Application of Auricular Cartilage Scaffold Combined With L-Shaped Prosthesis in Asian Rhinoplasty

Abstract

Rhinoplasty is a common surgical procedure in medical cosmetology. From patients with saddle nose deformity to beauty seekers with low and short noses, this surgery is mainly sought to improve the nose’s appearance. To investigate the effect of modified auricular cartilage scaffold combined with L-shaped prosthesis in rhinoplasty. This retrospective study included 54 patients who underwent auricular cartilage augmentation rhinoplasty with L-shaped implants in our hospital from July 2018 to July 2021. The function of nasal ventilation and olfaction was inspected. As a result, the degree of nasal tip protrusion and the changes in the superior lip angle of columella were improved. The patients’ satisfaction was measured a year after the surgery. Patients who underwent auricular cartilage augmentation rhinoplasty with L-shaped prosthesis were satisfied with the surgery outcomes. Using a protective auricular cartilage scaffold combined with an L-shaped implant for augmentation rhinoplasty reduced the shortage of the application and reinforced the stability of the auricular cartilage augmentation rhinoplasty. At >12 months follow-up, there were no serious adverse effects on nasal ventilation and olfactory function in any of the patients. The presented method made full use of auricular cartilage so that it reduced the harvest of the cartilage. Besides, it achieved the remarkable lift of the nose tip, thus simulating the appearance of costal cartilage rhinoplasty. Furthermore, the risk of implant exposure was efficiently reduced, making it worthy of clinical application.

INTRODUCTION

In Asia, rhinoplasty programs reverted from the original prosthesis rhinoplasty to various grafts and implants, such as septal cartilage, rib cartilage, auricular cartilage, porous polyethylene, polytetrafluoroethylene, and silicone prosthesis. Different material selection produces different surgical results.¹ As Asians’ septal cartilage lacks volume and hardness, the surgical method with septal cartilage has been gradually abandoned since the rate of complications and postoperative deformity is relatively high. Because of the influence of web celebrity esthetic, autogenous rib cartilage augmentation rhinoplasty has become a favored procedure. However, the hardness of the nose tip after the operation, the damage to the donor site, and the increase in the operation risk avert some of these beauty seekers from pursuing this surgery.^2–4 The high cost and risk of implant exposure impede porous polyethylene from becoming widely used. Polytetrafluoroethylene is also an expensive implant; however, its postoperative infection rate is relatively higher than that of silicone prosthesis augmentation rhinoplasty.

Auricular cartilage rhinoplasty is more popular among beauty seekers because of its easy selection and low surgical risk. Nonetheless, the strength of the material may not provide the adequate support needed to lift the tip of the nose. The shape of the autologous cartilage scaffold carving and building structure determine the quality of the nasal shape and patient satisfaction after plastic surgery to a large extent. Nonetheless, mimicking the esthetic outcomes of costal cartilage rhinoplasty with auricular cartilage remains challenging. The amount of auricular cartilage taken for nose augmentation alone is quite large when performed with the traditional approach. In many cases, it is necessary to take cartilage from both sides of the ears. After the cartilage is removed, the ear is less supportive or elastic. Besides, the pleated scar may also present an unwanted issue among beauty seekers.⁵ Accordingly, reducing the cartilage needed for augmentation rhinoplasty would be a great advantage for this population. In this study, we investigate the effect of a modified auricular cartilage scaffold combined with an L-shaped prosthesis in rhinoplasty.

METHODS

A total of 54 patients who underwent the augmentation rhinoplasty with modified auricular cartilage scaffold combined with L-shaped prosthesis between July 2018 and July 2021 were included in the study. The utility model solved the shortboard and stability of the supporting force of the auricular cartilage augmentation rhinoplasty and improved the postoperative satisfaction of beauty seekers. Inclusion criteria were the following: no history of nasal trauma, no history of tumor or cardiovascular disease, and age over 18 years. Exclusion criteria were the presence of nasal dyspnea and dysosmia, a history of diabetes, a recent history of upper respiratory tract infection, and an acute stage of rhinitis. This study was conducted in accordance with the principles of the Declaration of Helsinki. All the patients signed the informed consent.

