Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) -, -e- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 The conchal cartilage graft in nasal reconstruction * Armando Boccieri*, Alessandro Marano 1 Department of Maxillo-Facial Surgery, S. Camillo Hospital, Rome, Italy Received 5 August 2005; accepted 8 February 2006 KEYWORDS Conchal graft; Nasal reconstruction; Revision rhinoplasty; Nasal deformity Reconstructive rhinoplasty often entails the use of grafts for structural deficiencies due to developmental traumatic or iatrogenic causes. While * This study was presented at the XIV National Meeting of Italian Society of Maxillo-Facial Surgery, 2005 June 9e11. * Corresponding author. Viale U. Tupini 133, 00144 Rome, Italy. Tel./fax: þ39 06 54220252. E-mail address: armando.boccieri@libero.it (A. Boccieri). 1 Via Ceruso 5, 00147 Rome, Italy. Summary Graft selection remains a problem in nasal reconstruction, where the use of autologous cartilage still provides the best resistance to infection and a low degree of resorption. As the nasal septum is often absent or insufficient in such patients, the auricular concha offers a valid alternative. A group of 53 patients suffering from developmental iatrogenic and posttraumatic nasal pathologies were treated surgically by means of conchal grafts. Detailed examination of the anatomical defects presented by the patients made it possible to plan the removal of grafts from the area of the auricular concha with great precision. Guidelines were developed for the areas of the cymba concha and cavum concha to be used as sources for some types of commonly used graft. The technique described made it possible to restore the anatomically deficient structures with satisfactory aesthetic and reconstructive results. The use of cartilage grafts also addressed functional breathing problems. The auricular concha is easy to shape and can provide grafts to reconstruct the various anatomical components of the nasal pyramid. To this end, it proves very useful to save as much cartilage as possible and to pinpoint affinities between some areas of the concha and the structures to be reconstructed. ª 2006 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. positive results have been reported recently in the literature for the use of alloplastic materials, 1,2 these can hardly offer the flexibility characteristic of the tissues to be replaced and present a greater risk of inflammatory response. At the same time, the major case studies in the literature document the reliability of cartilage grafts, which are recognised as easy to shape and resistant both to infection, and to resorption. 3,4 The latter 1748-6815/$30 ª 2006 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. doi:10.1016/j.bjps.2006.02.005 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 PRAS174_proof Š 29 April 2006 Š 1/7
2 A. Boccieri, A. Marano 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 characteristically manifests itself early in the initial postoperative period and proves short-lived. 5 As regards the donor region, septal, auricular or costal cartilage can be used in order of preference. It should be borne in mind, however, that septal cartilage is often unavailable or insufficient to fill all the structural gaps in the case of reconstructive rhinoplasty. On the other hand, the use of costal cartilage can prove more complex and present greater softness of the donor region. The auricular cartilage is an alternative to the septum as a source of grafts for reconstruction of all the cartilaginous structures of the nasal pyramid. 6,7 The use of grafts of cartilage, primarily conchal, has won increasing favour over the last few years. The ease of harvest, the absence of softness and visible scars in the donor region, and the large amount of tissue available unquestionably constitute the basic reasons for this preference. The purpose of this article is to develop some guidelines for selection of the most suitable areas of the concha for certain types of graft. Materials and methods The functional respiratory disorders were assessed by means of a simple preoperative questionnaire where patients were asked to assess their nasal patency on a scale from 0 (complete obstruction) to 10 (optimal airflow). 8 The same patients were also subjected to basal rhinomanometry followed by decongestion in accordance with the method described by Costantian. 