Allogenous cartilage graft versus autogenous cartilage graft in augmentation rhinoplasty: a decade of clinical experience

Subcutaneously Transplanted Fresh Cartilage in Allogeneic and Xenogeneic Immunocompetent Mouse

Cartilage is considered to be immune privileged in general. Clinically, live cells are removed from subcutaneously transplanted allogeneic cartilage mainly for preservation and for infection control. However, because maintaining cartilage feature requires live chondrocyte, it would be beneficial to subcutaneously transplant cartilage with live chondrocyte even if it was allogeneic. We harvested femoral head from 3-week-old male C57BL/6 mice, subcutaneously transplanted to 6-week-old male mice, BALB/c, BALB/c nu/nu, or C57BL/6-Tg (enhanced green fluorescent protein [EGFP] under the control of the CMV-IE enhancer, chicken beta-actin promoter, rabbit beta-globin genomic DNA [CAG promoter]), as allogeneic, allogeneic immunodeficient control, or syngeneic transplantation. We also transplanted cartilaginous particles from human induced pluripotent stem cells derived from human leukocyte antigen homozygous donor to 6-week-old male mice either BALB/c and BALB/c nu/nu as xenogeneic or xenogeneic immunodeficient control. The transplantation periods were 1, 2, 3, 4, 8, 12, and 24 weeks. As the result, we did not observe exposure of the transplant or apparent macroscopic inflammatory in all samples. Histological analysis suggested that the femoral head showed focal ossification and thinning in syngeneic transplantation. In allogeneic transplantation, slight invasion of CD3 (+) T cell and the denaturation of the cartilage were observed, suggesting immune reaction against allogeneic cartilage. In xenogeneic transplantation, slight invasion of CD3 (+) cell and CD4 (+) cell and the structure of the perichondrium-like tissue got unclear, suggesting slight immune reaction against xenogeneic cartilage. Our findings suggest that we should carefully investigate for appropriate procedure to control immune reaction against allogeneic cartilage with live chondrocyte and to maintain its cartilage feature for long time.

Cost Utility Analysis of Costal Cartilage Autografts and Human Cadaveric Allografts in Rhinoplasty

BACKGROUND

Human cadaveric allograft (HCA) and costal cartilage autograft (CCA) have been described for reconstruction during rhinoplasty. Neither are ideal due to infection, resorption, and donor site morbidity. The clear superiority of 1 graft over the other has not yet been demonstrated. This study assesses comparative costs associated with current grafting materials to better explore the cost ceiling for a theoretical tissue engineered implant.

MATERIALS AND METHODS

A cost utility analysis was performed. Initial procedure costs include physician fees (CPT 30420), hospital outpatient prospective payments, ambulatory surgical center payments, and fees for the following: rib graft (CPT 20910), hospital observation, and DRG (155) for inpatient admission. Additional costs for revision procedure, included the following fees: physician (CPT 30345), rib graft, hospital outpatient prospective payment, and ambulatory surgical center payments. Total costs under each scenario were calculated with and without the revision procedure. Comparison of total costs for each potential outcome to the estimated health utility value allowed for comparison across rhinoplasty subgroups.

RESULTS

The mean cost of primary outpatient rhinoplasty using HCA and CCA were $8075 and $8342 respectively. Revision outpatient rhinoplasty averaged $7447 and increased to $8228 if costal cartilage harvest was required. Hospital admission increased the cost of primary rhinoplasty with CCA to $8609 for observational admission and to $13653 for 1 day inpatient admission. Revision CCA rhinoplasty with an inpatient admission complicated by pneumothorax increased costs to $21 099.

CONCLUSION

Cost of rhinoplasty without hospitalization was similar between HCA and CCA and this cost represents the lower limit of a practical cost for an engineered graft. Considering complications such as need for revision or for admission after CCA due to surgical morbidity, the upper limit of cost for an engineered implant would approximately double.

Three-Dimensional Analysis of Definitive Secondary Unilateral Cleft Rhinoplasty Using Cartilage Graft

OBJECTIVE

Three-dimensional assessment of nasal morphology in patients with unilateral cleft lip nose treated by cartilage graft augmentation.

DESIGN

Retrospective study.

