Autologous cartilage graft rhinoplasties

M-Shaped Auricular Cartilage as Modified Septal Extension Graft: A Study by Three-Dimensional Anthropometric Analysis in Asian Rhinoplasty

BACKGROUND

The septal extension graft is one of the most commonly used grafts in Asian tip plasty techniques. However, the septal extension graft usually induces a hard and immobile nasal tip. The purpose of this study was to evaluate the esthetic outcomes of the modified septal extension graft with M-shaped auricular cartilage by three-dimensional anthropometric analysis.

METHODS

A total of 36 patients received augmentation rhinoplasty with M-shaped auricular cartilage as septal extension graft combined with silicone implant. Thirteen measurement items were evaluated using three-dimensional anthropometric techniques, and the preoperative and postoperative results were compared.

RESULTS

The majority of patients (91.7%) were satisfied with the postoperative nasal shape. No infection, gross absorption, graft exposure, implant exposure, or implant migration was observed. Compared with the preoperative value, the nasal length, nasal height, nasal depth, nasion height, columella width, nasolabial angle, nasofrontal angle, and nasal depth-nasal width index significantly increased. The nasal width, nasal tip width, and nasal index significantly decreased.

CONCLUSION

We performed tip plasty with the M-shaped auricular cartilage as modified septal extension graft, achieving a soft and mobile tip with satisfying tip projection in most patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Harvesting Split Costal Cartilage Graft in Revision Rhinoplasty Without Disturbing the Costal Integrity

BACKGROUND

Graft use is inevitable in some primary and secondary rhinoplasty cases with cartilage or bone deficiency. Although rib graft is one of the best graft sources, it has several disadvantages. The purpose of this study is to minimize the risks of using rib grafts.

MATERIAL AND METHODS

Between 2018 and 2020, a total of 21 patients aged between 25 and 55 have undergone revision rhinoplasty under general anesthesia with a split cartilage graft of central origin. A 3-4-mm-thick bridge was left at the superior and inferior edges of the donor area, and the graft was harvested from the central region without disrupting the costal integrity. A special retractor was placed between the perichondrium and the rib at the posterior of the costa to prevent damage to the pleura while cutting the rib. The previously marked grafts were cut in the donor area and harvested ready for use. The harvested grafts were used as spreader, strut, alar rim and nasal valve grafts.

RESULTS

None of the patients had complications due to rib graft harvesting. After the operation, pain in the donor region and analgesic requirement of these patients were less compared to the patients with full-layer grafts.

CONCLUSIONS

The grafts taken from the center of the costa without breaking its integrity seem quite suitable for revision rhinoplasty surgeries. This technique prevents various morbidities and enables patients to have a more comfortable postoperative period.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Anthropometric Analysis of Secondary Cleft Lip Rhinoplasty Using Costal Cartilage Graft

Despite the improvement of primary repair of nasal deformities during the management of cleft lip in infancy, this does not exclude the need for revision rhinoplasty in adulthood for complete patients' rehabilitation. The purpose of this study was to evaluate the aesthetic outcome of secondary rhinoplasty using costal cartilage grafts in patients with unilateral cleft lip nasal deformity. Twenty patients who were operated at earlier ages for correction of cleft lip and had a residual unilateral cleft lip nasal deformity were included in this study. Costal cartilage rib grafts were harvested; carved and used for maxillary augmentation, columellar strut graft, and lateral crural strut graft. Five anthropometric measurements (nostril height, width and gap area, columellar axis deviation angle and nasal base inclination angle) were used for evaluation of aesthetic results. The ratio of nostril width, height and gap area between the cleft side and the non-cleft side showed significant improvement (P <0.05). The columellar axis deviation showed significant improvement towards the midline (P = 0.004), and the alar base inclination showed improvement towards the horizontal line (P = 0.0045). In conclusion, the aesthetic outcomes of secondary cleft lip rhinoplasty using the costal cartilage are satisfactory. The costal cartilage has the required strength, is easily carved and maintains shape for considerable time.

Correction of the Over-resected Nose

Overzealous reduction during rhinoplasty may result in manifold functional as well as aesthetic injuries to the nose and is a prevailing antecedent of revision rhinoplasty. Although challenges for the revision rhinoplasty surgeon abound, careful assessment of the anatomic deficiencies of the nose, accurate evaluation and management of a patient's expectations, and precise planning and execution of surgical technique serve to facilitate a successful result. Contemporary techniques for correction of the over-resected nose are discussed, with special attention directed toward costal cartilage grafting and diced cartilage fascia techniques.