9 All the patients underwent nasal endoscopy and preoperative CT scans were used in the case of malformation to examine the skeletal structures. The removal of conchal cartilage is carried out by means of a retroauricular approach. A vertical median-posterior incision is made and the posterior surface of the auricular concha is completely exposed. Four or five straight needles are then inserted into the anterior surface to map out the shape of the graft, leaving the antihelix fold and helix root intact. It is thus possible to cut into the cartilage of the concha on the posterior surface with no risk of damaging the morphology of the auricular pavilion. Subperichondrial detachment of the anterior surface of the graft is then carried out for the purposes of complete isolation and removal. The cutaneous incision is sutured with 5.0 nylon. A contralateral excision can also be made if necessary. The conchal cartilage removed can be used to prepare grafts of different shapes and types in accordance with reconstructive requirements (Fig. 1). The shaping required in the case of saddle-nose deformity is easily performed in that it consists of a median incision to obtain two pieces, which are then placed one on top of the other and sutured. Shaping is instead far more complex in the case of the structural reconstruction of a number of anatomical components. Particular importance attaches to the careful planning and rationalisation of the different pieces to be obtained from the concha (Fig. 2). In particular, if a shield graft 10 is required for reconstruction of the nasal tip, it is advisable to use the cartilage of the cavum concha, which proves particularly suitable to correct the definition and projection of the tip by virtue of its shape and stiffness. The cymba concha instead proves more suitable for reconstruction of the lateral crura or for a Peck onlay graft. 11 Given its particular robustness, the median border region between the cavum and the cymba proves the best place to obtain columellar struts 12 (Fig. 3). Two spreader grafts 13 can be obtained from the marginal region of the cavum or the cymba and then sutured to the sides of the dorsal septum, with the concave face towards the centre, in order to reconstruct the middle nasal vault and restore the inner nasal valve (Fig. 4). Alar batten grafts 14 can also be obtained from the cavum or the cymba. These grafts must be inserted in a precise pocket extending from the caudal margin of the triangular cartilage, at the level of the third of the lateral crura, as far as the pyriform aperture. In such cases, the laterally oriented convex face of the graft helps to lateralise the collapsed portion of the nasal wall. For the subtotal reconstruction of the nasal septum, use was made of a conchal graft together with two spreader grafts obtained from the same concha and attached to it in order to straighten its shape and strengthen its structure. 15 Nakakita s technique 16 was often employed for augmentation Figure 1 Diagram of the normal concha. 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 PRAS174_proof Š 29 April 2006 Š 2/7
Conchal cartilage graft in nasal reconstruction 3 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 Figure 2 Left concha. (From the top) Harvesting of two alar grafts from the cymba concha, one columellar strut from the border region, one shield graft from the cavum concha, and one plumping graft from cartilage residues. rhinoplasty in the case of nasal malformations. Two superimposed strips of cartilage serving to augment the ridge are combined with an eyeletshaped strip acting as a columellar strut. The result is an L-shaped framework (Fig. 5). Finally, plumping grafts are easy to obtain through fragmentation of the cartilage residues present in Figure 3 Insertion of columellar strut between the medial crura. Figure 4 Left concha. Harvesting of spreader grafts from the outer edge of conchal cartilage. the concha between one graft and another. Particular care was taken in all cases to round off the edges of the grafts. Results Grafts of auricular concha of various types were carried out on 53 patients over a period from Figure 5 Nakakita technique. Placement of the graft: two sheets in the pocket of the nasal dorsum, one rolled sheet between the medial crura acting as a columellar strut. 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 PRAS174_proof Š 29 April 2006 Š 3/7
4 A. Boccieri, A. Marano 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 February 2000 to June 2003. The group consisted of 34 males and 19 females with ages ranging from 16 to 62 years. Malformations were presented in 21 cases, iatrogenic pathologies in 24, and posttraumatic deformities in the remaining 18. A degree of nasal obstruction was present in 34 patients. The concha was the sole source of graft material. A single harvest of concha was used in 41 cases and bilateral excisions proved necessary in 12. Rhinoplasty was combined in 13 cases with orthognathic surgery to correct malocclusion of malformative or post-traumatic origin. Surgical revision proved necessary in two cases. A male patient aged 35 with saddle-nose deformity was treated with a second