Dorsal nasal augmentation with "open sandwich" graft consisting of conchal cartilage and retroauricular fascia

Background: Augmenting the nasal dorsum with conchal grafts can cause visible irregularities over time due to the morphological qualities of that material. Objectives: This study describes the senior authors' technique of dorsal nasal augmentation with chondrofascial "open sandwich" grafts consisting of pieces of conchal cartilage and retroauricular fascia. The authors assess the efficiency and reliability of this graft in nasal dorsal augmentation. Methods: The authors retrospectively reviewed the cases of 19 patients who underwent dorsal augmentation rhinoplasty with chondrofascial grafts. Both cartilage and fascia were harvested through the same incision in the retroauricular sulcus. The conchal graft was cut in 2 to 4 pieces and slightly crushed with tissue forceps. The pieces of cartilage were arranged and fixed to the fascia in different patterns according to the nasal dorsum contour. Results: The follow-up period ranged from 12 to 35 months in 16 patients who qualified for inclusion in the final data. The maximal thickness of the chondrofascial graft was 4.5 mm. There were no major complications in the recipient area, except 1 case of undercorrection. There were 2 complications in the donor area. In 1 case, a hematoma was treated conservatively. In another case, a strip of skin necrosis in the conchal area occurred and was treated by excision and direct suture with satisfactory resolution. Conclusions: The autologous chondrofascial graft is appropriate for slight to mild dorsal nasal augmentation. The method, as with most rhinoplasty techniques, requires careful and judicious preoperative examination, planning, and execution. The postoperative scar is inconspicuous and the donor site morbidity is minimal. Level of Evidence: 4.     

Augmentation des Nasenrückens mit Knorpelschrot-Fibrinkleber

Background

The ideal method for augmentation of the nasal dorsum has yet to be found due to specific characteristics of alloplastic materials and autologous tissue. This review article describes a variation of the use of autologous diced cartilage.

Current opinion and practice

In the western world the use of autologous tissue has increasingly become accepted as the gold standard, particularly as a diced cartilage glue graft wrapped in fascia. This review discusses various augmentation techniques and details of a modification of a diced cartilage transplant using fibrin glue. This technique is innovative by impregnating diced cartilage with a thrombin solution, moulding it into the desired form and finally bonded with a fibrin solution. This technique substantially extends the spectrum of possible transplant forms. Its application for more than 5 years and a morphometric study with a 15-month follow-up confirm the long-term stability of the transplant.

Conclusion

The use of autologous tissue for augmentation of the nose is in line with the wishes of the majority of patients and surgeons. The diced cartilage glue graft has proved to be a welcome addition to the rhinoplasty armamentarium.     

Modification of the Skoog dorsal reduction for preservation of the middle nasal vault

Preservation of the middle nasal vault has increasingly become a topic of interest and concern in rhinoplasty. Modification of the nasal dorsum with traditional techniques may create unfavorable cosmetic results and adverse functional sequelae due to collapse of the middle nasal vault. Nasal dorsal reduction invariably involves separating the upper lateral cartilage (ULC) attachments from the dorsal septum. A number of procedures are used to reestablish the width of the middle nasal vault and competence of the internal nasal valve. Spreader grafts are the most frequently used technique. Although these grafts reliably preserve the middle vault, dorsal irregularities may result. Alternative techniques, such as suture suspension of the ULCs to dorsal onlay grafts or direct suturing of the ULCs to the septum, may pose similar problems. We have found that a modification of the Skoog technique for dorsal hump reduction preserves both a favorable aesthetic contour of the middle nasal vault and proper function of the internal valve. This procedure involves removal of the osseocartilaginous dorsum en bloc. The nasal dorsum is further reduced; the removed portion of nasal dorsum is sculpted and then replaced anatomically. Once a favorable position is found for the native dorsal graft, the upper lateral cartilages are resuspended to the graft with suture fixation. The dorsal segment thus acts as a dorsal onlay spreader graft, reestablishing a natural dorsal contour and preserving the middle nasal vault. We can avoid osteotomies in patients with an appropriate preoperative width of their bony base while correcting the open roof with the replaced dorsal segment.     

