Aesth Plast Surg (2015) 39:300–305 DOI 10.1007/s00266-015-0461-4
I N N OV A T I V E T E C H N I QU E S
AESTHETIC
Pectoralis Major Fascia in Rhinoplasty Rui Xavier
Received: 23 November 2014 / Accepted: 8 February 2015 / Published online: 5 March 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015
Abstract Fascia is frequently used in rhinoplasty, for several different purposes. The deep temporalis fascia is most often chosen, though harvesting this fascia requires a separate surgical field that adds surgical time to the procedure and morbidity to the patient. In augmentation rhinoplasty cases as well as in many revision rhinoplasty cases, costal cartilage may be required. In these cases, when costal cartilage is harvested from the 5th to 7th ribs, pectoralis major fascia is in the surgical field and must be incised to provide access to the costal cartilage. Pectoralis major fascia is similar to the deep temporalis fascia, sharing many physical and histological characteristics with it. Pectoralis major fascia can be harvested from the same surgical field as costal cartilage and used in the nose whenever autologous costal cartilage is harvested, thus precluding the need for a separate surgical field for fascia harvest. The surgical technique for harvesting pectoralis major fascia is demonstrated, and two clinical cases of patients in whom this fascia was harvested and used in the nose are presented. Pectoralis major fascia may be considered an alternative option for use in rhinoplasty cases whenever autologous costal cartilage is used. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
R. Xavier (&) Department of Otolaryngology and Head and Neck Surgery, Hospital da Arrabida, Rua Aristides Sousa Mendes 210, 4150-088 Porto, Portugal e-mail: [email protected]
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Keywords Pectoralis major fascia Fascia in rhinoplasty Rhinoplasty
Introduction Deep temporalis fascia is frequently used in rhinoplasty, both in primary cases and in revision rhinoplasty cases. Temporalis fascia has ideal pliability and thickness for use in the nose has a good survival rate and is resistant to infection [1]. Alternatively, autologous fascia lata and Tutoplast-processed fascia lata have also been used in rhinoplasty [2–5]. In primary rhinoplasty cases, fascia may be used as a cover blanket over the nasal osteocartilaginous framework to prevent any irregularity from becoming apparent, especially in thin skin patients. Fascia may also be layered to slightly augment the nasal dorsum or to increase tip definition. In revision rhinoplasty cases, temporalis fascia can be particularly useful to camouflage any irregularity of the bony or cartilaginous nasal framework. Temporalis fascia may also be used in patients requiring major augmentation of the nasal dorsum or in saddle nose patients, as the outer layer and container of diced cartilage in the Turkish delight graft. Harvesting deep temporalis fascia is a straightforward technique that, nevertheless, does require a second surgical incision in a separate surgical field, adding surgical time to the rhinoplasty procedure and morbidity to the patient. These relative disadvantages also apply to harvesting autologous fascia lata, not to mention the visible scar that results from this procedure. Fascia lata is also somehow stiffer [6], therefore not ideal for using in rhinoplasty. Homografts, such as Tutoplast-processed fascia lata and Alloderm, have also been used in rhinoplasty. Tutoplast-
Aesth Plast Surg (2015) 39:300–305
processed fascia lata, however, is expensive and nonviable [1]. Alloderm is best used for camouflaging irregularities of the nasal dorsum. It is not ideal for patients with larger tissue requirements, due to its unpredictable rate of resorption [1]. Pectoralis major fascia is a thin lamina of connective tissue. It covers the great pectoralis muscle and spans from the clavicle and sternum to the fascia of the back. Distally, it is reinforced by fibrous expansions originating from the rectus abdominis sheath [7]. Histologically the pectoralis major fascia is formed by a single layer of undulated collagen fibers, intermixed with many elastic fibers in an irregular mesh [6, 7]. Its thickness varies from 0.2 mm to 1.14 mm [8], being thinner cephalically and thicker caudally. Therefore, the histological structure and thickness of this fascia, especially in the caudal region, are not substantially different from those of the deep temporalis fascia. Pectoralis major fascia is routinely elevated and removed during radical mastectomy, in cases of breast cancer. No specific surgical manoeuver is necessary in these cases to prevent great pectoralis muscular dehiscence or any other complication. Furthermore, it has been demonstrated that the removal of pectoralis major fascia during mastectomy has no influence on the amount of perioperative bleeding or in the postoperative formation of seroma [9]. In breast augmentation surgery, pectoralis major fascia is frequently elevated from the underlying muscle to create a pocket external to the pectoralis major muscle used to introduce the silicone implant [8]. Pectoralis major fascia may be released from the muscle to assist on pectoralis major muscle closure of the mediastinum after mediastinitis [10]. This fascia may also be expanded and transposed to assist