The diagnostic utility of CT attenuation values in detecting calcification within costal cartilage.

BACKGROUND: To establish and verify diagnostic criteria for the identification of costal cartilage calcification based on computed tomography (CT) attenuation value. METHODS: 360 chest CT slices of 120 patients were reviewed and annotated retrospectively and receiver operating characteristic curve was used to evaluate the diagnostic ability of CT attenuation value. Another 20 slices containing calcification were randomly selected and annotated by 4 doctors for further validation. hematoxylin and eosin and collagen type X (COLX) staining was performed on the residual costal cartilage. RESULTS: In total 355,129 voxels were detected and 187.5 was confirmed as the optimal CT attenuation value threshold, with a sensitivity of 98.6% and a specificity of 99.7%, for costal cartilage calcification diagnosis. Threshold-based identification of calcification demonstrated a similarity of nearly 80% with specialists' assessments, and exhibited advantages in the identification of subtle calcifications in the further validation. We also observed that CT attenuation values among males demonstrated a centralized distribution, whereas those among females exhibited a bimodal distribution. Threshold-based identified calcification showed a positivity of COLX. CONCLUSIONS: CT attenuation value could validly and reliably diagnose calcification within costal cartilage. Further investigations involving larger cohorts of patients are required to elucidate the risk factors and underlying mechanisms of costal cartilage calcification.

Auricle reconstruction with autologous costal cartilage versus polyethylene implants in microtia patients: a meta-analysis.

BACKGROUND: Auricle reconstruction is among the most challenging procedures in plastic and reconstructive surgery, and the choice of framework material is a critical decision for both surgeons and patients. This meta-analysis compared the outcomes of autologous auricle reconstruction using costal cartilage with those of alloplastic reconstruction using porous polyethylene implants. METHODS: A literature review was conducted using the PubMed and Embase databases to retrieve articles published between January 2000 and June 2024. The outcomes analyzed included postoperative complications such as framework exposure, infection, skin necrosis, hematoma, and hypertrophic scars, as well as patient satisfaction. The proportions of reconstructive outcomes from each selected study were statistically analyzed using the "metaprop" function in R software. RESULTS: Fourteen articles met our inclusion criteria. The group undergoing polyethylene implant reconstruction exhibited higher rates of framework exposure, infection, and skin necrosis, whereas the autologous reconstruction group experienced higher rates of hematoma and hypertrophic scars. Of all the complications, framework exposure was the only one to show a statistically significant difference between the two groups (p < 0.0001). In terms of patient satisfaction, those who underwent autologous cartilage reconstruction reported a higher rate of satisfaction, although this difference did not reach statistical significance in the meta-analysis (p = 0.076). CONCLUSION: There is no statistically significant difference in postoperative complications such as infection, hematoma, skin necrosis, and hypertrophic scars between auricle reconstructions using autologous costal cartilage and those using polyethylene implants. However, reconstructions with polyethylene implants show a significantly higher rate of framework exposure.

Reprojecting the Severely Damaged Nose.

Reprojecting the severely damaged nose is a challenging operation fraught with pitfalls. This panel discussion covers 6 fundamental questions answered by 3 surgeons, each with decades of experience. Discussion points include management of the 3 components necessary for successful reconstruction-the soft tissue envelope, the support structure, and the internal lining. The authors also discuss how their practices have changed in the last few years.

Abdominal muscles infiltration analgesia for donor-site pain in autologous ear reconstruction: A randomized controlled clinical trial.

