Cartilage Grafting in Nasal Reconstruction

State of the Evidence for Facial Skin Cancer Reconstruction

This review provides a comprehensive presentation of the evidence available in facial reconstruction post-Mohs micrographic surgery. Given the large diversity in post-Mohs reconstruction, there are limited guidelines in the management of defects. The aim of the present work is to provide a review of the best evidence as it pertains to several considerations in facial reconstruction. Data suggests that Mohs micrographic surgery and many reconstructive procedures can be performed as outpatient procedures under local anesthesia, with narcotic pain medication only given in certain patient populations following a minority of reconstructive procedures. Perioperative and topical antibiotics are generally not indicated. Aspirin and warfarin can generally be continued for most reconstructive procedures, but clopidogrel and novel anticoagulants may predispose to increased bleeding complications. Delayed reconstruction appears to be safe, although data are discordant on this topic. No specific wound closure technique or suture choice appears to be consistently superior. Given the lack of robust comparative studies, consistent methodology, and variable defect sizes/locations, no robust evidence-based guidelines can be generated for reconstruction techniques of facial subsites.

Auricular Framework Construction Using Cadaveric Costal Cartilage in Type III Microtia: Preliminary Results

PURPOSE

Non/minimally irradiated Cadaveric Costal Cartilage (NCCC) is commonly used for grafts in nasal reconstruction; however, no information exists on its use in total ear reconstruction for type III microtia. In this case series we describe preliminary results from the novel use of NCCC for auricular framework construction in 7 ear reconstructions.

METHODS

Patients requiring total ear reconstruction from August 2020 to October 2021 were eligible and underwent ear reconstruction using NCCC from MTF Biologics (Edison, NJ). Patients were evaluated for surgical site infection, skin necrosis, cartilage exposure, warping, and resorption during regular follow up visits.

RESULTS

Seven ears were reconstructed using NCCC across 5 patients with type III microtia. Patients ranged from 5 to 51 years old at the time of surgery. Follow up time ranged from 12 to 78 weeks (mean: 46 wk). No patients experienced surgical site infections or significant cartilage resorption. All procedures were done outpatient, total time under anesthesia was <90 minutes in 5/7 cases and postoperative narcotics for pain management were not needed in 5/7 cases. Complications included minor skin necrosis that was repaired via primary closure, construct exposure in the immediate postoperative period, which was successfully salvaged with a local flap, and explantation of one construct after reconstruction for a complicated revision surgery involving a previous temporoparietal fascial flap.

CONCLUSION

NCCC serves as an immediately available alternative to alloplastic and autologous materials for construction of auricular frameworks during ear reconstruction. Longer follow up times and a larger sample size will further elucidate long-term efficacy.

Columellar Strut in Correcting the Recurrent Vestibular Stenosis

Management of vestibular stenosis is always a challenge in rhinology, especially for patients with complete vestibular stenosis. Tip plasty (with columella strut) can be supplemented to the primary surgery, can ensure good functional and cosmetic outcomes in patients with complete vestibular stenosis.

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.

Thermo-Mechanical Behaviour of Human Nasal Cartilage

The aim of this study was to undergo a comprehensive analysis of the thermo-mechanical properties of nasal cartilages for the future design of a composite polymeric material to be used in human nose reconstruction surgery. A thermal and dynamic mechanical analysis (DMA) in tension and compression modes within the ranges 1 to 20 Hz and 30 °C to 250 °C was performed on human nasal cartilage. Differential scanning calorimetry (DSC), as well as characterization of the nasal septum (NS), upper lateral cartilages (ULC), and lower lateral cartilages (LLC) reveals the different nature of the binding water inside the studied specimens. Three peaks at 60–80 °C, 100–130 °C, and 200 °C were attributed to melting of the crystalline region of collagen matrix, water evaporation, and the strongly bound non-interstitial water in the cartilage and composite specimens, respectively. Thermogravimetric analysis (TGA) showed that the degradation of cartilage, composite, and subcutaneous tissue of the NS, ULC, and LLC take place in three thermal events (~37 °C, ~189 °C, and ~290 °C) showing that cartilage releases more water and more rapidly than the subcutaneous tissue. The water content of nasal cartilage was estimated to be 42 wt %. The results of the DMA analyses demonstrated that tensile mode is ruled by flow-independent behaviour produced by the time-dependent deformability of the solid cartilage matrix that is strongly frequency-dependent, showing an unstable crystalline region between 80–180 °C, an amorphous region at around 120 °C, and a clear glass transition point at 200 °C (780 kJ/mol). Instead, the unconfined compressive mode is clearly ruled by a flow-dependent process caused by the frictional force of the interstitial fluid that flows within the cartilage matrix resulting in higher stiffness (from 12 MPa at 1 Hz to 16 MPa at 20 Hz in storage modulus). The outcomes of this study will support the development of an artificial material to mimic the thermo-mechanical behaviour of the natural cartilage of the human nose.

