Diced cartilage combined with warm blood glue for nasal dorsum enhancement

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.

The current techniques in dorsal augmentation rhinoplasty: a comprehensive review

BACKGROUND

An essential aspect of rhinoplasty is the enhancement of the nasal dorsal contour by performing dorsal augmentation (DA) rhinoplasty. A wide range of techniques are available for DA as the demand for aesthetic nasal refinement grows. This review aims to provide a comprehensive overview of the current techniques used in DA rhinoplasty.

MAIN BODY

Research articles on DA rhinoplasty techniques were identified through a comprehensive literature search. Scopus, PubMed, and Web of Science were used as electronic databases. Each database was searched for articles published since its inception. DA rhinoplasty techniques were examined in this literature review. Methodological quality was assessed for the selected studies, and data was extracted to examine materials used, surgical approaches, and reported outcomes for each technique. Various DA methods, including autologous grafts and synthetic implants, are examined in-depth in this review. Comparing approaches can help better understand their respective advantages and limitations.

CONCLUSION

A wealth of techniques is available for DA rhinoplasty, each with advantages. Patients' nasal anatomy, desired outcomes, and potential risks must be considered by surgeons when determining their surgical approach. DA methods continue to evolve rapidly, creating a need for a thorough understanding of the current landscape to make informed decisions.

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.

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.

Cartilage Chips in Rhinoplasty

OBJECTIVE

 This study reveals that the cartilage chips can be a good solution for camouflage and augmentation in rhinoplasty.

METHODS

 In this study, 64 patients who had undergone rhinoplasty from 2014 to 2019 were retrospectively studied. The average age was 31. Forty-nine patients had primary and 15 revision rhinoplasties. Cartilage chips were cut into less than 0.5-mm thickness dimensions changing from 2 to 10 mm. They were used to fill deep radix, depressions at the key area, supratip area, around the grafts to prevent their visibility at the tip. In addition, they were used in the fascia for augmentation. The cartilage chips were sculpted from the septal cartilage in 47, rib in 16, and ear cartilage in one case.

RESULTS

 They were applied on the radix in 25, middle vault in 37, supratip area in 32, and on the tip in 12 cases. In 30 cases, cartilage chips were mixed with cartilage dust for better fixation and camouflage. They were placed in the fascia in three cases for dorsal augmentation. Complications were seen in three cases in the form of irregularities.

CONCLUSION

 Cartilage chips are found to be a powerful solution in terms of camouflage and augmentation.

Use of an Autologous Diced Cartilage Graft and Fat Graft Combination to Improve Regeneration in Rhinoplasty

BACKGROUND

In rhinoplasty, many techniques are used to increase the permanence of the planned final shape of the nose. Cartilage grafts can be diced and applied directly to the nasal dorsum, or by wrapping with a material. We aim to show that mixing and using diced cartilage grafts with fat grafts can contribute to the viability of cartilage grafts by comparing our early postoperative and long-term results.

MATERIALS AND METHODS

A total of 228 cases were analyzed. Postoperative 1-month, 6-month, and 1.5-year photographs of the patients were compared and the places that descended on the nasal dorsum were measured. In addition, dorsal height was measured and compared. Preoperative and postoperative first-year rhinoplasty outcome evaluation scales were performed. Specimens from 6 patients were examined histopathologically.

RESULTS

After the first month, the mean regression in the dorsum was measured as 1.4 mm. The decrease in dorsal height between 1 month and 6 months was significantly greater than the decrease between 6 months and late periods. According to the rhinoplasty outcome evaluation (ROE) scale, the average preoperative score of the patients was 45, while the mean postoperative score was 81.5. The viability of chondrocyte cells was measured as 85-90% histopathologically.

CONCLUSION

This approach has been evaluated as an application that satisfies both the surgeon and the patient due to the advantages of fat grafts such as preventing the cartilage and osteotomy lines from being palpated in thin-skinned patients, holding the diced cartilage grafts together by acting as a glue, increasing the viability of cartilage grafts.

LEVEL OF EVIDENCE IV

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

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 .

"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 .

The Role of Skin Thickness in the Choice of a Rhinoplasty Technique for Thin-Skinned Patients: Analysis of Long-Term Results and Patient Satisfaction

INTRODUCTION

This randomized controlled study aimed to analyse the long-term results of thin-skinned patients who underwent rhinoplasty.