BACKGROUND: Costal cartilage donor-site pain is an adverse effect of autologous ear reconstruction. This study aimed to introduce rectus abdominis and external oblique muscle infiltration analgesia (RAM+EOM-IA) for costal cartilage donor-site pain and evaluate its efficacy and safety. METHODS: The study was a randomized controlled clinical trial. Patients were randomized between intermittent RAM+EOM-IA combined with intravenous patient-controlled anesthesia (IPCA) and IPCA alone. Thirty patients were followed in the RAM+EOM-IA combined with the IPCA group and 30 patients in the IPCA alone group. The primary outcome was the numerical rating score (NRS) of pain recorded during 48 h postoperatively. Secondary outcomes included the Barthel index (BI) and rescue analgesic consumption. Sensory block areas were tested using a cold stimulus. RESULTS: NRS was significantly lower with RAM+EOM-IA combined with IPCA than with IPCA alone at 28 h (P < 0.01), 32 h (P < 0.01), 36 h (P < 0.01), 44 h (P < 0.001), and 48 h (P < 0.01) postoperatively. The number of patients who received rescue analgesics (P < 0.01) and consumption (P < 0.01) was significantly higher for IPCA alone. RAM+EOM-IA improved the BI at 24 h postoperatively (P < 0.001), especially for mobility (P < 0.001), using the stairs (P < 0.001) and toilet use domains (P < 0.001). At 10 and 60 min after RAM+EOM-IA, the total sensory block area in the abdomen had not extended proximally beyond the xiphoid, distally beyond the navel, and beyond midaxillary and midsternal lines on either side. CONCLUSION: RAM+EOM-IA effectively and safely prevented costal cartilage donor-site pain by blocking anterior and lateral cutaneous branches of intercostal nerves from T6 to T10 in microtia patients.

Do we have to redefine type B-fractures of the rib cartilage?

OBJECTIVES: Aim of this work was the evaluation and validation of the AO/OTA classification of the anterior chest wall, here especially for the rib cartilage. METHODS: Study design was a retrospective analysis of patients who were hospitalized with fractures of the thoracic wall in the years 2010-2016. This resulted in a collective of n = 124 patients. All fractures of the anterior chest wall were classified according to their location, dislocation and fracture type according to the AO classification. An analysis of possible subtypes was carried out. RESULTS: 29.0% (36) of the patients had fractures of the rib cartilage. 23 of the 36 (64%) patients had multiple fractures, the total number of single fractures amounted to 94. 53.2% (50) of these fractures were in the right hemithorax, 46.8% (44) in the left hemithorax. 95.7% (90) of the fractures were A-fractures, 4.3% (4) were C-fractures. There were no B fractures. The C fractures also consisted exclusively of A fractures (AA fractures). 59.6% (56) of the fractures showed a dislocation. 30.9% (29) were avulsion fractures of either the osteochondral (22.3% (21)) or the sternocostal junction (8.5% (8)). DISCUSSION AND CONCLUSION: The costal cartilage obviously does not show typical B fractures as we know them from shaft fractures of long bones. We have compiled a structured analysis in the attached manuscript and validated the classification proposal. In conclusion, we propose an adaptation of the classification proposal based on our data with redefining type B fractures as fractures of the osteochondral joints.

U shaped costal cartilage resection to reduce donor site morbidity.

OBJECTIVE: The aim of our study is to reduce the complications of pain and chest wall deformity by modifying conventional costal cartilage graft harvesting. METHOD: In this method while the superior part of the costal cartilage is removed completely, medial, lateral, and inferior parts are excised incompletely and used as a graft. Hence, continuity of the costal cartilage is maintained inferiorly. RESULTS: Nineteen primary and 28 revision rhinoplasty patients were included in the study. There were no donor site complications in the early postoperative period or during one-year follow-up. CONCLUSION: The modified costal cartilage graft harvesting technique we described is a safe conservative surgical method.

Middle Vault Dorsal Augmentation in Rhinoplasty as "Push-up" Preservation Technique or as "Modified Dorsal Split Extended Push-up" Procedure.

BACKGROUND: Primary or secondary dorsal augmentation rhinoplasty addresses aesthetic and functional issues related to a deficient, under-projected, or depressed nasal dorsum, frequently in middle vault. Traditional treatments often involve costal cartilage grafts, which can result in palpable irregularities and additional morbidity. Implementing dorsal preservation techniques in selected patients may improve predictability and outcomes of dorsal augmentation. MATERIALS AND METHODS: We conducted a case series involving 12 patients with saddle nose deformities and significant nasal function impairment. All patients underwent either "push-up" preservation technique or "modified dorsal split extended push-up" technique. The techniques were evaluated for feasibility, safety, and efficacy. Functional outcomes were assessed using the nasal obstruction symptom evaluation (NOSE) scale preoperatively and three months postoperatively. RESULTS: Eight patients underwent "push-up" technique, and four patients required "dorsal split extended push-up" technique due to extensive scarring and mucosal adhesions from previous surgeries. All patients demonstrated significant postoperative improvement in nasal function as indicated by a reduction in NOSE scores (p < 0.05). Aesthetic outcomes showed a naturally augmented and smooth dorsum with no palpable irregularities. Patient satisfaction was rated very high (9 or 10 out of 10) in 10 patients and high (7 or 8 out of 10) in 2 patients. Follow-up was 6 months. CONCLUSION: "Push-up" preservation technique and its extended variant provide a new surgical alternative for primary and secondary rhinoplasty with costal cartilage. These techniques offer improved and highly predictable aesthetic outcomes of the nasal dorsum with decreased morbidity, demonstrating significant potential for clinical practice and future research. 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 .

