**5. Dorsal problems**

#### **5.1. Shallow radix**

**4.1. Important points**

will not be possible.

This technique:

**Indications:**

**a.** Restores pinch deformities

**b.** Reinforces external nasal valve

**a.** To reinforce external nasal valve

**c.** To provide a pleasant nostril borders [25]

reinforce the lateral crural cartilage. [26]

**4.2. Weak lower lateral cartilages and pinch deformity**

774 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

This technique is based on two cartilage flaps that are in fact excessive parts of the lower lateral cartilages. These cartilages are supposed to be trimmed and resected in normal rhinoplasty. It is clear that in weak cartilage, or in case a small strip of cartilage is to be trimmed this approach

Strength and consistency of lower lateral cartilages play an important role in shape and function of the lower one third of the nose. Many techniques have been proposed to reinforce

**1. Batten grafts**: a batten graft is a thin oval piece of cartilage that is used over deficient or weak cartilaginous part of the nose to reshape and reinforce the nose. This graft is frequently fabricated from septal cartilage or chonchal cartilage. It may be used on one

**2. Lateral crural strut graft**: Unlike batten grafts the lateral crural strut graft is placed beneath the lower lateral cartilages, so after adequate injection of local anesthetic under the lower lateral cartilages, the lateral crura is precisely stripped off from its underlying skin and a

**c.** Corrects moderate to severe cephalic positioning of lower lateral cartilages [23,24]

**d. Alar contouring grafts**: Alar contour or alar rim grafts are quite simple and effective techniques frequently used for several aesthetic and functional indications. These grafts are narrow strips of cartilage placed in a pocket anterior to the lower lateral cartilages.

**d. Lateral crural transposition flap**: In this technique excessive parts of lower lateral cartilages that are usually trimmed and discarded in rhinoplasty, are folded inside, in this way, wide lateral crural cartilages are reshaped while excessive cartilage is used to

and reshape the lower lateral cartilages; all may be used in specific indications:

side or bilaterally according to specific needs and indications. [20,22]

quadrangular piece of cartilage is fixed under the lateral crura.

This graft is made from septal or chonchal cartilage.

**b.** To correct minor cephalic positioning of lower lateral cartilages

In some patients pre-operative evaluations show that radix augmentation will help gain a pleasant aesthetic appearance. A complete familiarity with common autografts, their poten‐ tials and limitations will help the surgeon to select a predictable and stable graft with accept‐ able results in each specific indication. [27,28]

#### **5.2. Low dorsum**

Augmentation of a low dorsum is an important task in current concepts of rhinoplasty. Many modalities and techniques are proposed, though all of them have their own advantages and disadvantages and no one technique seems to cover all the indications for dorsal augmentation. Proper case selection and familiarity with characteristics of each technique are prerequisites for a successful dorsal augmentation.

#### **5.3. 1-rib graft**

Rib grafts are extensively used in reconstructive nasal surgery. Considerable amounts of cartilage and bone, acceptable mechanical properties such as strength and load bearing as well as its resistance to resorption has made it the gold standard for massive cartilaginous aug‐ mentations and reconstructions. Availability of other autografts, potential drawbacks of rib cartilage and patient compliance has limited its use to severe deformities and the need for excessive amount of graft material.

#### **5.4. Important points**

Graft distortion (warping) is a common complication in rib cartilage grafting. Many modalities have been proposed to control this unwanted effect. Some authors drill the core of the graft with a long delicate orthopedic bur and insert a strong Krishner wire to control any possible distortion. Sometimes it is thought that core of the graft has the least potential for warping so it is suggested to trim the periphery of the graft and to use the core of rib cartilage as the graft material.[29,31]
