Irradiated Homologous Rib Grafts in Nasal Reconstruction

ORIGINAL ARTICLE Irradiated Homologous Rib Grafts in Nasal Reconstruction

Dirk J. Menger, MD; Gilbert J. Nolst Trenite´, MD, PhD

Objective: To assess the long-term efficacy of irradi- The rate of resorption increased with duration of follow- ated homologous rib grafts (IHRGs) for both augmen- up. Complete resorption was found in 1 IHRG, and mod- tation and support function in rhinoplasty in general and erate resorption was observed in 55 IHRGs (31%). Resorp- for specific recipient sites within the nose. tion was characterized by a loss of support function rather than a loss of volume. Moderate resorption had a negative Design: A retrospective study was conducted at an aca- clinical outcome for shield grafts only. demic medical center to evaluate the loss of volume and support function of IHRGs in 9 specific recipient sites Conclusions: Irradiated homologous rib grafts were safe in the nose. to use in rhinoplasty. In cases requiring a shield graft, IHRGs should be avoided. Results: We studied 66 patients, with a total of 177 IHRGs, dating back 9 years, with an average follow-up of 51 months. Arch Facial Plast Surg. 2010;12(2):114-118

ONTROVERSY PERSISTS The second involves trauma or micro- about the resorption and trauma due to muscle activity and stresses complication rates for ir- that may be associated with higher resorp- radiated homologous rib tion rates.9 The IHRGs that were used to grafts (IHRGs) in rhino- reconstruct the auricle, for example, were plasty and facial plastic and reconstruc- more susceptible to graft failure than na- C 10 tive surgery. In general, IHRGs can be used sal grafts. Previous studies have shown to augment and/or to provide structural that the resorption of IHRGs can be char- support in a recipient site. The accepted acterized by a loss of volume and/or a loss advantages of this material are the elimi- of support function. The latter can be ex- nation of additional incisions for graft har- plained by the replacement of the origi- vesting and donor site morbidity as well nal IHRGs by fibrous scar tissue.2,8,9 In rhi- as ready availability. Nevertheless, there noplasty, however, there are still no reports are conflicting reports regarding the re- (to our knowledge) about resorption rates sorption rate, the resistance to infection for specific nasal recipient sites.2 The aim and extrusion, and the threat of introduc- of this study was to assess the long-term ing infections with viruses or prions. resorption and complication rates for The first publication relating to the use IHRGs in rhinoplasty, with special em- of IHRGs in the human face dates back al- phasis on particular nasal recipient sites. most half a century.1 Since that study, mul- We hoped to identify the nasal regions tiple clinical reports have been pub- where IHRGs are safe to use and to deter- lished, often with low complication and mine whether they achieve a stable long- resorption rates.2-5 However, both animal term result in terms of the structural sup- studies and long-term follow-up series port function and volume preservation. have shown that the incidence of resorption increases with the duration of fol- Author Affiliations: 6-8 low-up to rates in excess of 75%. In ad- METHODS Department of dition to the time factor, the recipient site Otorhinolaryngology–Head and also seems to affect the rate of resorp- Neck Surgery, Center for Facial 2,9,10 Plastic and Reconstructive tion. This could be explained by 2 fac- This study included all patients undergoing na- Surgery, Academic Medical tors. The first involves the vascularity of sal surgery with IHRGs between November 1998 Center, University of the implant in the recipient bed. Rela- and August 2005 in the Academic Medical Cen- Amsterdam, Amsterdam, tively low vascularity is thought to be as- ter, University of Amsterdam, Amsterdam, the the Netherlands. sociated with higher resorption rates.8,10 Netherlands.

