Free Diced Cartilage: A New Application of Diced Cartilage Grafts in Primary and Secondary Rhinoplasty

Advantages and Disadvantages of Reconstructive and Preservation Rhinoplasty: Surgical Techniques, Outcomes, and Future Directions

Reconstructive rhinoplasty, a specialized surgical procedure, aims to restore both the form and function of the nose, particularly after trauma, congenital defects, or prior surgeries. This review evaluates the advantages and disadvantages of various surgical techniques used in reconstructive and preservation rhinoplasty. The study focuses on the outcomes of commonly employed methods such as cartilage grafting, flap techniques, and alloplastic materials, assessing both functional and aesthetic results. Recent advancements, including 3D imaging, tissue engineering, and artificial intelligence, are discussed as potential future directions that could enhance surgical precision, safety, and patient care. The review systematically examines clinical studies from the past decade, highlighting the evolving landscape of rhinoplasty and its impact on patient outcomes.

Closure of Nasal Septal Perforations Using a Diced Cartilage in Fascia Graft

The spectrum of surgical techniques in the repair of nasal septal defects is wide. The objective of this study was to assess the feasibility of using a diced cartilage in fascia (DC-F) graft for successful closure of nasal septal perforations and to evaluate symptom reduction. This was a retrospective study of 18 patients undergoing surgical repair of symptomatic nasoseptal perforations of different etiologies using a DC-F graft from 2020 until 2021. The procedure was feasible in all of the 18 patients. Reconstruction of septal defects with a DC-F graft led to reduction of crust formation, reduction of epistaxis, and improvement of nasal breathing in 13 out of the 18 patients when seen for their 2-month follow-up. Reperforation occurred in three cases, leaving defects of 1, 7, and 5 mm in diameter. In one case, the reperforation was symptomatic. A DC-F graft proved to be a reliable and reproducible method for the closure of nasoseptal perforations of variable sizes, of different locations, and of different etiologies.

Mechanically fragmented cartilage grafts in rhinoplasty: An up-to-date systematic review

INTRODUCTION

Grafts play key roles in functional and aesthetic rhinoplasty. Autologous grafts are generally preferred for their biocompatibility and less visibility when used in a fragmented fashion. The aim of this study was to review mechanically fragmented cartilage grafts techniques described in the literature, outlining indications, outcomes, and complications.

MATERIAL AND METHODS

A systematic review of articles published from 1999 until December 2022 was conducted, using the following key words: "rhinoplasty," "cartilage," and "graft." Studies were selected according to the inclusion and exclusion criteria, and data were extracted and grouped for subgroup analysis. Rates of partial resorption, total resorption, surgical revision, and major and minor complications were statistically analyzed.

RESULTS

Thirty eligible studies were included. Three cartilage fragmentation methods were identified: diced, shaved, and crushed. Cartilage grafts were further divided into injectable and noninjectable grafts. Diced cartilage was the most commonly used. Dorsal irregularities were the main indication. Overall, 1.68% of patients experienced partial resorption, 0.27% experienced total resorption, and 1.46% needed revision. The partial resorption rate in the diced group was significantly lower than that in the shaved group. Injectable grafts showed a higher rate of partial resorption. The revision rate was higher with noninjectable grafts.

CONCLUSION

The partial resorption rate was lower in patients treated with diced cartilage. Injectable grafts are malleable and suitable for the correction of minimal irregularities, although they are affected by a higher rate of partial resorption. Wrapping materials may be used when significant augmentation is required.

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 Use of Posterior Auricular Fascia Graft (PAFG) for Slight Dorsal Augmentation and Irregular Dorsum Coverage in Primary and Revision Rhinoplasty: A Prospective Study

INTRODUCTION

Augmentation and coverage of irregularities of the nasal dorsum remain a challenge in rhinoplasty. Different techniques have been described in the current literature for this purpose. The aim of this study is to assess and illustrate the author experience and outcomes using the posterior auricular fascia graft (PAFG) for dorsal camouflage and augmentation in primary and revision rhinoplasty.

MATERIAL AND METHODS

A prospective bicentric study was conducted, including patients with slight dorsal deficiencies and/or with dorsal irregularities following hump resection, trauma or previous rhinoplasty receiving PAFG to improve the rhinoplasty outcome. To objectively assess the graft resorption rate, MRI was performed 2 weeks and 18 months after surgery. To investigate patient satisfaction, the preoperative and 1-year postoperative scores obtained using the rhinoplasty outcomes evaluation (ROE) scale were compared. The scores following a normal distribution obtained for each patient were compared using a paired t-test.

