Immune Rejection of Cartilage in a Swine Vascularized Composite Allotransplantation Model.

BACKGROUND: Cartilage is a crucial tissue in vascularized composite allotransplantation (VCA) and plays a pivotal role in restoring motor function, especially in joint allotransplantation. Nevertheless, our understanding of immune rejection in cartilage remains limited and contentious. This study seeks to investigate the immune rejection of cartilage in a large animal model of VCA. METHODS: Cartilage, including articular cartilage and meniscus, as well as skin, muscle and lymph node, was retrieved from a swine heterotopic VCA graft when the skin of the graft suffered from grade III-IV rejection. Histologic examination, transmission electron microscopy and immunofluorescent staining were used to investigate immune rejection. RESULTS: Histologic examination revealed the infiltration of inflammatory cells and tissue destruction in cartilage. Transmission electron microscopy confirmed tissue damage and necrosis in cartilage. However, cartilage exhibited milder tissue damage when compared to rejected skin and muscle. Immunofluorescent staining revealed the activation of both the innate and adaptive immune systems, accompanied by an up-regulation of cell death biomarkers, including apoptosis and pyroptosis, in the rejected cartilage. CONCLUSION: Our study demonstrates that cartilage is not immunologically privileged and undergoes immune rejection concurrently with skin and muscle in the VCA graft, though with less severe inflammation and rejection.

Single-stage reconstruction of severe question mark ear with the absence of large portions of the lobule using affected cartilage graft and 3 flaps.

BACKGROUND: Question mark ear (QME) is a congenital abnormality characterized by a prominent curve within the helix that resembles a question mark. Several surgical reconstruction techniques have been proposed to treat this deformity. In this study, we aimed to evaluate the cosmetic outcomes of a new cartilage and postauricular flap surgical reconstruction technique for patients diagnosed with severe QME. METHOD: From 2017 to 2023, 33 patients with severe QMEs were treated with a new reconstruction surgical technique at the Plastic Surgery Hospital of Peking Union Medical College. The perimeter, width, length, and auriculocephalic angles of both ears were measured and compared to assess the symmetry. The patient's satisfaction with the surgical outcomes and incidence of post-operative complications were also evaluated. The average follow-up duration was 15.48 months. RESULTS: The auricular perimeter, width, and length changed significantly after surgery. The dimensions of the left and right ear did not vary significantly in patients with unilateral or bilateral severe QME after surgery and at the end of the 1-year follow-up. Most patients (87.88%) or carers were satisfied with the cosmetic outcomes after surgery. All patients underwent suture removal 14 days after surgery and exhibited excellent wound healing without any complications such as hematoma, infection, and flap necrosis. CONCLUSION: Our new surgical reconstruction technique for severe QME resulted in good cosmetic outcomes, high patient satisfaction, fast recovery, and no post-operative complications.

A systematic review and meta-analysis of complications associated with crushed cartilage in rhinoplasty.

BACKGROUND: Crushed cartilage grafts improve augmentation and contour irregularities in rhinoplasty; however, they are associated with complications including resorption, asymmetries, palpability, and need for revision surgery. METHODS: A systematic review and meta-analysis following the preferred reporting items for systematic reviews and meta-analyses guidelines was performed on all recorded history up to November 2022 using the search query ("crush" or "crushed") AND cartilage AND rhinoplasty for PubMed, World of Science, Embase, and Cochrane online registries. Data were collected on study information, patient demographics, surgical details, and outcomes. Graft resorption and revision surgery were pooled in a random-effects model, and a subgroup analysis was performed for coverage/non-coverage of the cartilage and degree of crushing. RESULTS: The initial search yielded 163 results, with 11 studies included in the final full-text review. A total of 1132 patients were analyzed, with 456 (40.3%) women, mean age of 48.0 years, and an average follow-up period of 24.9 months. Cartilage resorption rates were statistically higher in graft preparation using severely crushed cartilage (3.4%) compared to non-severely crushed cartilage (0.9%, p = 0.049). There was no significant difference in resorption rate for patients with covered cartilage graft (1.3%) compared to those with non-covered grafts (1.8%, p = 0.7). There were significantly more revision surgeries for severely crushed (17.9%) compared to non-severely crushed (3.5%, p = 0.003) cartilage grafts. CONCLUSIONS: Severely crushed cartilage grafting provides smooth contour and less palpability compared to other degrees of crushing but demonstrates significantly higher rate of resorption.