graft of contralateral concha after an interval of nine months. This was probably due to the fact that the graft used was barely sufficient to correct the defect in the first place and subsequently became insufficient through resorption. In the other case, involving a woman of 32 years with a poor outcome from previous rhinoplasty, a second operation proved necessary after an interval of eight months to correct some slight asymmetries and irregularities in nasal shape. The causes were the presence of particularly thin skin and failure to round off the edges of the grafts sufficiently. The follow-ups carried out at intervals from 18 to 26 months revealed no cases of infection, resorption or displacement of the grafts. Satisfactory aesthetic and reconstructive results were achieved for all the patients in the view of the surgeons present at the follow-up examinations, the family physicians, and the patients themselves, none of whom requested further treatment. In the cases with nasal obstruction, the results of the postoperative self-assessment questionnaire indicated a subjective improvement (Fig. 6). The comparison of preoperative and postoperative rhinomanometric data also showed a decrease in nasal resistance and an increase in nasal functionality, with an improvement in the postoperative mean nasal airflow registered for all of the patients. We present preoperative and postoperative photographs of two clinical cases treated with multiple grafts taken from the auricular concha (Figs. 7e14). Discussion Grafts of auricular cartilage have been the most favoured material for nasal reconstructions from many years now. Material can be removed easily from both the auricular conchae in accordance with reconstructive requirements. 17e19 Strips of cartilage are obtained from the concha and joined together to form a single graft capable of making good structural defects in various sections of the nose. 16,20 The curved shape of the conchal cartilage has also been straightened out by means of techniques involving the use of incisions, sutures and the superimposition of grafts. 15,21e23 An important consideration in harvesting is to cut all the grafts needed for reconstructive purposes from the concha without any waste of tissue. It is also important to use those portions of concha most similar to the nasal anatomical components to be reconstructed. For example, the cymba Figure 6 Black column: preoperative self-assessment of nasal airflow. White column: postoperative selfassessment. 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 PRAS174_proof Š 29 April 2006 Š 4/7
Conchal cartilage graft in nasal reconstruction 5 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 Figure 7 view. Case 1. Revision rhinoplasty. Preoperative concha is the first choice for reconstruction of the lateral crura because it possesses a curved threedimensional structure that closely resembles the element to be replaced. The particular flexibility and thinness of the cymba concha also makes it the best source for Peck onlay grafts to correct bossae and/or increase the degree of tip projection. The Figure 8 Case 1. Revision rhinoplasty. Postoperative view: reconstruction using dorsal grafts and alar batten grafts. Figure 9 view. thickness and particular stiffness of the cavum concha instead make it the best source for shield grafts serving to improve the definition, symmetry, and projection of the nasal tip. The greater robustness of the transitional region between the cavum and the cymba makes it the first choice for the preparation of columellar struts. Both the cymba concha and the cavum concha can be Figure 10 view. Case 1. Revision rhinoplasty. Preoperative Case 1. Revision rhinoplasty. Postoperative 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 PRAS174_proof Š 29 April 2006 Š 5/7
6 A. Boccieri, A. Marano 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 Case 2. Cleft lip nose deformity. Preopera- Figure 11 tive view. used for the preparation of alar batten grafts, which are frequently required in secondary rhinoplasty for problems regarding the excessive resection of lateral and/or triangular cartilages with weakening and retraction of the lateral nasal wall. Spreader grafts can easily be obtained from the marginal region of the cavum and the concha, thus Figure 12 Case 2. Cleft lip nose deformity. Postoperative view. Reconstruction using columellar strut, shield graft and alar graft. Case 2. Cleft lip nose deformity. Preopera- Figure 13 tive view. leaving the central part of the concha available for the rest of the reconstruction. The curved shape of all the conchal cartilage makes it suitable for the correction of saddle-nose deformities of various degrees. To this end, various layers of cartilage can be sutured together depending on the scale of the deformity. Finally, the unused cartilage left between one graft and another or after the further Case 2. Cleft lip nose deformity. Postopera- Figure 14 tive view. 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 PRAS174_proof Š 29 April 2006 Š 6/7
