Viability of diced, crushed cartilage grafts and the effects of Surgicel (oxidized regenerated cellulose) on cartilage grafts

New Wrapping Biomaterial Alternatives for Fascia in Diced Cartilage Grafts: A Comparative Study on Viability and Stability

OBJECTIVE

The aim of this in vivo study is to compare cartilage viability within diced cartilage grafts from the perspective of three wrapping biomaterials Group A acellular dermal matrix (FlexHD®), Group T bovine pericardium (Tutopatch®), and Group F allogeneic human fascia for a possible implementation in the clinical use.

MATERIALS AND METHODS

This in vivo study was conducted on 5 SCID (Severe Combined Immunodeficiency)/Gamma Mice with a duration of eight weeks. The cartilage within composite grafts were obtained from the remaining cartilage following secondary rhinoplasty performed on a single donor. Diced cartilage grafts were wrapped separately with acellular dermal matrix (ADM), bovine pericardium, and fascia to form three groups. A total of five mice were utilized in all three experimental groups, with a total of 15 experimental materials being examined. One composite graft from each group was implanted into the backs of the mice. The effects of the biomaterials on the viability and stability of the composite grafts were evaluated. Viability was evaluated through LIVE/DEAD cell analysis and histopathological examinations. Stability was assessed by comparing weight and volume changes of the grafts, measured using a precision balance and computed tomography, respectively.

RESULTS

A significant increase in weight was found in the fascia group after implantation (p < 0.05). In the ADM (Group A) and bovine pericardium (Group T), no statistically significant weight change was observed (p > 0.05). A significant increase in volume was found in the ADM (Group A) group after implantation (p < 0.05). Flow cytometry showed the highest cartilage viability percentage in the fascia (Group F) and the lowest in the ADM (Group A). No significant difference was found in viability percentages between the groups. Histopathological examinations supported the flow cytometry findings.

CONCLUSION

Our study revealed that cartilage grafts wrapped in allogenic fascia (Group F) showed better viability and stability compared with ADM (Group A) and bovine pericardium (Group T). This suggests that while fascia may remain the gold standard, alternative biomaterials also hold potential. Further experimental and clinical studies with larger sample sizes are needed to support these findings.

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 .

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 .

Characterization of Injury Induced by Routine Surgical Manipulations of Nasal Septal Cartilage

Importance

This study characterizes and compares common surgical manipulations' effects on septal cartilage to understand their implications for rhinoplasty outcomes based on cell viability and cartilage health.

Objective

To illustrate distinct differences in the impact of various surgical manipulations on septal cartilage in an in vitro septal cartilage model. A secondary objective is to better understand the chondrocyte's response to injury as well as how alterations in the extracellular matrix correspond to chondrocyte viability.

Design, Setting, and Participants

In this bench-top in vitro porcine model using juvenile bovine septal cartilage from bovine snouts, easily obtainable septal cartilage was used to generate large numbers of homogenous cartilage specimens. Quantitative outcomes at early and late time points were cell viability, cell stress, matrix loss, and qualitative assessment through histologic examination. The study was performed at a single academic tertiary care research hospital.

Interventions

Four common surgical manipulations were contrasted with a control group: crushed cartilage, scored cartilage, diced cartilage, and shaved cartilage.

Main Outcomes and Measures

Following the manipulation of the cartilage, the quantitative outcomes were glycosaminoglycan release to the media, lactate dehydrogenase release to the media, and cell death analysis through apoptosis staining. The qualitative outcomes were histologic staining of the manipulated cartilage with safranin-O/fast green stain to identify proteoglycan loss.

Results

The crushing followed by shaving manipulations were the most damaging as indicated by increased levels of lactate dehydrogenase release, glycosaminoglycans loss, and cell death. Matrix loss did not increase until after 48 hours postinjury. Furthermore, chondrocyte death was seen early after injury and accelerated to the late time point, day 9, in all manipulations. Conversely, cell stress was found to be greater at 48 hours postinjury, which then declined to the late time point, day 9.