Surgical Procedure

Preparation of Autologous Auricular Cartilage

The surgeon marked the area for removal of autologous auricular cartilage from single ear, and made a 20.0 mm incision on the cavum conchae near the antihelix after the infiltration anesthesia. The perichondrium layer and the cartilage were separated from the cavum conchae to cavum conchae (Fig. 1A). To minimize the deformity of the ear after the auricular cartilage was removed, the crura helicis was left intact. The size of the removed cartilage was some 15.0×10.0 mm to 18.0×12.0 mm, depending on the size of the external ear (Fig. 1B, C). To prevent the nose tip from showing an angular shape after the operation, 5.0×10.0 mm fascia was harvested (Fig. 1D). A 7-0 nylon thread was used to suture the incision, and pressure was applied with an iodophor cotton ball and vaseline gauze.

FIGURE 1.

(A) The perichondrium layer and the cartilage were separated from the cavum conchae to cavum conchae. (B, C) The size of the removed cartilage was some 15.0×10.0 mm to 18.0×12.0 mm. (D) 5.0×10.0 mm fascia was harvested.

Building of Autologous Auricular Cartilage Scaffold

An inverted “V” incision was made at the narrowest part of the columella. After fully losing prosthetic space in the nose tip and creating the tunnel in the nasal dorsum through the external approach (Fig. 2A), the nasal septum was clearly exposed and injected with lidocaine (Fig. 2B–D). The nasal septal cartilage was separated from the perichondrium, and the redundant fibrous connective tissues of the nasal septal caudal margin were dissected (Fig. 2E, F). The L-shaped prosthesis was sculptured according to the esthetic line of the nasal dorsum. The short arm of the implant was carefully bisected with a no.11 blade so that the short arm was like a fork (Fig. 3), narrowing the width of the junction of the long and short arms of the L-shaped prosthesis at the tip of the nose. The forked part was placed on the caudal end of the nasal septum and sutured to be fixed. The auricular cartilage was cut into 3 slices (Fig. 4A–C), and homologous fascia was saved as a standby application (Fig. 4D). Two long pieces of the same size were, respectively, placed in the form of concave-to-concave at each side of nasal septal cartilage to reinforce the strength of the septal extension graft (SEG) (Fig. 5A, B). Most of the auricular cartilage was inserted into the septum from both sides, while the part that exceeded the nasal septum was trimmed and sutured at the nasal apex position and fixed to the corner point of the prosthesis. The nasal tip could be fully lengthened and elevated by rejoining the lower lateral cartilage with suture fixation, after which we placed the third small piece of auricular cartilage to achieve a good apex projection. The third piece of auricular cartilage acted as the cap-shaped graft, and the edge of the cartilage was compressed (Fig. 5C). Homologous fascia was fixed to the body position of the nasal infratip lobule. The nasal tip protrusion and the nasolabial angle were measured immediately after the operation with a ruler and protractor.

FIGURE 2.

(A) After fully losing prosthetic space in the nose tip and creating the tunnel in the nasal dorsum through the external approach. (B–D) The nasal septum was clearly exposed and injected with lidocaine. (E, F) The nasal septal cartilage was separated from the perichondrium, and the redundant fibrous connective tissues of the nasal septal caudal margin were dissected.

FIGURE 3.

The auricular cartilage was cut into 3 slices. The short arm of the implant was carefully bisected with a no.11 blade so that the short arm was like a fork.

FIGURE 4.

(A–C) The auricular cartilage was cut into 3 slices. (D) Homologous fascia was saved as a standby application.

FIGURE 5.

