Irregularities of the nasal dorsum are regularly appearing sequelae after hump removal in aesthetic rhinoplasty. Small elevations, notching, and discrete asymmetry frequently occur. The problem is aggravated in thin-skin patients and in secondary cases where the original anatomy is frequently destroyed. Free solid cartilage grafts processed with a morselizer were the treatment of choice for a long time. However, grafts to the nasal dorsum are challenging because of their visibility if not placed precisely. In addition, secondary dislocation of large solid grafts may occur, as well as unpredictable resorption when crushed to fit in place.1 Alloplastic material, in contrast, is associated with unwanted side effects and is rarely used in the non-Asian rhinoplasty world.2 Since the 1990s, the use of autologous or allogenic fascia has gained increasing popularity.3 In the past decade, diced cartilage grafts in fascia were used as diced cartilage in fascia for dorsal augmentation.4–6 Ever since the evolution of diced cartilage grafts, surgeons have been searching for a scaffold to simplify placement and shaping of the coarse-grained cartilage granulate. Among other techniques, grafts were wrapped in autologous or allogenic fascia, oxidized cellulose polymer (Surgicel; Ethicon, Inc., Somerville, N.J.), or acellular dermal matrix (AlloDerm; LifeCell Corp., Branchburg, N.J.).5,7,8 Other published approaches demonstrate the agglutination of the cartilage pieces with fibrin glue9–13 or the patient’s own blood.14–16 However, scaffolds may be associated with higher costs, longer operating time, and increased complication rates such as infections and unpredictable graft resorption. Consequently, the aim of our study was to develop a new way of preparing cartilage grafts to supersede the use of scaffolds, to ease the placement and shaping of the graft, and to increase its viability. In the present study, we present our method of meticulously dicing and placing free diced cartilage harvested from septum, rib, or ear cartilage to smoothen, augment, or camouflage the nasal dorsum in primary and revision rhinoplasties.
PATIENTS AND METHODS
This study was approved by the appropriate institutional and national research ethics committee and was performed, including all procedures, in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. All participants gave their informed consent in writing before inclusion in the study, specifically for publication of photographs.
A retrospective analysis of multisurgeon consecutive rhinoplasties including the use of diced cartilage grafts was conducted at a single institution. From January of 2014 through December of 2014, 488 primary and secondary open approach rhinoplasties were performed by five different senior surgeons. Forty-two patients (9.38 percent) could not be examined 7 months postoperatively and were considered lost to follow-up. Therefore, 446 patients (270 female and 176 male patients) were included in the current study, of which 277 (62.11 percent) underwent primary rhinoplasty and 169 (37.89 percent) had undergone at least one previous rhinoplasty. Fifty-six percent of patients had thin skin, 21 percent had intermediate skin, and 23 percent had thick skin, based on the surgeon’s preoperative evaluation.
Thirty-eight patients (8.52 percent of all patients included in the study) presented with a congenial or nontraumatic deformity such as cleft nose, Binder syndrome (maxillonasal dysplasia), Wegener granulomatosis, or Marfan syndrome. All patients included in the study were seen and physical examination was performed according to our standard protocol 7 months postoperatively. At this point, the indication for revision surgery was set if dorsal irregularities were present. Patients’ medical records and photographs were reviewed, and a history of previous operations, the donor site of the cartilage, and the technique of dicing and placing diced cartilage grafts were documented. Our newly developed preparation and application technique of free diced cartilage was compared to classic techniques using fascia with or without diced cartilage grafts. In all cases, the application to the nasal dorsum for smoothening, augmentation, and camouflage was evaluated. Accordingly, patients included in the study were divided into three groups (groups I, II, and III).
In 325 cases, free diced cartilage was applied onto the nasal dorsum, either for augmentation or for coverage of irregularities (group I). Two hundred twelve cases (65.23 percent) were primary, and 113 (34.77 percent) were secondary operations. The mean age at the time of surgery in group I was 33 ± 12.63 years (range, 14 to 73 years).
In group II, 73 patients [48 (65.75 percent) primary and 25 (34.25 percent) secondary cases] were included, and mean age at the time of surgery was 34 ± 12.63 years (range, 17 to 69 years). Twenty-four patients (33 percent) received fascia only and 49 patients (67 percent) received fascia in combination with free diced cartilage. In 71 cases, allogenic fascia lata (Tutoplast; Tutogen Medical GmbH, Neunkirchen am Brand, Germany) was used, and two patients received autologous deep temporal fascia.
