Dr. Alejandro Nogueira's Case #BMKNJEM4

For such purposes the reconstructive plan began by a very meticulous and difficult dissection to lift the nasal skin cover without damaging it, performing a thorough debridement of all the massive and exuberant fibrosis, a complete capsulectomy and explantation of the silicone dorsal prosthesis, freed from the skin adhesions and the looming cutaneous piercing and extrusion; the caudal septum was prepared as structural grafting support and the requirements for cartilage skeleton supportive supply were assessed.

Both ears were graft harvested from their concha bowls and the rib cartilage was necessarily harvested as well. It is outstanding how the ears experienced no shape modification, much less deformity of any kind, after the maximum available extraction was performed on them; this is a proof of good technique and shows the ear as an excellent donor site, in contraposition to the common cases of botched ear harvesting that can be found online, in which the ears got deformed after a poor technique of extraction not respecting the anatomical frames. Another remarkable point is how a well chosen rib cartilage does not warp; it is well known that only the shaft or center of the rib cartilage stays straight, it is the cortex that warps and has to be discarded; this case is a good proof of it, as well as is a good example of how problematic and unwise are nasal prostheses and the neat superiority of own patient's tissues as reconstructive material which, however, are more demanding technically for the surgeons due to their extraction and tailoring, this explains why it is so uncommon finding well trained and state of the art compliant surgeons able to manage these difficult cases.

A pair of strong and thick caudal septum extension grafts were mounted as septocolumellar grafts in an L shape and using the tongue in groove principle with another vertical columellar and tip strut thick rib graft, which was the main pillar or scaffold to lengthen, augment, reproject and downturn the nose.

On top of and using the L shaped septocolumellar rib grafts as stand point the rebuilt tip was assembled, since the original alar and columellar cartilages were deemed useless or irreparable; therefore the ear cartilage as tailored and freely customized to make new lateral cruras, a columella shaping graft and a customized tip graft.

Then was moment for the dorsum reconstruction, using a full length en bloc rib cartilage graft from radix to supratip, reinforced at the upper half of it with a second layer of rib to double its thickness and create the suitable dorsal profile; this graft was tailored, beveled and finally fixed with sutures in place.

As final stage a superficial temporalis fascia graft was harvested from the temple and used as camouflage of the dorsal graft due to the transparencies of the, somehow, thin dorsal skin and thus avoid a tombstone deformity; this graft was placed between the skin and the dorsal rib graft.

As can be seen from the final result the nose turned from being barely existent to a brand new and in practical terms fully rebuilt from scratch using the creativity, artistry and surgical skills deployment of the most advanced and difficult rhinoplasty techniques.

Regarding the chin it must be stated the patient was already carrier of an insufficient, frustrating, disappointing and useless silicone chin implant; it is obvious not only the chin implant failed to provide enough anterior projection, it also could not add any vertical height increase to the chin, which was one of the most important needs of this genioplasty case; so the surgical procedure at the chin began performing debridement of fibrosis, capsulectomy and explantation of the chin prostheses.

Then an oblique osteotomy was performed following meticulous preoperative planning in order to achieve a two dimensional augmentation genioplasty, by means of inserting a quite large interpositional bone graft harvested from the iliac bone of the hip and suitably sculpted to match the anatomy of the chin; finally steel wiring allowed the assemble and fixation of the osseous puzzle.

The chin massively increased and created a new and optimal facial balance, stretching the soft tissues of the face and neck, thus producing a facelift effect on the cheeks, jowls, perioral tissues, the double chin and the neck, creating the well known rejuvenation side effect of augmentation genioplasties.

The final comprehensive outcome of both procedures is, literally, a whole brand new face; this is indeed one of the most difficult cases which can be met in facial plastic surgery.