(A) The forked part was placed on the caudal end of the nasal septum and sutured to be fixed. (B) Two long pieces of the same size were respectively placed in the form of concave-to-concave at each side of nasal septal cartilage to reinforce the strength of the septal extension graft. (C) The third piece of auricular cartilage acted as the cap-shaped graft, and the edge of the cartilage was compressed.

Postoperative Evaluation Criteria

All the included patients were given a questionnaire about satisfaction with esthetic outcomes 1 year after surgery. According to the tripartite satisfaction survey taken by doctors, beauty seekers, and a nonmedical worker, the postoperative results that satisfied all 3 parties were graded as a high level of satisfaction; the results that satisfied any 2 parties were graded as satisfactory; results that satisfied only 1 of the interested parties were graded as average, and the results that did not satisfy any of the interested parties were graded as dissatisfied; the cases where patients had serious complications, including infection, and prosthesis exposure were graded as extremely dissatisfied. The evaluation was based on a 5-point Likert scale (score: 1, 2, 3, 4, 5), where 1=extremely dissatisfied, 2=dissatisfied, 3=average, 4=satisfied, and 5=very satisfied.

RESULTS

The outcomes were assessed for the degree of satisfaction on a scale from 1 to 5, with 1 standing for extremely dissatisfied and 5 for very satisfied. (Table S1, Supplemental Digital Content 1, http://links.lww.com/SCS/E947) The esthetic evaluation of the preoperative and 12-month postoperative appearance was obtained for all 54 patients: it was very satisfying in 44 patients (81.5%), satisfied in 8 patients (14.8%), and the average in 2 patients (3.7%). Nasal ventilation and olfactory function remained normal before and after surgery. There were no serious complications, such as deformity, hematoma, or apparent infection, in any of the patients during the 12-month postoperative period; however, some mild resorption of the grafted cartilage was observed in revision surgeries (Table S2, Supplemental Digital Content 1, http://links.lww.com/SCS/E947).

Patient 1 was a 27-year-old woman with no history of rhinoplasty, no obvious deviations of the nasal septum, normally developed auricular cartilage, no surgical contraindications who underwent augmentation rhinoplasty with autologous auricular cartilage and L-shaped prosthesis (Fig. 6A–D).

FIGURE 6.

(A) The left is the front preoperative photograph. The right is the front postoperative photograph of 12 months. (B) The left is at nasal basal position preoperative photograph. The right is the nasal basal position postoperative photograph of 12 months. (C) The left is at a 45-degree oblique lateral position preoperative photograph. The right is at a 45-degree oblique lateral position postoperative photograph of 12 months. (D) The left is at a 90-degree lateral position preoperative photograph. The right is at a 90-degree lateral position postoperative photograph of 12 months.

Patient 2 was a 25-year-old woman with no history of rhinoplasty, no obvious deviations of the nasal septum, normally developed auricular cartilage, no surgical contraindications, who underwent augmentation rhinoplasty with autologous auricular cartilage and L-shaped prosthesis (Fig. 7A–D).

FIGURE 7.

(A) The left is the front preoperative photograph. The right is the front postoperative photograph of 12 months. (B) The left is at nasal basal position preoperative photograph. The right is the nasal basal position postoperative photograph of 12 months. (C) The left is at a 45-degree oblique lateral position preoperative photograph. The right is at a 45-degree oblique lateral position postoperative photograph of 12 months. (D) The left is at a 90-degree lateral position preoperative photograph. The right is at a 90-degree lateral position postoperative photograph of 12 months.

