Shield Graft Research Articles

Repair of Tympanic Membrane Perforations with Customized Bioprinted Ear Grafts Using Chinchilla Models.

The goal of this work is to develop an innovative method that combines bioprinting and endoscopic imaging to repair tympanic membrane perforations (TMPs). TMPs are a serious health issue because they can lead to both conductive hearing loss and repeated otitis media. TMPs occur in 3-5% of cases after ear tube placement, as well as in cases of acute otitis media (the second most common infection in pediatrics), chronic otitis media with or without cholesteatoma, or as a result of barotrauma to the ear. About 55,000 tympanoplasties, the surgery performed to reconstruct TMPs, are performed every year, and the commonly used cartilage grafting technique has a success rate between 43% and 100%. This wide variability in successful tympanoplasty indicates that the current approach relies heavily on the skill of the surgeon to carve the shield graft into the shape of the TMP, which can be extremely difficult because of the perforation's irregular shape. To this end, we hypothesized that patient specific acellular grafts can be bioprinted to repair TMPs. In vitro data demonstrated that our approach resulted in excellent wound healing responses (e.g., cell invasion and proliferations) using our bioprinted gelatin methacrylate constructs. Based on these results, we then bioprinted customized acellular grafts to treat TMP based on endoscopic imaging of the perforation and demonstrated improved TMP healing in a chinchilla study. These ear graft techniques could transform clinical practice by eliminating the need for hand-carved grafts. To our knowledge, this is the first proof of concept of using bioprinting and endoscopic imaging to fabricate customized grafts to treat tissue perforations. This technology could be transferred to other medical pathologies and be used to rapidly scan internal organs such as intestines for microperforations, brain covering (Dura mater) for determination of sites of potential cerebrospinal fluid leaks, and vascular systems to determine arterial wall damage before aneurysm rupture in strokes.

Endoscopic Lateral Cartilage Graft Tympanoplasty.

Objective To describe a novel technique for lateral graft tympanoplasty. Study Design Case series with chart review. Setting Tertiary care university hospital. Subjects and Methods Pediatric and adult patients with tympanic membrane perforations deemed unfavorable for a medial graft technique due to the perforation characteristics or myringitis. Results Between 2014 and 2016, 34 ears from 31 patients underwent a transcanal endoscopic lateral cartilage graft tympanoplasty. The mean age was 24.4 years (range, 6-71 years), and 22 patients (65%) were younger than 18 years. All patients had tympanic membrane perforations. Eighteen patients (53%) had total or near-total perforations, leaving a minimal anterior remnant, and 16 patients (47%) had extensive myringitis. A bisected tragal cartilage-perichondrium shield graft was used in 33 patients (97%). The mean (SD) follow-up length was 9.8 (5.7) months. Initial perforation closure rate was 88.2% (30/34). Three of the persistent perforations underwent a revision endoscopic medial graft tympanoplasty with successful closure, leaving a final closure rate of 97.1% (33/34). Five patients (15%) required topical therapy for postoperative myringitis. Mean (SD) pure-tone average and air-bone gap significantly improved by 11.5 (10.7) dB ( P < .001) and 11.4 (10.6) dB ( P < .001), respectively. Twenty-seven patients (79%) closed their air-bone gap within 20 dB. Conclusion Transcanal endoscopic lateral cartilage graft tympanoplasty is feasible, and initial data support favorable outcomes. Further data are necessary for evaluation of long-term results and efficacy comparisons.

Contracted Nose Correction with Dermofat and Conchal Cartilage.

Contracted Nose Correction with Dermofat and Conchal Cartilage.