In group III, only diced cartilage in fascia was used. We included 48 patients [17 primary (35.42 percent) and 31 (64.58 percent) secondary cases], with a mean age of 34 ± 11.84 years at the time of surgery (range, 17 to 53 years). Twenty-four patients (50 percent) patients received allogenic fascia lata (Tutoplast), whereas 24 patients (50 percent) received autologous deep temporalis fascia. Means and standard deviations were calculated using Excel (Microsoft Corp., Redmond, Wash.).
Cartilage is harvested without perichondrium from the nasal septum, the concha or tragus of the ear, or the rib. Subsequently, it is diced into pieces smaller than 0.2 mm in diameter, thereby differing from the originally larger size described by Daniel and Calvert.5 For cutting, a sharp dermatome blade is used like a chopping knife (Fig. 1). During the dicing process, small amounts (1 to 3 ml) of normal saline or gentamicin solution cause an adhesive effect through surface tension. To maintain viability of the chondrocytes, it is important not to squeeze the cartilage during the cutting process. Finally, a fine-particle free diced cartilage granulate is fabricated, featuring characteristics of a shapable paste (Fig. 2). The application of the paste can be performed in two ways: it can either be put onto a Freer raspatory and thus be placed to the relevant region under direct vision (Fig. 3, above); or, as in most cases, it can be applied after redraping the skin flap and suturing the transcolumellar incision. For this purpose, the free diced cartilage paste is filled into a 1-ml syringe (Fig. 3, center), dried (Fig. 3, below), and finally injected directly into the relevant region (Fig. 4). Having applied free diced cartilage to the nasal dorsum, we massage and immediately fixate it with paper drape. At the end of the procedure, a cast stabilizes the result. Every irregularity and even the smallest dimplings can be filled up with free diced cartilage to create a smooth contour of the dorsum of the nose.
Of 325 patients undergoing primary or secondary rhinoplasty from January of 2014 through December of 2014 with free diced cartilage applied onto the nasal dorsum (group I), 30 patients (9.2 percent) were scheduled for revision surgery 7 months postoperatively. In group II, consisting of 73 patients undergoing primary or secondary rhinoplasty with fascia alone or in combination with free diced cartilage during the same period, seven patients (9.6 percent) were scheduled for revision surgery 7 months postoperatively. Of 48 patients included in group III, receiving diced cartilage in fascia for dorsal augmentation or coverage of dorsal irregularities in the same period, 15 patients (31.3 percent) were scheduled for revision surgery 7 months after surgery.
Subgroup analysis of reasons for revision showed that in group I, 17 of the 30 revision operations were performed because of persisting dorsal irregularities or deformities, yielding an overall revision rate of 5.2 percent for problems associated with the nasal dorsum in this group. Nine of the revisions for dorsal irregularities were performed in the subgroup of the 212 primary cases (4.25 percent), whereas eight of the revisions were performed in the subgroup of the 113 secondary cases (7.08 percent).
In group II, six of seven revisions were performed because of persisting dorsal irregularities or deformities, yielding a revision rate of 8.2 percent for problems with the nasal dorsum. Five of the revisions were performed in the subgroup of the 48 primary cases (10.42 percent), whereas one revision was performed in the subgroup of the 25 secondary cases (4.00 percent). Only one revision operation was performed in the fascia-only subgroup, whereas five revisions were performed in the subgroup in which fascia in combination with free diced cartilage was applied.
Of 15 revision operations conducted in group III, 12 cases were caused by dorsal irregularities or deformities, resulting in a revision rate of 25 percent for dorsal irregularities or deformities in this group. Three of the revisions were performed in the subgroup of the 17 primary cases (17.65 percent), and nine of the revisions were performed in the subgroup of the 31 secondary cases (29.03 percent).
Revision surgery because of persistent dorsal irregularities was recommended but refused by an additional two patients from group I, and by one additional patient from group II. All patients for whom revision surgery was recommended from group III underwent surgery. Apart from dorsal irregularities and deformities, indications for revision surgery in all groups included inadequate rotation or projection of the nasal tip (n = 8), persisting functional problems (n = 3), postoperative alar retraction or deformity (n = 3), and others (n = 3).
