Graft Alternative Strategies

Several alternative strategies for the use of graft material can be considered. The following suggestions are recommended for specific cases, such as the five described above.

1. Plan to take some other tissue: Let the patient know that you will need an alternative and plan to take what you think you will need.

2. Stretch two pieces of septum into one: Godfrey10 presents a technique for splicing two lengths of septal cartilage together. Could work for cases 2 or 4.

3. Try a pericranial graft: Ioannides and Fossion11 report this technique in which a hidden incision can provide large quantities of easily stackable firm tissue.

For all cases in which mesh would have worked, such as 1, 2, and 3.

4. Use an autogenous rib: An excellent report by Sherris and Kern12 details the harvesting techniques as well as some of the uses for rib for dorsal grafts, columellar struts, and tip grafts. The extra incision should be no problem if your patient is prepared for it.

Excellent choice for cases 1, 3, and 4. Overkill, perhaps, for cases 2 and 5.

5. Try alloderm: Is it a graft or an implant? Yes, it comes in a box, but it is a biologic material and is incorporated into

1. Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Facial Plast Surg 1997;13:279-290

2. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd Ed. St. Loius, MO: CV Mosby; 1987

3. Tardy ME Jr. Rhinoplasty—The Art and the Science. Philadelphia: WB Saunders; 1997

4. Conrad K, Gillman G. A 6 year experience with the use of expanded polytetrafluoroethylene in rhinoplasty. Plast Recon-str Surg 1998;101:1675-1683

5. Romo T III, Sclafani AP, Sabini P. Use of porous high density polyethylene in revision rhinoplasty and in the platyrrhine nose. Aesthetic Plast Surg 1998;22:211-221

6. Juraha LZ. Experience with alternative material for nasal augmentation. Aesthetic Plast Surg 1992:16:133-140

7. Wu ZQ. Complications of hump nose after transplantation of tissue ersatz materials. Chin J Surg 1992;30:50-64

the host tissue. Although "the jury is still out" on this, I believe it could be useful for premaxillary augmentation, dorsal augmentation, lateral wall fill, and possibly tip grafting as well. It is not a structural graft. Applies to cases 1, 2, 3, and 5.

Use autologous fat: Coleman13 and others have refined the techniques of autologous fat transplantation to the point where long-term corrections of volume deficiency can be reliably corrected. Fat is harvested by syringe and small can-nulae, handled minimally, and injected through small needles or cannulae.

A wonderful technique for case 5, possibly an alternative to revision rhinoplasty in case 1.

7. Possibly try auricular cartilage: This material has not been mentioned until now. Because you have already thought of it, I include it for the sake of completeness and because we should be reconsidering it. Endo et al.14 report 1200 cases of augmentation rhinoplasty in Japanese and detail their methods for getting rid of that troublesome cartilage spring. Tardy3 and Sheen2 go into great detail on their handling of auricular cartilage so that it can provide either structure or contour replacement.

Very useful for cases 1, 2, and 5. May work to provide length (case 4) for Sheen, but this is perhaps a stretch for the ordinary surgeon.

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