The Fate of Diced Cartilage Grafts of Traumatized Versus Nontraumatized Origin

Background Diced cartilage grafts have long been used in rhinoplasty. Along with their various reported advantages, they also have some disadvantages. The irregular resorption rate of the engrafted mass is one of the major issues noted with diced cartilage grafts. An explanation for the unpredictable resorption rate has not yet been elucidated. This study aimed to determine the role of traumatized versus nontraumatized cartilage as the source of diced cartilage grafts. Methods This study included the noses of 32 patients (19 traumatized noses and 13 nontraumatized noses) who underwent surgery using Surgicel-wrapped diced cartilage grafts. Results The most remarkable result noted in this study was that a Surgicel-wrapped diced cartilage graft, if prepared from traumatized cartilage (in 19 patients), failed to maintain a stable long-term volume. Partial volume loss was noted in 100% of these patients. However, the rate of this partial resorption was different for every individual and could not be predicted. The highest retention of cartilage graft volume was seen primarily over the nasal osseocartilaginous junction. In nontraumatized patients, however, the engrafted mass maintained long-term volume stability. These patients evidenced no visible external irregularities, and only a few very slight imperfections were noted with finger palpation. Conclusion Diced cartilage of traumatic origin is not recommended for any purpose. In such cases, the authors’ engrafting algorithm consists of autobone or ear conchal cartilage grafts for dorsal augmentation, columellar struts from the nontraumatized part of the septum, and spreader grafts from the nontraumatized part of the septum or ear concha.     

提高自体软骨移植物活性的研究进展

软骨移植物主要包括自体软骨、同种异体软骨、冷冻同种胚胎软骨、骨膜、软骨膜和生物材料等。但软骨移植存在许多缺陷,如供区继发性病变、进行性供区结构异常、移植物弯曲变形,移植物吸收与存活等问题。本文就提高自体软骨移植物活性的方法,包括软骨碎片或颗粒移植和包裹技术等进行综述。     

Comparison of AlloDerm, fat, fascia, cartilage, and dermal grafts in rabbits

OBJECTIVE: To compare various graft materials in the rabbit model, including autologous cartilage, dermal tissue, fat, and AlloDerm (a cadaver-derived material). METHODS: Twenty-five New Zealand white rabbits were used. Equally sized autogenous (fat, fascia, cartilage, and dermal) grafts and AlloDerm were implanted into subcutaneous dorsal pockets on the rabbits. Animals were killed 1, 2, 3, and 4 months after surgery. The grafts were examined microscopically for thickness, resorption, fibrosis, neovascularization, inflammation, eosinophilia, and the presence of multinucleated giant cells or microcysts. RESULTS: The cartilage grafts revealed excellent viability with no resorption. The fascial grafts showed negligible volume loss. The dermal grafts developed epidermoid cysts. The AlloDerm grafts demonstrated graft thickening at 1 month and total resorption at 3 and 4 months. The fat grafts demonstrated 30% to 60% partial resorption. CONCLUSIONS: The major disadvantage of using an autogenous fat graft was partial resorption, whereas cyst formation was observed with dermal grafts. AlloDerm caused tissue reaction and resorption. The best graft material was cartilage, with a low absorption rate, good biocompatibility, and minimal tissue reaction or fibrosis, followed by fascia, with a minimal shrinkage capacity and tissue reaction.     