An Innovation Technique in East Asia Rhinoplasty.

OBJECTIVE: To investigate the application and therapeutic efficacy of a novel cartilage framework: the external septa framework in East Asian rhinoplasty. METHODS: From November 2021 to April 2023, Department of Plastic and Aesthetic (Burn) Surgery, the Second Xiangya Hospital, Central South University, treated 41 patients with autologous costal cartilage rhinoplasty using an innovation external septal framework. The surgical open approach used an inverted V-shaped trans-columellar incision and marginal incision. The sixth or seventh costal cartilage was harvested to form the nasal columella support grafts (strut), external nasal septal graft, cap grafts, and shield grafts, in which the nasal column support graft and external nasal septal graft are connected in a way of tongue in groove to form a external septum framework to support and lengthen the tip. A cap graft is used to shape the tip of the nose, the rectus abdominis fascia is used to cover the tip of the nose, and the shield grafts are used to augment the inferior lobules. ePTFE was sculpted according to the degree of augment of the nasal dorsum and implanted on the dorsal to augment the nasal dorsum. Clinical outcomes were assessed through standard facial photographs taken during the preoperative and follow-up periods, and a postoperative satisfaction survey was completed with regular follow-up using the rhinoplasty outcome evaluation scale (ROE) and visual analogue scale (VAS). Results of objective and subjective measurements before and after surgery were compared utilizing paired-sample t tests. Values of P < 0.05 were considered significant. Nasal framework's objective evaluation outcomes were assessed by measuring the patients' preoperative and postoperative nasolabial angle, nasal length, and nasal tip projection. (The distance between the pronasale and the alar-cheek junction was calculated as the tip projection.) The comparison of preoperative and postoperative nasolabial angle and nasal length was performed using the paired-sample t test, and the comparison of nasal tip projection was performed using the Wilcoxon signed rank-sum test for the comparison of paired samples. Values of P < 0 .05 were considered significant. RESULTS: A total of 41 patients were treated, including 9 males and 32 females, ranging in age from 17 to 48 years(32.8 ± 1.5 years old), In the study, an average follow-up period of 19.85 ± 4.88 months was observed (range 12-29 months). There was no long-term or short-term complication observed. The aesthetic outcome of all cases such as saddle nose, deviated nasal columella, bilateral asymmetry of the nose, bilateral nasal base depression, and bulbous tip was satisfactory. Patient satisfaction evaluation: The ROE scale was (11.85 ± 2.46) preoperatively and (17.43 ± 2.15) postoperatively. The VAS scores were (4.86 ± 1.60) preoperatively and (8.48 ± 1.25) postoperatively. The difference of ROE scale and VAS scores among the patients was statistically significant (P < 0. 05), and 88.9% of patients were satisfied following those procedures. In terms of nasolabial angle, preoperative and postoperative measurements of 41 patients were (86.11 ± 2.25)° and (98.66 ± 1.90)°, respectively, and the difference of nasolabial angle was statistically significant (P < 0.05); nasal length measurements were 39.43 ± 1.55 mm (37.95-43.51 mm) preoperatively and 42.17 ± 1.46 mm (40.23-45.62 mm) postoperatively; in terms of nasal tip projection, preoperative and postoperative measurements of median values were 1.84(1.73,2.01) cm and 2.15(2.02,2.32) cm, respectively; and the difference between preoperative and postoperative values was statistically significant (P < 0.05). CONCLUSIONS: The innovative cartilage framework-external septal framework, avoids the dissection of septa and absorption of septal cartilage with compression of ESG, it is easy to be performed, and it is also stable and strong to achieve in good aesthetic result. LEVEL OF EVIDENCE V: 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 .

