Recycling the Distal Dorsum as a Sheen Graft

Background: Surgeons performing rhinoplasty are increasingly faced with secondary procedures in graft-depleted patients. Objective: A method is described for recycling resected distal dorsum as a Sheen tip graft. Methods: Each of 16 primary rhinoplasty patients was treated with a Sheen graft to the nasal tip harvested from the distal cartilaginous dorsum; the dorsal cartilaginous hump was removed without dorsal mucosal disruption. Intact dorsal vestibular mucosa acts as a mucosal spreader graft by adding width between the dorsum and the resected upper lateral cartilages. The hump must be large enough that resection of the distal dorsum will not result in overresection of the midvault. Results: Postoperative photographic analysis of each of the 16 patients after 1 to 5 years of follow-up shows increased nasal tip projection, establishment of a tip-deﬁning point, and a double break (a supratip and infralobular break). No graft absorption was clini-cally noted. Conclusions: Recycling of the distal dorsum as a Sheen graft in selected patients results in an aesthetic contour. This method limits surgical dissection to a single donor area, saves time, preserves the septum, avoids potential septal perforation or hematoma, and decreases hemorrhage and edema. report a versatile technique for recycling dorsal hump cartilage that would ordinarily be discarded. This study introduces improvements in a previously described technique, 6 affords longer follow-up, and demonstrates that preservation of the perichondrium is not mandatory. The unique and speciﬁc properties of dorsal cartilage are reviewed. This technique has been useful in correcting the boxy nasal tip and the tip with inadequate projection and for preservation of the tip and infralobular aesthetics.

I ncreasingly, surgeons performing rhinoplasty are faced with secondary procedures in graft-depleted patients. 1,2 The shield graft introduced by Dr. Sheen is frequently used to enhance tip projection, develop tip-defining points, and establish a double break (a supratip and infralobular break). [3][4][5] The Sheen graft is most commonly fashioned from septal cartilage and, when necessary, from ear cartilage.
In this article, I report a versatile technique for recycling dorsal hump cartilage that would ordinarily be discarded. This study introduces improvements in a previously described technique, 6 affords longer follow-up, and demonstrates that preservation of the perichondrium is not mandatory. The unique and specific properties of dorsal cartilage are reviewed. This technique has been useful in correcting the boxy nasal tip and the tip with inadequate projection and for preservation of the tip and infralobular aesthetics. 7

Anatomy
Embryologic studies have revealed the absence of an early, definite demarcation between the septum and the upper lateral cartilages. 8 Embryologically, 3 broad plates develop into the septum and upper lateral cartilages, which chondrify independently, separated by fibrous tissue. 9 Anatomical fusion of these 3 structures allows en bloc resection, producing a cartilaginous unit suitable for fashioning into a tip graft. The nasal bones overlie the upper lateral cartilages. 9

Indications
Indications are predicated on the surgeon's decision to place a cartilaginous tip graft, medial crural strut graft, alar contour/filler graft, or osseous buttress. First, and most important, only those patients with an extremely full cartilaginous dorsum are suitable candidates for use of the distal dorsum as a Sheen graft. The amount of cartilage removed can be substantial in this selected subgroup of primary rhinoplasty patients, but overresection of the midvault must be avoided.
Second, the midvault should be evaluated preoperatively to make certain that there is no loss of structural integrity (midvault collapse or deviation) or support to the upper lateral cartilages (extremely narrow midvault) that might be a predisposing factor to postoperative nasal airway obstruction. 10 Traction on the cheek pulling lateral to the midvault (Cottle's test) should be negative for increased air flow on the ipsilateral side while manually occluding the contralateral nostril. Direct internal valve inspection should rule out an angle of impingement of less than 15 degrees.
Third, ideal candidates should be free from marked septal deviation; otherwise, septal cartilage should be readily available for the tip graft. The goal of this particular technique is to limit the dissection to one area and obviate entering the septum.

