Adding Volume in Surgical and Non-surgical Rhinoplasty
Facial surgeons describing rhinoplasty today nearly always discuss adding volume to the nose. I have advocated adding volume and strength to the nose for the last 22 years that I have been an educator and rhinoplasty surgeon. Although mostly a positive thing, there are also perils to volume in the nose.
SELECTING THE APPROPRIATE GRAFT
The first peril during surgery is when selecting the grafts to use to add volume.
Nasal Septal Cartilage: The most ideal graft comes from the nasal septum. The thickness and relative malleability of septal cartilage makes it an ideal graft. Septal cartilage when implanted into the nose seems to last a lifetime. Septal cartilage can be shaved, thinned, cut, chopped, scored or crushed to create the ideal graft for a particular location in the nose. For example, if it is required as a hidden supporting graft, it can be tailored to fit exactly where it is needed, creating support without adding bulk. On the other hand, if it is required to camouflage surface irregularities, it can be crushed so that it appears invisible yet does the job.
However, septal cartilage can warp or the graft can become displaced, either due to the tension forces of healing or due to technical error when placing the graft. These problems can occur with any cartilage graft. Indeed all other grafts’ performances are measured against septal cartilage, the near-ideal graft.
Ear Cartilage: Why do some surgeons turn to the ear before the septum for their grafts? The best answer is that they are not comfortable harvesting septal cartilage. Ear cartilage is inferior to septal cartilage in strength, malleability and rigidity. Ear cartilage only surpasses septal cartilage as a soft, camouflage graft. There are portions of the ear that can be used for structural support, but using the ear is a compromise only worth undertaking when septal cartilage is unavailable due to previous surgery or extensive trauma.
Rib Cartilage: Rib cartilage is better than septum in its abundance. Rib cartilage is more rigid than septal cartilage, and will begin ossifying by age 50 in most patients, making it brittle. Rib is typically reserved for revision rhinoplasty by most surgeons, when extensive rebuilding of the nose is required and, even if septal cartilage were available, it would be insufficient for the task.
In older patients, irradiated rib cartilage is sometimes chosen for revision cases since the patient’s own ribs would most likely be extensively ossified, making them unusable.
Skull or Pelvis Bone: Bone from the skull or pelvis used to be used for nasal reconstruction but has been proven inferior to rib cartilage in terms of longevity and versatility.
Artificial Implants: Alloplasts, or artificial implants, were used extensively in rhinoplasty in the past, but their relatively high infection rates make them less favorable than septum, ear or rib. In primary augmentation rhinoplasty, for example, to build up the bridge in a patient with a low profile, expanded tetrafluoroethylene (e-PTFE) implants have proven the best over time, with the lowest infection and extrusion rates. However, their safety in revision rhinoplasty has not proven as good.
WHERE IS THE VOLUME ADDED?
Almost any area where the nose is too low or too flat requires volume during rhinoplasty. Common areas include the bridge, the sidewall, and the tip. A bulbous, wide tip almost always could benefit from some type of graft to create better definition and tip shape.
One area that is more subtle in its volume requirements is the nostril edge. When a nostril is too high, almost always there is a volume deficit in that area of the nose. Grafts that force the edge of the nostril down, such alar rim grafts or alar batten grafts, need to be strong but still a bit malleable lest they create too rigid a nostril edge. Septal cartilage works best.
When the volume deficit is severe causing extensive retraction of the nostril rim, then not only is additional cartilage required, but also additional lining. For this, composite grafts made from skin and cartilage from the ear work best. Since skin is required, there will be a skin defect in the ear that has to be repaired. This can be done leaving only a well-hidden scar by the competent rhinoplasty surgeon.
Adding volume is made more challenging in the thin skinned patient, because thin skin allows everything beneath it to show. In these special cases, the rhinoplasty surgeon does three things:
- Place grafts beneath normal cartilages, so the smoothness of the normal cartilage is what is closest to the skin.
- If grafts must be placed directly beneath the skin, smoothen the grafts as much as possible and fixate them with dissolvable sutures so they stay where they belong.
- Add a layer of soft tissue between the grafts and the skin if necessary. The ideal material for this is temporalis fascia, harvested through an incision in the hair of the temple. Fat can also be used.
If a patient is not ready for rhinoplasty, and can benefit from added volume to build up a bridge or correct asymmetries caused by deviations, then non-surgical, liquid rhinoplasty is a choice.
Here, the facial plastic surgeon or dermatologist injects a temporary dermal filler to create better height and/or symmetry. Many products can be used for this, including Radiesse, Sculptra, liquid silicone, Restylane or Juvederm. Of these, my preference is Restylane-L.
Restylane-L is a hyaluronic acid filler with lidocaine, an anesthetic, added to it. Restylane-L is reversible in case the filler ends up traveling to the wrong place, is compact enough to expand the soft tissue in most areas of the nose, and lasts about one year. Caution must be taken not to obstruct blood vessels into the skin of the nose during injection since this can cause skin loss in the area. When injecting, the injector always has hyaluronidase (e.g. Vitrase) available in case the injected Restylane-L needs dissolving. [Note: Restylane-L is FDA-approved for soft tissue filling of the deep dermis, and not for the nose; it is used off-label with the permission of the patient]. Obviously, injecting the nose is not like injecting the rest of the face, so be sure you use an experienced injector.
Today’s rhinoplasties add strength and volume to the nose, creating results that last a lifetime.
For more information about rhinoplasty, see our webpage at Westlake Dermatology & Cosmetic Surgery. For information about the cost of rhinoplasty, see Dr. Constantinides’ article Rhinoplasty Cost, or call (512) 615-2730 for a free consultation.