on reconstruction of scar contractures of the face and neck [11]. It has been proposed that pectoralis major fascia may be harvested and used as an alternative donor site for repairing dura mater defects after neurosurgical procedures [12]. In patients requiring augmentation rhinoplasty as well as in revision rhinoplasty cases, autologous costal cartilage is commonly harvested and used for providing tissue material to augment the nasal pyramid or for providing strong pieces of cartilage to reestablish the structural support of the nose. Costal cartilage has clear advantages over auricular cartilage for these purposes, as it can provide a substantial quantity of cartilaginous tissue for reconstruction or for nasal augmentation and strong and straight pieces of cartilage can be tailored from it. When harvesting costal cartilage, if the 5th to 7th ribs are chosen, pectoralis major fascia is in the surgical field and has to be incised to provide access to the deeper surgical plane where the costal cartilage lies. A piece of this
301
fascia may be harvested and used in the nose, precluding the need for another surgical field with its inherent morbidity.
Surgical Technique When harvesting autologous costal cartilage, if the 5th to 7th ribs are chosen, pectoralis major fascia appears directly in the surgical field after the skin and subcutaneous tissues have been incised and elevated, covering the pectoralis major muscle. The lower insertion of the pectoralis major muscle is in the 6th or, frequently, in the 7th rib, at the level of the skin incision used for harvesting costal cartilage from these ribs. The superficial surface of the pectoralis major fascia may easily be exposed if one elevates the skin and subcutaneous tissues from the superior margin of the skin incision (Fig. 1). The deep surface of the fascia may be bluntly elevated from the pectoralis major muscle fibers after incising the fascia, if one dissects deep to the fascia and superficial to the muscle fibers in a superior direction (Fig. 2). Close to this lower margin of the pectoralis major muscle, the fascia is reinforced by fibers of the rectus abdominis sheath, being relatively thick and easy to dissect. Before moving away the pectoralis major muscle fibers to expose the underlying costal perichondrium, a piece of fascia may be elevated and harvested. The size of this piece of fascia is determined according to the intended purpose of its use in the nose. If a Turkish delight is being planned, a piece of approximately 5 9 4 cm is harvested, if the fascia is taken to be used as a blanket to prevent any irregularity of the nasal dorsum a smaller piece is harvested. After the costal cartilage is harvested, the muscle fibers of the pectoralis major are re-approximated and sutured. Two to three cm of Ropivacaine is injected locally. Finally, the external incision is sutured.
Fig. 1 The superficial surface of the pectoralis major fascia may be exposed by elevating the adjacent subcutaneous tissues (left on the picture: cephalic)
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Fig. 2 The deep surface of the pectoralis major fascia may be bluntly elevated form the underlying muscle after incising the fascia (left on the picture: cephalic)
Clinical Cases Two cases of patients in whom we harvested pectoralis major fascia for use in the nose are presented. Case 1 (Fig. 3) is a 35-year-old woman with a history of nasal trauma during early childhood and no previous surgery. She complained of nasal airway obstruction and esthetic deformity of the nose. The analysis of her nose revealed the characteristic stigmata of septal absence or weakness, with saddling of the nasal dorsum, lack of tip definition and projection, columellar retraction and a long upper lip. The examination of her nasal fossae
Fig. 3 Preoperative photos of patient 1
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demonstrated a complex deviation of the cartilaginous nasal septum. During surgery, costal cartilage was harvested from the 6th rib and a piece of pectoralis major fascia was also harvested. An open rhinoplasty was performed. The cartilaginous septum, severely deformed, was removed and substituted with a new septum tailored from the costal cartilage. This new septum was suture fixated to the nasal bones (after holes had been drilled on these with a burr) and to the anterior nasal spine. The medial crura of the alar cartilages were then sutured to the caudal part of this septum, in a tongue-in-groove way, and a double-dome suture was tied. A unilateral spreader graft was used on the right side. A shield graft and a buttress graft were also sutured in place. A piece of pectoralis major fascia was used over the shield and buttress grafts to prevent any sharp edge from becoming visible. A Turkish delight graft was tailored with diced costal cartilage and using the pectoralis major fascia to wrap the diced cartilage. This Turkish delight graft was sutured over the nasal dorsum. Preoperative and 1-year postoperative photos of this patient are shown on Figs. 3 and 4. Case 2 (Fig. 5) is a 43-year-old woman with no previous nasal surgery or known history of nasal trauma. She complained of nasal airway obstruction and esthetic deformity of the nose. She had a saddle nose, an underprojected and bulbous tip, bilateral alar hooding, and a long upper lip.