Clinical Outcomes of Endoscopic Butterfly Inlay Cartilage Myringoplasty.

OBJECTIVE: To review a 3-year case series of endoscopic butterfly inlay cartilage myringoplasty performed by a single surgeon (W.S.K.) and analyze the clinical surgical outcomes. STUDY DESIGN: Retrospective study. SETTING: Tertiary care academic center. PATIENTS: We enrolled 60 ears with tympanic membrane (TM) perforation, receiving endoscopic inlay butterfly myringoplasty between 2019 and 2022. MAIN OUTCOMES AND MEASURES: We reviewed patients' demographics, size and location of TM perforation, operation time, complications, and postoperative pain evaluated by the numerical rating scale (NRS). We analyzed the graft uptake success rate in 5 weeks and the perforation closure rate in 4 months after surgery. We also compared the air-bone gap (ABG) before and after the surgery. RESULTS: Among the 60 ears included, the mean age was 57.0 years, and 78.3% (47 of 60) had small perforations. The average operation time was 48.9 ± 11.5 minutes, and the postoperative NRS was 2.0 ± 1.6. The immediate graft uptake success rate evaluated at postoperative 5 weeks was 96.7% (58 of 60), with myringitis occurring in three ears. Except for 11 patients lost to follow-up, the perforation closure rate evaluated at postoperative 4 months was 100% (49 of 49). The mean ABG significantly improved from preoperative status (8.87 ± 5.51 dB HL) to postoperative 4 months (6.22 ± 6.03 dB HL) ( p = 0.019). CONCLUSIONS: A single surgeon's success rate for endoscopic butterfly inlay cartilage myringoplasty was almost 100%. This surgical procedure is safe and effective, with a high graft success rate.

Outcomes of endoscopic modified cartilage-perichondrium tympanoplasty on different sized perforations.

OBJECTIVES: To evaluate the anatomic and functional outcomes of type1 tympanoplasty with endoscopic modified butterfly cartilage-perichondrium technique. METHODS: In our modification, perichondrium was elevated circumferentially till the attached part of the composite graft was approximately same size and shape of the perforation, cartilage was trimmed based on the perforation but 0.5 mm larger. Cartilage portion of the graft was placed medial to the edge of the perforation, then perichondrium was rolled out and draped on the circumferential raw surface of remaining tympanic membrane around. RESULTS: At 4 months postop, the anatomic integrity rate of the tympanic membrane perforation for small & medium sized perforation and large sized perforation group were 100 % and 94 % (p > 0.05). For the small & medium perforation group, the mean pre and 4 months postop ACs were 30 ± 8 dB and 18 ± 6.4 dB (p < 0.01). The mean pre and 4 months postop ABGs were 19 ± 11 dB and 9 ± 3 dB (p < 0.01). For the large perforation group, the mean pre and 4 months postop ACs were 43 ± 12.5 dB and 21.5 ± 7 dB (p < 0.01). The mean pre and 4 months postop ABGs were 34 ± 8.5 dB and 12.5 ± 6 dB (p < 0.01). The differences of mean 4 months postop ACs and mean 4 months postop ABGs between the two groups were not significant (p > 0.05). CONCLUSIONS: Compared to the conventional inlay butterfly cartilage tympanoplasty technique, large or marginal perforations can be sealed more securely by this modification.

[Management of patients with complex ear deformities]. / Prise en charge des patients présentant des déformations complexes du pavillon de l'oreille.

Complex ear reconstruction requires specialized multidisciplinary care. Most patients present with microtia, often associated with hearing disorders. The management of these disorders is a priority, and reconstruction of the external ear remains optional. Nowadays, auricular reconstruction is based on the subcutaneous implantation of either autologous cartilage or an allogeneic implant. Autologous reconstruction requires highly specialized surgical expertise and involves harvesting rib cartilage but carries a lower risk of exposure compared to allogeneic implants. Both techniques yield good results with a high success rate and have a positive impact on the social functioning and daily life of patients.

