Fresh Frozen Homologous Rib Cartilage: A Narrative Review of a New Trend in Rhinoplasty.

Background: Revision rhinoplasty is a technically demanding surgical procedure that can put every surgeon in trouble. The main issue of these cases is often an altered osteocartilaginous framework following over-resection during the first intervention. Moreover, the available septal or auricular cartilage for grafting is usually not enough. This review aims to examine contemporary advances in applications of fresh frozen cartilage in rhinoplasty. Methods: A structured review of the current literature (up to December 2023) was performed on four bibliographic databases: PubMed, EMBASE, Cochrane and Medline. The search terms were combinations of "Rhinoplasty" and "Cartilage Graft", "Allograft" or "Fresh Frozen Cartilage". The citations of selected studies and review articles were also evaluated if present. Results: The research resulted in 152 articles, and only ten met the inclusion criteria: nine clinical articles and one in vitro study. One of the ten eligible articles was excluded. Conclusions: Fresh frozen rib cartilage proved to be a viable alternative to autologous rib grafts and irradiated homologous rib graft. Despite the higher costs, FFRG can provide a sufficient amount of tissue for grafting avoiding donor site complications and reducing the operative time and proved to have more chondrocytes and to be less prone to resorption compared to irradiated rib.

Use of an autologous dermal flap and rib cartilage graft in the repair of a large tracheoesophageal fistula with tracheal stenosis.

Management of large tracheoesophageal fistulas complicated by tracheal stenosis remains challenging as it requires an ideal replacement for the membranous defect as well as a permanent buttress to reconstruct the stenotic segment. We present the successful use of an autologous free dermal flap reinforced with a pedicled pectoralis major muscle to repair the tracheal membranous wall and a rib cartilage graft to enlarge the tracheal lumen.

Correction of the Overly Shortened Nose.

The overly shortened nose can often be the result of previous rhinoplasty. The causes can include weakening or missing cartilage for nasal tip support as well as contraction and scarring of the skin. The purpose of this article was to provide the authors' approach to this deformity.

Multilayered Costal Cartilage Graft for Nasal Dorsal Augmentation.

BACKGROUND: Nasal dorsal augmentation is one of the most commonly performed rhinoplasty procedures in Asia. We describe our experience with multilayered costal cartilage grafting (MCG) for dorsal augmentation in Asian patients. We aimed to evaluate the aesthetic outcomes and complications of MCG in comparison with those of one-block concentric carving costal cartilage graft (OCG) using objective and subjective assessment criteria. METHODS: Eighty-two consecutive patients who underwent dorsal augmentation with OCG (n = 39) or MCG (n = 43) by a single surgeon between November 2010 and September 2018 with > 12 months of follow-up were included in this retrospective cohort study. The aesthetic outcomes, which were determined by both anthropometric analysis and consensus decision, were compared. Patients' satisfaction and postoperative complications were also analyzed. RESULTS: Dorsal height ratios and radix height ratios increased significantly by 14.0% and 19.4%, respectively, after the OCG technique (p < 0.001) and by 13.5% and 19.0%, respectively, after the MCG technique (p < 0.001). Anthropometric comparison revealed that OCG did not show any significant differences in dorsal height ratio (p = 0.707) and radix height ratio (p = 0.856) postoperatively when compared with MCG. However, the warping rate was higher in the OCG (15.4%) than in the MCG (4.7%) group, although not significantly. There were no differences in overall patient satisfaction between the two groups. CONCLUSIONS: Dorsal augmentation with MCG produces similar aesthetic outcomes but a lower warping rate than that with OCG. The MCG technique may minimize graft warping and thus might be an effective alternative for nasal dorsal augmentation, particularly in Asian rhinoplasty. 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 .

Technical note on the harvesting of rib osteochondral autografts for upper limb bone and joint repair surgery.

Rib cartilage grafts are widely used in maxillofacial surgery, but not in orthopedic surgery. The aim of this technical note is to describe the technique used to harvest this graft and to report on donor site complications in the 136 cases we have published on up to now. Harvesting is carried out at the osteochondral junction of the eighth rib. The osteochondral junction is located under the external oblique muscle and a perichondrium layer, which is retracted to allow safe harvesting. The amount of cartilage harvested depends on the size of the area being grafted. Harvesting of a rib osteochondral graft is easy to carry out, provides a considerable amount of hyaline cartilage for the reconstruction of degenerative and traumatic lesions on a joint surface and results in few donor site complications.

