Dr. Alejandro Nogueira's Case #W2VMFF3E

Three key aspects feature African noses; the barely existent dorsum and the truncated nasal pyramid, from which half or more is missing; the totally collapsed nasal tip which lacks any kind of support due to totally incompetent filmy alar cartilages, tip which is also disproportionately augmented by a huge fibrofatty pad; and the large nostrils and excessively protruding alar flare.

The first stage after the open approach dissection of the nose is defatting the massive pad which typically makes these noses bulbous and large; this adipose mass is not only located above and in between the alar cartilage domes, like in any other ethnicity, but also extends between the medial cruras of the columella and spreads over the lateral cruras, the supratip dorsum and the sides of the lower nasal wall; a very meticulous defatting is a must, a very delicate maneuver that must be carried out with great care not to damage the cartilaginous structures and the overlying skin.

It is clearly noticeable in the images how weak, filmy and thin are the alar cartilages in this ethnicity, they play almost no structural role, if any, in the tip and alae shape, being the whole tip unsupported, collapsed and its shape made out of the fibrofatty mass and the skin itself; additionally the tip has no definition is too short and its cartilages lack sufficient length to comply with the required lengthening of the tip and the nose; for all these reasons the lateral cruras were discarded and replaced by new ones made out of the cartilage rib grafts.

The tip and the columella also needed full replacement, therefore an en bloc tip and columella extended graft was sculpted out from the rib cartilage grafting; a slot was tailored at the rear side of the columellar part of it so that this graft could be interlocked with the septum inserted in it; a cubic chip was removed at its top so that the dorsal reconstruction and augmentation graft could be inserted and interlocked into this space.

Therefore this is a dorsocolumellar replacement graft augmented with one extension to build the tip and another extension to lengthen the columellar support down to the nasal septum; this structure achieved longitudinal and lateral blockage with stability by pressure forces between the radix, the dorsum, the septum and the interlocking between the dorsal and tip columella parts, with lateral assistance at the tip by means of the side pods formed by the new lateral cruras; no suturing was required to achieve stability of this dorsocolumellar structure.

In the end, the whole dorsum, tip, columella, medial cruras and lateral cruras were replaced by handmade brand new anatomical elements.

It is remarkable how the septum is also massively short in these ethnicities; this makes the septum insufficient as donor of grafting in most cases and technically forces to some kind of septal lengthening and nose lengthening maneuvers; this was accomplished in this case by the dorsocolumellar structure which bridged over the missing gap of septum, as can be seen in the images of this case; no need for direct septal lengthening grafting.

Several methods allow rebuilding a massively missing nasal dorsum, either by congenital causes like ethnicity or by acquired traumatisms or iatrogenic dorsal over resections during previous rhinoplasties.

The alloplastic or synthetic prosthesis, made from Gore Tex, Medpor, Silastic, silicone, polyurethane, etc., is a tempting option since it is as easy as an out of the box solution, the surgeon only has to open the sterile sealed package and insert into the nose, only in few cases a slight shaving may be necessary to adapt the prosthetic dorsum to the patient's nose; however this is the worst of all the available technical solutions, to begin with it is unfeasible achieving an optimal fitting on the dorsum, the prosthesis is noticeable through the skin, they look pretty fake and unnatural, the rate of complications like infections, displacement or extrusion are terribly high, they are prone to dislocate, develop capsular contracture, extrude or become secondarily infected during their lifetime, which actually is not indefinite and will need replacement after a few years.

Fat transfer and dermal or fascial rolls are not suitable, they lack volume to rebuild such noses, their look is weird, it is impossible to shape the dorsum with precision and they are not consistent enough; apart from the former they are prone to complications, infection and resorption; they'll likely disappear in the postoperative or be short lasting.

Bone grafting is not recommended, the rates of resorption are very high and the look is not natural; the ideal material to rebuild massive dorsal shortfalls is cartilage grafting, being several the modalities.

Irradiated human or animal cartilage from a tissue bank is not a recommended option; firstly because it is not own patient's tissue, making no sense when there are excellent donors sites available of safer quality, however mainly because the rates of resorption, infection and dislocation with deformities are very high with irradiated cartilage, which in practical terms is a cartilage biologically destroyed by radiation.

Ear and septum cartilage harvested from the patient's tissues are excellent donors biologically but in the vast majority of cases not valid because the available amount is scarce or their shape might not be optimal; notwithstanding their use may be suitable in selected cases.

