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The extended dorsal-shield graft in augmentation rhinoplasty.

Rhinoplasty on the congenitally malformed nose, such as that occurring in cleft lip or other syndromes affecting the facial skeleton, is often the most challenging. To correct such deformities, numerous grafts traditionally are required. With the lack of adequate tip support, the surgeon must then reconstitute the major tip support elements. Often multiple tip grafts (columellar struts, shield grafts, lateral crural strut grafts, premaxillary plumping grafts) are used for the aforementioned purposes. (1,2) In an effort to prevent shifting, these grafts are sutured to native cartilage or placed in precise pockets. With such maneuvers, there exists the potential for warping from unequal scar and wound contracture forces. (3)

In this article we explain how a single extended dorsal-shield graft provides both dorsal augmentation and projection to a patient with Binder syndrome. Presumably a single graft with combined augmentation vectors can better resist contraction forces, thus limiting the potential for warping. (4)

The patient is a 37-year-old African-American man with Binder syndrome and nasal airway obstruction. Upon examination, his nasal vestibule was noticed to be extremely small, his nostrils were oblong and restricted, his middle nasal vault was collapsed, and he had a flattened nasal tip with little to no columella. There was little to no tip support secondary to a lack of cartilaginous strength and a deficient anterior caudal septum. In addition, he had thick nasal skin and a deficient premaxilla that also contributed to his lack of tip support (figure 1). He was noted to have a class III malocclusion, and he declined corrective orthognathic surgery offered to him.


The patient subsequently underwent open nasoseptorhinoplasty with a caudal septal extension graft, V-Y columellar lengthening, spreader grafting, and a combined dorsal strut/shield graft using costal cartilage. The nose was opened using a V-Y plasty along the midphiltrum because of the soft-tissue deficiency along the columella and the need to recruit an extra skin envelope to allow closure over the grafts (figure 2). A caudal septal extension and spreader grafts were fashioned to correct the aforementioned deficiency and provide central support to the nose.


In order to correct the deficiency in the dorsum and provide needed projection to the tip, a combined dorsal-shield graft was carved (figure 3). This combined graft was carved with a notch in the central portion to allow the septal extension graft to be dovetailed and precisely seated in the middle of the graft. The natural curvature of the medial portion of the sixth rib was then used to contour the degree of angulation over the domes to provide bulk and projection. The cephalic portion was thinned and placed in a precise subperiosteal pocket over the central nasal bones (figure 4).



Postoperatively, the nostrils and tip were elevated completely off their retruded ptotic position (figure 5). The tip remained stiff on palpation--as to be expected when rib cartilage is used. (5) There were no irregular step-offs or twists along the dorsum or tip. The thick nasal skin provided additional camouflage yet adequate refinement without the need for crushed cartilage grafts. Intranasally, all flaps were well healed, the septum remained straight, and there were no perforations noted.

As in this case of congenital malformation, rhinoplasty in ethnic populations often warrants a graft versatile enough to correct dorsal deficiency, under-projection, malrotation, and cartilage deficiency. The traditional approach to nasal tip and dorsal augmentation grafting has been to use individual grafts with multiple sutures. However, multiple-graft suturing techniques have been fraught with complications such as warping, scarring, and contracture.

Warping can be circumvented by using combination grafts. These grafts are single-unit and yet have several functions in altering the cosmetic appearance of the nose. They may act in both refining the tip and augmenting or widening the nasal dorsum. These principles have been elucidated in the article by Pastorek et al on the columellar-strut tip graft. (6) This versatile graft is used in endonasal rhinoplasty to provide contour and projection to the nasal tip. The columellar-strut tip graft was created as a way to anchor the graft properly and provide form and support to an underprojected tip. This graft is advantageous because it serves two aesthetic functions and yet is a unit construction element--not dependent on suturing to other tip architecture for its projection force. (6)


The extended dorsal-shield graft provides excellent dorsal augmentation and projection, and it circumvents the possibility of scarring and cartilage warping that can occur with multiple individual grafts. No additional sutures are needed, and the graft can be carved from a single block. This graft can be especially powerful in selected cases in which cartilaginous augmentation is required.


(1.) Sykes JM, Jang Y]. Cleft lip rhinoplasty. Facial Plast Surg Clin North Am 2009;17(1):133-44, vii.

(2.) Sykes JM. The importance of primary rhinoplasty at the time of initial unilateral cleft repair. Arch Facial Plast Surg 2010;12(1): 53-5.

(3.) Gunter JP, Clark CP, Friedman RM. Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: A barrier to cartilage warping. Plast Reconstr Surg 1997;100(1):161-9.

(4.) Song C, Mackay DR, Chait LA, et al. Use of costal cartilage cantilever grafts in negroid rhinoplasties. Ann Plast Surg 1991;27(3): 201-9.

(5.) Toriumi DM, Patel AB, DeRosa J. Correcting the short nose in revision rhinoplasty. Facial Plast Surg Clin North Am 2006;14(4):343-55, vi.

(6.) Pastorek NJ, Bustillo A, Murphy MR, Becker DG. The extended columellar strut-tip graft. Arch Facial Plast Surg 2005;7(3):176-84.

Giancarlo F. Zuliani, MD; Kailash Narasimhan, MD

From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Wayne State University School of Medicine, Detroit (Dr. Zuliani and Dr. Narasimhan); and the Department of Plastic and Reconstructive Surgery, University of Texas Southwestern, Dallas (Dr. Narasimhan).

This article has been expanded and updated from its presentation as a poster at the American Academy of Facial Plastic and Reconstructive Surgery Fall Meeting; Sept. 23-26, 2012; Boston.
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Author:Zuliani, Giancarlo F.; Narasimhan, Kailash
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Dec 1, 2012
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