Relative effects of serratus anterior plane block performed with dexmedetomidine combined with ropivacaine or ropivacaine alone on quality of recovery in children undergoing ear reconstruction.

BACKGROUND: Dexmedetomidine (Dex) as a local anesthesia adjuvant for nerve block procedures can improve the quality of patient recovery. However, the impact of using Dex as a local anesthetic adjuvant for serratus anterior plane block (SAPB) procedures on recovery quality for children undergoing ear reconstruction remains unclear. METHODS: Eighty-four patients who underwent ear reconstruction with autogenous costal cartilage (ACC) were randomized into two groups (n = 42/group) in which SAPB was performed with ropivacaine alone (R group) and with Dex and ropivacaine (DR group). Primary outcomes were patient 15-item quality of recovery (QoR-15) scale scores on days 1 and 2 post-surgery. Secondary outcomes included postoperative rest and coughing numerical rating scale (NRS) chest pain scores, duration of analgesia, oral rescue analgesic usage, and opioid-related side effects. RESULTS: Forty patients per group completed the study. QoR-15 scores on days 1 and 2 post-surgery in the DR group were significantly increased relative to the R group (126.35 ± 9.81 vs. 115.53 ± 8.58 and 131.78 ± 8.67 vs. 122.80 ± 8.59, all P < 0.001). Rest and coughing NRS chest pain scores at 2, 4, 8, 12, and 24 h postoperatively in the DR group were all significantly lower relative to the R group (all P < 0.05). The DR group also exhibited significantly longer analgesic duration (P < 0.001) and significantly reduced incidences of oral rescue analgesic usage and opioid-related side effect (all P < 0.05). CONCLUSION: Combining Dex and ropivacaine for SAPB in children undergoing ear reconstruction with ACC can significantly improve the quality of recovery, quality of analgesia, and analgesic duration.

Costal margin reconstruction for slipping rib syndrome: Outcomes of more than 500 cases and advancements beyond earlier sutured repair technique.

Objectives: To evaluate results of sutured repair for slipping rib syndrome (SRS), identify failure points, and discuss technique modifications to improve outcomes through costal margin reconstruction (CMR). Methods: Patients undergoing repair of SRS between February 2019 and February 2024 at an academic referral institution were retrospectively analyzed. Pain scores, quality of life, pain medication use, and reoperations were evaluated pre- and postoperatively at 1 and 6 months. In patients failing sutured repair we identified specific failure points and devised a new CMR technique to overcome them. Subsequent CMR patients were followed at 1, 6, 12, 18, and 24 months using the same outcome measures. Results: Four hundred forty-nine patients underwent repair. Two hundred forty-one patients underwent sutured repair with revision required in 66. Median time to revision was 14 months. CMR was developed and performed in 247 patients. In CMR patients, preoperative mean pain score of 7.5 out of 10 dropped postoperatively to 4.0, 2.5, 1.9, 1.3, and 0.9 at 1, 6, 12, 18, and 24 months, respectively (P < .001). Mean quality of life of 38% improved to 73%, 83%, 88%, 93%, and 95% at the same intervals (P < .001). Preoperatively, 29% of patients chronically used opioid medications. Opioid use dropped postoperatively to 11%, 4%, 4%, 0%, and 0% at the same intervals. Use of nonopioid medications followed a similar pattern. One CMR patient required full revision. Conclusions: SRS is a debilitating, but correctable disorder. Improved pain and quality of life, reduction in chronic opioid use, and freedom from revision surgery suggest that CMR should be considered the standard operation for SRS.

Outcomes of dorsal nasal augmentation using costochondral graft.