RESULTS

Forty-five patients were enroled in this study. Average follow-up duration was 35.4 months. Patients' age ranged from 17 to 57 years. No cases of infection or major graft resorption were observed. No postoperative scars were visible at the donor site. All patients were satisfied after surgery, and a statistically significant difference between pre- and postoperative scores (p<0.0001) was observed.

CONCLUSION

This study showed that PAFG is a reliable technique for dorsal camouflage and slight augmentation in primary and revision rhinoplasty. The procedure is safe, easy and quick and only requires a small learning curve.

LEVEL OF EVIDENCE II

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 .

Safety and Efficacy of Autologous Cartilage Graft in Augmentation Rhinoplasty

Augmentation rhinoplasty or commonly known as "nose jobs" is one of the most common plastic surgical procedures aimed to improve cosmetic appearance. This procedure is considerably safer, less time consuming with faster recovery and immediate cosmetic effect. This procedure needs of highly experienced and well-trained plastic surgeon. According to facial analysis you can select the type of rhinoplasty. Open discussion with the patient to select appropriate surgical technique and its possible risks with your plastic surgeon to ensure the highest level of safety and satisfaction. Autologous grafting materials are safe, efficient and also the first choice for rhinoplasty due to it can survive without a vascular supply, the resorption rate of cartilage is much lower than that of a bone graft. Autologous grafting materials are stable and resistant to infection and extrusion over time so, they are successfully used for dorsal augmentation. To perform successful augmentation rhinoplasty, surgeons should be highly experienced and well-trained and augmentation materials that are currently available and understand their risks, benefits and uses. Autologous cartilage graft regarded as the graft of choice in augmentation rhinoplasty because of their lower rate of infection, rejection, resorption, extrusion, donor site morbidity, easy reshaping.

Template for Diced Cartilage with Platelet-Rich Fibrin (PRF) in Rhinoplasty: An Easy Solution for Millimetric Camouflage of the Full Dorsal Esthetic Unit

Dorsal irregularities are one of the most common issues in modern rhinoplasty. Rhinoplasty surgeons propose placing interface grafts lining the hole dorsum to ensure a natural unoperated look. Diced cartilage embedded in Choukroun's platelet-rich fibrin (PRF) scaffold being one of the most recent innovations in the field. However, no method has been described to help with the creation of thin, malleable, and reproductive graft with millimetric precision using that technique. The senior author details his protocol and his experience with a newly developed template for the creation of reproductive grafts with standard size and thickness, using diced cartilage, injectable PRF (iPRF), and advanced PRF (aPRF), for full dorsal camouflage and lining in rhinoplasty. This retrospective case series was conducted to evaluate the results looking at the dorsal esthetic unit at a minimum of 6 months for patients who beneficiated from a millimetric dorsal augmentation from 1 to 2mm using diced cartilage with iPRF and aPRF. The author reports his experience with 54 cases operated from April 2018 to May 2022 using his newly developed template.The template is an innovative technique to allow faster and more reliable fabrication of soft grafts using diced cartilage with both iPRF and aPRF. This novel approach allows for millimetric dorsal augmentation from 1 to 2mm with great precision and high reproductivity with good esthetic outcome.

Hybrid Autologous Costal Cartilage Grafting for Augmentation Rhinoplasty in Asian Patients

BACKGROUND

Autologous costal cartilage has been used for augmentation rhinoplasty in Asia for many years. This study aimed to assess the effectiveness and safety of hybrid grafting of costal cartilage for dorsal augmentation, septal reconstruction, and tip augmentation for Asian patients.

METHODS

A surgical technique was introduced and patients having rhinoplasty using this technique from April 2020 to March 2021 were retrospectively studied. In this technique, costal cartilage was meticulously carved or diced and grafted in various ways mainly based on the anatomic characteristics of nasal skin and subcutaneous soft tissues as well as bone and cartilage framework. The surgical outcomes, patient satisfaction, and complications retrieved from the documented medical records were reviewed and analyzed.

RESULTS

Twenty-five patients having rhinoplasty with the proposed technique were followed up from 6 months to 12 months. As for cosmetic outcomes, 21 patients were graded as good, 3 patients were graded as fair, and only 1 patient was graded as poor. Those patients who were not graded as good had over-rotated tips, insufficient dorsal augmentation, or asymmetry of nostrils and soft tissue contracture. The overall patient satisfaction was as high as 96.0%. Local infection occurred in 1 patient and hematoma was not observed. Warping and visibility of costal cartilage were not observed in any patients. Slight displacement of diced cartilages was found in 2 patients near the radix 1 week postoperatively.