Conchal cartilage graft in nasal reconstruction 7 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 shaping of the various grafts can be used as plumping grafts to adjust the nasal labial angle or provide the finishing touches in rhinoplasty. It is considered useful in practical terms to schematise the reconstructive grafts obtainable from the concha in major and minor structural subunits. Spreader grafts, grafts replacing lateral crura, and alar batten grafts, which are generally removed in pairs, belong to the first group. Shield grafts, Peck onlay grafts, struts, and plumping grafts belong to the second. Our experience is that each concha can supply at most five mixed subunits (including elements from both groups) or four subunits from the major group, after which it becomes necessary to use the other concha. In the case of saddle-nose deformity, the use of one or two conchae will obviously depend on the scale of the problem. It should finally be stressed that careful preoperative assessment of the structural problems presented by the patient is essential in every case of nasal reconstruction. This assessment can also be carried out with still greater clarity during the operation, when use of the open approach permits a direct view of the patient s problems. The removal of auricular cartilage must be carried out with a view to the precise replacement of anatomical structures that are missing or hypoplastic. The shape and form of the grafts taken from the auricular concha must be tailored to the specific situation presented by the case in question. In addition to the schematic and abstract planning of grafts, it is thus always necessary to take into account the specific situation to be resolved. References 1. Romo T, Sonne J, Choe KC. Revision rhinoplasty. Facial Plast Surg 2003;19:299e307. 2. Jongwook H, Miller PJ. Expanded polytetrafluoroethylene implants in rhinoplasty: literature: review, operative techniques, and outcomes. Facial Plast Surg 2003;19:331e9. 3. Endo T, Nakayama Y, Ito Y. Augmentation rhinoplasty: observation on 1200 cases. Plast Reconstr Surg 1991;87:54e9. 4. Tardy ME. Rinoplastica: lo stato dell arte. Napoli: EdiSES S.r.l.; 1999. 5. Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Facial Plast Surg 1997;13:279e90. 6. Quatela VC, Jacono AA. Structural grafting in rhinoplasty. Facial Plast Surg 2002;18:223e32. 7. Becker DG, Becker SS, Saad AA. Auricular cartilage in revision rhinoplasty. Facial Plast Surg 2003;19:41e51. 8. Sciuto S, Bernardeschi D. Upper lateral cartilage suspension over dorsal grafts: a treatment for internal nasal valve dynamic incompetence. Facial Plast Surg 1999;15:309e16. 9. Costantian MB, Clardy RB. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg 1996;98:38e53. 10. Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal cartilage graft. Plast Reconstr Surg 1975;56:35e40. 11. Peck GC. The onlay graft for nasal tip projection. Plast Reconstr Surg 1983;71:27e37. 12. Foman S, Goldman IB, Neivert H, et al. Management of deformities of the lower cartilaginous vault. Arch Otolaryngol 1951;54:467e72. 13. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 1984;73:230e7. 14. Toriumi DM, Josen J, Weinberger M, et al. Use of alar batten graft for correction of nasal collapse. Arch Otolaryngol Head Neck Surg 1997;123:802e8. 15. Boccieri A. Subtotal reconstruction of the nasal septum using a conchal reshaped graft. Ann Plast Surg 2004;53:118e25. 16. Nakakita N, Sezaki K, Yamazaki Y, et al. Augmentation rhinoplasty using an L-shaped auricular cartilage framework combined with dermal fat graft for cleft lip nose. Aesthetic Plast Surg 1999;23(2):107e12. 17. Hage J. Collapsed alae strengthened by conchal cartilage (the butterfly cartilage graft). Br J Plast Surg 1965;18: 92e6. 18. Juri J, Juri C, Elias J. Ear cartilage grafts to the nose. Plast Reconstr Surg 1979;63:377e82. 19. Muenker R. The bilateral conchal cartilage graft: a new technique in augmentation rhinoplasty. Aesthetic Plast Surg 1984;8(1):37e42. 20. Dyer WK, Yune ME. Structural grafting in rhinoplasty. Facial Plast Surg 1997;13:269e77. 21. Arden RL, Crumley RL. Cartilage grafts in open rhinoplasty. Facial Plast Surg 1993;9:285e94. 22. Neu BR. Combined conchal cartilageeethmoid bone grafts in nasal surgery. Plast Reconstr Surg 2000;106:171e5. 23. Farrior EH. Revision rhinoplasty for monographs in facial plastic surgery contemporary rhinoplasty. Facial Plast Surg 1997;13:299e308. 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 PRAS174_proof Š 29 April 2006 Š 7/7