Preservation of Autogenous Septal Cartilage for Revision Surgery

The aim of this study is to find the ideal solution and the optimum temperature to protect the viability of the cartilage graft. This randomized prospective study consists of 30 patients with septal deviation. All patients had septoplasty operation for chronic nasal obstruction. Ten strips of cartilages were prepared from each excised septum and then immersed in formalin, alcohol (96%), saline (0,9%), gentamicin (80 mg), and cefazolin sodium (Cezol 1gr) solutions in a total of 300 vials. Those vials were stored for 6 months at both +4°C and -18°C temperatures. Two groups were compared with each other. 22 cases were male (73%) and 8 patients were female (7%). The age range was between 20 and 48 (average 25.34 ± 4.09 years). Parameters at +4°C; the cartilage volume was not significantly different among the solutions (P >0.05). Necrosis was significantly lower in the alcohol (46.7%) compared to other solutions (P = 0.001). Calcification was lower in the gentamicin group (56.7%). The loss of metachromasia was lower in the alcohol solutions (P = 0.000). Parameters at -18°C; the loss of metachromasia was higher in the gentamicin group (56.7%) than the other solutions (P = 0.003). The authors observed no significance in the rates of necrosis, calcification, metaplasia, inflammation, vascularity, or fibrosis among the solutions (P >0.05). Less necrosis and metachromosis loss in the alcohol solution indicated that alcohol was more suitable for preservation of the cartilage. In addition, temperature degree for the preservation of the cartilage did not show any significant differences.

Toward tissue-engineering of nasal cartilages

Nasal cartilage pathologies are common; for example, up to 80% of people are afflicted by deviated nasal septum conditions. Because cartilage provides the supportive framework of the nose, afflicted patients suffer low quality of life. To correct pathologies, graft cartilage is often required. Grafts are currently sourced from the patient's septum, ear, or rib. However, their use yields donor site morbidity and is limited by tissue quantity and quality. Additionally, rhinoplasty revision rates exceed 15%, exacerbating the shortage of graft cartilage. Alternative grafts, such as irradiated allogeneic rib cartilage, are associated with complications. Tissue-engineered neocartilage holds promise to address the limitations of current grafts. The engineering design process may be used to create suitable graft tissues. This process begins by identifying the surgeon's needs. Second, nasal cartilages' properties must be understood to define engineering design criteria. Limited investigations have examined nasal cartilage properties; numerous additional studies need to be performed to examine topographical variations, for example. Third, tissue-engineering processes must be applied to achieve the engineering design criteria. Within the recent past, strategies have frequently utilized human septal chondrocytes. As autologous and allogeneic rib graft cartilage is used, its suitability as a cell source should also be examined. Fourth, quantitative verification of engineered neocartilage is critical to check for successful achievement of the engineering design criteria. Finally, following the FDA paradigm, engineered neocartilage must be orthotopically validated in animals. Together, these steps delineate a path to engineer functional nasal neocartilages that may, ultimately, be used to treat human patients. STATEMENT OF SIGNIFICANCE: Nasal cartilage pathologies are common and lead to greatly diminished quality of life. The ability to correct pathologies is limited by cartilage graft quality and quantity, as well as donor site morbidity and surgical complications, such as infection and resorption. Despite the significance of nasal cartilage pathologies and high rhinoplasty revision rates (15%), little characterization and tissue-engineering work has been performed compared to other cartilages, such as articular cartilage. Furthermore, most work is published in clinical journals, with little in biomedical engineering. Therefore, this review discusses what nasal cartilage properties are known, summarizes the current state of nasal cartilage tissue-engineering, and makes recommendations via the engineering design process toward engineering functional nasal neocartilage to address current limitations.

Measurement of Warping Angle in Human Rib Graft: An Experimental Study

BACKGROUND

The purpose of this study was to determine the warping angle of the costal cartilage in vivo.

METHODS

A nasal framework reconstruction with a rib graft was performed in a total of 130 patients. After the cartilage specimens were prepared, the remaining grafts were used for study. The angle of warping in all grafts was measured at 0, 30, and 60 minutes; after 24 hours; and after 1 week. Eight subgroups of graft thicknesses from central and peripheral groups, determined according to the perichondral distance of the grafts, were evaluated, and the warping angles of 48 osteochondral and chondral grafts were measured individually. Three-way analysis of variance was used to compare the change in warping over time to detect differences in the grafts.