La reconstruction complexe du pavillon auriculaire nécessite une prise en charge multidisciplinaire spécialisée. La majorité des patients nécessitant ce geste présentent une microtie, souvent associée à des troubles de l'audition. La prise en charge de ceux-ci est prioritaire et la reconstruction du pavillon reste facultative. Aujourd'hui, la reconstruction du pavillon se base sur l'implantation sous-cutanée d'une maquette de cartilage autologue ou d'un implant allogène. La reconstruction autologue demande une expertise chirurgicale hautement spécialisée et nécessite un prélèvement de cartilage costal mais présente un risque d'exposition inférieur par rapport à l'implant allogène. Les deux techniques permettent d'atteindre de bons résultats avec un taux de réussite élevé et un effet positif sur le fonctionnement social et le quotidien des patients.

Hybrid Chin Advancement: Combining Fat and Sliced Cartilage Grafts for Chin Augmentation During Rhinoplasty.

BACKGROUND: Facial balance significantly impacts aesthetics, particularly in the middle and lower thirds. Patients with chin retrusion often benefit from sagittal plane chin advancement in rhinoplasty, enhancing surgical outcomes and satisfaction. OBJECTIVES: This article presents a method for analyzing chin deformities and discusses a hybrid treatment approach to harmonize facial features, complementing rhinoplasty. METHODS: The chin positions of patients treated by the senior author were assessed. A retrospective analysis included 49 patients with chin retrusion of 2.5-6 mm. Among them, 22 patients initially offered chin implants declined, leading to planned chin augmentation. Fat grafting was exclusively performed for 20 patients lacking sufficient cartilage. The "Hybrid Chin Advancement" technique involved supporting tissues beneath muscles with nasal septum cartilage and fat injections and tissues above muscles with fat injection alone. RESULTS: Pre- and postoperative Legan angle measurements and chin advancements were compared across three groups. While preoperative Legan angles were statistically similar, postoperative Legan angles and advancement changes were significantly higher in the implant group (p < 0.0001). Comparing hybrid chin advancement and fat grafting groups, postoperative Legan angles and advancement changes were significantly higher in the hybrid chin group (p < 0.0001). CONCLUSIONS: Fat grafting suffices for mild advancements (~ 2 mm), while the hybrid chin method is effective for moderate advancements (~ 4 mm). For advancements exceeding 6 mm, implants or osseous genioplasty are optimal. Our study's hybrid approach offers an easy, safe, and reliable method for achieving facial harmony in the lower two-thirds without compromising patient expectations. 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 .

Mechanically fragmented cartilage grafts in rhinoplasty: An up-to-date systematic review.

INTRODUCTION: Grafts play key roles in functional and aesthetic rhinoplasty. Autologous grafts are generally preferred for their biocompatibility and less visibility when used in a fragmented fashion. The aim of this study was to review mechanically fragmented cartilage grafts techniques described in the literature, outlining indications, outcomes, and complications. MATERIAL AND METHODS: A systematic review of articles published from 1999 until December 2022 was conducted, using the following key words: "rhinoplasty," "cartilage," and "graft." Studies were selected according to the inclusion and exclusion criteria, and data were extracted and grouped for subgroup analysis. Rates of partial resorption, total resorption, surgical revision, and major and minor complications were statistically analyzed. RESULTS: Thirty eligible studies were included. Three cartilage fragmentation methods were identified: diced, shaved, and crushed. Cartilage grafts were further divided into injectable and noninjectable grafts. Diced cartilage was the most commonly used. Dorsal irregularities were the main indication. Overall, 1.68% of patients experienced partial resorption, 0.27% experienced total resorption, and 1.46% needed revision. The partial resorption rate in the diced group was significantly lower than that in the shaved group. Injectable grafts showed a higher rate of partial resorption. The revision rate was higher with noninjectable grafts. CONCLUSION: The partial resorption rate was lower in patients treated with diced cartilage. Injectable grafts are malleable and suitable for the correction of minimal irregularities, although they are affected by a higher rate of partial resorption. Wrapping materials may be used when significant augmentation is required.