MATERIALS AND METHODS

All the included study patients had the following characteristics: underwent primary rhinoplasty for functional and/or cosmetic problems, were thin-skinned, had been followed for almost 2 years, underwent both standard pre- and post-operative photography, had a good understanding of the Italian language, and had signed a consent form for inclusion in the study. The patients were randomly divided into 4 groups as follows: group 1, camouflage of the dorsum by diced cartilage; group 2, camouflage of the dorsum with lipofilling; group 3, camouflage of the dorsum by a temporal fascia graft; and group 4 (control group), without camouflage of the dorsum. Patients answered the Italian version of the FACE-Q rhinoplasty module. The Obagi skin pinch test was used to measure nasal skin thickness. We compared pre- and post-operative patient satisfaction with the appearance of their nose between the 4 patient groups by the Chi-squared test for unpaired data. Two plastic surgeons reviewed all the post-operative photographs of the study patients and rated the photographs on a scale of 1 to 5.

RESULTS

A total of 101 patients who underwent primary rhinoplasty between January 2016 and March 2018 in our department of plastic surgery and satisfied the inclusion criteria were enrolled in this study. The mean patient age was 38.5 years. The mean follow-up time was 2.5 years. The differences between the preoperative and post-operative FACE-Q values for group 1 were significant (P < 0.01), whereas the differences between the preoperative and post-operative FACE-Q values for the other groups were not significant. The results for group 1 patients remained stable over the long-term follow-up compared with the results for other groups (P < 0.01). Groups 2 and 4 underwent more secondary procedures than groups 1 and 3 (P < 0.01). The 2 reviewers determined that patient groups 1 and 3 obtained more satisfactory outcomes than groups 1 and 4 (P < 0.01).

CONCLUSIONS

This was the first randomized study to demonstrate that diced cartilage grafts used for thin-skinned patients was the best approach for obtaining a satisfactory long-term outcome and durable natural appearance.

LEVEL OF EVIDENCE I

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 .

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.

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.

Autogenous control augmentation system - A refinement in diced cartilage glue graft for augmentation of dorsum of nose

Background

In the context of different grafts being used for dorsal augmentation, diced cartilage with glue has gained worldwide acceptance.

Aims

To develop a system of tools to objectively evaluate the desired dimensions of the required graft for dorsal augmentation and to prepare a corresponding customized-glued-diced cartilage construct.

Materials and Methods

A modification of the diced cartilage glue technique called Autogenous control augmentation system (ACAS) was used in ten patients.

Results

Of the ten patients, in which this technique was used, eight underwent primary rhinoplasties and two underwent secondary rhinoplasties between July 2017 and December 2017 with a follow-up ranging from 3 to 8 months. In all the cases, the dorsum is straight, and height is maintained.

Conclusion

The technique has all the advantages of the diced cartilage glue. The shape resembles alloplastic implant with height and width varying from radix to tip. There is tapering of the cephalic and caudal ends for more natural results. The brow tip aesthetic lines are better defined. The limitation of this study is short follow up.

Shaping the nasal dorsum

Shaping a proper dorsum must constitute an essential part of rhinoplasty. This article addresses the main current concepts that play a significant role in dorsal modifications: proper exposure at the keystone, component separation and incremental reduction, straightening the septum and positioning it in the midline, mobilizing and reshaping the nasal bones by osteotomies and osteoplasties, and finally reconstituting a barrel vault of appropriate width and proper contour. The importance of power tools and piezoelectric instrumentation is highlighted, as well as the relevance of simulation and computed tomography (CT) imaging as key to bone and septal work. Finally, the key principles of rebuilding the dorsum in revision rhinoplasty are detailed.

Camouflage of the Nasal Dorsum in Thin-Skinned Patients with Diced Cartilage Combined with a New Cross-Linked Hyaluronan (NCH) Gel and Blood: A New Method

INTRODUCTION

Nasal dorsum irregularities after rhinoplasty are still one of the most common complaints among both surgeons and patients. In this study, we used a new cross-linked hyaluronan (NCH) gel and blood mixture as the stabilisation scaffold. Diced cartilage combined with the NCH gel and blood mixture was used for nasal dorsum camouflage.

PATIENTS AND METHODS

Fifty-two thin-skinned patients (29 females and 23 males) underwent primary rhinoplasty including nasal dorsum enhancement with diced cartilage combined with the NCH gel and blood mixture. The cartilage tissue was diced into small pieces; then, 1 cc NCH gel and blood were added into diced cartilage. The mixture was delivered onto the nasal dorsum via dorsal retractor.

RESULTS

After 1 year of follow-up, there were no irregularities in the nasal dorsum area observed, nor any displacement or absorbance of the camouflage material. No complications occurred.

CONCLUSION

The use of diced cartilage combined with the NCH gel and blood is an effective, simple and safe method for nasal dorsum camouflage in thin-skinned patients in rhinoplasty. The NCH gel within the mixed graft also reduces adhesions at the osteotomy lines.

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 .

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.