Postoperative pain control by preventive intercostal nerve block under direct vision followed by catheter-based infusion of local analgesics in rib cartilage harvest for auricular reconstruction in children with microtia: A randomized controlled trial.

BACKGROUND: Children with microtia complain of severe postoperative pain during early postoperative days after rib cartilage harvest for auricular reconstruction. The purpose of this study was to evaluate the effects of preventive donor site wound analgesia by intercostal nerve block (ICNB) and catheter-based infusion of local analgesics on postoperative pain after rib cartilage graft for auricular reconstruction in children with microtia. METHODS: In this prospective randomized study, 66 children underwent postoperative pain control using either preventive ICNB followed by catheter-based infusion (33 patients, study group) or intravenous (IV) analgesia alone (33 patients, control group). ICNB was performed under direct vision by the surgeon by injecting 0.5% bupivacaine into each of the three intercostal spaces before perichondrial dissection. Catheters were placed in three subchondral spaces before wound closure, and 0.5% bupivacaine was infused every 12 h for 48 h postoperatively. Pain degrees were recorded every 4 h during the first 48 postoperative hours using a visual analogue scale. RESULTS: The study group showed significantly lower mean pain scores of the chest at rest (3.7 vs. 5.1, p = 0.001), the chest during coughing (4.3 vs. 5.8, p = 0.006), and the ear (3.0 vs. 4.1, p = 0.001) than the control group. The amount of use of rescue IV ketorolac was smaller in the study group (p = 0.026) than in the control group. No side effects related to the intervention were noted. CONCLUSIONS: Preventive ICNB followed by catheter-based infusion is effective and safe in postoperative pain relief in rib cartilage graft for auricular reconstruction. (The clinical trial registration number: WHO ICTRP, apps.who.int/trialsearch (KCT0001668)).

Correction of severe columella and tip retraction in silicone implanted Asian short noses.

BACKGROUND: Silicone Implants and other alloplastic materials are frequently used in rhinoplasty to augment Asian short noses. However, nasal deformities as a result of implant-related infections are increasing in incidence. The resulting tissue scarrings hinder the application of traditional techniques of lengthening short noses. The following paper presents a technique to correct severe postoperative retractions of the tip and columella caused by silicone implants. METHODS: We present a retrospective case study of two Asian patients with recurrent acute infections, secondary to silicone dorsum implants, leading to chronic inflammation of the tip and columella. The treatment consisted of implant removal and the immediate nasal reconstruction by combining uni- or bilateral gingivobuccal flaps along with L-shaped costal cartilage grafting. To evaluate the surgical results, various anthropometric measurements, particularly the nasal length (NL) and nasal tip projection (NTP) of pre- and postoperative profile photographs, were analyzed. RESULTS: Successful nasal lengthening and correction of columellar retraction were achieved. In case I, postoperative NTP and NL increased by 34.7% and 21.1%, respectively. In case II, NL and NTP increased by 23.8% and 10.6%, respectively. However, case II presented necrosis of the distal extremity of one gingivobuccal flap without rib graft resorption, which later healed by secondary intention. CONCLUSION: Pronounced columellar retraction in severe short noses can be successfully managed with a combination of gingivobuccal flaps along with L-shaped costal cartilage grafting. The use of autologous materials decreases the risk of long-term extrusion through the tip. The gingivobuccal flap provides vascularity to the exposed rib cartilage on the columella and prevents its resorption.

Reconstrucción de una pérdida parcial del pabellón auricular por trauma / Reconstruction of a partial traumatic auricular loss

La posición expuesta de la oreja la hace vulnerable a muchos tipos de lesiones, entre las que se encuentran los traumas. Nuestro propósito es presentar un caso clínico en el que se realizó la reconstrucción de una pérdida parcial del pabellón auricular por trauma. Acude al cuerpo de guardia del Hospital Universitario General Calixto García un paciente masculino de 42 años refiriendo haber perdido un fragmento de oreja en una riña. Se decide realizar hemostasia y fijación mediante puntos de sutura del pabellón auricular remanente a la región temporal, previa incisión en la zona. A los 3 meses del evento traumático se reevalúa con fines de realizar la planificación preoperatoria reconstructiva. Se decide la realizarla mediante injerto de cartílago costal colocado en forma de bolsillo en la región temporal. Al mes de esta última intervención quirúrgica se realiza, bajo anestesia local, la liberación de la región auricular, el avance de un colgajo temporal y la colocación de un injerto libre de piel en la cara posterior del área reconstruida. Se observa una excelente evolución posoperatoria. El paciente refirió una gran satisfacción por los resultados estéticos obtenidos. En este caso se empleó una secuencia diagnóstica y terapéutica, según elección de los cirujanos involucrados, ante un defecto traumático parcial del pabellón auricular en sus tercios superior y medio. Este tipo de secuela traumática requirió el empleo de procederes quirúrgicos en varios tiempos operatorios que garantizaran un buen aporte sanguíneo de los tejidos y adecuados resultados estéticos finales(AU)