Aesth Plast Surg (2015) 39:300–305
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Fig. 4 One-year postoperative photos of patient 1
Costal cartilage was harvested from the 6th rib and a piece of pectoralis major fascia was also harvested. An open rhinoplasty was performed and the septum was exposed. An L-strut tailored from costal cartilage was sutured to the anterior nasal spine and to the septum, in a slightly more anterior and caudal position in relation to the original septum. Spreader grafts were introduced bilaterally and the dorsal edge of the L-strut was sutured to these and to the upper lateral cartilages. The medial crura of the alar cartilages were sutured to the caudal edge of the L-strut in a tongue-in-groove way. A double-dome suture was used. A Turkish delight graft made with diced costal cartilage and using pectoralis major fascia to wrap the diced cartilage was put in place. A shield graft and a buttress graft were also introduced and two small pieces of pectoralis major fascia were layered over these to improve tip projection and definition. Preoperative and 1-year postoperative photos of this patient are shown on Figs. 5 and 6.
Discussion
Fig. 5 Preoperative photos of patient 2
Fascia is frequently used in rhinoplasty, both in primary cases and in revision rhinoplasty cases. There are several reasons for using fascia in rhinoplasty: fascia is resistant to infection, has a good survival rate, and is easy to shape yet
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Aesth Plast Surg (2015) 39:300–305
Fig. 6 One-year postoperative photos of patient 2
strong enough to be sutured. The thickness of the fascia allows it to be sutured and to serve as the outer layer and container of diced cartilage. It has been demonstrated that wrapping diced cartilage in fascia has several advantages over wrapping diced cartilage with Surgicel, as was originally described by Erol [13]. Histological analysis of diced cartilage wrapped in Surgicel showed evidence of fibrosis and lymphocytic infiltration causing the remnants of cartilage to be metabolic inactive [14, 15]. On the contrary, diced cartilage wrapped in fascia showed coalescence of the diced cartilage into a single-cartilage mass with organized cellular architecture and viable chondrocytes with normal metabolic activity [14, 15]. Due to these histological differences, diced cartilage wrapped in Surgicel does not provide reliable longterm results, whereas fascia seems to prevent resorption of diced cartilage and to provide long-term stability of the graft. This advantage is probably related to the properties of fascia and should also apply not only to deep temporalis fascia but also to pectoralis major fascia, which is histologically and physically identical to deep temporalis fascia. The deep temporalis fascia is most frequently used in rhinoplasty, as the plasticity and thickness of this fascia are ideal for use in the nose. Harvesting this fascia requires a straightforward surgical technique and the resulting scar is hidden by hair. Nevertheless, a second surgical incision in a separate surgical field is necessary for harvesting this fascia, adding surgical time to the rhinoplasty procedure
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and morbidity to the patient. In patients requiring deep temporalis fascia as well as auricular cartilage, it has been suggested that a single incision for harvesting both may be a better option in an effort to avoid the extra complications of an additional wound, including scarring, pain, infection, and dehiscence [16]. In patients requiring autologous costal cartilage, as frequently occurs in augmentation rhinoplasty cases and in revision rhinoplasty cases, and if costal cartilage is taken from the 5th to the 7th ribs, pectoralis major fascia is directly in the surgical field for rib harvest and has to be incised to provide access to the thoracic grid. Harvesting this fascia at this stage of the surgery is straightforward. Costal perichondrium may also be harvested from the rib chosen to provide cartilage to the nose, but the limited extension of perichondrium that can be taken limits its applications in rhinoplasty. It is also thicker and less pliable than fascia, which can result in postoperative thickening [1]. Pectoralis major fascia covers all the surface of the pectoralis major muscle and is, therefore, abundant. It is not only thin and elastic but also strong, sharing many physical and histological characteristics with the deep temporalis fascia. It has, therefore, ideal features to be used in the nose, just as much as the deep temporalis fascia. Pectoralis major fascia may be used over the bony and cartilaginous nasal framework to prevent any irregularity from becoming apparent, may be layered over the nasal
