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

Complications Associated with Alloplastic Materials in Rhinoplasty and Their Operative Management

Whereas rhinoplasty with a reduction of the dorsum and modification of the tip is a common procedure among Caucasians, augmentation of the dorsum remains a challenge in Asians. Choice of the ideal grafting material for dorsal augmentation is a matter of preference and remains under discussion. Autologous and alloplastic materials have their advantages and disadvantages. We report our experiences of the extrusion of alloplastic materials and their management. We report of 18 patients, who had rhinoplasty in the past for dorsal augmentation with alloplastic material. Augmentation rhinoplasty was performed in Asia (n = 15) and Germany (n = 3). All cases showed recurrent signs of foreign body infection and/or partial extrusion and therefore underwent revision surgery in our centers. Once all patients had been successfully treated with antibiotics, we performed a one-stage revision rhinoplasty with explantation of the alloplastic material and subsequent reconstruction with autologous rib cartilage. The nasal dorsum was augmented with either solid rib cartilage grafts, diced cartilage in fascia, or free diced cartilage in platelet-rich fibrin. All patients received pre-, peri-, and postoperative antibiotics. The outcome was screened via clinical examination, ultrasound examination pre- and postoperatively, two-dimensional/three-dimensional (3D) imaging, and magnetic resonance imaging scans.Alloplastic augmentation of the nasal dorsum runs the risk of foreign body reaction, recurrent infections, uncontrolled scarring, and unsatisfying long-term results. We have obtained a series of aesthetically and functionally satisfying results after single-stage revision surgery with autologous cartilage and demonstrate a variety of novel postoperative screening tools including 3D imaging and high-frequency ultrasound. LEVEL OF EVIDENCE:  N/A.

Mechanically fragmented cartilage grafts in rhinoplasty: An up-to-date systematic review

INTRODUCTION

Grafts play key roles in functional and aesthetic rhinoplasty. Autologous grafts are generally preferred for their biocompatibility and less visibility when used in a fragmented fashion. The aim of this study was to review mechanically fragmented cartilage grafts techniques described in the literature, outlining indications, outcomes, and complications.

MATERIAL AND METHODS

A systematic review of articles published from 1999 until December 2022 was conducted, using the following key words: "rhinoplasty," "cartilage," and "graft." Studies were selected according to the inclusion and exclusion criteria, and data were extracted and grouped for subgroup analysis. Rates of partial resorption, total resorption, surgical revision, and major and minor complications were statistically analyzed.

RESULTS

Thirty eligible studies were included. Three cartilage fragmentation methods were identified: diced, shaved, and crushed. Cartilage grafts were further divided into injectable and noninjectable grafts. Diced cartilage was the most commonly used. Dorsal irregularities were the main indication. Overall, 1.68% of patients experienced partial resorption, 0.27% experienced total resorption, and 1.46% needed revision. The partial resorption rate in the diced group was significantly lower than that in the shaved group. Injectable grafts showed a higher rate of partial resorption. The revision rate was higher with noninjectable grafts.

CONCLUSION

The partial resorption rate was lower in patients treated with diced cartilage. Injectable grafts are malleable and suitable for the correction of minimal irregularities, although they are affected by a higher rate of partial resorption. Wrapping materials may be used when significant augmentation is required.

Rib Plaster: A Versatile, Moldable Derivative from Scraping the Periphery of the Rib

SUMMARY

A simple technique is described for obtaining rib plaster by scraping the whitish peripheral portion of residual segments of rib after the perichondrium is removed and appropriate multiple laminations are derived. This putty-like substance tends to conglomerate appropriately because of its high density and has unique properties. It is readily compacted into diced cartilage inserters, smoothly injected, and easy to mold. Rib plaster works well for camouflage of irregularities of the dorsum and tip as well as in mild augmentation. It adds no further cost, and is in adequate supply once a full-thickness rib segment has been harvested for secondary rhinoplasty.

Outcomes of Diced Cartilage Dorsal Augmentation in Dorsal Aesthetic Deformities

Objective: To investigate the effectiveness of diced cartilage graft for dorsal augmentation in rhinoplasty. Methods: In a retrospective study, patients who underwent rhinoplasty with dorsal augmentation using diced cartilage graft from June 2017 to December 2021 were identified. Patients with complete preoperative and at least one postoperative Standardized Cosmesis and Health Nasal Outcomes Survey-Cosmesis (SCHNOS-C) and visual analogue scale (VAS) scores were included in the study. Postoperative periods were classified into ≤6 and >6 months. Mean preoperative outcome scores were compared with postoperative scores utilizing a Paired t-test, and postoperative scores were compared utilizing a Wilcoxon rank-sum test. Results: A total of 71 patients with a median age of 36 years, range (18-74) fit inclusion criteria. Majority were female patients 49 (69%). The postoperative period ranged from 17 days to 3.5 years. The mean follow-up period (standard deviation) for ≤6 and >6 months was 2.8 (1.5) and 14.2 (6.3) months, respectively. A decrease in mean SCHNOS-C, SCHNOS item 8, and an increase in VAS scores (p < 0.0001) were seen at both postoperative time periods compared with preoperative levels. Conclusion: This study demonstrates that dorsal augmentation with diced cartilage graft is an effective technique in correcting dorsal aesthetic deformities.

Using platelet-rich fibrin scaffolds with diced cartilage graft in the treatment of empty nose syndrome

Empty nose syndrome (ENS) is a rare entity in patients who undergo sinonasal surgery due to over-resection of the turbinate. This syndrome leads to debilitating symptoms that include dry nose, painful nasal breathing, paradoxical nasal obstruction, crusting, and sleep disorder. The goal of surgical treatment is to reestablish the volume of the turbinates to rehabilitate the nasal resistance. Endonasal microplasty with cartilage implants on the lateral wall of the nasal cavity is useful for creating the neoturbinate. Here, we present 2 cases that describe the management of empty nose syndrome by endonasal microplasty using platelet-rich fibrin (PRF) scaffolds embedded with a diced cartilage graft. The integration of the PRF scaffolds with diced cartilage efficiently facilitated the reestablishment of the neoturbinate. This autologous biomaterial is suitable for the treatment of ENS.