Nose and paranasal augmentation: autogenous, fascia, and cartilage

The up-to-date plastic surgeon should consider using augmentation rhinoplasty with relative frequency. In selected cases, for improving the face integrally, it is desirable to augment the paranasal area. In the author's hands, grafts of cartilage and fascia are the preferred tissues, based on the experience of many years. Fascia can be used alone or combined, and in the last few years we have used it alone quite often. A temporoparietal fascia graft has great versatility in the correction of a number of nasal deformities. A depressed nasal dorsum can be augmented by utilizing fascia grafts. A depressed nasal radix can be corrected successfully by utilizing fascia grafts. Submucosal placement of strips of fascia has proved to be an effective method of reconstructing the roof of the middle cartilaginous vault. For augmenting the nasal dorsum when it is a case of primary rhinoplasty, the author prefers the use of fascia alone, but if the patient is having a secondary rhinoplasty, then the graft of fascia and cartilage combined is preferred.     

Viability of crushed and diced cartilage grafts: a study in rabbits

OBJECTIVE: To investigate the effects of dicing and different degrees of crushing on cartilage graft viability and outcome in rhinoplasty. METHODS: Cartilage was harvested from both ears of 29 rabbits. For each animal, 6 cartilage pieces were prepared as follows and inserted into the paraspinal subcutaneous tissue: (1) left intact, (2) diced to approximately 1 x 1-mm pieces and then wrapped in oxidized regenerated cellulose, (3) slightly crushed, (4) moderately crushed, (5) significantly crushed, and (6) severely crushed. Animals were killed at 2, 5, and 10 months, and graft specimens were microscopically examined. RESULTS: As crushing intensity rose, cartilage viability decreased and more cartilage tissue was transformed to connective tissue. The intact and slightly crushed grafts showed significant chondrocyte proliferation. This decreased as crushing intensity increased, and the severely crushed and diced cellulose-wrapped grafts exhibited almost no peripheral chondrocyte proliferation. CONCLUSIONS: Slight crushing of a cartilage graft can produce outstanding graft material that forms softer nasal contours and fills defects well. However, severe crushing of cartilage grafts results in extensive necrosis and eventual reduction in graft volume. The use of oxidized regenerated cellulose to wrap diced cartilage grafts also tends to reduce clinical predictability owing to negative effects on cartilage viability and regeneration.     

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.     

The use of preserved autogenous septal cartilage in "touch-up" rhinoplasty

The management of minor contour irregularities after primary aesthetic rhinoplasty often requires correction of soft tissue defects with autogenous cartilage, allograft materials, xenograft matrix, or alloplasts. Inasmuch as the use of native cartilage requires an additional procedure (and potential donor site morbidity) and alloplast insertion raises the specter of extrusion or cicatrical deformity, the use of preserved autogenous cartilage is an attractive alternative, particularly for minor revision surgery. This study describes the experience and technique of the senior author (P.F.G.) with the use of isopropyl alcohol-preserved autogenous nasal cartilage during revision rhinoplasty in which only minor contour correction is required. When grafts are needed for revision surgery, they are inserted via small intranasal stab incisions into minor irregularities of the tip, alae, and dorsum. This technique eliminates the need for additional surgery to obtain graft material, reduces costs and risks associated with alloplasts, and is particularly useful for minor revision rhinoplasty. Office-based techniques for preserving cartilage are reviewed.     

Radiologic and Histologic Assessment of Diced Cartilage Grafts for Cranial Bone Defects of Rabbits: An Experimental Study

This study was performed to experimentally evaluate the viability and coverage of diced cartilage grafts for cranial defects. Biparietal bone defects were prepared in each of 20 rabbits. Otogenous bone grafts were fixed to one side, whereas cartilage grafts taken from the right ear, diced, and wrapped with oxidized regenerated cellulose (Surgicel) were placed on other side. Parenchymal impression, contour, and ossification of all grafts in the 16 rabbits surviving after 8 weeks were evaluated with computed tomography and magnetic resonance imaging. The existence of ossification was examined pathologically. Parenchymal impression was significantly more frequent in bone grafts than in cartilage grafts (p < 0.05). This difference probably is attributable to the application technique. There was no significant radiographic difference in other parameters between the two groups. No significant difference in ossification was found. In conclusion, ossification was seen radiologically and pathologically in diced cartilage grafts. Because of autogenicity, ease of shaping, absence of postoperative warping, reduced resorption rates, and inherent viability and ossification properties, the authors suggest that diced cartilage grafts may be an alternative material for cranial defects, especially for frontal cranial reconstruction in which deformities may cause aesthetic and functional disabilities. The authors believe that further long-term studies also are needed.     

