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Rhinoplasty has grown and developed over so many years but the choice of the graft material in revision rhinoplasty and rhinoplasty for post-traumatic cases still remains debatable. In such patients, non-availability of adequate autogenous graft, multiple septal fractures and skin fibrosis are a challenge to the rhinologist. To deal with this problem authors have used diced cartilage pieces as a grafting material. Secondary rhinoplasty for correction of the nasal dorsum was done in 32 patients and evaluated. The study, highlights the distinct advantages of using diced cartilage wrapped in fascia for dorsal augmentation. Full length grafts were used in all patients and this was supported on a L-shaped cartilage fixed between the two upper lateral cartilage. Fascial tube was prepared from fascia lata and conchal, rib or septal cartilage was the source of diced cartilage (0.5–1 mm sized pieces). The L-shaped structural support was prepared from the remnant of septal cartilage if any or from the conchal or rib cartilage. Patients were followed for a period of 6 months–3 years. In 30 patients post-op course was uneventful with good reconstruction results. Step-deformity was encountered in one patient and in another patient the tube opened with extrusion of diced cartilage pieces. Both these patients were effectively managed. In conclusion, diced cartilage wrapped in fascial tube has distinct advantages like it is simpler procedure and graft material is adequate and autogenous. Grafts can be prepared as per the desired length, shape and size to fit the specific defect. These being highly malleable can be used without any tension on the already thickened and fibrosed skin and soft tissue. Complications like step deformity and extrusion rarely occur and can be easily managed. Over correction and graft visibility were not met with.
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ORIGINAL ARTICLE
Diced Cartilage: An Effective Graft for Post-Traumatic
and Revision Rhinoplasty
Brajendra Baser Shenal Kothari Manya Thakur
Received: 8 February 2012 / Accepted: 14 February 2012 / Published online: 25 February 2012
ÓAssociation of Otolaryngologists of India 2012
Abstract Rhinoplasty has grown and developed over so
many years but the choice of the graft material in revision
rhinoplasty and rhinoplasty for post-traumatic cases still
remains debatable. In such patients, non-availability of
adequate autogenous graft, multiple septal fractures and
skin fibrosis are a challenge to the rhinologist. To deal with
this problem authors have used diced cartilage pieces as a
grafting material. Secondary rhinoplasty for correction of
the nasal dorsum was done in 32 patients and evaluated.
The study, highlights the distinct advantages of using diced
cartilage wrapped in fascia for dorsal augmentation. Full
length grafts were used in all patients and this was sup-
ported on a L-shaped cartilage fixed between the two upper
lateral cartilage. Fascial tube was prepared from fascia lata
and conchal, rib or septal cartilage was the source of diced
cartilage (0.5–1 mm sized pieces). The L-shaped structural
support was prepared from the remnant of septal cartilage
if any or from the conchal or rib cartilage. Patients were
followed for a period of 6 months–3 years. In 30 patients
post-op course was uneventful with good reconstruction
results. Step-deformity was encountered in one patient and
in another patient the tube opened with extrusion of diced
cartilage pieces. Both these patients were effectively
managed. In conclusion, diced cartilage wrapped in fascial
tube has distinct advantages like it is simpler procedure and
graft material is adequate and autogenous. Grafts can be
prepared as per the desired length, shape and size to fit the
specific defect. These being highly malleable can be used
without any tension on the already thickened and fibrosed
skin and soft tissue. Complications like step deformity and
extrusion rarely occur and can be easily managed. Over
correction and graft visibility were not met with.
Keywords Diced cartilage Revision rhinoplasty
Fascia lata
Introduction
Patients report to rhinoplastic surgeons for varied com-
plaints like visible nasal deformity or nasal blockage.
Reconstruction of the dorsum is difficult and requires good
pre-op planning, intra-op implementation and post-op care.
Open and closed rhinoplasty along-with different grafting
technique (classical en-bloc cartilage/osseous dorsal aug-
mentation) and osteotomy techniques have been judi-
ciously used in primary rhinoplasty but their role in
secondary rhinoplasty is debatable. The rhinoplasty tech-
nique has grown all these years to come to present form
where we have started using diced cartilage with or without
fascia in various ways and overcome the problem of non-
availability of adequate graft material. These grafts are,
autogenous and fresh therefore more viable [1], sometimes
even leading to fresh bone formation. They are easy to
prepare and need not be freezed.