Outcomes of type I tympanoplasty using a cartilage shield graft in patients with poor prognostic factors

ObjectiveAlthough fascia is widely used as the grafting material in tympanoplasty (TP), unsatisfactory outcomes can result in patients with poor prognostic factors. Recently, cartilage has emerged as a graft material in TP. This study examined the operative outcomes of type I TP using a cartilage shield graft (CSG) in patients with poor prognostic factors. MethodsThis study reviewed the medical records of patients who underwent type I TP using CSG performed by the same surgeon, with over 24 months of follow-up. ResultsThere were 94 patients (mean age 46 years). Preoperatively, 39 patients had near-total perforation, 29 had a previous TP or myringoplasty, 14 had adhesive otitis media, and 12 had a marginal perforation covering ≥50% of the tympanic membrane area. The mean postoperative air-bone gap was significantly (p<0.0001) reduced compared to preoperative measurements. Postoperatively, tympanic membrane perforation occurred in 2.1% and otorrhea in 6.4%. There were no cases of retraction, adhesion, or lateralization. One subject complained of autophonia and ear fullness. ConclusionType I TP using CSG has excellent surgical results and minimal complications, even in patients with poor prognostic factors, and should thus be considered in those patients.

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

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

Clinical efficacy of lengthening the short nose with X- septal extended spreader graft

Objective To investigate a safe and effective method of lengthening the short nose. Methods 29 females (17-37 years) with short nose were corrected with septal extended spreader grafts using autologous cartilage and combined with expanded polytetrafluoroethylene (e-PTFE) to reconstruct the supporting structures underneath to improve the upward and forward strength of the nasal tip in order to increase the nasal length and to correct the over rotation of nasal tip. The shield and cap grafts were also used for the patients whose nasal tip were too low with verticaI dome division technique. Results All the patients showed preserved nasal length after surgery with well-proportioned nasal features and the nasal lip angles were normal. There was no evidence of postoperative nasal shortening. No operative or postoperative complications (infection, deviation, extrusion, and delayed inflammation, perforation of nasal septum and dorsal depression) were detected by follow-up from 6 to 12 months, except 2 patients felt tip extended defects. All the patients were pleased with the surgical results achieved. Conclusions It is necessary to provide powerful forward and upward strength to lengthen nose and correct the over rotation of nasal tip effectively and safely. The use of septal extended spreader grafts by autologous cartilage and combined with expanded polytetrafluoroethylene (e-PTFE) represents a valuable tool for the short nose and proper cartilage grafts can improve the height of the nasal tip and correct the over rotation of the nasal tip further. Key words: Short nose; Septal cartilage; Grafts; Expanded polytetrafluoroethylene (e-PTFE)

Principles of Structural Rhinoplasty in South East Asian Noses

Principles of Structural Rhinoplasty in South East Asian Noses

Grafts Are Superior to Sutures for Nasal Tip Projection: A Meta‐analysis of Goodes Ratio

Objectives: (1) Discuss relevant tip projection ratios involved in surgical planning of rhinoplasty. (2) Implement findings of meta-analysis in cosmetic surgery planning. Methods: Meta-analysis of journal articles through June 2013. Intervention: Cosmetic rhinoplasty for underprojected tip. Outcome Measurements: Pre- and postoperative Goode Ratio in cosmetic rhinoplasty patients. Null hypothesis: None of 3 techniques provides superior tip projection among: suture, internal graft, and external graft. Results: External graft techniques, such as Sheen shield grafting, were found to significantly increase tip projection over suture only techniques. External vs suture: P = .017. (2) Internal graft techniques, such as columellar strut grafting, approached significance in increased tip projection over suture only technique. Internal vs suture: P = .053. (3) Internal and external graft techniques did not differ significantly, but external graft techniques displayed a tendency to increase tip projection more. External vs internal: P = .360. Conclusions: (1) Meta-analysis of the Goode Ratio has never been reported in the literature. (2) No technique has been proven to have significance in the past. (3) External grafts produce a significant change in nasal tip projection over suturing, and internal grafts approach significance. (4) This research allows the surgeon to rank techniques in order of magnitude of change desired.

Perspectives in asian rhinoplasty.

