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  Ancient history
  Modern history
  Traditional operation
  Open rhinoplasty
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  Alar base reduction
  Septal surgery
  Cartilage grafts
  Bone grafts

Cartilage Grafts

Cartilage grafts are harvested from various parts of the body. The best source is the nasal septum  4  where a moderately large flat piece of cartilage is normally available. Augmentation of the bridge of the nose (nasal dorsum) can be done with septal cartilage. The graft has to be long enough and flat enough to do the job. The graft may be single or multiple layers sutured together.

Septal cartilage is also excellent for augmentation of the nose tip. Dr Ron Gruber of Oakland, CA, designed a particularly good tip graft comprising two small pieces of cartilage sewn together. The graft is fixed in place with sutures via the open rhinoplasty operation. Placing large pieces of cartilage in the tip is not advised because tip skin will not stretch enough.

The second preference is ear cartilage. The supplies are obviously limited but it is good for reconstructing various parts of the nasal skeleton, especially the nose tip. There would be enough cartilage to make spreader grafts, grafts that are used to reconstruct the normally wider middle third of the nasal dorsum.

The third preference is rib cartilage and is used when large quantities are required. The problem with rib cartilage is its tendency to bend and twist caused by a high concentration of elastic fibres in the surface layer. If the cartilage is thinned by splitting it down the middle it curls away from the knife much like a celery stick. The cartage can go on bending long after it has been implanted, sometimes causing a bizarre nasal shape. These problems do not occur if the cartage is carved so there is a symmetrical amount of elastic tissue on opposite sides. This prerequisite does limit the possible shapes than can be made from the material. Photo of a patient with a deformed rib cartilage graft

Rib cartilage graft from nose tip to mid dorsum has bent forward at top end

Increasing the projection of the whole of the tip structure is a major undertaking. The desired effect can be demonstrated by holding the columella forward between finger and thumb. The nose tip advances and tilts upwards in a pleasing manner, correcting any droop of the nose which may have been caused by previous surgery or just the ageing process. This effect is difficult to achieve surgically because the lip muscles are very strong and pull the advanced columella back. A relatively large graft such as rib cartilage is often required to do the job. The graft is placed as a strut between the anterior nasal spine and the columella base, sometimes via the mouth.

The nasal septum  1  is a good donor site because it is out of sight. The septum may be deviated and removal of the deflected cartilage will correct the septum as well as provide the graft tissue. There is very little discomfort associated with harvesting the graft apart the possible need for packing or intra nasal splinting afterwards. A new cartilage usually forms within the septal tissue. This takes a few years and it is only a thin layer.

The ear is a good donor site provided the cartilage is taken from within the shell of the ear. It is often impossible to tell by looking that cartilage has been removed from the ear. There will be a scar on the back of the ear which looks like a normal crease in the skin. Very rarely will the scar thicken and become a keloid. The alternative is a scar within the shell of the ear. This scar is visible but the quality is much better if there is a tendency to form keloids.

Rib cartilage grafts produce a painful donor site. Pain can be felt with each breath and this can persist for many weeks. However, strapping the ribs is not usually necessary. A scar is present at the donor site and this may become moderately thickened especially if the skin has an elastic property. Taping the scar with paper tape for many weeks improves the scar quality. Keep taping until the scar is becoming a paler pink colour.

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