Abstract
Augmentation rhinoplasty or commonly known as “nose jobs” is one of the most common plastic surgical procedures aimed to improve cosmetic appearance. This procedure is considerably safer, less time consuming with faster recovery and immediate cosmetic effect. This procedure needs of highly experienced and well-trained plastic surgeon. According to facial analysis you can select the type of rhinoplasty. Open discussion with the patient to select appropriate surgical technique and its possible risks with your plastic surgeon to ensure the highest level of safety and satisfaction. Autologous grafting materials are safe, efficient and also the first choice for rhinoplasty due to it can survive without a vascular supply, the resorption rate of cartilage is much lower than that of a bone graft. Autologous grafting materials are stable and resistant to infection and extrusion over time so, they are successfully used for dorsal augmentation. To perform successful augmentation rhinoplasty, surgeons should be highly experienced and well-trained and augmentation materials that are currently available and understand their risks, benefits and uses. Autologous cartilage graft regarded as the graft of choice in augmentation rhinoplasty because of their lower rate of infection, rejection, resorption, extrusion, donor site morbidity, easy reshaping.
Keywords: Rhinoplasty, Augmentation rhinoplasty, Autologous graft
Introduction
Augmentation rhinoplasty is an important surgery for both cosmetic and functional indications. Functional reasons for augmentation include providing structural support for areas deficient of material, such as the upper or lower lateral cartilages, nasal dorsum, nasal tip and nasal valves [1–3].
Different materials are used for augmentation rhinoplasty. This includes alloplastics (synthetic implants), allogeneic materials (obtained from cadavers) or autogenic materials (harvested from the patient's own tissues). Graft material needs enough rigidity to support the surrounding soft tissues [4].
Autogenous cartilage is generally the first choice in the graft material for rhinoplasty. Since it can survive without vasculature, the rate of cartilage resorption is much lower than that of a bone graft. Moreover, when the perichondrium is left intact, less resorption is seen. Cartilage is also smooth and supple, giving the nose a more natural feel than a bone graft [5].
The best and most convenient source of cartilage graft is the septum, because it is harvested from the same operative field and does not induce an immune response. When septal cartilage is not available, especially in revision rhinoplasty cases, auricular and costal cartilages are the next best choices [6].
Augmentation rhinoplasty used for many different causes such as a congenital defect of 1 or more components of the bones and/or cartilaginous structure of the nose, traumatic defects are more common causes of augmentation rhinoplasty due to accidental trauma that results from a crushing injury to the structures of the nose or from septal hematoma and iatrogenic trauma that include excessive removal of bone and cartilage at the time of rhinoplasty causes. Infectious and inflammatory conditions such as sarcoidosis, relapsing poly chondritis, or Wegener granulomatosis can also destroy the support structures of the nose. Neoplasms of the nose which invade the skin and the underlying structures, can require a reconstructive procedure and augments [7].
Careful nasal analysis reveals the need for augmentation rhinoplasty to bring the dimensions of the nose into harmony with the rest of the face. These principles should be demonstrated to the patient to gain his or her acceptance of the surgical plan. Careful history taking to determine the nature of the problem is crucial to proper surgical planning. This process should include an inquiry about previous trauma or surgery and symptoms of nasal obstruction, as well as a clear discussion of the patient's objectives [8].
On physical examination, the aesthetic value of the nasal dorsum must be critically evaluated. The frontal view is examined. Two slightly curved, divergent lines that extend from the medial supraciliary ridges to the tip-defining points outline the brow-tip aesthetic line of the dorsum. The aesthetics of the profile must be analyzed critically. No single ideal profile exists, because each individual has his or her own tastes and priorities. However, some rules pertaining to the desirable components of a theoretic ideal are important in guiding the decision-making process of the surgeon [9].
The physical examination must include an assessment of the internal nasal anatomy, any septal deviations or perforation, and the position and quality of the upper and lower lateral cartilages [10].
The nasal bones must be palpated especially those patients with short nasal bones (in which the bony pyramid is less than one third the distance from the nasofrontal angle to the septal angle) [11].
Augmentation rhinoplasty used to correct over resection of the nasal dorsum, to camouflage deviations or asymmetries of the dorsum, to raise the height of the dorsum to improve the relationship of the tip to the dorsum, to raise the height of the dorsum to create an appearance of narrowing the nose without narrowing the airway, to reconstruct the dorsum in persons with significant deformities (eg, saddle nose deformity), to widen the dorsum, to correct radix disproportion [12].