Asian patients present with relatively poorly developed dorsal and tip height and thicker skin, so augmentation rhinoplasty is the most commonly performed rhinoplasty procedure. Tip surgery using autologous cartilage followed by dorsal augmentation using an alloplastic implant material is the most widely performed surgical procedure for augmentation rhinoplasty on Asian patients. Cartilage tip grafting procedures, including shield grafting, multilayer tip grafting, onlay grafting, and modified vertical dome division, are key maneuvers for building up and providing better definition on a relatively poorly developed Asian tip. When performing primary cosmetic dorsal augmentation using alloplastic implants, the implant material should be selected according to the surgeon's experience, the pros and cons of available dorsal implant materials, and host factors such as skin thickness, associated deformities, and aesthetic goals. The costal cartilage is best reserved for difficult revisions, except in a limited number of primary cases who present with a very poorly developed nasal skeleton and thick skin.

Oriental Nose Elongation Using an L-Shaped Polyethylene Sheet Implant for Combined Septal Spreading and Extension

The currently recommended strategies for short nose elongation were designed primarily for the Caucasian nasal framework. For Oriental patients, more elongation often is required because a hypoplastic septal cartilage requires more elongation, resulting in a higher risk of complications. This report proposes a modified technique for Oriental nose elongation, which adjusts the pressure points after nasal elongation using an L-shaped implant. Between January 2007 and December 2009, 58 patients underwent Oriental nose elongation using an L-shaped, porous, high-density polyethylene sheet implant. Augmentation rhinoplasty and conchal cartilage shield grafts were performed depending on the nasal shape. Pre- and postoperative nasal length, height, and projection as well as columella-labial angle, columella-lobular angle, and nasal tip angle were measured and compared. A patient satisfaction survey was performed postoperatively. All occurring complications were recorded. The postoperative nasal length was significantly elongated from 47.0±10.4 mm to 49.3±10.1 mm (p=0.003), and the nasal height increased significantly from 48.5±9.1 mm to 50.4±8.5 mm (p=0.011). The initially obtuse columella-labial angle improved significantly from 100.8°±12.1° to 92.5°±15.5° (p=0.014). No significant changes were found regarding nasal projection, nasal tip angle, or columella-lobular angle. The majority of the patients (91.3%) were highly satisfied or satisfied with the aesthetic results. A major complication in terms of implant exposure was observed in one case. The minor complications included stiffness of the nasal tip (3 patients) and tip redness (1 patient). In Oriental nose elongation, the use of an L-shaped graft is a feasible and safe treatment option that allows for an excellent aesthetic outcome and reduces the incidence of complications. 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 www.springer.com/00266 .

A comparative study of audiological and surgical results in partial versus complete strip cartilage reinforcement tympanoplasty

Abstract Different techniques used in cartilage tympanoplasty are palisade technique, shield graft, in-lay butterfly graft, and island flap cartilage. The aim of the study was to compare audiological and graft take results in partial versus complete strip cartilage reinforcement tympanoplasty. A total of 60 patients with central perforation of the tympanic membrane and age ranging from 18 to 40 years were selected. They were divided into two equal study groups of 30 patients each. The first group underwent complete strip cartilage reinforcement tympanoplasty and the second group underwent partial strip cartilage reinforcement tympanoplasty. The overall success rate was 83.3% in the complete strip technique and 86.66% in the partial strip technique. In both study groups, there was statistically significant difference between the audiological results before and after operation. Furthermore, audiological and graft take results were better in the partial strip technique but with no statistically significant difference. The overall results of partial strip tympanoplasty are better than complete strip tympanoplasty regarding graft take and audiological results.

