Use Of Costal Cartilage Research Articles

Reconstrucción nasal secundaria con injerto costal: caso clínico y revisión de la literatura

Introduction: Secondary rhinoplasty, or reintervention, is a surgery on a previously operated nose, which represents a greater surgical challenge compared to primary rhinoplasty. The ideal is the use of autologous cartilage graft since it meets biocompatibility characteristics and resembles an ideal graft. The costal cartilage is a good alternative since it has characteristics similar to septal cartilage, with the advantage of offering a larger amount of material to work with and it does not deform over time. Clinical case: male, 31 years old, admitted due to a hit to the face with a blunt object. It evidenced complex facial fracture, with Le Fort I components on the right and Le Fort III components on the left, as well as a left naso-orbital-ethmoid fracture. It performs reduction and intermaxillary fixation. It performs nasal reconstruction with a double nasal cartilage graft and bone graft for the back, and septal cartilage graft to construct the columella stem. It plans secondary rhinoplasty with a seventh rib graft correct the saddle nose defect. Outpatient follow-up at 14 and 30 days with favorable cosmetic results. Discussion: This procedure generally gives good results with a low complication rate. In the latest systematic reviews with an average follow-up of 14.4 months (6-96 months) they concluded that in the donor area the most frequent complication was the development of scars in the surgical site with 2.08% (0. 31-4.83%) and pneumothorax was close to 0% (0-0.46%). In the recipient area, the most frequent were graft retraction with 3.05% (1.35-5.19%) and 1.45% (0.34-3.06%) of infection of the recipient area. Conclusion: With the presentation of this clinical case, you can observed that the use of costal cartilage in secondary rhinoplasty is an achievable option, with good results in the short and medium term, in addition to having a low rate of complications, but a team of experienced plastic surgery must perform it.
 Fecha recepción: noviembre 2022 | Fecha aceptación: febrero

Incidence and Predisposing Factors of Postoperative Infection after Rhinoplasty: A Single Surgeon's 16-Year Experience with 2630 Cases in an East Asian Population.

This study evaluated the incidence and clinical characteristics of postoperative infection following rhinoplasty. This article is a retrospective review of 2630 East Asian rhinoplasty cases performed by a single surgeon (Y.J.J.), from July of 2003 to June of 2018. There were 1595 male patients (69.9 percent) and 687 female patients (30.1 percent), and the median age was 31 years. The incidence of infection was compared between primary and revision cases and analyzed according to the materials used. The authors evaluated the organisms cultured and the timeframe of infection development and intervention. There were 2134 primary and 496 revision cases. Materials included autologous costal cartilage (413 cases), conchal cartilage (572 cases), homologous fascia lata (829 cases), homologous costal cartilage (102 cases), Gore-Tex (373 cases), and silicone (32 cases). The authors identified 22 cases (0.84 percent) of postoperative infection, 18 of which were revision. Revision surgery had a 19-fold greater infection rate than primary surgery (3.63 percent versus 0.19 percent). Women were 3.6 times as likely to develop an infection ( p = 0.002). The infection rate using autologous costal cartilage was 3.39 percent, and that for simultaneous correction of a septal perforation was 8.57 percent. In 11 cases (50 percent), infection developed within 1 month after surgery (12 ± 7 days). Methicillin-resistant Staphylococcus aureus was cultured in eight cases. Infection manifested at the nasal tip in 45 percent and the caudal septum/columella in 32 percent of cases. Twenty cases (90.9 percent) underwent surgical débridement. Revision rhinoplasty in women, requiring the use of costal cartilage or simultaneous correction of septal perforation, showed a higher risk of postrhinoplasty infection, which usually manifested at the nasal tip and caudal septum/columella and needed to be managed by surgical débridement. Therapeutic, IV.

