ABSTRACT: Boston Aesthetic Surgery Society

The Versatile Scaphal Graft for Nasal Reconstruction

Authors: Denton D. Weiss, MD and James H. Carraway, MD

Nasal reconstruction and revision rhinoplasty surgery has been fraught with multiple complications and difficulties in the past. Synthetic grafts, bone grafts, and cartilage grafts have been used in a myriad of ways. The synthetic grafts have helped in the correction of nasal dorsal abnormalities, and at times, the lower third of the nose. It is this region that is fraught with exposure to these types of implants. Bone grafting, again, is effective in the upper third of the nose, but in the lower third, lack of pliability leads to unnatural appearances. Cartilage continues to be the mainstay for lower third reconstructive work and revision rhinoplasty. We reviewed our rhinoplasty nasal reconstructive work in an attempt to determine the best cartilage grafts for lower third reconstruction.

We reviewed our data over the past 5 years, specifically looking at ear cartilage uses for nasal reconstruction. In our review, both pre and post-operative photos were evaluated. Frontal and side view photographs represented the standards used. We also reviewed the surgical techniques used, specifically in harvesting cartilage from the ear. A new graft source, the scapha (triangular fossa), was used on numerous occasions for both nasal tip reconstruction, as well as, composite grafting of the soft triangle region. Technically, this portion of cartilage can be removed from either an anterior or posterior approach if the cartilage is to be used for tip grafting. An anterior approach is used for a composite graft. The incision line for an anterior approach is placed along the antihelix, specifically along the lower crura of the antihelix. The incision can be placed such to take an ellipse of skin, half of which typically can be removed from the region hidden by the crus of the helix. The natural curvature of this antihelix crura, tracking into the triangular fossa or scapha, is removed using a simple anterior elevation of the skin and beveling the edges of the cartilage with a 15 blade technique. The cartilage can be removed from a posterior approach by simply making a high incision over the back side of the scapha. Placing a 27 g needle from the anterior surface of the ear through and through the posterior surface, a marking pen can be used to mark out the cartilage scaphal resection. Cartilage grafts taken from the conchal bowl were predominantly taken from a posterior incision line approach. Again, a 27 g needle through and through technique allowed for marking of the cartilage to be harvested. Care was taken throughout the procedures to preserve the crus of the helix as it forms a cartilaginous bar into the conchal bowl. Septal cartilage grafts were harvested in the standard fashion used for septoplasty with mucoperichondrial elevation.

Pre-Op Cartilage Harvest, Placement Post-Op

We have found that the scaphal graft is an ideal nasal tip graft and a nearly perfect composite graft for this soft triangle reconstructive region. The scapha (triangular fossa) can be removed from either an anterior or posterior approach. The incision lines are easily hidden. Concerns and questions about contour irregularity have been presented in the past, and we find that the cosmetic and structural strength of the ear relatively unchanged. The structural posts necessary for support of the ear, specifically the antihelix, the crus of the helix, and antitragal cartilages all remain supportive after harvesting of these cartilage grafts. The scaphal cartilage has the appropriate contour to be used as a tip graft in that it softens the tip, and yet, allows for good tip projection without the need for stacking of cartilage. The composite graft, because of its strong curve at the antihelical fold and the gentle curve as the scapha tracks into the superior position, have allowed the cartilage to be used to hold the contracting soft triangle tissue in position and, thus, reconstruct this area. Other grafts that we have used from the ear and nasal septum have not been as ideal largely due to contour and shape mismatching. There are no significant complications in the use of the scaphal cartilage graft.

In conclusion, ear cartilage grafts are the ideal for lower one-third nasal reconstruction in both the cancer resection patient and revision rhinoplasty patient. In both of these types of patients, septal cartilage access and availability is often limited. The scapha graft is one of the most versatile grafts in the head and neck region. This graft is easily harvested under local anesthesia and the post-operative ear position and contour are relatively unchanged.