Revision of the Cleft Lip Nose

Secondary or revision rhinoplasty for the cleft nasal deformity represents one of the most challenging problems in rhinoplasty surgery. The secondary nasal deformity of the unilateral cleft lip involves a retrodisplaced dome of the ipsilateral nasal tip, hooding of the alar rim, a secondary alar-columellar web, and other deficiencies. This article discusses techniques to achieve the best possible outcome for patients with cleft nasal deformities. We emphasize the importance of early intervention by way of primary cleft rhinoplasty and highlight the typical challenges presented in delayed (secondary) or revision cleft rhinoplasty. We describe how the sliding flap cheilorhinoplasty effectively corrects these deformities using a laterally based chondrocutaneous flap via an open rhinoplasty approach. Columellar struts and shield grafts are some of the techniques combined with this approach to produce optimal results.

Is the Tragal Cartilage Necessary for Type 1 Tympanoplasties?

The use of cartilage grafts in tympanoplasties is recommended in cases with a higher probability of failure. Many grafting techniques have been reported, including palisade, cartilage island, and cartilage shield grafts. Cartilage minimizes the inflammatory tissue reaction, ensures resistance against infection during the recovery process, and provides good support against the retraction by virtue of its rigidity.This study compared the anatomic and functional results of conchal cartilage, tragal cartilage, and temporal muscle fascia grafts in primary type 1 tympanoplasty. Between January 2007 and January 2011, 79 patients with subtotal dry tympanic membrane perforation and an intact ossicular chain underwent primary type 1 tympanoplasty in our clinic. The postoperative perforation closure ratios, air and bone pure tone averages, and mean air-bone gap (ABG) in the 3 groups were compared with the preoperative values. The improvement in the mean ABG was assessed.The perforation closure ratio was 80.6%, 100%, and 88.5% in the muscle fascia, conchal cartilage, and tragal cartilage groups, respectively, and the mean increase in the ABG was 5.7, 8.9, and 9.7 dB, respectively.The island graft with cartilage perichondrium, which has recently become popular, can be also used in type 1 tympanoplasty. Because it does not require a second incision, conchal cartilage can be used routinely in tympanoplasties performed via a postauricular approach.

Creating Elegance and Refinement at the Nasal Tip

Enhancing nasal tip definition requires a three-dimensional approach encompassing both form and function. Dome refinements achieved during surgery should be created with sufficient integrity to withstand postoperative healing forces. Stabilizing the nasal base is the first component of dome alterations and prevents loss of tip rotation and projection. Structural grafting can be used to enhance tip definition and at the same time adds support to the cartilaginous framework. Tip shield grafts camouflage dome asymmetries, establish the tip-defining point, and enhance the supratip break. Shield grafts can be placed in all skin types with appropriate contouring and camouflaging techniques.

Rhinoplasty for the Asian Nose

When compared with Caucasian noses, the typical Asian nose appears to be relatively small and flat and has poor tip definition. Therefore, the main concept of rhinoplasty for Asians is augmentation rather than reduction. In selecting the dorsal implant material, skin thickness should be considered. Although autologous cartilage has the lowest risk of infection among graft materials, autologous cartilage including costal cartilage is associated with a significant risk of revision surgery due to aesthetic failure. Alloplastic implants, including silicone and Gore-Tex, are easy to use and can reduce operation time. But they carry significant risks of complications including infection, deviation, extrusion, and delayed inflammation, which must be seriously considered by rhinoplasty surgeons. Cartilage grafting procedures, including shield graft, onlay graft, modified vertical dome division, and septal extension graft, are mainstays in proper projection and better refinement of the Asian tip, which is intrinsically round and underdeveloped in its appearance. In placing a shield graft, it is important to place an additional supporting graft at the cephalic border and additional tip grafts at the caudal aspect, so that the final tip graft complex has an antero-caudal projection on the profile view.