Compulsory auricular cartilage use: Modified septal extension graft application in revision rhinoplasty

OBJECTIVE: This study aimed to demonstrate how to perform a tongue-in-groove graft with the method we developed using auricular cartilage to provide adequate nasal tip support in 17 revision rhinoplasty cases. METHODS: This retrospective study was conducted on 17 patients (17 females; mean age: 23.9+3.7 years; range, 19 to 30 years) who underwent revision rhinoplasty (RR) operations for a low nasal tip between February 2019 and September 2020. After auricular cartilage was removed with a standard posterior auricular intervention, it was folded in two to increase its resistance and fixed to the caudal part of the nasal septum as a tongue-in-groove graft. RESULTS: Solid nasal tip support and satisfactory nasal tip projection and rotation were achieved in all patients. One (6%) patient developed auricular hematoma as a complication on the third postoperative day, and three (17%) of our patients complained of nasal obstruction in their postoperative follow-up. CONCLUSION: When the use of costal cartilage is limited due to social and cultural reasons in RR cases performed due to a low nasal tip, auricular cartilage can be used as a modified tongue-in-groove graft and provides a satisfactory aesthetic appearance.

Complications of Costal Cartilage Asian Rhinoplasty and Their Management.

The abundance, biocompatibility, and versatility of autologous costal cartilage allow rhinoplasty surgeons to perform an array of maneuvers needed to successfully manage cases that require an ample source of grafting materials. Hence, there has been a steady increase in the use of costal cartilage in Asian rhinoplasty. Despite its many advantages, autologous costal cartilage rhinoplasty is also associated with complications, which include warping, infection, and displacement, as well as donor-site morbidity issues such as pneumothorax, pain, and chest scars. Many of these can be minimized by adhering to the recommended techniques. In this review, operative techniques that focus on the prevention and management of complications associated with the use of autologous costal cartilage are presented.

Modified Use of Costal Cartilage in Asians for the Correction of Nostril Asymmetry in Unilateral Secondary Cleft Lip Nasal Deformity.

BackgroundWeak alar cartilage and lack of soft tissue on the cleft side are considered to be the main critical factors leading to the asymmetry of bilateral nostrils. The costal cartilage can provide strong structural support and can be used to maintain long-term stability of nostril shape after surgical correction. With the advancement in rhinoplasty techniques, the application and understanding of costal cartilage in cleft lip nasal deformity is still on going. Herein, we present our technique of applying costal cartilage to provide nostril support and correct asymmetry in Asian patients with unilateral secondary cleft lip nasal deformity.MethodsNinety-seven patients who underwent nostril asymmetry correction from January 1, 2013, to October 31, 2018, were analyzed retrospectively. Modified integrative alar cartilage strut and diced nostril augmentation with costal cartilage were implemented to improve the collapsed and flat cleft-side nostril. The release and restoration of muscle and bone were also performed when required. Surgical outcomes were analyzed based on the comparison of nostril parameters, the shape and contour, and symmetry of bilateral nostrils after surgery. During postoperative follow-up, the patients' satisfactions with the corrective outcomes were also investigated.ResultsAll patients received the corrective operations with complete survival of all implanted cartilages. The nostril width was narrower in postoperative group (P < 0.05). The nostril height and long axis angle were higher postoperatively (P < 0.05). After correction, the proportion of moderate type increased from 13.4% to 80.4%, whereas the proportion of horizontal type decreased from 86.6% to 17.5%. The symmetry score on the nostril parameters manifested the rate of high score (AS >3) in postoperative groups were 84.5%, 93.8%, and 87.6% for width, height, and angle of the long axis, respectively. They were higher compared with those of preoperative group (0%). More than 95% of the patients were satisfied with the overall aesthetic outcome of the surgery.ConclusionsThrough ameliorating its constructive technology and optimizing its filling form, the modified use of costal cartilage displayed excellent correction effects in the width, height, and long axis angle asymmetry of Asian patients' nostril. Precise and comprehensive rhinoplasty technique is the cornerstone for achieving satisfactory long-term aesthetic outcomes, especially in severe cases, such as secondary cleft lip nasal deformity.

