What are best options to build up my bridge?

By far, the most common requested change in rhinoplasties is to take down a hump.  Everyone wants a nice straight smooth profile.  But some patients- particularly ethnic patients, will feel their bridge is too low and will want to build up their nasal dorsum.  As with almost every question asking about best option, the answer is never one answer.  Different outstanding surgeons will have their particular preferred technique to achieve certain goals.  And what works great for one master surgeon won’t work at all for another.  But there are several well accepted techniques to build up a nose’s height.

The most popular option to build up your nasal bridge is taking your own cartilage.  In ideal world, using your own body’s tissue to make changes is always better because there is virtually no risk of rejection.  There is much lower risk of infection.  Unfortunately, there is not an unlimited supply of cartilage to use.  Furthermore, different cartilage from different parts of the body have different structural qualities and may or may not work for a particular indication.  By far, the most useful cartilage is your own septal cartilage.  Septal cartilage can be used for almost every indication.  It provides good support.  It can be morselized if the surgeon needs a softer effect.  The main problem is there is only a limited supply.  The surgeon must maintain a minimum of septal cartilage behind (at least 1 cm) or risk violating your nose’s structural support.  When you then factor in that many ethnic noses also have less septal cartilage than say Caucasians, then presents a major challenge.  Another situation is a revision rhinoplasty patient who needs more dorsal support may not have enough septal cartilage because the first surgery already removed or used the available septal cartilage.

If not enough septal cartilage is available, what are the next sources?  There are basically two additional areas to get cartilage—your ears and your ribs.  Ear cartilage has benefit that it’s easy to harvest and it’s right in the field of surgery.  The main challenge is ear cartilage is generally too soft if you need structural support.  If only minor support is needed, the surgeon may be able to suture two pieces of shaped ear cartilage together.  For example, if you only needed some columella support or maybe a spreader graft.  I like ear cartilage for soft dorsal augmentation, or camouflage.  Recently, I’ve also been pleased with using ear cartilage to build up the bridge in Asian rhinioplasties.  By carefully carving the ear cartilage into separate specifically designed pieces, I can stack them up to build up the bridge.  There is a limit to how much height can be increased, and two ear cartilages can help.  Fortunately, I’ve found majority of Asian rhinoplasties can get desired height augmentation with one or two ear cartilages.  If more significant height is required, or in cases of significant structural problems (ie saddle nose deformities), then I believe rib cartilage is the best option.

Rib cartilage’s biggest advantage is the amount of cartilage that can be harvested.  A good rib cartilage will provide more than enough cartilage to tackle any nose- from simple to multiple revision cases that needs major structural changes.  Unfortunately, despite this major advantage, the critical problem with rib cartilage is the additional time and experience needed to harvest your own cartilage.  The procedure also introduces more risks of scarring, pain, and potentially pneumothorax.  Fortunately, this is a very rare complication, but if you get one, you will need a chest tube for some time.  In my opinion, the drawbacks of using your own cartilage outweigh the benefits your own rib cartilage provides.  Most rhinoplasty surgeons are solo surgeons.  Taking time to take out your rib adds additional time to your surgery and fees.  If you look at the world famous surgeons who frequently use patient’s own cartilage, many of them have fellows and other residents harvest the rib while the surgeon starts the nose job.  A solo surgeon may not want to deal with the rare but difficult task of managing a pneumothorax in a private practice setting.  And finally, cadaveric rib cartilage can achieve comparable results without subjecting you to the chest scarring and pneumothorax risks.  Cadaveric rib cartilage are treated donor tissue that have been tested for diseases and are safe for use.  Orthopedic and oromaxillofacial surgeons frequently use cadaveric tissue for their reconstructive surgeries and have a proven safety record.  Dr. Kridel, a famous rhinoplasty surgeon in Houston, published studies that established the safety and effectiveness of using cadaveric rib cartilage.  Both cadaveric rib cartilage and your own rib cartilage have risk of warping.  By employing certain techniques, this risk can be decreased in both cadaveric and own cartilages.  I do think a cadaveric rib cartilage may have a slightly higher risk of resorption (ie shrinking) than your own cartilage.  But I feel this risk is low and does not outweigh the risks and time involved with harvesting your own cartilage.

I would also make a final comment about synthetic implants. The two most common options here are silicone and Goretex.  Generally, many surgeons oppose using silicone or Goretex.  There is a real risk of infection when compared to using your own cartilage.  The advantages of synthetic material are it’s easy and quick to get, and there is no risk of not having enough material.  Many good surgeons will use synthetic materials to augment the bridge.  Silcone generally has a bad reputation, but for some reason, it has a good track record in Asian rhinoplasties.  And I still will use silicone for primary straight forward Asian rhinoplasties where patient just wants the bridge to stronger and they haven’t had prior surgeries.  The dreaded complication of implant extrusion may be due to the shape of implant used.  The L shaped implant may potentially put too much tension on the nasal tip and –over time—result in extrusion.  This is a bad complication and is difficult to manage.  The I shaped implant seems to have much lower risk of extrusion.

For more information about San Antonio rhinoplasty surgery, please visit our interactive website at www.dryuplasticsurgery.com. Dr. Kenneth Yu Facial Plastic and Reconstructive Surgery is a qualified team of experts serving the San Antonio, Texas area. To schedule a consultation, please contact our Concierge Patient Coordinator at (210) 876-6868 or info@dryuplasticsurgery.com.