Objective: To assess functional and aesthetic outcomes in patients having undergone dorsal nasal augmentation with costochondral graft in a tertiary care setting. METHODS: The single-centre, retrospective, observational study was conducted at Shifa International Hospital, Islamabad, Pakistan, and comprised data of patients who underwent dorsal nasal augmentation using costochondral graft between January 1, 2018, and December 31, 2022. Aesthetic outcomes in terms of patient satisfaction were assessed using Facial Appearance, Health-related Quality of Life and Adverse Effects scores. Data was analysed using SPSS 26. RESULTS: Of the 46 patients, 28(61%) were males and 18(39%) were females. The overall mean age was 28.39±9.13 years. Dorsal nasal deficiency occurred secondary to congenital causes in 12(26.1%) patients, trauma 19(41.3%) and prior surgery 15(32.6%). Postoperative complication rate was 7(15%); 3(6.5%) had recipient site infection and 2(4.3%) had rib graft resorption. Besides, 1(2.2%) patient reported pain 2 months postoperatively and 1(2.2%) had hypertrophic scarring. Patient satisfaction with the outcome was noted in all the 10 parameters analysed. Most commonly reported problem was that the nose was 'looking thick/swollen' by 12(26.1%) patients, but the issue resolved during 1-year follow-up. Conclusion: Costochondral graft was found to be an ideal material for dorsal nasal augmentation, with high patient satisfaction rate.

A Technique of Autologous Costal Cartilage Graft Combined With Auricular Cartilage Folding to Correct Question Mark Ear in a Single Procedure.

Background: Question mark ear is a rare congenital deformity, mainly characterized the interruption of the natural continuity between the lower border of the helix and the earlobe. In severe cases, the earlobe may be absent. In addition, there may be protrusion and outward expansion of the upper part of the auricle, with partial or complete disappearance of the antihelix. This article aims to introduce a technique that combines autologous costal cartilage carving with auricular cartilage folding to achieve a stable and aesthetic auricle. Method: This study included 26 patients with sporadic question mark ear deformity who were treated at our clinical center from January 2020 to December 2022. Based on the different appearances of the lower part of the auricle, they were divided into 2 categories:11 cases showed a natural continuity interruption between the helix and the earlobe, while 15 cases showed the absence of the earlobe. All patients underwent corrective surgery using costal cartilage transplantation combined with the upper part of the auricular cartilage folding, performed by senior surgeons. Results: Question mark ear was effectively improved and with no significant rebound. The average follow-up period was 8.4 months (ranging from 6 to 12 months). A satisfaction survey showed that 23 patients (88%) were satisfied, 3 patients (12%) were partially satisfied, and no patients were dissatisfied. Most patients experienced temporary swelling after surgery, which resolved within 3 months to half a year. Conclusion: Autologous costal cartilage transplantation combined with folding of the auricular cartilage is an ideal surgical method to correct question mark ear.

Minimally Invasive Costal Cartilage Harvesting Incision for Chest Deformity in Microtia Reconstruction.

BACKGROUND: Chest deformity is a potential complication associated with auricular reconstruction using autologous costal cartilage. The impact of the incision size employed for costal cartilage harvesting on chest deformities remains unclear. This study aimed to investigate the correlation between the incision size used for harvesting costal cartilage and the occurrence of chest deformities. METHODS: We retrospectively analyzed patients who underwent ear reconstruction using autologous costal cartilage between June 2021 and September 2022. The patients were categorized into two groups based on the size of the costal cartilage incision: large and small. Chest computed tomography (CT) was performed 18-24 months postoperatively, followed by three-dimensional color map quantification to assess the degree of asymmetry of the chest surface. Subsequently, quantitative data analysis was performed to compare the extent of chest asymmetry between the large- and small-incision groups. The Visual Analog Scale (VAS) was used to assess patient satisfaction with chest morphology. RESULTS: This study included 62 patients, with an equal distribution of 31 in each group. The mean asymmetry value of the small and large incision groups was -3.15 ± 1.88 and -5.27 ± 3.63, respectively. Moreover, the mean VAS score for the small and large incision groups was 7.48 ± 0.72 and 5.09 ± 0.94, respectively. Statistically significant differences were observed between the two groups. CONCLUSIONS: Small incision costal cartilage harvesting can effectively alleviate the severity of chest deformities and significantly enhance patient 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 .

Comprehensive analysis of donor-site chest deformities after autologous costal cartilage microtia reconstruction: A systematic review.

