The Journal of Laryngology and Otology December 1991, Vol. 105, pp. 1018-1020
Calvarial bone grafts for augmentation rhinoplasty BRAJENDRA BASER, M.S., REKHA SHAHANI, M.S., SHALINI KHANNA, M.B.B.S., D. S. GREWAL, M.S.
(Bombay, India)
Abstract A large variety of graft materials have been used for augmentation rhinoplasty. To date there has been no graft material which can be regarded as completely satisfactory. The modern trend is to prefer autologous material to new biological material. The membranous bones of the calvarium are extremely suitable for augmenting moderate to severe saddle nose deformities. Calvarial bone grafts can be harvested easily, with minimum donor site morbidity and disfigurement. Our experience with calvarial bone grafts for augmentation rhinoplasty is presented.
a wide variety of synthetic implants, for example silicone, proplast and supramid. For mild saddle deformities we prefer autologous septal cartilage. However, most of the cases presenting to us for augmentation rhinoplasty usually have a moderate to severe saddle deformity. Septal cartilage in these cases is either unavailable or inadequate. Hence, over the last three years, we have come to rely totally on calvarial bone grafts for moderate to severe saddle deformities, with minimum morbidity and excellent long-term results.
Introduction The nasal dorsum is the most conspicuous feature of the face and even a small depression in this region produces an unsightly deformity. In our country the nose has traditionally been considered a symbol of prestige. Moreover a saddle nose brings to the lay mind the image of a leper which in India is still considered a stigma. No wonder, saddle nose deformity is one of the commonest aesthetic problems encountered by the nasal plastic surgeon in our country. Historically a variety of graft materials have been used for nasal augmentation. These include ivory, metals; homograft, allograft and xenograft bone and cartilage; irradiated cartilage, autografts such as temporalis fascia, dermofat; septal, costal and conchal cartilage; bone from the iliac crest; rib tibial and olecranon process and
Surgical technique The nasal deformity which includes the dorsum and the tip projection is analysed. This gives an idea of how much bone will be required. Usually, a single straight
FIG. 1 Graft outline marked on calvarium.
FIG. 2 Direction of osteotome for removal of the graft.
Accepted for publication: 29 August 1991. 1018
1019
CALVARIAL BONE GRAFTS
i FIG. 3 Scalp scar 2 weeks following harvesting of bone graft.
piece of bone is sufficient; if greater augmentation is required, several pieces of bone are used. If the tip requires simultaneous augmentation, we prefer using a simultaneous umbrella graft for the tip augmentation as the traditional cantalavier bone graft gives an unnatural stiffness to the tip (Baser, 1991). The donor site selected is usually the parietal area, near the vertex on the non-dominant side. In male patients the area selected is a little lower to avoid baldness. Pre-operatively, on the night prior to surgery as
well as on the morning of surgery, all the patients have a Savlon® hair wash. No pre-operative shaving is advised. On the table, under general anaesthesia, only the incision site (less than 5 mm) is shaved and neomycin ointment is applied on the sides. The operative area is infiltrated with xylocaine and adrenaline solution (1:10,0000) ten minutes prior to commencing surgery. Depending on the length of the graft required, an incision, usually 5-6 cm long is made and the cut edges of the scalp are retracted with a self retaining mastoid retractor. The periosteum is incised, elevated and retracted. The outline of the graft is marked out on the calvarium, the width kept to the requirement (usually 1 cm) (Fig. 1). With the help of a small cutting burr and continuous irrigation the sides of the graft are burred until the diploic space is encountered. This is identified by the brisk bleeding which occurs from the cancellous bone of the diploe. Continuous irrigation is required to prevent heat and frictional damage to the bone. Once the diploic level is achieved on all sides of the graft, a piece of bone 3-4 mm is drilled out on the lateral side to make space for the osteotome. This manoeuvre helps to keep the direction of the osteotome parallel to the calvarium thus avoiding damage to the underlying dura and intracranial structures (Fig. 2). With the help of short controlled taps, the piece of bone is removed. This step is the most important as any impatience can cause serious complications. Care should be taken to avoid using the osteotome as a fulcrum as the graft may fracture. Bone wax is used to control only brisk bleeding. The periosteum is sutured with 3-0 catgut and the skin with 3-0 silk. A small Penrose drain is kept in place for 48 hours. The graft is now shaped with a large cutting burr,
Fio. 4 X-ray of nasal bone showing graft 1 year following augmentation rhinoplasty.