Surgical Steps
The operation is begun as an open rhinoplasty. The dorsal
skin flap is dissected and raised to analyse the intra-op
This manuscript has nor been published anywhere neither it has been
presented at any meeting.
B. Baser (&)S. Kothari M. Thakur
Department of E.N.T, SAIMS Medical College, Indor-Ujjain
State Highway, Bhanwarsala, Sanwer Road, Indore, India
e-mail: baserbv@gmail.com
123
Indian J Otolaryngol Head Neck Surg
(August 2013) 65(Suppl 2):S356–S359; DOI 10.1007/s12070-012-0525-6
nasal anatomy and surgical plan is readdressed. Following
points are to be considered—obtain fascia lata, obtain
cartilage (and dice it), prepare fascial bag as per the mea-
sure, fill the diced cartilage in the fascial bag and finally
use this for filling the defect by placing it on a L-shaped
cartilaginous support between the two upper lateral carti-
lage. This method can effectively augment up to a height of
1–8 mm of any length and shape.
1. Raising the dorsal skin flap.
2. Obtain fascia lata: Lateral side of one of the thighs is
prepared by shaving, painting and draping. About 2
inches long skin incision is given and deepened to the
fascia. This is freed from the overlying and underlying
soft tissue. A 2 92 inches (or bigger for larger
defects) area of fascia lata is taken out and teased off
the fibrous tissue.
3. Obtain cartilage: The pinna (one or both) is prepared.
The outline of the conchal eminence is marked with
the help of 26 gz. needles. An incision is made along
this line and deepened up to the perichondrium. This is
elevated and the cartilage harvested by separating it
from underlying perichondrium. This is cut into small
pieces (diced cartilage) with a 11 no. surgical blade
(Fig. 1). These are filled in a tuberculin syringe and
kept on one side.
4. Prepare fascial bag: The sheet of fascia is spread
around the tuberculin syringe and two opposite borders
stitched together and then the base sewed to prepare a
bag open at one end. Now, the plunger of the syringe is
withdrawn while pushing the diced cartilage filled
previously in the syringe (Fig. 2). Thus a malleable
pillow of diced cartilage is formed ready to be used for
desired augmentation.
5. Placing the diced cartilage pillow: An L-shaped
support is created from the septal cartilage remnant
and the cartilage bag placed between the two upper
lateral cartilage into the desired recipient pocket after
measuring (Fig. 3) and preparing it to the desired
shape and size.
6. Finally the skin is closed and plaster cast applied.
In this way the diced cartilage graft sits onto the desired
site and possibility of palpability is also avoided by use of
fascia.
Discussion
The idea of grafting diced cartilage pieces in rhinoplasty
especially for revisions has stood the test of time for last
5–7 decades. Their utility in rhinoplasty has been studied
and highlighted by various authors [24]. The use of diced
cartilage chopped into 0.5–1 mm pieces was first intro-
duced by Peer [5] and then popularised by Erol [6]. It is
probably the best of fillers available to camouflage various
forms of nasal defects like that at radix, half length, full
length, peri-pyriform, infra-lobule or lateral nasal wall. The
results in secondary rhinoplasty have dramatically
improved ever-since the use of diced cartilages as it can be
used in various forms—freely or along-with fascia or sur-
gical. It survives as living tissue, is seldom resorbed and
doesn’t stimulate immune response [79]. Uncorrected
deficiencies above dorsal hump from previous osteotomies
or fractures are corrected more aesthetically. Ease of
insertion and malleability is a big advantage with use of
diced cartilage. Moreover, over corrections and under-
corrections are predictable as the graft remains mobile for
almost 2 weeks. Some authors have advocated use of
autogenous soft tissue like temporalis fascia [10] and der-
mal grafts [11] for covering dorsal irregularities.
Fig. 1 Dicing the cartilage into 1–2 mm pieces
Fig. 2 a Filling the fascial tube
with diced cartilage,
bGradually withdrawing the
syringe while filling it
Indian J Otolaryngol Head Neck Surg (August 2013) 65(Suppl 2):S356–S359 S357
123
At times the radix grafts become visible, therefore it is
best to use full length grafts as we have used in all our
patients. Also, in this way we can at best avoid supratip
deformities. Just as in all other studies none of our patients
had post-op warping or malalignment. Further extrusion or
graft resorption is also avoided, the graft being autogenous.