Conclusions and Relevance

The crushing manipulation followed by shaving and then dicing were the most destructive methods of cartilage manipulation relative to control specimens. Collectively, these outcomes demonstrate the range of injury which occurs with all septal cartilage manipulations and can inform rhinoplasty practice to use the least damaging effective surgical manipulation to obtain the desired outcome.

Level of Evidence

NA.

Effect of oxidized cellulose on human respiratory mucosa and submucosa and its implications for endoscopic skull-base approaches

BACKGROUND

Regenerated oxidized cellulose (ROC) sheets have gained popularity as an adjunct to a vascularized nasoseptal flap for closure of dural defects after endoscopic endonasal skull-base approaches (EESBS). However, evidence supporting its impact on the healing process is uncertain. This study was performed to evaluate the impact of ROC on the nasal mucosa and assess its effects on tissue pH, structure, and cell viability.

METHODS

In 5 patients, a 1-cm² piece of ROC gauze was placed on the surface of the middle turbinate before it was resected as part of a standard EESBS. Mucosa treated with ROC was separated from untreated mucosa and a histologic examination of structural changes in the respiratory epithelium was performed. To assess the effect of ROC on pH, increasing amounts of ROC were added to culture medium. Nasal fibroblasts viability was assessed in the presence of ROC before and after the pH was neutralized.

RESULTS

Compared with unexposed controls, treated mucosa exhibited a higher incidence of cell necrosis and epithelial cell detachment. When added to Dulbecco's modified Eagle medium, ROC caused a dose-dependent decrease in pH of the medium. Only 1 ± 0.8% of cultured fibroblasts exposed to the ROC-induced acidic medium were alive, whereas 98.25 ± 0.5% of the cells were viable when the pH was neutralized (p < 0.001).

CONCLUSION

ROC applied in vivo to nasal mucosa induced epithelial necrosis likely by diminishing the medium pH, because pH neutralization prevents its effect. The ultimate effect of this material on the healing process is yet to be determined.

Effects of the Human Amniotic Membrane on the Cartilage Graft: Prognosis and Absorption in White Rabbits

BACKGROUND

Cartilage grafts are generally accepted for the restoration and reconstruction of nasal contours. The main concern that plastic surgeons may need to address after surgery pertains to the resorption and disfigurement of the grafted cartilage, especially in allogenic and heterogenic grafts.

METHODS

A total of 12 white rabbits were divided into three groups according to the types of graft including autograft, allograft, and heterograft. We used three shapes of grafts, including block, crushed, and diced cartilage in the upper, middle, and lower rows. However, in each rabbit, these grafts were divided into two columns of wrapped and unwrapped grafts, with human amniotic membrane (HAM) grafted on each side of the rabbit’s back.

RESULTS

In total, 60 specimens underwent histopathological examination. No inflammation was observed in about 50% of the block-shaped conchal cartilages with HAM, and in 50%, less than 25 inflammatory cells per unit were seen. The prognosis and absorption of autograft specimens in block-shaped cartilages with HAM were significantly better compared with other shapes of cartilages with HAM and without HAM. The proliferation rate of fibroblasts in autograft and allograft specimens was more than that in heterograft specimens with HAM.

CONCLUSION

Our findings have demonstrated the new role of HAM in clinical applications, indicating that HAM may be used as a low-cost, easily accessible alternative for wrapping in cartilage grafts instead of fascia or surgicel in early future. It is useful for improving the long-term outcomes and decreasing the resorption rate.

