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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 19  |  Issue : 2  |  Page : 58-64

The outcome of temporalis fascia versus diced cartilage wrapped in temporalis fascia for dorsal augmentation in septorhinoplasty


1 Dpartment of ENT, King Abdallah Medical City, Makkah, Saudi Arabia
2 Dpartment of ENT King Abdallah Medical City, Makkah, Saudi Arabia
3 Medical Iterns, Um Al Qura University, Makkah, Saudi Arabia
4 Ophthalmology Resident, Western Region, Jeddah, Saudi Arabia
5 Family Medicine Resident King Abdul Aziz Medical City Ministry of National Guard, Jeddah, Saudi Arabia
6 Umm Al-Qura University, Makkah, Saudi, Arabia
7 Umm Al-Qura University, Makkah, Saudi Arabia

Date of Web Publication7-Jan-2020

Correspondence Address:
MD Mohammed Saad Eldin Aly
Consultant, ENT Department KAMC, Makkah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.275317

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  Abstract 


Objective: Rhinoplasty is a difficult operation and has the highest rates of revision surgery. It is often accompanied by septoplasty. Osseocartilagenous vault irregularity, radix depression and saddle deformity of the nose are common problems encountered in rhinoplasty. Deep temporalis fascia available in large quantity can be used alone or in combination with diced cartilage for augmentation rhinoplasty, and to camouflage the nasal dorsal irregularities. A wide variety of grafts is used to augment the nasal dorsum. The aim of the study was to note the nasofrontal, nasolabial, nasofacial angles measurements, functional and aesthetic assessment before and after septorhinoplasty.
Methods: A retrospective chart review was done on 69 patients, who underwent septorhinoplasty at our institute (Jan 2011 – Jan 2014). Out of these, 31 patients underwent dorsal augmentation with temporalis fascia as a blanket endonasal coverage in one group and diced cartilage with temporalis fascia in the other group (38 patients). The diced cartilage was obtained from nasal septum in 16 cases (42.1%), chonchal cartilage in 14 cases (36.84%), rib cartilage in 5 cases (13.15%) and Goretex in 3 cases (7.89%) wrapped in temporalis fascia for dorsal augmentation was included in the same group.The operative details, surgical outcome, and complications noted have been mentioned.
Results: The nasofrontal angle, nasal labial angle and nasofacial angle were reduced in the dorsal augmentation using diced cartilage with temporalis fascia group compared to the temporalis fascia alone group. As per the functional point of view (breathing quality) score, we found in the first group that all 31 patients were satisfied (100%), while in the second group we found that 37 patients out of 38 were satisfied (97.4%). Only one patient (3.2%) out of 31 patient in the first group was not satisfied form the aesthetic point of view while in the second group we found that 6 patients (15.5%) out of 38 were not satisfied.
Conclusion: Temporalis fascia used in any form like a blanket, or with diced cartilage wrapped with fascia offers the advantage of smooth nasal dorsum, a reasonable functional improvement and a better option for nasal dorsal osseocartilagenous reconstruction.

Keywords: Diced cartilage, septorhinoplasty, temporalis fascia, dorsal augmentation


How to cite this article:
Aly MS, Raza SA, Al-Zuraiqi B, Awad BI, Alghamdi AS, Ibrahim MS, Aldhahwani BM, Shahbahi R, Alzaidi AA, Althobaiti IA, Marglani O. The outcome of temporalis fascia versus diced cartilage wrapped in temporalis fascia for dorsal augmentation in septorhinoplasty. Saudi J Otorhinolaryngol Head Neck Surg 2017;19:58-64

How to cite this URL:
Aly MS, Raza SA, Al-Zuraiqi B, Awad BI, Alghamdi AS, Ibrahim MS, Aldhahwani BM, Shahbahi R, Alzaidi AA, Althobaiti IA, Marglani O. The outcome of temporalis fascia versus diced cartilage wrapped in temporalis fascia for dorsal augmentation in septorhinoplasty. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2017 [cited 2021 Apr 21];19:58-64. Available from: https://www.sjohns.org/text.asp?2017/19/2/58/275317




  Introduction Top


The main purpose of septorhinoplasty is to achieve nasal balance and maintain facial harmony thereby preserving functional aspect of the nose. The common deformities noticed following trauma and postoperatively are variations in dorsum/low radix and inadequate tip projections, narrow middle vault and alar cartilage malposition [1]. A wide variety of grafts have been used to overcome the nasal dorsal irregularities and to augment the nasal dosum. Some of them include temporalis fascia, fascia wrapped in diced cartlage septal or rib, and surgicel wrapped in cartilage [2].