It is to be learnt that the graft prepared inside the fascial
sleeve needs to be placed in the exact desired area where
the graft must stay. These need not be over-corrected as the
diced cartilages do not resorb. Over corrections if at all
encountered can be dealt with pituitary rongeur or if small
enough covered with fascia. However, the revision cases in
this study were free of any such complications.
The fascial sleeve may be prepared from temporalis
fascia or the fascia lata, later was used for all the cases
included in this study. This procedure is simple, quick and
aesthetically superior. Cartilage can be obtained from rib
cartilage or septal cartilage or the concha. All cases
included in this study were grafted with conchal or rib
cartilage. It is easy to harvest and large enough to prepare
as big dorsal constructs as required to reconstruct full
length larger defects also. Septal cartilage may not be
enough to fill larger defects in revision cases or in post-
traumatic cases wherein there is loss of tissue. Rib cartilage
harvesting is difficult and may leave a big scar or pneu-
mothorax or persistent pain.
Although cartilage has been used freely or under fascial
cover or wrapped in fascial tube, all revision cases in this
study underwent grafting with fascial tube filled with diced
conchal cartilage. It is possible to combine these grafts
with solid rib grafts, dorsal struts or columellar support.
The author here have supported the wrapped diced carti-
lage on L-shaped septal support fixed between the two
upper lateral cartilages. Some investigators [12] have
implanted diced cartilage into prepared tissue pockets by
syringing the graft material through small incisions.
Careful note was taken to prepare a tight pocket so that
perfect contouring could be achieved. All revision cases
had good post-op results. Two cases had post-op compli-
cation one in the form of opening of the tube spilling out of
the diced cartilage pieces (cleft lip) and other with a radix
graft had a step deformity. Both these cases were handled
effectively and were uneventful later. Step deformities are
more identifiable in thin skinned population.
To summarize, in cases with thickened skin, scars and
fibrosis the pocket for placing the graft is very tight and
therefore a more malleable graft is required for correction
Fig. 3 Measuring and preparing the desired shape and size of the
cartilage pillow
Fig. 4 1 Pre-op. and 2 Post-op. afront view, bbasal view, cside view
S358 Indian J Otolaryngol Head Neck Surg (August 2013) 65(Suppl 2):S356–S359
123
in these patients. Moreover, stretching and skin necrosis is
known with use of bone grafts in such cases, which again
can be avoided with diced cartilage technique. Further
osseous tissue may undergo ossification and harden, it can
wrap and curl over a period of few years.
To conclude, the technique of using diced cartilage is
definitely advantageous in cases with multiple septal frac-
tures (post-traumatic) or in cases when the graft material is
inadequate or when there thickening of the skin (revision or
trauma). Revision is possible as early as 2 months after the
previous surgery, which may otherwise will have to be
delayed for as long as 6 months. The postoperative results
are very good as can be seen in Figs. 4and 5.
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Fig. 5 1 Pre-op. and 2 Post-op. afront view, bbasal view, cside view
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123
... They reported proper maintenance of the graft without evidence of graft absorption. In the same field, Baser et al. used diced cartilage wrapped in fascia lata in 32 revision rhinoplasty cases, in which they highlighted the distinct advantages of that composite graft in augmenting the nasal dorsum 19 . These advantages were that the grafts were simple, autogenous, and readily malleable to compensate for dorsal defects of various sizes and positions. ...
... These advantages were that the grafts were simple, autogenous, and readily malleable to compensate for dorsal defects of various sizes and positions. Moreover, they reported that over-correction and under-correction were manageable, as the graft could remain mobile for almost 2 weeks postoperatively; gentle digital manipulation of the nasal dorsum followed by steri-strip application for 1 week could be used to maintain the desired nasal profile 19 . Jang et al., as well as other authors, investigated the use of Tutoplast-processed fascia lata (TPFL) as an alternative homograft for nasal dorsal augmentation in rhinoplasty, used either as a separate graft or with a sandwiched cartilaginous core. ...
... This study introduces the term 'cigar' graft to describe diced cartilage wrapped in fascia. The authors consider this to be more convenient to represent the chondrofascial graft than other synonyms reported in the literature, like bag, sandwich, sleeve, basket and pillow [13][14][15][16][17][18][19][20][21][22] . ...