Histology and Long-term Clinical Outcome of Crushed Cartilage with Double-layer Gelatin Sponge Membrane for Dorsum Refinement in Primary Rhinoplasty

This article demonstrates the ability to use autologous crushed cartilage grafts in rhinoplasty with rapid recovery and optimal nasal functionality without any tissue damage and allows its rapid rejuvenation. Eligible patients underwent primary rhinoplasty using autologous crushed cartilage graft followed by microscopy imaging of the grafted tissue after recovery. Tissue and cytological analysis using optical microscopy, transmission electronic microscopy (TEM), and scanning electronic microscopy (SEM) showed complete viability of chondrocytes, formation of new collagen fibers, neo-perichondrium, neo-angiogenesis, and exhibiting optimal aesthetic outcome. The surgical approach is easy to perform, feasible, and less time-consuming, with excellent tissue rejuvenation and rapid recovery.

Revision Rhinoplasty Using Glued Diced Costal Cartilage Shaped With Mold for Management of Complicated Silicone Rhinoplasty

BACKGROUND

Complicated silicone nose is a common clinical problem. Selection of replacement material for revision dorsal augmentation is a challenging task.

OBJECTIVES

The authors presented their experience in the use of molded glued diced cartilage graft (GDCG) for revision rhinoplasty in patients who had complicated silicone augmentation.

METHODS

The authors performed a retrospective review of the medical records of 28 patients who underwent silicone implant removal and revision dorsal augmentation with costal cartilage at a tertiary center between February 1, 2018, and February 28, 2022. Patient demographics, surgical technique, anthropometric measurements, and complication data were retrieved and analyzed. Aesthetic outcome scoring and anthropometric measurements were performed.

RESULTS

Twenty-eight patients (9 males and 19 females) who underwent revision rhinoplasty with augmentation were reviewed. The principal indication for revision was cosmetic dissatisfaction. Mean postoperative follow-up duration was 18.3 months. All patients had revision dorsal augmentation with molded GDCG. Other key surgical techniques include the use of caudal septal extension and extended spreader and tip grafts. The majority of the patients were judged to have good or excellent outcomes (91.1%). There were significant percentage increases in dorsal height, radix height, nasal length, and nasal tip projection (2.78%, 2.26%, 7.53%, and 2.40%, respectively; P < .05) and reduction of nasal axis deviation of 1.15° (P < .05) postoperatively. Two patients had postoperative complications, including infection and cosmetic dissatisfaction.

CONCLUSIONS

Revision rhinoplasty following unsuccessful silicone augmentation is commonly encountered in the Asian population. Molded GDCG for revision dorsal augmentation is a reliable option that delivers good to excellent aesthetic outcomes with acceptable complication rates.

LEVEL OF EVIDENCE: 4

Complications of Diced Cartilage Wrapped in Blood Products in Rhinoplasty: A Meta-Analysis

BACKGROUND

Diced cartilage wrapped in blood products has been increasingly advocated in rhinoplasty. The complication is a major concern of the procedure. This meta-analysis aims to assess the complication rates and revision rate of this procedure.

METHODS

All original articles published up to March 2022 were searched through PubMed, Embase, and Web of Science databases. Additional articles were added through reference searching. Articles were included for meta-analysis according to inclusion criteria. Data were extracted by 2 individuals independently and the analysis was conducted through Stata 12.0 software (StataCorp., College Station, Texas).

RESULTS

A total of 559 articles were initially found and an additional 1 article was added through reference searching. A total of 11 articles including 469 patients were included for meta-analysis. The results indicated that the total complication rates were 1.2% for irregularity, 0.2% for visibility, 0.7% for deviation, 1% for erythema, and 0% for graft resorption, depression, and infection. The revision rate was 1.2%.

CONCLUSIONS

The overall complication and revision rates of diced cartilage wrapped in blood products in rhinoplasty were relatively low. Considering the limited number of related studies, a larger sample size, long-term follow-up, clear diagnostic criteria, and detailed methods of measurement are expected in further research.

Viability and Stability of Various-Sized Free Diced Cartilage in an Experimental Study

BACKGROUND

Historically, research of diced cartilage for rhinoplasty has mainly explored the efficacy of wrapped materials, with few studies dedicated to various sizes of diced cartilage.

OBJECTIVES

The authors of this study sought to evaluate the viability and stability of various-sized free diced cartilage.

METHODS

The remaining costal cartilage was harvested during rhinoplasties and implanted into subcutaneous pockets on the backs of nude mice: shaved cartilage (group A, n = 8), diced cartilage with a diameter <0.5 mm (group B, n = 8), 0.5 to 1.0 mm (group C, n = 8), and 1.0 to 1.5 mm (group D, n = 8). After 12 weeks, weight and volume retention rates, histopathological examinations, and biomechanical properties were evaluated.

RESULTS

Cartilage grafts in groups A and B showed an obvious loss of contour and severe dispersion. The weight and volume of cartilage graft in group A were significantly decreased (all P < 0.05). Although there was no significant difference, group D (122.8 ± 15.4%) achieved the highest weight retention rate compared with groups B and C (114.6 ± 7.1% and 114.3 ± 10.1%, respectively). Group A showed the most apparent chondrocyte nucleus loss with the least peripheral proliferation, and group D showed the best regeneration potential (all P < 0.05). Group C achieved less chondrocyte nucleus loss than group B (P < 0.05). The compressive elastic modulus increased with the diameter of diced cartilage (all P < 0.05).

CONCLUSIONS

Diced cartilage with a diameter of 1.0 to 1.5 mm may have the highest viability and stability, followed by those of 0.5 to 1.0 mm and <0.5 mm.

A Combination Method of Costal Cartilage Injection Techniques for Augmentation Rhinoplasty

BACKGROUND

The multiple toothpick-shaped costal cartilage (MTCC) injection technique was introduced as an improvement based on the free diced costal cartilage (FDCC) injection technique for augmentation rhinoplasty. However, radix irregularities may occur when using the MTCC technique. Considering that the FDCC grafts are easier to shape at the nasal radix, we adopted a combination method of the 2 techniques to achieve natural and smooth contour.

METHODS

Four patients accepted this method for augmentation rhinoplasty. Through a unilateral marginal incision, the costal cartilage grafts were injected for nasal augmentation at the subperiosteal plane. The FDCC grafts and the MTCC grafts were used for nasal radix and dorsum augmentation, respectively. Nasal contour was adjusted by external shaping. The follow-up ranged from 24 to 43 months.

