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.

http://archfaci.ama-assn.org/content/9/5/352.full

http://www.eclips.consult.com/eclips/article/Plastic-and-Aesthetic-Surgery/S1535-1513%2808%2970595-2

http://www.ncbi.nlm.nih.gov/pubmed/17690607

http://emedicine.medscape.com/article/881443-treatment

http://deantoriumi.com/faq1.asp

Crushed vs Diced Cartilage: Similarities and Differences

Looking at some forums I noticed some people are using the words crushed and diced cartilage interchangeably as if they are same thing. Another important  issue i would like to address here is correlation between  the degree of crushed cartilage and how it effects the long term outcome (re absorption rate) of the surgery.

Crushing cartilage is procedure that takes pieces of cartilage and crushes it in a device called Cottle cartilage crusher and/or using a mallet. They can be crushed to varying degree's from slightly crushed to severely crushed. They are then inserted in the desired area of the nose using a medical tweezer.

Dicing cartilage is procedure where the cartilage is sliced using a straight edge razor blade into small fine pieces.  The cartilage is normally diced into <0.5mm squares, using two #11 blades avoiding, not being morselized or crushed. . Then it is placed in a syringe to be later injected in the desired area and molded/shaped accordingly. Usually diced cartilage  is wrapped in soft material preferably deep temporal fascia.

Both crushed and diced cartilage is used to smoothen out or camouflage nasal surface area's where cartilage is placed in the nose , like the dorsum, to conceal any irregularities. Both can be wrapped or combined with different material as well.

Crushed cartilage grafts can be used for the following purposes: (1) to cover the sharp edges of an irregular nasal framework after hump resection    (2) to serve as an underlying padding material to prevent skin adhesion   (3) to fill pit holes and, thus, mask irregularities   (4) as a filler to mask asymmetries and depressions on the side walls  (5) for tip grafting   (6) to camouflage the edges of solid onlay grafts  , (7) to supply minor dorsal augmentation for the correction of an overresected dorsum, and (8) to increase the thickness and natural color of the overlying skin where skin atrophy had occurred. I believe diced cartilage can be used in most of the above situations as well.

Crushed Cartilage Grafts for Concealing Irregularities in Rhinoplasty

1. Ozcan Cakmak, MD;
2. Fuat Buyuklu, MD

Our current clinical series confirmed our previous animal⁹ and human cell culture¹³ studies that the degree of crushing applied is important to the long-term clinical outcome of crushed cartilage grafts used in rhinoplasty.

The results showed a correlation between the degree of crushing applied and the resorption rate of the crushed graft, especially in grafts applied at the dorsum. The resorption rate was zero in slightly crushed grafts, 2.1% in moderately crushed grafts, and 13.1% in significantly crushed grafts. Our results show that slight or moderate crushing of the autogenous cartilage produces an outstanding graft material that is effective in concealing irregularities, filling defects, and creating a smoother surface, with excellent long-term clinical outcome and predictable esthetic result. We suggest that intact cartilage should be used to correct major deformities and that moderately crushed grafts should be used for smaller depressions to minimize resorption. The severely crushed form of cartilage should not be used as filler except to correct negligible depressions in atrophic skin.

The edges of solid onlay grafts might be softened by placing small pieces of moderately crushed grafts on or around the solid graft. The tiny pieces of moderately or significantly crushed grafts might be successfully used in final contouring at the conclusion of surgery. In patients with thin skin or in whom revision is required, a thin layer of moderately or significantly crushed cartilage would be the proper option as a padding material to prevent the adhesion of skin and to camouflage the sharp edges of the nasal skeleton that might be visible after edema has subsided.

