All About Rhinoplasty Grafts And The Advantages Of the Fialkov Method of Harvesting Cartilage
There are three sets of grafts that are most commonly used in rhinoplasty. That I use most commonly. One is termed spreader grafts. The other is called lateral crural strut grafts and the third is columellar strut graft. All three have different purposes and address different parts of the nose. I’ll start with the spreader graphs which are one of the most common ones used. And, in fact, all of these I use commonly in primary rhinoplasty, certainly in secondary rhinoplasties. Spreader graphs are little shims of cartilage that are harvested from the septum which is the keel in the middle of the nose. Part of the septum that’s not necessary for function or for form. We take that cartilage and we cut it up into small slots or staves depending on the size and shape that we need. And the spinographs are two that sit on either side of the septum in this area.
Their function is to open up what we call cartilaginous or middle vault of the nose. We want this part, the cartilage part of the nose to match the width of the bone part of the nose. Which in a rhinoplasty may also be narrowed if the nose is wide. But the ultimate goal is to have this bony vault match the width of this cartilaginous vault. Once the bony vault is set. We narrow the bone to the degree that we want. We then use the spreader grafts to widen this part of the nose to match it.
That has an aesthetic outcome because we want the shadow line that extends from the top of the nose at the eyes all the way down to the tip of the nose. We want that to be a smooth line. That’s the aesthetic ideal. Those are called the dorsal aesthetic lines. The other reason for the spreader grafts is to open up the breathing passages because this middle vault is where the air flows through. It comes up through the middle vault. So those little shims of cartilage open that up.
Those are spreader grafts. Lateral crural strut grafts are primarily used as a reinforcement as I referred to before, that we’ve taken all of this soft tissue apart and all this structure apart. Now we’re gonna put this soft tissue back on and that soft tissue will, internally is gonna scar. And we know scars contract and move. So we’ve gotta reinforce and solidify our structure to withstand those forces. Lateral crural strut grafts are grafts that just do exactly that.
They’re small, again, shins of cartilage taken usually from the septum. There are other sources if we need them, and there’s no septum left. And they’re put right across this part of the cartilage here. Which is called the lateral crura, and they reinforce the lateral crura. Bottom of the nose, we call it a tripod. There are two pods going this way, two legs going this way, and then there are two that form the middle pod of the tripod. And if forces push the tripod in one way or another or there’s a buckling of one of those pods, the tip of the nose shifts.
The lateral pearl struts are meant to reinforce these two pods. Imagine a stool with one weak leg. You know, were some force trying to pull that leg down. We’re using those lateral crural struts as a way of reinforcing those legs. And then the last graft that I mentioned, which is a columellar strut is exactly that again, a reinforcing strut, a shim of cartilage that goes to reinforce that middle pod.
It sits right between the two cartilages that make up the middle portion of the nose, the columella. So that’s called a columellar strut. Those are the most common grafts. There’s a myriad of other grafts that are used. But in a primary rhinoplasty, those are almost always used. So it depends what the goal of your cartilage graft is. If they’re structural, as I discussed just now with spreader grafts. Lateral crural strut grafts and columellar struts. Then you need the hard, firm, strong cartilage to withstand the forces of the contraction of scar et cetera.
The septum is your best bet because it’s [indistinct] that’s the type of cartilage we want is nose cartilage. Strong cartilage. If there’s no septum, the ear provides cartilage, but it doesn’t have the same strength. And so really, if you want something good and structural, the rib is your next best bet. Now rib grafts have a bit of a problem, because rib grafts are like carrots. In fact rib cartilage very much looks like a carrot except it’s white, not orange of course. But you know, if you try to peel a slab off of a carrot or take a slice of the carrot in a longitudinal fashion which is how these grafts are required.
There are, we need long grafts. It bends. If you take it off the top of the curve it’s gonna bend towards the top of the curve. If you take it off the bottom, it’s gonna bend towards the bottom. So there are a number of methods to try and stop cartilage from bending. And in fact, we’re just working on a paper now, hopefully to be published in the near future. That is an innovative and new way of harvesting rib cartilage where we have got over a hundred samples that we had in the lab cooking for four weeks. We now have shown that the way we harvest the cartilage, the way I’ve been doing it for, now, probably most of five or six years.
There’s absolutely no warping and no bending. This is a huge advantage in secondary rhinoplasty, because, as you mentioned, often in the secondary rhinoplasty the septum is gone. Somebody’s already harvested that septum and used it for their, first, operation. And we need a good source of structural cartilage. So, by using this particular method, which actually I just presented at the Canadian Society plastic surgery in Montreal, this past summer, we know have a method of obtaining rib cartilage and we can sort of rest assured that it’s not gonna warp over time. So its a good way of ensuring once again predictability of the outcome.