Operative Technique Video Articles
In Asian rhinoplasty, for patients who mostly have low and small noses compared to Caucasians, the most frequently performed procedures are nasal tip projection, lengthening and augmentation.
Various alloplastic materials such as silicone, polytetrafluoroethylene, high-density polyethylene (Medpor, Stryker), etc., have been applied for such operations even until recently.1,2 However, when these implants are used improperly or cause infection, it may result in severe contracture that is very hard to correct.
- Dermofat graft is harvested from sacral area.
- The soft-tissue skin envelope (STSE) is elevated superficially from the scar tissue as evenly as possible.
- All the alloplastic materials are removed.
- The alar cartilage is made by complete release of the scar tissue or the support structure that has been holding the tip structure firmly.
- Alar cartilage compound is fixed without tension to proper location using extension or spreading grafts.
- Dorsal augmentation with dermofat graft.
- Tip plasty by shield graft and cap graft with conchal cartilage and reinforcing nasal tip with a piece of dermofat.
See Video 1, Supplemental Digital Content 1, which demonstrates elevation of skin and soft-tissue envelope (STSE) superficially from the scar tissue, and removal of alloplastic materials. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A412.
In this video case, which is secondary rhinoplasty, I correct the contracted nose with dermofat graft and conchal cartilage graft as autologous material. The video demonstrates STSE elevation and Medpor that was applied for septal extension, and spreading is removed. The second video displays scar tissue, and alar cartilage compound is sufficiently released from surrounding contracted scar and upper lateral cartilage.3 (See Video 2, Supplemental Digital Content 2, which shows the free movement of the alar cartilage, without tension, after complete release of the scar tissue or the support structure and the rebuilding of the nasal tip with derotation type dorsal batten graft. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A413.) When destruction or deformity of alar cartilage is extreme with severe scar formation, it should be released as the alar compound with certain shape and volume rather than trying to separate the scar from alar cartilage completely. Septal cartilage is not harvested concerning instability of caudal septum where Medpor was applied. Extended alar compound is fixed by derotation type dorsal batten graft4 using conchal cartilage.
The third video shows dermofat graft being harvested mostly from sacral region where the thickest dermis can be obtained5 and is molded into a suitable shape by molding sutures. By such molding technique that is introduced by Dr. Jo, Korean plastic surgeon, not only the most suitable shape can be achieved but also substantial decrease of absorption rate is possible. (See Video 3, Supplemental Digital Content 3, which shows harvest and manipulation of dermofat graft. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A414.)
Also, skin dimpling on nasal tip is corrected by underlying supporting graft with a small piece of conchal cartilage, and favorable nasal tip contour is made with dermofat graft. (See Video 4, Supplemental Digital Content 4, which shows nasal tip plasty using shield graft and cap graft, correction of the skin dimpling on nasal tip. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A415.)
For prevention of hematoma, internal compressive splint with silastic sheet and Merocel (Ivalon) sponge was applied after surgery. For external dressing, gauze pillows are applied with Joseph dressing to give gentle compression on the sides, and peripheral venous catheter is inserted.
Patients provided written consent for the use of their images.
1. Sajjadian A, Naghshineh N, Rubinstein R. Current status of grafts and implants in rhinoplasty: part II. Homologous grafts and allogenic implants. Plast Reconstr Surg. 2010;125:99e–109e.
2. Winkler AA, Soler ZM, Leong PL, et al. Complications associated with alloplastic implants in rhinoplasty. Arch Facial Plast Surg. 2012;14:437–441.
3. Kim JH, Song JW, Park SW, et al. Tip extension suture: a new tool tailored for Asian rhinoplasty. Plast Reconstr Surg. 2014;134:907–916.
4. Paik MH, Chu LS. Correction of short nose deformity using a septal extension graft combined with a derotation graft. Arch Plast Surg. 2014;41:12–18.
5. Hwang K, Kim DJ, Lee IJ. An anatomic comparison of the skin of five donor sites for dermal fat graft. Ann Plast Surg. 2001;46:327–331.
Supplemental Digital Content
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.