Irradiated Homologous Rib Grafts in Nasal Reconstruction

To assess the long-term efficacy of irradiated homologous rib grafts (IHRGs) for both augmentation and support function in rhinoplasty in general and for specific recipient sites within the nose. A retrospective study was conducted at an academic medical center to evaluate the loss of volume and support function of IHRGs in 9 specific recipient sites in the nose. We studied 66 patients, with a total of 177 IHRGs, dating back 9 years, with an average follow-up of 51 months. The rate of resorption increased with duration of follow-up. Complete resorption was found in 1 IHRG, and moderate resorption was observed in 55 IHRGs (31%). Resorption was characterized by a loss of support function rather than a loss of volume. Moderate resorption had a negative clinical outcome for shield grafts only. Irradiated homologous rib grafts were safe to use in rhinoplasty. In cases requiring a shield graft, IHRGs should be avoided.

Frequently Used Grafts in Korean Rhinoplasty: Nomenclature and Definitions

Background and ObjectivesZZNo definite concepts or nomenclature have yet been established in Korean for a number of different grafts used frequently in Korean rhinoplasty. The aims of this study were to define indications and usages of grafts frequently used in Korean rhinoplasty and to suggest appropriate Korean nomenclatures for these grafts. Materials and MethodZZWe prepared diagrams and explanations for the grafts frequently used in rhinoplasty in Korea and suggested Korean nomenclature that were considered the most appropriate. We carried out a survey on the rhinoplasty experts in order to reach a consensus on the nomenclature. We also reviewed recent Korean articles on rhinoplasty to investigate how names of each graft had been translated into Korean nomenclature. ResultsZZWe classified grafts according to anatomical locations; the nasal dorsum, the nasal tip, the alar region, and the alar base. Grafts of the nasal dorsum included radix graft, dorsal onlay graft, dorsal sidewall onlay graft, and spreader graft. Grafts of the nasal tip were the columellar strut, shield graft, buttress graft, cap graft, and septal extension graft. The alar batten graft, alar rim graft, composite alar rim graft, lateral crural onlay graft, and lateral crural strut graft belonged to grafts of the alar region. Grafts of the alar base included the columellar plumping graft, premaxillary graft, and alar base graft. The names of all these grafts were translated into Korean. ConclusionZZWe set definitions, indications, and usages of each graft, and suggested the most appropriate Korean nomenclature. We hope that this nomenclature can be widely accepted and used in future papers and books on Korean rhinoplasty. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:412-8 Key WordsZZRhinoplasty·Graft·Nomenclature·Definition·Korean.

Temporalis Fascia and Cartilage-Perichondrium Composite Shield Grafts for Reconstruction of the Tympanic Membrane

We sought to compare the long-term functional results of tympanic membrane reconstruction with temporalis fascia and cartilage shield grafting. This study includes 113 patients who had tympanoplasty type I tympanic membrane reconstruction between 1997 and 2007, 47 with tragal cartilage and 66 with temporalis fascia. Fourteen patients in the cartilage group and 9 patients in the temporalis fascia group also had mastoidectomy. The average follow-up was 3.2 years. The hearing threshold was calculated as the mean value of the thresholds for 500, 1,000, 2,000, and 3,000 Hz. A paired-samples t-test was used for comparison of the preoperative and postoperative air and bone conduction hearing thresholds and air-bone gaps. Significant recovery was found in the postoperative air conduction threshold and air-bone gap in both the temporalis fascia and cartilage groups as compared to those before surgery (p < 0.001). However, the average air and bone conduction thresholds and air-bone gap were found to be statistically different after surgery in the cartilage group as compared to those in the temporalis fascia group. There was no significant difference in hearing parameters before and after surgery in patients with or without mastoidectomy in either the cartilage group or the temporalis fascia group. The hearing gain in patients with cartilage shield grafting was better than that in those who had temporalis fascia tympanoplasty, although experimental analysis shows loss of acoustic energy for thick and large shield cartilage grafts.

