Management of the Nasal Dorsum in Rhinoplasty: Technique, Outcomes, and Complications

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Management of the Nasal Dorsum in Rhinoplasty: Technique, Outcomes, and Complications

Most intervention regarding the nasal dorsum involves either augmentation in cases of deficiency or reduction in the presence of an existing hump. Augmentation is generally performed to fortify the nasal dorsum and improve contour irregularity. Authors have published a plethora of techniques using a broad array of tissues and/or implants.

Autogenous & Homologous Tissue

Autogenous Cartilage

Although a multitude of options exist for augmentation of the nasal dorsum, it appears that autogenous cartilage is likely the preferred method. Available options are multiple in the primary rhinoplasty but may be limited in revision surgery. Cartilage was harvested from a variety of areas using ear, septal, costal, and the upper or lower lateral cartilages. There exists no consensus regarding the preferred donor site when all are available, although utilization of septal cartilage obviates a second wound. Warping and migration were found to be problems in some patients who received costal cartilage grafts. Graft resorption, infection, and revision rates were comparable despite the donor cartilage used. Furthermore, some authors used diced cartilage, whereas the remainder of articles discussed the use of en bloc augmentation. The techniques implemented for graft insertion possessed substantial variation.

Complications from the use of autogenous cartilage included infection (1.5-5%), implant migration (1-12.5%), resorption (0.5-5%), and warping (2.5-5%).

Homologous Cartilage

Complications from the use of irradiated cartilage included infection (0.87-7.4%), resorption (1-7.4%), displacement (0.3-5.9%), warping (1-14.8%), and exposure (3.6%).

Bone

Although cartilage appears to be the preferred tissue for dorsal augmentation, multiple authors have described the use of bone as well. Bone was commonly used for moderate or greater dorsal defects. Sites of bone harvest included calvaria, mastoid, osseous nasal septum, inferior turbinate, tibia, and olecranon.

Complications included extrusion (3.4-6.3%), infection (1.9-5%), resorption (4-49%), and displacement (1.9-3.6%).

Soft Tissue

Other authors have suggested the use of dermal grafts and superficial musculoaponeurotic system tissue for the purpose of dorsal augmentation. The results of both revealed high patient satisfaction, with the most common complication being underaugmentation. The use of cadaveric dermis, autogenous fat, and fibrofatty tissue grafts were reported to have acceptable results. Of note, soft tissue was used primarily as a tool for augmentation in mild to moderate dorsal depression and/or contour defects. There were no reports of extrusion, infection, or displacement.

Synthetic Implants

Synthetic implants in rhinoplasty have been the topic of great controversy. Introduction of a foreign body and the ensuing inflammatory changes to such unforgiving anatomy is of great concern.

Silicone

The use of silicone in rhinoplasty is a point of worldwide contention among plastic surgeons. Perhaps the difference in opinion on whether or not this is a valid option stems from what some surgeons deem acceptable risk and others do not. Albeit small according to the literature reviewed, there does exist the risk of implant extrusion and subsequent skin loss. Combined with the risk of local infection, it
appears prudent to state that introducing silicone for the purposes of dorsal augmentation should be used in only the most judicious manner.

Complications reported included extrusion (2.1-3.7%), infection (3.7%), and displacement (3%). Several authors found graft dislocation to be a primary concern.

Expanded Polytetrafluoroethylene (Gore-Tex)

Gore-Tex should also be used with caution. Although the extrusion rates appear to be lower, there still exists the potential for complications related to this foreign body. As Gore-Tex is a foreign body that is placed in close proximity to the nasal cavity, which has a naturally high bacterial load, it may be more susceptible to infection.
This is a logical explanation for the observed complication of extrusion. However, further studies are needed to further assess the cause of this issue. The rate of infection in Gore-Tex appears comparable to that of silicone after systematic review.

Complications included extrusion (1%) and infection (1-3.2%). Several studies noted a higher complication rate in those patients undergoing revision surgery, urging caution in this subset. Several studies also reported acceptable results when Gore-Tex was used in combination with cartilage grafts.

High-Density Polyethylene (Medpor) and Polyethylene Terephthalate (Dacron)

Complications included extrusion (3.1-10.7%) and infection (1-6.25%). Several authors noted patient complaints of local firmness and numbness.

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