The exposed position of the ear makes it vulnerable to many types of injuries, including traumas. It is our purpose to present a clinical case in which reconstruction was performed of a partial traumatic auricular loss. A 42-year-old male patient presents at the emergency service of General Calixto García University Hospital and reports having lost a piece of his ear in a fight. It was decided to perform hemostasis and fixation by stitching the remaining section of the auricle to the temporal region, after making an incision in the area. Three months after the traumatic event re-evaluation was conducted with a view to planning reconstructive surgery. It was decided to carry out the reconstruction placing a pocket-shaped rib cartilage graft in the temporal region. One month after the operation, auricular release, advancement of a temporary flap and placement of a free skin graft on the back of the reconstructed area were performed under local anesthesia. Excellent postoperative evolution was observed. The patient reported great satisfaction with the esthetic results obtained. The case herein presented was based on a diagnostic and therapeutic sequence of actions determined by the surgeons involved with a view to correcting a partial traumatic defect of the upper and middle thirds of the auricle. This type of traumatic sequel required the use of surgical procedures at several operative moments ensuring good blood supply to tissues and appropriate final esthetic results(AU)

Reconstrucción de una pérdida parcial del pabellón auricular por trauma / Reconstruction of a partial traumatic auricular loss

La posición expuesta de la oreja la hace vulnerable a muchos tipos de lesiones, entre las que se encuentran los traumas. Nuestro propósito es presentar un caso clínico en el que se realizó la reconstrucción de una pérdida parcial del pabellón auricular por trauma. Acude al cuerpo de guardia del Hospital Universitario General Calixto García; un paciente masculino de 42 años refiriendo haber perdido un fragmento de oreja en una riña. Se decide realizar hemostasia y fijación mediante puntos de sutura del pabellón auricular remanente a la región temporal, previa incisión en la zona. A los 3 meses del evento traumático se reevalúa con fines de realizar la planificación preoperatoria reconstructiva. Se decide la realizarla mediante injerto de cartílago costal colocado en forma de bolsillo; en la región temporal. Al mes de esta última intervención quirúrgica se realiza, bajo anestesia local, la liberación de la región auricular, el avance de un colgajo temporal y la colocación de un injerto libre de piel en la cara posterior del área reconstruida. Se observa una excelente evolución posoperatoria. El paciente refirió una gran satisfacción por los resultados estéticos obtenidos. En este caso se empleó una secuencia diagnóstica y terapéutica, según elección de los cirujanos involucrados, ante un defecto traumático parcial del pabellón auricular en sus tercios superior y medio. Este tipo de secuela traumática requirió el empleo de procederes quirúrgicos en varios tiempos operatorios que garantizaran un buen aporte sanguíneo de los tejidos y adecuados resultados estéticos finales(AU)

The exposed position of the ear makes it vulnerable to many types of injuries, including traumas. It is our purpose to present a clinical case in which reconstruction was performed of a partial traumatic auricular loss. A 42-year-old male patient presents at the emergency service of General Calixto García; University Hospital and reports having lost a piece of his ear in a fight. It was decided to perform hemostasis and fixation by stitching the remaining section of the auricle to the temporal region, after making an incision in the area. Three months after the traumatic event re-evaluation was conducted with a view to planning reconstructive surgery. It was decided to carry out the reconstruction placing a pocket-shaped rib cartilage graft in the temporal region. One month after the operation, auricular release, advancement of a temporary flap and placement of a free skin graft on the back of the reconstructed area were performed under local anesthesia. Excellent postoperative evolution was observed. The patient reported great satisfaction with the esthetic results obtained. The case herein presented was based on a diagnostic and therapeutic sequence of actions determined by the surgeons involved with a view to correcting a partial traumatic defect of the upper and middle thirds of the auricle. This type of traumatic sequel required the use of surgical procedures at several operative moments ensuring good blood supply to tissues and appropriate final esthetic results(AU)

Paravertebral Nerve Block for Donor Site Pain in Stage I Microtia Reconstruction: A Pilot Study.

