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Les greffons en rhinoplastie ethnique

Nous avons vu les principes techniques de la rhinoplastie ethnique. les greffons y ont une part majeure . Cela s’explique par le fait que si le nez parait gros et épaté, il est en fait assez vide.On retrouve souvent une quasi absence des os propres du nez, cartilages faibles et peu aptes au soutien de la pointe. De plus la peau très épaisse lourde et grasse, n’est en général pas suffisamment soutenue et portée par la charpente ostéo-cartilagineuse.
Ainsi donc, l’une des 2 étapes essentielles de la rhinoplastie ethnique va consister, comme dans toute rhinoplastie d’augmentation, à insérer deux greffons.

-Un greffon du dorsum
-Un greffon columellaire

Differents greffons : cartilage en dé , os cranien, cartilage écrasé

Le greffon dorsal d’augmentation est souvent de grand volume et remonte très haut pour combler l’angle naso-frontal. Il ne présente pas de particularité spécifique. Les avis sont partagé et les techniques en constante évolution. Cartilage écrasé, cartilage en dés, inclus dans un manchon d’aponévrose, ou inclus dans de la colle de fibrine. Dans tous les cas ce greffon doit être solide, car ce n’est pas simple greffon de comblement. C’est pour cela que certains utilisent préférentiellement l’os, et dans ce cas la tendance est à l’os crânien.

Pour les greffons de cartilage, la conque d’oreille est la plus utilisée, mais certains préfèrent la cote. Dans les 2 cas. la crainte d’une cicatrice chéloïde (grosse cicatrice très évolutive et assez spécifique de la peau noire) est réelle. et doit faire préférer la voie d’abord antérieure pour l’oreille. classiquement sans chéloïde. Quant au prélèvement costal une cicatrice chéloïde à ce niveau peut s’avérer très fâcheuse lorsque vous êtes en maillot de bain…

Le greffon columellaire, lui non plus ne présente pas de grande particularité. Il doit être solide et suffisamment long.Il est prélevé en même temps que le précédent. J Hoeflin célèbre chrurgien de Los Angeles recommande de placer un  » pea pod graft  » qui a donc une forme de haricot vert. Ce greffon est placé, non pas entre, mais en avant des cartilages mésiaux. Il a l’avantage d’ouvrir très efficacement l’angle naos-labial fermé.

Les 2 greffons sont donc positionnés plus ou moins en L comme dans toutes les rhinoplasties d’augmentation.
A ces greffons, on rajoute parfois un greffon de Sheen pour mieux définir la pointe si celle si reste un peu ronde malgré le greffon columellaire.
Ces greffons permettent de résoudre la quasi totalité des problèmes, parfois on associe des ostéotomies latérales quand la racine est large.

Reste le gros problème des narines qui sera évoqué lors du prochain post.

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