Dr. Alejandro Nogueira's Case #WEAUTA49

The patient had sustained a severe nasal traumatism many years ago, which received no treatment in the acute phase; later on he was victim of a very poor repair attempt by means of a peculiar septorhinoplasty during which the surgeon performed a total mutilation of the cartilaginous nasal septum plus other many damages to anatomical elements, without any improvement, to the contrary the outcome was the deformity introduced in this case.

Several are the reasons why the rib cartilage was essential in this case; to begin with the scarceness of other donors due to the septum mutilation and the large amount of cartilage required which was unavailable from the ears; secondly the requirement of very strong, firm, highly supportive and resistant neo structure to beat the shape memory of so many years of deformed skeleton and the thickness of the skin; finally the need of very long caudal extension grafts and septal replacement, as long as 5 cm, only available from the rib in suitable size and strength.

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 whole caudal septum was reconstructed and both the tip and the nose were lengthened by means of an L Shaped septocolumellar caudal extension graft with total septal replacement. Due to the lack of any available septum to which the new skeleton could be anchored it was necessary using the triangular cartilages to hold it; this septocolumellar structural graft acted as columellar push down graft; it was placed in an angled up fashion so that the right vector of oblique nasal expansion would be achieved.

The middle vault was irremediable sunken due to so many years lacking septal support; all maneuvers to release it and raise it were unsuccessful, thus an onlay graft was necessary to bridge the gap between the nasal bones and the tip.

There was a hump but not in as much excess as it seemed at first glance, since its protrusion was aggravates by the sunken middle vault, so the principle of the double elevator had to be applied, by which the upper half of the dorsum had to be lowered but not as much as it seemed, and the lower half had to be raised but neither as much as it could be thought initially; the right dorsum level was somewhere between the level of the osseous hump and the level of the sunken middle vault.

Due to the mixed dorsal work, part shaved down and part raised with a graft, a temporalis fascia graft was necessary to hide the visible irregularities and prevent transparency of the graft, also known as tombstone deformity; the temporalis fascia graft was carefully pinned in full extension to prevent its shrinkage.

The lateral and medial cruras of the lower lateral cartilages had many irregularities, loops, concavities and spirals due only in part to congenital reasons and in great part to the posttraumatic and iatrogenic deformities acquired; the lateral and medial cruras were meticulously repaired and then shortened to deproject the tip; the concavities and convexities featuring them were solved by the tightening achieved and the plication to the midline on top of a strong columellar strut; by means of this and additional symmetrization maneuvers the crooked tip was realigned.

The severely crooked nasal pyramid was managed by the mandatory osteotomies and paramedial resection of the posttraumatic bone scar or synostosis between the nasal bones.

At the end of the procedure a conservative alar flare and nostril sill resection was applied.

This reconstructive rhinoplasty after a double injury, one accidental traumatism and one ablative surgical procedure, is one of the worst technical scenarios a revision rhinoplasty surgeon can meet.