RESULTS

All patients were satisfied with the surgical outcome. There were no major complications occurred during the follow-up. One patient underwent rasping revision due to her own beauty-appreciation changes.

CONCLUSIONS

The combination method can take advantages of the FDCC and MTCC injection techniques. It can effectively lower the incidence of contour irregularities and graft displacement. Meanwhile, it is easy to perform without special procedure, and is time-saving and cartilage-saving.

The Effect of Perichondrium and Graft Modification on the Viability of Conchal Cartilage Graft: An Experimental Study in Rabbit

OBJECTIVE

Cartilage grafts are widely used in reconstructing nasal deformity for structural and aesthetic purposes. Despite being immunologically privileged, cartilage grafts are susceptible to volume loss with high risk of resorption over time. Therefore, experts opt for cartilage handling modification to resolve this issue through graft dicing, wrapping, or perichondrium preservation. This study will evaluate the effect cartilage graft preparations on graft viability.

DESIGN

Single-randomized post-test-only study design.

SETTING

Animal Hospital at Bogor Agricultural Institute.

PARTICIPANTS

Six New Zealand, male, Hycole rabbits.

INTERVENTION

Conchal cartilage grafts were retrieved from 6 experimental rabbits and distributed into 3 treatment groups: diced cartilage graft (DC; control), one-sided perichondrium-attached scored cartilage (OPSC), and tube-shaped perichondrium-wrapped diced cartilage (TPDC).

MAIN OUTCOME MEASURES

Macroscopic (weight and contour) and microscopic (chondroblast proliferation, graft thickness, apoptotic cells) evaluation through histological measures were recorded on week 12. Statistical analysis was done to compare between groups.

RESULTS

Diced cartilage and OPSC groups showed significant weight changes on week 12 (P < .05) with OPSC presenting with the biggest difference. Diced cartilage and OPSC group showed moderate cell proliferation on week 12 while TPDC displayed most abundant apoptotic cells (5.8%; P < .05). Diced cartilage group had the highest cartilage thickness ratio (P < .05).

DISCUSSION

Bare DC technique promoted graft thickness while perichondrium-attached scored cartilage showed the most abundant chondroblast proliferation and the least apoptotic cells. Perichondrium contributes to enhanced new cartilage formation.

CONCLUSION

Diced cartilage graft is suitable for masking irregularity and volume augmentation, while perichondrium-attached cartilage graft is better for structural support in nasal reconstruction.

Twelve-Year Experience With Nasofrontal Angle (Radix) Augmentation in Rhinoplasty

ABSTRACT

The nasofrontal angle (radix) has a great impact on the rhinoplasty outcome. Minimal alterations in this area can give an unusual nasal appearance and midfacial length. Different management approaches have been described with regard to radix augmentation. This study aimed to describe the techniques of rhinoplasty, different materials used in the procedure, and results of at least 1 year of follow-up in our 12-year experience in this field. The authors retrospectively reviewed the data of patients who underwent rhinoplasty/septorhinoplasty with radix augmentation performed by 1 of the authors (a senior surgeon at our institution) using different graft materials, between January 2007 and December 2019. Patients younger than 18 years or who were followed up for less than 1 year were excluded from the study. In total, 387 patients (235 [60.7%] female; age range, 19-39 years) were included. Primary procedures were performed in 311 patients (80.5%), and revision procedures were performed in 76 patients (19.6%). Most patients (97%) were satisfied with the aesthetic result. There was no incidence of infection, displacement, or extrusion of the graft. The only complications observed were irregularities; 3% required revision surgery. It is important to consider the nasal radix when pursuing a balanced profile in rhinoplasty. Many graft materials can be used safely and can achieve good aesthetic outcomes. Proper anatomical analysis and patient selection are essential for successful graft placement.

Crushed Septal Cartilage-Covered Diced Cartilage Glue (CCDG) Graft: A Hybrid Technique of Crushed Septal Cartilage

BACKGROUND

Diced cartilage glue (DG) grafts have been widely used in dorsal augmentation but can induce dorsal irregularities. The authors evaluated the postoperative feasibility of a crushed septal cartilage-covered diced cartilage glue (CCDG) graft.

METHODS

The medical records of 38 patients who underwent dorsal augmentation rhinoplasty with an open approach were retrospectively reviewed. DG graft was used in 18 patients (47.4%), and CCDG graft was used in 20 patients (52.6%). Surgical outcomes were assessed by comparing anthropometric data on facial photographs and satisfaction questionnaires on aesthetic outcomes and palpable irregularities on nasal dorsum before and after surgery.

RESULTS

Both groups showed successful aesthetic outcomes. Dorsal height, radix height, and tip projection were all increased postoperatively in both groups. Tip rotation did not significantly increase (p > 0.05). Both groups showed similar outcomes in terms of aesthetic satisfaction but a significant difference in palpable irregularity. CCDG graft group showed significantly better (p = 0.04) satisfaction with dorsal irregularities (4.15 ± 0.75) than the DG graft group (3.56 ± 0.92). CCDG graft group also showed significantly better mean values (p = 0.048) in the degree of irregularity by two surgeons (3.85 ± 0.65) than the DG graft group (3.25 ± 0.97). No patient had significant complaints about irregular dorsum, and none of them underwent a revision rhinoplasty.

CONCLUSION

CCDG graft can be a complementary option for avoiding postoperative irregular dorsum complications.

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 .

Diced Cartilage Techniques in Rhinoplasty

Diced cartilage has been widely applied in rhinoplasty, especially for segmental dorsal augmentation, with favorable outcomes over time. Various techniques were developed to increase both stability and viability of diced cartilage, including wrappings with non-blood material/blood products and changing the shapes of the diced cartilage, while the optimal technique is inconclusive. This article systematically reviews the current strategies of diced cartilage technique for rhinoplasty in the databases and emphasizes different wrapping materials. Free diced cartilage has a potential risk of gathering in certain regions and causing postoperative irregularities. Among non-blood wrapping materials, Surgicel is now rarely used due to severe foreign body reactions. The obvious drawbacks of fascia are donor site morbidity, inadequate quantity, and time-consuming. Although diced cartilage wrapped in tutoplast-processed fascia lata, AlloDerm, or esterified hyaluronic acid has achieved primary encouraging results, the increased inflammation raised controversies regarding their clinical use. Diced cartilage wrapped with blood products, such as platelet-rich fibrin or concentrated growth factor, achieved long-term reliable aesthetic results, and shaved cartilage and ultra-diced cartilage have recently shown satisfactory clinical outcomes, while further study is still needed. 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 .

