Dr. Milos Kovacevic

The operation principle of functional-esthetic rhinoplasty does not only include reduction of hypoplastic parts of the outer nose; sometimes also volumizing measures concerning the bridge of the nose are necessary. A very low radix is by no means point of orientation for more reduction of the bridge; it is a part of the nose that needs to be padded, as well as a slight to moderate saddle nose or a low bridge.

Modern rhinoplasty today still tends toward autologous transplants, since all allogenic, xenogeneic, and synthetical transplants show rejection reactions and sometimes also uncontrollable resorption. In rare, but nevertheless very unpleasant cases for patient and surgeon, very strong inflammation processes emerge/develop, which include scarring and shrinking of the outer nose’s skin and sometimes also fistulization. In order to avoid such complications, ground-breaking ways to autologous transplants are being Autologous cartilage in the sense of the, the septal cartilage, rib cartilage or the ear cartilage do not show any rejection tendency, but display an esthetically very unfortunate visibility of the transplant border and a change in the form in the course of time.

Autologous temporalis fascia has proven successful when it comes to little irregularities of the nose’s bridge or a relatively low radix. A quick removal of the transplant and a very good modelling quality without significant resorption are the advantages of this type of transplant.

According to the author, for a greater demand of volume, the diced cartilage wrapped in Fascia-method by Daniel has proven itself successful as a volumizing transplant in the region of the nose’s bridge. It is a method by which cartilage cut into small pieces up to the size of 1mm are being injected into a type of formative sack of temporalis fascia. The temporalis fascia serves the purpose of neoperichondrium and long-term observation has shown no significant resorption. However, two of the author’s 28 patients showed small irregularities in spite of careful and targeted placing of the transplant. One of the transplants displayed a slight overlapping in the caudal part, the other one exhibited small irregularities in the arrangement of the cartilage pieces, making a visual buffer between transplant and skin necessary. With allogeneic transplants there is always the risk of rejection and inflammation of the surrounding tissue, including flush and swelling and subsequent formation of visible scars and a higher resorption tendency. Since unilateral temporalis fascia had already been removed, the autologous fascia lata from the tractus iliotibialis, which is about 0.94mm thick in anatomical preparation, lent itself to the procedure. It was removed through a small cut of about 1.5cm; the transplant’s size being about 8 x 1.5cm. The resulting muscle hernia was closed up by two 4.0 PDS sutures. The two sutures closed up the hernia from the cranial and the caudal side and were then tied up in the middle in order to provide more stability. First a subcutaneous and then an intracutaneous suture make for an adequate closure of the wound with a barely visible scar. Only one out of 17 patients complaint about light to medium pain, which lasted about two days; none of the patients who had fascia lata removed showed muscle hernia or severe scarring.
For patients who do not have sufficient septal cartilage due to anatomy, a post-traumatic condition or prior surgery and for patients who object to a removal of rib cartilage, the new type of transplant in the form of multilayer fascia lata coiled in temporalis fascia is a superb solution.
The temporalis fascia conceals the borders to the multilayer transplant and thereby makes possible a visually soft transition into the surrounding tissue. Moreover, it grows together well with the subcutis and the perichondrium and periost and thereby keeps the transplant from warping during the first postsurgical phase. The big advantages of the fascia-lata transplant in comparison with the rib-cartilage transplant are significantly higher plasticity and adaptability without significant resorption, no warping tendency, an essentially smaller scar across the cut where the transplant is being removed, as well as less pain after the removal and no serious risk of complications like pneumothorax for instance. The time spent in the surgery should not be ignored, either: The removal of a rib cartilage transplant takes a lot more time and the warping tendency of the rib transplant does not show until a few hours after removal and preparation.
The combination transplant made of multilayer fascia lata and temporalis fascia is convenient in all cases of a volume defect of the nose bridge and for all forms of a saddle nose, as well as for patients with a very low radix, for who a temporalis fascia transplant alone would not suffice . Fascia lata also offers an ideal supporter function when it comes to obturating a septumperforation, obturation of cerebrospinal fluid fistulas with skull-base defects, especially with immune-suppression patients, and as a volumizing transplant for the “empty-nose-syndrom”.
The autologous fascia lata is therefore very suitable as a multi-functional autologous transplant, offering quite a number of advantages in comparison with many other cartilage transplants.

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