CONCLUSIONS

Hybrid autologous costal cartilage grafts can be used for both tip refinement and dorsal augmentation for East Asian patients and achieve an outcome of a natural-looking nose with minimal complications.

LEVEL OF EVIDENCE

Level IV.

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.

A Combination Method of Costal Cartilage Injection Techniques for Augmentation Rhinoplasty

BACKGROUND

The multiple toothpick-shaped costal cartilage (MTCC) injection technique was introduced as an improvement based on the free diced costal cartilage (FDCC) injection technique for augmentation rhinoplasty. However, radix irregularities may occur when using the MTCC technique. Considering that the FDCC grafts are easier to shape at the nasal radix, we adopted a combination method of the 2 techniques to achieve natural and smooth contour.

METHODS

Four patients accepted this method for augmentation rhinoplasty. Through a unilateral marginal incision, the costal cartilage grafts were injected for nasal augmentation at the subperiosteal plane. The FDCC grafts and the MTCC grafts were used for nasal radix and dorsum augmentation, respectively. Nasal contour was adjusted by external shaping. The follow-up ranged from 24 to 43 months.

RESULTS

All patients were satisfied with the surgical outcome. There were no major complications occurred during the follow-up. One patient underwent rasping revision due to her own beauty-appreciation changes.

CONCLUSIONS

The combination method can take advantages of the FDCC and MTCC injection techniques. It can effectively lower the incidence of contour irregularities and graft displacement. Meanwhile, it is easy to perform without special procedure, and is time-saving and cartilage-saving.

Current Practices in Dorsal Augmentation Rhinoplasty

BACKGROUND

Dorsal augmentation rhinoplasty addresses the aesthetic and functional impairments caused by a deficient nasal dorsum. Augmentation rhinoplasty can be performed using a variety of different surgical techniques and grafting materials that all have distinct advantages and disadvantages.

METHODS

Grafting materials have unique characteristics, uses, and safety profiles. A detailed overview of various grafting materials and their uses, risks, and benefits is provided.

RESULTS

Autologous grafting materials include septal cartilage, auricular cartilage, and costal cartilage. These donor sites can provide various amounts of en bloc or diced cartilage. Alternatively, bone may be used when strong structural stability is required, and soft tissue may be used to fill mild to moderate defects. Homologous grafts (e.g., irradiated and nonirradiated rib) and acellular dermal matrices are alternatives to autologous graft with many similar advantages and no need for an additional surgical site. Lastly, alloplastic implants may be successfully used for dorsal augmentation if both patient and surgeon understand their associated risks.

CONCLUSION

To perform successful dorsal augmentation, surgeons should be familiar with the wide variety of operative approaches and augmentation materials that are currently available and understand their risks, benefits, and uses.

Paranasal Augmentation Using Diced Costal Cartilage for Midface Concavity: A Retrospective Study of 68 Patients

BACKGROUND

Paranasal augmentation was effective management for midface concavity. Both alloplastic graft (e.g. silicone, porous polyethylene, or expanded polytetrafluorethylene) and autologous tissue (e.g. costal cartilage) were used for paranasal augmentation. The study aims to evaluate the safety and efficacy of paranasal augmentation using diced costal cartilage for midface concavity.

METHODS

A retrospective review of demographic data and complications was conducted for consecutive patients who underwent paranasal augmentation using diced costal cartilage. A questionnaire was used for investigating the patient's satisfaction (i.e. overall satisfaction, bilateral alar bases symmetry, improvement of concavity, and foreign body sensation). Patients' photographs were used to evaluate aesthetic outcomes (i.e. overall satisfaction, bilateral alar bases symmetry, and improvement of concavity) by third-party doctors.

RESULTS

Sixty-eight patients (60 females; mean age, 27.1 ± 8.2 years) were included. During a median follow-up of 6.5 months, costal cartilage migration occurred in 13 (19.1%) patients and partial resorption occurred in 2 (2.9%) patients. Seventy-five per cent of the patients and 98.5% of the doctors reported overall satisfaction. Bilateral alar bases asymmetry by 20 (29.4%) patients, no improvement of concavity by 13 (19.1%) patients, and foreign body sensation by 13 (19.1%) patients were reported. While bilateral alar bases asymmetry was not reported, improvement of concavity was reported in 67 (98.5%) patients by third-party doctors. On both univariate and multivariate analyses, improvement of concavity was significantly associated with patients' overall satisfaction (p = 0.008 and 0.045, respectively), while bilateral alar bases symmetry and foreign body sensation were not (all p > 0.05).

