Lateral Margin Graft for Minimizing Visible Lateral Margin on Radix Using Autologous Rib Cartilage in Asian Rhinoplasty.

BACKGROUND: Visible lateral margin (VLM) after rhinoplasty is considered one of the potential complications. PURPOSE: The purpose is to assess the suitability of implementing a lateral margin graft (LMG) to mitigate the occurrence of a VLM during augmentation rhinoplasty with autologous rib cartilage. STUDY DESIGN, SETTING, SAMPLE: This is a retrospective cohort study between January 2016 and April 2022 in a private clinic. The inclusion criteria were patients who underwent augmentation rhinoplasty for esthetic purposes using autologous rib cartilage. Patients who received allogenic tissue grafts or alloplastic materials, those with systemic diseases, and pregnant or breastfeeding females were excluded. PREDICTOR VARIABLE: The primary predictor variable is the implementation or nonimplementation of an LMG. MAIN OUTCOME VARIABLES: The primary outcome variable is the esthetic satisfaction and the degree of minimization of the VLM when LMG is implemented and when it is not. Therefore, to understand the esthetic satisfaction, the author used the Rhinoplasty Outcome Evaluation (ROE) questionnaire, and to understand the degree of minimization of the VLM, the author measured the lateral margin visibility score (LMVS) using a 5-point Likert scale score. COVARIATES: The evaluated covariates included sex, age at surgery, number of previous rhinoplasties, purpose of surgery, and postoperative complications. ANALYSES: The data were analyzed using the independent sample t test, paired t test, one-way analysis of variance test. A significance level of P < .05 was employed for all statistical analyses. RESULTS: A total of 69 consecutive patients were included in the study, divided into groups 1 (21 patients without LMG) and 2 (48 patients with LMG). Postoperative ROE scores increased by 15.31 ± 4.03 in group 1 and 22.60 ± 6.77 in group 2 compared to preoperative ROE scores (P < .001). In the patients' LMVS, group 1 had a score of 2.48 ± 0.81, while group 2 had a score of 3.06 ± 0.76 points (P = .009). In the surgeons' LMVS, surgeon 1 indicated scores of 2.38 ± 0.74 and 2.94 ± 0.89 points, respectively (P = .007). Furthermore, surgeon 2 indicated scores of 2.28 ± 0.72 and 2.90 ± 0.83 points, respectively (P = .002). CONCLUSION AND RELEVANCE: When performing rhinoplasty using autologous rib cartilage, the use of an LMG can minimize the VLM, which increases patient satisfaction and surgical completeness.

Quantitative Framework Fabrication with Autogenous Costal Cartilage in Microtia Reconstruction.

Hearing improvement is another basic requirement for microtia patients in addition to aesthetic needs. This quantitative framework fabrication method can reduce the learning curve, obtain satisfactory aesthetic results with few complications, and reserve a certain space for future canalplasty. Laryngoscope, 134:148-153, 2024.

Costal Cartilage Considerations: Novel Use of Handheld Ultrasound Device in Rhinoplasty.

Handheld ultrasound devices can be used in revision rhinoplasty to evaluate the calcification of costal rib cartilage that is to be harvested for grafting. This article provides instructions on how to perform this technique. Laryngoscope, 134:651-653, 2024.

Application of 3D printing in ear reconstruction with autogenous costal cartilage: A systematic review.

