Grafts in nasal surgery

Grafts in Nasal Surgery

D.J. Menger

International Course in Modern Rhinoplasty Techniques
The Netherlands

www.rhinoplastycourse.nl

Dear colleague,

In modern rhinoplasty, especially in revision cases, nasal graft are often essential to improve the function
of the nose, the nasal breathing, or to reach a nasal skeleton that dictates a new shape to the overlying
soft tissue envelope that is in pleasing harmony with the rest of the face.
This lecture illustrates the use of cartilaginous nasal grafts from the nasal septum, the auricle or rib.

CAUTION: The lecture contains pictures taken during surgery, which might be shocking. The lecture is
intended for colleagues and is part of the "International Course in Modern Rhinoplasty Techniques".

Dirk Jan Menger, MD
Course Director

The Netherlands


Columellar strut
preferred cartilage graft: septal, auricular, costal or irradiated rib.
DJ Menger


A columellar strut stabilizes the medial crura of the lower lateral cartilages. They can be used to straighten and
strengthen the columella. In this patient in combination with a hump reduction, tip refinement and upward
rotation of the drooping tip.
Pre- and postoperative views.
DJ Menger


Pre- and postoperative lateral view.


Shield graft
preferred cartilage graft: auricular or septal. Second choice: costal
DJ Menger


A shield graft is positioned anterior to the medial crura above the dome area. It brings the overlying skin tissue
in a higher position which gives the illusion of more nasal tip projection. The shield can camouflage
asymmetries of the tip and it can lengthen the short nose.
DJ Menger


This patient had a cleft lip on the left side including all the characteristics of the cleft lip nose; a strong septal
deviation, flattening of the left ala and lack of nasal tip projection.
DJ Menger


Spreader graft
preferred grafts: septal, auricular, costal or irradiated rib.
DJ Menger


A spreader graft is placed between the nasal septum and the upper lateral cartilages. The effect is fourfold:
widening the internal nasal valve angle, camouflage of concavities in the mid nasal third, prevention of the
inverted V syndrome and lengthening of the short nose.
Pre- and postoperative frontal view.
DJ Menger


This patient had breathing problems and a concavity of the mid nasal third on the right side. One graft was
used, a spreader graft in combination with a hump reduction and tip suture techniques.
DJ Menger


Dorsal onlay and septal replacement graft
preferred cartilage grafts: septal, auricular, costal or irradiated rib
DJ Menger


A dorsal onlay graft can be used to camouflage irregularities- or a saddle of the nasal dorsum. The edges could
be beveled securely in order to avoid the graft to be visible through the overlying skin.
DJ Menger


This patient had previous septal surgery elsewhere and developed a septal abscess postoperatively. The caudal
septum was reconstructed with auricular cartilage in combination with a limited hump removal and a small
dorsal onlay graft. Pre- and postoperative views.
DJ Menger


Dorsal onlay graft and caudal septal correction
DJ Menger


A deviation of the caudal part of the nasal septum can be straightened with scoring, always in combination with
splinting of this area with a strong- and straight piece of cartilage graft. Fixation in the midline to the anterior
nasal spine.
DJ Menger


This patient had nasal trauma and developed a saddle nose deformity. Reconstruction was performed using a
dorsal onlay graft in combination with a limited hump reduction, osteotomies and a septal correction. Pre- and
postoperative lateral view.
DJ Menger


DJ Menger


Pre- and postoperative basal view.
DJ Menger


Dorsal augmentation and tip refinement
DJ Menger


This patient had a previous rhinoplasty elsewhere. Her nasal dorsum was too low and not in harmony with the
rest of her face, especially with her strong mandible. She had bifidity and hanging nasal tip defining points, this
was refined and balanced using tip suture techniques and LC-overlay. Pre- and postoperative frontal view.
DJ Menger


Pre- and postoperative oblique view.
DJ Menger


DJ Menger


Reallocation of the lateral crura
DJ Menger


This patient had breathing problems due to concavities of the lateral crura of the lower lateral cartilages, which
protruded into the nasal vestibule. This concave configuration can be altered by complete dissection of the
lateral crura in order to turn them around. Intra-operative view
DJ Menger


DJ Menger


Osteotomies, spreader grafts, reallocation of the lateral crura, septal correction, columellar strut and tip suture
techniques. Pre- and postoperative frontal view.
DJ Menger


Augmentation of the fronto-nasal angle
preferred materials: septal, auricular, costal, irradiated costal grafts
DJ Menger


This patient had a pseudo over-projection of the nasal tip due to an unbalanced nose in which the naso-frontal
angle was too deep. Only the radix was augmented using auricular cartilage through an endonasal approach.
DJ Menger