Surgical Technique
Although this technique can be performed through use of an endonasal approach, [11][12][13][14][15] the open approach is preferred, especially for the less experienced surgeon. [16][17][18][19] In the present series, 16 primary rhinoplasty patients successfully underwent this technique, 8 with the open approach and 8 with the endonasal approach. Each of the 16 patients was treated with a Sheen graft to the nasal tip harvested from the distal cartilaginous dorsum. One patient treated through use of the open approach received a buttress graft of bony dorsum with an onlay graft of cartilaginous dorsum superficial to the buttress. 20 Surgical analysis followed established methods. [21][22][23] If insufficient material was obtained or the graft was too soft for a patient with very thick skin needing ultratip projection, then septal cartilage was harvested. To harvest septal cartilage, the upper lateral cartilage on one side of the septum was detached and cartilage was harvested from deep inside the septum, an overlying 8-to 10-mm dorsal caudal L strut being preserved. [24][25][26] S c i e n t i f i c F o r u m

A B C
This technique is suitable in any patient with a very large dorsum. In my experience, preservation of perichondrium on the graft is not necessary, but it may be left attached to the surface of the resected hump. The anatomy of the fusion area between the upper lateral cartilages and the septum should be kept in mind, because the dorsal aspect of the cartilaginous septum is shaped like a Y, T, or I (proceeding proximal to distal), depending on the level of the dorsum. 27,28 The septum and upper lateral cartilages are fused, but in the lower third of the dorsal septum they are separated by fibrous tissue. 29 The procedure for returning the cartilaginous and bony hump extramucosally is begun with hydrodissection through use of local anesthesia. Extramucosal tunnels are then dissected at the septal angle by means of sharp, curved scissors used with a spreading motion and then through use of the long end of a Cottle elevator; this is similar to the making of a pocket for spreader grafts ( Figure 1). 8,30,31 Undermining is carried upward beneath the dorsal hump and upper lateral cartilages. 32,33 The extramucosal approach reflects the mucosa beneath the upper lateral cartilages, which allows dorsal cartilaginous hump removal without dorsal mucosal disruption. The vestibular mucosa acts as a natural spreader to keep the dorsal upper laterals from abutting the dorsal septum. 34 Great care must be taken to preserve the underlying mucosa to prevent subsequent scarring or webbing of the vestibule. The distal portion of the hump in the area of the septal angle is left intact. This is the prime donor area for the shield graft, though any substantial portion of the hump may be used. If there is any uncertainty about compromise of the upper lateral cartilages, the hump is used for spreader grafts and an alternative donor site (usually septum) is used for the tip graft.
The lower lateral cartilages are retracted caudally (open approach; Figure 2) or anteriorly (closed approach) to expose the nasal dorsum and septal angle. The dorsal cartilaginous septum is then trimmed with a #15 or #15c scalpel or with a broken #11 blade; I start inferior to the keystone area and pull the sharp edge of the scalpel toward the septal angle to resect the dorsal cartilaginous septum and septal angle area as a single unit (Figure 3). 35 When an extremely large cartilaginous hump is present, it provides an ample quantity of cartilaginous graft material. 28,32,36 Once resection is complete, the mucosa of the internal valve areas is carefully inspected (Figure 4). Any compromise to the mucosa can be repaired with a fine gut suture to restore normal anatomy and prevent communication of the nasal vestibule with the subcutaneous space. 34 If valve compromise is a serious concern, a portion of the resected dorsum can be used as a spreader graft to reestablish the internal valve. 30,31,35 The elasticity of dorsal nasal cartilage differs from that of septal cartilage ( Figure 5). Extreme stiffness can be overcome by transversely incising the midportion of the shield Recycling the Distal Dorsum as a Sheen Graft  graft, as described by Gruber. 37,38 There may be an inherent ridge on the underside of the resected dorsum from the septal projection that forms a T. This ridge may be preserved and seated between the domes and medial crura 6 or according to the methods of Sheen and Sheen. 31 The edges should be softened meticulously to prevent blanching of the overlying lobular skin. This can be done with a #15 scalpel blade or a Bovie scratch pad used as sandpaper.
If an open approach is used, the shield is stabilized with approximately 6 sutures (6-0 polydioxanone suture) to ensure that there is no subsequent migration ( Figure 6). 22 The shield is placed (closed approach or delivery technique) through a marginal incision. A double-armed, 4-0 plain gut suture may be placed through the shield to pull it into the pocket and stabilize it for the first postoperative week.
In the closed approach, Sheen 7 emphasizes packing tip cartilage grafts over an ethmoid buttress as a method of tip grafting when this is necessary. An osseous dorsum buttress graft may be placed behind the cartilaginous shield graft harvested from the bony dorsum.