Acute Interventional Perioperative Pain Service consultants have routinely placed paravertebral nerve block (PVB) catheters for the continuous release of ropivacaine following stage I microtia reconstruction with costal cartilage graft at our institution since 2010. A retrospective chart review from July 2006 was performed to compare the length of hospital stay, median pain score (0-10 scale), and opioid use of patients receiving PVB with those of historical controls. Statistical analysis included t, Mann-Whitney U, and Fisher's exact tests. A total of 15 stage I microtia surgeries were included, 10 with PVB and 5 without. Patients with and without PVB had high peak pain scores (8.4 vs 7.8), remained in the hospital for 3.5 and 3.8 days, and consumed 0.69 and 0.36 mg/kg morphine equivalents, respectively. These findings highlight the feasibility of PVB, but larger studies are needed to optimize pain relief in this population.

Harvesting Rib Cartilage in Primary and Secondary Rhinoplasty.

Satisfactory and consistent long-term results in primary and secondary rhinoplasty rely on adequately resupporting or reconstructing the nasal osseocartilagenous framework. Autogenous rib cartilage has been our graft material of choice for major nasal reconstruction when sufficient septal cartilage is not available. The rib provides the most abundant source of cartilage for graft fabrication and is the most reliable when structural support is needed.

A persistent tracheocutaneous fistula closed with two hinged skin flaps and rib cartilage interpositional grafting.

Persistent tracheal fistula after tracheostomy decannulation is a recognized sequel to long-term tracheostomy use, causing important morbidity including difficult to vocalization and control of air secretions, recurrent pulmonary infections, and cosmetic and social problems. Herein, we reported a new method for closure of persistent tracheocutaneous fistula with rib cartilages. Compared to other techniques previously reported, the variations of our strategy were the use of temporary metal-covered tracheal stent and the hinged turnover skin bi-flaps reinforced with rib cartilage grafts. Rib cartilages were useful in order to reconstruct the trachea and prevent stenosis. Since it become difficult to obtain the maintenance of the trachea stability until healing of suture was well established, a covered metallic stent was also inserted to avoid flap collapse. The stent was removed 3 months later. Six months follow-up showed normal tracheal patency.

Rib cartilage graft for posttraumatic or degenerative arthritis at wrist level: 10-year results.

Background Posttraumatic arthritides of the radiocarpal joint, secondary to scaphoid nonunion advanced collapse (SNAC), scapholunate advanced collapse (SLAC), or Kienböck disease or in cases of intraarticularmalunion of the distal radius, are classically solved by some type of arthrodesis procedure. Osteochondral grafting provides a possible motion-sparing option that can diminish pain in the active patient. Description of Technique A chondrocostal graft harvested from the ninth rib was inserted and fixed with a plate in place of the articular defect in cases of a malunited intra-articular distal radius fracture (7 cases) or to replace the proximal pole of the scaphoid in cases of SNAC or SLAC (18 cases). In Kienböck disease, the graft was inserted as a free cartilage spacer (4 cases). Results Harvesting the graft from the ninth rib had minimal morbidity without pleural injury in the reported series. Graft union was achieved in all cases of fixation. No graft resorption or necrosis were observed on X-ray and magnetic resonance imaging (MRI) evaluation at the longest follow-up of 10 years. Histological analysis performed at the time of plate removal showed the vitality of the graft. Two thirds of the patients had excellent or good results using the Green and O'Brien score. Conclusions Reconstruction of a partially destroyed articular surface using a costal graft is reliable and provides an alternative option for resurfacing the articular surface with viable cartilage.