RESULTS

Significant differences were not observed in the 1- to 3-mm-thick grafts of peripheral and central origin before 30 minutes (p > 0.05), although significant differences were observed in these groups for all time points after 30 minutes (p < 0.05). In central and peripheral grafts thicker than 4 mm, a significant warping angle was not observed (p > 0.05). In central origin grafts thinner than 1 mm, significant differences were not observed in the warping angle (p > 0.05), although they were observed in the same grafts of peripheral origin (p < 0.05). Peripheral origin grafts thicker than 1 mm showed warping in the direction of the perichondrium (p < 0.05), whereas central origin grafts thinner than 1 mm showed warping angle irregularities.

CONCLUSION

Interlocking stresses are very important in rib grafts when balanced cross-sectional carving occurs from the peripheral to the central areas.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Osseous-Cartilaginous Spreader Graft and Nasal Framework Reconstruction

Revision rhinoplasties and saddle nose deformities usually require grafting for reconstruction. Between January 1, 2000, and January 1, 2017, autologous rib grafts were used in 127 secondary and tertiary rhinoplasty patients [(57/127 females) and (70/127 males)]. Osseous-cartilaginous rib grafts (OCRGs) were divided into three parts (i.e., 1/3 upper peripheral, 1/3 central, and 1/3 lower peripheral). The harvested OCRGs were also shaped as vertical strips using a number 11 scalpel blade. These OCRGs were shaped to form the L-strut cartilaginous graft (LSCGs), osseous-cartilaginous spreader grafts (OCSGs), osseous-cartilaginous onlay grafts, nasal valve grafts (NVGs), and lower lateral cartilaginous grafts (LLCGs). The upper peripheral portion of the rib was usually used as an onlay graft for dorsal reshaping. The shape of this part was minimally convex after being cut from the main graft, and the convex shape was very appropriate for use as an onlay graft. The middle portion of the graft that consisted of the osseous and cartilaginous structure was used for the OCSGs. The middle portion of the graft that contained only cartilage was used for the LSCGs, NVGs, and LLCGs. OCRGs were used for the dorsal, alar, septal, upper lateral, and columellar struts for all patients. OCSGs were used for all of the septal grafts to provide further stability. In the nasal valve failure patients, the rib cartilage was fixed onto the lower lateral and upper lateral cartilage and was sutured using polyglactin to improve nasal valve function. One edge of the graft was sutured over the septum, and the other edge was positioned against the maxillary crest to allow for air flow at the nasal valve. After an OCSG was sutured to the septum, a flat and smooth dorsum was shaped before the dorsal onlay graft was placed and fixed. The bone fragments of the grafts that consisted of spreader and onlay grafts were tied to the radix nasi bone without any space. After 6 months of follow-up, a minimally warping defect was apparent in 8 patients but none of these patients requested another surgery. The analysis of the questionnaire responses revealed that >90% of the patients were satisfied with the outcome of the procedure. Level of evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Overview of Asian Rhinoplasty

East Asian rhinoplasty is an expanding topic in the field of rhinoplasty. Although the main principles of various rhinoplasty techniques apply equally to the East Asian nose, East Asian rhinoplasty is unique owing to its different anatomy and ethnicity. In recent years, there have been some noteworthy developments in East Asian rhinoplasty. Traditional techniques using alloplastic implants with endonasal approach are changing due to the advent of new beauty concept, introduction of new techniques, and development of newly improved materials expended polytetrafluoroethylene as an alloplastic material has gained popularity in Asian augmentation rhinoplasty. Soft expended polytetrafluoroethylene sheets as augmentation material provide promise in the future. In this review, we will highlight some of the recent advances of Asian rhinoplasty with emphasis on dorsal augmentation, advances in implant material, and tip surgery using autologous cartilage.

Milestones of Asian Rhinoplasty

The field of plastic surgery originally developed out of the necessity to reconstruct the human body after the destruction of war. However, injured soldiers were not the only people who desired a change in appearance. After World War II, many people in Asian countries sought to attain a more Western look through surgery. Along with eyes, the nose was the main focus for these cosmetic procedures. In this article, the authors examine the evolution of Asian rhinoplasty from its original description in 1964 to the present. The characteristic anatomical differences between the Western and Asian nose are identified in relation to the technical challenges for rhinoplasty surgeons. Then the benefits and risks of the two major surgical approaches, autograft versus alloplast, are detailed. Finally, the coevolution of techniques and implant usage is traced from a dorsum-only implant, to an L-shaped implant, a cartilaginous cap graft with a one-piece rhinoplasty, an I-shaped implant, and a two-piece augmentation rhinoplasty. Outlining these changes demonstrates the advancement of the field of plastic surgery and the growing expectations of the patient. These advancements have provided the tools necessary to better align a patient's aesthetic goals and their unique anatomical presentation with a specific surgical approach.