Single centre review of the use of costal cartilage for reconstruction of the nasal dorsum

Reconstruction of the nasal skeleton aims to allow optimal air passage as well as a cosmetically pleasing appearance. Autogenous graft materials are the gold standard due to low extrusion and infection rates. A larger source of cartilage is required for complex secondary nasal reconstruction which makes costal cartilage an ideal source of autogenous material. We performed a retrospective review of all patients undergoing nasal reconstruction with autogenous costal cartilage between the years 2005 to 2016. All procedures were performed by a single surgeon across two hospital sites. Patient charts were reviewed to determine aetiology, indication for surgery, referral source, post-operative complications, need for revision surgery and the length of follow-up. There was a total of 28 patients, 68% male with an average age of 37 years. The majority were referred from ENT (50%) followed by plastic or maxillofacial surgeons (21%). The commonest indication for surgery was previous nasal trauma (53%), and 88% of patients with trauma as the aetiology had previous nasal surgery prior to costal cartilage reconstruction. The commonest complication was warping of the costal cartilage graft; this occurred in 18% of patients; a slipped costal cartilage graft occurred in 4%. The revision rate was 32%. There were no cases of pneumothorax, pleural tear and post-operative infection. Despite the availability of alternative cartilage sources and the risk of cartilage warping, autogenous costal cartilage is still the ideal cartilage source for complex nasal reconstruction. It is readily available, durable and versatile. Several recent studies have reported alterations in surgical technique to reduce warping. This will subsequently reduce rates of revision surgery and ensure this versatile cartilage source continues to be utilised by surgeons in future. Level of Evidence: Level IV, therapeutic study

Dorsal Augmentation Using Autologous Costal Cartilage or Microfat-Infused Soft Tissue Augmentation

Costal cartilage grafting is increasing in popularity with increased demand for augmentation rhinoplasty and increased need for grafting material for structure rhinoplasty techniques. Use of costal cartilage for dorsal grafting is both art and science. The art is demonstrated in the act of carving a dorsal graft that will reflect the actual contour of the nasal dorsum. The science is linked to the methodology of how the grafts are contoured to match the patient's desires and how the graft is fixed to the bony dorsum to minimize the risk of warping and displacement. Variations in dorsal graft design and methods of fixation are described. Use of the perichondrial interface between dorsal graft and perforated/rasped nasal dorsum acts to ossify the dorsal graft to the underlying bone, creating an immobile and natural appearing nasal dorsum. The fixation of the dorsal graft limits movement and hence decreases the likelihood of warping or deformity. Use of microfat in rhinoplasty has tremendous potential for camouflage and to promote healing of compromised tissues. Using microfat-infused soft tissue augmentation (MISTA), the surgeon is able to deliver microfat to an open surgical field, promote healing, and provide soft tissue augmentation. In this technique, microfat is injected into soft tissue carriers (perichondrium, temporalis fascia, etc.) and then implanted into the surgical field. MISTA has tremendous potential utility in many areas of cosmetic and reconstructive surgery.

Correction of saddle and short noses.

The review summarizes the basic concepts and recent updates on the management of saddle and short noses, with a particular focus on the selection of septal reconstruction techniques and dorsal augmentation material. Different techniques have been reported for septal cartilage reconstruction, including various combinations of extended spreader and caudal septal extension grafts, as well as L-strut grafts. For dorsal augmentation, materials that help avoid costal cartilage warping including, diced costal cartilage with or without fascia, costal cartilage obtained by oblique cutting, diced conchal cartilage with perichondrial attachments, and lipofilling of the nasal dorsum have been reported. The article highlights the importance of rebuilding the septal cartilage support system by the proper use of costal cartilage and selection of an appropriate technique for the successful management of saddle and short noses. In addition, the importance of selecting suitable dorsal augmentation materials and other adjunctive maneuvers are emphasized.

