Dr. Alejandro Nogueira's Case #JBAXHF2I

There was also an overprojected or Pinoccio's nasal tip which was left unattended during the previous intervention; finally a left nostril collapse required investigation and repair.

Considering and large amount of dorsum missing according to this patient's facial features, it was deemed necessary the use of rib cartilage grafting harvested from the 7th arch so that enough amount of tissue supply with the suitable firmness would be supplied.

This case shows how reliable and useful, even essential in some situations, is the rib as donor of cartilage grafting during revision, ethnic and some structure rhinoplasties; it can be seen how the core or central shaft of the rib cartilage does not warp or experience any deformity as long as the surgeon knows the basics of its harvesting and tailoring; the cortex of the rib cartilage is the only one prone to warp, whilst the central part of the rib cartilage is form stable.

Notwithstanding, the 7th and 6th rib arcs have perfectly straight and flat portions of cartilage near the sternum bone which offer surgeons material of excellent quality and straight cartilaginous streaks which, in any case, prevent warping and late onset of nasal deformities.

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 rib had thick, long and strong synchondrosis or cartilaginous bridges of fusion between it and the precedent 6th 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 thick synchondrosis between 7th and the neighbouring 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.

The customized dorsal block of cartilage had a quadruple role aiming to correct the saddle nose deformity, the open roof deformity, the inverted V deformity and the pinching of the middle vault; in other cases and with other technical options the pack of grafting for this purpose would have been spreader or spacer grafts, onlay dorsal grafts and probably temporalis fascia graft as onlay camouflage.

However with the design depicted in this case's images, one single fragment of cartilage was shaped as dorsal rebuild graft with two rails or ridges sticking out from the undersurface of such dorsal graft; these rails had a double purpose, firstly act as spacer or spreader grafts at the middle vault, and secondly provide stability by blockage obtained when inserted in the slots formed by the open roof deformity at the recipient site between the nasal walls and the nasal septum; this means the nasal septum fits in between the rails of the graft and the nasal wall at the outer side of such rails.

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.

During the procedure it could be stated the cause of the left alar collapse was a random and unexplainable damage to the left lateral crura; the right alar cartilage had a iatrogenic damage transecting the tip dome at the union of the medial and lateral cruras.

Once the dorsal grafting block was thoroughly tested and deemed as definitive in terms of aesthetic effect and mechanical stability, the tip was ambitiously deprojected by means of resection of lateral and medial cruras segments; the interdomal and intercrural fibrofatty pad was intact and therefore was removed to reduce bulbosity; then an extended columellar strut graft and lateral cruras strut grafts were used to repair and support the alar cartilages; some suture plications allowed final tip shaping without any additional grafting at that point.

Due to the relatively massive, if the size of the rib and nose are compared, amount of donor material available no ear or septal cartilage was employed; 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 and the slots of the open roof deformity.

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