their secondary rhinoplasty, five of seven were implanted with free diced cartilage grafts and the other two with diced cartilage grafts wrapped in surgicel. The average patient age was 26 years (range 22–30 years). Five of the patients had an internal vault collapse, and two of them had an external vault collapse. The patients were followed for a minimum of 1 year (range 12–20 months) with intervals of 3 months. Functional improvement was assessed with self- evaluation of nasal patency ranging from 0 (complete obstruction) to 10 (optimal airflow). The v 2 test was used for statistical analysis. Surgical Technique The technique is shown schematically in Fig. 1. It can be used either with an endonasal or open approach under general anesthesia. Following the incisions, the nasal dor- sum is undermined through the supra-perichondrial and subperiosteal plane (Fig. 2a). Afterwards, the distal part of the diced cartilage island attached to the nasal dorsal skin is released until the island can be transposed to the tip area (Fig. 2b, c). The bleeding from the edges of the flap indi- cates good vascular supply. This vascularized cartilaginous tissue, attached to the nasal dorsal skin proximally, is formed as a flap and moved distally as an advancement flap, then sutured to the posterior of the dome area with 4/0 Polydioxanone (Fig. 2d). At the same time, upward rota- tion of the tip is achieved (Fig. 2e). If a tip projection is desired, DCF should be sutured to the posterior of the medial cruras. Case #1 A serious SND is shown in a 22-year-old female patient as an example of absorption of the DCG (Fig. 3a–c). The photographs depicting the surgical technique are from this patient (Fig. 2). As seen in Fig. 3c, the patient had poor skin quality and thin skin. The surgical procedure included DCF technique, osteotomies, tip plasty with sutures and lateral crural suture for narrowing the caudal area of the nose. During the 20-month follow-up period, the result was satisfactory both esthetically and functionally (Fig. 3d–f). Case #2 A serious SND is shown in a 29-year-old female patient as an example of displacement of the DCG (Fig. 4a–c). The surgical procedure included DCF technique, tip plasty with sutures, left lateral crural graft, and rim graft for Table 1 The chart of the patients Case Age Gender Prior operations Deformity Preop patency Postop patency Location Size (cm) Nature #1 22 F Free DC 1/3 distal 1 Absorption 4 9 #2 29 F Free DC 1/3 distal 0.7 Displacement 6 8 #3 23 M Free DC 1/3 distal 0.5 Absorption 3 8 #4 26 M DC-wrapped in surgicel 1/3 distal 0.8 Absorption 5 8 #5 30 F Free DC 1/3 distal 1 Absorption 4 9 #6 25 M Free DC 1/3 distal 0.7 Absorption 3 8 #7 27 F DC-wrapped in surgicel 1/3 distal 1 Absorption 2 9 #8 20 M Free DC 2/3 proximal 1 Absorption 6 9 #9 21 F DC-wrapped in fascia 2/3 proximal 0.75 Displacement 4 9 #10 26 F Free DC 2/3 proximal 0.5 Absorption 4 10 #11 29 M Free DC 2/3 proximal 1 Displacement 3 8 #12 24 F Free DC 2/3 proximal 1.5 Absorption 7 8 DC diced cartilage Aesth Plast Surg (2015) 39:764–770 765 123

reconstructing the left internal and external valves. During 19-month follow-up period, the result was satisfactory both esthetically and functionally (Fig. 4d–f). Results The DCF technique achieved very satisfactory results, having the advantage of no donor side morbidity, imme- diate and stable results during the follow-up period, and also tip projection if desired. All patients were satisfied with the results. No complications such as resorption of the graft or permanent wrinkles on the skin of the nasal dorsum were observed in any of the cases, as judged by serial physical examinations, serial photography, and input received from the patients during the follow-up period, although some wrinkles may be seen after the flap trans- position in the operation. To correct the internal vault collapse in five of seven patients, three lateral crural and two spreader grafts were used and to correct the external vault collapse, two rim grafts were used. Nasal obstruction was reduced after surgery, and self-evaluation of nasal patency scores significantly increased in all patients (p \ 0.001) (Table 1). Discussion Following a primary rhinoplasty, if over-resection is per- formed, a saddle nose deformity will occur. A variety of methods have been described in the literature for the cor- rection of post-rhinoplasty SND. These include grafting techniques with free diced cartilage, free diced cartilage wrapped in fascia or surgicel, costal cartilage, bone, or alloplastic materials [ 4–6]. Commonly, the DCG technique is used for correcting this deformity. Some rhinoplasty surgeons even use DCG in primary rhinoplasties to prevent the dorsum irregulari- ties [6]. However, DCG may cause some problems such as graft absorption, displacement, or palpability/visibility [ 4]. To prevent these complications, in the literature, a tight recipient pocket was performed or free diced cartilage wrapped in fascia [ 4] or surgicel was used [ 5]. The chal- lenge is how one should revise the postoperative deformity following the application of the DCG technique, whether the reason for the revision is absorption or displacement. In these tertiary cases, there are also concomitant asymmetries in the areas of the tip and upper lateral car- tilage as in the presented cases. This needs a large dis- section area and therefore causes displacement risk if we select DCG again. The author considers that the DCF technique eliminates this risk. All anatomic structures and relationships between them should be preserved in rhinoplasty. If failed, reconstruction of these relationships has to be planned [ 7]. In the pre- sented case series, the real problem is the loss of connec- tion between the tip and nasal dorsum and the solution should be case specific for best results [ 7, 8]. The available techniques are the tongue-in-groove technique [ 9], septal extension graft technique [ 10], tip control suture [ 11], deep SMAS layer technique [ 7], and modified lateral crural suspension flap technique [ 8]. In the presented technique, this relationship is established by suturing of the DCF to the dome area or medial cruras. With this technique, the SND is corrected and a desired tip projection and upward rotation are gained. Fig. 1 a Nose anatomy is shown from profile. b A saddle nose deformity, which had been previously attempted to be fixed with DCG (stained blue), is observed in the distal 1/3 of the nasal dorsum. c After the nasal dorsum is undermined through the supra-perichon- drial and subperiosteal plane, the distal part of the diced cartilage island attached to the nasal dorsal skin is released until the island can be transposed to the tip area. The diced cartilage flap, which attaches to the nasal dorsal skin proximally, is advanced toward dome area. Thus, an upward rotation of the tip is achieved. The blue arrow shows the direction of the movement of the flap, red arrow shows the direction of the movement of the tip. d Final closure is observed. Red circle shows the suturing between the flap and the dome area 766 Aesth Plast Surg (2015) 39:764–770 123