The characteristics of the ideal graft material for augmentation rhinoplasty include the following: the host is tolerant of the material, without an immunologic reaction, the shape and size of material is stable over time, the material is reasonably malleable to carve or mold into the desired shape, the material does not cause discoloration or transillumination of the intervening tissue, the material is pliable, the material is easily obtainable, an adequate supply of the material is available, minimal donor site morbidity [13].
Autogenous graft materials have the potential to be incorporated into the host tissue bed, offering stability, as well as resistance to infection and extrusion over time [14].
One of the advantages of septal cartilage is the ease of harvest from the surgical field. Septal cartilage tends to be well suited for augmentation because it retains its shape well with minimal warping. A relative disadvantage is that an adequate amount of septal cartilage has been often not available for moderate-to-severe augmentation in patients who have undergone previous septorhinoplasty. This shortcoming is due to resection of septal cartilage at the time of previous surgery or the resorption of the residual septal cartilage over time. In some cases, the amount of augmentation material required simply exceeds the available cartilage despite the presence of a normal native septum [15].
Material and Methods
Ethical Approval
In this study, all procedures involving human participants followed the institutional research editorial boards’ ethical standards, the1964 Helsinki declaration and its later amendments, or comparable ethical standards.
Study Design
This is a cross-sectional study.
Study Subjects
This was a study evaluating patients with nasal deformity. Informed consent and approval were obtained.
Collection of Data
This study was carried out on 30 patients (19 males (63.3%) and 11 females (36.6%)) with age ranging from 24 to 46 years with nasal deformity. This study was carried out in Al-Azhar University Hospital, Damietta, Egypt at 2022–2023. Written informed consent for all procedures was obtained from patients. Detailed history, clinical examination, routine investigations and special investigations, including photography and CT of the nose and paranasal sinus were carried out. Standard Performa was prepared dually filled for each patient. Only those patients were included in the study who were suffering from nasal deformity and were available for follow up and those patients who were unfit for surgery and those cases operated somewhere else were excluded from the study. The follow up of cases was carried out from 6 to 18 months. All the patients were operated for augmentation rhinoplasty using one of these autologous cartilage grafts septal cartilage, auricular cartilage.
Exclusion criteria
Patients unfit for surgery.
Consent
Informed consent and approval were obtained.
Procedure
Anesthesia
Rhinoplasty can be performed under various depths of anesthesia including local anesthesia, intravenous sedation (also called twilight anesthesia, MAC anesthesia, or IV sedation), and general anesthesia. Each option has advantages and disadvantages, including variations in cost, awareness, safety, and side effects. Because rhinoplasty is considered to be an elective, non-emergent procedure, pre-operative testing is sometimes performed to determine anesthetic suitability. However, the vast majority of rhinoplasty patients enjoy good overall health and can choose from any of the aforementioned anesthetic options. Regardless of the anesthetic option, all rhinoplasty anesthesia is performed in conjunction with local anesthesia (lidocaine mixed with epinephrine) to numb the nose and to reduce bleeding. Few surgeons use local anesthesia alone due to the anxiety and discomfort associated with injecting and operating upon a fully awake patient [16].
Steps
Augmentation rhinoplasty is performed either using a closed procedure, where incisions are hidden inside the nose, or an open procedure, where an incision is made across the columella, the narrow strip of tissue that separates the nostrils. Through these incisions, the skin that covers the nasal bones and cartilages is gently raised, allowing access to reshape the structure of the nose [17].
Augmentation rhinoplasty was done by adding cartilage graft materials either from the septum or auricular and costal cartilages. If the septum is deviated, it can be straightened and the projections inside the nose reduced to improve breathing [18].
Once the underlying structure of the nose is sculpted to the desired shape, nasal skin and tissue is redraped and incisions are closed. For a few days, splints and gauze packing may support the nose as it begins to heal [19].
The results of rhinoplasty surgery will be long-lasting. While initial swelling subsides within a few weeks, it may take up to a year for your new nasal contour to fully refine. During this time, you may notice gradual changes in the appearance of your nose as it refines to a more permanent outcome. we compare between before and after augmentation rhinoplasty as shown in Figs. 1, 2, 3, 4, 5, 6, 7 and 8. The success of the surgery depends on the patient's satisfaction with the results of the surgical intervention [20].
Fig. 1.
Before augmentation rhinoplasty
Fig. 2.
Before augmentation rhinoplasty
Fig. 3.
