Dermis graft in rhinoplasty

Dermis is one of the skin layers, which is in between the epidermis and subcutanous layer. It is the thickest part of the skin. The thinnest one is 0.6 mm in the upper eyelid and the thickest one is about 3 mm in the palm, sole, and back. For rhinoplaty purpose, dermis is harvested from the buttock, which has the thickest layer. After elliptical skin excision, epidermis and subcuatenous tissue are removed to obatin dermis (below photos).

Dermis is commonly used to cover the tip grafts to prevent showing. It is also used to camouflage damaged skin after failed rhinoplasties. Some surgeons use it to augment the dorsum after silicone removal. Augmenting the dorsum with dermis has two potential disadvantages: one is infection and the other is resorption. Once the dermis graft is infected, there is a high possibility of comcomittant skin damage, so absolute sterile technique is important. Resorption of dermis is somewhat unpredictable. In severe revision cases that has decreased blood supply to the dorsum, the resoption rate is very high. Resorption occurs slowly, so although it may look OK after a year, the dorsal volume decreases dramatically after 2-3 years.

Resorption of the dermis can be minimized or prevented by using dermis and cartilage together. Dermis acts as soft tissue camouflaging material on top and cartilage acts as volume filler underneath. By combination, the resorption rate of the original volume can be minimized.

From the photos above, dorsal augmentation using cartilage and dermis combination is well maintained even 4 years after surgery.

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Deviated & hump nose correction

This lady in below photos had nasal deviation, hump nose, and tip ptosis with breathing difficulty. Septum was corrected first, and this made the lower 2/3 of the nose straight. Hump was not resected but rasped with Piezotome and this did not breach the keystone area, which made spreader grafts unnecessary.Bilateral osteotomies with Piezotome made her bone straight. Together with septum correction and effective osteotomies, her nose became straight from the frontal view. Tip was modified with sutures and onlay graft only. No strut or septal extension graft was used and this made the tip soft even after considerable amount of rotation and projection increase. Radix was augmented with bruised cartilage. Overall, she could breath much better after surgery and her nose became more harmonious and feminine.

Creating more feminine nose

The lady in below photos visited my clinic for rhinoplasty. She wanted to have more feminine nose instead of her muscline nose. She had a long nose with slight bump on the dorsum, overprojected, slightly bulbous and droopy tip, and slighly wide dorsum. Surgery was focused on creating more feminine look: hump removal, narrowing the bony dorsum with osteotomies, tip volume reduction, decreasing tip projection, and slight cephalic rotation. Photos taken 2 weeks after surgery (because she returnd back to her country after surgery) shows changes on the dorsum and the tip. Dorsum became slender with creation of smooth brow-tip aesthetic line. Tip was refined with volume reduction, slight underprojection, and cephalic rotation. Although the changes are not radical, her nose looks more feminine.

Rib cartilage rhinoplasty

Using rib cartilage in rhinoplasty needs lots of attention both in patient's and surgeon's perspective. For patient, it means additional incision on the chest, possible harvest site complications including chest pain, scar, and penumothorax, more cost, longer surgery time, and possibility of warping. From the surgone's perspective, rib cartilage is usually the last resort of autogenous material for rhinoplasty. It affords a lot of possibilities for rhinoplasty such as dorsal augmentation, tip grafts, and lots of septal grafts, all of which are not possible with other autogenous sources. It also means a lot of experience is necessary for skillful use of rib cartilage. I have used rib cartilage for rhinoplasty for more than 15 years. As cases accumulate, I can harvest the rib with small incision (less than 1.5 cm) without any complications such as peumothorax or severe pain. I do not cut the muscle and only retract it and this helps to reduce pain. Scar can be minimi...

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