Chin augmentation using diced cartilage

Eight patients with microgenia have undergone augmentation with diced nasal cartilage. Cartilage grafts were harvested from the nose during rhinoplasty. These grafts were cut into 0.5 to 1.0 mm pieces using a #11 blade and were wrapped in one layer of Surgicel (oxidized regenerated cellulose). This cartilage mass was inserted into the chin pocket. All patients underwent clinical evaluation, magnetic resonance imaging (MRI), and photography. These investigations showed that diced cartilage grafts maintained 75% of their dimensions at six months after implantation. The follow-up period was 12 months, and the aesthetic results were satisfactory. Received: 5 May 1997 / Accepted: 21 August 1997     

前臂骨间背侧动脉逆行脂肪筋膜瓣联合皮片移植修复手背缺损创面

目的 探讨前臂骨间背侧动脉逆行脂肪筋膜瓣联合皮片移植修复手背缺损创面的临床疗效.方法 应用前臂骨间背侧动脉逆行脂肪筋膜瓣联合皮片移植修复14例手背部缺损创面患者.术前进行脂肪筋膜瓣设计,脂肪筋膜瓣切取面积8 cm×6 cm~12 cm×9 cm,覆盖创面后在脂肪筋膜瓣表面加皮片移植.结果 14例脂肪筋膜瓣及移植皮片全部成活.患者均获随访,时间4～10个月.脂肪筋膜瓣色泽、质地、弹性均良好,无臃肿,无前臂骨间背侧神经损伤,患者功能恢复较满意.结论 前臂骨间背侧动脉逆行脂肪筋膜瓣联合植皮是修复手背部创面缺损的有效方法.     

Bone Chips and Diced Cartilage: An Anatomically Adopted Graft for the Nasal Dorsum

Since 1996, cranial bone chips or septal bone chips harvested during septal deviation surgery and small chips of ear or septal cartilage have been used in 67 patients for dorsal nasal augmentation or for smoothing dorsal nasal irregularities. In this study, 59 overresections of ostecartilaginous nose structures during previous aesthetic nose surgeries and 8 primary rhinoplasties occasioned the use of bone or cartilage grafts. For 57 patients both bone and ear cartilage grafts were used for the reconstruction. Bone grafts were used for seven cases and cartilage grafts for three cases.The results from 7 years, of experience with this method of nasal dorsum reconstruction were satisfactory and durable. The most important advantage of this method is that the bony side of the nose is reconstructed with bone and the cartilage side with cartilage. Another advantage is that the bone chips are incorporated with both nasal bones, building a strong dorsal nasal bony monoblack.This technique also is useful for augmenting mild saddle nose deformity and dorsal nasal projection deficiency on the bony part, cartilage part, or both parts.Presented at 16th Congress of ISAPS, Istanbul, Turkey, 26–29 May 2002 and 24th National Meeting of the Turkish Plastic Reconstructive Aesthetic Surgery Society, Ankara, Turkey, 18–20 October 2002.     

Cartilage implantation in head and neck surgery: report of a national survey

As enthusiasm for alloplastic grafts wanes, the use of biologic materials for reconstructive and aesthetic surgery is regaining popularity. A plethora of methods exists for preservation of one of the most popular implants, human cartilage. The controversy over the efficacy of autologous v preserved homologous cartilage grafts continues. A national study was developed to determine the efficacy of autologous v the various techniques of cartilage preservation based on the criteria of graft extrusion, infection, and absorption. Autologous grafts were most commonly used. The most popular preservation methods used alcohol or merthiolate. Autologous grafts had less absorption than preserved grafts, but both groups had approximately equivalent infection and extrusion rates. Irradiated cartilage showed the least absorption of all preservation methods.     