After augmentation rhinoplasty
Fig. 4.
After augmentation rhinoplasty
Fig. 5.
Before augmentation rhinoplasty
Fig. 6.
Before augmentation rhinoplasty
Fig. 7.
After augmentation rhinoplasty
Fig. 8.
After augmentation rhinoplasty
Statistical Analysis
Data were fed to the computer and analyzed using IBM SPSS Corp. Released 2013, Version 22.0. Armonk, NY: IBM Corp. Qualitative data were described using number and percent. Quantitative data were described using median (minimum and maximum) and mean, standard deviation for parametric data after testing normality using Kolmogrov-Smirnov test. Significance of the obtained results was judged at the (0.05) level. Chi-Square and Monte Carlo tests for comparison of 2 or more groups of qualitative variables. MC-Nemar test is used to compare pre and post treatment results.
Results
This study was carried out on 30 patients (19 males (63.3%) and 11 females (36.6%)) with age ranging from 24 to 46 years with nasal deformity.
In our study the min indication for augmentation rhinoplasty was cosmetic and nasal obstruction (60%). In all patients autologus cartilage graft was used. The etiological factor for nasal deformity in majority of cases was trauma (66.6%). The incidence of Cartilage grafts failure rate was (6.7%).
Discussion
To perform successful augmentation rhinoplasty, surgeons should be highly experienced and well-trained and augmentation materials that are currently available and understand their risks, benefits and uses. Open discussion with the patient to select appropriate surgical technique and its possible risks with your plastic surgeon to ensure the highest level of safety and satisfaction. Autogenous cartilage is generally the first choice in the graft material for rhinoplasty. Because it can survive without a vascular supply, the resorption rate of cartilage is much lower than that of a bone graft. Moreover, when the perichondrium is left intact, less resorption is seen. Cartilage is also soft and pliable, and therefore provides a more natural feel to the nose than a bone graft. The best and most convenient source of cartilage graft is the septum, because it is harvested from the same operative field and does not induce an immune response. When septal cartilage is not available, especially in revision rhinoplasty cases, auricular and costal cartilages are the next best choices [21, 22].
In our study the min indication for augmentation rhinoplasty was cosmetic and nasal obstruction (60%). In all patients autologus cartilage graft was used. The etiological factor for nasal deformity in majority of cases was trauma (66.6%). The incidence of Cartilage grafts failure rate was (6.7%) (Tables 1, 2, 3 and 4).
Table 1.
Demographic characteristics of the studied group
| Age/years | 30 patients |
| mean ± SD | 30.58 ± 10.65 |
| (Min–Max) | 24–46 |
| Sex | n | % |
|---|---|---|
| Males | 19 | 63.3 |
| Females | 11 | 36.7 |
 | ||
Table 2.
Indications for augmentation rhinoplasty
| No | Disease | No of patient (30) | Percentage |
|---|---|---|---|
| 1 | Cosmetic | 8 | 26.7 |
| 2 | Nasal obstruction | 4 | 13.3 |
| 3 | Cosmetic and Nasal obstruction | 18 | 60.0 |
 | |||
Table 3.
Etiology of Nasal deformity in patients
| No | Etiology | No of patient (30) | Percentage |
|---|---|---|---|
| 1 | Trauma | 20 | 66.6 |
| 2 | Surgery | 8 | 26.7 |
| 3 | Infection | 2 | 6.7 |
 | |||
Table 4.
Incidence of complications
| No | Complications | No of Patient (30) | Percentage |
|---|---|---|---|
| 1 | Graft absorption | 0 | 0.0 |
| 2 | Graft Extrusion | 0 | 0.0 |
| 3 | Cartilage grafts failure rate | 2 | 6.7 |
 | |||
Conclusion
Autologous cartilage graft regarded as the graft of choice in augmentation rhinoplasty because of their lower rate of infection, rejection, resorption, extrusion, donor site morbidity, easy reshaping.
Author’s Contributions
MA: methodology, idea formulation, data collection and review writing and revision; MA: reference collection and final revision, formal analysis and idea formulation; NZ: editing final draft and drafting the article or revising it critically for important intellectual content.
Funding
The authors have no funding or financial relationships to disclose.
Data Availability
The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Conflict of interest
The authors have no conflict of interests to declare.
Consent to Participate
Explanation and informed written consent for this research has been taken from all patients.
Consent for Publication
Formal consent was signed by the patients to share and to publish their data in this research.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.