Rib cartilage harvesting in rhinoplasty procedures based on CT radiological data
Department of Otorhinolaryngology, Kliniken Maria Hilf, Mönchengladbach, Germany. Acta oto-laryngologica
(Impact Factor: 1.1).
01/2011; 131(1):67-71. DOI: 10.3109/00016489.2010.502185
In general, harvesting of costal cartilage from the seventh rib from the right side appears advisable for rhinoplasty procedures in male and female patients. The thickness of the soft tissue envelope anterior to the different ribs varies significantly, which demands an individual consideration in rhinoplasty procedures.
To clarify which of the sixth, seventh or eighth rib contains the maximum amount of cartilage and degree of calcification in relation to age, side, and gender.
Digital 2 mm slices of spiral diagnostic thorax CT scans were used to measure costal cartilage sizes in a retrospective study. A total of 60 male and 60 female patients with normal findings were collected and stratified by age (range 16-70 years).
On both sides, the seventh rib was identified as the most cartilage-containing rib, independent of gender. The length of costal cartilage of the sixth and seventh rib was significantly related to age on both sides (p < 0.01). This finding did not reach statistical significance for the eighth rib, on either the right (p = 0.376) or the left side (p = 0.204). Calcification of the sixth and seventh rib, but not of the eighth rib, significantly increased with age. In general, calcification was not related to gender or one side.
Available from: Elad Azizli
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ABSTRACT: The aim of this study was to compare the biomechanical properties of septal cartilage (SC) and costal cartilage (CC) grafts harvested from different ribs and to find at which level CC has characteristics closest to SC.
Experimental cadaver study.
Istanbul Training and Research Hospital.
Cartilage grafts were harvested from the 6th, 7th, and 8th ribs and the SC of 10 fresh cadavers. Shaped cartilage grafts were subjected to a bending test. Results were measured, and the force-deflection curve was plotted. Flexural strength (σ(f)) and flexural modulus of elasticity (E(f)) were determined. Fractured surfaces were evaluated by scanning electron microscopy (SEM).
According to F(max), it was determined that ribs 6, 7, and 8 have significantly more durability compared with the SC (Ps = .030, .004, and .001). With regard to deflection, there was no significant difference between the SC and the 6th and 7th ribs and between the 6th and 7th ribs (Ps = 1.000, .088, and .306), while a significant difference was found between the SC and the 8th rib (P = .001). According to σ(f), no differences were seen between the 6th and 7th rib (P = .782), while difference was detected between the 6th and 8th and the 7th and 8th ribs (p = .001). Similar trends were established in E(f) values as in σ(f.) These results were confirmed by SEM images.
The 7th CC can be used as autograft because it shows similar properties to SC. However, the 6th CC is preferred if more flexibility is desired, and the 8th CC is preferred where more strength is needed.
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ABSTRACT: Tissue banks around the world store human cartilage obtained from cadaveric donors for use in diverse reconstructive surgical procedures. To ensure this tissue is sterile at the time of distribution, tissues may be sterilized by ionizing radiation. In this work, we evaluate the physical changes in deep frozen costal cartilage (-70 °C) or costal cartilage preserved in high concentrations of glycerol (>98 %) followed by a terminal sterilization process using ionizing radiation, at 3 different doses (15, 25 and 50 kGy). Tension and compression tests were carried out to determine the mechanical changes related both to the different preservation methods and irradiation doses. For both methods of preservation, tension strength was increased by about 24 %, when cartilage tissue was irradiated with 15 kGy. Deep frozen samples, when irradiated with 25 or 50 kGy, had a decrease in their mechanical performance, albeit to a lesser extent than when tissues were preserved in high concentration of glycerol and equally irradiated. In conclusion, processing in high concentration of glycerol did not increase tissue protection against radiation damage; while cartilage preserved in high concentrations of glycerol withstands radiation up to 25 kGy, deep frozen human costal cartilage may be sterilized with a doses up to 50 kGy without significant mechanical impact.
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ABSTRACT: Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e., tonsillotomies) are increasingly performed. The aim of this study was to evaluate alleged medical malpractice, technical traps and pitfalls associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications or medico legal implications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published verdicts in Germany.The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed 9 cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including 2 children (5 and 8 years of age) and 7 adults (aged 20-69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; 4 patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. 3 Conciliation Boards submitted expert opinions concerning cases TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only 3 of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (11; 41%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials based on LN were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thorough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff, readily available surgical instruments and appropriate airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.
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