BACKGROUND: Autologous costal cartilage has gained widespread acceptance as an important material for ear reconstruction in patients with microtia. Despite its recognition as being "worth the trade-off," attention should be directed toward donor-site deformities. This systematic review focused on existing English literature related to microtia reconstruction and aimed to reveal the incidence of chest wall deformities and assess the effectiveness of the various proposed surgical techniques aimed at reducing donor-site morbidities. METHODS: A comprehensive search was conducted on Pubmed and OVID using the keywords "microtia," and "chest deformity" or "rib harvest." Articles were screened based on predefined inclusion and exclusion criteria. Data acquisition encompassed patient demographics, employed surgical techniques, methods for evaluating chest deformity, and incidence of associated complications. RESULTS: Among the 362 identified articles, 21 met the inclusion criteria. A total of 2600 cases involving 2433 patients with microtia were analyzed in this review. Perichondrium preservation during cartilage harvesting led to a significant reduction in chest deformities. However, the wide incidence range (0% to 50%) and the lack of specific assessment methods suggested potential underestimation. Computed tomography revealed reduced chest wall growth in the transverse and sagittal directions, resulting in decreased thoracic area. Innovative surgical techniques have shown promising results in reducing chest deformities. CONCLUSIONS: Although a quantitative analysis was not feasible, objective evidence of deformities was established through computed tomography scans. This analysis highlighted the need for dedicated studies with larger sample sizes to further advance our understanding of chest wall deformities in microtia reconstruction.

Histological assessment of microtia cartilage, a potential source of autograft tissue in ear reconstruction.

Cartilage is a strong and flexible connective tissue that has many forms and functions in our body. While cartilage exhibits some forms of limited repair, for the most part, it is not particularly regenerative. Thus, in situations where patients require cartilage reconstruction, surgeons may use autografts to replace missing or damaged tissue. Cartilage tissues from different regions of the body exhibit histological differences and are in limited supply. Thus, it is important to characterize these differences to determine the most appropriate autograft source. In the case of microtia, a congenital deformity where the pinna is underdeveloped, reconstruction commonly utilizes cartilage sourced from a patient's own costal cartilage. This presents a potential morbidity risk. In this study, we evaluate the histological characteristics of microtia cartilage compared with normal auricular and costal cartilage obtained from human patients undergoing surgical resection. Histochemistry was used to evaluate cellularity, lipid content, and ECM content. Using a Bayesian statistical approach, we determined that while costal cartilage is the standard tissue donor, the microanatomy of microtia cartilage more closely reflects normal auricular cartilage than costal cartilage. Therefore, microtia cartilage may serve as an additional reservoir for cartilage during reconstruction.

The relay graft, a tailored supplement between the nasal hump and established tip in East Asian rhinoplasty.

BACKGROUND: In East Asian individuals, the nasal bone already has sufficient height for an ideal dorsal profile, but the tip requires enhancement for a desired projection. Consequently, the gap between the intrinsic bony structure and the established nasal tip requires appropriate management. The options are either to reduce the keystone region to create a smooth bed for a conventional dorsal onlay graft or to preserve the original osseocartilaginous structures and then customize a supplementary graft. The aim of this study was to detail and validate the utilization of a relay graft, a transition graft that fills the structural gap between the upper dorsum and established tip graft. The proper application of this graft could prevent osteotomy and preserve the intrinsic dorsum. METHODS: Relay grafts were applied during rib-based rhinoplasty in East Asian patients. Three-dimensional stereophotogrammetric evaluations of the patients were performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection improvement, radix elevation, and the angulation of kyphion and pronasale. RESULTS: Fifteen female patients, ranging in age from 21 to 40 years (average 24.5 years), were included. In all cases, the relay graft was applied as one essential element for filling the structural gap. No crooked dorsal profile or visible graft was noted in all cases. Fifteen patients completed the pre- and postoperative stereophotogrammetric study. Postoperative analysis showed great improvement of tip position as well as a slight elevation of the radix, evidenced by the consistent change of kyphion/pronasale angulation and sellion elevation. CONCLUSIONS: The relay graft effectively mitigates the necessity of a disruptive dorsal reduction. It is entirely possible for East Asians to achieve a smooth dorsal profile when only the lower half of the dorsum is transitioned to the proposed tip position. LEVEL OF EVIDENCE: Level IV, case series.

