Assessing Contracture — What I Look For

I assess the degree of contracture along three axes together. The first is how much the nose is lifted — I check the rotation angle of the tip and how much the nostrils are exposed. The second is tissue firmness — through palpation, I judge how hard the scar tissue has become. The third is change over time: when photos are available from right after the previous surgery, I trace when and in which direction the nose has been changing. Even with the same appearance, an ongoing contracture and a stabilized one call for different approaches.

Autologous vs. Donor Rib Cartilage — How I Choose

The first thing I check is how the patient feels about scarring. Autologous rib cartilage leaves an incision below the chest, so the patient's acceptance of that largely drives the choice.

That said, there are cases where I do recommend autologous rib cartilage.

First, when the nose is small but a substantial gain in length is needed. Stretching a short structure significantly requires a support strong enough to withstand that tension.

Second, when contracture has developed from prior inflammation. Here two problems overlap: the reconstruction must withstand greater force as the structure is lengthened, and the inner cartilage may have partially dissolved from inflammation, increasing the amount of tissue needed for reconstruction. Because both strength and volume must be secured, the patient's own tissue is advantageous.

Why I Adopted BESPOCO

Off-the-shelf implants rarely fit an individual's nasal bone perfectly. Where they don't fit, lifting or displacement can occur, and this may develop into problems over time.

I concluded that fabricating an implant to match each person's anatomy reduces these risks while getting closer to the shape the patient wants. The methods are a 3D custom implant based on CT data, and dorsal augmentation using particles of the patient's own rib cartilage. Neither is a matter of "choosing from fixed options" — both are about "building for this specific person."