Chondroplastic graft augmentation rhinoplasty

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

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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.

Uses of Various Grafting Techniques in External Approach Rhinoplasty: An Overview

The surgeons performing rhinoplasty found Graft selection the greatest challenge. To avoid an immune response the preferred choice thus far for nasal reconstruction would be autograft compared to allograft due to its lower rate of rejection. We have evaluated 30 patients who underwent open rhinoplasty and We used conchal and septal cartilaginous grafts in various forms by the open approach to correct various nasal deformities compared our experience regarding the operative technique, graft availability, indications, and limitations. No bony graft material or synthetic materials were used. Preoperative extensive evaluation of the patient was done in order to determine the type of deformity and the type of graft to be used in order to correct the deformity. Preoperative and postoperative photographs were taken in four basic views: frontal, lateral, lateral-oblique and basal in order to assess the results of the surgery. The study was done on 30 patients (20 male and 10 females) using the external rhinoplasty approach using the septal and conchal cartilages in different forms. Autologous septal cartilage was used in most of the patients (25 out of 30) and conchal cartilage was used in 5 patients. Multiple grafting techniques were used in some patients. Three patients had traumatic etiology. Columellar strut graft along with TIG technique was used in 16 patients, spreader graft was used in 8 patients, and septal extension graft was used in 5 patient and shield graft in 1 patient. Septorhinoplasty continues to evolve through various new techniques and modifications with the main goal to improve functional nasal airway and to restore cosmetic harmony to the face. Optimum result is very much dependent on the surgeon's attention to functional, aesthetic, and reconstructive principles and graft selection.

The rabbit costal cartilage reconstructive surgical model

Rib grafts in facial plastic surgery are becoming more frequently used. Small animal models, although not ideal may be used to emulate costal cartilage-based procedures. A surgical characterization of this tissue will assist future research in the selection of appropriate costal segments, based on quantitative and qualitative properties. The objective of this study is to assess the surgical anatomy of the rabbit costal margin and evaluate costal cartilage for use in either in vivo or ex vivo studies and to examine reconstructive procedures. Detailed thoracic dissections of 21 New Zealand white rabbits were performed post-mortem. Costal cartilage of true, false, and floating ribs were harvested. The length, thickness, and width at proximal, medial, and distal locations of the cartilage, with perichondrium intact were measured. Further qualitative observation and digital images of curvature, flexibility, and segmental cross-sectional shape were recorded. The main outcome measure(s) is to characterize, describe, and assess the consistency of dimensions, location, and shape of costal cartilage. In this study, 12 to 13 ribs encase the thoracic cavity. Cartilage from true ribs has an average length, width, and depth of 23.75 ± 0.662, 3.02 ± 0.025, and 2.18 ± 0.018 mm, respectively. The cartilage from false ribs has an average length, width, and depth of 41.97 ± 1.48, 2.00 ± 0.07, 1.19 ± 0.03 mm, and that of floating ribs are 7.66 ± 0.29, 1.98 ± 0.04, and 0.96 ± 0.03 mm. Rib 8 is found to be the longest costal cartilage (49.10 ± 0.64 mm), with the widest and thickest at ribs 1 (3.91 ± 0.08 mm) and 6 (2.41 ± 0.11 mm), respectively. Cross-sectional segments reveal the distal cartilage to maintain an hourglass shape that broadens to become circular and eventually ovoid at the costochondral junction. The New Zealand white rabbit is a practical source of costal cartilage that is of sufficient size and reproducibility to use in surgical research where the long-term effects of operations, therapies, devices, and pharmacologic on cartilage can be studied in vivo.

Clinical study of graft selection in malaysian rhinoplasty patients

Graft selection remains the greatest challenge for surgeons performing rhinoplasty. The preferred choice thus far for nasal reconstruction would be autograft compared to allograft due to its lower rate of infection and extrusion as it does not induce an immune response. We have evaluated 26 patients who underwent open structured rhinoplasty at our center and compared our experience regarding the operative technique, graft availability, indications, and limitations. The racial distribution was 18 Indians, 5 Chinese, and 3 Malays with a mean age, hospitalization, and followup of 30.5 years, 16.9 months, and 4.4 days, respectively. Majority of the patients (57.6%) presented with twisted nose and 30.7% of the patients presented with history of nasal trauma. All the patients had deviated septum of varying severity. The most common graft used was quadrangular cartilage graft and the common complications noted were ala deformity and tip anaesthesia in 7.6% patients respectively.