Cartilage grafts alone or along with temporalis fascia have been used extensively to correct functional as well as aesthetic aspect of the nasal framework [3]. When the skin is thin the osseocartilage framework deformity is visible and onlay temporalis fascia graft helps to cover this defect [4].

As many techniques have been used in rhinoplasty one learns from his own mistakes as well as others’ cases in order to give acceptable results. The main objective of this study was to comapare the nasofrontal, nasolabial and nasofacial angles, functional and aesthetic measurements in deformed nose pre and post septorhinoplasty.


  Methods Top


Study design: A retrsospective chart review was conducted after creating a septorhinoplasty database using Microsoft Excel. All our patients underwent septorhinoplasty with temporalis fascia and diced cartilages from nasal septum or the rib wrapped in temporalis fascia [Table 1]. All patients underwent preoperative counselling. Photographs were obtained using digital camera Nikon D3200, with 18-25 mm lens in a standardized setting by a single photographer. Pre and postop lateral, frontal, basal and dynamic views were taken after obtaining informed written consent. Pre-operative and post-operative functional and aesthetic assessment was done using Likert scale (Likert items are used to measure respondents attitudes to a particular question or statement). To analyse the data it is usually coded as follows, 1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5=Strongly agree [5]. Nasofrontal, nasofacial, and nasolabial angle measurements done using photograph analyzing software [6]. The angle difference was measured after subtracting the pre from the post treatment values. All cases were operated by a single experienced surgeon (M.S) under general anesthesia. Appropriate patients demographics, diagnosis, surgical details, complications and outcomes were included. Inclusion criteria included nasal obstruction with deformity and cases having at least one of the following problems: radix depression, saddle nose, revision rhinoplasty, dorsal irregularity or thin skin. Cases which require exclusive cosmetic purpose correction, nasal polyps/ pathology with nasal deformity, patients under 18 years, and those average follow up less than 1 year were excluded from this study. Institutional review board approval was obtained vide letter 13-074 dated 1-12-2013.
Table 1: Temporalis fascia used with diced cartilage from different sites 38 out of 69 patients

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Surgical technique

All patients underwent standard preoperative evaluation including history, clinical examination, nasal endoscopy and CT Scan of paranasal sinuses to exclude sinonasal pathology. The diagnosis was made on the basis of history of nasal trauma/obstruction with nasal deformity and clinical examination. [Table 1] shows the types of nasal deformities in our patients.

Open septorhinoplasty was performed after infilterating the nose with 1:200000 2% Xylocaine with adrenaline, using standard inverted V-shaped incision on the columella middle 1/3 combined with intercartilaginous incisions, transfixion incision, elevation of the subcutaneous tissue over upperlateral cartilages upto the caudal border of nasal bones, exposing the nasal cartilages and dorsum, septoplasty, osteotomies, hump reduction, if needed according to the case and tip plasty. Closed rhinoplasty involved alar and transfixion incision, exposing the nasal dorsum, delivering the lower lateral cartilages and correction of desired deformity.

Method of obtaining temporalis fascia and cartilage:

Deep Temporalis fascia is that part of the fascia which covers the temporalis muscle and measures approximately 10 x 12 cm. A vertical line is drawn from the tragus upwards till the temporalis muscle marking the anterior limit of the fascia. Two angular lines from this point run backwards in the hair bearing area over temporalis muscle about 5 cm length, the subcutaneous tissue exposed and wider temporalis fascia approximately 5x5 cm is obtained which enables to cover the nasal dorsal irregularities and to use it as a diced cartilage and fascia sleeve [Figure 1]. The cartilage obtained from the chonchal postaurally, and usually the rib cartilage is obtained from right 9th rib, retrograde approach after making skin incision. The cartilage obtained is crushed into small pieces using 11 no blade and put in a sleeve of fascia, brought out in the skin over the nasal dorsum using 4-0 vicryl and stabilized using steristrips. External nasal splint applied postoperatively and changed weekly for 3 consecutive weeks. The skin over the hair bearing area was closed using staplers. Internal nasal splint was removed after 1 week. All patients were followed up weekly upto 1 month, bimonthly for three months and every 3 months thereafter to assess postop function, aesthetic and nasal angle measurements. Data were analyzed using SPSS version 21.0. Numeric variables were presented as mean ± standard deviation, the median and interquartile range according to data distribution. Comparisons of pre and postoperative nasal measurements and satisfaction scores were done by Wilcoxon sign rank test at a two sided alfa of 0.05.
Figure 1: Deep Temporalis fascia is a fascia that covers the temporalis muscle and measures 6 x 6 cm. An imagining line 10cm above targus drown vrtically then inverted v shape incision post auricularly

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  Results Top


A total of 69 patients underwent septorhinoplasty, out of them 49 (71.0%) were males and 20 (29.0%) were females. The age ranged between 19 to 60 years. Twelve ( 17.4%) patients underwent closed septorhinoplasty technique and 57 (82.6%) underwent open technique. All patients had an average 1-3 years follow up. Sixty three (91.3%) patients were from Saudi Arabia and 6 (8.7%) were non Saudis. Thirty one patients underwent septorhinoplasty with temporalis fascia and diced cartilage wrapped in temporalis fascia was used in the other 38 cases. The diced cartilage was obtained from nasal septum in 16 cases (42.1%), chonchal cartilage in 14 cases (36.84%), rib cartilage in 5 cases (13.15%) and Goretex in 3 cases (7.89%). Thirteen (18.8%) patients had undergone revision septorhinoplasties before they presented to us. Diode Laser assisted turbinoplasty was performed in 3 (4.3%) out of 69 cases, and rigid 0- degree nasal endoscope was used in 59 (85.5%) out of 69 cases to assess the nasal dorsal irregularities and inspect radix while performing septorhinoplasty.

The average preoperative nasofrontal angles for the patients underwent septorhinoplasty with temporalis fascia alone, was 140.52o, while postoperative was 140.71o, the average preoperative nasofrontal angles for the patients underwent rhinoplasty with diced cartilage wrapped in temporalis fascia (n=38) was 141.29o, while postoperatively was 140.26o. The average preoperative nasolabial angles for the patients underwent septorhinoplasty with temporalis fascia alone, was 95.48° while postoperative was 103.55°, the average preoperative nasolabial angles for the patients underwent rhinoplasty in diced cartilage wrapped with temporalis fascia (n = 38) was 94.61°, while postoperatively was 98.50°. The average preoperative nasofacial angles for the patients underwent septorhinoplasty with temporalis fascia alone, was 34.61°, while postoperative was 36.48°, the average preoperative nasofacial angles for the patients underwent rhinoplasty with diced cartilage wrapped in temporalis fascia (n = 38) was 33.97°, while postoperatively was 33.79°. In the functional aspect, out of 38 patients underwent septorhinoplasty with diced cartilage wrapped in temporalis fascia, 37 patients (97.4%) were not satisfied preoperatively, while only two patient (5.3%) were not satisfied postoperatively, and out of 31 patients underwent septorhinoplasty with temporalis fascia, 23 patients (74.2%) were not satisfied preoperatively, while all patients satisfied postoperatively. From the aesthetic point of view, all the patients were not satisfied preoperatively in the two groups, while out of 38 patients underwent rhinoplasty with diced cartilage wrapped in temporalis fascia, 6 patients (15.8%) were not satisfied postoperatively, while 1 (3.2%) out of 31 cases was not satisfied postoperatively in the group where temporalis fascia was used. With reference to the nasal irregularity, out of 31 patients underwent septorhinoplasty with the usage of temporalis fascia, only one patient showed nasal irregularity (3.2%). Compared to patients who underwent rhinoplasty with diced cartilage wrapped in temporalis fascia 11 (28.9%) out of 38 patients showed nasal irregularity. In comparison between these two groups, there is statistical a significant difference in the nasal irregularity when temporalis fascia is used rather than septorhinoplasty with diced cartilage wrapped in temporalis fascia, p-value=0.008[Table 2],[Table 3].
Table 2: Types of nasal deformities or in combination with other deformities. Preoperative out of 69 patients