Fluid Cartilage as New Autologous Biomaterial in the Treatment of Minor Nose Defects: Clinical and Microscopic Difference Amongst Diced, Crushed, and Fluid Cartilage

Developing cartilage constructs with injectability, appropriate matrix composition, and persistent cartilaginous phenotype remains an enduring challenge in cartilage repair. Fourteen patients with minor contour deformity were treated with fluid cartilage filler gently injected as autologous fluid graft in deep planes of defect of the nose that were close to the bone or the cartilage. A computerized tomographic scan control was performed after 12 months. Pearson's Chi-square test was used to investigate differences in cartilage density between native and newly formed cartilages. The endpoints were the possibility of using fluid cartilage as filler with aesthetic and functional improvement and versatility. Patients were followed up for two years. The constructs of fluid cartilage graft that were injected in the deep plane resulted in a persistent cartilage tissue with appropriate morphology, adequate central nutritional perfusion without central necrosis or ossification, and further augmented nasal dorsum without obvious contraction and deformation. This report demonstrated that fluid cartilage grafts are useful for cartilage regeneration in patients with outcomes of rhinoplasty, internal nasal valve collapse, and minor congenital nose aesthetics deformity.

The Use of Double-Layer Collagen Membrane for the Improvement of Nasal Dorsum Skin Thickness and Texture in Primary Nose Surgery

OBJECTIVES

To place a collagen membrane containing crushed nasal septal cartilage over the nasal dorsum to see how this graft can improve the results of visible postsurgical irregularities in thin skinned patients.

METHODS

Fifty-seven patients were treated between 2006 and 2010 (26 males and 31 females) whose ages ranged between 31 and 55 years old. They were divided into group a, defect <1 mm, group b defect between 1 and 2 mm, group c defect >3 mm. These patients presented intraoperative nasal dorsum irregularities that were corrected with 57 cartilage grafts in conjunction with collagen membrane.

RESULTS

All of our patients showed an initial over-correction. A dense network of collagen fiber bundles was observed running parallel to the surface of the membrane at the connective tissue-membrane interface. The clinical percentage of volume reabsorption was about 5% after 6 months, measured with clinical pictures and a clinical follow-up. No infection was noted, only 1 patient of dislocation was observed, and 5 patients required some refinements at the long-term follow-up.

CONCLUSIONS

In the authors' experience the use of bilayered combined cartilage and collagen membrane grafts gives the best aesthetic results with balanced tip projection and dorsum fullness, and avoids thickness and texture modification of the skin above the graft. The use of Bio-gide membrane avoids all problems related to the donor site and shortens surgical time.

Otoplasty for prominent ears - demographics and surgical timing in different populations

INTRODUCTION

Prominent ears are seen in approximately 5% of the population. This benign condition can be treated surgically to reduce or prevent psychological and social problems, most commonly in children before the start of school. Our aim was to examine the demographic characteristics of patients undergoing prominent ear surgery in Finland, and compare findings with international data.

METHODS

A retrospective study of all the patients treated for prominent ears in our academic tertiary care referral center during 2007-2011 was performed to gather demographic details of operated patients. A systematic review of published series of prominent ear surgery after the year 2000 was performed to gather demographic details for international comparison.

RESULTS

A total of 180 patients were operated in our institution for prominent ears, most of the cases (78.9%) were bilateral. Age at operation ranged between 3 and 36 years, with mean of 9.2 y and median of 7 y. The most common reason for seeking operative treatment was aesthetic complaint, followed by bullying. Review process gathered 20 publications, describing a total of 4433 patients who had been operated for prominent ears. There was wide variation the mean age at operation, ranging 7-38 y while the mean overall was 15.0y. Gender distribution of patient samples was also very variable, with percentage of females ranging from 38 to 71% (overall 52%). There was also considerable variation in the tendency to perform unilateral operations: from 0% up to 21% of the reported population. There were no statistically significant correlations linking these demographic variables, though there was a trend that females are more likely to have this operation performed at an older age.

CONCLUSIONS

The treatment culture of prominent ear surgery varies substantially in international comparison. The age at which this operation is performed showed most variation. Omitting some of the basic demographic variables while reporting the results of surgery was common in the reviewed publications.