Comparing the Analgesic Effects Between the Pre- and Post-costal Cartilage Harvest Cohorts Using Ultrasound-Guided Deep Serratus Anterior Plane Block in Children with Microtia Undergoing Auricular Reconstruction: A Randomized Clinical Trial.

PURPOSE: Pain following costal cartilage harvest surgery is the most common complaint of auricular reconstruction (AR). Anesthesiologists are continuously searching for an effective postoperative pain control method. METHODS: This study was conducted from 10 April 2022 to 10 June 2022. Sixty children undergoing AR using costal cartilage were randomly assigned to either a serratus anterior plane block performed before costal cartilage harvest (SAPB-pre-cohort; n = 30) or the SAPB-post-cohort (Post-costal cartilage Harvest Cohort: n = 30). The primary endpoint measures were the Numerical Rating Scale (NRS) scores of the chest and ear pain degrees recorded at 1-, 6-, 12-, 24-, and 48-h after surgery. Intraoperative anesthetic and analgesic dosages, sufentanil consumption and rescue analgesia consumption during the first 24 h post-operation, cough score during extubation, extubation agitation score, length of stay, the extubation time, first ambulatory time, analgesia duration, and opioid-related adverse effects and SAPB-related adverse effects were the secondary endpoints. RESULTS: The rest and coughing NRS scores were significantly reduced in the SAPB-pre-cohort 6 and 12 h post-operation in comparison with the SAPB-post-cohort (rest 6 h p = 0.002, others p < 0.001). No significant difference in the NRS ear scores existed between the two cohorts (p > 0.05). The use of propofol and remifentanil for general anesthesia during the SAPB-pre-procedure was significantly reduced compared to the SAPB-post-group, with statistical significance (p < 0.001). Sufentanil consumption and rescue analgesia consumption were significantly reduced in the SAPB-pre-cohort (p = 0.001, p = 0.033). The extubation time and first ambulatory time were markedly shorter in the SAPB-pre-cohort (all p < 0.001). Analgesia duration was markedly longer in the SAPB-pre-cohort (p < 0.001). No significant differences were noted in the cough score during extubation, extubation agitation score, length of stay between the two cohorts (all p > 0.05). Opioid-related adverse effects occurred more in the SAPB-post-cohort, while there was no statistical significance (16.7 vs. 36.7%; p = 0.082). There were no blockade-related complications observed in either cohort. CONCLUSION: The analgesic effect of the SAPB-pre-cohort was better than the SAPB-post-cohort suggesting both efficacy and feasibility of preemptive analgesia. 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 .

Bilateral Costal Cartilage Harvest for Auricle Reconstruction: A New Technique to Prevent Postoperative Thoracic Deformity.

HYPOTHESIS: Unilateral costal cartilage harvesting (UCCH) for auricle reconstruction in children tends to cause thoracic deformities. Therefore, our study aimed to develop a novel bilateral costal cartilage harvesting (BCCH) method to prevent and reduce thoracic deformities. METHODS: Patients with unilateral microtia who underwent either UCCH (n = 50) or BCCH (n = 46) were enrolled in this study. The grafts for the BCCH group were harvested from the 6th costal cartilage of the ipsilateral hemithorax and the 7th and 8th cartilage from the other hemithorax. Computed tomography and physical examination were performed to identify any physical deformities in the chest contours post-surgery. The cosmetic appearance of the thoracic scars post-surgery was evaluated using the Scar Cosmesis Assessment and Rating Scale (SCAR) and Visual Analogue Scales (VAS cosmetic). The numerical rating scale (NRS) was used to quantify the pain in donor sites. The reconstructed ears were assessed during the follow-up period. RESULT: None of the patients in the BCCH group developed thoracic deformities, while 16 patients within the UCCH group developed mild (n = 12) or severe (n = 4) thoracic deformities (p < 0.001). The SCAR (3.09 vs. 2.92, p = 0.580) and VAS scores (0.96 vs. 0.90, p = 0.813) did not differ significantly between the two groups. For both treatment arms, the NRS scores were highest on the first-day post-surgery and gradually dropped over the 10 days. No significant differences were found in the NRS scores and the aesthetic outcomes of the reconstructed ears between the two groups. CONCLUSION: The BCCH method effectively reduced the incidence of thoracic deformity at the donor site without increasing postoperative pain and cosmetic concerns for patients. It could be used clinically to improve patient outcomes of costal cartilage grafts. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3572-3580, 2024.