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Table 3: Showing postoperative nasal irregularity after 1 year follow up

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  Discussion Top


Septorhinoplasty is the commonly performed surgery for nasal deformities. It involves complex mechanism in which we need to cater many issues at a single point of time, and at the same time many end up with revision surgeries. This study mainly aims at discussing the objectives like nasofrontal, nasolabial, nasofacial angle measurements, functional and aesthetic aspects when temporalis fascia and diced cartilage with temporalis fascia used for dorsal augmentation in septorhinoplasty [7]. Nasofrontal angle is the angle between the nasal and frontal bones. Normally it ranges from 115 to 1350. The nasolabial angle is the angle formed between the plane of the columella and upper lip. Ideally, it measures between 105-115 degrees in females and 90-105 degrees in males. The nasofacial angle is formed by the intersection of two lines. One line drawn from nasion to pronasalae and another line drawn from nasion to pogonion. This angle ideally approximates 36 degrees [8],[9],[10].

In a study done by (Murilo, Brazil) [11] it is seen that the nasofrontal angle increased by 80 after the surgery and similar increase postop of nasofrontal angle was also noted by studies done by Powel and Humphreys, Ingels et al and Kuran et al. In our study there is a reduction in the goretexnasofrontal angle in the diced cartilage group compared to temporalis fascia alone group and also when compared to Murilo study where there is increase in the nasofrontal angle. The nasolabial angle is also reduced in our study when compared to Murilo study in the diced cartilage with fascia when compared to temporalis fascia alone, this could be because strut graft might have not been placed adequately in all cases and it could be probably because of technical difficulties in measuring the nasofacial angle measurements, the techniques of rhinoplasty performed and also the geographical variations in the size of the nose in different regions and countries and we had done more cases of open rhinoplasty.The nasofacial angle is also reduced minimally which is consistent with Murilo’s study. All the nasal angle measurements used are of measurements after average 1 year of follow up of patients.

Functional (breathing) – It is important to keep in mind about the valve area which tends to get narrowed following osteotomies thereby affecting breathing. Functional assesement was subjective measurements done using Likert scale. In our study group from point of view of (breathing quality) score, we found in the first group that all 31 patients were satisfied (100%), while in the second group we found that 37 patients out of 38 were satisfied (97.4%). The functional benefit could be probably because some patients underwent laser turbinoplasty,however the number of patients were few. The minimal handling and preserving the valve area is an important factor that has to be kept in mind while performing septorhinoplasty[Table 4].
Table 4: Shows various nasal angle measurements with and without temporalis fascia pre and post op

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Aesthetic satisfaction - As there are too much expectations with the surgery, proper counselling and psychiatric assessment should be done. In our set up we do more often functional rhinoplasty. In our study we found in the first group that only 1 patient out of 31 was not satisfied (3.2%), while in the second group we found that 6 patients out of 38 were not satisfied (15.5%) from the asthetic aspect when diced cartilage with temporalis fascia were used after 1 year followup. This could be because of under or oversize of the graft in diced cartilage with fascia group. In 1 case out of the 3 cases where goretex wrapped with temporalis fascia group there was infection and discolouration of the nasal dorsal skin in which the implant had to be removed[Table 5].
Table 5: comparing the change of nasal angles pre op and post op of this study with Murilo’s study in degrees

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dorsal augmentation using diced cartilage was suggested by Erol. Turkish delight technique uses diced cartilage wrapped in surgical with excellent success rates [12]. Modified Turkish delight finely using surgicel diced chips of medpore with oxidized cellulose (Surgicel), but the problem with block implants is visibility and distortion. Sheen, Guerrerosantos and Miller used temporalis fascia for radix augmentation with 99% success rates and advised 25% overcorrection using this technique. Comparing to various studies mentioned below our success rate of using temporalis is 97% fo radix augmentation and correcting nasal dorsal irregularities [13][Table 6].
Table 6: Comparision various studies using temporalis fasia/diced cartilage techniques:

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  Conclusion Top


Temporalis fascia when used, in the form of thin sheet covering the nasal dorsum or wrapped in cartilage along with diced cartilage is an excellent material for radix augmentation and to cover nasal dorsal irregularities,also preserves the nasal function.