Dorsal Onlay with Diced Homologous Processed Rib Cartilage Grafts

BACKGROUND

Diced cartilage wrapped in fascia or modeled with tissue sealant has successfully been used as dorsal onlay grafts in rhinoplasty. The use of autologous material introduces the risk of donor site morbidity, and sometimes availability is limited.

METHODS

We present a series of nine cases that were performed using diced irradiated homologous rib cartilage as an onlay graft.

RESULTS

Good functional and cosmetic outcomes were achieved in all nine patients, and no significant resorption was seen after a mean follow-up of 20 months.

CONCLUSION

Homologous diced cartilage grafts are an attractive and well-tolerated alternative. The use of diced homologous material does not seem to lead to significant resorption. These results must be reproduced in larger series.

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 .

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.

Survival of Minced Cartilage Grafts with Comparison Surgicel(®) Original and Fibrillar

BACKGROUND

Cartilage grafts are commonly used in nasal surgery for structural and/or esthetic purposes. The viability of cartilage grafts has been investigated in many forms since the use of cartilage grafts in surgical procedures.

OBJECTIVES

The objective of this study was to investigate the viability of minced cartilage grafts and whether there is a difference between grafts wrapped in Surgicel(®) Original and Surgicel Fibrillar.

METHODS

A total of ten New Zealand rabbits were used for the study. Cartilage grafts were harvested from one side ear. Four groups were formed. Group 1: minced cartilage graft wrapped in Surgicel Fibrillar; Group 2: minced cartilage graft wrapped in Surgicel Original; Group 3: bare minced cartilage graft; and Group 4: bare diced cartilage graft. Four small subcutaneous pockets were made in the backs of the rabbits, and the grafts were placed in these pockets. All of the rabbits were sacrificed at the end of 3 months, and the samples were collected. The sections were stained with hematoxylin and eosin (H&E), toluidin blue, safranin-O, masson trichrome, and glial fibrillary acidic protein immunohistochemical. All specimens were assessed histopathologically under a light microscope.

RESULTS

There was no statistically significant difference between the Surgicel Fibrillar and Surgicel Original groups with respect to any of the parameters. Bone formation, calcification, inflammation, fibrosis, and basophilia were similar in all groups, with no significant difference among them. In the Surgicel Fibrillar and Surgicel Original groups, a heavy chondrocyte nucleus loss accompanied by a minimal peripheral proliferation was observed.

CONCLUSIONS

The viability of bare minced cartilage grafts was found to be similar to that of bare diced cartilage in this study. Minced cartilage grafts can be used in the correction of minor dorsal defects and irregularities in persons with thin nasal skins, especially in primary and revision rhinoplasty. Although there is no statistically significant difference between the Surgicel Fibrillary and Surgicel Original groups, we think that, if it is necessary to use oxidized regenerated cellulose, it should be in the fibrillar form.

NO LEVEL ASSIGNED

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 http://www.springer.com/00266 .

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.

Diced Cartilage Grafts Wrapped in Rectus Abdominis Fascia for Nasal Dorsum Augmentation

BACKGROUND

Dorsum augmentation is one of the most delicate components of rhinoplasty. Although various solid grafts have been used in the past for this purpose, diced cartilage grafts wrapped in fascia have become popular in recent decades. In this study, the authors analyze and discuss the results of using diced cartilage grafts wrapped in rectus abdominis muscle fascia for dorsal augmentation.

METHODS

Nasal dorsum augmentation using the diced cartilage wrapped in rectus abdominis fascia technique was performed on 109 patients between 2008 and 2014. Six patients were primary cases, 69 patients were secondary, and 18 were tertiary. Sixteen patients had previously undergone more than three operations. In all patients, the rectus abdominis fascia was harvested with the described technique and wrapped around the diced cartilages obtained from the costal cartilage.