DISCUSSION

The morphological basis of the nose is related to the indication of cartilage augmentation rhinoplasty.⁶ The type of autologous cartilage chosen for the surgery depends on many factors, such as the quality of nasal cartilage, the esthetic expectation of the patient, history of past surgery or trauma, and congenital monstrosity.⁷ The first part of the preoperative assessment includes the nasal skin elasticity. Nasal columella can be pulled up, down, and forward with 2 swabs, which are gently put in the nostrils. In fact, this level of stretching is the maximum height that can be reached after rhinoplasty. If nasal skin has a very good range of motion and malleability, the fibrous adhesion inside is relatively soft and suitable for auricular cartilage. Besides, in revision rhinoplasty, the contractile forces of the scar are a limiting factor for reconstruction, making costal cartilage more suitable than auricular cartilage. The second part relates to the existence of significant structural deficiency. If there is a serious deviation of the nasal septum, rebuilding the nasal framework and correcting complex anatomy will require an appropriate selection of grafting materials like costal cartilage.⁸ Third, it is very critical to consider the patient’s expectations. The treatment expectations include at least 3 points, that is, esthetic appearance, the flexibility of the nose tip, and tactile impression. If the patient presents with so-called “Garlic nose,” “Saddle nose,” or “Short nose,” all of which are characterized by the lack of nasal tip prominence or excessive nasal tip rotation, and expresses the preference to have a tall nose, then strong materials like costal cartilage are an appropriate choice.⁹ On the contrary, those with a good foundation do not require significant nose lengthening or nose lifting; in such patients, the attention is placed on the natural esthetic line of the dorsum nasi, postoperative nasal tip flexibility, and soft tactile, so the transplantation of autologous auricular cartilage might be a more suitable approach.¹⁰

After deciding the kind of autogenous materials, the surgical technique is essential for achieving durable surgical outcomes, as not all techniques withstand the test of time.¹¹ The surgical method, which is based on traditional L-shaped silicone prosthesis placed by endonasal rhinoplasty approaches without being fixed to nasal cartilage, is no longer in use. Because of inadequate cavities, long-term contact between the silicone implant and the subcutaneous tissue and tight fibrous capsule formed at the dorsum nasi can easily lead to skin damage at the nose or even prosthesis tip extrusion. An external rhinoplasty approach provides a clear surgical vision for improving diagnosis, correcting asymmetries, and precisely placing grafts. Besides, the adequate capacity of the implant is formed, and the implant can be efficiently fixed to improve the appearance of the nasal tip and reduce complications afterward. Even though some surgeons advocate endonasal approaches from both sides of columella nasi to avoid the incision on the front of columella nasi, the durative traction of the nasal septum and an extension of the operating time due to inadequate surgical exposure area may increase edema and inconvenienced reconstructing of major framework deficiencies. Currently, external approaches are mastered by a majority of rhinoplasty surgeons. Skilled surgeons can perform fine sutures of nasal columella so that the scar is inconspicuous. Whether to open the nasal septum is also a focal topic in rhinoplasty. Due to the specificity of each human race, the nasal septum of Asian people cannot be compared with that of western people in terms of strength, hardness, and tissue volume. Therefore, to build high nasal tip protrusion, it is necessary to strengthen the nasal septal cartilage by SEG; otherwise, the nasal septum may bend because of the multilayered nasal tip graft. Besides, the nasolabial angle can become large because the nasal septum of Asian people does not have sufficient strength to resist the contractile forces while healing. Given this, external rhinoplasty technology with SEG is a suitable approach for rhinoplasty in Asian patients.

Our technique has general 2 parts and key points, which are explained below.

Preparation of Autologous Auricular Cartilage

Auricular cartilage was mainly obtained from the concha cavum, while the crus helicis was left intact to reduce the chance of postoperative ear deformation.¹² The auricular cartilage incision was about 2 mm away from the skin incision, and the edge of the skin incision was separated from the point where the cartilage breaks off to ensure the smoothness of the incision. The separation level was subperichondrial instead of subcutaneous. Perichondrium was kept as far as possible so that the ear support and skin flatness would be minimally influenced. The postauricular fascia was taken to fill the nasal subcutaneous soft tissue and make the nasal tip elastic.

