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>> Dr. Lamperti: This is Seattle Facial Plastic Surgeon, Dr. Thomas Lamperti. Today I'm going
to show you how we can use rib cartilage to fix an over-rotated, short nose. The first
step is to prepare the caudal septal extension graft using the rib cartilage. You can see
here that I'm carving the rind or outer portions of the rib in order to obtain the central
core which is the most stable portion of cartilage regarding staying straight and avoiding re-curvature.
First we'll peel away these outer layers and then obtain the central portion. This rib
cartilage carving is actually occurring over at least an hour or so. This is done to allow
the various portions to bend and curve as they might occur as they settle. This is occurs
as the various forces within the cartilage tissue become evident as it is trimmed. We're
now further refining and thinning the central core to create a nice straight, but strong
central strut for the caudal extension graft. Now you can see how the other portions of
the rib cartilage have bent to various degrees. And these portions can be used for other maneuvers
such as batten grafts, spreader grafts, and bridge augmentation grafts. So this rib cartilage
isn't useless but just has to be used for various purposes. You can see the nice straight
cartilage that I'll now further refine and trim. It is important to leave the strut relatively
thin so as to not overly widen the tip as we will be sewing the tip cartilages to this
strut in the middle. Now we'll further bevel the edges to then allow us to secure it to
the caudal septum, the outer edge of the septum, to lengthen it. Here we are now placing the
graft into position between the medial crura. Now we are using a suture the graft to the
septum itself. This is done in several different areas to create a nice bond between the graft
itself and the septum. This becomes quite stable as it then heals over time. The movement
of de-rotating the tip is quite difficult and we do need a nice strong support structure
to maintain this position. Otherwise with scar contracture the tip cartilage unit will
want to rotate back up again. I do actually use several sutures to secure the graft to
the septum but I won't show you all of these steps but you do get the idea of the technique
itself I think. Once I'm happy with the stability of the caudal septal extension graft I will
then maneuver the tip dome defining points downward onto the graft. So here I am placing
a suture through the right interdomal area -- I'll take a bite of that tissue -- and
then carry it downward onto the extended septum itself allowing the placement of the tip in
a more derogated position. Im now aligning the area where I want to go through the graft
itself and then enter the other side where we'll make a loop and secure the cartilage
on this side down onto the extension graft as well. Obviously, symmetry and precise placement
is very important here to create a symmetric tip and to make sure the position is even
so we're placing it quite carefully and guiding the needle precisely where I want it to make
sure the cartilage ends up precisely where I want it. Now I'll secure the cartilage and
move to the next area and secure the cartilage in a different position. This is just a further
interdomal stitch to bring the tip cartilages together. You can see that the caudal extension
graft seems a bit long and you're right. I actually make it on purpose a little long
and that allows me to then trim it to the exact height that I need rather than having
it a little bit too short. I'd rather that it be a little long and then trim the graft
after the fact once I know the exact length that I need. This is especially the case with
rib cartilage where I have plenty of cartilage to work with. So I'm now trimming it to size
-- a little bit of tailoring so to speak. I'm just making sure there are no portions
of the graft that will stick up through the skin. Now that the graft is trimmed there
I'm going to do additional interdomal sutures between the dome defining points to bring
the tip defining points closer together to a more natural position to make sure that
I'm not overly widening the tip. The goal with this patient wasn't to widen the tip
at all as the tip width at the domes were perfect already so I didn't want to change
those at all. So we're going to do an additional suture which allows us to bring the dome defining
points of the tip just a little bit above the tip that will help to hide or obscure
the graft to further ensure that it isn't palpable or visible through the skin at any
point. Once we're happy with the tip position we can bring the skin of the tip back down
over the tip to secure it and complete the case.