Rhinoplasty using rib chondro-osseous graft in Asian patients

Corrective rhinoplasty for functional and aesthetic recovery relies much on the use of grafts. This may be effectively accomplished with alloplastic materials; however, certain circumstances mandate the use of autologous grafts. Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. Here, we present our experiences with the correction of nasal deformities using chondro-osseous rib grafts, aiming at anatomic and functional reconstruction of the nose dorsum, especially the keystone area. The deformity was the result of trauma in 16 patients, postrhinoplastic deformities in 7, and congenital deformities in 5 patients. All the patients underwent reconstructive rhinoplasty using the sixth or seventh rib complex graft. Overall, functional and aesthetic outcome was satisfactory in all patients. Rigid bony union, good nasal projection, and symmetry were obtained. Graft exposure, displacement, warping, and significant bone absorption were not observed. The seventh or sixth rib provided not only the greatest overall available length and thickness, but also less donor-site morbidity. In conclusion, using rib bone and cartilage combination graft as a single unit allowed more predictable and reliable reconstruction of the nose deformity than did the conventional dorsal grafts.

Analysis of the Physical Properties of Costal Cartilage in a Porcine Model

OBJECTIVE

To determine the impact of interventions on the degree of warping of costal cartilage.

METHODS

The project was conducted at a large university animal research laboratory. The costal cartilage of eight 30-kg domestic pigs was harvested. The cartilage was cut into central and peripheral segments with a standard cutting die. Two sizes of rectangular cubes were compared. The central portions of costal cartilage were segmented and glued with octyl-2-cyanoacrylate. The shape of the cartilage was documented with both digital and film photography. The cartilage was placed into subdermal pockets on the dorsum of the pigs. The animals were killed at 4 weeks, and the cartilage was photographed. Adobe Photoshop software was used to measure the degree of warping. Statistical analysis was calculated by t test analysis.

RESULTS

A total of 115 rectangular costal cartilage blocks were treated. Large blocks warped less than small blocks (P<.02). Centrally cut blocks warped less than peripherally cut blocks (P<.03). The octyl-2-cyanoacrylate incited a significant sterile inflammatory response such that the blocks could not be accurately assessed for warpage.

CONCLUSION

Costal cartilage can be effectively used for grafting in rhinoplasty with minimal warping if large grafts from the central portion of cartilage are used.

In vitro tissue engineering to generate a human-sized auricle and nasal tip

OBJECTIVES/HYPOTHESIS

Tissue engineering has successfully generated cartilage in a xenograft and an autograft model. However, challenges remain with both of these in vivo techniques before clinical application can be realized. We hypothesized that a human-sized cartilaginous structure could be generated completely in vitro as a complementary or an alternative technique.

METHODS

Scaffolds were created in the shape of five full-sized human auricles and five nasal tip cartilaginous skeletons. Bovine shoulder chondrocytes at a concentration of 50 million cells/mL were seeded onto the scaffolds and were grown for 12 weeks in vitro. Two of the auricular scaffolds had internal support provided by soft acrylic sheets and were later implanted into nude rats.

RESULTS

All of the scaffolds maintained shape and size through 12 weeks of in vitro culture. On gross examination the scaffolds were progressively replaced by cartilage, which was confirmed by histological and biochemical analysis. The auricular scaffolds with the acrylic internal support had the most natural rigidity, which was observed by gentle palpation. The nasal scaffolds maintained excellent definition even without internal support.

CONCLUSION

An adult human-sized auricle and nasal tip cartilaginous structure can be grown entirely in vitro using principles of tissue engineering.

[Cartilaginous grafts in rhinoplasty]

We present a revision of 38 cases operated on for augmentation rhinoplasty from 1992 to 2001, using a cartilaginous graft. 83% of our patients were men and 17% were female. The mean age was 31 years old. In 33 rhinoplasties, the graft was placed in the nasal dorsum; in 4 cases it was placed at the nasal tip and in one case reconstruction of the dorsum and the tip was performed. The most frequently used graft was septal cartilage, in 28 cases. Conchae cartilages were used in 3 cases, lower lateral cartilage in 5 cases, rib cartilage in one, and in another case, septal and lower lateral cartilage were used in the same patient. We stabilized the graft fixing it to the skin with a suture which is removed after a week. We did a postoperative follow-up on 25 of the patients. In terms of patient satisfaction, 12% of them felt that their nasal appearance had improved, 76% felt that there had been a great improvement, and 12% did not notice any change. Only one patient had to be reoperated on because of an overprojection of the graft in the nasal dorsum. We conclude that the use of autologous cartilaginous grafts offers important advantages in rhinoplasty; they are easy to be obtained, easy to mould and with a low index of resorption.

Viability of chondroplastic graft

The operation of chondroplastic graft augmentation rhinoplasty was described in a previous paper by the present author. Seventeen months following one such clinically successful operation, the opportunity was taken at a subsequent nasal procedure to remove a small portion of the original graft and submit this to histological examination. The results of this confirm the viability of a graft harvested and implanted by this technique.