RESULTS

The average follow-up period was 19.6 months (range, 6 to 47 months). Satisfactory results were obtained with acceptable complications and revision rates. Three patients underwent reoperation because of overcorrection. Insufficient augmentation was seen in five patients. In four patients, infection developed after postoperative day 5. One patient complained of a hypertrophic scar on the donor site. None of the patients showed any symptoms indicating an abdominal hernia.

CONCLUSIONS

Techniques using diced cartilage grafts wrapped in fascia have now become the gold standard for dorsal augmentations. When it is considered that secondary cases requiring dorsal augmentation are usually those also needing costal cartilage grafts, rectus abdominis fascia becomes a useful carrier for diced cartilages, which is in the same donor area.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

Study of Outcome of an Implanted Autologous Auricular Cartilage: A Preliminary Experimental Research in Rabbits

To investigate the viability of the implanted crushed and uncrushed auricular cartilage graft with intact perichondrium with respect to macroscopic and microscopic parameters. Cartilage grafts from 8 white New Zealand rabbits were harvested from the right auricle, with intact perichondrial layers. There were two categories Pre implant and Post-implant and two types, mildly crushed and uncrushed cartilage graft. The cartilage grafts were implanted into the subcutaneous pockets over the right upper paraspinal area. At the end of 2 months, implanted grafts were retrieved and examined histopathologically. There was a difference among the both types of cartilages in both the categories with respect to chronic inflammation, fibrosis, cartilage mass viability and vascularization. The mildly crushed auricular autologous cartilage with intact perichondrium does not lose the viability and maintains the structural integrity and thus increasing the clinical predictability for cosmetic correction of nose in rhinoplasty.

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.

Rib Diced Cartilage-Fascia Grafting in Dorsal Nasal Reconstruction: A Randomized Clinical Trial of Wrapping With Rectus Muscle Fascia vs Deep Temporal Fascia

BACKGROUND

Rib cartilage is an abundant source for cartilage grafts when significant dorsal nasal augmentation or structural support is indicated. Diced cartilage wrapped in fascia was developed to counteract warping, visibility, and displacement of rib cartilage as a dorsal solid graft. The technique for wrapping diced cartilage has evolved during the past several years.

OBJECTIVES

The authors compared 2 distinct fascial sleeves for wrapping rib diced cartilage in the treatment of patients who required major dorsal nasal augmentation.

METHODS

Thirty-six patients who planned to undergo major dorsal nasal reconstruction with diced costal rib cartilage were assigned randomly to 1 of 2 groups: the intervention group, which received grafts wrapped with rectus muscle fascia from the rib cartilage harvesting site, or the control group, which received deep temporal fascia harvested separately. Outcomes were compared between the groups.

RESULTS

Patients in the intervention group had significantly shorter operating times, significantly higher average satisfaction scores, and significantly shorter postoperative hospital stays than did patients in the control group.

CONCLUSIONS

Harvesting rectus muscle fascia for wrapping diced rib cartilage is a feasible and reliable technique in dorsal nasal reconstruction surgery. It is associated with favorable outcomes and a high level of patient satisfaction.

LEVEL OF EVIDENCE

4.

Comparison of autogeneous and homogeneous nasal dorsal onlay grafts in an experimental design

An experimental model was used for the comparative evaluation of autogeneous and homogeneous nasal dorsal onlay cartilage grafts. This study was conducted on 18 adult white New Zealand male rabbits. Nasal septal cartilage (NSC), sliced nasal septal cartilage (SNSC) and auricular cartilage (AC) grafts were prepared in autogeneous and homogeneous forms and placed into the subcutaneous pockets of the nasal dorsum of rabbits. After a period of 3 months, the animals were painlessly killed, and each site was analyzed histologically for inflammation, neovascularization, fibrosis and resorption. Inflammation, fibrosis and neovascularization were found to be significantly more extensive in the homogeneous graft groups and autogeneous SNSC group 3 months after implantation. Resorption was significantly high in both homogeneous and autogeneous AC groups and significantly low in the autogeneous and homogeneous SNSC groups. There was no significant difference between the homogeneous and autogeneous grafts in terms of resorption rates. In conclusion, the results of this experimental study demonstrate that resorption was lesser than expected in the sliced cartilage graft and that homologous cartilage graft applications had activity and reliability similar to that of autogenous cartilage grafts.