One popular option which deserves severe criticism is the so called Turkish Delight technique or better named as diced cartilage wrapped in fascia; it essentially consists in harvesting cartilage from the patient's donor sites, commonly the rib, and crush down to tiny bits, which means destroying the chondrocytes or cartilage cells and annihilating any biological viability; once this jelly mass is obtained the surgeon sticks the bits together by applying a synthetic fibrin glue, rolling them in temporalis fascia or both; this roll is inserted as neo dorsum, however the result is an avascular cylinder in which this mass of crushed tissue develops necrosis, resorption, eventually infection, irregularities, deformities, cystic phenomena, etc.; the results are between poor and disastrous in the mid and long term, the touch is fake like jelly and the dorsum experiences molding like it would be clay with palpation or bearing the glasses pads.

The ideal option to massively rebuild nasal dorsums is own patient's rib cartilage; in relative terms to the nose size it is an unlimited source of cartilage, it is biologically compatible and safe since it belongs to the patient, the likeliness o resorption, infection and displacement are terribly low, is firm and strong enough to expand the skin, is form stable, the touch and feel is natural, when it is well tailored the look is totally natural, it should be lifetime lasting and totally opposite to what many surgeons think it does not warp; the only caution to be taken is harvesting straight fragments of rib cartilage and not the curvy ones, and as additional caution peel off the cortex and use mainly the core or central shaft of the cartilage, since the cortex or outer layers have curvaceous streaks of cartilage making it prone to warp.

In the case posted here the rib cartilage not only was an excellent option to rebuild the dorsum but also served as donor for other grafts required, like the tip and columella replacement graft and the lateral cruras replacement grafts; the septum, otherwise very short, and the ears remained untouched.

When harvesting this patient's 7th rib cartilage, the one chosen as first instance in standard cases, it was found its size with atypically small and insufficient for the reconstruction requirements, therefore the 6th rib cartilage was also extracted.

The images show how difficult may be the dissection and how delicate has to be the surgeon's dexterity to extract the cartilage not producing pleural tears and pneumothorax, a serious complications which eventually and accidentally might be associated to rib harvesting maneuvers; particularly in cases like this one in which the 7th and 6th ribs had strong synchondroses or cartilaginous bridges of fusion between them and between them and the precedent 5th and the lower 8th ribs.

The plane of dissection to harvest the rib can be subperichondral, this means under the perichondrium sheath around the cartilage, versus extra or supraperichondral plane which takes place between the perichondrium and the parietal pleura or sheath around the lungs; should the parietal pleura be punctured or torn the occurrence of a pneumothorax is likely.

In spite of being a more tedious dissection the choice was the subperichondral plane of dissection to harvest the rib cartilage, in order to carry a safer maneuver far from the parietal pleura; in this patient's peculiar anatomy the synchondrosis between 5th, 6th, 7th and 8th ribs made the dissection highly intricate.

Once the cartilage was freed and the donor site meticulously closed by means of layered sutures, the sculpting stage started so that the necessary anatomical elements could be restored in this patient's nose.

With the design depicted in this case's images, one single fragment of cartilage was shaped as dorsal rebuild graft with a hollow cylinder carved in at the undersurface of such dorsal graft; this cylinder had the purpose of providing stability by blockage obtained when the patient's natural dorsum would be inserted within; this dorsal graft has other very tricky and interesting geometrical features in its design, like the beveled upper end to match the contour of the nasal radix and the frontalis bone at the frontonasal sulcus, the slope gradient at its lower end to prevent a supratip prominence or polly beak deformity, the somehow imperfect broken contour at its sides in a very slightly rhomboid shape to mimic a natural bridge and avoid a plasticized nasal look, and the thin on top towards thick on bottom of dorsum gradient of dorsal raise in order to create a correct nasal profile; at its caudal end this dorsal graft was shaped featuring a cubic prong matching the tip and columella extended graft in order to achieve interlocking stability by perfect pressure effect.

Once the dorsocolumellar grafting structure was thoroughly tested and deemed as definitive in terms of aesthetic effect and mechanical stability, the final closure of the skin allowed the assessment and planning of the nostril sills resection and the alar flare wedge reduction; this was accomplished by means of a fleur de lis design covering alar reduction, alar rim narrowing with inwards rotation and nostril sill reduction.

The smooth contour and the perfection of the tailoring of the dorsal block made unnecessary additional camouflage with temporalis fascia or specific blockage gestures to prevent its displacement, since the final assembly was a perfect puzzle matching under pressure between the frontalis bone, the original dorsum and the caudal septum.

Experience, fine skills and large amounts of creativity are of paramount importance in order to successfully approach these complex rib cartilage ethnic rhinoplasties.