[Rhinosurgery in children: developmental and surgical aspects of the growing nose]. / Rhinochirurgie bei Kindern: Entwicklungsphysiologische und chirurgische Aspekte der wachsenden Nase.

The anatomy of the nasal skeleton in newborns and adults are not alike. The complete cartilaginous framework of the neonatal nose becomes partly and gradually ossified during the years of growth and is more vulnerable to trauma in that period. Injury in the early youth may have large consequences for development of a nasal deformity which will increase during growth and reach its peak during and after the adolescent growth spurt. To understand more of the underlying problems of nasal malformations and their treatment (septoplasty) these items became the focus of multiple animal studies in the last 40 years. The effects of surgery on the nasal septum varied considerably, seemingly depending on which experimental animal was used. In review, however, it appeared that the very different techniques of surgery might be even more influential in this respect. Study of one of the larger series of experiments in young rabbits comprised skeletal measurements with statistical analysis and microscopic observations of the tissues. The behaviour of hyaline cartilage of the human nose appeared to be comparable to that of mammals. Cartilage, although resilient, can be easily fractured whereas its tendency to integrated healing is very low, even when the perichondrium has been saved. Also surgical procedures - like in septoplasty - may result in growth disturbances of the nasal skeleton like deviation or nasal spine. Loss of cartilage, as might occur after a septum abscess, is never completely restored despite some cartilage regeneration. In this article the many experimental studies are reviewed and compared. Still there remains a lack of real consensus in the literature concerning the developmental effects of rhinosurgry in children. Based on their observations in animals and a few clinical studies, mostly with small numbers of patients but with a long follow-up, the authors have compiled a list of guidelines to be considered before starting to perform surgery on the growing midface in children.

Subglottic stenosis after endolaryngeal intubation in infants and children: result of wound healing processes.

OBJECTIVE: To study the histopathology of subglottic stenosis in children of different ages after treatment during different periods of time, with or without laser application. Partial resection of the anterior cricoid with adhering stenotic subglottic area in the live young patient provides unique material for studying wound healing and scarring processes. METHODS: 25 specimens obtained from partial cricotracheal resection (PCTR) in children, were histologically processed and stained with Haematoxylin and Eosin, Resorcin and Fuchsin (for elastic fibers), and immunohistochemical staining (for the presence of macrophages). RESULTS: All specimens were found to have severe and sclerotic scarring with squamous metaplasia of the epithelium, loss of glands and elastic mantle fibers (tunica elastica), and dilation of the remaining glands with formation of cysts. Also, the cricoid cartilage was affected on the internal and external side, with irreversible loss of perichondrium on the inside and resorption by macrophages of cartilage on both sides. Detrimental effects of laser therapy were demonstrated in four cases. The normal intercellular matrix was completely destroyed and the number of chondrocytes in the cartilage structure diminished. CONCLUSION: Wound healing after laryngeal injury is a process of intense restoration and reorganization of the various tissues involved. This process, however, does not guarantee complete repair. In the severe cases irreversible scarring has replaced normal tissues. There seems to be no direct relationship between the length of the post-lesional period, the age of the patient and the severity of the stenosis. When subglottic stenosis has developed and the majority of the tissues is replaced by dense fibrous tissue, PCTR is strongly indicated to achieve renewed patency of the airway.

The potency of culture-expanded nasal septum chondrocytes for tissue engineering of cartilage.

Tissue engineering techniques to create extra autologous cartilage for reconstructive surgery receive more and more scientific and industrial attention. The objective of this experimental study was to assess the use of in vitro multiplied chondrocytes of the nasal septum for generation of cartilage grafts using tissue engineering techniques. Cells isolated from a biopsy of septal cartilage of rabbits and humans were expanded in culture to get a sufficient number of cells to engineer a cartilage graft. The drawback of the expansion procedure is that the cells lose their cartilaginous phenotype (dedifferentiation). We studied a method to reverse the dedifferentiation of expanded cells to stimulate them to produce cartilage matrix of good quality. Rabbit chondrocytes showed reversion of dedifferentiation (redifferentiation) when fetal calf serum was replaced by the growth factors IGF1 and TGFbeta2. This was expressed by increased glycosaminoglycan synthesis and increased numbers of collagen type II-producing cells. The redifferentiation capacity of septal cartilage cells of young rabbits was higher than that of adult rabbits. In human chondrocytes from the nasal septum redifferentiation could also be induced by replacement of serum with IGF1 and TGFbeta2. This method, however, was less efficient than in rabbits. Chondrocytes of older patients (>40 years old) were no longer sensitive to the growth factor treatment. In conclusion, our study demonstrates a method to regain cartilage phenotype in multiplied cells of nasal septum cartilage needed for tissue engineering of new cartilage. These results are promising for this technique to generate cartilage grafts for facial plastic surgery of the nasal septum.

Growth factor expression in cartilage wound healing: temporal and spatial immunolocalization in a rabbit auricular cartilage wound model.

OBJECTIVE: The ability of cartilage to regenerate following injury is limited, potentially leading to osteoarthritis. Integrative cartilage repair, necessary for durable restoration of cartilage lesions, can be regarded as a wound healing process. Little is known about the effects of growth factors regulating acute cartilage wound healing in vivo. In this study the temporal expression patterns of growth factors and proteoglycan content in cartilage wound edges in vivo were studied. DESIGN: Cartilage wounds were created in rabbit ear cartilage using a 6 mm biopsy punch. Specimens were subsequently harvested 1, 3, 7, 14 and 28 days after surgery. Paraffin sections were thionin stained to visualize proteoglycan loss and replacement. Immunohistochemical staining of TGFbeta1, TGFbeta3, IGF-1, IGF-II and FGF-2 was used to define growth factor expression at the cartilage wound sites. RESULTS: Almost no effect of cartilage wounding was observed one day after surgery. A decrease of proteoglycan content, with a maximal loss at day 7, and a subsequent restoration was observed at the wound edges. Growth factor expression increased simultaneously. Maximal immunostaining for IGF1, IGFII, FGF2 and TGF-beta3 was observed at day 7, followed by a gradual decrease. Increased expression of TGFbeta1 lasted from day 3 until day 14. CONCLUSION: We have demonstrated the ability of chondrocytes to increase growth factor expression and to restore the rapid decrease in proteoglycan content in the initial phase following acute wounding. A temporal increase in intracellular growth factor expression suggests an autocrine and/or paracrine metabolic stimulation, which can be regarded a sign of chondrocytes repair capacity.

A new in vivo model for testing cartilage grafts and biomaterials: the 'rabbit pinna punch-hole' model.

In this study an animal model was developed for evaluation of the feasibility of cartilage grafts. In the cartilage of the external ear of the rabbit multiple holes, 6 mm in diameter, were punched, leaving the adherent skin intact. Different experimental groups were evaluated. First, the punch-hole model was validated under various conditions to study spontaneous or perichondrial initiated regeneration of the cartilage defect. When both cartilage and perichondrium was excised no spontaneous repair of the cartilage defect was observed. When perichondrium is present, variable patch-like closure of the punch hole was found. As 'golden standard' a punched out piece of cartilage was reimplanted directly. This condition showed adequate closure of the punch hole, however, no perfect integration of graft and surrounding cartilage was observed. Secondly, to evaluate the 'punch-hole model' a biomaterial, trabecular demineralized bovine bone matrix (DBM), was implanted and tested as a scaffold for tissue engineering techniques in vivo and in vitro. Direct implantation of DBM did not lead to any cartilage formation to close the defect. In vivo engineered cartilage, generated by enveloping DBM in perichondrium for 3 weeks, could adequately close the punch hole. When DBM was seeded with isolated chondrocytes in vitro before implantation in the defect, a highly fragmented graft, with some islets of viable cells was seen. To promote an efficient and reliable evaluation of cartilage grafts a semi-quantitative grading system was developed. Items such as quality, quantity and integrity of the cartilage graft were included in a histomorphological grading system to provide information about the properties of a specific cartilage graft. To validate the grading system, all conditions were scored by two independent observers. An excellent reliability (R = 0.96) was seen between the observers. In summary, the rabbit pinna punch-hole model is a reliable and efficient method for first evaluation of cartilage grafts. The results can be easily analyzed using a semi-quantitative grading system.

In vitro redifferentiation of culture-expanded rabbit and human auricular chondrocytes for cartilage reconstruction.

To construct an autologous cartilage graft using tissue engineering, cells must be multiplied in vitro; they then lose their cartilage-specific phenotype. The objective of this study was to assess the capacity of multiplied ear chondrocytes to re-express their cartilage phenotype using various culture conditions. Cells were isolated from the cartilage of the ears of three young and three adult rabbits and, after multiplication in monolayer culture, they were seeded in alginate and cultured for 3 weeks in serum-free medium with insulin-like growth factor 1 (IGF-1) and transforming growth factor-beta2 (TGF-beta2) in three different dose combinations. As a control, cells were cultured in 10% fetal calf serum, which was demonstrated in previous experiments to be unable to induce redifferentiation. Chondrocytes from the ears of young, but not adult, rabbits, synthesized significantly more glycosaminoglycan when serum was replaced by insulin-like growth factor-1 and transforming growth factor-beta2. The number of collagen type II-positive cells was increased from 10 percent to 97 percent in young cells and to 33 percent in adult cells. Using human ear cells from 12 patients (aged 7 to 60 years), glycosaminoglycan synthesis could also be stimulated by replacing serum with insulin-like growth factor and transforming growth factor-beta. Although the number of collagen type II-positive cells could be increased under these conditions, it never reached above 10 percent. Data from five patients showed that further optimization of the culture conditions by adding ITS+ and cortisol significantly increased (doubled or tripled) both glycosaminoglycan synthesis and collagen type II expression. In conclusion, this study demonstrates a method to regain cartilage phenotype in multiplied ear cartilage cells. This improves the chances of generating human cartilage grafts for the reconstruction of external ears or the repair of defects of the nasal septum.

Langerhans cell histiocytosis of the larynx.

A pediatric case of Langerhans cell histiocytosis leading to severe and recurrent subglottic stenosis, ultimately necessitating partial cricotracheal resection, is presented and the literature on this very rare disorder is briefly reviewed.

Fixation-dependent immunolocalization shift and immunoreactivity of intracellular growth factors in cartilage.

The effects of fixation on immunolocalization and immunoreactivity in cartilage tissues were studied using monoclonal antibodies against peptides that can effectively stimulate chondrocytes in vitro and have been shown to play a role in musculoskeletal tissue regeneration: transforming growth factor beta1, transforming growth factor beta3, insulin-like growth factor I, insulin-like growth factor II and fibroblast growth factor 2. Paraffin sections fixed in buffered formalin, buffered paraformaldehyde, Carnoy and methacarn, as well as cryosections, were tested. A strong immunoreaction was observed in tissue fixed in formaldehyde-based fixatives, with a resemblance to that in cryopreserved tissues. Immunoreactivity was reduced in alcohol-fixed tissues. Furthermore, a striking intracellular immunolocalization shift from cytoplasm to nucleus was observed using alcohol-based fixatives as compared to cryopreserved or formaldehyde-based fixatives. We concluded that, for the detection and localization of growth factors in cartilage tissues, fixation in buffered formalin or paraformaldehyde is optimal.

Chondrogenic potential of in vitro multiplied rabbit perichondrium cells cultured in alginate beads in defined medium.

Perichondrium has a chondrogenic capacity and is therefore a candidate tissue for engineering of cartilage in vitro. Donor age and culture conditions probably influence chondrogenesis. The aim of this study was to compare the chondrogenic capacity of ear and nasal perichondrium from young and adult rabbits, using serum containing and serum-free culture conditions. This study demonstrates that more than 1 million cells can be generated out of 1 cm(2) of perichondrium tissue in 3-5 weeks of culture, irrespective of age. Culturing of these cells in alginate in medium with 2, 10, or 20% fetal calf serum did result in the production of small amounts of glycosaminoglycan, but no collagen type II was demonstrated. When serum was replaced however by insulin-like growth factor-1 (IGF-1) (10 ng/mL) plus transforming growth factor-beta2 (TGF-beta2) (10 ng/mL) an increased glycosaminoglycan production and induction of collagen type II was found, especially in cells isolated from perichondrium of the ear. Cells derived from perichondrium of young rabbits showed larger chondrogenic potential than cells from perichondrium of adult rabbits. Moreover, stimulation of both glycosaminoglycan synthesis and collagen type II production was about five times higher in cells isolated from the ear perichondrium of young rabbits than of adult rabbits. We conclude that young auricular perichondrium seems a useful source of cells for tissue engineering of cartilage when cultured in serum-free medium in combination with IG-F1 and TGF-beta2.

Tissue-engineered cartilage using serially passaged articular chondrocytes. Chondrocytes in alginate, combined in vivo with a synthetic (E210) or biologic biodegradable carrier (DBM).

In vitro multiplication of isolated autologous chondrocytes is required to obtain an adequate number of cells to generate neo-cartilage, but is known to induce cell-dedifferentiation. The aim of this study was to investigate whether multiplied chondrocytes can be used to generate neo-cartilage in vivo. Adult bovine articular chondrocytes, of various differentiation stages, were suspended in alginate at densities of 10 or 50 million/ml, either directly after isolation (P0) or after multiplication in monolayer for one (P1) or three passages (P3). Alginate with cells was seeded in demineralized bovine bone matrix (DBM) or a fleece of polylactic/polyglycolic acid (E210) and implanted in nude mice for 8 weeks. The newly formed tissue was evaluated by Alcian Blue and immunohistochemical staining for collagen type-II and type-I. Structural homogeneity of the tissue, composed of freshly isolated as well as serially passaged cells, was found to be enhanced by high-density seeding (50 million/ml) and the use of E210 as a carrier. The percentage of collagen type-II positive staining P3-cells was generally higher when E210 was used as a carrier. Furthermore, seeding P3-chondrocytes at the highest density (50 million/ml) enhanced collagen type-II expression. This study shows promising possibilities to generate structurally regular neo-cartilage using multiplied chondrocytes in alginate in combination with a fleece of polylactic/polyglycolic acid.

Pediatric otorhinolaryngology in Europe.

Nowadays Europe encompasses more than 30 countries. These countries differ in climate, in culture, in population density, in history, in socio-economic system and in the organization of medical care. Despite these differences there is a general trend of unification in politics, in industry and in science. In the field of medicine, medical faculties and professional organizations try to harmonize medical curricula and training programmes for medical specialists.

The role of trabecular demineralized bone in combination with perichondrium in the generation of cartilage grafts.

The use of a composite graft of bovine trabecular demineralized bone matrix (DBM) and perichondrium has been found a reliable method for in vivo generation of cartilage. In the present study, the mechanism whereby this commercially available matrix increases cartilage formation was investigated. First, the time course of cartilage formation in vivo, in the combined implant of perichondrium and DBM in the rabbit ear was studied, with special focus on tissue reactions to DBM. DBM was colonized by macrophages from day 3 post-operatively, reaching a maximum after 2 weeks. Only a minimal number of neutrophils was found. After 3 weeks the DBM appeared to be resorbed. In the first week the DBM was invaded with chondroblasts, and chondrogenesis occurred between the first and second week of implantation. After 3 weeks, the initially formed islets of cartilage had fused. Next, the chondrogenic capacity of DBM itself was investigated by implantation of DBM without perichondrium. This never resulted in cartilage formation. Immunohistochemistry showed only a faint staining of the DBM for growth factors. This indicates a minimal chondrogenic effect of DBM alone and the requirement of perichondrium as cell provider. In order to define the conditions which cause chondrogenesis in composites of perichondrium and DBM, a series of in vitro culture experiments was performed in which the in vivo situation was mimicked step by step. The basic condition was perichondrium cultured in medium with 10% FCS. In this condition, cartilage formation was variable. Because in the in vivo situation both DBM and macrophages can release growth factors, the effect of IGF1, TGFbeta2 or OP1 added to the culture medium was tested. Neither the incidence nor the amount of cartilage formation was stimulated by addition of growth factors. Perichondrium wrapped around DBM in vitro gave cartilage formation in the perichondrium but the incidence and amount were not significantly stimulated compared to cultures of perichondrium without DBM. However, cartilage-like cells were found in the DBM suggesting an effect of DBM on perichondrium-derived cells. Finally, macrophages and/or blood were added to the composite DBM-perichondrium to mimic the in vivo situation as close as possible. However, no effect of this treatment was found. In conclusion, this study indicates that DBM itself has few chondrogenic qualities but functions merely as a spacer for cell ingrowth. The fast resorption of DBM by macrophages in vivo seems of importance for the cartilage forming process, but in vitro the presence of macrophages (in combination with blood) could not enhance chondrogenesis.

Effect of transforming growth factor-beta on proteoglycan synthesis by chondrocytes in relation to differentiation stage and the presence of pericellular matrix.