Use of osseocartilaginous paste graft for refinement of the nasal dorsum in rhinoplasty

In both primary and secondary rhinoplasty, establishment or refinement of nasal dorsal aesthetic lines is of paramount importance. Many different techniques used to create a cosmetically acceptable nasal dorsum have been published. The material to be used in nasal dorsal contouring should create a harmonic contour and should be easily shaped, long-lasting, and resistant to infection. Resection of the hump yields an osseocartilaginous complex as a single unit when an osteotome is used. Use of a rasp gives a good amount of fragmented material comprising bone, cartilage, soft tissues, and blood. The authors used this material as a paste graft to refine the nasal dorsum in rhinoplasty and retrospectively evaluated the outcomes. A retrospective chart review of 77 patients who underwent this procedure between 2003 and 2009 was performed. The follow-up period ranged from 22 to 40 months (median, 28 months). The postoperative evaluations included clinical examination and digital photographic documentation. The satisfaction of each patient was assessed with a questionnaire completed at the 12th postoperative month. The described graft, which combines the advantages of cartilage and bone, was shown to be clinically durable. This combination also results in an ideal texture and consistency for molding due to its diced form. The texture of this graft enables the surgeon to give a final shape to the nasal dorsum bimanually. In this study, a paste graft was shown to be a versatile and reliable composite material for nasal dorsal contouring and refinement.

Survival of diced and block cartilage grafts in combination with injectable calcium hydroxylapatite

OBJECTIVES/HYPOTHESIS

Dorsal nasal irregularities after trauma, and various procedures such as excessive nasal hump resection, are major problems for patients who have undergone rhinoplasty. Many grafts have been described for the correction of dorsal nasal irregularities. In this study, we used an injectable implant, in combination with diced or block cartilage grafts, to test the efficacy of injectable calcium hydroxylapatite on the survival of diced or block cartilage grafts.

STUDY DESIGN

Prospective, controlled, parallel group animal study.

METHODS

Fourteen New Zealand white rabbits were used. Block cartilage and diced cartilage grafts, alone and in combination with injectable calcium hydroxylapatite, were placed subcutaneously in the rabbits' dorsal thoracolumbar region. On the 90th day following surgery, the graft areas were extracted immediately after the rabbits were sacrificed. Pathological examination was conducted on all specimens.

RESULTS

The pathologic and histochemical findings were compared between groups. There was chronic inflammation observed in all of the groups. However, none of the groups had metaplastic bone formation or calcification. The group that received diced cartilage in combination with the injectable implant received the highest scores for peripheral chondrocyte proliferation, matrix collagen, elastic fiber, and proteoglycan content (P < 0.05). A comparison of the block and diced cartilage grafts revealed that peripheral chondrocyte proliferation was more pronounced in the diced cartilage grafts (P < 0.05).

CONCLUSION

The use of calcium hydroxylapatite in combination with diced cartilage grafts does not have any long-term negative effects on chondrocyte viability.

Diced autologous rib cartilage for primary treatment or refinement of minor chest wall deformities

BACKGROUND

Various methods of corrective thoracoplasty for congenital anterior chest wall deformities have been described. To date, no studies have described the use of diced cartilage as a surgical procedure in thoracoplasty. The authors present their experience with 23 patients for whom diced cartilage grafts were used as an innovative approach for thoracoplasty.

METHODS

A retrospective review of 23 patients was performed. From January of 2004 to September of 2010, 18 patients underwent repair of pectus excavatum, three patients underwent repair of pectus arcuatum, and two patients underwent repair of pectus carinatum using diced rib cartilage grafts. Intraoperative and postoperative complications, patient satisfaction, and clinical outcome were evaluated. Preoperative and postoperative photographs were examined, and the results were assessed by independent surgeons.