Gender effect on the preoperative cardiovascular responses in pediatric patients undergoing two-stage ear reconstruction surgery for microtia

BACKGROUND: The hemodynamic reactions to psychological stress were different between adult genders. Our aim was to investigate the hypothesis that preoperative cardiovascular responses in children undergoing ear reconstruction surgeries will be different according to gender. METHODS: We obtained data from children, aged 7-16 years, undergoing reconstruction surgeries for microtia during 2005-2009. Number of boys receiving primarily rib cartilage graft (RCG) surgery and secondarily ear elevation procedure was 121 and 83, respectively, and girls 48 and 28, respectively. Preoperative systolic (S), diastolic blood pressure (DBP) and heart rate (HR) on each surgery were compared between genders, and within genders. RESULTS: Boys were younger than girls by one year at first and second admission. Boys showed significantly lower preoperative DBP than girls (mean difference [MD]: -3.7 mmHg, 95%CI: -6.1 to -1.3, P = 0.032) before RCG, whereas significantly higher SBP (MD: 21.5 mmHg, 95%CI: 16.6 to 26.4, P < 0.001), and DBP (MD: 10.2 mmHg, 95%CI: 6.0 to 14.4, P < 0.001) before ear elevation. Comparison between the two surgeries within the same gender indicated that boys demonstrated significantly higher SBP (P < 0.001) and DBP (P < 0.001) before ear elevation than before RCG; however SBP was comparable and DBP was significantly lower (P = 0.035) before ear elevation than before RCG in girls. CONCLUSIONS: Gender impact on the preoperative cardiovascular reactions was evident in children undergoing microtia surgery.

Complications in the Recipient Sites of Autologous Rib Cartilage Grafts for Microtia

PURPOSE: Microtia is a congenital anomaly resulting from abnormal development of the branchial apparatus. Although significant modification and improvement of operative procedures for the reconstruction of the auricle with a natural appearance have been reported, postoperative complications, such as infection, flap necrosis and deformity, still remain serious problems in patients. Many studies with long-term results have focused mainly on operative procedures for an acceptable auricular shape without consideration of possible complications. METHODS: We conducted a retrospective study on postoperative complications at the recipient sites of 183 patients who underwent auricular reconstruction with autologous rib cartilage grafts from November 1987 to January 2007 at the Division of Pediatric Plastic Surgery, Seoul National University Children's Hospital. Patients were analyzed in terms of the kinds and incidences of complications, and their treatment options. RESULTS: Postoperative complications included wound dehiscence, flap necrosis, infection, hypertrophic scar, auricular deformity and absorption of rib cartilage grafts. The complications occurred in 47 patients with a complication rate of 25.7%. Fourteen patients were successfully managed with conservative treatment. However, surgical treatment was required in 51 reoperations(33 patients) of total 329 operations. CONCLUSION: Postoperative complications at the recipient sites of autologous rib cartilage grafts occurred with relatively high incidences and required long-term treatments and multiple surgeries. The results of this study may provide information on the causes and proper management of postoperative complications as well as safe procedures for the reconstruction of the auricle.

Correction of Constricted Ear

The constricted ear was suggested by Tanzer for the purpose of obviating the confusion involving lop ear, cup ear and prominent ear as defect whose helix turns down, and scapha and fossa triangularis are narrowed. The constricted ear has a spectrum of severity and therefore, requires a graded surgical approach. Tanzer has described the degree of deformities of the constricted ear as falling into three groups. For the correction of constricted ear, there are numerous techniques but we have had difficulties in adopting these techniques in various type. We also describe the various constricted ear as the Tanzer's classification and adopted three methods to each type, banner flap(group I), concha cartilage graft (group II) and rib cartilage graft(group III) for reducing postoperative deformity and confusion in correcting the ear deformities. Constricted ear repairs must be individualized to accomodate each specific deformity. We corrected 22 cases of constricted ear in 20 patients using each optimal method described above according to the degree of deformities. Mild deformities need only reshaping and adjusting of existing tissues, moderate deformities need additional skin and severe deformities require a cartilage graft. For correction of constricted ear, accurate identification of the severity of deformity is essential. The results were satisfactory and we report our experience with relative literatures.

Nasal deformities and their treatments in the leprosy patients (I) / 나학회지

Lepra bacilli invade the nasal mucosa from early stage. The infiltrated mucous membrane breaks down and ulcerates easily. Irritating crusts and ulcers occur, creating in perforation of the septum. When most of the septum and inner mucosal lining of the nose is destroyed, the nose is deprived of its support and it collapses. The nasal bones are typically intact, and the collapsed nose adheres to the facial skeleton, giving the characteristic 'sunken and short nose' deformities. We have operated on 25 patients with deformities such as short nose, sunken nose, collumela deformity and ala collapse since 1992. In short nose we operated with a paramedian forehead flap and rib cartilage graft in a cantilever pattern. In ala collapse we used a conchal cartilage graft. Lastly, in collumela deformity we used the local flap and a composite graft.