Management of Saddle Nose Deformity Using Dermal Fat and Costal Cartilage "Sandwich" Graft: A Problem-Oriented Approach and Anthropometric Evaluation

Complications Associated with Autologous Costal Cartilage Used in Rhinoplasty: An Updated Meta-Analysis

OBJECTIVE

To estimate the complications using autologous costal cartilage as grafts in rhinoplasty objectively and systematically with newly published literature.

METHODS

The literature was searched systematically; included studies were published between July of 1990 and April of 2020. Meta-analysis was performed using a random-effects model.

RESULTS

Twenty studies involving 1648 patients were included for meta-analysis. The pooled rates of complications were 3.05% of warping (95% CI 1.36-5.19%), 1.2% of resorption (95% CI 0.26-2.56%), 1.45% of infection (95% CI 0.34-3.06%), and 1.53% of contour irregularity (95% CI 0.53-2.88%). The revision rate was 2.25% (95% CI 0.96-3.9%). Regarding of donor-site morbidities, the rate of hypertrophic chest scar was 2.08% (95% CI 0.31-4.83%), and the rate of pneumothorax was 0% (95% CI 0-0.46%). The pooled rates of complications were 9.06% (95% CI 6.13-12.43%) at the recipient site when complications at the recipient site did not include revision surgery, 1.47% (95% CI 0.17-3.56%) at the donor site, and 15.13% (95%CI 11.03-19.69%) overall. The recipient-site adverse event rate was 12.44% (95% CI 8.98-16.33%).

CONCLUSIONS

Warping was found the most common complication after rhinoplasty with autologous costal cartilage. Revision after rhinoplasty using autologous costal cartilage was increased in these years. Donor-site complications increased the complication rate after rhinoplasty using autologous rib cartilage by 22%.

LEVEL OF EVIDENCE III

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.

Simple method of saddle nose correction: A double-layer dermofat graft: case report

INTRODUCTION

Saddle nose deformities are typically reconstructed with cartilage grafts; however, conchal cartilage grafts are and associated with a risk of damage to the posterior auricular ligament and insufficient amounts, and costal cartilage grafts require invasive surgery under general anesthesia. We proposed a double-layer dermofat graft as an alternative to these methods.

PATIENT CONCERNS

Two patients with type IV saddle nose deformity underwent reconstruction with nasal augmentation with a double-layer dermofat graft harvested from the gluteal sulcus.

DIAGNOSIS

After operation, photogrammetric analysis demonstrated an improvement in the dorsal depression area, which corresponded to the angle between the sellion, most depressed point, and pronasale. Rhinoplasty Outcome Evaluation questionnaire was assessed.

INTERVENTIONS

The graft was divided into 2 sections; the first section was implanted transversely into the depressed nasal framework, and the second section was inserted vertically from the nasion to the supratip break for augmentation.

OUTCOMES

Both patients reported high satisfaction with the Rhinoplasty Outcome Evaluation questionnaire. The mean preoperative angle between the sellion, most depressed point, and pronasale was 157.8°, and the mean postoperative angle at 6 months was 176.9°.

CONCLUSION

The simple method double-layer dermofat graft technique demonstrated excellent outcomes in saddle nose deformity correction, did not require cartilage, and was easily performed under local anesthesia.

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.

Review of literature of saddle nose deformity reconstruction and presentation of vomer onlay graft

OBJECTIVE

Saddle nose deformity is a well-described condition that most commonly results from trauma or prior surgery. For larger saddle nose deformity defects, bone grafts are a reconstructive option that provide adequate structure for repair. One new technique for repair of these deformities is a vomerian bone onlay graft. We aim to provide a review of literature on autogenous repair of saddle nose deformities, as well as introduce a new technique in which the vomer bone is used as an onlay bone graft.

METHODS

Literature review and case series. Five cases in which vomer onlay grafts were used for repair of saddle nose deformity were reviewed between January 2013 and December 2015. Aesthetic outcomes and postoperative complications were evaluated at subsequent follow-up visits in clinic.

RESULTS

In all cases where vomer bone was harvested, the vomer onlay graft provided adequate structure to traverse the saddle nose deformity. No postoperative complications were observed in an 18 month follow-up period.