Comparison of the efficacy of fat, cartilage, and bone grafts in traumatic and asymmetric noses.

BACKGROUND: Correction of asymmetry and irregularity deformities with autologous grafts, without osteotomies, offers advantages to both plastic surgeons and patients with severe deviation. Various autologous tissues such as fat, bone, and cartilage grafts are viable options for this purpose. OBJECTIVES: This study aimed to compare the efficacy of 3 autologous filling materials in patients with bone asymmetry. METHODS: A retrospective evaluation was conducted on 297 patients seeking aesthetic nose surgery between 2015 and 2022. Only primary patients without prior surgery and those with bone asymmetry from trauma, with dorsum protrusion <3 mm, and without osteotomy were included. Patients were divided into fat, cartilage, and bone groups. Grafts were applied to the concave side during closed rhinoplasty, and evaluations were done 12 months after surgery by blinded plastic surgeons and patients using established assessment tools. RESULTS: Fat, cartilage, and bone grafts were utilized in 74, 127, and 96 patients, respectively, with a mean follow-up of 19 months. The mean graft volumes were 1.0 cc (bone), 1.3 cc (cartilage), and 1.6 cc (fat). The patient self-assessment scores were 75%, 84.9%, and 86.6%, respectively. The Asher-McDade averages were 77.2%, 86.7%, and 88.4%, respectively. Cartilage and bone graft results were statistically similar in patients' self-evaluation and significantly higher than those of fat grafts. Blinded assessments showed no significant difference between the cartilage and bone groups. CONCLUSION: Placing autologous grafts on the concave side for patients with minimal nasal bone protrusion (<3 mm) yields successful results. Cartilage grafts offer advantages in volume, result estimation, and preparation time, making them suitable for larger patient cohorts.

Outcomes of surgical repair of Type III and IV laryngotracheoesophageal clefts with posterior cartilage grafting.

PURPOSE: To describe the clinical outcomes of patients who underwent surgical repair through an anterior approach that involved interposition a posterior cartilage for Type III or Type IV laryngotracheoesophageal cleft (LTEC). METHODS: A chart view was performed on patients with Type III or Type IV LTEC between May 2017 and May 2022. Demographic features and surgical outcomes were collected and analyzed. RESULTS: Seven patients were finally included. Five patients were diagnosed with Type III LTEC and two patients were diagnosed with Type IV LTEC. All but one patients survived and thrived. Four patients were able to successfully extubate with acceptable voice, and two patients were tracheostomized. Five patients were deemed safe for all consistencies food and one was safe for thickened food. After a mean follow-up of 49 months (18-83 months), neither complications nor recurrences were observed. CONCLUSION: An anterior laryngofissure approach to the cleft repair with a posterior cartilage grafting is an effective and safe treatment for Type III or IV LTEC, which enables closure of LTEC and reconstruction of cricoid plate in order to avoid tracheoesophageal fistula formation or subglottic stenosis postoperatively. Severe tracheomalacia and GERD are two main causes for surgical failure.

Analysis of the effect on costochondral graft for TMJ ankylosis with jaw deformities in pediatrics.

OBJECTIVES: To evaluate the effects of costochondral grafting (CCG) used for temporomandibular joint ankylosis (TMJA) in growing patients. MATERIALS AND METHODS: Pediatric patients with TMJA treated by CCG from 2010.5 to 2021.7 were included in the study. CT scans were performed before and after operations with at least 1 year follow-up. The height of the mandibular ramus, menton deviation or retraction, osteotomy gap, etc. were measured by ProPlan CMF1.4 software. CCG growth, resorption, and relapse were evaluated and analyzed with influencing factors such as age, ostectomy gap, etc. by generalized estimating equation. RESULTS: There were 24 patients (29 joints) with an average age of 6.30 ± 3.13 years in the study. After operation, the mandibular ramus was elongated by 5.97 ± 3.53 mm. Mandibular deviation or retrusion was corrected by 4.82 ± 2.84 mm and 3.76 ± 2.97 mm respectively. After a mean follow-up of 38.91 ± 29.20 months, 58.62% CCG grew (4.18 ± 7.70 mm), 20.69% absorbed (2.23 ± 1.16 mm), and 20.69% re-ankylosed. The re-ankylosis was negatively correlated with the osteotomy gap (OR:0.348,0.172-0.702 95%CI, critical value = 6.10 mm). CCG resorption was positively correlated with the distance of CCG ramus elongation (OR:3.353,1.173-9.586 95%CI, critical value = 7.40 mm). CONCLUSIONS: An adequate osteotomy gap and CCG ramus elongation distance are the key factors for successful treatment of TMJA with jaw deformities in growing patients. CLINICAL RELEVANCE: TMJA affects mouth opening and jaw development in pediatric patients. The most common autogenous bone graft for pediatric patients is CCG due to its growth potential, convenient access and easy contouring. Also, it can simultaneously reconstruct the TMJ and improve jaw deformity by lengthening the mandibular ramus. But the growth of CCG is unpredictable. In this study, we explored several factors that may affect the absorption and re-ankylosis of CCG, expecting to provide several suggestions to improve future CCG treatment.

