The purpose of this study was to evaluate four standard techniques for radix augmentation during primary rhinoplasty: Skoog, crushed septal cartilage, temporalis fascia, and crushed cartilage wrapped in temporalis fascia. The main criterion for a patient to be included in this study was the need for radix augmentation, which was determined through preoperative evaluations. All patients requiring total dorsal augmentation were excluded from the study. This study included 63 rhinoplasty patients who underwent radix augmentation. The Skoog technique was applied in 15 patients, crushed septal cartilage in 16, temporalis fascia in 17, and crushed cartilage wrapped in temporalis fascia in 15. In those undergoing the Skoog technique, sharp edges of graft were palpable in three patients and were even visible in one patient. In the crushed cartilage group, seven patients showed irregularities during the postoperative follow-up. The results of this study indicate that all four autologous grafts represent acceptable graft material for radix augmentation. The algorithm suggests using the easier techniques first and that secondary donor sites should be considered only when the ideal result is not achieved.
Current trends in rhinoplasty are based on conservative trimming of the excessive parts of the nose and on augmenting the deficient components with a predictable and safe material. A shallow deficient nasal radix is a relatively common anatomical variation that is usually diagnosed preoperatively and requires the planning of appropriate grafts at the same time.
The use of the excised hump as an autograft is a relatively old technique in rhinoplasty. This technique was originally described by Skoog in 1966 to restore an overly resected hump. This valuable autograft may also be used to augment a shallow radix. In this modification, the excessive hump is resected and is then displaced superiorly to augment a deep nasal root. This material has the best contour and may easily be integrated with the remaining parts of the dorsum.
Diced cartilage is another option that is frequently used to fill nasal defects. Here, the cartilage is diced and several of the small particles (0.5–1 mm) are packed into the defective parts of the nose. This type of graft may be moulded easily by finger pressure. In most cases, it provides a smooth surface, while tiny particles may be palpated through thin skin. Diced cartilage is usually prepared from rib cartilage, although septal and conchal cartilage may also be used in this technique.
In 2000, Erol proposed the ‘Turkish delight’ technique for dorsal augmentation. With this technique, diced cartilage particles are soaked in blood and wrapped in Surgicel (Ethicon, Somerville, NJ, USA). This technique formed the basis for several other methods. Daniel and Calvert wrapped the diced particles in temporalis fascia, which improved adaptation and the long-term stability of the results. The use of amniotic membrane, alloderm, and post-auricular fascia to cover diced cartilage has also been reported.
Crushed cartilage is an alternative that softens the sharp edges of cartilage. With this method, the cartilage is gently crushed in a crusher until a smooth textured graft is obtained. As cartilage treated this way preserves its integrity, the particles are not dispersed in the recipient site and thus it may be used in any defective part of the nose.
Temporalis fascia is a known and acceptable graft material in facial aesthetic surgery. Temporalis fascia provides a smooth surface and its borders fade completely into normal donor site tissues. It has sometimes been termed the ideal material for radix augmentation.
Many other materials used with different techniques have been described for augmentation of the radix, although not all of these techniques and materials can be used in all cases. Further analysis of the available materials may help the surgeon to identify the optimal approach.
After investigating many techniques and materials over the past decade, an algorithm has been designed for the selection of some known techniques for nasal radix augmentation. This article provides a mid-term analysis of the results following the application of this algorithm. The specific characteristics of each technique, as well as its advantages, limitations, and rate of complications, are discussed based on these study findings.
Materials and methods
This prospective study was designed and conducted in 2010 to evaluate four standard techniques in radix augmentation during primary rhinoplasty: Skoog, crushed septal cartilage, temporalis fascia, and crushed cartilage wrapped in temporalis fascia. Approval was obtained from the necessary research and ethics committee prior to commencing the study.
The main criterion for a patient to be included in this study was the need for radix augmentation, which was determined during the preoperative evaluations. Cases requiring dorsal augmentation were excluded from the study. Patients who met the inclusion criteria were informed of the risks associated with all of the aforementioned types of grafting and were asked to give verbal and written consent to participate in this study.
Algorithm for radix augmentation
The selection of the technique was based on an algorithm designed by the present authors. With this algorithm, the main priority in technique selection is to choose a more conservative approach and to avoid accessing any secondary donor site as much as possible, while harvesting septal cartilage or temporalis fascia when conservative approaches do not provide suitable augmentation material.
The first choice is the Skoog technique. With this technique, composite excision of the dorsal hump is performed and the resected hump is refined, tailored, and used in a more cephalic position to fill the deficient radix ( Fig. 1 ). When the excised cartilage does not fit the recipient site or when such a graft is not available after hump surgery, the next option is considered.