A 41-year-old woman presented with a deviated nose and a high nasal dorsum (Figs. 5, left, and 6, left). She had undergone previous rhinoplasty and suffered from severe breathing problems. Endonasal examination revealed a severe septal deviation to the left and hypertrophy of the right inferior turbinate. The nasal skin was thin.
Open approach revision rhinoseptoplasty included the following:
- Straightening of the septum.
- Lowering of the nasal dorsum using component reduction.
- Paramedian, low-to-low lateral and transverse osteotomies.
- Spreader flaps to open the inner nasal valve.
- Tip refinements with domal and interdomal sutures and spanning suture.
- Reconstruction of the tip support with columellar strut.
- Augmentation of the nasion with free diced cartilage plus smoothening of dorsal irregularities with free diced cartilage.
Postoperative follow-up revealed midline sagittal realignment of the nose in bony and cartilaginous parts 7 months postoperatively. A straight profile with stable augmentation of the nasion could be seen (Figs. 5, right, and 6, right). Marked functional improvement was also achieved.
A 25-year-old man presented with dorsal irregularities after three previous rhinoplasties, including septal reconstruction with rib cartilage and dorsal augmentation with diced cartilage in fascia. Preoperative examination revealed a free nasal airway and a straight septum. However, a step was seen at the reconstructed bone/cartilage junction with an elevation in the bony part and an indentation in the cartilaginous part (Figs. 7, left, and 8, left).
Open approach revision rhinoplasty included the following:
- Rasping of the bony part.
- Harvesting of conchal cartilage of the right ear.
- Smoothening of the dorsum with free diced cartilage.
Seven-month follow-up revealed a straight and smooth nasal dorsum. Mild supratip fullness was acceptable to the patient (Figs. 7, right, and 8, right).
A 24-year-old woman presented with a deviated nose with a dorsal hump, complaining of breathing impairment. She related a trauma to the nose during childhood. Clinical examination showed a septal deviation to the right with an anterior deviation to the left. Both inferior turbinates were hypertrophic. The profile view showed an underprojected nasion. The tip was broad and undefined, and a narrow midvault was seen (Figs. 9, left, and 10, left).
Open approach rhinoseptoplasty included the following:
- Straightening of the septum.
- Dorsal reduction using component reduction.
- Widening of the inner nasal valve with spreader grafts.
- Submucous resection of the inferior turbinates.
- Reconstruction of the tip support with a columellar strut and tip suspension with anterior sling.
- Tip rotation, cephalic trim of lower lateral cartilages, dome sutures, rim grafts.
- Augmentation of the nasion and smoothening of the dorsum with free diced cartilage.
One year postoperatively, the patient reported a marked functional improvement. The profile was straight with a stabile augmentation of the nasion. A slight deviation of the nasal axis could still be seen (Figs. 9, right, and 10, right).
Most rhinoplasty procedures affect the nasal dorsum,17 which plays a key role in both nasal form and nasal function. Hump reduction with subsequent widening of the bony dorsum and reconstruction of the internal nasal valves by spreader flaps or grafts causes changes, especially in the bone/cartilage junction, and irregularities that need to be smoothened occur regularly. In our daily work, we often deal with patients presenting with unsatisfying results after one or several previous operations, asking for improvements. An overresected framework with mild or moderate dorsal depression or even severe saddle nose deformity is common. According to Yu et al., upper third dorsal irregularities are the third most frequent problem among patients looking for aesthetic improvement and the second most frequent surgeon finding.18 Even experienced rhinoplasty surgeons are confronted with the complexity of these problems, which remain a challenging topic in primary and revision rhinoplasty. To manage the challenges of the nasal dorsum, several techniques including a wide range of different grafts and implants have been described.17
In the Tasman technique, and in the technique described by Bracaglia et al., fibrin glue is used for coherence of small cartilage pieces before delivering it to the nasal dorsum,9–11,14 thereby avoiding dispersion of fragments and providing ease of molding. Öreroğlu et al. describe a way of delivering a bone dust and diced-cartilage mixture with addition of the patient’s blood to the nasal dorsum,15 whereas Codazzi et al. pay special attention to the blood temperature as the activity of the coagulation factors is reduced at lower temperatures.16 Both techniques avoid time-consuming preparation of tissue glue or harvesting of a wrapping fascia. In addition, without wrapping material, revascularization may be quicker, and erythema and inflammation may be minimal.