PATIENTS AND INTERVENTION

Thirteen patients with unilateral cleft lip nose underwent definitive secondary rhinoplasty and postsurgical changes were examined using a three-dimensional (3D) laser scan.

MAIN OUTCOME MEASURE

Nasal dorsum length, nasal tip, alar width, and alar base width in frontal view; nasion depth, nasal tip projection, nasal dorsal angle, and nasal tip angle in lateral view; nostril width, nostril height, and nasal tip height in basal view were measured at preoperative (T1: within 6 months), short follow-up (T2: 2-10 weeks), and long follow-up (T3: 9-14 months).

RESULTS

A significant change in alar width, alar base width, nostril width, and nostril height at the cleft side, nasal dorsum length, nasion depth, nasal tip projection, and nasal tip height was observed from T1 to T3 follow-up after rhinoplasty (P < .05), whereas the nostril height at the noncleft side was also significantly increased at T2 follow-up but the mean change in height relapsed at T3 follow-up. Alar width, alar base width, and nostril width at the noncleft side, and nasal tip angle did not change significantly after surgery at any follow-up period.

CONCLUSIONS

3D imaging evaluation after secondary cleft rhinoplasty demonstrated improved functional and aesthetic outcomes using a septal or conchal graft.

Comparing autologous versus allogenic rib grafting in pediatric cleft rhinoplasty

BACKGROUND

Patients with cleft lip with or without cleft palate suffer from varying degrees of nasal deformity, often requiring nasal reconstruction to provide improved form and function. Rib cartilage is an excellent source of grafting material for nasal reconstruction and is available either as an autologous or allogenic graft. There is a paucity of literature comparing outcomes of autologous and allogenic rib grafts in pediatric cleft rhinoplasty.

METHODS

A retrospective chart review was performed on patients who underwent cleft rhinoplasty with autologous or allogenic rib grafting at a tertiary pediatric hospital between January 1, 2003 and December 31, 2017. Outcome data were gathered over a 6-month postoperative period.

RESULTS

There were 23 cleft rhinoplasties performed with rib graft, 12 with autologous rib and 11 with allogenic rib. Those in the autologous group tended to be older than those in the allogeneic group (15.6 ± 4.4 v 12.4 ± 5.2 years, p = 0.13). The most common types of grafts used were columellar strut (20/23), shield graft (9/23), and unilateral or bilateral batten grafts (7/23). Length of stay was significantly longer for patients who underwent autologous rib grafting compared with those with allogenic rib grafting (25.8 ± 4.7 v 11.9 ± 7.2 h, p < 0.05). Each group reported one complication.

CONCLUSION

Autologous and allogenic rib grafts are safe and effective in pediatric rhinoplasty. The most common grafts used in this sample were columellar strut, batten, and shield grafts. Autologous rib grafts were more likely to be used in older patients and require longer hospital stay compared to allogenic grafts.

Chondrogenesis of Adipose-Derived Stem Cells on Irradiated Cartilage

BACKGROUND

Irradiated allogeneic costal cartilage is an alternative option of cartilage graft in patients with insufficient autologous cartilage. However, complications can occur during long-term follow-up. This study investigated whether Tutoplast-processed cartilage, one of the irradiated allogeneic costal cartilages, acts as a scaffold for adipose-derived stem cells and chondrogenesis.

METHODS

In vitro setting, human adipose-derived stem cells seeded onto Tutoplast-processed cartilage were cultured in chondrogenic medium and observed using a scanning electron microscope. Next, 3 types of irradiated cartilage-including Tutoplast-processed cartilage, undifferentiated stem cells on Tutoplast-processed cartilage (undifferentiated group), and chondrogenic differentiated stem cells on Tutoplast-processed cartilage (chondrogenic group)-were implanted subcutaneously into nude mice. Gross, histologic, and gene expression analyses of Tutoplast-processed cartilages were performed at postoperative weeks 2 and 4.

RESULTS

Human adipose-derived stem cells subjected to in vitro three-dimensional culture differentiated into chondrocytes and expressed cartilage-specificgenes. Adipose-derived stem cells seeded onto Tutoplast-processed cartilage were differentiated into chondrocytes in chondrogenic medium. In the chondrogenic group, the chondrogenic-differentiated cells attached to the surface of the Tutoplast-processed cartilage were maintained during the follow-up and were distinct from the existing Tutoplast-processed cartilage. Moreover, the chondrogenic group had higher expression of cartilage-specific genes compared with the undifferentiated group.

