I almost always use grafts in every rhinoplasty because most nasal surgeries require more than reduction alone.

The traditional concept of rhinoplasty has been that the skeleton is constant and the skin is variable; in other words, if the surgeon reduces the size of the bones and cartilages, the skin will shrink to whatever new size he or she has created. However, skin only has a limited ability to shrink, and so infinite reduction is not possible. Secondly, the best possible nasal shape cannot often be produced by reduction alone. It is uncommon to see a patient whose nose is perfectly shaped in every respect, except slightly too large. More common is the patient whose bridge has low and high areas, or whose tip may be not only too large or bulbous but poorly shaped. In situations like this, reduction only corrects half of the problem: it removes the parts that are too large. The other half, creating the best possible shape, must be done by adding the support and contour that only adding cartilage, in the form of a nasal graft, can produce. Many secondary rhinoplasty patients at my practice near Boston and Manchester have come to me seeking revision surgery because their previous operation involved only reduction and did not yield satisfactory results.

If septal cartilage is available in adequate amounts, it is almost always the best building material: septal cartilage and bone are generally flat and relatively straight, and can be contoured for use in the bridge or tip or to support the airways. Even the “deviated septum” usually produces very adequate building material. If the septum has been removed previously, the other choices are ear cartilage, rib cartilage or bone, or occasionally bone grafts from the outer layer of the skull. Each type of nasal graft material has its own optimal uses and idiosyncrasies. None are perfect but all are better than artificial materials, and all can produce excellent results. The trick is knowing when and where to use each type of building material, and deciding with the patient how to best reach his or her goals with the least complexity and the greatest chance of success.

Rhinoplasty surgeons who prefer artificial implants, like silicone, or have had bad experiences with grafts often say that grafts can either become visible and irregular or can simply disappear.  That is occasionally true, but the problems with grafts are largely under the surgeon’s control. The surgeon does not control the quality of the building material (in other words, how much there is and whether it is brittle, thin or thick, or calcified) nor the patient’s skin healing.  However, with experience the surgeon can learn to use septal, ear, or rib cartilage in ways that will minimize the chance of a postoperative problem and maximize the chance of a good result.  There will always be variability among patients in the types of building materials that they provide, but the majority of nasal graft problems are under the surgeon’s control.  Where nasal skeleton has been removed, or where there is a deficiency or lack of support that deforms the shape or impairs the airway, there is no substitute for using the patient’s own cartilage to try to recreate the normal and ideal.

I do reduce the nose, but most noses have areas that are too small or flat, just as they have areas that are too large or broad. A nasal graft maintains a stable airway and helps me achieve the best overall balance in the nose. Further, there are areas of the nose that cannot usually be improved only by reduction.  A good example is the tip, where very often some parts of the tip should be reduced and other parts supported in order to give the tip a better shape, either to make the tip stronger (so that the profile is straight), or simply to add contour or symmetry to the tip.  Remember that it is not the shape of the nasal skin that makes the nose look good; it is the shape of the cartilage underneath, supporting the skin and creating that good shape.