Fig. 2 a Nasal dorsum is undermined through the supra- perichondrial and subperiosteal plane. The diced cartilage island is fully inside of the skin flap. b Distal area of diced cartilage island is detached until the island can be transposed to the tip area. c After releasing the distal part of the diced cartilage island from subcutaneous tissue, the mobility of the flap is observed. The bleeding of the edges of the flap indicates good vascular supply. d The advancement flap is sutured to the posterior of the dome area. e Immediate intraoperative result is observed. Her preoperative and late postoperative results are shown in Fig. 3 Aesth Plast Surg (2015) 39:764–770 767 123

The superiorities of this new technique over completely detaching the graft and repositioning are (1) It is a flap and thus the possibility of absorption is minimal since it has its own supply, (2) since the flap attaches to the skin proxi- mally, the flap has a pivot point on the radix and continuity with radix of the nose; therefore, this prevents depression of the radix and provides upward rotation of the tip. A small group of seven cases with a gap smaller than 1 cm in the lower third of the dorsum was presented. The disad- vantage of this technique comes from the limitations of the patient selection. In gaps larger than 1 cm, this technique may cause permanent wrinkles on the dorsum, a shortened nose or may not have enough advancement to close the defect. Conclusion The mentality of the advancement of diced cartilage tissue as a flap comes from the prelaminated flap. In selected patients, not only successful results were achieved with this technique, but also tip projection and upward rotation can be established. This is an alternative, new, practical Fig. 3 Case #1. Preoperative a front, b lateral and c top appearance. At 20 months postoperative d front, e lateral and f top appearance 768 Aesth Plast Surg (2015) 39:764–770 123

technique for correcting SND in the lower 1/3 of the nasal dorsum, previously operated on using DCG. Compliance with Ethical Standards Conflicts of interest The author declares that he has no conflicts of interest, commercial associations, or intent of financial gain regarding this research. References 1. Celik M, Halilog ˘lu T, Bayc¸in N (2004) Bone chips and diced cartilage: an anatomically adopted graft for the nasal dorsum. Aesthetic Plast Surg 28(1):8–12 2. Celik M, Tuncer S (2000) Nasal reconstruction using both cranial bone and ear cartilage. Plast Reconstr Surg 105(5): 1624–1627 3. Daniel RK (2006) The role of diced cartilage grafts in rhino- plasty. Aesthet Surg J 26(2):209–213 4. Daniel RK, Calvert JW (2004) Diced cartilage grafts in rhino- plasty surgery. Plast Reconstr Surg 113(7):2156–2171 5. Erol OO (2000) The Turkish Delight: a pliable graft for rhino- plasty. Plast Reconstr Surg 105(6):2229–2241 6. Daniel RK (2008) Diced cartilage grafts in rhinoplasty surgery: current techniques and applications. Plast Reconstr Surg 122(6): 1883–1891 7. Tas¸ S (2014) A new way for supporting tip projection in closed rhinoplasty: using the medial deep SMAS layer. Plast Reconstr Surg 133(1):76–77 Fig. 4 Case #2. Preoperative a front, b lateral and c top appearance. At 19 months postoperative d front, e lateral and f top appearance Aesth Plast Surg (2015) 39:764–770 769 123

8. Tas¸ S (2014) Modification of the lateral crural suspension flap. J Oral Maxillofac Surg 72(5):846–847 9. Kridel RW, Scott BA, Foda HM (1999) The tongue-in-groove technique in septorhinoplasty. A 10-year experience. Arch Facial Plast Surg. 1(4):246–256 10. Byrd HS, Andochick S, Copit S, Walton KG (1997) Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg 100(4):999–1010 11. Tebbetts JB (1994) Shaping and positioning the nasal tip without structural disruption: a new, systematic approach. Plast Reconstr Surg 94(1):61–77 770 Aesth Plast Surg (2015) 39:764–770 123