Effects of Esterified Hyaluronic Acid, Adipose Tissue, and Blood Glue on Survival of Diced Cartilage Grafts

OBJECTIVES

Diced cartilage grafts are used for correcting nasal dorsal deformities and irregularities. However, cartilage resorption is among most common problems after rhinoplasty. The purpose of this experimental study was to investigate the effects of esterified hyaluronic acid, adipose tissue, and blood glue on the viability of diced cartilage grafts.

METHODS

A total of 24 Wistar albino rats were used for the study. Cartilage grafts were obtained from 1 side ear and diced. The rats were divided into 4 groups (6 in each group): bare diced cartilage (group 1), diced cartilage wrapped with adipose tissue (group 2), diced cartilage blended with blood glue (group 3), and diced cartilage wrapped with esterified hyaluronic acid (group 4). The grafts were inserted into the subcutaneous pockets of the back of same rat. After 2 months follow-up specimens were harvested for histopathological and dimensional examination. The sections were stained with Hematoxylin and Eosin, Masson-Trichrome, and Elastic Van-Gieson. Chronic inflammation, loss of chondrocyte nucleus, vascularization, foreign body reaction, collagen content of matrix, and extent of elastic fiber were assessed under light microscopy.

RESULTS

Foreign body reaction in adipose tissue and blood group was significantly higher than bare cartilage and esterified hyaluronic acid group (P = 0.001). With respect to loss of chondrocyte nucleus esterified hyaluronic acid group had significant higher rate of nucleus loss than other groups (P = 0.002).

CONCLUSIONS

This study suggests that blood glue, esterified hyaluronic acid and autologous adipose tissue have not beneficial effects in improving viability of diced cartilage grafts.

The Silicone Turkish Delight for Dorsal Augmentation in Rhinoplasty

ABSTRACT

Rhinoplasties are the most challenging facial aesthetic procedures with the majority of the cases requiring dorsal augmentation either in the form of autogenous or alloplastic materials. Although autogenous grafts are the gold standard, these grafts have their innate issues such as donor site morbidity, occasional displacement, resorption, tendency to warp or develop sharp edges over time with increased perceptibility and clinical visibility of the graft with time. These issues were addressed by Erol in 2000 who advocated the use of finely diced autologous cartilage wrapped in a monolayer of surgical and termed it Turkish delight. This technique has been extensively modified by surgeons across the world with an attempt to forgo the use of autogenous grafts preventing donor site morbidity and replacing it with alloplastic materials. Silicon's inert nature, resorption resistance, absence of a secondary surgical site and economical value make it a widely utilized allograft augmentation option in Asian countries. The authors hereby present a modification of the original Turkish delight technique by utilizing diced silicone pieces amalgamated with 1 to 2 ml of autologous blood and wrapped in monolayer of surgicel (oxidized cellulose). The technique produced clinically stable results in 27 patients who were followed up for a period of 24 to 60 months (average 30 months). Improved pliability, negated risk of graft extrusion with no donor site morbidity are the key advantages of this technique over conventional autologous grafts and silicon block augmentation techniques. These results point towards the viability of the technique for performing dorsal augmentation in rhinoplasty.

Comparison of Free Diced and Multiple Toothpick-Shaped Costal Cartilage Injection Techniques for Augmentation Rhinoplasty

BACKGROUND

The free diced costal cartilage (FDCC) injection technique has been used in the augmentation rhinoplasty for a long time. In order to lower the incidence of nasal contour irregularities and graft displacement, we developed the multiple toothpick-shaped costal cartilage (MTCC) injection technique. This comparative study was conducted to introduce and assess this new technique.

METHODS

This retrospective analysis included 51 patients who underwent augmentation rhinoplasty with either the FDCC or MTCC injection technique at the 17th Department of Plastic Surgery in the Plastic Surgery Hospital between July 2014 and May 2020. The patients were divided into the FDCC (n = 30, 58.82%) and MTCC (n = 21, 41.18%) groups. General data, postoperative patient satisfaction, complications and revision rate were compared between the groups.

RESULTS

Except for the follow-up period, there were no significant differences in general data (age, sex, preoperative dorsum deformity, preoperative rhinoplasty history) between the groups. Postoperative patient satisfaction, complications and revision rate were similar between the two groups.

CONCLUSIONS

The MTCC injection is a safe and effective technique for augmentation rhinoplasty. Like the FDCC injection technique, the new technique is relatively easy to perform and time-saving with concealed scarring and minimal postoperative edema. Most of its revision surgeries are also easy to perform by simple rasping and reinjection. According to our experience, the new technique may have wider indication as well as lower incidence of nasal contour irregularities and graft displacement. Therefore, we suggest that the MTCC injection technique is reliable and worthy of recommendation.

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 .

Ultra Diced Cartilage Graft in Rhinoplasty: A Fine Tool

BACKGROUND

Free diced cartilage smaller than 0.2 mm in diameter to smoothen the nasal dorsum is a well-known procedure. However, creating smaller diced cartilage takes a really long time. In contrast, the free diced cartilage technique has some visibility problems, especially in thin-skin patients, although a fine job is done to chop the cartilage. The author aimed to present the "ultra diced cartilage graft" and the way to achieve it, to eliminate the problems of diced cartilage during rhinoplasty, and compare it with free diced cartilage grafting technique.

METHODS

Between April of 2015 and December of 2018, the ultra diced cartilage graft technique in 104 patients and the free diced cartilage graft technique in 113 patients were used to smoothen the dorsum or augment the radix/dorsum. Operation records, rhinoplasty outcome evaluation questionnaire, palpation test, and evaluation of the immediate postoperative photographs on the table with postoperative 1-year postoperative photographs by two independent blinded plastic surgeons were analyzed.

RESULTS

Ultra diced cartilage seemed superior to free diced cartilage grafting with regard to graft visibility and resorption.