CONCLUSIONS

Adipose-derived stem cells seeded onto Tutoplast-processed cartilage underwent chondrogenic differentiation, generating new cartilage, which was maintained after implantation without critical complications. The findings are clinically valuable in terms of overcoming the limitations of irradiated allogeneic costal cartilage, and broaden the surgical options for treatments requiring cartilage.

Outcomes of Cadaveric Allograft versus Autologous Cartilage Graft in Functional Septorhinoplasty

OBJECTIVE

Our goal was to elucidate the efficacy and outcome profile of cadaveric allografts (homograft costal cartilage) in functional septorhinoplasty as compared with autografts (quadrangular cartilage, conchal cartilage, and autologous costal cartilage).

STUDY DESIGN

Retrospective chart review.

SETTING

Otolaryngology division of the Penn State Health Milton S. Hershey Medical Center.

SUBJECTS AND METHODS

A chart review of a single surgeon's practice was conducted with Current Procedural Terminology codes for septorhinoplasty (30410, 30420, 30430, 30435, 30450, 30465) from August 1, 2014, to August 1, 2017. All patients underwent functional septorhinoplasty for a chief complaint of nasal obstruction. Outcomes were collected up to 12 months following the operation and included the validated Nasal Obstruction Symptom Evaluation (NOSE), infection rate, malposition/warping of the graft, need for revision surgery, and graft loss.

RESULTS

A total of 171 cases were included in our data analysis. On multivariate analysis, there were no significant differences between patients who had autografts and those who had allografts in 3-, 6-, or 12-month postoperative NOSE score. Preoperative NOSE score was the only covariate to demonstrate a significant positive relationship to postoperative NOSE score. Regarding outcomes between autograft and allograft, no significant differences were found in rate of graft resorption (3.4% vs 5.6%, P = .680), graft warping (3.4% vs 0%, P = .309), infection (0% vs 1.9%, P = .316), or need for revision surgery (4.3% vs 5.6%, P = .709).

CONCLUSION

Autologous grafting is often the first choice in septorhinoplasty because of its presumed resistance to infection and resorption. Similar to autologous grafts, allografts are resistant to infection and resorption and demonstrate prolonged efficacy following functional septorhinoplasty.

Histological, Physical Studies after Xenograft of Porcine Ear Cartilage

BACKGROUND

Because of the relatively similar size of organs to human and the physiological and structural similarities, the use of porcine as xenograft donors is progressing very actively. In this study, we analyzed the characteristics of porcine ear cartilage and evaluated its suitability as graft material in reconstructive and cosmetic surgery.

METHODS

The auricular cartilage was harvested from two pigs, and subjected to histological examination by immunohistochemical staining. To determine the collagen content, samples were treated with collagenase and weight changes were measured. After sterilization by irradiation, the samples were grafted into rats and stained with Hematoxylin and Eosin and Masson Trichrome to observe inflammation and xenograft rejection.

RESULTS

In IHC staining, extracellular matrices were mainly stained with type II collagen (20.69%), keratin sulfate (10.20%), chondroitin sulfate (2.62%), and hyaluronic acid (0.84%). After collagenase treatment, the weight decreased by 68.3%, indicating that about 70% of the porcine ear cartilage was composed of collagen. Upon xenograft of the sterilized cartilages in rats, inflammatory cells were observed for up to 2 months. However, they gradually decreased, and inflammation and reject-response were rarely observed at 5 months.

CONCLUSION

The porcine ear cartilage was covered with perichondrium and cellular constituents were found to be composed of chondrocytes and chondroblasts. In addition, the extracellular matrices were mainly composed of collagen. Upon xenograft of irradiated cartilage into rats, there was no specific inflammatory reaction around the transplanted cartilage. These findings suggest that porcine ear cartilage could be a useful alternative implant material for human cosmetic surgery.

Polydioxanone plates are safe and effective for L-strut support in functional septorhinoplasty

OBJECTIVES/HYPOTHESIS

To evaluate the safety, efficacy, and result stability of polydioxanone (PDS) plate use for L-strut stabilization.