Augmentation rhinoplasty using a folded "pure" dermal graft

BACKGROUND

Although there are several reports about the use of dermal or dermofat grafts, there are only a few reports about augmentation rhinoplasty performed using a "pure" dermal graft. Authors introduce the refined techniques, clinical experience, and report an aesthetically pleasing result of augmentation rhinoplasty performed using a folded pure dermal graft.

MATERIALS AND METHODS

Between 2008 and 2012, augmentation rhinoplasty was performed in 68 cases using a folded pure dermal graft. Pure dermal graft was harvested from one side of the buttock close to the intergluteal crease and the graft length was approximately 7-8 cm and the graft width was 1.5-2 cm, and the epidermis and fat were completely removed. Tip-plasty was performed using a conchal or septal cartilage as a columellar strut and an onlay graft. Pure dermal grafts are folded into 2 layers and sculpted to the desired size and shape, and are inserted into the supraperiosteal pocket. Ultrasonography was performed to know the absorption rate of the folded pure dermal grafts.

RESULTS

The thickness of a dermal graft at postoperative 12 months was 60.3% of that at postoperative 1 month. Even with 39.7% of reduction in the thickness of the dermal graft, the height of nasal dorsum after postoperative 1 year is considered to be well maintained. Among the 68 cases that underwent augmentation rhinoplasty (43 primary and 25 secondary), most of the patients sustained consistent cosmetic results; however, 12 patients (17 %) showed over-absorption, under-absorption or contour irregularity of the dermal graft, and slight erythema. There were no aesthetically or medically serious problems needing secondary rhinoplasty such as hematoma formation, warping of the graft, graft extrusion, infection, and rejection of the graft.

DISCUSSION

Augmentation rhinoplasty using a folded pure dermal graft has many advantages and is a very useful surgical option in patients who have an aversion to the use of artificial implants, who want to change the postoperative appearance of their nose due to insertion of an artificial implant into a more natural appearance, and when there is too much thinning of the skin due to repeated insertion of silicone implants.

Bone dust and diced cartilage combined with blood glue: a practical technique for dorsum enhancement

The combination of dorsal nasal reconstruction and camouflage of surface irregularities is an important step in rhinoplasty. We hereby present our technique of delivering diced cartilage in combination with bone dust to the nasal dorsum using the patient's blood as a carrier. We advocate use of an autologous material (blood) as a scaffold for graft delivery, dismissing the use of a foreign material or fascial wrapping of the graft. Using the patient's blood for this purpose not only stabilizes the graft into a malleable structure that is easily applicable to the nasal dorsum, it also decreases the potential for reaction against foreign material.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Costal cartilage is a superior implant material than conchal cartilage in the treatment of empty nose syndrome

OBJECTIVE

The objective of this study was to evaluate the outcomes of endonasal microplasty in treating empty nose syndrome by comparing the use of costal and conchal cartilage implants to construct neoturbinates.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

A total of 31 patients who were diagnosed with empty nose syndrome and underwent endonasal microplasty with conchal cartilage (n = 17) or costal cartilage implants (n = 14) were included. Each patient's clinico-demographic profile was reviewed to compare the conchal cartilage group and the costal cartilage groups. Pre- and postoperative Sino-Nasal Outcome Test (SNOT-25) scores were also compared.

RESULTS

Both groups showed a significant improvement in SNOT-25 scores following surgery (P < .05). The group who received costal cartilage implants demonstrated more significant improvements than the conchal cartilage group in terms of the mean difference between pre- and postoperative SNOT-25 scores (P = .023). Symptom outcomes related to depression demonstrated significant improvements in the conchal cartilage group (P < .05), while in the costal cartilage group, in addition to these 3 variables, 7 items related to functional problems also demonstrated significant improvements (P < .05).

CONCLUSIONS

Costal cartilage is a more useful material than conchal cartilage as implants for the treatment of empty nose syndrome patients.

State of the art in augmentation rhinoplasty: implant or graft?

PURPOSE OF REVIEW

There is ongoing debate regarding the optimal material for augmentation rhinoplasty. Each graft and implant has its own advantages and disadvantages. This review addresses the use of several grafts and implants in augmentation rhinoplasty, with a particular focus on dorsal augmentation.

