Section 4 Plastic and Reconstructive Problems

gical exposure of the dorsum with a large space cre- ated under the nasal skin to allow maneuvering and placement of the diced cartilage is necessary to pre- vent fracturing or distortion of the graft ( Figure 4 ). Thus, an open rhinoplasty approach is the preferred method of performing this surgery. I believe that should an endonasal approach be used by the surgeon, diced cartilage placed within a temporal fascial tube is the preferred method of preparing the graft for aug- mentation of the dorsum. However, it is likely the fas- cial tube containing the diced cartilage will be difficult to insert and properly orient using the endonasal approach. Bullocks et al 10 recently reported using diced cartilage grafts with an endonasal approach. They created a malleable construct of autologous diced cartilage grafts stabilized with autologous tissue glue created from platelet-rich plasma (platelet gel) and platelet-poor plasma (fibrin glue). The authors combined the diced cartilage with the tissue glue and placed the mixture in a 5-mL syringe with the plunger removed and the distal beveled portion cut off. The plunger was then replaced, and the graft material was injected on the nasal dorsum. With this technique, the authors were able to graft the nasal dorsum with diced cartilage using the open as well as endonasal approach. Using diced cartilage solidified by thrombin mixed with fibrinogen has the theoretical advantage of earlier and more rapid revascularization compared with diced cartilage that is surrounded by an avascular fascia graft. The fascia itself must be revascularized before the carti- lage within the fascial tube undergoes ingrowth of vas- cular channels. Thus, it is likely that graft integration is delayed by the suboptimal porosity of the fascia. Diced cartilage and perichondrocyte coalesced with fibrin offers rapid imbibition through the interstitial matrix and optimal adherence of the graft to adjacent bone and cartilage. In patients with severe saddle noses from loss of car- tilaginous septal support, I use autogenous costal carti- lage to construct an L-shaped strut to restore support to the nasal dorsum and tip. The strut also provides a foun- dation for further dorsal augmentation if required to achieve an ideal profile using diced cartilage solidified by tissue sealant ( Figure 5 ).

from the trough and placed in the recipient site on the dorsum. The graft must be maneuvered very gently with smooth forceps because it is fragile and can be disrupted. The dorsal nasal skin must be widely elevated to create a space larger than the graft. This facilitates placement, since the graft is semirigid and can be fractured easily if excessive forces from a constricting soft-tissue pocket are exerted on the graft. Because the graft is fragile, it is best to place the graft on top of the skin of the dorsum and trim it to the appropriate size before placing the graft beneath the nasal skin ( Figure 3 ). Once the graft is in place, the nasal skin is redraped over the graft. The tissue sealant mixed with diced cartilage produces a graft that has the consistency of very soft but solid silicone rubber. Because the graft is pliable, it can be molded by gentle compression through the nasal skin to adjust the graft for an ideal profile. However, because the graft material is malleable, overzealous compression may disrupt the graft resulting in loss of graft integrity. Once the grafting procedure is complete and adjust- ments are made to create the ideal profile, incisions are closed, the nose is taped, and an external splint is applied. The splint should be applied with limited digital compression so the graft is not fractured or disrupted. It would be difficult to use an endonasal approach for placement of the diced cartilage grafts. A wide sur-

Figure 3. Diced cartilage graft is best modified for proper length and width by placing graft on the dorsal surface of the nasal skin rather than attempting to modify the graft once it has been placed beneath skin.

A

B

Figure 4. Same patient shown in Figure 3 before (A) and after (B) dorsal placement of dice cartilage graft.

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