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Irregularities of the nasal dorsum after rhinoplasty are frustrating for the patient and the surgeon. Different grafts and implants have been adopted to camouflage this nasal imperfection. This study was performed to assess the outcome of a composite chondrofascial 'cigar' graft for contouring an irregular nasal dorsum. Thirty-six patients who underwent rhinoplasty between May 2014 and October 2016 were studied prospectively. The cartilaginous core of the graft was obtained from the septal or conchal cartilage, while the graft outer sleeve was harvested from the right lateral thigh fascia lata. The graft was secured over the nasal dorsum through an external rhinoplasty approach. The patients were followed up for at least 18 months postoperative. All participants were evaluated objectively by two independent rhinoplasty surgeons and subjectively by Rhinoplasty Outcome Evaluation (ROE) score. Donor site morbidity was also assessed. All patients had satisfactory aesthetic results with no apparent irregularities detected over the nasal dorsum. The ROE score improved, from a mean of 20.94 AE 8.67 (range 8-58) preoperatively to a mean of 79.56 AE 10.65 (range 50-96) postoperatively. Insignificant donor site morbidity was encountered, with inconsequential effects. The chondrofascial cigar graft is a reliable method for contouring dorsal irregularities, particularly in patients with thin nasal skin.
... Patients report to rhinoplastic surgeons for varied complaints like visible nasal deformity or nasal blockage. Reconstruction of the dorsum is difficult and requires good pre-operative planning, intra-operative implementation and post-operative care [2] . ...
... Rhinoplasty has grown and developed over so many years but the choice of graft material still remains debatable [2] . ...
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Background: Nasal dorsal irregularities after rhinoplasty are troublesome for both patient and surgeon, especially in patients with thin dorsal skin, which may be seen after improper hump reduction and multiple surgeries. Many types of grafts have been used for nasal contouring, augmentation and camouflage as diced cartilage, fascia, dermal grafts, alloderm and banked allograft.
... Patients report to rhinoplastic surgeons for varied complaints like visible nasal deformity or nasal blockage. Reconstruction of the dorsum is difficult and requires good pre-operative planning, intra-operative implementation and post-operative care [2] . ...
... Rhinoplasty has grown and developed over so many years but the choice of graft material still remains debatable [2] . ...
... Besides, It is a useful stand-alone technique or in conjunction with other procedures, and is probably the best filler available to camouflage various forms of nasal defects [8,13]. Advantages of diced cartilage grafts compared to the range of graft material used in rhinoplasty surgery are [5,11,[13][14][15]; ...
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Maxillary Le Fort II fracture reconstruction plays one of the challenging surgery in the field of maxillofacial trauma. The goal of treatment is reduction, reposition, fixation of fractures and restoration of occlusion. However, it is often not enough to bring back the appearance aesthetically. The challenge that we face today is that patients frequently complain about their nose postoperatively, hence, they believe that the deformity still remains. Secondary rhinoplasty post-trauma is often performed to overcome this deformity. We proposed direct rhinoplasty using diced cartilage fascia graft in Maxillary Le Fort II fracture reconstruction to provides better post-op aesthetic appearance. Reporting three cases of Maxillary Le Fort II fractures. All patients had undergone open reduction and internal fixation combined with rhinoplasty using diced cartilage wrapped with fascia. The graft provides a better nasal contour and shape, also camouflage irregularities. There was no clinical signs of graft absorption or infection. The patients were satisfied, and none of the patients complaint about their nose after surgery. Rhinoplasty using diced cartilage fascia graft simultaneously with ORIF is a breakthrough in Maxillary Le Fort II reconstruction. It brings off the incorporation of aesthetic surgery concept into reconstruction, annihilating post-op complaint from patients and preventing secondary rhinoplasty due to previous trauma.
... It must be noted that overcorrection is not recommended with diced cartilage graft as graft resorption is minimal or absent. 25,28 Septal cartilage deformities, such as fractures or bending, can elicit various effects on nasal function, structure and aesthetics depending on the location and type of the deformity. ...
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... Conchal, septal, and rib cartilage were often used as implant materials. [16][17][18][19][20][21][22][23][24][25][26] However, the donor site morbidity and limitation of resources made it necessary to handle these materials with great care. ...
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