A Modified Suction-Assisted Technique of Transfer of Diced Cartilage Graft to Carrier Material and Outcome of Direct Injection of Unwrapped Diced Cartilage in Rhinoplasty

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.

The Treatment of Alar Base Depression in Rhinoplasty with Diced Autologous Cartilage or Mass Cartilage: A Systematic Review

BACKGROUND

Alar base is the basal part where the two sides of the nose and the upper lip are connected. Alar base depression affects the overall facial contour by making the nasolabial folds deepen, the nasolabial angle smaller, the center of the face flat, etc. Despite the rapid development of rhinoplasty, controversy still exists regarding the treatment of alar base depression. This systematic review aims to evaluate the efficacy and safety of two prevalent techniques-diced autologous cartilage and mass cartilage-for addressing alar base depression.

METHODS

A systematic review was conducted by searching the literature published in PubMed, Embase and Web of Science, Cochrane from January 2000 to April 2023 with the key words 'alar base depression or depressed alar base' and 'alar base augmentation,' and 2 investigators independently screened the retrieved literature according to inclusion and exclusion criteria.

RESULTS

A total of 269 articles were obtained through database search. After removing duplicates, reading titles and abstracts, and finally reviewing the full text, 6 articles were included in the final study, including 165 patients.

CONCLUSIONS

The results demonstrate that both diced autologous cartilage and mass cartilage techniques exhibit favorable outcomes in correcting alar base depression. Diced autologous cartilage offers better malleability, lighter border contours, and a more natural appearance. On the other hand, diced autologous cartilage seems to offer superior long-term effects, while mass cartilage presents certain surgical procedural advantages. Also, compared to diced cartilage, mass cartilage may have a lower rate of long-term resorption and a lower risk of displacement. This review emphasizes the need for personalized treatment selection based on individual patient characteristics.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

Comparing definitive unilateral cleft rhinoplasty with and without diced-cartilage alar-base augmentation: A retrospective cohort study

This retrospective cohort study aimed to compare the long-term aesthetic outcomes and satisfaction of patients who underwent two techniques of definitive unilateral cleft rhinoplasty. The two cohorts, comprising patients with mature unilateral cleft deformity, were managed with definitive rhinoplasty, either with or without diced-cartilage alar-base and peri-alar augmentation (ABPA). Thirty patients were included in each cohort. Anthropometric measurements, complications, patient satisfaction scores, and third-party surgeon assessment scores were reviewed. In both cohorts, anthropometric parameters improved. Rhinoplasty with ABPA was the superior cohort in terms of columellar length (10.3 ± 1.0 in the cohort with ABPA, compared with 7.9 ± 0.6 in the cohort without ABPA; p < 0.001), alar-base angle (0.2 ± 0.2, compared with 4.3 ± 0.3; p < 0.001), and columellar deviation (2.5 ± 1.4, compared with 10.3 ± 2.1; p < 0.001). This cohort also had more symmetry in nostril height and nostril width (p < 0.001), a lower recurrence rate (one case compared with 22 cases; p < 0.001), a higher patient satisfaction score (p = 0.002), and a higher surgeon assessment score (p < 0.001, Cronbach's alpha = 0.706, Kendall's coefficient of concordance = 0.787). Within the limitations of this study, it appears that the described technique for augmenting the alar-base and peri-alar maxillary area is manageable, and yields consistent long-term results.

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 .

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.

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.