Aesth Plast Surg (2015) 39:300–305
dorsum to induce a slight dorsal augmentation, may be layered over the nasal tip to slightly increase tip definition and projection and may be sutured to be used as the outer layer of diced cartilage. Two patients in whom pectoralis major fascia was harvested and used in the nose are presented (Figs. 3, 4, 5, 6). The results obtained in our patients at 1-year postsurgical follow-up, though not long-term, seem to provide excellent avenues for the use of pectoralis major fascia in the nose. We have been routinely harvesting a piece of pectoralis major fascia whenever autologous costal cartilage is to be used for rhinoplasty. In this way, a piece of fascia of the necessary size is obtained and a second surgical incision in the temporal region is avoided, as is the inherent morbidity associated with another surgical field. We have experienced no local complications such as local seroma formation or muscle dehiscence, in line with other kind of surgeries in which the pectoralis major fascia is also elevated from the pectoralis muscle. In contrast to the rectus abdominis fascia, which is thicker than the pectoralis major fascia and important to the integrity and contractility of the abdominal wall, pectoralis major fascia may be elevated from the underlying muscle with no local consequences. This fascia is routinely elevated and removed during radical mastectomy and no measures to prevent muscular dehiscence need to be taken. Furthermore, it has been demonstrated that the removal of pectoralis major fascia during mastectomy has no influence on the amount of bleeding during surgery or on the postoperative formation of seroma [9]. In breast augmentation surgery the pectoralis major fascia is frequently elevated from the underlying muscle to create a potential space external to the pectoralis major muscle where the implant is introduced [8]. Pectoralis major fascia may also be harvested and used as a free graft to repair dura mater defects in neurosurgical procedures [12]. Harvesting and using pectoralis major fascia in rhinoplasty cases requiring autologous costal cartilage precludes the need for a separate surgical field adding extra surgical time to the procedure and extra morbidity to the patient. Pectoralis major fascia may be an alternative source of fascia for rhinoplasty. Conflict of interest to disclose.
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References 1. Daniel RK, Sajadian A (2012) Secondary rhinoplasty: management of the overresected dorsum. Facial Plastic Surg 28(4):417–426 2. Karaaltin MV, Batioglu-Karaaltin A, Orhan KS, Demirel T, Guldiken Y (2012) Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg 23(3):719–723 3. Karaaltin MV, Orhan KS, Demirel T (2009) Fascia lata graft for nasal dorsal contouring in rhinoplasty. J Plast Reconstr Aesthet Surg 62(10):1255–1260 4. Jang YJ, Kim JH (2011) Use of tutoplast-processed fascia lata as an onlay graft material for tip surgery in rhinoplasty. Otolaryngol Head Neck Surg 144(4):528–532 5. Jang YJ, Wang JH, Sinha V, Song HM, Lee BJ (2007) Tutoplastprocessed fascia lata for dorsal augmentation in rhinoplasty. Otolaryngol Head Neck Surg 137(1):88–92 6. Findley T, Chaudhry H, Stecco A, Roman M (2012) Fascia research—A narrative review. J Bodyw Mov Ther 16(1):67–75 7. Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, de Caro R (2009) The pectoral fa´scia: anatomical and histological study. J Bodyw Mov Ther 13(3):255–261 8. Jinde L, Jianliang S, Xiaoping C, Xiaoyan T, Jiaqing L, Qun M, Bo L (2006) Anatomy and clinical significance of pectoral fascia. Plast Reconstr Surgery 118(7):1557–1560 9. Dalberg K, Johansson H, Signomklao T, Rutqvist LE, Bergkvist L, Liljegren G, Ambre T, Sandelin K (2004) A randomised study of axillary drainage and pectoral fa´scia preservation after mastectomy for breast caˆncer. Eur J Surg Oncol 30(6):602–609 10. Spiess AM, Balakrishnan C, Gursel E (2007) Fascial release of the pectoralis major: a technique used in pectoralis major muscle closure of the mediastinum in cases of mediastinitis. Plast Reconstr Surg 119(2):573–577 11. Gao JH, Ogawa R, Hyakusoku H, Lu F, Hu ZQ, Jiang P, Yang L, Feng C (2007) Reconstruction of the face and neck scar contractures using staged transfer of expanded ‘‘Super-thin flaps’’. Burns 33(6):760–763 12. Louis RG, Tubbs RS, Mortazavi MM, Shoja MM, Loukas M, Cohen-Gadol AA (2013) Harvest of autologous clavipectoral fa´scia for use in duraplasty: cadaveric feasibility study. J Craniofac Surg 24(2):619–621 13. Erol OO (2000) The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr Surg 105(6):2229–2241 14. Daniel RK, Calvert JW (2004) Diced cartilages grafts in rhinoplasty surgery. Plast Reconstr Surg 113(7):2156–2171 15. Calvert JW, Brenner K, DaCosta M, Evans GR, Daniel RK (2006) Histological analysis of human diced cartilages grafts. Plast Reconst Surg 118(1):230–236 16. Vasani SS, Anmolsingh R, Kwame I, East C (2014) A single incision for harvesting conchal cartilage and temporalis fa´scia in diced cartilage-fascia grafts. Jama Facial Plastic Surg 16(5):374
The author has no potential conflicts of interest
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I N N OV A T I V E T E C H N I QU E S
AESTHETIC
Pectoralis Major Fascia in Rhinoplasty Rui Xavier
Received: 23 November 2014 / Accepted: 8 February 2015 / Published online: 5 March 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015
Abstract Fascia is frequently used in rhinoplasty, for several different purposes. The deep temporalis fascia is most often chosen, though harvesting this fascia requires a separate surgical field that adds surgical time to the procedure and morbidity to the patient. In augmentation rhinoplasty cases as well as in many revision rhinoplasty cases, costal cartilage may be required. In these cases, when costal cartilage is harvested from the 5th to 7th ribs, pectoralis major fascia is in the surgical field and must be incised to provide access to the costal cartilage. Pectoralis major fascia is similar to the deep temporalis fascia, sharing many physical and histological characteristics with it. Pectoralis major fascia can be harvested from the same surgical field as costal cartilage and used in the nose whenever autologous costal cartilage is harvested, thus precluding the need for a separate surgical field for fascia harvest. The surgical technique for harvesting pectoralis major fascia is demonstrated, and two clinical cases of patients in whom this fascia was harvested and used in the nose are presented. Pectoralis major fascia may be considered an alternative option for use in rhinoplasty cases whenever autologous costal cartilage is used. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
R. Xavier (&) Department of Otolaryngology and Head and Neck Surgery, Hospital da Arrabida, Rua Aristides Sousa Mendes 210, 4150-088 Porto, Portugal e-mail: [email protected]
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Keywords Pectoralis major fascia Fascia in rhinoplasty Rhinoplasty
Introduction Deep temporalis fascia is frequently used in rhinoplasty, both in primary cases and in revision rhinoplasty cases. Temporalis fascia has ideal pliability and thickness for use in the nose has a good survival rate and is resistant to infection [1]. Alternatively, autologous fascia lata and Tutoplast-processed fascia lata have also been used in rhinoplasty [2–5]. In primary rhinoplasty cases, fascia may be used as a cover blanket over the nasal osteocartilaginous framework to prevent any irregularity from becoming apparent, especially in thin skin patients. Fascia may also be layered to slightly augment the nasal dorsum or to increase tip definition. In revision rhinoplasty cases, temporalis fascia can be particularly useful to camouflage any irregularity of the bony or cartilaginous nasal framework. Temporalis fascia may also be used in patients requiring major augmentation of the nasal dorsum or in saddle nose patients, as the outer layer and container of diced cartilage in the Turkish delight graft. Harvesting deep temporalis fascia is a straightforward technique that, nevertheless, does require a second surgical incision in a separate surgical field, adding surgical time to the rhinoplasty procedure and morbidity to the patient. These relative disadvantages also apply to harvesting autologous fascia lata, not to mention the visible scar that results from this procedure. Fascia lata is also somehow stiffer [6], therefore not ideal for using in rhinoplasty. Homografts, such as Tutoplast-processed fascia lata and Alloderm, have also been used in rhinoplasty. Tutoplast-
Aesth Plast Surg (2015) 39:300–305