PURPOSE: In recent years, 3D printing technology has been employed as a production method that builds materials layer upon layer, providing notable advantages in terms of individual customization and production efficiency. Autologous costal cartilage ear reconstruction has seen substantial changes due to 3D printing technology. In this context, this research evaluated the prospects and applications of 3D printing in ear reconstruction education, preoperative planning and simulation, the production of intraoperative guide plates, and other related areas. METHODOLOGY: All articles eligible for consideration were sourced through a comprehensive search of PubMed, the Cochrane Library, EMBASE, and Web of Science from inception to May 22, 2023. Two reviewers extracted data on the manufacturing process and interventions. The Cochrane risk of bias tool and Newcastle-Ottawa scale were used to assess the quality of the research. Database searching yielded 283 records, of which 24 articles were selected for qualitative analysis. RESULTS: The utilization of 3D printing is becoming increasingly widespread in autogenous costal cartilage ear reconstruction, from education to the application of preoperative design and intraoperative guide plates production, possessing a substantial influence on surgical training, the enhancement of surgical effects, complications reduction, and so forth. CONCLUSION: This study sought to determine the application value and further development potential of 3D printing in autologous costal cartilage ear reconstruction. However, there is a lack of conclusive evidence on its effectiveness when compared to conventional strategies because of the limited number of cohort studies and randomized controlled trials. Simultaneously, the evaluation of the effect lacks objective and quantitative evaluation criteria, with most of them being emotional sentiments and ratings, making it difficult to execute a quantitative synthetic analysis. It is hoped that more large-scale comparative studies will be undertaken, and an objective and standard effect evaluation system will be implemented in the future.

Cog graft, a new septal extension graft for designing nasal tip rotation and projection in rhinoplasty.

BACKGROUND: Adjusting the nasal tip rotation and tip projection according to the patient's face and wishes is a very important stage in rhinoplasty with the use of a cog graft positioning the tip point in the appropriate place is possible by adjusting the nose length, tip projection and tip rotation together. OBJECTIVE: The aim of this study is to facilitate positioning the tip rotation and projection in the appropriate place according to the patient's needs in rhinoplasty with Cog graft. MATERIALS AND METHODS: Cog graft was applied in 32 patients who underwent rhinoplasty. Cog graft was prepared from costal cartilage in 10 patients and from septal cartilage in 22 patients. Cog graft was prepared by shaping the superior edge of the septal extension graft like a gear wheel. It is fixed to provide desired projection to the caudal septum. In the position where rotation and projection are evaluated adequately, the graft is fixed with sutures. They were followed in average 18 months (between 6 and 24 months). RESULTS: Twenty of the patients were primary cases and 12 were revision cases. The targeted rotation and projection results were achieved in all patients. All patients had satisfactory esthetic results. CONCLUSIONS: Cog graft is a useful graft with which we can adjust the nose length, projection and rotation appropriately and in a short time with a single graft.

Efficacy of hyperbaric oxygen after microtia reconstruction using costal cartilage: A retrospective case-control study.

Introduction: Microtia reconstruction with autologous costal cartilage framework grafting is challenging because the three-dimensional structure of the ear is highly complex, and meeting the high aesthetic demands of patients can be difficult. If the skin flap overlying the framework is thinned to achieve a smooth and accentuated outline, a poor blood supply in the thin skin flap may lead to skin necrosis, exposure of the framework, and poor surgical results. Hyperbaric oxygen (HBO2) therapy can promote the healing of complex wounds and flaps. This study sought to determine the effectiveness of HBO2 therapy for the prevention of postoperative complications after framework grafting in microtia reconstruction. Methods: We retrospectively evaluated postoperative complications and compared outcomes in pediatric patients who underwent costal cartilage grafting for microtia reconstruction at our institution between 2011 and 2015, according to whether or not they received postoperative HBO2 therapy. HBO2 therapy was applied once daily for a total of 10 sessions starting on the first postoperative day. Results: During the study period, eight patients received HBO2 therapy after costal cartilage grafting, and 12 did not. There was no significant difference in the incidence of postoperative ulcers. However, the incidence of framework exposure was lower, and the healing time was shorter in patients who received HBO2 therapy than in those who did not. Discussion: HBO2 therapy can be used safely in pediatric patients to reduce postoperative complications and improve the aesthetic outcome of microtia reconstruction. After costal cartilage grafting, HBO2 therapy should be considered as adjuvant therapy.

Novel "Z" Technique to Overcome Warping of Costal Cartilage.