Combined silicone and cartilage implants: augmentation rhinoplasty in Asian patients

Various alloplastic materials are used for nasal augmentation in Asian patients. Of these, silicone is the most prevalent because it is durable and facilitates sculpting. However, silicone grafts have been associated with complications, including tip extrusion, infection, and graft shifting. Often the nasal tip is involved, with skin discoloration and possible implant extrusion due to increased mechanical pressure. Autogenous material provides a safer alternative for nasal augmentation, but the supply of septal or auricular cartilage in Asian patients is limited. To augment optimally and reduce extrusion risk, we use auricular cartilage grafts at the nasal tip and silicone implants for the nasal dorsum in Asian patients. We report the results of this technique in 100 Asian patients with up to 5 years of follow-up. Patients were extremely satisfied, and no implant extrusions resulted. Other complications included further surgical revision due to misalignment of the silicone dorsal implant (5 patients), tip graft shifting (2 patients), and recurrent dorsal edema over the implant requiring removal (1 patient).     

Combined use of triple cartilage grafts in secondary rhinoplasty.

Secondary rhinoplasty on a patient with a middle vault deformity is one of the most challenging procedures for a plastic surgeon. In order to achieve proper nasal aesthetics and airway function, a surgeon most commonly chooses to engraft the nose with a spreader, dorsal onlay, or columellar graft. This paper examines the aforementioned techniques in the management of 25 patients who presented with a severe middle nasal vault deformity. METHODS: During the last 5 years, 25 patients received secondary rhinoplasty using triple cartilage grafts to repair severe middle vault deformities. Patients were then questioned at least 3 months postoperatively about both airway problems and cosmetic satisfaction. RESULTS: All the 25 patients indicated cosmetic satisfaction with 23 of the patients also achieving complete nasal airway function. Only two patients persisted to have an insufficient nasal airway. An endonasal examination revealed a slight nasal synechiae in one patient, while no anatomic problem was identified in the second patient. From a cosmetic standpoint, a straight dorsum with improved dorsal aesthetic lines and nasal profile, along with nasal-facial balance were achieved. When indicated, secondary rhinoplasty to repair a middle vault deformity using the combination of spreader, dorsal onlay, and columellar grafts to augment the nose has shown to have both functional and cosmetic benefits.     

The use of diced cartilage as a testicular replacement in rabbits

Silicone prostheses have primarily been used for cosmesis after orchiectomy, but complications have been reported. In this experimental study, diced cartilage graft has been used for testicular replacement in rabbits. Although later reduction of the volume was seen in the MRI studies, diced cartilage grafts can be used for testicular prostheses but overcorrection of the volume seems to be desirable. Received: 21 February 1997 / Accepted: 2 September 1997     

自体鼻中隔软骨在鼻背凹陷充填术中的应用

目的 介绍用自体鼻中隔软骨充填鼻背凹陷的方法。方法 按常规鼻中隔矫正术切取鼻中隔软骨，根据鼻背凹陷的不同程度和部位，将充填软骨修削成单层卵圆形，或将软骨分割成2～3块叠加后缝合在一起，或将软骨制成倒“V”形，根据鼻背凹陷的大小和形状进行鼻背部充填。结果 43例患者短期效果全部满意，30例经6个月至5年随访，其中3例软骨有轻度吸收，鼻背稍凹陷，其余均较满意。结论 自体鼻中隔软骨充填鼻背整形，取材在同一手术野内完成，方法简便易行，软骨能与周围组织融合在一起，无排斥反应，长期效果较好，可作为鼻背美容整形的选择材料。