CONCLUSIONS

Ultra diced cartilage graft is an effective and easily reproducible technique in rhinoplasty. There is no extra cost, and it is the easiest and fastest way to have this perfectly pliable cartilage have no dead space. The ultra diced cartilage grafting technique should be known by all plastic surgeons to achieve fineness in rhinoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Long-Term Complications from Diced Cartilage in Rhinoplasty: A Meta-analysis

Objective: To analyze the incidences of long-term complications and revision surgery associated with diced cartilage grafts in dorsal augmentation rhinoplasty. Methods: The PubMed, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for clinical studies on the use of diced cartilage for dorsal augmentation published. A meta-analysis was conducted to pool the estimated rates of infection, overcorrection, visible irregularity, absorption, and revision surgery. Result: A total of 14 studies involving 2380 patients were included in the systematic review. The combined rates were 11.5% for overall complications and 5.3% for revision surgery. The rates of the most frequently reported complications were 4.5% for infection, 5.3% for visible irregularity, 0.7% for overcorrection, and 0.5% for absorption. There was no significant difference in the rates of visible irregularity (p = 0.23) and revision surgery (p = 0.71) among the wrapped diced cartilage, glued diced cartilage, and free diced cartilage groups. Conclusion: This meta-analysis presents the first comprehensive and quantitative report of long-term complications associated with diced cartilage in dorsal augmentation rhinoplasty. Infection and visible irregularity were the most frequently reported complications. The rates of irregularity and revision surgery were not correlated with the diced cartilage packing methods.

Efficacy and Safety of Lyophilized Articular Cartilage Matrix as an Injectable Facial Filler

OBJECTIVE

To evaluate the efficacy and safety of an injectable lyophilized articular cartilage matrix (LACM) which is in the form of cartilage powder that may increase the convenience of use and become unaffected by donor site morbidity as a potential filler.

METHODS

The safety test was conducted using 20 rabbits with an intravascular embolization model. Commonly used commercial hyaluronic acid (HA), acellular dermal matrix (ADM), polymethyl methacrylate (PMMA), and polylactic acid (PLA) products were selected for comparison of efficacy and adverse effect of LACM. The efficacy test was performed using 30 mice subcutaneous buttock-injection model. Gross assessments of the changes in size of injected materials and histological examinations were conducted.

RESULTS

Regarding the safety test, in one rabbit in the HA group, complete blurring occurred in the left eye, and necrosis of the posterior auricular artery was observed in one rabbit in the ADM group. In the ADM, severe ecchymosis around the injection sites was observed, and the bruises lasted longer than in the other groups. The LACM exhibited faster bruise resolution. Comparing the changes in size between weeks 4 and 12 in the mouse model, no significant changes in size were observed in the LACM (p = 0.359), HA (p = 0.421), and ADM (p = 0.097), but a significant change was observed in the PMMA (p = 0.001). In the histological examination, LACM exhibited well-demarcated margins with good biocompatibility.

CONCLUSION

The LACM shows potential as a facial filler according to the in vivo safety and efficacy tests LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Lengthening of the Asian Nose

The Asian nose has its unique morphology and forms a significant proportion of noses treated by the rhinoplasty surgeon not only in Asia but also in other countries where the Asian diaspora resides. The anatomical features and dimensions of the Asian nose differ from noses of persons of African, Caucasian, Indian, and Middle Eastern origins, poses its own challenges, and warrants a unique set of techniques for its aesthetic improvement. In this article, we present an overview of the approach to the lengthening of the Asian nose, drawing from our own experience with managing the Asian nose and referencing the published literature on the subject.

"Radix Pillow" Constructs with Fascial Extension for Radix Augmentation in Primary Rhinoplasty

Temporalis fascia and diced cartilage, in varying combinations, are currently commonly employed for augmentation of the radix in rhinoplasty. Although existing literature is replete with papers and suggested variations, there is some lack of practical detail on how to use such techniques. The authors present a reproducible, multilayered, "pillow" construct of temporalis fascia for selective radix augmentation in primary rhinoplasty, with or without the addition of diced cartilage. Precise measurements for accurate multiple folding, exact tailoring of the construct to recipient size dimensions, and fixation by a "litter" concept with proximal and distal fixation point are key to this technique. 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 .

Grafting in Modern Rhinoplasty

Rhinoplasty is considered one of the most technically difficult surgical procedures because of the limited access and requirement for three-dimensional visual perception and manipulation. Grafting is an essential part of primary and secondary rhinoplasties and forms the foundation for a successful functional and aesthetic outcome. Septal cartilage is the most commonly used grafting material, although many reliable alternatives exist. No randomized clinical trials have been conducted comparing graft materials and techniques for specific indications. In this review, the authors discuss the most common grafting materials and configurations used in the modern rhinoplasty.

Diced Cartilage in Fibrin Glue for Dorsal Reconstruction as Part of Staged Paramedian Forehead Flap Reconstruction

The use of diced cartilage grafting is a powerful tool during rhinoplasty for dorsal augmentation; however, its application to nasal structural reconstruction has rarely been reported. Here we present a unique technique for Mohs defect reconstruction combining diced cartilage graft for dorsal augmentation and a folded paramedian forehead flap for soft tissue. A 54-year-old female presented with recurrent basal cell carcinoma of the nose that had been previously resected 3 times in the past. This was treated with Mohs surgery resulting in a through and through nasal defect. This was reconstructed with a staged folded paramedian forehead flap with staged. Due to a loss of dorsal volume and definition creating an excess supratip break, a diced cartilage graft with fibrin glue and temporalis fascia was used for dorsal augmentation. The use of diced cartilage has regained popularity over the last 2 decades with multiple techniques utilizing diced cartilage alone, wrapped in fascia, covered in fascia, wrapped in oxidized methylcellulose, or solidified with fibrin glue. Literature describing the use of fibrin glue suggests that it improves wound healing by promoting cartilage growth, stabilization, and diffusion of nutrients to the graft. Its malleable nature allows for adjustments after the initial placement. This report demonstrates the viability of diced cartilage graft for dorsal augmentation with a paramedian forehead flap for nasal reconstruction. This technique can serve as a powerful tool for the nasal reconstructive surgeon needing scaffolding to rebuild and define the nasal dorsum.