CONCLUSIONS

Paranasal augmentation using diced costal cartilage seems a safe and effective method for midface concavity. Improvement of concavity may be significantly associated with patients' overall satisfaction.

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 .

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 .

Crushed Septal Cartilage-Covered Diced Cartilage Glue (CCDG) Graft: A Hybrid Technique of Crushed Septal Cartilage

BACKGROUND

Diced cartilage glue (DG) grafts have been widely used in dorsal augmentation but can induce dorsal irregularities. The authors evaluated the postoperative feasibility of a crushed septal cartilage-covered diced cartilage glue (CCDG) graft.

METHODS

The medical records of 38 patients who underwent dorsal augmentation rhinoplasty with an open approach were retrospectively reviewed. DG graft was used in 18 patients (47.4%), and CCDG graft was used in 20 patients (52.6%). Surgical outcomes were assessed by comparing anthropometric data on facial photographs and satisfaction questionnaires on aesthetic outcomes and palpable irregularities on nasal dorsum before and after surgery.

RESULTS

Both groups showed successful aesthetic outcomes. Dorsal height, radix height, and tip projection were all increased postoperatively in both groups. Tip rotation did not significantly increase (p > 0.05). Both groups showed similar outcomes in terms of aesthetic satisfaction but a significant difference in palpable irregularity. CCDG graft group showed significantly better (p = 0.04) satisfaction with dorsal irregularities (4.15 ± 0.75) than the DG graft group (3.56 ± 0.92). CCDG graft group also showed significantly better mean values (p = 0.048) in the degree of irregularity by two surgeons (3.85 ± 0.65) than the DG graft group (3.25 ± 0.97). No patient had significant complaints about irregular dorsum, and none of them underwent a revision rhinoplasty.

CONCLUSION

CCDG graft can be a complementary option for avoiding postoperative irregular dorsum complications.

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 .

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 .

Comparison of Free Diced and Multiple Toothpick-Shaped Costal Cartilage Injection Techniques for Augmentation Rhinoplasty

BACKGROUND

The free diced costal cartilage (FDCC) injection technique has been used in the augmentation rhinoplasty for a long time. In order to lower the incidence of nasal contour irregularities and graft displacement, we developed the multiple toothpick-shaped costal cartilage (MTCC) injection technique. This comparative study was conducted to introduce and assess this new technique.

METHODS

This retrospective analysis included 51 patients who underwent augmentation rhinoplasty with either the FDCC or MTCC injection technique at the 17th Department of Plastic Surgery in the Plastic Surgery Hospital between July 2014 and May 2020. The patients were divided into the FDCC (n = 30, 58.82%) and MTCC (n = 21, 41.18%) groups. General data, postoperative patient satisfaction, complications and revision rate were compared between the groups.

RESULTS

Except for the follow-up period, there were no significant differences in general data (age, sex, preoperative dorsum deformity, preoperative rhinoplasty history) between the groups. Postoperative patient satisfaction, complications and revision rate were similar between the two groups.

CONCLUSIONS

The MTCC injection is a safe and effective technique for augmentation rhinoplasty. Like the FDCC injection technique, the new technique is relatively easy to perform and time-saving with concealed scarring and minimal postoperative edema. Most of its revision surgeries are also easy to perform by simple rasping and reinjection. According to our experience, the new technique may have wider indication as well as lower incidence of nasal contour irregularities and graft displacement. Therefore, we suggest that the MTCC injection technique is reliable and worthy of recommendation.

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 .

Sliced vs crushed cartilage for camouflage: long-term graft survival and histological outcomes

PURPOSE

In this study, we proposed a "sliced-partial thickness cartilage graft" for nasal contour restoration purposes and compared the long-term graft survival and histological changes of sliced, crushed, and intact cartilage grafts.

METHODS

Nasal septal and auricular cartilage grafts were harvested from 8 rabbits. Sliced, crushed, or intact cartilage grafts were measured in thickness with a micrometer and re-implanted. 4 months later, specimens were histologically evaluated and thickness were measured.

RESULTS

Both nasal septal and auricular crushed cartilage lost significantly more chondrocytes than sliced samples together with fibrosis, multiple fracture lines, and even ossification. Sliced and intact cartilages were histologically similar except sliced cartilage had some minor changes limited to its cut surface. Sliced cartilages retained their thickness, histology, and structural properties in the long term similar to intact cartilages whereas -contrary to expectations- crushed specimens had significantly higher thickness measurements at the end of 4 months.

