Diced Cartilage Grafts Wrapped in AlloDerm for Dorsal Nasal Augmentation :

The use of diced cartilage grafts in rhinoplasty surgery was recently revived by Erol with the publication of his technique for "Turkish delight" grafts (i.e., diced cartilage grafts wrapped in Surgicel). The present study details the authors' experience with 50 consecutive diced cartilage grafts used in three configurations during a prospective study of 50 primary and secondary aesthetic rhinoplasty procedures performed by the senior author (Daniel). Part I consists of 22 diced cartilage grafts wrapped in Surgicel and placed in the radix (n = 14), radix/upper dorsum (n = 4), and full-length dorsum (n = 4). All grafts were performed adhering meticulously to Erol's technique without modification. This portion of the study was halted abruptly at 4 months because of the unexpected absorption and clinical failure of all diced cartilage grafts wrapped in Surgicel. Subsequently, five patients had revision surgery, and biopsy specimens were taken at the prior grafting site and analyzed histologically. After this clinical failure, part II of the study began, consisting of 20 patients who had diced cartilage grafts wrapped in fascia. The range of applications was comparable: radix (n = 12), radix/dorsum (n = 3), and full-length dorsum (n = 5). Because of our prior practice of overcorrecting by 20 percent with diced cartilage grafts wrapped in Surgicel, we had excessive amounts of material in six of our initial diced cartilage wrapped in fascia radix grafts, but no subsequent grafts. The overcorrections were easily reduced at 6 weeks to 11 months postoperatively using a pituitary rongeur under local anesthesia, and the material was sent for histologic analysis. Minimum 1-year follow-up of all 20 cases has shown maintenance of the grafts without evidence of absorption. Part III of this study comprised eight patients who had diced cartilage grafts without a fascial covering placed throughout the nose, including on the sides of osseocartilaginous rib grafts to the dorsum. At 14 months, there was no evidence that any of these grafts had been absorbed. Histologic analysis of the biopsy specimens from the diced cartilage grafts wrapped in Surgicel showed evidence of fibrosis and lymphocytic infiltrates with small amounts of Surgicel visible on birefringent microscopy. Remnants of cartilage were present but were metabolically inactive on the basis of negative glial fibrillary acidic protein staining. Control specimens of fresh septal cartilage and banked septal cartilage were remarkably similar to each other and demonstrated normal cartilage architecture and cellular activity. The diced cartilage grafts wrapped in fascia showed coalescence of the diced cartilage into a single cartilage mass, with viable cartilage cells and normal metabolic activity on the basis of glial fibrillary acidic protein staining. All of the diced cartilage grafts wrapped in Surgicel absorbed and failed to correct the clinical problem for which they were performed. All of the diced cartilage grafts wrapped in fascia and pure diced cartilage grafts did correct the clinical deformities and appear to have survived completely. The diced cartilage grafts wrapped in fascia placed along the dorsum were distinctly palpable throughout the postoperative period, as was one prior case with a 6-year follow-up. The authors' clinical experience confirms the experimental studies of Yilmaz et al. that question the use of Surgicel for wrapping diced cartilage grafts in clinical rhinoplasty surgery.

Augmentation of the nasal dorsum using autologous cartilage remains an exacting task in rhinoplasty. Precise, long-term control over graft contour and alignment can be difficult to achieve. In an attempt to alleviate these problems, the use of diced cartilage wrapped in a supportive sleeve has recently seen a resurgence of interest. The Turkish delight technique uses Surgicel as the sleeve material, whereas Daniel and Calvert have proposed autologous fascia. The objective of this study was to assess the efficacy and reliability of diced cartilage-fascia grafts in the treatment of dorsal nasal volume deficiencies. Over a 2-year period, 20 adult patients underwent nasal augmentation using diced cartilage-fascia grafts. The indications for dorsal grafting were congenital saddling, racial refinement, or iatrogenic or posttraumatic deformities. Apart from one infection, all of the hybrid grafts retained their original volume and had not undergone resorption by a mean time of 16 months postoperatively. A critical analysis of the radix-dorsum aesthetics led to a minor modification of the original technique. This series supports the use of diced cartilage-fascia grafts for the correction of difficult dorsal nasal defects with grafting in the 3- to 5-mm range in primary and secondary rhinoplasty.

This article describes the author's successful experience with AlloDerm onlay grafts for the correction of nasal contour deformities in secondary rhinoplasty. AlloDerm is a cadaver dermal filler graft, an off-the-shelf product that is readily available, pliable, and affordable. It is particularly suited for secondary rhinoplasty patients who are graft-depleted. The maximum dorsal augmentation is less than or equal to 3 mm; it is not a support graft. The major indication in this study was dorsal augmentation in the overresected secondary rhinoplasty patient to create a soft, smooth bridge and pleasing dorsal aesthetic lines. Twenty-five secondary rhinoplasty patients underwent multiple nasal corrections and were followed for 2 to 8 years. Analysis demonstrated no contour changes between year 1 and year 2, showing the dermal grafts to be stable after 1 year. Long-term follow-up for 2 years or longer showed good results, although partial graft resorption (defined to be < or = 50 percent) occurred in 45 percent of patients. Resorption was most common over the bony dorsum, with approximately 20 to 30 percent of the graft absorbing; over the tip, approximately 10 to 15 percent of the graft absorbed. Absorption did not seem to relate to the number of layers used. AlloDerm does not shift. Overall, the experience for nasal augmentation in secondary rhinoplasty was encouraging. Partial absorption, especially over the bony dorsum in a thin-skinned patient, is a definite disadvantage. Complete absorption was not seen in this study. The author has discovered that it is imperative to overcorrect the defect intraoperatively. Regrafting is possible and sometimes necessary.