The SPF-SPLF Graft: Building the Ideal Dorsum in Revision Rhinoplasty

Achieving a natural appearing dorsum in secondary rhinoplasty remains an elusive goal. An inherent contradiction exists between the two most usually used techniques: solid rib segment and diced cartilage fascia constructs. The former will often cause edge visibility, in addition to potential warping and distortion; the latter prevents from both but may generate obtuse, ill-defined borders with poor shape control, possible contour asymmetries, and often a tubular appearance. A solution to the equation can be found in an innovative technique that combines three elements: perichondrium, rectus fascia, and a rib lamination. The combination is called the sandwich of perichondrium and fascia (SPF) or the sandwich of perichondrium, rib lamination, and fascia (SPLF). As a single unit over the entire dorsum, the issues of junction irregularity inherent in the use of separate graft segments, and of asymmetries in the dorsal contour because of inadequate distribution of diced cartilage, are avoided. In a greater than 18-month experience on 23 cases at the time of writing, the SPF-SPLF graft has proved to be an ideal solution. Adequate edge definition and elegant related shadowing are provided, precise tailoring is attained, and proper height of the dorsum contour is reestablished, following adequate reconstruction of the underlying dorsal plateau. The gradual flow from SPF to SPLF is logical and progressive according to need, and proper fixation ensures long-term stability of the hybrid construct. All three elements required are harvested from the same donor site with a resulting minimal scar.

The Effect of Perichondrium on Biological and Biomechanical Properties of Molded Diced Cartilage Grafts

BACKGROUND

Diced cartilage is a significant alternative approach to cartilage grafting. However, the viability and biomechanical properties of diced cartilage grafts remain to be improved, and the role of perichondrium is largely neglected. This study aimed to evaluate the histological and biomechanical effects of perichondrium on custom-shaped diced cartilage grafts constructed via a high-density porous polyethylene mold.

METHODS

Seven New Zealand rabbits were used. Unilateral auricular cartilage was harvested and divided into 2 parts, with or without perichondrium, diced into 1 × 1 × 0.5 mm cubical pieces, and filled into high-density porous polyethylene molds. Three grafts with the perichondrium removed and 3 with the perichondrium preserved were implanted subcutaneously at the dorsum. The grafts underwent biomechanical and histological tests 4, 8, and 12 weeks after the implantation.

RESULTS

The diced cartilage merged into integrated blocks without observable resorption in both groups at each time point. Additionally, the retention rate of weight was higher in the perichondrium-preserved group (P < 0.05). We observed regenerated cartilage that stained positively for type II collagen and glial fibrillary acidic protein (GFAP). A greater area of regenerated cartilage and higher scores of GFAP staining were observed in the perichondrium-preserved group (P < 0.05). The yield stress and modulus of elasticity were also higher in the perichondrium-preserved grafts from week 8 after implantation (P < 0.05).

CONCLUSIONS

Diced cartilage grafts with a custom shape can be constructed using a high-density porous polyethylene mold. The preservation of perichondrium can improve graft viability and biomechanical properties.

LEVEL OF EVIDENCE

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Use of Nasal Implants and Dorsal Modification When Treating the East Asian Nose

Dorsal augmentation and tip surgery are essential procedures for East Asians seeking rhinoplasty, because they generally have thicker skin and poorly developed nasal dorsum and tip. For dorsal augmentation, many Asian surgeons prefer using alloplastic material, like silicone, Gore-Tex, and filler injection, for cost-effectiveness, easy handling, and short operation times. Compared with autologous implant materials, the use of synthetic implant is suggested to be associated with many complications, such as infection, extrusion, and deviation. However, even with the use of the autologous material, problems such as reabsorption after grafting, donor site complications can take place.

Rib cartilage in Asian rhinoplasty: new trends

PURPOSE OF REVIEW

Costal cartilage has many advantages over other grafting materials because of its large quantity and high biocompatibility. As a result, it has been considered as a good option for Asian rhinoplasty. However, costal cartilage is difficult to use and is associated with a high complication rate. To avoid the disadvantages and complications of costal cartilage graft, several techniques have been proposed in the literature. This review addresses the conventional uses of costal cartilage in Asian rhinoplasty and recent updates.

RECENT FINDINGS

Different techniques have been reported for Asian rhinoplasty using costal cartilage. Solid-block costal cartilage and diced cartilage with or without wrapping materials are widely used for dorsal augmentation. Many different grafting techniques for the tip and septal reconstruction have been reported by numerous surgeons. When using costal cartilage graft, surgeons should pay attention to both graft complications, such as warping or infection, and donor-site morbidity. Several strategies have recently been developed to avoid these complications.

SUMMARY

This article summarises grafting options for Asian rhinoplasty using costal cartilage and possible complications. This information may assist with proper selection of appropriate techniques for harvesting, carving and grafting costal cartilage.

Use of a fibrinogen-thrombin sponge in rhinoplasty

BACKGROUND

Although several methods have been described to address nasal dorsum augmentation and smoothing of irregularities in rhinoplasty, establishing the ideal method has proven controversial.

OBJECTIVE

Here, we introduce a novel technique of cartilage grafting for nasal dorsum augmentation by wrapping cartilage in a fibrinogen- and thrombin-coated collagen patch called TachoSil®.

MATERIAL AND METHODS

In a pilot study comprising ten cases, the use of the collagen patch was examined in various indications in rhinoplasty. Patients were clinically monitored for up to 8 months and photometric and sonographic documentation was performed pre- and postoperatively.

RESULTS

In nine patients, the collagen patch was used for fixation of cartilage grafts in different indications: saddle nose deformities (n = 5), open roof (n = 1), nasal dorsum irregularities (n = 3). A diced cartilage graft enclosed by a bilayer of TachoSil® was applied in seven patients. Solid pieces of cartilage were either embedded in a bilayer of the collagen patch (n = 1) or covered by a monolayer (n = 1). Moreover, the collagen patch alone served as a soft tissue support in one patient with thin skin. Six patients were revision cases. All patients had uneventful healing without adverse events such as allergic reactions and infections.

CONCLUSION

The collagen patch TachoSil® is eligible for various indications in rhinoplasty. It is a useful material predominantly for nasal dorsum augmentation by sandwiching diced or solid cartilage in the collagen patch, leading to better graft fixation and precise profile shaping. At the same time, TachoSil® helps with blood control. Follow-up studies will be performed to assess the material's long-term behavior.