Results
Of the 16 patients in this series, 10 were followed for more than 4 years, 1 for more than 2 years, and 5 for more than 1 year. Follow-up included direct clinical examination and photographic analysis.
Outcomes of this study showed no compromise of internal valves in any patient. However, resection of a smaller hump without spreader grafts caused an open roof in 2 patients. One patient followed for more than 2 years underwent an osseous dorsal buttress graft behind the cartilage tip graft. Results from postoperative photographic analysis demonstrated improved tip aesthetics. 39

Case Report
One patient was a 24-year-old woman (Figure 7) who complained of "a broad nose with wide nostrils, a droopy tip, and a hump." On frontal view, she was seen to have broad nasal bones, a boxy nasal tip, wide ala, and thick  The patient underwent open rhinoplasty through use of the described method. Extramucosal tunnels beneath the upper lateral cartilages were undermined before dorsum modification. 33,35 The dorsum, including the dorsal upper lateral cartilages, was resected en bloc, the mucosa of the internal valves being preserved for spreader grafts of vestibular mucosa. The distal cartilaginous portion was fashioned into a shield graft sutured fairly high over the new domes. Double-level (intermediate) osteotomies narrowed the bony vault.
The 5-year postoperative result shows maintenance of tip elevation, a tip-defining point, supratip break, and pleasing dorsal aesthetic lines. The patient has increased infralobular height and perhaps too much retrousse, although she is very pleased. The basilar view shows tip refinement with narrowing of the footplates.

Discussion
This procedure is indicated in a small subgroup of patients who require (1) resection of dorsal cartilaginous septum that is greater than 2 mm and (2) a tip graft. This method would not be applicable for patients requiring septoplasty, because a primary septoplasty usually offers adequate graft material. Potential limitations include possible overresection of the midvault or distal leading edge of the upper lateral cartilages that may cause midvault collapse as well as impairment of the internal valves. If this occurs, a spreader graft should immediately be placed. It is prudent to minimize the risk of overresection by performing this procedure only in patients with a large dorsal hump.
One of the major advantages of the technique is the use of a single surgical donor area, which obviates additional dissection of the septum or the ear. This saves time for the surgeon and potentially allows an easier recovery for the patient, because the duration of anesthesia is reduced  This technique preserves the septum and avoids potential septal perforation or hematoma. The extramucosal dissection results in fewer raw areas of incised mucosa, provides accurate hump removal, and is accompanied by less intraoperative and postoperative hemorrhage and edema. 40 It also provides spreader grafts of mucosa or a closed space for spreader grafts and encourages a more anatomic repositioning of the midvault. 41 A large hump may provide sufficient material for spreader grafts as well as a Sheen graft. All grafts in this series were used for structural support and tip refinement.
Many of the patients in this series had thick skin and stiff dorsal cartilage requiring minimal modification. At times, the donor cartilage may be too stiff, especially in patients with thin skin. Meticulous trimming of the grafts is necessary, along with possible scoring of the graft transversely through the center to give a more natural infralobular break. 36,37 Conclusion Done through use of extramucosal dissection, recycling of the distal dorsum as a Sheen graft in selected patients results in an aesthetic contour without internal mucosal disruption. Preservation of the perichondrium is not necessary. The procedure should be performed only in a patient with a large dorsal hump to minimize the risk of overresection of the midvault and to provide normal anatomic elements for dorsal spreader grafts of cartilage or mucosa. The osseous portion of the dorsum may act as a buttress. This method limits surgical dissection to a single donor site, saves time, preserves the septum, avoids potential septal perforation or hematoma, and decreases hemorrhage and edema. No graft absorption was noted after long-term follow-up. ■ I thank Paula Hanegraaf Kenow for her preparation and multiple revisions of the manuscript. I appreciate and express my gratitude to Rod Rohrich, MD, for the use of his illustration outline in Figure 1, B and to James Peterson and Chris Gryskiewicz for their technical assistance.