processed fascia lata, however, is expensive and nonviable [1]. Alloderm is best used for camouflaging irregularities of the nasal dorsum. It is not ideal for patients with larger tissue requirements, due to its unpredictable rate of resorption [1]. Pectoralis major fascia is a thin lamina of connective tissue. It covers the great pectoralis muscle and spans from the clavicle and sternum to the fascia of the back. Distally, it is reinforced by fibrous expansions originating from the rectus abdominis sheath [7]. Histologically the pectoralis major fascia is formed by a single layer of undulated collagen fibers, intermixed with many elastic fibers in an irregular mesh [6, 7]. Its thickness varies from 0.2 mm to 1.14 mm [8], being thinner cephalically and thicker caudally. Therefore, the histological structure and thickness of this fascia, especially in the caudal region, are not substantially different from those of the deep temporalis fascia. Pectoralis major fascia is routinely elevated and removed during radical mastectomy, in cases of breast cancer. No specific surgical manoeuver is necessary in these cases to prevent great pectoralis muscular dehiscence or any other complication. Furthermore, it has been demonstrated that the removal of pectoralis major fascia during mastectomy has no influence on the amount of perioperative bleeding or in the postoperative formation of seroma [9]. In breast augmentation surgery, pectoralis major fascia is frequently elevated from the underlying muscle to create a pocket external to the pectoralis major muscle used to introduce the silicone implant [8]. Pectoralis major fascia may be released from the muscle to assist on pectoralis major muscle closure of the mediastinum after mediastinitis [10]. This fascia may also be expanded and transposed to assist on reconstruction of scar contractures of the face and neck [11]. It has been proposed that pectoralis major fascia may be harvested and used as an alternative donor site for repairing dura mater defects after neurosurgical procedures [12]. In patients requiring augmentation rhinoplasty as well as in revision rhinoplasty cases, autologous costal cartilage is commonly harvested and used for providing tissue material to augment the nasal pyramid or for providing strong pieces of cartilage to reestablish the structural support of the nose. Costal cartilage has clear advantages over auricular cartilage for these purposes, as it can provide a substantial quantity of cartilaginous tissue for reconstruction or for nasal augmentation and strong and straight pieces of cartilage can be tailored from it. When harvesting costal cartilage, if the 5th to 7th ribs are chosen, pectoralis major fascia is in the surgical field and has to be incised to provide access to the deeper surgical plane where the costal cartilage lies. A piece of this
301
fascia may be harvested and used in the nose, precluding the need for another surgical field with its inherent morbidity.
Surgical Technique When harvesting autologous costal cartilage, if the 5th to 7th ribs are chosen, pectoralis major fascia appears directly in the surgical field after the skin and subcutaneous tissues have been incised and elevated, covering the pectoralis major muscle. The lower insertion of the pectoralis major muscle is in the 6th or, frequently, in the 7th rib, at the level of the skin incision used for harvesting costal cartilage from these ribs. The superficial surface of the pectoralis major fascia may easily be exposed if one elevates the skin and subcutaneous tissues from the superior margin of the skin incision (Fig. 1). The deep surface of the fascia may be bluntly elevated from the pectoralis major muscle fibers after incising the fascia, if one dissects deep to the fascia and superficial to the muscle fibers in a superior direction (Fig. 2). Close to this lower margin of the pectoralis major muscle, the fascia is reinforced by fibers of the rectus abdominis sheath, being relatively thick and easy to dissect. Before moving away the pectoralis major muscle fibers to expose the underlying costal perichondrium, a piece of fascia may be elevated and harvested. The size of this piece of fascia is determined according to the intended purpose of its use in the nose. If a Turkish delight is being planned, a piece of approximately 5 9 4 cm is harvested, if the fascia is taken to be used as a blanket to prevent any irregularity of the nasal dorsum a smaller piece is harvested. After the costal cartilage is harvested, the muscle fibers of the pectoralis major are re-approximated and sutured. Two to three cm of Ropivacaine is injected locally. Finally, the external incision is sutured.
