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