Caroline Helwick

October 31, 2012

Rhinoplasty need not always involve a scalpel, according to plastic surgeons at the Plastic Surgery 2012: American Society of Plastic Surgeons Annual Meeting in New Orleans, Louisiana.

In one presentation, Onur Erol, MD, from the ONEP Plastic Surgery Science Institute in Istanbul, Turkey, described using injections of diced cartilage from the septum to fill small and large pockets in the nose, without the need for wrapping material. The method simulates the carved costal cartilage that is traditionally used for this purpose.

"The injection takes only few minutes...[and] the amount of injected cartilage graft is predictable, since it consists purely of cartilage," Dr. Erol explained.

He designed thin (0.2 × 12 cm) and thick (0.5 × 12 cm) stainless steel cartilage syringes. He fills the syringe with diced cartilage and then injects it into a prepared pocket in the dorsum, columella, or tip of the nose.

He reported excellent results in 621 patients who have been followed for 1 to 5 years. "The take of cartilage graft was complete, and the smooth surface that was obtained gave them a natural look," he said.

There was partial resorption of cartilage in only 29 patients. It was corrected by reinjecting a small amount of the diced cartilage. There were no cases of total or subtotal resorption.

Fat Grafting Alone or in Combination

In another presentation, the use of fat grafting, both alone and in combination with dissection, was described.

"Fat grafting can play a significant role in primary rhinoplasty. In a limited number of cases, nasal augmentation can be achieved with fat grafting alone," said first author Eser Yuksel, MD, from the Baylor College of Medicine in Houston, Texas.

Most surgeons use fat grafting to tweak outcomes after the initial surgery. "We have done that for 10 years; it helps, but in this study we used fat grafting solely or in combination with surgery for primary rhinoplasty," he explained.

"Even when we used it with traditional surgical techniques, the fat grafting allowed us to minimize the dissection and improve the skin quality due to preadipocyte contribution," he added.

In the study, 59 patients underwent primary rhinoplasty involving autologous fat grafting for nasal volume restoration and contour adjustment.

Twelve patients had external nasal fat grafting without dissection (i.e., fat grafting alone), whereas 47 had fat grafting as part of rhinoplasty in addition to cartilage grafting and other steps.

The anatomic distribution of the fat grafts included the tip (n = 10), columellar base (n = 18), proximal nasal bridge (n = 16), middle third of the dorsum (n = 24), nasion (n = 39), anterior columellar column (n = 13), and glabellar/forehead projection (n = 41).

Fat grafting was repeated 1 to 3 times at different time points and in various anatomical areas.

Ten independent assessors interpreted preoperative and postoperative photos at 8 weeks to evaluate improvement in the 59 subjects. The color and surface extraction method was used to quantify the projection differences. The results were scored as follows: grade 1, negative progression; grade 2, no significant change; grade 3, minimal improvement; and grade 4, significant improvement.

Overall, 36 patients had significant improvement (grade 4), 18 had minimal improvement (grade 3), 4 had no change (grade 2), and 1 had a negative result (grade 1).

Fat grafting produced improvements as the sole modality, but it was more effective in certain sites and when the defect was more planar, Dr. Yuksel noted.

Complications included tip excess related to vertical shift (n = 3), supratip fullness related to vertical shift (n = 4), and inadequate height that required additional grafting (n = 3).

"A Very Interesting Approach"

James Stuzin, MD, from Coconut Grove, Florida, who moderated the session on cosmetic surgery at the meeting, said he was particularly impressed with the use of diced cartilage to correct small and large defects.

"When you have an overresected bridge (i.e., a saddle nose deformity) in reoperative rhinoplasty, the traditional approach is to use costal cartilage to rebuild the bridge," he explained. In the Turkish study, diced cartilage from the nasal septum, as opposed to the rib, made into an injectable was used to correct large defects. "This is a very interesting approach," he noted.

He was not as impressed with the fat grafting because the assessment of the results was not rigorous. "In the past 5 to 7 years, we have seen a trend for using injectables such as Restylane and Juvéderm to correct minor defects nonsurgically. We can build up noses with these materials and it lasts 9 months to a year or so. This works well for small irregularities," he said.

"Fat is a biologic material, so you will see more patient variability in terms of graft survival. In my own patients, I've seen them look great at first, but the effect may not last. Fat grafting can work well, but it is less predictable," Dr. Stuzin said.

Dr. Erol, Dr. Yuksel, and Dr. Stuzin have disclosed no relevant financial relationships.

Plastic Surgery 2012: American Society of Plastic Surgeons (ASPS) Annual Meeting. Presented October 28, 2012.

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