CONCLUSION

Sliced cartilage grafts prepared with an atraumatic cartilage slicer are an ideal camouflaging material with its uniform thickness, and malleability. Crushed cartilages seemingly getting thicker without histological findings could be explained by lower than actual initial measurements due to its structural weakness and getting squeezed when the standard pressure of the micrometer was applied.

Ultra Diced Cartilage Graft in Rhinoplasty: A Fine Tool

BACKGROUND

Free diced cartilage smaller than 0.2 mm in diameter to smoothen the nasal dorsum is a well-known procedure. However, creating smaller diced cartilage takes a really long time. In contrast, the free diced cartilage technique has some visibility problems, especially in thin-skin patients, although a fine job is done to chop the cartilage. The author aimed to present the "ultra diced cartilage graft" and the way to achieve it, to eliminate the problems of diced cartilage during rhinoplasty, and compare it with free diced cartilage grafting technique.

METHODS

Between April of 2015 and December of 2018, the ultra diced cartilage graft technique in 104 patients and the free diced cartilage graft technique in 113 patients were used to smoothen the dorsum or augment the radix/dorsum. Operation records, rhinoplasty outcome evaluation questionnaire, palpation test, and evaluation of the immediate postoperative photographs on the table with postoperative 1-year postoperative photographs by two independent blinded plastic surgeons were analyzed.

RESULTS

Ultra diced cartilage seemed superior to free diced cartilage grafting with regard to graft visibility and resorption.

CONCLUSIONS

Ultra diced cartilage graft is an effective and easily reproducible technique in rhinoplasty. There is no extra cost, and it is the easiest and fastest way to have this perfectly pliable cartilage have no dead space. The ultra diced cartilage grafting technique should be known by all plastic surgeons to achieve fineness in rhinoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Long-Term Complications from Diced Cartilage in Rhinoplasty: A Meta-analysis

Objective: To analyze the incidences of long-term complications and revision surgery associated with diced cartilage grafts in dorsal augmentation rhinoplasty. Methods: The PubMed, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for clinical studies on the use of diced cartilage for dorsal augmentation published. A meta-analysis was conducted to pool the estimated rates of infection, overcorrection, visible irregularity, absorption, and revision surgery. Result: A total of 14 studies involving 2380 patients were included in the systematic review. The combined rates were 11.5% for overall complications and 5.3% for revision surgery. The rates of the most frequently reported complications were 4.5% for infection, 5.3% for visible irregularity, 0.7% for overcorrection, and 0.5% for absorption. There was no significant difference in the rates of visible irregularity (p = 0.23) and revision surgery (p = 0.71) among the wrapped diced cartilage, glued diced cartilage, and free diced cartilage groups. Conclusion: This meta-analysis presents the first comprehensive and quantitative report of long-term complications associated with diced cartilage in dorsal augmentation rhinoplasty. Infection and visible irregularity were the most frequently reported complications. The rates of irregularity and revision surgery were not correlated with the diced cartilage packing methods.

Differences between Primary and Revision Rhinoplasty: Indications, Techniques, Grafts, and Outcomes

BACKGROUND

The nose is at the center of the face and has essential functional and aesthetic properties. Over recent years, rhinoplasty has gained increasing popularity through the influence of "selfies" and social media. As a result, a growing demand for secondary correction has also emerged. Revision rhinoplasty is more complex than primary cases and often requires the use of extranasal grafting material. The authors sought to analyze the indications, techniques, and outcomes after primary and revision rhinoplasty.

METHODS

A total of 245 patients (153 primary cases and 92 revisions) undergoing surgery at the authors' specialized clinic for facial plastic surgery were included. All patients were treated by an experienced facial plastic surgeon according to the authors' established clinic standards. A retrospective data analysis was performed to evaluate the differences between the groups regarding the indications, intraoperative techniques, and postoperative outcomes.

RESULTS

Although more patients sought revision surgery for aesthetic reasons alone than isolated functional issues, almost two-thirds of the revision patients had functional and aesthetic problems in combination. Complex reconstructive techniques, extracorporeal septoplasties, and extranasal grafts were more commonly used in revision cases. The occurrence of another revision during the follow-up period was significantly higher after revision surgery compared to primary rhinoplasty cases (primary rhinoplasty, 10.5 percent; revision surgery, 23.9 percent; p = 0.006).

CONCLUSIONS

There are differences between primary and revision rhinoplasty that must be appreciated by the treating surgeon. The patient should be informed about the increased complexity of the secondary procedure, the possible need for extranasal grafts, and the increased risk of a further revision.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

"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 .

