For her internal nasal valve collapse, Dr. Wang felt a spreader graft would be insufficient and he utilized a butterfly graft. “The butterfly graft has a fairly high learning curve, but once you’ve mastered that, it tends to work very well,” he added. “I rarely now, with the butterfly graft, need to use lateral crural strut grafts.”
Explore This IssueJune 2015
In the end, he was pleased with the result. “We were able to get better alignment by doing these maneuvers to establish the brow-tip aesthetic line,” he said.
Case 2: Nasal Obstruction and Three Prior Surgeries
Robin Lindsay, MD, a facial plastic and reconstructive surgeon at Massachusetts Eye and Ear Infirmary in Boston, discussed her approach to care for a 56-year-old woman with nasal obstruction and three previous rhinoplasties. Septal, conchal, and rib grafts had been used in the past, but the previous operative reports weren’t available.
“Her No. 1 priority is that she was unable to breathe through her nose,” Dr. Lindsay said. “However, she was very upset by the appearance of her nose.” Dr. Lindsay had seen photos taken before the first procedure, and the nose had been aesthetically pleasing then.
“In managing expectations, I discuss with patients that this isn’t what you would expect after a first operation,” she said. “What we want now is for you to be able to breathe through your nose, for you to have a nose that, when you see yourself in photos, you’re pleased. When you get up in the morning and wash your face, you don’t think about your nose all the time. And I think that’s a very important discussion to have with patients who are undergoing multiple revision procedures.”
Dr. Lindsay used a rib graft in this case because she didn’t think conchal cartilage would provide enough support to rebuild the structure of the nose, and she hadn’t had a wealth of experience using cadaveric rib. Additionally, she has seen literature indicating that the reabsorption rate for cadaveric rib is as much as 30%, but solid numbers are hard to come by. “I think at this point it’s personal preference, but it would be nice to really know,” Dr. Lindsay said.
She used extended spreader grafts to straighten out the woman’s septum to restore the middle wall of the nose, a columellar strut graft to reset the tip, and lateral crural strut grafts to provide lateral wall support. When using rib grafts, she suggested, it’s important to make the grafts as thin as possible, because the ribs are structurally firm and there is no need for them to be thick.
Dr. Lindsay stressed that it’s important to make sure patients have realistic expectations and to follow them post-operatively. “Keeping that close contact can help” avoid potential problems, she said.