OT
Otolaryngology

Tip and lobule grafts

December 21, 2011.
Stephen W. Perkins, MD,

Educational Objectives

The goal of this program is to improve the management of patients undergoing cosmetic reconstructive surgery of the nose. After hearing and assimilating this program, the clinician will be better able to:

1. Describe the uses of tip and lobule grafts.

2. Utilize the appropriate type of graft for nasal tip
grafting.

Summary

Uses for tip grafts: camouflage; effacement of interdomal bifidity; alar stabilization; infratip lobular graft for aesthetic improvement; increasing length and projection

Graft material: septal cartilage primary choice for lobule reconstruction; conchal cartilage (for alar contour); supratip nasal soft tissue for camouflage; cephalic margin cartilage as drape-over graft

Columellar strut graft: placed endonasally or through external columellar approach; make pocket anterior to nasal spine; use double hook to hold domes up; using 4-0 plain gut on short Keith needle, insert through vestibular skin and medial crura to stabilize; suture medial crura caudally in mattress fashion for support; in endonasal approach, make pocket with small incision to side of columella; through medial crus; dissect up and down; slip graft in secure precise pocket

Infratip lobule graft: for patients with inadequate tip projection from previous surgery; speaker approaches endonasally; places infratip lobular graft after closing marginal incisions; when putting in full shield grafts, can place infratip lobular graft in that precise pocket; pocket made precise by closing marginal intercartilaginous incisions, except for small area on one side; onlay graft for length and definition; distance of tip-defining points to alar nostril margin aesthetically improved

Cap graft: in infratip lobule area; usually sutured in place in external columellar approach; increases height, length, and projection; sutured directly to medial crura (or intermediate part of medial crura); or, sutured on top of shield graft

Interdomal graft: if too much narrowing occurs during operation, bring both domes out and insert interdomal graft before transdomal suturing; useful to maintain interdomal width

Shield and blocking grafts: sutured-in full columellar shield graft gives length, projection to tip (if long enough), and higher domal prominence; speaker uses blocking graft with extended shield grafts; carve and bevel top edge of graft; suture in situ; use mattress sutures to stabilize at base; stable graft; provides stability to lateral ala; in patient with underprojected nasal tip reduces hump and increases tip projection; extends height of lobule; edges of cartilage may become apparent when skin over lobule retracts and contracts (tombstone appearance); can bevel, but will lose height; or use blocking graft to fill in behind; blocking graft — prevents cephalic rotation of shield graft; fills in dead space, providing softer contour; helps stabilize ala

Peck graft: placed on top of domes; useful for slight projection on top of already good domes; can use conchal cartilage

Cap graft: speaker’s definition — caps what attempting to accomplish with shield graft; provides increased infratip lobular contour and length; provides more aesthetically pleasing profile, giving length to infratip lobular area; cleft lip and palate, nose — provides good projection when reconstructing ala; release left lateral crus and bring up to height of normal domal side; for lateral deficit, replace with alar strut and/or batten graft, filling in laterally; tip graft helps improve symmetry

Alar replacement grafts: possibly same as alar batten graft; batten graft usually contour support on existing ala; even if remnant, replace with strong septal cartilage; conchal cartilage may work if large enough; lateral crura often need grafting, especially in cases of cephalic malposition, weak lateral alar side walls, pre-existing recurvature, or lateral and posterior cephalic portion of lateral crus hanging into airway; support with alar strut graft or alar batten graft; alar batten graft — used for contour and support; on superficial or more external surface of lateral crus; works for replacement;can give strength; alar strut graft — on vestibular surface; positioned not with alar cartilage; can be more caudal; should be more lateral and outside pyriform aperture; may dissect more into soft tissue part of ala; possible to place endonasally, although difficult; easier through external columellar approach; do some hydrodissection on vestibular side of cartilage; before removal of cephalic margin, speaker often dissects entire pocket; make alar strut graft preferably with septal cartilage; suture it directly to cartilage initially, or, with transvestibular approach put in 3 or 4 mattress sutures; reapproximate vestibular skin

Refinements to total lobular reconstruction: surgeon can handle revision or difficult primary rhinoplasty as long as comfortable taking lobule apart and putting back together with proper grafting; replace, reposition, and add material as needed; refinements take to new level; addresses small problems, eg, alar margin not quite right, grafts little sharp, thin skin; camouflaging — can bevel edges of cartilage grafts but sometimes not enough; speaker lays on nasal fibrofatty soft tissue; if none available, uses temporalis fascia or acellular dermis; speaker lays nasal fibrofatty soft tissue wherever needed for camouflage or to soften contour; may drape it up and over area of dome; adds to long-term aesthetic improvement; if facets weak or one side does not look same as other side, can take alar cephalic margin or small amount of shaved septal cartilage and suture in place; speaker uses 30-gauge needles to stabilize grafts before suturing in place

Rim graft: to improve contour of alar margin; performed endonasally or in external approach; speaker makes separate pocket; makes incision just large enough to use curved scissors; dissect pocket up; more caudal than marginal incision; back elevate toward base of ala; contour graft and slip it into pocket; tuck tail in (2-3 mm of back elevation); use 1 or 2 5-0 plain gut sutures to close; can make pocket on elevated flap from domal side back laterally; performed at very end of operation

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Perkins was recorded at The UC Irvine Otolaryngology Update, held February 19-22, 2011, in Indian Wells, CA, and sponsored by the University of California, Irvine, School of Medicine, Department of Otolaryngology–Head and Neck Surgery. Information about upcoming meetings from UC Irvine, School of Medicine, can be found at som.uci.edu/events.asp. The Audio-Digest Foundation thanks Dr. Perkins and the University of California, Irvine, School of Medicine, Department of Otolaryngology-Head and Neck Surgery for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT442403

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation