Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose.

OBJECTIVE: In 1993, Kridel and Konior published a preliminary report (in the Archives of Otolaryngology-Head and Neck Surgery) on the use of irradiated homologous costal cartilage (IHCC) or homograft cartilage in the nose. This is a follow-up study to share our experience in answering fundamental questions: (1) What are the major long-term complications of IHCC, and are they any greater than with the use of the patient's own cartilage? (2) Is IHCC a reliable and safe implant? (3) Does IHCC resorb over time? (4) What measures are implemented in our practice to minimize the sequelae? DESIGN: We performed a retrospective review of patient medical charts in a university-affiliated private practice setting. A total of 357 patients underwent primary or revision rhinoplasty using IHCC grafts with postoperative follow-up duration ranging from 4 days to 24 years (mean [SD], 13.45 [2.83] years). A total of 1025 IHCC grafts and 373 other grafts (including 218 autogenous cartilage [AC] grafts) were used. A total of 201 grafts were dorsal onlay grafts, and 74 of them have been further followed up since the previous report. The grafts were evaluated for warping, infection, infective resorption, noninfective resorption, mobility, and extrusion. Patient satisfaction evaluation was performed in 42 patients. RESULTS: The total complication rate related to IHCC grafts was 3.25%, which included 10 warped grafts of 941 palpable or superficial IHCC grafts (1.06%), 9 infections of 1025 IHCC grafts (0.87%), 5 cases of infective resorption of 1025 IHCC grafts (0.48%), 5 noninfective resorptions of 943 palpable IHCC grafts (0.53%), and 3 cases of graft mobility of 941 palpable grafts (0.31%). Nine cases of local infection were treated and could have arisen from any of the 1025 IHCC grafts as well as from the 373 other grafts. Among the 9 cases of infection, in 2 patients IHCC grafts were used alone, and in 7 patients IHCC grafts were used in combination with other types of graft materials; therefore, the actual infection rate related to the pure use of IHCC was 2 of 1025 or 0.2%. Of the 218 AC grafts used at the same operative intervention along with IHCC grafts, 3 grafts (1.37%) underwent minimal resorption. The overall comparative resorption rates were 1.01% (IHCC) vs 1.37% (AC). The complication rate in conjunction with the use of 162 IHCC s in 53 cases of septal perforation repair was 2.46% (4 cases), including only 1 case of infection, 1 case of mobility of the graft, 1 case of warping, and 1 case of infective resorption (0.61% for all). Of the 25 AC grafts used in septal perforation cases, there were 2 cases of noninfective resorption (8%). The overall comparative complication rates in septal perforation cases were 2.46% for IHCC vs 8% for AC, which indicated a 3.25-times higher complication with the AC than with IHCC. No allergic reaction or systemic disease was reported by patients as a result of use of the IHCC. Irradiated homograft cartilage also proved to be a reliable graft in 2 patients with progressive autoimmune diseases over 2.08 years and 10 years of follow-up. The average rates of patient satisfaction increased during a mean follow-up of 7.87 years, from 91.31% to 94.18%, in 4 categories, including nasal appearance, nasal breathing, nasal symptoms, and quality of life. CONCLUSIONS: Based on careful and extensive review of the data, we have concluded that IHCC is well tolerated as a grafting material in rhinoplasty and yields superb functional, structural, and cosmetic results in the most complex and challenging operative cases necessitated by previous unsuccessful nasal surgery, septal perforations, and even in autoimmune diseases that led to nasal deformity. Not only did very few complications occur following the use of 1025 IHCC grafts in 357 patients after 386 rhinoplasties over 24 years (rate, 3.25%), but the rate of complications was no greater than rhinoplasty complication rates when AC grafts are used. The results indicate safety and reliability and justify the convenient use of IHCC grafts for primary and revision rhinoplasty without creating donor site morbidity. Irradiated homograft cartilage grafts are quite stable in the nose and maintain structural contour and support in most cases. Irradiated homograft cartilage grafts should be considered as an alternative or even a primary grafting material when the patient does not have adequate quantities of septal or auricular cartilage remaining to provide the correction or when the shape or quality of such an AC does not adequately provide the structure required. Autogenous rib cartilage is also an alternative material but also increases operative and anesthesia time and adds potential morbidity. The use of IHCC is both cost- and time-effective.

Postrhinoplasty nasal cysts and the use of petroleum-based ointments and nasal packing.

Nasal cysts are rare complications of rhinoplasty, and numerous theories exist regarding their cause. The term "paraffinoma" has been used to describe cyst formation observed after topical antibiotic ointment application with nasal packing in the immediate postoperative period. Such complications are rare but may occur because of the inherent properties of the agent used or a lack of meticulous technique (in the placement of incisions and nasal packing). Three cases of postrhinoplasty cysts with a variety of presentations, including incidental intraoperative findings, bilateral medial canthal masses, and a draining dorsal cyst, are described. Although such cysts are uncommon, techniques to prevent these unwanted sequelae should routinely be used, with the judicious application of non-petroleum-based topical antibiotic preparations.

Techniques for creating inconspicuous face-lift scars: avoiding visible incisions and loss of temporal hair.

Patients seeking rhytidectomy desire an improved neckline, jawline, and midface, but rarely at the price of signs that betray a face-lift, namely, visible incisions. We describe our face-lift incisional planning and the rationale behind specific surgical maneuvers for preventing unwanted sequelae. The telltale signs of poorly placed incisions include temporal hair loss, conspicuous scars, an unnatural appearance to the tragus, and a posterior hairline distorsion. Special considerations are given to the male patient and to the salvage of readily visible incision lines from previous surgery.

Evaluation of nasoalveolar cysts for the facial plastic surgeon.

Asymmetrical alar flare without a history of trauma, surgery, or congenital clefting is extremely rare; therefore, a thorough investigation into the underlying reasons for the asymmetry should be undertaken before a unilateral alar base resection is performed. Nasoalveolar cyst is a readily apparent diagnosis that should not be missed after proper intranasal and intraoral examination. Excision is recommended via a sublabial approach. We describe a patient in whom a unilateral alar base reduction was initially recommended, when in fact she had a nasoalveolar cyst. We also discuss the histologic characteristics, embryological pattern, and differential diagnosis.