The effects of transforming growth factor-beta (TGF-beta) on proteoglycan synthesis of chondrocytes are controversial. The hypothesis that the differential effect of TGF-beta is related to the differentiation stage of the chondrocytes is investigated in this study. Rabbit auricular chondrocytes were cultured in alginate. When seeded in alginate immediately after isolation, cells keep their cartilaginous phenotype. When cells are first cultured in monolayer, they lose their cartilaginous phenotype and become dedifferentiated. We used three different cell populations: (1) Differentiated cells (P0: immediately after isolation); (2) partially (de)differentiated cells (P1: after one passage in monolayer); (3) dedifferentiated cells (P4: after four passages in monolayer). Cells were characterized by morphology using electron microscopy, amount of proteoglycans using the Farndale assay and type of collagen produced using immunohistochemistry. The effects of addition of 10 ng/ml TGF-beta2 for 7 days to P0, P1 and P4 cells were compared. TGF-beta was added either directly from the start of the alginate culture, or after a preculture period of three weeks in alginate. The amount of proteoglycans was increased in all chondrocyte populations when TGF-beta was added immediately after seeding in alginate, indicating that the effect of TGF-beta on proteoglycan synthesis does not depend on the differentiation stage of cells. After preculture in alginate, stimulation of proteoglycan synthesis (as measured by amount of proteoglycans and 35S-sulfate incorporation) had vanished. This effect was independent of differentiation stage . A dose-response experiment with TGF-beta (1, 10, 50 ng/ml) confirmed this differentiation-stage-independent effect of TGF-beta on proteoglycan synthesis. Stimulation by TGF-beta can be retained after enzymatic digestion of the pericellular matrix and reseeding of the cells in alginate, indicating the importance of pericellular matrix for the effect of TGF-beta on matrix synthesis. Alkaline phosphatase (ALP) activity was largely inhibited by TGF-beta in P0 chondrocytes, either with or without preculture in alginate. After culturing in monolayer, ALP activity was not substantially changed by TGF-beta. This indicates that the effect of TGF-beta on ALP activity, in contrast to the effect on proteoglycan synthesis, does depend on the differentiation stage of the cells. Furthermore, the fact that ALP synthesis in P0 cells is still inhibited by TGF-beta after preculture indicates that these cells remain responsive to TGF-beta. This provides additional evidence for the importance of the pericellular matrix for regulation of the effect of TGF-beta on proteoglycan synthesis. The results indicate that, in pathological cartilage, matrix depletion might be the trigger for increased matrix synthesis in reaction to TGF-beta, suggesting an important role for TGF-beta in cartilage repair.

Efficacy of perichondrium and a trabecular demineralized bone matrix for generating cartilage.

A pedicled auricular perichondrial flap wrapped around trabecular demineralized bovine bone matrix can generate an autologous cartilage graft. In earlier experimental studies, it was demonstrated that this graft could be used for nasal and cricoid reconstruction. It was assumed that the vascularization of the perichondrial flap was obligatory, but it was never proven that the flap should be pedicled. Moreover, for clinical use, the dimensions of the auricle would set restrictions to the size of the graft generated. Therefore, the possibility to generate cartilage with a composite graft of a free perichondrial flap wrapped around demineralized bovine bone matrix, by using young New Zealand White rabbits, was studied. This composite graft was implanted at poorly (subcutaneously in the abdominal wall; n = 12), fairly (subcutaneously in the pinna; n = 12), and well-vascularized sites (quadriceps muscle; n = 12). As a control, trabecular demineralized bovine bone matrix was implanted without perichondrial cover. Half of these grafts (n = 6) were harvested after 3 weeks, and the remaining grafts (n = 6) after 6 weeks of implantation. In histologic sections of these grafts, the incidence of cartilage formation was scored. Furthermore, the amount of newly formed cartilage was calculated by computerized histomorphometry. Trabecular demineralized bovine bone matrix without perichondrial cover demonstrated early resorption; no cartilage or bone was formed. In demineralized bovine bone matrix wrapped in perichondrium, early cartilage formed after 3 weeks at well- and fairly vascularized sites. No cartilage could be detected in grafts placed at a poorly vascularized site after 3 weeks; minimal cartilage formed after 6 weeks. In summary, the highest incidence of cartilage formed when trabecular demineralized bovine bone matrix was wrapped either in a pedicled auricular perichondrial flap or in a free perichondrial flap, which was placed at a well-vascularized site. Second, a significantly higher percentage of the total area of the graft was cartilaginized at well-vascularized sites after 3 weeks. The newly generated cartilage contained collagen type II and proteoglycans with hyaluronic acid binding regions, whereas collagen type I was absent, indicating the presence of hyaline cartilage. This study demonstrates that new cartilage suitable for a graft can be generated by free perichondrial flaps, provided that the site of implantation is well vascularized. Consequently, the size of such a graft is no longer limited to the dimensions of the auricle.