Evaluation of A Well-Known Technique with Ultrasound: Dorsal Grafting in Rhinoplasty

OBJECTIVE

We aimed to evaluate the survival of a well-known camouflage technique using ultrasound imaging of the graft through the nasal dorsum and supratip.

MATERIAL AND METHOD

Twenty-two patients (8 women and 14 men) who underwent primary rhinoplasty performed by the same surgeon in Isparta, Turkey, between December 2013 and February 2015, were evaluated in this retrospective study. We used the remaining pieces of harvested septal cartilage during rhinoplasty as autologous graft material and venous blood mixture as a scaffold in a Turkish Delight fashion. We used a 10- to 14-MHz broadband linear ultrasound probe (Toshiba Aplio MX ultrasound system, Toshiba Medical Systems, Tustin, California). The mean total skin thickness values through bone (nasal dorsum) and cartilage (upper lateral cartilage) were calculated for each patient. Data were recorded for statistical analysis. We evaluated the patients pre- and postoperatively on the seventh day, first month, sixth month, and just before the end of the first year using ultrasonography. We made detailed ultrasonographic images of the skin and the underskin through the bone sculpture and compared the measurements. All patients were scanned at the same time of day to exclude diurnal variation of dermal edema. Patients who presented for primary functional rhinoplasty were included in the study.

RESULTS

Nasal dorsum cartilage was significantly thicker on the seventh postoperative day, but the difference was not statistically significant in the sixth month after surgery compared with baseline values. There was no statistically significant difference between preoperative measures and measures in the sixth month. The difference in supratip thickness was significantly greater on the seventh postoperative day, and there was a large difference at the first month compared with preoperative values, but this did not reach significance. There was no significant difference in supratip thickness between pre- and postoperative values at the sixth month.

CONCLUSION

This method can be easily performed to reduce visual and tactual irregularities on the dorsum of the nose and can promote perfection on the dorsal esthetic line, but it is not sufficient for augmentation.

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 the online Instructions to Authors www.springer.com/00266 .

The hydroxyapatite Turkish Delight: a technical note

Nasal dorsum augmentation is commonly performed using autologous cartilage grafts, also in the Turkish Delight technique. The aim of this study was to describe a modification of the Turkish Delight technique for dorsal augmentation consisting of small hydroxyapatite-calcium carbonate granules (0.5-1 mm) that were wrapped in layers of oxidized cellulose and glued with 1-2-cm3 fibrin sealant and to compare its utility with that of other techniques. Clinically stable and satisfactory results were achieved in the four cases examined. Cone-beam computerized tomography (CBCT) imaging revealed that there was no degradation of the graft up to 2 years after surgery. The use of a modified Turkish Delight method using hydroxyapatite granules promises to be a valuable option for the correction of nasal dorsum deficiency.

Free Diced Cartilage: A New Application of Diced Cartilage Grafts in Primary and Secondary Rhinoplasty

BACKGROUND

Irregularities or deformities of the nasal dorsum after hump reduction account for a significant number of revision rhinoplasties. The authors therefore developed a technique of meticulously dicing and exactly placing free diced cartilage grafts, harvested from septum, rib, or ear cartilage. The cartilage paste is used for smoothening, augmentation, or camouflaging of the nasal dorsum in primary or revision rhinoplasties.

METHODS

A retrospective analysis of multisurgeon consecutive open approach rhinoplasties from January to December of 2014 was conducted at a single center. The authors compared the outcome of three different techniques to augment or cover the nasal dorsum after an observation period of 7 months. In group I, 325 patients with free diced cartilage grafts as the only onlay were included. In group II, consisting of 73 patients, the dorsal onlay was either fascia alone or in combination with free diced cartilage grafts. Forty-eight patients in group III received a dorsal augmentation with the classic diced cartilage in fascia technique.

RESULTS

Four hundred forty-six patients undergoing primary and secondary rhinoplasties in which one of the above-mentioned diced cartilage techniques was used were included in the study. The authors found revision rates for dorsal irregularities within the 7-month postoperative observation period of 5.2, 8.2, and 25 percent for groups I, II, and III, respectively.

CONCLUSION

The authors' findings strongly support their clinical experience that the free diced cartilage graft technique presents an effective and easily reproducible method for camouflage and augmentation in aesthetic and reconstructive rhinoplasty.

Effect of Concentrated Growth Factor on Survival of Diced Cartilage Graft

BACKGROUND

Diced cartilage grafts are important in rhinoplasty for raising the dorsum and eliminating dorsal irregularities. The most common problems with the use of diced cartilage are wrapping and cartilage resorption.

OBJECTIVES

To histopathologically investigate and compare the viability of diced cartilage grafts wrapped with concentrated growth factor, fascia and fenestrated fascia, or blood glue.

METHODS

Cartilage grafts were harvested from the ears of 10 New Zealand White rabbits and diced into 0.5 to 1 mm³ pieces. The grafts were divided into five groups for comparison: (1) bare diced cartilage; (2) diced cartilage wrapped with fascia; (3) diced cartilage wrapped with fenestrated fascia; (4) diced cartilage wrapped with concentrated growth factor (CGF); and (5) diced cartilage wrapped with blood glue. Each of the five grafts was autologously implanted into a subcutaneous pocket in the back of each rabbit. Three months later, the rabbits were sacrificed and the implants were harvested and examined histopathologically.

RESULTS

Nucleus loss, calcification, inflammation, and giant cell formation differed significantly between the CGF group and both fascia groups. Chondrocyte proliferation was the highest in the CGF group. Nucleus loss rates were similar between the fascia and fenestrated fascia groups.

CONCLUSIONS

Our findings suggest that CGF improves the viability of diced cartilage grafts, while fascia hampers it. Punching holes in the fascia does not improve diced cartilage graft viability and neither does blood glue wrapping.

Histology and Long-term Stability of Diced Cartilage Graft for Revision Rhinoplasty in a Cleft Patient

Diced cartilage graft wrapped in Surgicel or fascia has been widely reported in the literature. Pure diced cartilage graft without the use of a “sleeve,” on the contrary, is not as commonly reported. This could be due to concerns of graft dispersion, palpability, or visibility. In this case report, histologic findings of a pure diced cartilage graft placed 4½ years ago are reported. In addition, advantages and disadvantages of this technique are discussed in detail. Two pieces of the diced cartilage graft placed 4½ years prior were excised and sent for histologic analysis during a revision procedure. The microscopic examination reveals several small blocks of mature hyaline cartilage embedded in dense fibrous connective tissue with widely scattered small vascular channels. The cartilage is vital with scattered chondrocytes within their lacunae. Histology of the diced cartilage graft demonstrated viability and stability of the graft 4½ years after insertion. This case report also suggests that pure diced cartilage graft can provide reliable volume augmentation of nasal dorsum in cleft rhinoplasty.