FIG. 5 Saddle nose deformity in a middle aged female due to myasis.
1020
FIG. 6 Post-operative result 2 years following augmentation rhinoplasty using calvarial bone grafts.
copious irrigation being required to protect the bone. The desired contour is boat shaped with a wide centre and tapering ends, the end towards the nasal tip being the narrowest. For severe deformities multiple bone grafts tied together can be used. This graft is then inserted through the inter-cartilaginous incision or through an external rhinoplasty incision. The usual precautions are observed at the recipient site. The bone graft is placed beneath the periosteum in firm contact with the nasal bones. All bone grafts are temporarily immobilized with the help of a Kirshner wire. When a side wall augmentation is also required crushed autologous conchal cartilage is used. The nose is then kept in plaster for 2-3 weeks. Discussion Nasal trauma, post SMR deformity, leprosy and atrophic rhinitis are some of the common causes of moderate to severe saddle deformities in our country. Inert nonbiological grafts have the advantage of no donor site morbidity (Rozner, 1980). Being inert the chances of rejection are minimal. However, for the same reason, they do not becomefixedto the skeleton and malposition is a common sequela. Long-term follow-up studies show a high extrusion rate (Hiraga, 1980), the sequelae being the so-called 'crucified' noses. Non-biological grafts are also not suited for deformities following atrophic rhinitis (Baser, et al., 1990). Finally the cost of these implants is another limiting factor in our country. Bone grafts have been used (for nasal augmentation)
B. BASER, R. SHAHANI, S. KHANNA, D. S. GREWAL
for a long time. Autologous bones when kept in contact with the nasal bones become incorporated into the facial framework and thus provide a solid foundation for the nasal dorsum. The grafts do have a tendency to become absorbed but by placing the graft under the periosteum and with adequate immobilization this tendency can be minimized. A cortico-cancellous bone graft from the iliac crest is commonly used. The morbidity associated with harvesting an iliac bone graft does not justify its use in routine augmentation rhinoplasty. Post-operative pain and limping may persist for weeks. Hence we have practically stopped using iliac bone grafts. Rib cartilage provides a large amount of graft material and has little tendency for absorption. This is advantageous in certain clinical situations where the risk of bone absorption is high such as in atrophic rhinitis (Baser, et al., 1990). However, costal cartilage once implanted becomes hard and stiff. If not carved carefully (Gibson and Davis, 1958) they have a tendency to curl thus giving the nose a twisted appearance. Besides the technical difficulty of harvesting this graft there is also a risk of pneumothorax. Lastly, post-operative pain may persist for a considerable period of time. With the advances made in craniofacial surgery calvarial bone grafts are becoming increasingly popular. The outer table of the calvarium can be conveniently used. There is minimum donor site morbidity and postoperative pain, the scar is hardly visible (Fig. 3). The membranous bone of the calvarium resembles the other facial bones and easily becomes incorporated into the nasal framework with little tendency for absorption (Fig. 4). The long-term results of nasal augmentation with calvarial bone grafts are quite satisfactory (Fig. 5). To date we have not encountered any significant absorption. There is, however, a theoretical risk of injury to the dura and intracranial structures but with adequate training and cadaveric study this risk is minimal.
Acknowledgement The authors gratefully acknowledge the Dean, T.N. Medical College for permission to publish this paper.
References Baser, B. (1991). Umbrella grafting for nasal tip augmentation (unpublished data). Baser, B., Grewal, D. S., Hiranandani, N. L. H. (1990). Management of saddle nose deformity in atrophic rhinitis. Journal of Laryngology and Otology, 104: 404-407. Gibson, T., Davis, N. (1958). The distortion of autogenous cartilage grafts—its course and prevention. British Journal of Plastic Surgery, 10: 257-274. Hiraga, Y. (1980). Complications of augmentation rhinoplasty in the Japanese. Annals of Plastic Surgery, 4: 495^199. Rozner, L. (1980). Augmentation rhinoplasty. British Journal of Plastic Surgery, 33: 377-382. Address for correspondence: Brajendra Baser, Associate Professor of E.N.T., K.E.M. Hospital & Seth G.S. Medical College, Bombay-^tOO 012, India.
Key words: Rhinoplasty, calvarial bone grafts; Augmentation rhinoplasty.