Bullocks et al. use autologous tissue glue to stabilize diced cartilage grafts,13 thereby producing a malleable diced cartilage construction. In agreement with the aforementioned authors, they see the advantage that there is no barrier to prevent the diffusion of nutrients to the chondrocytes in the graft, with the result being better cartilage viability. As they use bovine thrombin, however, possible side effects are immune-mediated coagulopathy and temporary erythema of the nose following the insertion of the diced cartilage graft with autologous tissue glue.
Regarding the viability of cartilage grafts, there are currently contradicting results. Fatemi et al. found statistically significant resorption of diced cartilage grafts wrapped in fascia in their experimental study, whereas solid block cartilage grafts wrapped in fascia showed no statistically significant resorption rate.19 In contrast, Brenner et al. showed that wrapping diced cartilage with fascia confers higher chondrocyte viability associated with long-term permanence, making it the first choice when significant volume replacement is needed in the nasal dorsum.20
In the current study, we introduce our newly developed modification of the Daniel technique called free diced cartilage, enabling the surgeon to use a diced cartilage mass as spackling compound to fill irregularities in almost every region of the nose, especially the dorsum. Using the free diced cartilage technique alone for smoothening the nasal dorsum, we found revision rates for dorsal irregularities during the 7-month postoperative follow-up examination of 5.2 percent. In contrast, when fascia alone or in combination with free diced cartilage was used to treat irregularities of the nasal dorsum, we observed revision rates of 8.2 percent. The use of diced cartilage in fascia was associated with the highest revision rate (25 percent) in the current study. These findings strongly support our clinical experience that the free diced cartilage technique is an effective method for camouflage and augmentation of the nasal dorsum in both primary and secondary rhinoplasty.
Advantages of the free diced cartilage technique are the virtually limitless availability of grafting material and a low donor-site morbidity. Being autologous material mainly harvested from septal, costal, or conchal/tragal cartilage, no rejection was observed in our study.
In comparison to the above-mentioned techniques using the patient’s blood, bone dust, or fibrin glue, the permanent volume being added can be estimated much more precisely when using free diced cartilage. Moreover, the production and application of free diced cartilage is quicker and easier, thereby saving precious operating time. It can be combined with allogenic or autologous fascia; however, being a fine granulate, free diced cartilage can be used without any bonding material, making it a highly cost-effective technique.
In our institution, free diced cartilage is mainly applied at the end of the operation by either direct positioning under visual control using a Freer raspatory, or injected after skin closure through the open infracartilaginous incisions with a syringe. Using this technique, we did not observe any dislocation of the graft on clinical examination during the 7-month follow-up period in our series, rendering the use of additional scaffolds redundant.
Another advantage of our technique is the plasticity of the fine granulated free diced cartilage mass, enabling a large variety of shapes, and allowing the graft to perfectly fit in various recipient sites of the nose. However, correct handling and application of the free diced cartilage is crucial, and intraoperative swelling has to be taken into account to avoid unwanted overcorrection or undercorrection. Furthermore, free diced cartilage may be an ideal smoothening or augmentation graft and can even be used in combination with diced cartilage in fascia for “fine-tuning” of transition zones between diced cartilage in fascia and the nasal dorsum, but does not replace structural grafts like diced cartilage in fascia. According to our data, however, diced cartilage in fascia grafts should only play a role in cases where a larger amount of augmentation is required, as revision rates are high because of dislocations of the graft. This is partly because of the higher number of “severe” secondary cases in the diced cartilage in fascia group in the current study, as subgroup analysis showed nearly doubled revision rates for secondary cases compared to primary cases in the free diced cartilage–only and the diced cartilage in fascia groups. However, at least in our hands, there are undoubtedly technical difficulties associated with permanently keeping the graft in a proper position using the diced cartilage in fascia technique.
Free diced cartilage processed and used according to our new protocol presents an effective and easily reproducible method for camouflage and augmentation in aesthetic and reconstructive rhinoplasty and should have a permanent place among techniques available to the rhinoplasty surgeon. However, because of the relatively short postoperative observation period in the current study, the results should be considered preliminary and further studies should be performed to evaluate long-term results.
Patients provided written consent for the use of their images.
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