Saturday, January 1, 2011

Viability of diced and crushed cartilage with different supportive sleeve material

Diced and crushed cartilage can be wrapped in different sleeve material. One of the main purposes for this is to camouflage irregular firm jagged edges of cartilage for a smoother cosmetic result especially in those with thin skin. Nose Revision Specialists have used the following materials as sleeves or fillers: Autogenous deep temporal fascia, Perichondrium, Surgicel (oxidized methylcellulose), dermal grafts, synthetic material and  esterified hyaluronic acid (HYAFF). A couple of study's have indicated the superiority of using deep temporal fascia or  esterified hyaluronic acid over surgicel (The Turkish delight method). I haven't come across any clinical experimental study's on Perichondrium  viability- reabsorption rate comparisons .  Dr. Eugene  A. Chu of John Hopkins University Dept. of Otolaryngology makes a recommendation to remove the perichondrium completely from the costal cartilage to limit warping, however Dr. Dean Toriumi, has claimed years of success with using perichondrium which will make the skin thicker and more importantly  help prevent graft visibility and deformity. Apparently it has given him a better long term outcome. Even though a few Surgeons have claimed success on long term follow up's with the Turkish delight method, most clinical studies indicate it is an inferior material to use, due to higher reabsorption rate of the contained cartilage.

According to Dr. Ozcan Cakmak and Dr. Fuat Buyuklu:

Some authors have stated that autogenous soft tissue grafts, such as dermal grafts3 or temporalis fascia grafts,5 are satisfactory for covering underlying dorsal irregularities. However, those materials have disadvantages of possible partial resorption and donor-site morbidity. Although some authors have suggested that temporalis fascia grafts are among the most reliable materials and are associated with reasonably low resorption rates,5, 8, 23 those grafts are difficult to manipulate because they are thin and slippery.23-24 Alloplastic materials, such as gelatin film,4 polyglactin 910 (Vicryl suture; Johnson & Johnson Gateway LLC, Piscataway, New Jersey),6 and Gore-Tex (W. L. Gore & Associates Inc, Newark, Delaware),7 have also been advocated for that purpose. However, absorbable synthetics do not last long, and of all graft materials, nonabsorbable synthetics are associated with the highest rates of infection and extrusion.2, 11 A soft-tissue filler, AlloDerm (LifeCell Corp, Branchburg, New Jersey), which is derived from cadaveric skin, is another material frequently used to achieve a smoother nasal dorsum. However, AlloDerm has the definite disadvantage of partial graft resorption, especially when it is positioned over the dorsum in patients with thin skin.

Although the maintenance of typical cartilage viability and a high graft survival rate have been reported with the use of this material, harvesting the temporalis fascia adversely affects the donor site, where either permanent or transient alopecia can develop after surgery.

Many authors have used bare crushed cartilage grafts to conceal dorsal irregularities and to achieve a smoother nasal surface.

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