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from the trough and placed in the recipient site on the
dorsum. The graft must be maneuvered very gently
with smooth forceps because it is fragile and can be
disrupted. The dorsal nasal skin must be widely
elevated to create a space larger than the graft. This
facilitates placement, since the graft is semirigid and
can be fractured easily if excessive forces from a
constricting soft-tissue pocket are exerted on the graft.
Because the graft is fragile, it is best to place the graft
on top of the skin of the dorsum and trim it to the
appropriate size before placing the graft beneath the
nasal skin (
Figure 3
). Once the graft is in place, the
nasal skin is redraped over the graft. The tissue
sealant mixed with diced cartilage produces a graft
that has the consistency of very soft but solid
silicone rubber. Because the graft is pliable, it can be
molded by gentle compression through the nasal skin
to adjust the graft for an ideal profile. However,
because the graft material is malleable, overzealous
compression may disrupt the graft resulting in loss of
graft integrity.
Once the grafting procedure is complete and adjust-
ments are made to create the ideal profile, incisions
are closed, the nose is taped, and an external splint is
applied. The splint should be applied with limited
digital compression so the graft is not fractured or
disrupted.
It would be difficult to use an endonasal approach
for placement of the diced cartilage grafts. A wide sur-
gical exposure of the dorsum with a large space cre-
ated under the nasal skin to allow maneuvering and
placement of the diced cartilage is necessary to pre-
vent fracturing or distortion of the graft (
Figure 4
).
Thus, an open rhinoplasty approach is the preferred
method of performing this surgery. I believe that
should an endonasal approach be used by the surgeon,
diced cartilage placed within a temporal fascial tube is
the preferred method of preparing the graft for aug-
mentation of the dorsum. However, it is likely the fas-
cial tube containing the diced cartilage will be difficult
to insert and properly orient using the endonasal
approach. Bullocks et al
10
recently reported using
diced cartilage grafts with an endonasal approach.
They created a malleable construct of autologous
diced cartilage grafts stabilized with autologous tissue
glue created from platelet-rich plasma (platelet gel)
and platelet-poor plasma (fibrin glue). The authors
combined the diced cartilage with the tissue glue and
placed the mixture in a 5-mL syringe with the plunger
removed and the distal beveled portion cut off. The
plunger was then replaced, and the graft material was
injected on the nasal dorsum. With this technique, the
authors were able to graft the nasal dorsum with diced
cartilage using the open as well as endonasal
approach.
Using diced cartilage solidified by thrombin mixed
with fibrinogen has the theoretical advantage of earlier
and more rapid revascularization compared with diced
cartilage that is surrounded by an avascular fascia graft.
The fascia itself must be revascularized before the carti-
lage within the fascial tube undergoes ingrowth of vas-
cular channels. Thus, it is likely that graft integration is
delayed by the suboptimal porosity of the fascia. Diced
cartilage and perichondrocyte coalesced with fibrin
offers rapid imbibition through the interstitial matrix
and optimal adherence of the graft to adjacent bone and
cartilage.
In patients with severe saddle noses from loss of car-
tilaginous septal support, I use autogenous costal carti-
lage to construct an L-shaped strut to restore support to
the nasal dorsum and tip. The strut also provides a foun-
dation for further dorsal augmentation if required to
achieve an ideal profile using diced cartilage solidified
by tissue sealant (
Figure 5
).
Figure 3.
Diced cartilage graft is best modified for proper length and width
by placing graft on the dorsal surface of the nasal skin rather than attempting
to modify the graft once it has been placed beneath skin.
A
B
Figure 4.
Same patient shown in Figure 3 before (A) and after (B) dorsal placement of dice cartilage graft.
ARCH FACIAL PLAST SURG/VOL 14 (NO. 6), NOV/DEC 2012
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