However we need further studies of larger scale before we could make any generalization. Presenting and sharing these types of studies enables the researchers to overcome the difficulties encountered in the present study which will help them to give better results [Figure 2], [Figure 3].
Figure 2: Pre and post septorhinoplasty using temporalis fascia alone

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Figure 3: Pre and postop using temporalis fascia with goretex prosthesis

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Acknowledgements

Dr Osama Marglani, Head of department, ENT-KAMC, for his constant encouragement towards research, Dr Soha el Morsy, Dr Doa abdel Moety, research consultants for their help in research planning.

Conflict of interest: None

Funding: Not received any financial help/funding from any organization or pharmaceutical company.



 
  References Top

1.
Besharatizadeh R, Ozkan BT, Tabrizi R. Complete or a partial sheet of deep temporal fascial graft as a radix graft for radix augmentation. Eur Arch Otorhinolaryngol. 2011 0ct;268(10):1449-53.  Back to cited text no. 1
    
2.
Daniel RK, CalvertJW. Diced Cartilage Grafts in Rhinoplasty Surgery; Irvine and Long Beach, Calif. Plastic & Reconstructive Surgery. June 2004 - Volume 113 - Issue 7 - pp 2156-2171.  Back to cited text no. 2
    
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Elahi MM, JacksonIT, Moreira-Gonzalez, Yamini D. Nasal augmentation with surgical-wrapped dice cartilage a review of 67 consecutive cases; Southfield, Mich Plast Reconstr Surg. 2003;111-3) 981-137.  Back to cited text no. 3
    
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Backer TM, Courtiss EH. Temporalis Fascia Grafts in Open Secondary Rhinoplasty. Plast Reconstr Surg. 1994; 93(4):802-10.  Back to cited text no. 4
    
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Sullivan GM, Artino Jr AR . Analyzing and Interpreting Data From Likert-Type Scales. J Grad Med Educ. 2013; 5(4): 541-542.  Back to cited text no. 5
    
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Spoori S, Simmen D, Briner HR, Jones N.; Objective assessment of tip projection and the nasolabial angle in rhinoplasty; Arch Facial Plast Surg. 2004;;6(5): 295-8; discussion 299-300.  Back to cited text no. 6
    
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M. Bussi. F. Palonta, S. Toma.; Grafting in revision rhinoplasty; ACTA Otorhinolaryngologica Italica. 2013; 33:183-189. Acta Otorhinolaryngol Ital. 2013; 33(3): 183-189.  Back to cited text no. 7
    
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Steiger JD, Baker SR. Nuances of profile management: the radix. Facial Plast Surgery Clinic North America. 2009;17(1):15-28.  Back to cited text no. 8
    
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Denize ES, McDonald F, Sherrif M, Naini FB; Facial profile parameters; Korean J Orthod. 2014 ;44(4):184-94. Epub 2014 Jul 14.  Back to cited text no. 9
    
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Naini FB, Cobourne MT, Garagiola U, McDonald F, Wertheim D.; Nasofacial angle and nasal prominence. J carniomaxillofac Surg. 2016 ;44(4):446-52. Epub 2016 Jan 14.  Back to cited text no. 10
    
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Pasinato R, Mecellin M, Arantes MC, Coelho MS, Dall’igna DP, Soccol AT, et al. Pre and Post Operative Facial Angles in Patients Submitted to Rhinoplasty. Int Arch Otorhinolaryngol. 2008;12(3) : 393 - 396.  Back to cited text no. 11
    
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S. Richardson, N. A. Agni, Z. Pasha; Modified Turkish delight: morcellized polyethylene dorsal graft for rhinoplasty. Int J Oral Maxillofac Surg. 2011 ;40(9):979-82. Epub 2011 Apr 21.  Back to cited text no. 12
    
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Godin MS, Wadman SR, Johnson CM Jr.; Nasal augmentation using Gore-Tex. Arch Facial Plast Surg. 1999; 1(2):118-21: discussion 122.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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