RESULTS

The mean patient follow-up was 18.1 months. No major complications were observed in the perioperative period. Postoperative complications were mild recurrence of deformity (n = 2). No graft extrusion, infection, or contour irregularities occurred. The patients rated their cosmetic results as very good. All 25 of the wrapped diced cartilage grafts appear to have survived completely, with only one partial graft absorption. One patient had palpable diced cartilage.

CONCLUSIONS

The diced cartilage graft technique is a novel and safe procedure in thoracoplastic refinement procedures with clear advantages, including limited surgical trauma, autogenous material, easy preparation, absence of significant donor-site morbidity, absence of additional costs, high patient satisfaction, and good aesthetic results. The authors advocate using this technique for augmentation and contouring of minor anterior wall deformities in selected patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

: Therapeutic, IV.(Figure is included in full-text article.).

Autogenous dorsal reconstruction: maximizing the utility of diced cartilage and fascia

The problem of reconstructing the dorsum of the nose is complex and a source of frustration for both patients and surgeons. Dorsal deficiencies due to various etiologies and the need for dorsal contouring cause the plastic surgeon to look to time-honored techniques such as osseocartilaginous rib grafts while also searching for other options that may be less technically challenging and have the benefit of temporal success. Diced cartilage wrapped with deep temporal fascia is just such a method to achieve reliable dorsal reconstructions. The various ways to use diced cartilage and deep temporal fascia are discussed.

The fate of diced cartilage grafts of traumatized versus nontraumatized origin

BACKGROUND

Diced cartilage grafts have long been used in rhinoplasty. Along with their various reported advantages, they also have some disadvantages. The irregular resorption rate of the engrafted mass is one of the major issues noted with diced cartilage grafts. An explanation for the unpredictable resorption rate has not yet been elucidated. This study aimed to determine the role of traumatized versus nontraumatized cartilage as the source of diced cartilage grafts.

METHODS

This study included the noses of 32 patients (19 traumatized noses and 13 nontraumatized noses) who underwent surgery using Surgicel-wrapped diced cartilage grafts.

RESULTS

The most remarkable result noted in this study was that a Surgicel-wrapped diced cartilage graft, if prepared from traumatized cartilage (in 19 patients), failed to maintain a stable long-term volume. Partial volume loss was noted in 100% of these patients. However, the rate of this partial resorption was different for every individual and could not be predicted. The highest retention of cartilage graft volume was seen primarily over the nasal osseocartilaginous junction. In nontraumatized patients, however, the engrafted mass maintained long-term volume stability. These patients evidenced no visible external irregularities, and only a few very slight imperfections were noted with finger palpation.

CONCLUSION

Diced cartilage of traumatic origin is not recommended for any purpose. In such cases, the authors' engrafting algorithm consists of autobone or ear conchal cartilage grafts for dorsal augmentation, columellar struts from the nontraumatized part of the septum, and spreader grafts from the nontraumatized part of the septum or ear concha.