BACKGROUND: Dorsal augmentation with costal cartilage is generally used for aesthetic rhinoplasty. However, the tendency of costal cartilage to warp may jeopardize the aesthetic outcome. OBJECTIVES: The aim of this study was to describe a new "Z" technique to overcome the warping of costal cartilage after implantation and to evaluate the efficacy of this technique in vitro. METHODS: A total of 31 pairs of porcine costal cartilage grafts (40 mm × 10 mm × 5 mm) were obtained and kept in Dulbecco's Modified Eagle Medium (Sigma-Aldrich, St. Louis, MO) to maintain cell viability. Paired grafts were obtained and randomly allocated for preparation by the accordion technique and the "Z" technique. Standardized photographs (obtained immediately after operation and at 4 weeks) were used for warping analysis. Biomechanical testing was performed to measure the graft's capacity to resist deformation by an external force. RESULTS: Cell viability of the grafts at 4 weeks was comparably good in the accordion group and the Z group (61.88% ± 4.47% vs 67.48% ± 7.03%, P = 0.55). Warping angle was comparable between the 2 groups (P > 0.01). The capacity to resist external force was significantly better in the Z group; the force needed to cause deformation was 3.98 ± 1.04 N in the Z group vs 1.61 ± 0.47 N in the accordion group in lateral view (P < 0.0001), and 1.33 ± 0.41 N vs 0.96 ± 0.24 N, respectively, in frontal view (P = 0.0013). CONCLUSIONS: The "Z" technique appears to be a simple and effective method to minimize the tendency of costal cartilage to warp after implantation.

Ear reconstruction stage I: Minor modifications in sculpting the auricle support using the 7th and 8th costal cartilages.

BACKGROUND: The verisimilitude of the reconstructed auricle and its long-term stability largely depends on the framework sculpting. This study described three kinds of minor modifications based on Firmin's way of sculpting the auricle framework and reported the clinical outcomes achieved with them. METHODS: We conducted a retrospective study of congenital microtia patients undergoing detail-improved auricular reconstruction from June 2016 to June 2020. The three kinds of minor modifications included: (1) fabricating the base frame using the 7th costal cartilage, (2) fabricating the helix and the antihelix complex using the 8th costal cartilage, and (3) fabricating the helix using the combination of the 8th and 9th costal cartilage. RESULTS: Ninety-eight patients (aged 9-27 years, 62.2% male) were included. Ninety-five patients (97.0%) adopted minor modifications 1, 2, and 3 patients (3.0%) adopted minor modifications 1, 2, and 3. All patients achieved an excellent auricle appearance and a well-laid foundation for subsequent operations. During the follow-up period, 89 patients (90.8%) were satisfied with the reconstructed auricles, 6 (6.1%) complained of hypertrophic scars in the retroauricular sulcus or pigmentation in the skin graft area, and 3 (3.1%) developed surgery-related complications. CONCLUSIONS: Three minor modifications of the auricle framework sculpting can make more satisfactory use of cartilage and adjust with the flexibility of the reconstructed auricle in different situations, making it similar to the contralateral auricle, thus, improving patients' satisfaction.

Free dermofat grafting for chest deformity in microtia reconstruction.

OBJECTIVE: Chest deformity is one of the complications that occurs after costal cartilage harvesting for auricle reconstruction. In this study, we presented a novel method of free dermofat grafting to repair cartilage defect and aimed to evaluate its effect in ameliorating chest deformity. METHODS: Seventy-six pediatric patients were included in the study, comprising free dermofat grafting group (n = 38) and control group (n = 38). After harvesting costal cartilage, empty perichondrial space of right seventh costal cartilage was filled with free dermofat grafts in free dermofat grafting group. Thoracic computed tomography (CT) was performed three months after surgery and 3D colormap quantification was performed to quantify chest surface asymmetry. The quantified data were further analyzed to compare chest asymmetry level in free dermofat grafting and control groups. RESULTS: In the free dermofat grafting group, the mean of asymmetry level was 2.2 mm. While in the control group, the mean of asymmetry was 5.7 mm. After a comparison between the two groups, the level of asymmetry showed a significant difference (p < 0.01). CONCLUSION: Free dermofat grafting method is easy to perform and a feasible option for ameliorating chest deformity in microtia reconstruction.

Hybrid Autologous Costal Cartilage Grafting for Augmentation Rhinoplasty in Asian Patients.