RECENT FINDINGS

There are several grafts and implants available for dorsal augmentation. Autologous graft is commonly reported to be the preferred method. However, the proper selection of graft material varies depending on the technique and preference of the surgeon, as well as the anatomic and ethnic characteristics of the patient. Thus, there are a number of different options in the choice of graft or implant material, and there are debates and controversies as to the most appropriate choice.

SUMMARY

This article summarizes the advantages and disadvantages of several graft and implant options for dorsal augmentation. This information can help proper selection of the appropriate implant for dorsal augmentation, a critically important factor for minimizing morbidity while still achieving an optimal aesthetic result.

Current approaches to septal saddle nose reconstruction using autografts

PURPOSE OF REVIEW

To describe the contemporary techniques used for septal saddle nose and, based on these, present our approaches for correction of a spectrum of deformity severities.

RECENT FINDINGS

A review of different techniques currently in practice. These reflect greater emphasis on nasal structural framework repair rather than disguise and the use of autografts rather than allografts.

SUMMARY

We present our classification of septal saddle deformity, demonstrating that this condition requires a flexible surgical approach with different techniques required depending on the extent of the defect.

A novel autologous scaffold for diced-cartilage grafts in dorsal augmentation rhinoplasty

BACKGROUND

Diced-cartilage grafts have been used for dorsal nasal augmentation for several years with good results. However, compounds such as Surgicel and temporalis fascia used as a wrap have inherent problems associated with them, predominantly inflammation and graft resorption. An autologous carrier could provide stabilization of cartilage grafts while avoiding the complications seen with earlier techniques.

METHODS

In our patients, a malleable construct was used for dorsal nasal augmentation in which autologous diced-cartilage grafts were stabilized with autologous tissue glue (ATG) created from platelet-rich plasma (platelet gel) and platelet-poor plasma (fibrin glue).

RESULTS

A prospective analysis of 68 patients, who underwent dorsal nasal augmentation utilizing ATG and diced-cartilage grafts between 2005 and 2008, were included in the study. Although there was notable maintenance of the dorsal height, no complications occurred that required explantation over a mean follow-up of 15 months.

CONCLUSION

The use of ATG to stabilize diced-cartilage grafts is a safe, reliable technique for dorsal nasal augmentation. The platelet gel provides growth factors while the fibrin glue creates a scaffold that allows stabilization and diffusion of nutrients to the cartilage graft.

Aesthetic rhinoplasty of the Asian nasal tip: a brief review

Tip surgery, the most important part of the rhinoplasty procedure, has entered a new era in the past few decades. Various treatment protocols have been attempted. To date, however, opinions on the management of the Asian tip have not been solidified. To generalize and provide appropriate guidelines for the treatment of typical Asian tips, an English literature search from 1977 to March 2007 was conducted. Finally, a total of 26 papers were selected for review. The full text of each paper was read carefully, and data were extracted. Then all extracted information was imported into Microsoft Excel. Nine articles treating 11 groups of patients described the suitable techniques for Asian nasal tips, with 81.8% of the groups advocating that the protocol include a grafting technique, 64% reporting use of the grafting technique alone, and 9% applying cartilage reduction and a suturing technique. Of the 11 (18%) groups, 2 attempted more than one technique. Because of the Asian nasal tip's innate qualities, success with nasal tip plasty for Asians depends on the combined application of appropriate suturing, grafting, and defatting, with grafting techniques contributing the most.

Iatrogenic collapse of the nasal valve after aesthetic rhinoplasty

We present our experience of reconstruction of the nasal valve after iatrogenic collapse, and evaluate the feasibility and outcome of composite grafts. We selected all collapsed nasal valves that occurred after primary aesthetic rhinoplasties of the total number done at the University Tor Vergata in Rome. We excluded collapses that followed septoplasty for nasal deviation, reconstructions, and rhinoplasties for trauma. We selected 15 patients of 1252 who presented from January 1998 to December 2003. Eleven patients who had collapse of both the external and internal valve were treated with a composite graft (septum plus retroauricular) inserted by an "open tip" technique. Four patients (1 with both internal and external valve collapse, 3 with only internal) were treated with a section and opening of the upper lateral cartilages, transposition and repositioning of mucocartilaginous flaps. Good functional and aesthetic results were achieved in almost all patients without complications. Composite cartilaginous grafts are an easy and safe technique for the treatment of iatrogenic collapse of the nasal valve.