Fig. 1 The superficial surface of the pectoralis major fascia may be exposed by elevating the adjacent subcutaneous tissues (left on the picture: cephalic)
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Fig. 2 The deep surface of the pectoralis major fascia may be bluntly elevated form the underlying muscle after incising the fascia (left on the picture: cephalic)
Clinical Cases Two cases of patients in whom we harvested pectoralis major fascia for use in the nose are presented. Case 1 (Fig. 3) is a 35-year-old woman with a history of nasal trauma during early childhood and no previous surgery. She complained of nasal airway obstruction and esthetic deformity of the nose. The analysis of her nose revealed the characteristic stigmata of septal absence or weakness, with saddling of the nasal dorsum, lack of tip definition and projection, columellar retraction and a long upper lip. The examination of her nasal fossae
Fig. 3 Preoperative photos of patient 1
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demonstrated a complex deviation of the cartilaginous nasal septum. During surgery, costal cartilage was harvested from the 6th rib and a piece of pectoralis major fascia was also harvested. An open rhinoplasty was performed. The cartilaginous septum, severely deformed, was removed and substituted with a new septum tailored from the costal cartilage. This new septum was suture fixated to the nasal bones (after holes had been drilled on these with a burr) and to the anterior nasal spine. The medial crura of the alar cartilages were then sutured to the caudal part of this septum, in a tongue-in-groove way, and a double-dome suture was tied. A unilateral spreader graft was used on the right side. A shield graft and a buttress graft were also sutured in place. A piece of pectoralis major fascia was used over the shield and buttress grafts to prevent any sharp edge from becoming visible. A Turkish delight graft was tailored with diced costal cartilage and using the pectoralis major fascia to wrap the diced cartilage. This Turkish delight graft was sutured over the nasal dorsum. Preoperative and 1-year postoperative photos of this patient are shown on Figs. 3 and 4. Case 2 (Fig. 5) is a 43-year-old woman with no previous nasal surgery or known history of nasal trauma. She complained of nasal airway obstruction and esthetic deformity of the nose. She had a saddle nose, an underprojected and bulbous tip, bilateral alar hooding, and a long upper lip.
Aesth Plast Surg (2015) 39:300–305
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Fig. 4 One-year postoperative photos of patient 1
Costal cartilage was harvested from the 6th rib and a piece of pectoralis major fascia was also harvested. An open rhinoplasty was performed and the septum was exposed. An L-strut tailored from costal cartilage was sutured to the anterior nasal spine and to the septum, in a slightly more anterior and caudal position in relation to the original septum. Spreader grafts were introduced bilaterally and the dorsal edge of the L-strut was sutured to these and to the upper lateral cartilages. The medial crura of the alar cartilages were sutured to the caudal edge of the L-strut in a tongue-in-groove way. A double-dome suture was used. A Turkish delight graft made with diced costal cartilage and using pectoralis major fascia to wrap the diced cartilage was put in place. A shield graft and a buttress graft were also introduced and two small pieces of pectoralis major fascia were layered over these to improve tip projection and definition. Preoperative and 1-year postoperative photos of this patient are shown on Figs. 5 and 6.
