Literature Reading

Supervisor: Dr dr. Wijana, Sp.T.H.T.K.L (K) FICS

Presentant: Achmad P

Dept of Otorhinolaryngology HNS

Hasan Sadikin General Hospital
Bandung
2017

7/4/2017 1
 Introduction

The art and science of

total nasal Carl Von Graefe in 1818 Jacques joseph
reconstruction first to coin the term (1865- 1934) father
originated in India rhinoplasty of modern Rhinoplasty
around 1000 to 800 BC

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Surgical anatomy
The Skin And Soft Tissue Envelope
The thickness, elasticity, and general
characteristics of the S-STE can be
confirmed by palpation of the nose
Topographic analysis
useful to discuss and accurately
describe different anatomic landmarks
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
The Nasal Superficial Musculoaponeurotic
System
The major mimetic muscles of the nose include the levator labii
superiorisalaeque nasi, depressor septii nasi, alar nasi, and
transverse nasalis muscle

Maintaining the integrity of this vascularized layer is

important
when placing grafts and implants to maximize engraftment and
minimize infections

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 The importance of these anatomic issues is evident
when making surgical decisions

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 THE BONY FRAMEWORK

composed of the nasal bones and the nasal

process of the maxilla.

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 THE CARTILAGINOUS FRAMEWORK

Conforming the two lower thirds of the nose,

the cartilaginous nasal framework
contributes
important factors to nasal appearance and
function

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 THE NASAL SEPTUM

The septum can be conceptually divided into a

cartilaginous (quadrangular) portion and a bony
portion

The bony portion is composed of the

perpendicular plate of the ethmoid
posterosuperiorly, the maxillary crest inferiorly,
and the vomer posteriorly

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Four categories of facial implants are in
use
today:

1. alloplastic materials
2. homografts
3. Xenografts
4. autografts

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 ALLOPLASTS
Employing alloplastic materials shortens the
length of an operation by :

eliminating the harvesting step

eliminates donor site morbidity
can be easily tailored to
conform to the defect

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
there are several important
disadvantages
:

foreign body reaction at the implant

tissue interface
a limited ability to withstand
infection
a tendency to migrate

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 HOMOGRAFTS

Irradiated costal cartilage is harvested from

cadavers that meet the same criteria required for
organ donation (Venereal Disease Research
Laboratory, hepatitis B, human immunodeficiency
virus, tuberculosis, and slow virus testing)

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 .
Afterharvest, the graft is irradiated with
30,000 to 40,000 Gy of ionizing radiation to
eradicate potential pathogens

Benefits of homografts include their

availability, low infection rates, minimal host
immunogenic response, and decreased
operative times
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 The use of homografts is limited by

their tendency to resorb, sometimes

unpredictably; resorption rates as high as
80% have been reported at 2 years.

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Xenograft
A graft tissue taken from donor of one species and
grafted into recipient of another species (animal to
human)

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 AUTOLOGOUS IMPLANTS

the preferred type of favored for its

implant for correction biocompatibility, low
of saddle nose rate of infection and
deformities or severe extrusion, and
structural deficiencies limited inflammatory
response

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
lacks the risk of disease transmission

autologous implants remain the standard

to which all other implants are compared.

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 CARTILAGE

Extremely popular graft

material for most rhinoplasty
surgeons and can be harvested
from the septum, concha, or rib.

Septal and conchal cartilages do

not provide sufficient material for
repair of most saddle nose
deformities or severe tip structural
deficiencies
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Rib is the only source of cartilage that provides the
structural support required for major nasal
reconstruction

A significant advantage : readily available,

although moderate absorption rates and a
tendency to warp have been reported.

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 BONE
Autologous bone is rigid,
provides excellent support, and
can be contoured with an
otologic drill to create the
desired contour.