BACKGROUND: Autologous costal cartilage has been used for augmentation rhinoplasty in Asia for many years. This study aimed to assess the effectiveness and safety of hybrid grafting of costal cartilage for dorsal augmentation, septal reconstruction, and tip augmentation for Asian patients. METHODS: A surgical technique was introduced and patients having rhinoplasty using this technique from April 2020 to March 2021 were retrospectively studied. In this technique, costal cartilage was meticulously carved or diced and grafted in various ways mainly based on the anatomic characteristics of nasal skin and subcutaneous soft tissues as well as bone and cartilage framework. The surgical outcomes, patient satisfaction, and complications retrieved from the documented medical records were reviewed and analyzed. RESULTS: Twenty-five patients having rhinoplasty with the proposed technique were followed up from 6 months to 12 months. As for cosmetic outcomes, 21 patients were graded as good, 3 patients were graded as fair, and only 1 patient was graded as poor. Those patients who were not graded as good had over-rotated tips, insufficient dorsal augmentation, or asymmetry of nostrils and soft tissue contracture. The overall patient satisfaction was as high as 96.0%. Local infection occurred in 1 patient and hematoma was not observed. Warping and visibility of costal cartilage were not observed in any patients. Slight displacement of diced cartilages was found in 2 patients near the radix 1 week postoperatively. CONCLUSIONS: Hybrid autologous costal cartilage grafts can be used for both tip refinement and dorsal augmentation for East Asian patients and achieve an outcome of a natural-looking nose with minimal complications. LEVEL OF EVIDENCE: Level IV.

Revision Endoscopic Posterior Costal Cartilage Grafting: Is It Feasible?

The objective of this work is to examine the feasibility of revision endoscopic posterior costal cartilage graft (EPCCG) placement for posterior glottic stenosis (PGS) and bilateral vocal fold immobility (BVFI). Revision and primary cases were compared with respect to decannulation rates, and it was hypothesized that there would be no difference in outcomes. Twenty-one patients met inclusion criteria (14 primary, 7 revision). Thirteen (62%) had a primary indication of PGS, and 8 (42%) were for BVFI. There were no differences between revision and primary groups with respect to age, gender, or comorbidities (p > .05). There was no difference between groups with respect to decannulation rate (85% primary vs 100% revision, p = .32). Thus, revision EPCCG appears to have comparable results to primary EPCCG with respect to decannulation rate and time to decannulation. EPCCG may be a feasible alternative to open airway reconstruction for PGS and BVFI in selected patients.

The Ninth and Tenth Costal Cartilages Are Available and Safe Options for Rhinoplasty: A Cadaveric Anatomical Study.

SUMMARY: Some practitioners prefer the ninth costal cartilage for autogenous rhinoplasty, but few anatomical studies focus on tapering shape and harvesting safety regarding pneumothorax risk. Therefore, the authors studied the size and related anatomy of the ninth and tenth costal cartilages. Twelve fresh cadavers (24 ribs) were studied. The authors measured the length, width, and thickness of the ninth and tenth costal cartilages at the osteochondral junction (OCJ), midpoint, and tip. To evaluate safety during harvesting, the authors measured the thickness of the transversus abdominis muscle beneath the costal cartilage. The mean lengths of the ninth and tenth cartilages were 99.1 ± 25.0 and 60.6 ± 22.5 mm, respectively. The ninth cartilage was 11.8 ± 2.6, 9.0 ± 2.4, and 2.5 ± 0.5 mm wide, and the tenth cartilage was 9.9 ± 2.0, 7.1 ± 2.0, and 2.7 ± 0.5 mm wide at the OCJ, midpoint, and tip, respectively. The ninth cartilage was 8.4 ± 2.0, 6.4 ± 1.5, and 2.4 ± 0.6 mm thick, and the tenth cartilage was 7.0 ± 2.2, 5.1 ± 1.7, and 2.3 ± 0.5 mm thick at each point. For the transversus abdominis muscle, the thickness was 2.1 ± 0.9, 3.7 ± 1.0, and 4.5 ± 1.3 mm at the ninth cartilage and 1.9 ± 0.5, 2.9 ± 1.1, and 3.7 ± 1.4 mm at the tenth cartilage at each point. The size of the cartilage was sufficient for autogenous rhinoplasty. The transversus abdominis muscle provides thickness for safe harvesting. Furthermore, if this muscle is breached during cartilage harvest, the abdominal cavity is exposed, but the pleural cavity is not. Consequently, there is a very low risk of pneumothorax at this level.