This patient had over-resection of the bony nasal dorsum after a rhinoplasty performed elsewhere.
Augmentation was performed using septal cartilage. Pre- and postoperative lateral view.
DJ Menger


Alar retraction, rim reconstruction.
preferred material: composite graft, auricular cartilage
DJ Menger


This patient had a hump deformation, a "crowded upper-lip" and mild retraction of the alar rim. Pre- and
postoperative lateral view.
DJ Menger


A rhinoplasty was performed including a hump reduction, osteotomies, spreader grafts, reduction of the
anterior nasal spine, a columellar strut, tip sutures and a small composite graft. This graft was positioned
alongside the caudal rim of the lateral crura in order to lower the alar rim.
DJ Menger


DJ Menger


Alar rim graft.
preferred materials: septal, auricular, costal, irradiated costal grafts
DJ Menger


An alar rim graft can stabilize the alar rim, especially the soft triangle of Converse.
DJ Menger


Create a small pocked in the alar rim and introduce the graft.
DJ Menger


Fixation of the graft can be carried out with the use of a soluble suture through-and-through all layers.
DJ Menger


When the suture is reintroduced exactly at the same site where it came out (but in an other angle), you can pull
the suture through the cutis and fixate the graft.
DJ Menger


Slight augmentation of the fronto-nasal angle, reduction of the cartilaginous dorsum, columellar strut, a shield
graft and alar rim grafts. Pre- and direct postoperative view.
DJ Menger


Vestibular stenosis, auricular composite graft.
This patient had a cleft lip on the left side and an iatrogenic pinpoint-stenosis of the left vestibule due to
intubation in childhood. Stenosis of the vestibule was treated using an auricular composite graft in order to
restore the shortage of inner lining.
DJ Menger


The donor area can be closed with a free skin flap that can be harvested retro-auricular. This area can be closed
primarily.
DJ Menger


The composite graft was sutured in place in the nasal vestibule.
DJ Menger


before-, during- and one year after surgery
DJ Menger


In the postoperative period of vestibular stenosis and cleft lip surgery, a custom made vestibular device can be
used to reduce the chance of re-stenosis. (6 weeks day and night and than for a period of 6 weeks only during
the night)

Postoperative management of nasal vestibular stenosis: the custom-made vestibular device.
Menger DJ, Lohuis PJ, Kerssemakers S, Nolst Trenité GJ.
Arch Facial Plast Surg. 2005 Nov-Dec;7(6):381-6.
DJ Menger


Total septal replacement in children after nasal septal abscess.
preferred material: auricular or costal cartilage
DJ Menger


This girl had a nasal septal abscess after trauma. Her entire septal cartilage was destructed. Without
reconstruction she would develop a saddle nose deformity with too much upward rotation of the nasal tip and
underdevelopment of both the nose and the mid-face.
DJ Menger


Reconstruction was performed using auricular cartilage fixed to PDS plate. PDS acts as a carrier and stabilizes
the different pieces of cartilage into one large implant. This implant precisely fits between the perpendicular
plate, the upper lateral cartilages and the premaxilla. Fixation to the nasal spine and UL.

Nasal septal abscess in children: reconstruction with autologous cartilage grafts on polydioxanone plate.
Menger DJ, Tabink IC, Trenité GJ.
Arch Otolaryngol Head Neck Surg. 2008 Aug;134(8):842-7.
DJ Menger


Before and 2 years after surgery
DJ Menger


Autologous cartilage from the rib or auricle is the first choice for the reconstruction of the nasal septum in a
growing child.

Treatment of septal hematomas and abscesses in children.
Menger DJ, Tabink I, Nolst Trenité GJ.
Facial Plast Surg. 2007 Nov;23(4):239-43.
DJ Menger


A boy who developed a septal abscess after nasal trauma. There were still signs of abscess formation in the
septum at the time of presentation, two weeks after the trauma.
DJ Menger


In this case costal cartilage was used. Slices of 1 mm were fixated to PDS foil and placed back between the
mucoperichondrium blades.

Nasal septal abscess in children: reconstruction with autologous cartilage grafts on polydioxanone plate.
Menger DJ, Tabink IC, Trenité GJ.
Arch Otolaryngol Head Neck Surg. 2008 Aug;134(8):842-7.
DJ Menger


Total septal reconstruction in adults.
DJ Menger


In adults, not the entire septum has to be reconstructed because there is no chance of underdevelopment. A
dorsal splint attached to a caudal splint is sufficient to prevent a saddle deformity and retraction of the
columella respectively.
DJ Menger


In this case irradiated rib grafts were used. These grafts are safe to use and provide a stable long term
postoperative result. The grafts were fixated to PDS plate, behind the caudal splint a remnant of septal cartilage
was crushed and placed on the foil to avoid the chance of a septal perforation.
DJ Menger


The septal replacement graft was positioned between the mucosal layers and fixed to anterior nasal spine and
the bony pyramid.