Diced cartilage grafts in rhinoplasty surgery

The use of diced cartilage grafts in rhinoplasty surgery was recently revived by Erol with the publication of his technique for "Turkish delight" grafts (i.e., diced cartilage grafts wrapped in Surgicel). The present study details the authors' experience with 50 consecutive diced cartilage grafts used in three configurations during a prospective study of 50 primary and secondary aesthetic rhinoplasty procedures performed by the senior author (Daniel). Part I consists of 22 diced cartilage grafts wrapped in Surgicel and placed in the radix (n = 14), radix/upper dorsum (n = 4), and full-length dorsum (n = 4). All grafts were performed adhering meticulously to Erol's technique without modification. This portion of the study was halted abruptly at 4 months because of the unexpected absorption and clinical failure of all diced cartilage grafts wrapped in Surgicel. Subsequently, five patients had revision surgery, and biopsy specimens were taken at the prior grafting site and analyzed histologically. After this clinical failure, part II of the study began, consisting of 20 patients who had diced cartilage grafts wrapped in fascia. The range of applications was comparable: radix (n = 12), radix/dorsum (n = 3), and full-length dorsum (n = 5). Because of our prior practice of overcorrecting by 20 percent with diced cartilage grafts wrapped in Surgicel, we had excessive amounts of material in six of our initial diced cartilage wrapped in fascia radix grafts, but no subsequent grafts. The overcorrections were easily reduced at 6 weeks to 11 months postoperatively using a pituitary rongeur under local anesthesia, and the material was sent for histologic analysis. Minimum 1-year follow-up of all 20 cases has shown maintenance of the grafts without evidence of absorption. Part III of this study comprised eight patients who had diced cartilage grafts without a fascial covering placed throughout the nose, including on the sides of osseocartilaginous rib grafts to the dorsum. At 14 months, there was no evidence that any of these grafts had been absorbed. Histologic analysis of the biopsy specimens from the diced cartilage grafts wrapped in Surgicel showed evidence of fibrosis and lymphocytic infiltrates with small amounts of Surgicel visible on birefringent microscopy. Remnants of cartilage were present but were metabolically inactive on the basis of negative glial fibrillary acidic protein staining. Control specimens of fresh septal cartilage and banked septal cartilage were remarkably similar to each other and demonstrated normal cartilage architecture and cellular activity. The diced cartilage grafts wrapped in fascia showed coalescence of the diced cartilage into a single cartilage mass, with viable cartilage cells and normal metabolic activity on the basis of glial fibrillary acidic protein staining. All of the diced cartilage grafts wrapped in Surgicel absorbed and failed to correct the clinical problem for which they were performed. All of the diced cartilage grafts wrapped in fascia and pure diced cartilage grafts did correct the clinical deformities and appear to have survived completely. The diced cartilage grafts wrapped in fascia placed along the dorsum were distinctly palpable throughout the postoperative period, as was one prior case with a 6-year follow-up. The authors' clinical experience confirms the experimental studies of Yilmaz et al. that question the use of Surgicel for wrapping diced cartilage grafts in clinical rhinoplasty surgery.

Comparison of the biological activities of high-density porous polyethylene implants and oxidized regenerated cellulose-wrapped diced cartilage grafts

The use of alloplastic materials in plastic surgery has become more extensive with advancement of autogenous-tissue reconstruction techniques for the repair of defects, tissue augmentation, and the stabilization of bones. An ideal alloplastic material should be nonallergenic, noncarcinogenic, sterilizable, and easy to shape and should not cause rejection. Alloplastic material used for tissue augmentation should have a low rate of resorption and distortion. High-density porous polyethylene implants (Medpor) have been used widely and successfully for tissue augmentation. The Turkish Delight is a material composed of diced cartilage grafts wrapped in oxidized regenerated cellulose (Surgicel). Its indications are similar to those of the Medpor implant, and an additional donor site is usually not needed. Both materials are used in the same anatomical locations, especially for augmentation. Therefore, the authors evaluated the long-term stability of and suitable anatomical sites for these materials. Medpor implants or Turkish Delights were placed subperiosteally or subfascially in 10 young rabbits, and the resultant changes were evaluated 16 weeks after the operation by macroscopy and histopathology. Changes in projections were measured with an ocular micrometer. Medpor implants were neither resorbed nor distorted when placed subperiosteally or subfascially, and were highly stabilized by the surrounding tissues. Turkish Delight also enabled tissue augmentation, but had a significantly higher rate of resorption compared with the Medpor implant and was loosely bound to the surrounding tissue. The Turkish Delight was less resorbed and better fixed to adjacent tissues when placed subperiosteally than when placed subfascially.