[Effectiveness of comprehensive rhinoplasty on secondary nasal deformity with saddle nasal deformity after cleft lip surgery].

Objective: To investigate the effectiveness of comprehensive rhinoplasty with autogenous costal cartilage grafting and prosthesis augmentation rhinoplasty in the treatment of secondary nasal deformity with saddle nasal deformity after cleft lip surgery. Methods: The clinical data of 96 patients with secondary nasal deformity with saddle nasal deformity after cleft lip surgery between September 2008 and January 2019 were retrospectively analyzed. There were 17 males and 79 females with an average age of 25.6 years (range, 17-38 years). Autogenous costal cartilage grafts were used to construct stable nasal tip framework and enhance the strength of alar cartilage. Nasal dorsum prostheses (39 cases of bulge, 45 cases of silicone prosthesis) or autogenous costal cartilage (12 cases) were used for comprehensive rhinoplasty. Visual analogue scale (VAS) score was used to evaluate the postoperative satisfaction subjectively, and nasal alar height symmetry index, nasal alar width symmetry index, nasal dorsum central axis deviation angle, and nasal columella deviation angle were calculated to evaluate objectively before and after operation. Results: All patients were followed up 6 months to 8 years, with an average of 13.4 months. Nasal septal hematoma occurred in 3 patients after operation, which was improved after local aspiration and nasal pressure packing. Two cases had mild deformation of the rib cartilage graft of the nasal dorsum, one of which had no obvious deviation of the nasal dorsum and was not given special treatment, and one case underwent the cartilage graft of the nasal dorsum removed and replaced with silicone prosthesis. The incisions of the other patients healed by first intention, and there was no complication such as postoperative infection and prosthesis displacement. The nasal alar height symmetry index, nasal alar width symmetry index, nasal dorsum central axis deviation angle, and nasal columella deviation angle significantly improved after operation when compared with preoperative ones ( P<0.05). Postoperative subjective satisfaction evaluation reached the level of basic satisfaction or above, and most of them were very satisfied. Conclusion: Comprehensive rhinoplasty using autologous rib cartilage grafting to construct a stable nasal tip support, combined with dorsal nasal prosthesis or autologous cartilage implantation, can achieve good effectiveness on secondary nasal deformity with saddle nasal deformity after cleft lip surgery.

Autologous Costal Chondral/Osteochondral Transplantation and Costa-Derived Chondrocyte Implantation for Articular Cartilage Repair: Basic Science and Clinical Applications.

There has been increasing application of autologous costal chondral/osteochondral transplantation (ACCT/ACOT) and costa-derived chondrocyte implantation (ACCI) for articular cartilage repair over the past three decades. This review presents the major evidence on the properties of costal cartilage and bone and their qualifications as grafts for articular cartilage repair, the major clinical applications, and the risks and strategies for costal chondral/osteochondral graft(s) harvest. First, costal cartilage has many specific properties that help restore the articular surface. Costa, which can provide abundant cartilage and cylindrical corticocancellous bone, preserves permanent chondrocyte and is the largest source of hyaline cartilage. Second, in the past three decades, autologous costal cartilage-derived grafts, including cartilage, osteochondral graft(s), and chondrocyte, have expanded their indications in trauma and orthopaedic therapy from small to large joints, from the upper to lower limbs, and from non-weight-bearing to weight-bearing joints. Third, the rate of donor-site complications of ACCT or ACOT is low, acceptable, and controllable, and some skills and accumulated experience can help reduce the risks of ACCT and ACOT. Costal cartilage-derived autografting is a promising technique and could be an ideal option for articular chondral lesions with or without subchondral cysts. More high-quality clinical studies are urgently needed to help us further understand the clinical value of such technologies.