Irradiated homologous rib grafts in nasal reconstruction.
Menger DJ, Nolst Trenité GJ.
Arch Facial Plast Surg. 2010 Mar-Apr;12(2):114-8.
DJ Menger


A small hole was drilled in the nasal bone in order to suture the dorsal splint to the bony part.

Irradiated homologous rib grafts in nasal reconstruction.
Menger DJ, Nolst Trenité GJ.
Arch Facial Plast Surg. 2010 Mar-Apr;12(2):114-8.
DJ Menger


Total dorsal augmentation: “Leprosy Technique”
preferred materials: auricular, septal, costal or irradiated rib.

Reconstructive surgery of the leprosy nose: a new approach.
Menger DJ, Fokkens WJ, Lohuis PJ, Ingels KJ, Nolst Trenité GJ.
J Plast Reconstr Aesthet Surg. 2007;60(2):152-62. Epub 2006 Sep 14.
DJ Menger


This patient had complete lack of her bony dorsum. Reconstruction was performed using a costal cartilage
dorsal onlay graft attached to a columellar strut.

Reconstructive surgery of the leprosy nose: a new approach.
Menger DJ, Fokkens WJ, Lohuis PJ, Ingels KJ, Nolst Trenité GJ.
J Plast Reconstr Aesthet Surg. 2007;60(2):152-62. Epub 2006 Sep 14.
DJ Menger


Side-wall graft.
preferred materials: auricular, septal, costal or irradiated rib.
DJ Menger


A sidewall graft can be used to camouflage concavities or irregularities of the nasal sidewall. This patient had
previous surgery elsewhere with over-resection of the bony pyramid, the upper- and lower lateral cartilages.
DJ Menger


Reconstruction was performed using a dorsal onlay graft, side wall grafts and replacement of the lower lateral
cartilages. Pre- and postoperative oblique view.
DJ Menger


Alar batten graft.
preferred materials: auricular, septal, costal or irradiated rib
DJ Menger


Alar battens can be used to stabilize the lateral wall of the internal- and external nasal valve. They can also be
used to change the contour of the ala, for example in cleft-lip patients.
DJ Menger


A “guiding suture” can be helpful to position the batten in a pocket.
DJ Menger


To widen the external nasal valve, the battens should be pushed down as much as possible, while the lateral
crus is pulled up during fixation of the batten to the crus.
DJ Menger


This patient had a unilateral cleft-lip on the left side with the typical flattening of the ala.
DJ Menger


An alar batten graft on the left side was used to bring the lateral crus in a more symmetric position. The floor of
the nose was augmented using cartilage grafts. Pre- and postoperative basal view.
DJ Menger


This patient had breathing problems on the left side due to a caudal septal deviation and a concavity of the
lateral crus of the lower lateral cartilage on the lefts side.
DJ Menger


In this case not an alar batten but a lateral crus extension graft was used to alter the configuration of the crus.
The extension graft should be placed into a pocked that is relatively too small, this will push-up the lower
lateral. Pre-, intra- and postoperative result.
DJ Menger


An alternative for alar battens is “the lateral crus pull-up”. It is a suture technique in which the lateral crus is
pulled up laterally and upward to the bony pyramid. The effect is twofold; widening of the valve area and
strengthening of the lateral wall.

Lateral crus pull-up: a method for collapse of the external nasal valve.
Menger DJ.
Arch Facial Plast Surg. 2006 Sep-Oct;8(5):333-7.
DJ Menger


Lateral crus pull-up:
surgical steps

Lateral crus pull-up: a method for collapse of the external nasal valve.
DJ Menger

Menger DJ.
Arch Facial Plast Surg. 2006 Sep-Oct;8(5):333-7.

This patient had multiple rhinoplasties and other surgical procedures performed abroad. She had irregularities
of the nasal dorsum, severe columellar retraction, no tip projection and fibrosis and scars of the overlying soft
tissue envelope.
DJ Menger


There were no original structures of the nasal skeleton left. All nasal grafts were removed and rebuild, only the
overlying envelope was preserved.
DJ Menger


Recontruction was performed using rib grafts, auricular cartilage and composite grafts. A dorsal onlay graft was
attached to a columellar strut, sidewall grafts, a shield graft, lateral crus replacement grafts and composite
grafts to restore the inner lining of the nasal vestibule. Pre- and postoperative frontal view.
DJ Menger


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