[Advances in the Treatment of Osteochondral Lesions of the Talus]. / è·éª¨éª¨è½¯éª¨æŸä¼¤æ²»ç–—çš„ç ”ç©¶è¿›å±•.

Osteochondral lesion of the talus (OLT) is a localized cartilage and subchondral bone injury of the talus trochlea. OLT is caused by trauma and other reasons, including osteochondritis dissecans of the talus (OCD) and talus osteochondral tangential fracture. OLT can develop from being asymptomatic to subchondral bone cysts accompanied by deep ankle pain. OLT tends to occur on the medial and lateral sides of the talar vault. OLT seriously affects the patients' life and work and may even lead to disability. Herein, we reviewed advances in the treatment of OLT and the strengths and weaknesses of various treatments. Different treatment methods, including conservative treatments and surgical treatments, can be adopted according to the different subtypes or clinical symptoms of OLT. Conservative treatments mostly relieve symptoms in the short term and only slow down the disease. In recent years, it has been discovered that platelet-rich plasma injection, microfracture, periosteal bone grafting, talar cartilage transplantation, allograft bone transplantation, reverse drilling under robotic navigation, and other methods can achieve considerable benefits when each of these treatment methods is applied. Furthermore, microfracture combined with platelet-rich plasma injections, microfracture combined with cartilage transplantation, and various other treatment methods combined with anterior talofibular ligament repair have all led to good treatment outcomes.

Effects of no perforation margin trimming and EAC packing in cartilage underlay myringoplasty for chronic large perforations in children.

OBJECTIVE: Trimming of perforation margins and external auditory canal (EAC) packing are basic procedures in underlay myringoplasty for repairing chronic perforations. The objective of this study was to compare the operation time, graft outcome, hearing improvement, and complications of endoscopic cartilage underlay myringoplasty with and without trimming of perforation margins and EAC packing in children. STUDY DESIGN: Prospective, randomized study. SETTING: Tertiary referral center. MATERIAL AND METHODS: Pediatric patients older than 12 years with chronic perforations were randomly divided into two groups: myringoplasty with trimming of perforation margin and EAC packing (TPME) group or no trimming of perforation margin and EAC packing (NTPME) group. The operation time, graft success rate, hearing improvement, and complications were compared between the two groups. RESULTS: Fifty-two patients were ultimately included in the study. The mean operation time was 31.4 ± 4.2 min in the TPME group and 23.6 ± 1.7 min in the NTPME group; the difference was significant (P < 0.01). The rate of aural fullness significantly differed between the TPME and NTPME groups (P = 0.000). All participants were followed up for 12 months; the graft success rate did not significantly differ between the groups (88.5% vs. 96.2%; P = 0.603). No patients developed adhesive otitis media. Between the preoperative and postoperative measurements, the mean air-bone gap improved by 10.2 ± 2.8 dB in the TPME group and 11.6 ± 0.7 dB in the NTPME group; this was significant (P < 0.001) in both groups. CONCLUSIONS: Endoscopic cartilage underlay myringoplasty NTPME shorted the operation time and avoided aural fullness and EAC discomfort compared with the TPME technique; however, graft success and hearing improvement were comparable between the two techniques for repairing large perforations in children.