From the above study,  one would presume that  thinner and smaller diced cartilage would also have higher resorption rates then thicker larger pieces, but I haven't seen any clinical studies to support or contradict that conclusion. 

http://archfaci.ama-assn.org/content/9/5/352.full

The Role of Diced Cartilage Grafts in Rhinoplasty

The fundamental technique for the use of diced cartilage in rhinoplasty has been known for over 50 years. One of the most impressive uses of diced cartilage is in cranioplasty, which demonstrates that the individual pieces coalesce into a semirigid graft over time. The term diced cartilage graft may refer to several different types of cartilage, methods of preparation, and methods of containment. In the present report, only autogenous cartilage derived from excised material, septum, or distant grafts is used. Containment refers to placement of the diced cartilage directly into a tight pocket for contour, layering of the cartilage on either side of rigid dorsal graft for blending, or placement of the cartilage in peripyriform pockets to advance the midface. The technique and benefits of diced cartilage grafts in rhinoplasty were reviewed.

A prospective study of more than 150 patients in 3 years found no evidence of absorption and no warping. Any problems thus far with the diced cartilage graft have been technical problems rather than problems with the graft material itself. One problem has been the visibility of radix grafts, particularly in patients with very active eyebrows. This problem is easily corrected by reduction with a pituitary rongeur or replacement with fascia alone. Dorsal grafts may have “edge show” cephalically, and caudally there may be inadequate grafting of the supratip region. This problem is easily corrected with the patient under local anesthesia by use of a pituitary rongeur. A minor depression may develop in the supratip area because the surgeon has initially undercorrected in pursuit of an immediate supratip break. This problem is corrected by keeping the graft truly full length rather than shortening it to get tip set off.

Conclusions: 

In using diced cartilage grafts in rhinoplasty, diced cartilage wrapped in fascia is simpler to use, quicker, and aesthetically superior to solid cartilage grafts, without risks of warping, malalignment, and K-wire extrusion.

 http://www.eclips.consult.com/eclips/article/Plastic-and-Aesthetic-Surgery/S1535-1513%2808%2970596-4

For the author,Rollin K. Daniel, MD; diced cartilage grafts have revolutionized dorsal grafts in rhinoplasty, replacing layered septal grafts, stacked conchal grafts, and carved costal cartilage grafts. He asserts that diced cartilage wrapped in fascia is simpler to use, quicker, and aesthetically superior to solid cartilage grafts, without risks of warping, malalignment and K-wire extrusion.

Diced cartilage grafts in rhinoplasty surgery: current techniques and applications. 

Dr.Rollin K. Daniel has used diced cartilage grafts in nasal surgery for more than 30 years. However, the number of cases and the variety of techniques have increased dramatically over the past 6 years.  

http://www.ncbi.nlm.nih.gov/pubmed/19050542

Autogenous Dorsal Reconstruction: Maximizing the Utility of Diced Cartilage and Fascia

Jay Calvert, M.D., F.A.C.S.^1,2 and Kevin Brenner, M.D.²

 The problem of reconstructing the dorsum of the nose is complex and a source of frustration for both patients and surgeons. Dorsal deficiencies due to various etiologies and the need for dorsal contouring cause the plastic surgeon to look to time-honored techniques such as osseocartilaginous rib grafts while also searching for other options that may be less technically challenging and have the benefit of temporal success. Diced cartilage wrapped with deep temporal fascia is just such a method to achieve reliable dorsal reconstructions. The various ways to use diced cartilage and deep temporal fascia are discussed

The complications of using this technique are predictable and correctable. Because the cartilage is mobile for 10 to 14 days after placement, there can be defects that arise from poor management of the graft postoperatively. Edges are usually not visible, but they can be in a particularly thin-skinned patient. Overcorrection and undercorrection are probably the most common complications seen with this technique and must be managed accordingly. Malposition of the graft and mobility of the graft may also be seen in a rare number of cases. Absorption of the graft has not been seen in the longest of follow-ups (6 years).

In conclusion, the technique of diced cartilage with fascia (DC-F ) has been a useful method of dorsal reconstruction as a stand alone technique and in concert with other methods of building the dorsum. There are many permutations and surgical variations of the technique. The authors believe that proper preoperative analysis will help the surgeon to derive clear indications so that the correct graft variation is used with a clear purpose. There is no substitute for preoperative diagnosis and planning when using the DC-F graft. The technique is safe, easy to perform, has minimal morbidity, and is our favored method for addressing difficult problems in dorsal reconstruction.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884865/