Wound healing of cartilage structures in the head and neck region.

This study was performed to determine the various processes involved in the behaviour of hyaline cartilage during the wound healing period after trauma or surgery of vulnerable structures like the nasal septal cartilage and the cricoid. The results of different procedures (perpendicular and parallel to the cartilage surface) in young and young-adult animals were analyzed: septal incision at different locations (young-old), cricoid split (young-old), suturing cartilage, closing defects with autologous cartilage (young), biomaterials (young) and newly engineered cartilage in 4- and 24-week-old rabbits (series of ten animals). Cartilage of the young rabbit and child have similar hyaline cartilage with a varying distribution in thickness. Thinner areas are more susceptible to malformations. Incisions through younger cartilage give rise to some new cartilage formation covered by a new layer of perichondrium: through older, differentiated cartilage the incision causes superficial but permanent necrosis. Edges of cut cartilage mostly do heal by formation of fibrous junctions. This forms a weak spot, sensitive to deviations. The same fate goes for the healing between the autologous graft and the surrounding pre-existent cartilage. Trauma parallel to the surface, leads to inconsistent quantity of neocartilage. With ageing the wound healing and regenerative capacities decrease. In general, biomaterials are less accepted by the surrounding tissues and would impede further growth. Only newly engineered, and thus less differentiated (younger) cartilage of hyaline nature, appeared to be well accepted at the interface with the edges of a cartilage defect. There are indications that the release of growth factors might play a role in cartilage wound healing. In the child as well as the adult, wound healing of hyaline cartilage structures is incomplete, and surgery remains 'experimental' surgery. The clinical implications of gradual loss of the regenerative capacity of hyaline cartilage should be further investigated.

The immediate effects of local trauma on the shape of the cricoid cartilage.

Injury-induced abnormal development of the cricoid ring has been demonstrated in previous growth studies. In this study we focused on the immediate effects of various types of lesions to the cricoid, eliminating the influence of inserting muscles. In isolated, vital cricoids (cricoid explants) the anterior arch was split, creating a small gap between the cut ends. Previous injury to the internal surface of the cricoid ring resulted in a three to four fold increase of the diameter of the gap, actually widening the interrupted cricoid. On the contrary, injuring the external surface of the cricoid cartilage prior to anterior cricoid split, leads to an overlap of the cut edges, and a narrowing of the ring. These injury-specific changes in shape of the cricoid ring are ascribed to the release of interlocked stresses, present in the cartilage. It is suggested that the demonstrated methods to change the shape of the cricoid ring in a predictable way, are relevant for the treatment of patients with cricoid malformation.

Induction in vivo of cartilage grafts for craniofacial reconstruction.

In the craniofacial region, defects of cartilage structures are preferably reconstructed with autologous cartilage. Donor-site morbidity related to the creation of a new defect elsewhere, and a lack of growth potential of the graft--mandatory in children--have stimulated investigators to find other ways to generate new "extra" cartilage. Several biomaterials have been tested as a matrix for the ingrowth of (peri)chondroblasts in experimental animals. In young (growing) rabbits we have developed a process of heterotopic cartilage induction with the use of a demineralized (bovine) bone matrix which is enfolded in a pedicled flap of ear perichondrium for at least three weeks. During this period the demineralized matrix is colonized by macrophages and polymorphonuclear cells which start a process of complete biodegradation of the material. Simultaneously, the collagen matrix is invaded by mesenchymal cells, originating from the perichondrium and differentiating into chondroblasts and later, into chondrocytes forming the intercellular substance. The developing, very young cartilage could be demonstrated as collagen type II, thus, hyaline cartilage. When applied with its adherent perichondrium as a graft, it merges easily with the more matured host cartilage and even appears to be capable of further growth. Therefore, it seems suitable for the reconstruction of a cartilaginous defect in growing cartilaginous structures like the nasal septum or the larynx.