Interpositional arthroplasty using cartilage allografts for treating temporomandibular joint arthrosis: a 3- and 5-year retrospective clinical follow-up study.

OBJECTIVE: To evaluate the effect of arthroplasty using interpositional cartilage allografts in patients with temporomandibular joint (TMJ) arthrosis. STUDY DESIGN: This retrospective study included patients treated consecutively between 2007 and 2013 using discectomy and interpositional grafting with lyophilized costal cartilage allograft (Tutoplast) sheets. TMJ pain based on the visual analogue scale (VAS), maximal interincisal opening (MIO), joint tenderness to palpation, crepitus from the affected joint, and postoperative complications were assessed. RESULTS: Arthroplasty was performed on 37 joints among 34 patients (28 women; mean age: 54 years); 24 joints underwent simultaneous condyle shaving. At final follow-up (3 [n = 37] or 5 [n = 21] years), we observed reduced mean VAS (from 7.6 to 0.9; P < .001) increased mean MIO (from 32.5 to 41.1 mm; P < .001), number of joints with capsule tenderness (from 30 to 3; P < .001), and percentage of joints with crepitus (from 97% to 75%; P = .008). One joint required reoperation because of interposed cartilage fragmentation. No permanent facial nerve injury or malocclusion occurred after treatment. CONCLUSIONS: Interpositional arthroplasty is a relatively simple, moderately invasive, and effective surgical treatment for TMJ arthrosis with few complications. However, long-term outcomes of this treatment, specifically beyond 3-5 years postoperatively, remain unknown.

Use of Integra® on avascular tissue.

Integra® (Integra LifeSciences) is a well-known dermal regeneration template used in partial and full-thickness wound reconstruction. It can be applied directly on to vascular tissue to create a bed for a skin graft, which is often placed in a second surgery. We present our experience of its novel use in oral and maxillofacial surgery patients, using it directly on bone and cartilage (avascular tissue) without further skin grafting. Patients who required full-thickness excision of lesions down to bone or cartilage and who were treated using Integra® were included. After scalp or ear lesion resection, the collagenous dermal layer of Integra® was placed directly on to bone or cartilage and, along with its outer silicone epidermal layer, secured to the defect with absorbable sutures and a bolster dressing. The wounds were kept dry for 14 days, at which point the dressing and silicone were removed and patients continued regular wound care. Seventeen patients were included, 15 of whom had squamous cell carcinoma. One was lost to follow up. The rest achieved complete healing of the defect. Histology showed epidermis developing on the Integra® surface and at one year, the appearance of normal scarred skin. This novel approach could redefine the uses of Integra®, avoiding the need for free-flap surgery or skin grafting when reconstructing large defects. Further resection of close margins or recurrence is easier after reconstruction using dermal regeneration material than after reconstruction with a local or free flap.

The Two-Stage Folded Paramedian Forehead Flap Without Cartilage Grafts for Full Thickness Distal Nasal Defects: A Review of 35 Patients.

BACKGROUND: Full thickness defects of the ala, soft triangle, and nasal tip involving the nasal lining have traditionally been repaired with the three-stage folded paramedian forehead flap (FPFF), with a cartilage graft for support. For similar defects, the authors utilize the two-stage FPFF without cartilaginous support which provides reproducible functional and aesthetic results.  Objective: To describe the authors’ experience with the two-stage FPFF, including outcomes, complications, and design modifications to enhance functional and aesthetic success.  Methods: An IRB-approved retrospective database review of FPFF was performed at two sites. Using postoperative photographs, outcomes were assessed by blinded non-investigator dermatologist raters using a modified observer scar assessment scale. RESULTS: Thirty-five patients were reconstructed using the two-stage FPFF without cartilage grafts. Subjective assessment of scar vascularity, pigment, relief, and thickness by 3 independent reviewers yielded an overall cosmesis score of 8.4±1.9 (out of 40). CONCLUSION: The two-stage FPFF without cartilage grafts is a reliable, cosmetically elegant repair that can provide optimal functional and aesthetic results for complex unilateral distal nose defects.J Drugs Dermatol. 2024;23(4): doi:10.36849/JDD.7358.