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.