Building of Autologous Auricular Cartilage Scaffold

The subperiosteal and subperichondrial facets were dissected with Mayo dissecting or tissue scissors. It was not suitable to strip the radix area too widely; otherwise, effusion or implant displacement would occur. The nose has a tolerance rate due to an elastic stent, so a slight deviation of the caudal septum can be left temporarily uncorrected, but if there is a serious deviation, it should be addressed first.¹³ The nasal spine area was released to reduce the tension of the columella elevation. The portion of the prosthesis, which was placed upon nasal septum, including the bend area of the L-shape, was thinned to 3 mm, so the tip created less tissue tension than a traditional L-shaped prosthesis. The columella part of the prosthesis was split in 2 like a fork and sutured to the caudal septum through the split groove, which was to increases the support of the columella and decreases the amount of cartilage used. The overlap area size between the caudal septum and the short arm of prothesis was related to the development of the nasal septum. Suture fixation prevents the displacement of the columella part of the prosthesis. The knot was tied directly in front so that the knot reaction was small. The goal of this split is to achieve some overlap and support with the septal cartilage and 5-0 or 6-0 unabsorbable thread through the suture. Suturing and fixing the prosthesis on the septal cartilage and keystone area (dorsal nasal bone, vertical plate, and dorsal fusion of the septal cartilage) can decrease the implant displacement rate and increase the stability that the nasal tip shaking does not affect the nasal dorsum prosthesis. Two pieces of auricular cartilage are inserted into the dissecting surface of the nasal septum and fixed with the head area of the prosthesis.

Achieving better results at a lower cost has become the main direction of clinical research.¹⁴ Recently, the technique of nasal tip reconstruction with autogenous cartilage transplantation has received increasing attention.¹⁵ Our technique has several strengths: traditional auricular cartilage augmentation rhinoplasty requires a large amount of cartilage to build the “2+2” scaffold, so bilateral ears were chosen as donor sites. A large amount of removed cartilage could also result in distortion of the auricle. We took part of the prosthesis’s head and the short arm as part of an SEG, thus saving the amount of autologous cartilage; the key to rhinoplasty lies in the improvement of the esthetic degree of the nasal tip contour. The L-prosthesis is much more flexible than a normal nasal prosthesis, so the nasal tip’s postoperative movement level increases because of the prosthesis’s flexibility and auricular cartilage pliability. This level of natural feel is also what patients desire, as they are not merely satisfied with the good-looking shape of the nose but also want to feel as natural as possible. The fixation of the prosthesis, auricular cartilage, and nasal septal cartilage greatly inhibits the dorsal septum and caudal septum deformation. This kind of scaffold can inhibit the upper and lower rotation of the nasal tip in the late stage while supporting the nasal tip protrusion effect; to reduce the complications such as prosthesis extrusion and nasal septum perforation, the suture fixation was performed at 3 points, that is, keystone area or nasal superior lateral cartilage, nasal septum and nasal caudal septum anterior foot, and protect the nasal mucosa and skin by the use of auricular cartilage and fascia. The membranous septum covers the septal cartilage, and the membranous septum area is very thin, so we put the auricular cartilage beside the septal cartilage to protect the membranous septum and the nasal vestibular fornix from perforation. Besides, the stacked grafts composed of cartilage and fascia reduced the implant extrusion while participating in extending and raising the nasal tip. Therefore, we could fully use the advantage of the L-shape and auricular cartilage to improve the degree of nasal tip protrusion, reduce postoperative complications, and improve the clinical effect with high satisfaction.

CONCLUSIONS

Currently, simple and efficient rhinoplasty is the dominant trend.¹⁶ As is well known, many beauty seekers with different facial features, especially Asian people, are characterized by insufficient development of septal cartilage. Using this technique, it is possible to adjust the angles and shapes of our prostheses and auricular cartilage scaffold, highlighting the wide application range of the approach. Future research with long-term follow-up and bigger sample size is needed to further confirm the reported results.

Supplementary Material

scs-34-1661-s001.docx ^{(14.7KB, docx)}