Correction of over rotation of nasal tip

Objective To investigate a safe and effective method to correct the over rotation of nasal tip in rhinoplasty. Methods 16 cases, including 11 of primary and 5 of secondary over rotation of nasal tip, were corrected with strut grafts using autologous cartilage or combined with Medpor to reconstruct the supporting structures underneath to improve the upward and forward strength of the nasal tip in order to increase the nasal height and to correct the over rotation of of nasal tip. The shield and cap grafts were also used for the patients whose nasal tip were too low, with vertical dome division technique. Results 16 cases were corrected satisfactorily, the nasal lip angles were normal and there were no complications by follow-up from 6 months to 1 year. Conclusion It is necessary to provide powerful forward and upward strength to correct the over rotation of nasal tip effectively and safely, and proper cartilage grafts can im-prove the height of the nasal tip and correct the over rotation of the nasal tip further. Key words: Nasal tip; Abnormality; Cartilage implant

Isolated congenital absence of the left lower lateral cartilage

Introduction: Congenital defects of the nasal cartilaginous skeleton are rare, yet clinically relevant, entities that are important to recognize prior to operative repair Methods: A 47 year old woman was referred to our institution for lifelong leftsided nasal airway obstruction. On physical examination, a complete absence of the left lower lateral cartilage was suspected. Hypothesis: Complete congenital absence of the lower lateral cartilage Results: External approach rhinoplasty confirmed the above hypothesis, and reconstruction was performed with autologous septal cartilage. Conclusions: Careful history and physical examination is important in preoperative planning of nasal surgery. External rhinoplasty approach Isolated complete absence of left lower lateral cartilage identified (Figure 2a) Septal cartilage harvested Septal extension graft replaced the left medial crura Lateral crural strut graft replaced the left lateral crura Shield graft to orient and help reconstitute the tip Left domal onlay graft to emphasize left tip highlight Patient pleased with functional and aesthetic outcome Surgical Approach and Results 1. Losee JE, Kirschner RE, Whitaker LA, et al. Congenital nasal anomalies: a classification scheme. Plast Reconstr Surg 2004;113:676-689. 2. Bilkay U, Tokat C, Ozek C. Reconstruction of congenital absent columella. J Craniofac Surg 2004;15(1): 60-63. 3. Mavili ME, Akyurek M. Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps. Plast Reconstr Surg 2000;106(2):393 -399. 4. Yilmaz MD, Altunas A. Congenital vomeral bone defect. Am J Otolaryngol 2005;26(1):64-66. 5. Klinger M. Caviggioli, Klinger F, et al. Isolated congenital absence of the nasal bones and aesthetic surgical correction: managing and case report. Aesth Plast Surg 2005;29(4):246-249. References 47 year old otherwise healthy Latin American female Lifelong left sided nasal airway obstruction No prior facial trauma or surgery Exam showed mild septal deviation, profound nostril asymmetry, and the absence of any palpable cartilage within left side of the nasal tip (Figure 1) Case Presentation Figure 2a. Complete absence of lower lateral cartilage on the left. Figure 2b. Surgical repair with septal extension, lateral crural strut, and domal onlay grafts. Isolated, non-syndromic cases of absent nasal structures is exceedingly rare. No previous reports exist of isolated absence of a lower lateral cartilage. May occur after fusion of mesenchymal components by 10th week of gestation from vascular accident or pressure phenomenon. Despite its rarity, this anomaly reinforces the importance of careful pre-rhinoplasty analysis and familiarity with principles of open structure rhinoplasty. Conclusions Introduction History and physical examination are crucial to appropriate pre-operative planning of functional and cosmetic rhinoplasty Externally, special attention is paid to the characteristics of the skin-soft tissue envelope, the nasal bones, middle nasal vault, and the lower lateral cartilages. Internally, examination of the septum, the internal and external nasal valves, nasal sidewalls, inferior turbinates and the nasal mucosa. Congenital anomalies of the nose can be responsible for nasal airway obstruction and are present in 1/20,000 to 1/40,000 births Figure 1. Asymmetry of external nose noted with basal and frontal views.