For nasal reconstruction, osseous

rib and iliac crest are common
sources of endochondral bone,
while calvarium is the most
common source of membranous
boneGraft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Cartilage Grafting in
Rhinoplasty
GENERAL PRINCIPLES

Maintaining or achieving
structural integrity of the nasal
form is a formidable task in
rhinoplasty and nasal
reconstruction

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 INDICATIONS FOR CARTILAGE
GRAFTING

Septal grafts alone can be used for

support and augmentation

Auricular donor cartilage can be

fashioned into planoconcave or
planoconvex orientations to
support or replace absent or
deficient nasal structure
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Costal cartilage grafts provide an excellent source
of autologous cartilage in revision rhinoplasty
patients who lack septal or auricular cartilage.

Individuals who require significant augmentation or

rigid support are also best treated with use of costal
grafting

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 SEPTAL CARTILAGE
When an adequate supply is available, the most
desirable source of cartilage grafts is the nasal
septum

Septal cartilage is most commonly harvested

through a hemitransfixion or full transfixion incision as
in a standard septoplasty

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Complications of septal cartilage harvest
include compromise of dorsal or caudal
support if adequate struts are not maintained,
septal hematoma, septal perforation, and
intranasal synechiae if raw mucosal surfaces
are left in contact postoperative

Disadvantages of septal cartilage

are generally related to inadequate
supply
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
AURICULAR CARTILAGE
Auricular cartilage is
relatively easy to harvest
with minimal donor site
morbidity and little to no
visible scarring or
auricular deformity.

Adequate volume of
grafts is generally
available and bilateral
auricular cartilage can be
harvested based on
grafting
Graft requirements
and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Disadvantages
Disadvantages of auricular cartilage include fragility
of grafts, poor rigidity, and inadequate support, as
well as insufficient length.

Grafts may occasionally need to be stacked and

sutured or used in multiple pieces to address
volume or strength requirements.

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 COSTAL CARTILAGE

Costal cartilage is an excellent option if stronger

support is required and in cases where septal and/or
auricular cartilage grafts have been previously used.

Rib grafts provide an almost unlimited supply of

grafts in cases where a larger volume of cartilage
grafts are required

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Osteocartilaginous segments can be harvested if a
bony component is required. Overlying
perichondrium is frequently harvested and used as
a camouflaging blanket over dorsum and tip in
thin or compromised soft tissue

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Modifications

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 SPREADER GRAFTS
the workhorse of middle nasal vault surgery.

The original spreader graft is a matchstick-shaped

graft that is secured between the upper lateral
cartilage and septum extending from the bony
cartilaginous junction to the anterior septal angle.

The spreader graft has proved useful in correction

of the twisted nose,

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 BUTTERFLY GRAFTS
The butterfly graft is a useful tool in treating collapse
of the middle nasal vault.

It is an oval-shaped cartilage that is placed so that

it lies on the dorsal surface of the upper lateral
cartilages

Conchal cartilage is the ideal material for use as a

butterfly graft.

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 DORSAL GRAFTING
Grafting of the nasal dorsum falls into one of two
categories: structural or camouflage.

dorsal grafts can also be used to reconstruct the

middle third of the nose in the patient with a
severely injured, weak, or cartilage-depleted nose.
 Dorsal grafting material must be compatible with
use in the middle third

Autologous and irradiated rib are useful tools in

dorsal

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Dorsal grafting and
septoplasty

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Nasal Tip Modification
COLUMELLAR STRUT GRAFT

A columella strut graft is used in all patients,

even when deprojecting the tip, to ensure
maintenance of tip position

The columella strut graft can be used to straighten

the medialintermediate crural complex, as a
means to address the alarcolumella relationship

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 EXTENDED SHIELD
GRAFT
In some cases, the above-mentioned steps may fall
short of producing the desired tip definition,
projection, narrowing, or overall appearance

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Alar retraction and rim reconstruction

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 Vestibular stenosis

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.
 conclusion
Variation in patient anatomy, aesthetic expectation
and tolerance for postoperative recovery time
precludes the existence of single technique.

Differences in surgical technique gives variety of

approaches.

Graft consideration depend on the need of repair

Graft and Implants, Bailey, Byron J. Head and Neck Surgery-Otolaryngology, 5th edition, 2014.