Columellar Incision Scars in Asian Patients Undergoing Open Rhinoplasty.

An open approach has been adopted for rhinoplasty because of its wide and undistorted exposure. The formation of a columellar incision scar is the main drawback of this approach. To evaluate the incidence and evolution of and risk factors for columellar incision scars in an Asian population. A retrospective case series of 529 patients who underwent open rhinoplasty was performed in a tertiary care referral center in South Korea from January 1, 2011, to May 31, 2014. Problematic transcolumellar incision scars were categorized into wide and depressed, notching, and hyperpigmented wound types. Follow-up was complete on January 28, 2015, and data were assessed from July 1, 2014, to May 29, 2015. The incidence of each problematic scar and the time course of erythema evolution were evaluated. Factors affecting the formation of a problematic scar were also evaluated. Of 529 patients (176 female and 353 male patients; mean age, 31 [range, 5-70] years), 234 patients with at least 6 months of follow-up underwent evaluation for a problematic scar. Fourteen of the 234 patients (6.0%) had problematic incision scarring (wide and depressed wound, 4 [1.7%]; notching wound, 3 [1.3%]; hyperpigmentation, 4 [1.7%]; marginal incision hypertrophic scar, 2 [0.8%]; and columellar skin necrosis, 1 [0.4%]). Of the 243 patients with regular follow-up who underwent evaluation for erythema evolution, erythematous wounds were found in almost all in the immediate postoperative period and had normalized by a mean (SD) of 66.7 (37.4) postoperative days. Use of costal cartilage as tip graft material was associated with a problematic incision scar (2 of 25 patients [8.0%] vs 6 of 180 patients with other graft material [3.3%]; P = .02). In this cohort of Asian patients, the incisions used for an open rhinoplasty approach had some problems. However, the low incidence of problematic scars indicates that open rhinoplasty should not be discouraged because of the incision scar. 4.

Diced cartilage under perichondrial carpet with reinforcement (DCUP) technique for nasal dorsal augmentation

Background: Correction of the secondary cleft lip nasal deformity is a real challenge for the esthetic surgeons. Grafts are an integral part of modern rhinoplasty with costal cartilage being increasingly used in the secondary case. The use of costal cartilage is fraught with problems like visibility and warping. Introduction: We propose an innovative alternative technique, Diced Cartilage Under perichondrial carpet with reinforcement (DCUP) technique keeping in mind, the Indian noses which usually do not support the liquid (filler) or semisolid (diced cartilage in fascia [DCF]) augmentation due to thick skin and weak structural support. Aims and Objective: To introduce a technique which can provide both a softer and natural looking dorsum and a strong framework to withstand the stress of healing forces in early postoperative period. Materials and Methods: Over the past 3 years we have used this technique in 25 patients with primary as well as secondary rhinoplasties including posttraumatic and secondary cleft lip nose deformity. Postoperative follow-up was done with clinical examination and photography. Results: In our study, a total of 25 patients were operated, there were 9 males and 16 females, giving a male:female ratio of about 1:2. Mean follow-up was 18 months. All patients had rounded, well contoured, and smooth dorsum. There was no incidence of fracture, warping, visibility or extrusion of graft, or palpable or visible sutures. Conclusion: Proposed technique of Diced Cartilage Under Perichondrial carpet with reinforcement (DCUP) technique is a very good alternative especially in Indian setting to keep the good effects of DCF that is, smoother, softer, and natural looking dorsum and also able to withstand postoperative contracting forces owing to its stable base of costal cartilage graft.