Autologous Costal Cartilage With Expanded Polytetrafluorethylene (ePTFE) Implants for the Treatment of Nasal Deformity After Unilateral Cleft Lip Repair.

OBJECTIVE: To repair and reconstruct the secondary nasal deformity after unilateral cleft lip repair, we used autologous costal cartilage and expanded polytetrafluorethylene (ePTFE) to get a better nasal shape. METHOD: Nineteen patients with nasal deformity after unilateral cleft lip repair were treated from July 2018 to July 2021. During the operation, autologous costal cartilage was carved and formed and then implanted into the nasal tip and nasal columella, while the back of the nose was raised with ePTFE. RESULT: Nineteen cases were followed up for 6 to 30 months. No transplanted cartilage and swelling were exposed or discharged. The appearance was good, and the patients were satisfied. CONCLUSION: Autologous costal cartilage combined with ePTFE is an ideal treatment for nasal deformity after cleft lip repair.

Radiological and histochemical study of bone regeneration using the costal cartilage in rats.

PURPOSE: The purpose of this study was to conduct basic research on the possibility of using cartilage tissue for hard-tissue reconstruction and to observe morphological changes in the transition of the cartilage to bone. METHODS: A 4-mm diameter bone defect was created in the right mandibular angle of rats. Cartilage, autologous bone, and artificial bone were grafted into the defect. Computed tomography (CT) was performed to measure the increase in bone volume. Further histological evaluation of the grafted site was performed. RESULTS: At 12 weeks, CT show that bone formation in the costal cartilage group was comparable to that in the autogenous bone group. Histologically, in the artificial bone group, a clear boundary was observed between the existing bone and defect, whereas in the costal cartilage and autologous bone groups, laminar plate bone repair of the defect was observed. CONCLUSION: The findings in this study suggest that bone reconstruction achieved with cartilage grafting is almost equivalent to that with autogenous bone grafting and that bone reconstruction using cartilage is clinically feasible. In future, if regenerated cartilage is successfully applied clinically, bone reconstruction using regenerated cartilage may be feasible.

Analysis of the Cause of Cartilage Warping in the Rhinoplasty of Costal Cartilage and Application of Embed-In Graft in Revisional Surgery.

BACKGROUND: It is undeniable that costal cartilage is an excellent source of grafts, however it has some potential disadvantages, including a tendency to warp. There are very few studies that have examined how to resolve preexisting cartilage warping during secondary revisional surgery. OBJECTIVES: The aim of this study was to explore causes of cartilage warping other than the cartilage itself and ways to correct cartilage warping during revisional surgery. METHODS: In the present study, cases of cartilage warping in the past 5 years were retrospectively reviewed, and external factors of cartilage warping were evaluated to help design new cartilage grafts that could be employed to repair cartilage deformities. RESULTS: A total of 29 females and 3 males between the ages of 18 and 60 years participated in the study (average age, 32.5 years). In all cases, embed-in grafts were utilized to correct warping. All patients were satisfied with the results. As a result of our research, we found that another external cause of cartilage warping was the hump that was not removed completely during the initial surgery. CONCLUSIONS: Incomplete removal of the hump is a major contributing external factor to cartilage warping, particularly in the sagittal plane. This embed-in graft is not intended as a routine graft in normal circumstances, but rather as an immediate means of solving an unexpected situation. The graft is primarily for management of severely warped cartilage.

The 10th Costal Cartilage Graft in Secondary Cleft Rhinoplasty-A Versatile Rib.