Calvarial bone grafts for augmentation rhinoplasty BRAJENDRA BASER, M.S., REKHA SHAHANI, M.S., SHALINI KHANNA, M.B.B.S., D. S. GREWAL, M.S.
(Bombay, India)
Abstract A large variety of graft materials have been used for augmentation rhinoplasty. To date there has been no graft material which can be regarded as completely satisfactory. The modern trend is to prefer autologous material to new biological material. The membranous bones of the calvarium are extremely suitable for augmenting moderate to severe saddle nose deformities. Calvarial bone grafts can be harvested easily, with minimum donor site morbidity and disfigurement. Our experience with calvarial bone grafts for augmentation rhinoplasty is presented.
a wide variety of synthetic implants, for example silicone, proplast and supramid. For mild saddle deformities we prefer autologous septal cartilage. However, most of the cases presenting to us for augmentation rhinoplasty usually have a moderate to severe saddle deformity. Septal cartilage in these cases is either unavailable or inadequate. Hence, over the last three years, we have come to rely totally on calvarial bone grafts for moderate to severe saddle deformities, with minimum morbidity and excellent long-term results.
Introduction The nasal dorsum is the most conspicuous feature of the face and even a small depression in this region produces an unsightly deformity. In our country the nose has traditionally been considered a symbol of prestige. Moreover a saddle nose brings to the lay mind the image of a leper which in India is still considered a stigma. No wonder, saddle nose deformity is one of the commonest aesthetic problems encountered by the nasal plastic surgeon in our country. Historically a variety of graft materials have been used for nasal augmentation. These include ivory, metals; homograft, allograft and xenograft bone and cartilage; irradiated cartilage, autografts such as temporalis fascia, dermofat; septal, costal and conchal cartilage; bone from the iliac crest; rib tibial and olecranon process and
Surgical technique The nasal deformity which includes the dorsum and the tip projection is analysed. This gives an idea of how much bone will be required. Usually, a single straight
FIG. 1 Graft outline marked on calvarium.
FIG. 2 Direction of osteotome for removal of the graft.
Accepted for publication: 29 August 1991. 1018
1019
CALVARIAL BONE GRAFTS
i FIG. 3 Scalp scar 2 weeks following harvesting of bone graft.
piece of bone is sufficient; if greater augmentation is required, several pieces of bone are used. If the tip requires simultaneous augmentation, we prefer using a simultaneous umbrella graft for the tip augmentation as the traditional cantalavier bone graft gives an unnatural stiffness to the tip (Baser, 1991). The donor site selected is usually the parietal area, near the vertex on the non-dominant side. In male patients the area selected is a little lower to avoid baldness. Pre-operatively, on the night prior to surgery as
well as on the morning of surgery, all the patients have a Savlon® hair wash. No pre-operative shaving is advised. On the table, under general anaesthesia, only the incision site (less than 5 mm) is shaved and neomycin ointment is applied on the sides. The operative area is infiltrated with xylocaine and adrenaline solution (1:10,0000) ten minutes prior to commencing surgery. Depending on the length of the graft required, an incision, usually 5-6 cm long is made and the cut edges of the scalp are retracted with a self retaining mastoid retractor. The periosteum is incised, elevated and retracted. The outline of the graft is marked out on the calvarium, the width kept to the requirement (usually 1 cm) (Fig. 1). With the help of a small cutting burr and continuous irrigation the sides of the graft are burred until the diploic space is encountered. This is identified by the brisk bleeding which occurs from the cancellous bone of the diploe. Continuous irrigation is required to prevent heat and frictional damage to the bone. Once the diploic level is achieved on all sides of the graft, a piece of bone 3-4 mm is drilled out on the lateral side to make space for the osteotome. This manoeuvre helps to keep the direction of the osteotome parallel to the calvarium thus avoiding damage to the underlying dura and intracranial structures (Fig. 2). With the help of short controlled taps, the piece of bone is removed. This step is the most important as any impatience can cause serious complications. Care should be taken to avoid using the osteotome as a fulcrum as the graft may fracture. Bone wax is used to control only brisk bleeding. The periosteum is sutured with 3-0 catgut and the skin with 3-0 silk. A small Penrose drain is kept in place for 48 hours. The graft is now shaped with a large cutting burr,
Fio. 4 X-ray of nasal bone showing graft 1 year following augmentation rhinoplasty.
