Discussion
In fact, there have been many opinions that the columullar strut graft is inferior to the septal extension graft in recent years.6,7 A floating columellar strut, although effective in unifying the nasal tip and maintaining its position, is not nearly as efficient in increasing projection.6-8 But it is the degree of nasal tip projection andstructural integrity of the lower lateral cartilagesthat dictates how the columellar strut should beused.If surgeons supplement these shortcomings very well depending on how they reinforce the rigidity of the columellar strut graft to replace the septal extension graft, and how to mechanically complement the nasal tip with the surrounding structures, conchal cartilage has enough advantages. By utilizing it, the columellar strut graft may be superior to the septal extension graft.
Because of the extensive network of elastic fiber within its matrix, ear cartilage can withstand considerable bending without fracturing.9 In addition, its curved surface, flexibility, thinness, and its ability to withstandminimal distortion make it an ideal choice for functional and aesthetic nasal surgery.10-12
Because septal support is a key aspect of classic septal extension grafts, the use of folded conchal cartilage graft for septal extension is an attractive proposition. The nasal tip should be mobile, and as the strength of conchal cartilage is similar to that of the upper lateral cartilage, which suggests it should be a near ideal choice for nasal tip plasty in terms of nasal mobility.3The Asian nose is characterized by less height and length, less tip projection, and a wider nasal base than its Caucasian counterpart.1 In addition, it has also been reported that the distance between alar cartilages is greater, alar cartilage is weaker, and tissues of the dermis and subcutaneous tissues are thicker and more fibrous in Asians.13-15 Owing to these anatomical differences between Asian and Western noses, the objectives and techniques of rhinoplasty differ. The nasal tips of Westerners are usually oriented caudally, and thus, one objective during rhinoplasty is to rotate the nasal tip caudally from its cephalad orientation in East Asians.16
Although columellar struts have been found unreliable in increasing tip projection, it is the lack of control over nasal tip rotation that is their single most important limitation in conventional columellar strut graft technique.8,17 We designed a modified columellar strut graft technique using a non-incisional, back-to-back, bent double-layered conchal cartilage extension graft and a pagoda-shaped onlay graft. The method described above for harvesting a non-incisional, back-to-back, bent cartilage graft from an auricle and transplanting it into the recipient bed of the columella enables fine nasal tip reconstruction. The long-term follow-up results of the patients enrolled in the present study demonstrate that the non-incisional, back-to-back, bent double-layered conchal graft remains intact and produces adequate tip projection.
Conventional double-layered conchal cartilages used for augmentation rhinoplasty or anterior nasal septum reconstruction are incised before bending,9 and thus, the lack of incision of harvested cartilage is a major feature of our procedure. When conchal cartilage is folded without incision, it forms a mechanically robust unit that is able to support the onlay graft and increases the rigidity of transplanted cartilage and enables adequate tip projection. Furthermore, the folded portion is caudally directed to strengthen the strut and maintain the overall framework of the strut graft, and thus, prevents cephalic rotation and provides the strength required to support the onlay graft.
The addition of the pagoda-shaped onlay graft results in a more exquisite nasal tip. When placing the onlay graft, rather than simply stacking conchal cartilage portions of the same size and placing these on the strut, we stacked cartilage in a reducing manner to increase nasal tip stability. The results obtained were natural, physiologic, and onlay grafts migrated much less than grafts placed using other onlay graft methods. Septal extension grafts are not indicated for nosed with heavy lower lateral cartilages and normal or excessive tip projection.6,7,18 Even in this case, our new method is an excellent indication to replace the septal extension graft.
Several limitations of the present study should be considered, especially the relatively small number of cases, lack of a control group, short follow-up period, the use of photographs to measure distances and angles. We suggest that an additional larger-scale, longer-term study be performed to confirm that the described non-incisional, back-to-back, bent double-layered, conchal cartilage extension graft with pagoda-shaped onlay graft retains its excellent results in the long term. The described technique also has a drawback that concerns the harvesting of conchal cartilage, because sometimes the amount of cartilage available on one side is insufficient and both sides must be harvested. Furthermore, conchal cartilage is thinner than septal cartilage, and its thickness varies between individuals, and though it is rare that folding does not result in sufficient strength, some of low BMI female patients, thin conchal cartilage did not provide expected strength.
In conclusion, achieving an ideal nasal tip shape requires correct balance between nose projection, length, and height. Augmentation rhinoplasty of the dorsum and various tip projection techniques are commonly performed in Asian countries. The advantages of our technical methods are that the height can be adjusted, shape can be transformed relatively freely to prevent cephalic rotation, and the tip can be adjusted more finely in the desired direction. Furthermore, the described technique provides a means of improving nasal length, nasolabial angle, and projection and location of the nasal tip.
Funding : None
Conflicts of interest : None declared