Precise and Rapid Costal Cartilage Graft Sectioning Using a Novel Device

IMPORTANCE The use of costal cartilage as a graft in facial reconstructive surgery requires sectioning the cartilage into a suitable shape. OBJECTIVE To evaluate the accuracy of a novel mechanical device for producing uniform slices of costal cartilage and to illustrate the use of the device during nasal surgery. DESIGN Basic and clinical study using 100 porcine ex vivo costal cartilage slices and 9 operative cases. METHODS This instrument departs from antecedent devices in that it uses compression to secure and stabilize the specimen during sectioning. A total of 75 porcine costal cartilage ribs were clamped with minimal compression just sufficient to secure and stabilize the specimen while cutting. Slices having a length of 4 cm and width of 1 cm were obtained using the cartilage cutter at 3 thicknesses: 1 mm (n = 25), 2 mm (n = 25), and 3 mm (n = 25). The procedure was repeated for the 2-mm thick samples; however, the ribs in this group (n = 25) were clamped using the maximum amount of compression attainable by the device. Thickness was measured using a digital micrometer. Case presentations illustrate the use of the device in secondary and reconstructive rhinoplasty surgery. RESULTS All specimens were highly uniform in thickness on visual inspection and appeared to be adequate for clinical application. Sectioning was completed in several seconds without complication. In the porcine specimens sectioned using minimal compression, the percentage difference in thickness for each individual sample averaged 18%, 10%, and 11% for the 1-mm-, 2-mm-, and 3-mm-thick slices, respectively. Within the specimens sectioned using maximum compression, the percentage difference in thickness for each individual sample averaged 35% for the 2-mm-thick slices. In the setting of nasal reconstructive surgery, slices having a thickness from 1 to 2 mm were found to be well suited for all necessary graft types. CONCLUSIONS AND RELEVANCE The simple mechanical device described produces costal cartilage graft slices with highly uniform thickness. Securing the rib by clamping during cutting reduces uniformity of the slices; however, the imperfections are minimal, and all sectioned grafts are adequate for clinical application. The device can be adjusted to produce slices of appropriate thickness for all nasal cartilage grafts. This device is valuable for reconstructive procedures owing to its ease of use, rapid operation, and reproducible results.

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

Augmentation rhinoplasty of the Asian nose may be effectively accomplished with alloplastic materials. However, certain circumstances mandate the use of autologous grafts (e.g., dorsal augmentation that exceeds 8 mm and patient intolerance of alloplastic implants). Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. The use of costal cartilage for autologous augmentation in select Asian patients has proven to be a reliable method in more than 500 operative cases during a 10-year period. This study was designed to evaluate the ideal costal cartilage graft for augmentation rhinoplasty. Forty-two preserved cadavers were studied for the relationship of the individual rib cartilages to the surrounding tissue and for the length and caliber of each costal cartilage. The seventh rib was found to be the ideal rib graft by virtue of its safe location and overall size for grafting. The seventh rib is situated over the abdominal cavity, so the risk of pneumothorax is insignificant. The internal thoracic artery and vein descend in close apposition behind the first to sixth ribs but begin a course medial to the ribs inferior to this point, and therefore vascular injury during seventh-rib harvesting is unknown. The seventh rib also provides the greatest overall available length (90.7 mm, right; 89.6 mm, left) and thickness (17.6 mm, right; 17.5 mm, left). Despite the more conspicuous location of the incision required to harvest the seventh rib, the limited 3-cm incision that is used has healed favorably in almost all cases. The other major drawback for seventh-rib harvesting is the dissection required through the overlying rectus abdominis muscle, but little technical difficulty or postoperative morbidity is added with muscle dissection. The seventh rib is advocated as the ideal choice for augmentation rhinoplasty and potentially other recipient sites.

The use of costal cartilage as a spacer in the treatment of congenital metacarpal fusion

A case is reported in which a congenital metacarpal synostosis was corrected by splitting the synostosis and inserting an intermetacarpal costal cartilage graft. Costal cartilage does not tend to be absorbed with time and seems to be a more effective and safer spacer in the long term. Use of costal cartilage as a spacer may be of benefit in similar cases in hand surgery.