40 Years of Total Extracorporeal Septal Reconstruction: The Past, Present, and Future

BACKGROUND

Even today, severe septal deformities are a challenging problem for any rhinoplasty surgeon. Standard techniques are often not able to achieve satisfactory long-term results regarding function or aesthetic form. In such severe cases, a partial or total extracorporeal septal reconstruction may be used, as these techniques provide reliable and lasting results.

METHODS

The aim of this work is to present the authors' experience with the technique of total extracorporeal septal reconstruction and its development to today's standard and to prove its effectiveness in the long-term follow-up.

RESULTS

This article presents 40 years of clinical experience in this field and describes the technical changes that have evolved. Low complication rates, safe techniques, and favorable long-term outcomes of the total extracorporeal septal reconstruction show the benefits of this technique.

CONCLUSION

The indication for a total extracorporeal septal reconstruction has been limited by the development of less complex surgical procedures, but it still represents the best technique to achieve long-term functional and aesthetic results in patients with very complex septal deformities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

A Cartilage Dicing Tool for Rapid Preparation of Rhinoplasty Grafts

Over 220,000 rhinoplasties are performed in the U.S. annually, with approximately 90% of all procedures requiring the use of cartilage autografts or allografts to augment nasal structure or contour. Prior to implantation, graft cartilage is shaped into the desired form by facial plastic surgeons through carving, crushing, or dicing, and molding of the tissue. The use of diced cartilage has been shown in literature to be the optimal technique for creating contour grafts, permitting increased graft moldability, and resulting in the fewest postoperative complications. Despite superior clinical outcomes, adoption of diced techniques is challenged by the laborious, time-intensive process of dicing tissue, which requires up to 2 h in the operating room and is currently performed manually with a blade. Manual dicing can result in inconsistently sized pieces, which can increase risk of graft breakage. Existing cartilage processing tools are primarily intended for crushing tissue and are unsuitable for dicing. This work describes the design and validation of an easy-to-use, effective device for rapid, consistent cartilage dicing. Cartilage sizing analysis demonstrated that the device produced approximately five times more diced cartilage within 5 min compared to manual dicing. The rapid dicer (RD) device consistently dices cartilage to a size suitable for grafting while significantly decreasing processing time and cartilage loss compared to current methods. Future development will focus on performing further user testing of the device to design a more ergonomic instrument casing.

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 .

Outcome of Free Diced Cartilage Grafts in Rhinoplasty: A Systematic Review

Diced cartilage grafts are used to increase and refine the nasal contour, providing easy molding and versatility when compared with block grafts. However, all grafts present the possibility of visibility, distortion, and absorption. The aim of this study is to evaluate, through a systematic review, the outcome of the use of the free diced graft cartilage in rhinoplasty. A systematic search of the literature was performed in the databases (PubMed, Lilacs, Scielo, Cochrane) with the terms "diced cartilage" and "rhinoplasty." Studies were selected according to the inclusion and exclusion criteria and data extracted and grouped for analysis. Six eligible studies were included. In total, 4,044 patients underwent rhinoplasty with free diced cartilage graft, with 61 (1.51%) of them requiring reoperation. The main reasons were overcorrection and irregularities of the nasal dorsum. The infection rate was reported in three studies, with 2 (0.06%) of 3,252 patients presenting infection at the graft site. Two cases of displacement were treated with external molding, without reoperation. The graft resorption was reported in four articles, which described 22 (0.67%) cases of partial resorption in 3,288 patients. Therefore, the available evidence suggests that resorption of the graft and unfavorable outcomes are rare.

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.

A Simple Combination Approach for Costal Cartilage Augmentation Rhinoplasty

Autologous costal cartilage graft is optimal for augmentation rhinoplasty but with complications including markedly visible graft margins and dorsal contour irregularities. Therefore, the authors introduced the diced costal cartilage graft to smoothen the margins of bilateral spreader graft for nasal dorsum augmentation. A total of 6 patients were recruited for this augmentation rhinoplasty. The pre- and postoperative photographs were taken for improvement evaluation. During a mean follow-up of 15 months, none of the patients developed major complications that may require removal or revision of the costal cartilage grafts. Five patients (80%) were very satisfied with the aesthetic outcome. This simple algorithm facilitates the substantial augmentation and removes the visibility of dorsal graft in the costal cartilage rhinoplasty for the East Asian population.

The Effect of Perichondrium on Biological and Biomechanical Properties of Molded Diced Cartilage Grafts

BACKGROUND

Diced cartilage is a significant alternative approach to cartilage grafting. However, the viability and biomechanical properties of diced cartilage grafts remain to be improved, and the role of perichondrium is largely neglected. This study aimed to evaluate the histological and biomechanical effects of perichondrium on custom-shaped diced cartilage grafts constructed via a high-density porous polyethylene mold.