CONCLUSION

Vomerian bone onlay grafts are a reconstructive option for saddle nose deformity and nasal dorsum defects. While septal cartilage is commonly used, and ethmoidal bone has been previously described as an option for composite graft reconstruction, vomer bone onlay grafting has not been well described in the literature. This method may be of use when previous nasal surgery has been performed and standard septal cartilage is not possible to harvest. The aesthetic outcomes following nasal dorsum reconstruction using onlay grafts are favorable, but long-term outcomes of these grafts require further study.

LEVEL OF EVIDENCE

IV.

Comparison of Autologous vs Homologous Costal Cartilage Grafts in Dorsal Augmentation Rhinoplasty: A Systematic Review and Meta-analysis

Importance

Augmentation rhinoplasty requires adding cartilage to provide enhanced support to the structure of the nose. Autologous costal cartilage and irradiated homologous costal cartilage (IHCC) are well-accepted rhinoplasty options. Tutoplast is another alternative cartilage source. No studies, to our knowledge, have definitively demonstrated a higher rate of complications with IHCC grafts compared with autologous costal cartilage grafts.

Objective

To compare rates of outcomes in the published literature for patients undergoing septorhinoplasty with autologous costal cartilage vs IHCC grafts vs Tutoplast grafts.

Data Sources

For this systematic review and meta-analysis, the MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for articles published from database inception to February 2019 using the following keywords: septorhinoplasty, rhinoplasty, autologous costal cartilage graft, cadaveric cartilage graft, and rib graft.

Study Selection

Abstracts and full texts were reviewed in duplicate, and disagreements were resolved by consensus. Only patients who underwent an en bloc dorsal onlay graft were included for comparison to ensure a homogenous study sample. A total of 1308 results were found. After duplicate records were removed, 576 unique citations remained. Studies were published worldwide between January 1, 1990, and December 31, 2017.

Data Extraction and Synthesis

Independent extraction by 2 authors was performed. Data were pooled using a random-effects model.

Main Outcomes and Measures

All reported outcomes after septorhinoplasty and rates of graft warping, resorption, infection, contour irregularity, and revision surgery among patients receiving autologous grafts vs IHCC vs Tutoplast cartilage grafts.

Results

Of 576 unique citations, 54 studies were included in our systematic review; 28 studies were included after applying inclusion and exclusion criteria. Our search captured 1041 patients of whom 741 received autologous grafts and 293 received IHCC grafts (regardless of type). When autologous cartilage (n = 748) vs IHCC (n = 153) vs Tutoplast cartilage (n = 140) grafts were compared, no difference in warping (5%; 95% CI, 3%-9%), resorption (2%; 95% CI, 0%-2%), contour irregularity (1%; 95% CI, 0%-3%), infection (2%; 95% CI, 0%-4%), or revision surgery (5%; 95% CI, 2%-9%) was found.

Conclusions and Relevance

No difference was found in outcomes between autologous and homologous costal cartilage grafts, including rates of warping, resorption, infection, contour irregularity, or revisions, in patients undergoing dorsal augmentation rhinoplasty. En bloc dorsal onlay grafts are commonly used in augmentation rhinoplasty to provide contour and structure to the nasal dorsum.

Is it possible to recognize children diagnosed with ADHD from their facial anthropometric measures? A case-control study

The recent main focus of the researches on Attention-deficit Hyperactivity Disorder is on identifying behavioral phenotypes. For this purpose, neuroanatomical factors have recently become a focus. This study aimed to investigate whether the individuals diagnosed with Attention-deficit Hyperactivity Disorder differ from healthy individuals in terms of facial anthropometric measurements. Forty children, diagnosed with Attention-deficit Hyperactivity Disorder, were included in the study as the case group, and forty healthy children were included in the study as the control group. Two photographs were taken from the facial region, and anthropometric measurements were performed using the computer program "Image J" in the computer environment. It was found that a strong relationship between Attention-deficit Hyperactivity Disorder and nasal width, ear length and upper face debt length. The results obtained from the research support the knowledge that there is a close relationship between the forebrain development process and the facial development process during the embryonic development process.

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.