Discussion
Fig. 5 Preoperative photos of patient 2
Fascia is frequently used in rhinoplasty, both in primary cases and in revision rhinoplasty cases. There are several reasons for using fascia in rhinoplasty: fascia is resistant to infection, has a good survival rate, and is easy to shape yet
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Aesth Plast Surg (2015) 39:300–305
Fig. 6 One-year postoperative photos of patient 2
strong enough to be sutured. The thickness of the fascia allows it to be sutured and to serve as the outer layer and container of diced cartilage. It has been demonstrated that wrapping diced cartilage in fascia has several advantages over wrapping diced cartilage with Surgicel, as was originally described by Erol [13]. Histological analysis of diced cartilage wrapped in Surgicel showed evidence of fibrosis and lymphocytic infiltration causing the remnants of cartilage to be metabolic inactive [14, 15]. On the contrary, diced cartilage wrapped in fascia showed coalescence of the diced cartilage into a single-cartilage mass with organized cellular architecture and viable chondrocytes with normal metabolic activity [14, 15]. Due to these histological differences, diced cartilage wrapped in Surgicel does not provide reliable longterm results, whereas fascia seems to prevent resorption of diced cartilage and to provide long-term stability of the graft. This advantage is probably related to the properties of fascia and should also apply not only to deep temporalis fascia but also to pectoralis major fascia, which is histologically and physically identical to deep temporalis fascia. The deep temporalis fascia is most frequently used in rhinoplasty, as the plasticity and thickness of this fascia are ideal for use in the nose. Harvesting this fascia requires a straightforward surgical technique and the resulting scar is hidden by hair. Nevertheless, a second surgical incision in a separate surgical field is necessary for harvesting this fascia, adding surgical time to the rhinoplasty procedure
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and morbidity to the patient. In patients requiring deep temporalis fascia as well as auricular cartilage, it has been suggested that a single incision for harvesting both may be a better option in an effort to avoid the extra complications of an additional wound, including scarring, pain, infection, and dehiscence [16]. In patients requiring autologous costal cartilage, as frequently occurs in augmentation rhinoplasty cases and in revision rhinoplasty cases, and if costal cartilage is taken from the 5th to the 7th ribs, pectoralis major fascia is directly in the surgical field for rib harvest and has to be incised to provide access to the thoracic grid. Harvesting this fascia at this stage of the surgery is straightforward. Costal perichondrium may also be harvested from the rib chosen to provide cartilage to the nose, but the limited extension of perichondrium that can be taken limits its applications in rhinoplasty. It is also thicker and less pliable than fascia, which can result in postoperative thickening [1]. Pectoralis major fascia covers all the surface of the pectoralis major muscle and is, therefore, abundant. It is not only thin and elastic but also strong, sharing many physical and histological characteristics with the deep temporalis fascia. It has, therefore, ideal features to be used in the nose, just as much as the deep temporalis fascia. Pectoralis major fascia may be used over the bony and cartilaginous nasal framework to prevent any irregularity from becoming apparent, may be layered over the nasal
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dorsum to induce a slight dorsal augmentation, may be layered over the nasal tip to slightly increase tip definition and projection and may be sutured to be used as the outer layer of diced cartilage. Two patients in whom pectoralis major fascia was harvested and used in the nose are presented (Figs. 3, 4, 5, 6). The results obtained in our patients at 1-year postsurgical follow-up, though not long-term, seem to provide excellent avenues for the use of pectoralis major fascia in the nose. We have been routinely harvesting a piece of pectoralis major fascia whenever autologous costal cartilage is to be used for rhinoplasty. In this way, a piece of fascia of the necessary size is obtained and a second surgical incision in the temporal region is avoided, as is the inherent morbidity associated with another surgical field. We have experienced no local complications such as local seroma formation or muscle dehiscence, in line with other kind of surgeries in which the pectoralis major fascia is also elevated from the pectoralis muscle. In contrast to the rectus abdominis fascia, which is thicker than the pectoralis major fascia and important to the integrity and contractility of the abdominal wall, pectoralis major fascia may be elevated from the underlying muscle with no local consequences. This fascia is routinely elevated and removed during radical mastectomy and no measures to prevent muscular dehiscence need to be taken. Furthermore, it has been demonstrated that the removal of pectoralis major fascia during mastectomy has no influence on the amount of bleeding during surgery or on the postoperative formation of seroma [9]. In breast augmentation surgery the pectoralis major fascia is frequently elevated from the underlying muscle to create a potential space external to the pectoralis major muscle where the implant is introduced [8]. Pectoralis major fascia may also be harvested and used as a free graft to repair dura mater defects in neurosurgical procedures [12]. Harvesting and using pectoralis major fascia in rhinoplasty cases requiring autologous costal cartilage precludes the need for a separate surgical field adding extra surgical time to the procedure and extra morbidity to the patient. Pectoralis major fascia may be an alternative source of fascia for rhinoplasty. Conflict of interest to disclose.
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The author has no potential conflicts of interest
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