METHODS

Seven New Zealand rabbits were used. Unilateral auricular cartilage was harvested and divided into 2 parts, with or without perichondrium, diced into 1 × 1 × 0.5 mm cubical pieces, and filled into high-density porous polyethylene molds. Three grafts with the perichondrium removed and 3 with the perichondrium preserved were implanted subcutaneously at the dorsum. The grafts underwent biomechanical and histological tests 4, 8, and 12 weeks after the implantation.

RESULTS

The diced cartilage merged into integrated blocks without observable resorption in both groups at each time point. Additionally, the retention rate of weight was higher in the perichondrium-preserved group (P < 0.05). We observed regenerated cartilage that stained positively for type II collagen and glial fibrillary acidic protein (GFAP). A greater area of regenerated cartilage and higher scores of GFAP staining were observed in the perichondrium-preserved group (P < 0.05). The yield stress and modulus of elasticity were also higher in the perichondrium-preserved grafts from week 8 after implantation (P < 0.05).

CONCLUSIONS

Diced cartilage grafts with a custom shape can be constructed using a high-density porous polyethylene mold. The preservation of perichondrium can improve graft viability and biomechanical properties.

LEVEL OF EVIDENCE

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 http://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.

Management of the Mestizo Nose

Mestizo noses have mesorrhine nasal characteristics. They have a modest osteocartilaginous framework, nasal tips that tend to be bulbous with poor projection and rotation, and skins that tend to be thick and acne prone. A structural rhinoplasty approach is performed, focusing on anatomic findings. Conservative tissue excision with preservation or reinforcement of support structures of the nose is done. Structural grafting and suturing techniques are used to remodel cartilage and create better definition and support. The skin and soft tissue envelope is managed medically and surgically. The objective is to create balanced-looking noses that bring patients closer to their own aesthetic ideal.

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.

Comprehensive Application of Autologous Costal Cartilage Grafts in Rhino- and Mentoplasty

BACKGROUND

Underdevelopment of nose and chin in East Asians is quite common. Rhinoplasty and mentoplasty are effective procedures to solve the above-depicted defects and can achieve remarkable cosmetic effects. An autologous costal cartilage graft has become an ideal material for rhinoplasty, especially for revision surgery. However, many problems in the clinical application of costal cartilage remain unresolved. This study is to investigate application strategies of autologous costal cartilage grafts in rhino- and mentoplasty.

METHODS

The methods involved are as follows: application of an integrated cartilage scaffold; comprehensive application of diced cartilage; and chin augmentation of an autologous costal cartilage graft.

RESULTS

In this study, satisfactory facial contour appearance was immediately achieved in 28 patients after surgery; 21 patients had satisfactory appearance of the nose and chin during the 6- to 18-month follow-up. Cartilage resorption was not observed. Two patients had nasal tip skin redness and were cured after treatment.

CONCLUSION

This procedure can be used to effectively solve: curvature of the costal cartilage segment itself; warping of the carved costal cartilage; and effective use of the costal cartilage segment. The procedure has achieved satisfactory outcomes, and its application is worth extending to clinical practice.

Suture techniques and cartilage grafts in nasal tip surgery: An algorithm in primary and secondary rhinoplasty

OBJECTIVE

In most primary and secondary rhinoplasties, the adjustment of the nasal tip in terms of position, projection, and configuration is mandatory. Usually, this is one of the most challenging parts of the operation. The aim of this study was to present a step-by-step algorithm that evaluates popular techniques for a predictable outcome.

PATIENTS AND METHODS

A single-surgeon retrospective review of primary and secondary rhinoplasty patients was undertaken for nasal tip refinement. An overview of popular and clinically relevant suture techniques and cartilage grafts is provided, in particular, concerning the position, projection, and rotation. On the basis of clinical examples, we will present different indications, the latest operative treatment options, and long-term results.

RESULTS

Between 2013 and 2018, we devised an algorithm based on 322 patients. Ninety patients (28%) were admitted for primary rhinoplasties and 232 patients for secondary rhinoplasties (72%). Our patients reported overall high satisfaction rates, and no further revisions were required.

CONCLUSIONS

Preoperative analyses and the knowledge of different suture techniques and cartilage grafts for nasal tip surgery are crucial factors for a successful postoperative outcome.

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 .

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.