Correction of the Over-resected Nose

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

Reconstruction of Cutaneous Nasal Defects

Mohs micrographic surgery has become the standard of care for the treatment of cutaneous malignancies. Reconstructing cutaneous defects of the nose can be challenging, as form and function must be respected to the greatest extent possible. A wide range of reconstructive techniques are used. Secondary intent, primary closure, skin grafts, local flaps, and the interpolated workhorse flaps represent the spectrum of options, each with specific advantages and disadvantages. Vigilant postoperative care, including judicious use of adjunctive procedures, can improve outcomes. A subunit approach to reconstruction aids with surgical planning in order to achieve the best possible results.

Free Auricular Composite Graft for Acquired Nasal Stenosis

BACKGROUND

Acquired nasal stenosis poses a reconstructive challenge for the facial plastic surgeon. Many surgical options are available, ranging from primary closure to skin grafts to free flap reconstruction for complex defects. The free auricular composite graft is a single-stage procedure that can be used to repair nasal vestibular stenosis causing nasal obstruction.

CASE REPORT

We present the case of a patient with acquired nasal stenosis as a result of prolonged nasal tampon placement secondary to severe epistaxis and subsequent nasal vestibular infection. Repair via auricular composite graft was successful, and we provide a thorough explanation of graft design and operative technique.

CONCLUSION

Free auricular composite grafts can produce desirable functional and aesthetic outcomes and should be considered in patients presenting with acquired nasal stenosis.

Antihelical cartilage grafts for reconstruction of mohs micrographic surgery defects

OBJECTIVE

To illustrate the safety, efficacy, and versatility of the antihelix as the preferred donor site for auricular cartilage autografts in the reconstruction of nasal and auricular Mohs micrographic surgery defects.

MATERIALS AND METHODS

Retrospective chart review of all cartilage autografts performed at the Medical University of South Carolina for the 5-year period July 1, 2006, to June 30, 2011; 307 auricular cartilage autografts were performed in 297 patients. Each case was reviewed for demographic data, graft donor site, repair type, complications, and revisions.

RESULTS

Three hundred five of the grafts (99.3%) were harvested from the antihelix and the remaining two (0.7%) from the conchal bowl. The donor site complication rate was 3%. No patients experienced cosmetic or functional deformity of the donor ear. No patients experienced cartilage graft resorption or infection.

CONCLUSION

Antihelical cartilage grafts can serve as safe, effective, and versatile alternatives to septal, conchal bowl, and costal margin grafts. The authors feel strongly that the antihelix donor site should be favored when harvesting auricular cartilage for its easy accessibility, large dimension that may be harvested without aesthetic penalty, character of graft, and minimal operative morbidity.

Grafting in cosmetic rhinoplasty

As rhinoplasty techniques continue to evolve toward structural support and away from purely reductive techniques, the need for sophisticated grafting options will escalate to augment or replace critical support mechanisms of the nose. This will result in improved esthetic outcomes and functional results. We have found that well-planned and executed adjunctive grafting techniques can deliver lasting results with preservation of function and cosmesis. This article reviews the various graft materials and the techniques and indications for their use.