Autologous costal cartilage for rhinoplasty is an excellent graft material providing both volume and quality of cartilage required for nasal reconstruction. Commonly, the 5th, 6th, 7th, and 8th rib costal cartilages have been harvested but other ribs such as the 10th rib are often overlooked and yet offer an excellent graft option for columellar, alar rim, nasal tip, and dorsal augmentation grafts. The use of the 10th rib costal cartilage in patients with complex secondary cleft nasal deformity has scant reference in the literature. We demonstrate our simple and quick 10th rib cartilage harvesting technique and elicit its use in secondary rhinoplasty and cleft lip nasal deformities. The advantages of harvesting the 10th rib cartilage and our long-term results demonstrating ease of harvest, stability, and predicable outcomes are with several clinical cases. The senior author has used the 10th rib graft successfully in a variety of challenging secondary cleft rhinoplasty procedures with excellent and consistent outcomes. We advocate the use of the 10th rib graft in such procedures as it is easy to harvest, is a dynamic cartilage graft, and offers predictable results with low levels of complications.

Improvement of Nasal Dorsal Onlay Graft Appearance after Augmentation Rhinoplasty with Costal Cartilage for Thin-Skinned Patients.

BACKGROUND: The camouflage of the nasal dorsum is very important for thin-skinned patients. In this study, the authors presented an improved method for these patients and evaluated the safety and efficacy of this method in augmentation rhinoplasty. METHODS: Fifty-two thin-skinned nose Chinese patients, ranging in age from 18 to 42 years, who underwent open augmentation rhinoplasty with modified perichondrium on dorsal onlay graft were included in the study. Among these patients, 24 of them were primary cases, and the other cases were secondary. The Rhinoplasty Outcomes Evaluation (ROE) scale and Visual aid scoring (VAS) questionnaire were used to evaluate aesthetic outcomes. RESULTS: During the long-term follow-up (ranging from 6 to 20 months), the ROE scores of each item before and after surgery were statistically significant in our study. The total scores of the preoperative and postoperative ROE scale of the study were 9.77 ± 3.18 and 20.65 ± 1.88, respectively, which indicated reasonably high satisfaction. According to the VAS questionnaire, patients' own evaluations of the nasal dorsal improvement rendered a high satisfaction rate. One case of fat liquefaction at the donor site and two cases of warping occurred and no other major complications were encountered. CONCLUSION: Covering the two edges of the graft with perichondrium on the onlay dorsal graft seems a convenient and effective method for thin-skinned augmentation rhinoplasty, which was the best choice for camouflage of the nasal dorsum in our department. 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 ."

Complications Associated with Autologous Costal Cartilage Used in Rhinoplasty: An Updated Meta-Analysis.

OBJECTIVE: To estimate the complications using autologous costal cartilage as grafts in rhinoplasty objectively and systematically with newly published literature. METHODS: The literature was searched systematically; included studies were published between July of 1990 and April of 2020. Meta-analysis was performed using a random-effects model. RESULTS: Twenty studies involving 1648 patients were included for meta-analysis. The pooled rates of complications were 3.05% of warping (95% CI 1.36-5.19%), 1.2% of resorption (95% CI 0.26-2.56%), 1.45% of infection (95% CI 0.34-3.06%), and 1.53% of contour irregularity (95% CI 0.53-2.88%). The revision rate was 2.25% (95% CI 0.96-3.9%). Regarding of donor-site morbidities, the rate of hypertrophic chest scar was 2.08% (95% CI 0.31-4.83%), and the rate of pneumothorax was 0% (95% CI 0-0.46%). The pooled rates of complications were 9.06% (95% CI 6.13-12.43%) at the recipient site when complications at the recipient site did not include revision surgery, 1.47% (95% CI 0.17-3.56%) at the donor site, and 15.13% (95%CI 11.03-19.69%) overall. The recipient-site adverse event rate was 12.44% (95% CI 8.98-16.33%). CONCLUSIONS: Warping was found the most common complication after rhinoplasty with autologous costal cartilage. Revision after rhinoplasty using autologous costal cartilage was increased in these years. Donor-site complications increased the complication rate after rhinoplasty using autologous rib cartilage by 22%. 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.