A New Method for Partial Breast Reconstruction: 3-Year New Zealand Experience

In New Zealand, oncoplastic surgery is common, but partial breast reconstruction presents challenges for radiation therapy targeting. Tissue rearrangement creates ambiguity when targeting the tumor bed, with resultant overestimation of treatment volumes. Thus, adoption of advanced methods of radiation therapy have been hindered. This pilot study describes use of a novel three-dimensional implant that provides a scaffolding for tissue ingrowth during partial breast reconstruction and delineates the tumor bed more precisely to assist radiation planning and mammographic surveillance. After informed consent, 15 women were implanted with the three-dimensional bioabsorbable implant. The device was sutured to the tumor bed during lumpectomy, and tissue flaps were mobilized and attached to the implant. Visualization of the marker and radiation treatment volumes were recorded and compared. The implant provided volume replacement and helped to maintain breast contour. Cosmetic outcomes were excellent; no device- or radiation-related complications occurred. One patient had a postoperative hematoma that resolved after percutaneous drainage; there were no postoperative infections. Three-year follow-up shows no tumor recurrences and no untoward effects. When compared to conventional radiation targeting, use of the implant showed that a greater than 50 percent reduction in treatment volume was possible in some cases. Three-year mammograms show no significant artifact, normal tissue ingrowth, and minimal fibrosis. This study describes a method of oncoplastic breast reconstruction using an implantable device that marks the site of tumor excision and provides for volume replacement with tissue ingrowth. Patients tolerated it well, and radiation therapy planning, positioning, and treatment were facilitated.

Nasal Dorsal Augmentation with Freeze-Dried Allograft Bone: 10-Year Comprehensive Review

Supplemental Digital Content is available in the text.

Background:

The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. The 42-month report on 18 patients was published in 2009 in Plastic and Reconstructive Surgery with 89 percent success at level II evidence, and this article is the 10-year comprehensive review of 62 patients.

Methods:

All grafts met standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography, cone beam volumetric computed tomography, and computed tomography at up to 10 years. Vascularization and incorporation of new bone elements within the grafts were demonstrated by fluorine-18 sodium fluoride positron emission tomography at up to 10 years. Subjective estimation of graft volume persisting up to 10 years was obtained by patient response to a query conducted by an independent surveyor.

Results:

The authors report objective proof of persistence of volume alone or combined with proof of neovascularization in 16 of 19 allografts. The authors report the patient’s subjective opinion of volume persistence in 37 of 43 grafts. The dorsal augmentation was assessed overall to be successful in 85 percent of 62 patients evaluated between 1 and 10 years, with a mean of 4.7 years.

Conclusions:

Freeze-dried allograft bone is a safe and equal alternative for dorsal augmentation without donor-site morbidity. Further studies are needed to (1) confirm these findings for young patients needing long-term reconstruction, and (2) partially demineralize allograft bone to allow carving with a scalpel.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.

A reliable method to avoid contamination during cartilage graft preparation in septorhinoplasty

PURPOSE

The aim of the study is to determine the risk of contamination in the cartilage graft materials prepared on the swester table and those prepared in a sterile package, and to reveal a more reliable method by performing the microbiological examination of these materials.

METHODS

Cartilages removed from the nasal septum were divided into four pieces. The first part (Sample A) was directly placed into the medium. Sample B was prepared by being crushed in a sterile package. Sample C was prepared on the auxiliary swester table, and Sample D was prepared on the main swester table actively used by surgery team. All samples were transferred in a 1 ml brain heart(BH) liquid medium. From each BH medium, 100 µl culture was performed on blood agar, eosin-methylene blue-lactose-sucrose agar and chocolate agar.

RESULTS

Bacterial growth was detected in 2 of the samples A, in 4 of the samples B, in 24 of the samples C, and in 36 of the samples D. The number of patients with bacterial growth in the samples C and/or D despite no growth in the sample B was 35. When the samples A/B and C/D were compared in terms of bacterial growth, a significant difference was found in all matchings (p < 0.001 for all comparisons).  CONCLUSION: These findings showed that preparation of the cartilage grafts on the swester table was extremely risky for microbiological contamination. Arslan and his colleagues suggest that preparing a graft material in a sterile package is extremely simple, cheap, and it also reduces contamination risk significantly.

Free Diced Cartilage: Tips and Tricks of a Customized Procedure in Rhinoplasty

Supplemental Digital Content is available in the text.

Free diced cartilage graft represents a relatively innovative technique with multiple applications. It is conventionally used for smoothening, augmentation, or camouflaging of the nasal dorsum in primary or revision rhinoplasties. The aim of the article was to give some tips and tricks about harvesting and preparation of free diced cartilage to maximize its exploitation and make it easily repeatable, extending the field of application not only to the nasal dorsum but also other sites, such as the tip of the nose.