FIG. 5 Saddle nose deformity in a middle aged female due to myasis.
1020
FIG. 6 Post-operative result 2 years following augmentation rhinoplasty using calvarial bone grafts.
copious irrigation being required to protect the bone. The desired contour is boat shaped with a wide centre and tapering ends, the end towards the nasal tip being the narrowest. For severe deformities multiple bone grafts tied together can be used. This graft is then inserted through the inter-cartilaginous incision or through an external rhinoplasty incision. The usual precautions are observed at the recipient site. The bone graft is placed beneath the periosteum in firm contact with the nasal bones. All bone grafts are temporarily immobilized with the help of a Kirshner wire. When a side wall augmentation is also required crushed autologous conchal cartilage is used. The nose is then kept in plaster for 2-3 weeks. Discussion Nasal trauma, post SMR deformity, leprosy and atrophic rhinitis are some of the common causes of moderate to severe saddle deformities in our country. Inert nonbiological grafts have the advantage of no donor site morbidity (Rozner, 1980). Being inert the chances of rejection are minimal. However, for the same reason, they do not becomefixedto the skeleton and malposition is a common sequela. Long-term follow-up studies show a high extrusion rate (Hiraga, 1980), the sequelae being the so-called 'crucified' noses. Non-biological grafts are also not suited for deformities following atrophic rhinitis (Baser, et al., 1990). Finally the cost of these implants is another limiting factor in our country. Bone grafts have been used (for nasal augmentation)
B. BASER, R. SHAHANI, S. KHANNA, D. S. GREWAL
for a long time. Autologous bones when kept in contact with the nasal bones become incorporated into the facial framework and thus provide a solid foundation for the nasal dorsum. The grafts do have a tendency to become absorbed but by placing the graft under the periosteum and with adequate immobilization this tendency can be minimized. A cortico-cancellous bone graft from the iliac crest is commonly used. The morbidity associated with harvesting an iliac bone graft does not justify its use in routine augmentation rhinoplasty. Post-operative pain and limping may persist for weeks. Hence we have practically stopped using iliac bone grafts. Rib cartilage provides a large amount of graft material and has little tendency for absorption. This is advantageous in certain clinical situations where the risk of bone absorption is high such as in atrophic rhinitis (Baser, et al., 1990). However, costal cartilage once implanted becomes hard and stiff. If not carved carefully (Gibson and Davis, 1958) they have a tendency to curl thus giving the nose a twisted appearance. Besides the technical difficulty of harvesting this graft there is also a risk of pneumothorax. Lastly, post-operative pain may persist for a considerable period of time. With the advances made in craniofacial surgery calvarial bone grafts are becoming increasingly popular. The outer table of the calvarium can be conveniently used. There is minimum donor site morbidity and postoperative pain, the scar is hardly visible (Fig. 3). The membranous bone of the calvarium resembles the other facial bones and easily becomes incorporated into the nasal framework with little tendency for absorption (Fig. 4). The long-term results of nasal augmentation with calvarial bone grafts are quite satisfactory (Fig. 5). To date we have not encountered any significant absorption. There is, however, a theoretical risk of injury to the dura and intracranial structures but with adequate training and cadaveric study this risk is minimal.
Acknowledgement The authors gratefully acknowledge the Dean, T.N. Medical College for permission to publish this paper.
References Baser, B. (1991). Umbrella grafting for nasal tip augmentation (unpublished data). Baser, B., Grewal, D. S., Hiranandani, N. L. H. (1990). Management of saddle nose deformity in atrophic rhinitis. Journal of Laryngology and Otology, 104: 404-407. Gibson, T., Davis, N. (1958). The distortion of autogenous cartilage grafts—its course and prevention. British Journal of Plastic Surgery, 10: 257-274. Hiraga, Y. (1980). Complications of augmentation rhinoplasty in the Japanese. Annals of Plastic Surgery, 4: 495^199. Rozner, L. (1980). Augmentation rhinoplasty. British Journal of Plastic Surgery, 33: 377-382. Address for correspondence: Brajendra Baser, Associate Professor of E.N.T., K.E.M. Hospital & Seth G.S. Medical College, Bombay-^tOO 012, India.
Key words: Rhinoplasty, calvarial bone grafts; Augmentation rhinoplasty.