Controversies in Revision Rhinoplasty

Revision rhinoplasty is a complex operation with many variables that may influence the final esthetic and functional outcome of the procedure. Cartilage forms the structural framework of the lower two-thirds of nose and is essential for long-term support and maintenance of a patent nasal airway. The use of autologous cartilage grafting is the primary source of this material, limited by donor site quantity, quality, and harvest morbidity. Alloplastic materials, solid and injectable, are often used for augmentation purposes and may have devastating consequences. This article discusses past and current treatment concepts for various nasal deformities using available autologous grafting techniques.

Platelet-Rich Fibrin Improves the Viability of Diced Cartilage Grafts in a Rabbit Model

BACKGROUND

Diced cartilage may be wrapped with synthetic or biological materials before grafting to a recipient site. These materials have unique advantages and disadvantages, and a gold standard is not available.

OBJECTIVES

The authors investigated the effects of platelet-rich fibrin (PRF) on the survival of cartilage grafts in a rabbit model.

METHODS

In this experimental study, diced cartilage pieces from the ears of 9 male rabbits were left unwrapped or were wrapped with PRF, oxidized regenerated cellulose, or fascia. Specimens then were placed into subcutaneous pockets prepared on the backs of the rabbits. The animals were sacrificed 2 months after the procedure, and the grafts were excised for macroscopic and histopathologic examination.

RESULTS

The cartilage graft wrapped with PRF showed superior viability compared with the cartilage graft wrapped with oxidized regenerated cellulose. No significant differences were found among the other groups. The groups were not significantly different in terms of rates of inflammation, fibrosis, or vascularization.

CONCLUSIONS

PRF enhances the viability of diced cartilage grafts and should be considered an appropriate biological wrapping material for cartilage grafting.

Clinical effectiveness and safety of collagen sheet for dorsal augmentation in rhinoplasty

In Asian rhinoplasty, dorsal augmentation often requires the use of alloplastic materials because sufficient amounts of autograft are difficult to harvest. Given considerations of aesthetics, costs, and the characteristics of the oriental nose, silicone or Gore-Tex is commonly used when augmenting the nasal dorsum to a great extent. Such materials can often result in postoperative complications and foreign-body sensations. Moreover, extrusion or visualization of the implant may occur because of thinning of the skin over time. Permacol collagen implants are specifically indicated for soft tissue reinforcement and repair of the head and face in plastic and reconstructive surgery. The handling versatility of the flexible collagen sheet allows it to be layered over itself until the requisite thickness and desired shape are obtained. A total of 50 patients who underwent nasal augmentation rhinoplasty between December 2007 and May 2011 were observed for at least 24 months. Depending on the nasal dorsum, we layered the collagen sheet up to a maximum of 4 times and we have not seen any case of severe resorption or overcorrection in the nasal configuration. Collagen implant material is safe for use in select rhinoplasty patients because of its low complication rate, as shown in our series. It could therefore be considered as a useful alternative when reconstruction is problematic because of the low quality or lack of available autologous grafts.

A comparison of diced cartilage grafts wrapped in perichondrium versus fascia

Cartilage grafts are the most commonly used grafts for structural and aesthetic purposes. This study aimed to compare the viability of diced cartilage grafts wrapped in fascia with diced cartilage grafts wrapped in perichondrium. Approximately 2 × 2 cm cartilage grafts were harvested from the ears of seven New Zealand rabbits, diced to approximately 1-mm cubes, and then wrapped in perichondrium harvested from the ears or muscle fascia harvested from the right rear leg of the same rabbits. The wrapped grafts were then weighed and implanted into two paravertebral subcutaneous cavities created on the shaved backs of the donor rabbits. After 3 months, the rabbits were sacrificed and the grafts were removed, weighed and examined histopathologically. We found no statistically significant difference in the weights of the two graft types before and after embedding. The mean chondrocyte viability was 87.14 % in the perichondrium-wrapped cartilage grafts and 41.43 % in the fascia-wrapped grafts, which was determined to be statistically significant. Overall, our findings show that cartilage grafts wrapped in perichondrium led to higher chondrocyte viability and graft survival rates as compared with grafts wrapped in fascia. This method may be used as an alternative in clinical practice to provide patients requiring cartilage grafts with positive long-term effects, lower morbidity and lower costs associated with the procedure.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Comparison of outcomes using diced cartilage with or without tensor fascia latae wrapping in rabbits

BACKGROUND

Diced cartilage has been associated with several advantages and rewarding results, leading to its widespread application in various forms in rhinoplasty, but the outcomes of diced cartilage with and without tensor fascia latae wrapping have not been widely reported in evidence-based articles.

OBJECTIVES

The authors compared changes in weight, size, and histology of both bare and fascia-wrapped diced cartilage in rabbits as a model for human surgical outcomes.

METHODS

One auricle from each of 15 rabbits was divided into 2 pieces, and both samples were diced. The tensor fascia latae of the rabbit was wrapped around 1 cartilage specimen from each rabbit (group A specimen); the other specimen received no wrapping (group B specimen). A group A specimen and a group B specimen were implanted into separate subcutaneous pockets in each rabbit. After 3 months, samples were removed from the recipient beds and weighed to compare pre- and postoperative weights. All specimens were examined for evidence of cartilage viability by histologic methods.

RESULTS

There was a significant decrease in the weight of cartilage in group A. A nonsignificant weight increase was observed in group B. Histologic analyses of 5 parameters revealed no significant differences between the 2 groups, except for a significantly greater amount of new cartilage formation in group B.

CONCLUSIONS

Any type of wrapping around diced cartilage may inhibit its access to surrounding nutrients. Dicing increases the absorption surface, which may result in some overgrowth, but wrapping may have a negative impact on the viability of the diced cartilage.

LEVEL OF EVIDENCE

4.

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 .