Tip surgery using conchal cartilage
Chuan-Hsiang Kao, M.D.
Department of Otolaryngology-Head and Neck Surgery,
Cosmetic and Laser Center,
Tri-Service General Hospital,
National Defense Medical Center, Taipei, Taiwan, R.O.C.
The characteristics of nasal tips in Asia include the short columella, a bulbous appearance, alar flare, ovoid shaped nostrils, and weaker tip support. These are attributable to underdeveloped medical crus of the alar cartilage. To achieve the optimal cosmetic result of the Asian rhinoplasty, it is not sufficient to only increase the nasal dorsal high, but also to refine the shape of nasal tip. However, it has been a challenging operation for nasal tip rhinoplasty. Inadequate nasal tip projection and nasal length are the most common problems of primary and secondary rhinoplasty. Successful nasal tip rhinoplasty depends on well-balanced nasal tip support and projection. Many different techniques for tip support and projection have been proposed, and some have been in routine use, although controversies or limitations exist in the literature concerning their late results.
We introduced the caudal extension graft (CEG) as trapezoidal shape to predictably control nasal tip projection and shape. The trapezoidal caudal extension cartilage graft was harvested either from septal cartilage or costal cartilage. The CEG was fixed to the caudal septum and positioned in midline, between the bilateral medial crura of the lower lateral cartilages. It can provide a stable platform for tip complex suturing and also maintenance of tip projection. We routinely performed the trapezoidal caudal extension cartilage graft technique for patients requiring a mild to significant increase in tip projection and support. The graft’s size,location, and angle of advancement depend on theindividual requirements of the patient, whetherelongation of the nose or an increase in tip projectionor support. To prevent a possible bulboustip deformity after strut application, the two medial crura were suturedwith CEG. The trapezoidal caudal extension cartilage graftsupports the nasal tip pyramid very well, and helps to reestablish a new nasal tip.This graft is particularly useful in the patients characterized by a shot nose or a saddle deformity in Asian patients.
Due to the elasticity of the ear conchal cartilage being similar to the tip cartilage,we prefer to harvest the ear cartilage for the most tip grafting. When harvesting the ear cartilage, a retro-auricular incision is recommended, rather than the anterior incision, because the scar will be behind the ear and almost invisible after surgery. Subperichondrial dissection is done at the anterior side and supraperichondrial dissection at the posterior side. The wound is closed in running or interrupted sutures with a conchal packing fixed with two through-and–through mattress sutures.The cymba and cavum conchae are harvested for various tip grafts. We need to pay attention to meticulously carve the conchal cartilage to prevent the postoperative graft visibility and asymmetry. No major complications have been observed with tip grafting using conchal cartilage.