Wednesday, August 4, 2010

Irradiated cartilage (cadaver) grafts in nose surgery

So you need to have your nose built up but you don't have enough septal, or ear cartilage for support and you don't want synthetic implants in your nose, and your concerned about having your rib section operated on in order to harvest rib cartilage for nose grafting. Your option, Cadaver cartilage grafts. This is a controversial area, some nose surgeons say its much inferior to your own rib cartilage because of absorption problems, while others like Dr. Russell Kridel,  a facial plastics e.n.t. feels its a great option which shouldn't be overlooked and has shown studies (see medpagetoday link below) that support his view. Maybe it's a e.n.t. perspective vs the plastic surgeon's perspective. Most e.n.t.'s don't harvest rib cartilage for nose surgery (although this trend is changing) so it makes perfect sense they would be in favor of another option. But that's what makes things so interesting. The more options the better for the nose patient, however the debate between which is better can cause the patient to freeze in their tracks wondering who to believe and trust. Every surgeon has their own unique and favorite approach and so you have to consider what is best for you the patient and see if the surgeon has a lot of experience in the approach your seeking. What's right for one patient isn't right for another. Our general health, age, previous surgery's puts us all at a different place in time and has to be taken into consideration by the surgeon. It would be in the best interest of the surgeon to let the prospective patient know what options they provide and feel is appropriate. However they should not be afraid to also recommend another colleague to the patient, if that colleague does a procedure that they don't offer or specialize in yet is what  the patient is seeking. The surgeon will gain more respect from the patient this way, (meaning more referrals and positive internet forum comments) and therefore should not be afraid of losing the patient to someone else, since the patient will at the end go with who they feel is not only most qualified but with who can  offer what they want, making them feel more comfortable knowing they're on the same page with that particular surgeons view.

The Rate of Warping in Irradiated and Nonirradiated Homograft Rib Cartilage: A Controlled Comparison and Clinical Implication.      

In this study it was concluded that there was no difference in warping characteristics between irradiated and nonirradiated homograft (allograft) rib cartilage.  Make note:
The centrally cut pieces of cartilage in each group warped less than peripherally cut blocks in each group.

 Prevailing concerns with ICC and Costal AutoGrafts:
Homologous irradiated costal cartilage (ICC) has been shown to resorb on long-term follow-up and has the potential to warp but studies have shown contradictory results. In addition to problems with resorption, warping, and bacterial infection fear of viral transmission despite extensive sterilization has severely reduced its usage. However, irradiation of soft tissue allografts (ICC) with high dosage(>3Mrad) radiation can sterilize allograft tissue, destroying bacteria and viruses including HIV and hepatitis. [For more info. on risks of infection and transmitted diseases from allografts see my post Nov.25/10]  Costal cartilage autografts provides a large volume of graft material with excellent structural support.Autogenous rib grafts are known to warp,buckle and absorption can occur and be somewhat unpredictable, but there are techniques a well informed  or experienced surgeon will incorporate to limit warping capabilities in rib grafts. [See my post on techniques used to reduce warping - dated Nov 7/2010].  So the general disadvantages of Costal grafts are warping,  potential donor site morbidities, including pneumothorax, scar visibility, and chest wall deformity, but once again  keep in mind these can be avoided or be marginalized when performed by a surgeon who's well experienced in performing costal grafting.

Allograft vs. Autograft

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

Rib Cartilage Safe for Rhinoplasty

Irradiated costal cartilage in augmentation rhinoplasty
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