STUDY DESIGN

Retrospective analysis of a prospective cohort.

METHODS

Patients who underwent functional septorhinoplasty with the use of PDS plates between January 2013 and January 2017 were administered the Nasal Obstruction Symptom Evaluation (NOSE) scale pre- and postoperatively at 2, 4, 6, and 12 months. Patient demographics, reason for PDS use, graft type, complications, and outcomes were analyzed.

RESULTS

Eighty-eight patients aged 34.3 years (standard deviation [SD] = 15.7 years; range, 7.5-71.5 years) were included. All patients were found to have a fracture and/or severe deviation of the L-strut for which the PDS plate was used for rigid support. Mean preoperative NOSE score 65.2 (SD = 22.1) significantly decreased to 19.6 (SD = 21.6) at 7.2 months (SD = 5.5 months) postoperatively. There were no significant differences in NOSE scores between follow-up time points. There was one complication, a septal abscess, and one revision.

CONCLUSIONS

A PDS plate is a safe and effective material to be utilized in functional septorhinoplasty for patients with a fracture or iatrogenic injury to the septal L-strut or poor quality septal cartilage that requires stability without additional width. Outcomes are stable at 6 and 12 months, after the plate has dissolved. The use of a PDS plate may decrease the need for rib grafting in patients with a history of previous septoplasty and persistent nasal obstruction with a dorsal or caudal C-shaped septal deformity or fracture of the L-strut.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:2725-2730, 2017.

Izogenic cartilage transfer in rhinoplasty procedure

Cartilage is commonly grafted during primary and secondary rhinoplasties as a means of addressing both functional and esthetic issues. Generally, such grafts are taken from the nasal septum, but auricular conchae or ribs may serve as donor sites if needed. However, the latter often entail considerable morbidity and graft mismatch. To circumvent these drawbacks, use of implants or processed cartilage (allogenic or xenogenic in origin) has been proposed. Herein, the isogenic transfer of nasal septal cartilage between identical twins is reported.

Augmentation rhinoplasty in cleft lip nasal deformity: preliminary patients' perspective

The correction of cleft lip nasal deformity is challenging and there have been numerous methods described in the literature with little demonstrated technical superiority of one over another. The common clinical issues associated with cleft lip nasal deformity are its lack of symmetry, alar collapse on the affected side, obtuse nasal labial angle, short nasal length, loss of tip definition, and altered columella show among others. We carried out augmentation of cleft lip rhinoplasties with rib graft in 16 patients over the one-year study period. Each of these patients was reviewed and given questionnaire before and after surgery to evaluate their response on the outcome to the approach. Preoperatively, nasal asymmetry is the main complaint (14/16, 87.5%) among our series of patients. Postoperatively, 12 (75%) patients out of the 16 reported significant improvement in their nasal symmetry with the other four marginal. All patients reported excellent nasal projection postoperatively with good nasal tip definition. Our series of patients reported overall good satisfaction outcome and will recommend this procedure to other patients with cleft lip nasal deformity. In conclusion, augmentation of cleft lip rhinoplasty can be employed to achieve perceivable and satisfactory outcome in patients with cleft lip nasal deformity.

The use of Integra™ in rhinoplasty

Different biosynthesized materials and autologous grafts have been used for many years to increase the size or to change the shape of the nasal dorsum in augmentation rhinoplasty. To avoid the undesirable effects of these materials, such as reabsorption, intolerance, granulomas, visualization of the graft's edges, and the migration of the implant, a new technique is proposed that uses a dermic regeneration template (Integra™). The authors have performed 56 surgeries for patients with different indications, and 30 of these patients have been followed up for a minimum of 12 months. The advantage of using this template, a sheet comprising a porous matrix of collagen fibers and glycosaminoglycans, is that it provides a structure for autologous dermic tissue regeneration. Its handling versatility once the silicone sheet is removed allows it to be folded over itself until the needed thickness is obtained as well as the desired aesthetic results. The authors believe that the dermic regeneration template (Integra™) is a good alternative filler material because it is completely reabsorbed and replaced by autologous dermis. The action is not to replace but to help the development of the patient's own tissue, avoiding a possible intolerance because it does not act as a foreign body. The volume remains stable throughout time, and overcorrection is not necessary.