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All IHRGs were obtained from Tutoplast (Tutogen Medical Between February 1999 and August 2005, a total of 90 GmbH, Neunkirchen am Brand, Germany). The rib implants patients underwent reconstructive rhinoplastic surgery were selected according to stringent specifications with re- with IHRGs. We were unable to evaluate 24 patients spect to donor selection and serologic study results to mini- mize the risk of transmitting infectious disease. After the re- (27%). Fourteen of the 24 patients were untraceable: 6 moval of the rib cartilage, the process started with several cycles patients were satisfied with the functional and aesthetic of alternating baths in deionized water and 10% sodium chlo- result but did not want to participate in the study; 3 pa- ride. The cartilage was then soaked in 3% hydrogen peroxide tients underwent revision surgery with autogenous car- for 24 hours, after which the material was placed in pure ac- tilage grafts owing to persistent functional or aesthetic etone several times followed by evaporation under vacuum. Fi- problems that were not related to the resorption of the nal packaging consisted of placing the cartilage in sterile screw- grafts or other IHRG-related complication; and 1 pa- cap vials and adding sterile normal saline. The grafts were then tient died during follow-up as a result of causes that were sterilized by gamma irradiation with a minimum dose of 1780 not related to his nasal surgery. krad (to convert to grays, multiply by 10) and a maximum dose Sixty-six patients (73%) were evaluated in this study of 2010 krad. During surgery, the grafts were aseptically removed from (29 men and 37 women) during a follow-up period rang- the container and rinsed 3 times in 500 mL of sterile saline so- ing from 18 to 96 months (average follow-up, 51 months). lution. To prevent warping, the outer layers were removed, in- The patients’ ages on the date of surgery ranged from 15 cluding the perichondrium, leaving only the central portion of to 68 years, with an average of 39 years. A total of 177 the donor cartilage for reconstruction material. Graft implants IHRGs were implanted in these 66 patients (Table). Ten were shaped, sculptured, and beveled with fresh scalpels. In of the 66 patients underwent primary rhinoplasty, and most cases, the procedure consisted of an open approach through 56 underwent a revision procedure. Fifty-two of the 56 a broken columellar incision. An open approach was not tech- patients had undergone previous surgery elsewhere, and nically necessary in all cases, but it was used to prevent post- 4 had undergone previous surgery in our clinic: 2 with operative infection by minimizing intranasal incisions and tak- IHRGs and 2 without IHRGs. The endonasal approach ing advantage of the elongated distance between the graft implants and the outer world. Amoxicillin (1500 mg in 3 doses was used in 8 of the 66 patients, with 58 patients under- for 7 days) was administered orally to all patients to prevent going an external approach. The indication for nasal sur- postoperative infection. gery in 27 patients was a saddle nose deformity without recent infection; 21 patients had functional-aesthetic problems requiring nasal grafts; 15 patients had a unilateral EVALUATION OF THE POSTOPERATIVE RESULTS cleft lip; 2 patients had extrusion of a silicone implant; and 1 patient had a septal perforation. To evaluate the postoperative results, we analyzed the rate of The resorption rate of the IHRG implants was evalu- resorption, infection, extrusion, and warping and the condi- ated as described in the “Methods” section. Among the tion of the overlying soft-tissue envelope. We also assessed and classified the resorption rates for each individual graft. This group as a whole (66 patients, 177 nasal grafts), 121 of evaluation took into account the amount of volume or aug- the grafts (68%) had no signs of graft resorption and 55 mentation, graft integrity, and support function. The amount (31%) had moderate resorption (Table). One graft had of volume or augmentation of each implant was studied by com- complete resorption, which required revision surgery. In paring postoperative photographs 3 months after surgery with group 1 (29 patients, 75 nasal implants), 64 implants those taken at the time of evaluation. Also, each implant was (85%) showed no signs of resorption, and 11 (15%) palpated to assess graft integrity and support function. We de- showed moderate resorption. In group 2 (24 patients, 59 veloped 3 levels of resorption. The first level, N (none, 0%- nasal implants), 35 implants (59%) showed no signs of 25%), was classified as no loss of graft volume and no changes resorption, 23 (39%) showed moderate resorption, and in graft integrity or support function. The second level, M (mod- 1 (2%), a shield graft, showed complete resorption. In erate, 25%-50%), was classified as an evident loss of graft volume and/or evident loss of graft integrity or support function. group 3 (13 patients, 43 nasal implants), 22 implants The third level, C (complete, Ͼ50%), was classified as a com- (51%) showed no resorption, and 21 (49%) showed mod- plete loss of volume and/or a complete loss of graft integrity erate resorption. Complete resorption was not observed and support function. This third level was characterized by the in this group. After the use of alar batten grafts (n=40), necessity for revision surgery. functional improvement in nasal breathing was ob- The rate of postoperative infections was based on the served in 37 cases (92%). need for local or systemic antibiotic therapy, the localization In 15 of the 66 patients (23%), 17 complications other of the infection, and the need for surgical removal or extru- than resorption were observed. sion of the implant. We evaluated the functionality of the alar batten grafts by comparing the patients’ subjective nasal Complication No. passages with their condition 3 months after surgery. Infection 6 Finally, we assessed the rate of warping, the reactions in the Extrusion/removal of implant 0 overlying soft-tissue envelope, and the mobility of the Warping 2 implants. The patients were divided into 3 groups depending Reaction in soft-tissue envelope 7 on the duration of follow-up: the first group (group 1) was Mobility 2 followed up for 18 to 44 months; the second group (group Total 17 2) was followed up for 45 to 70 months; and the third group A postoperative inflammatory response was noticed (group 3) was followed up for 71 to 96 months. in 6 patients (9%) who had undergone revision surgery

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Resorption

Group 1a Group 2b Group 3c All 3 Groups, No. (%) (n=29) (n=24) (n=13) (N=66)

Type of Implant No. N MCN MCN MCN MC Columellar strut 42 16 4 0 9 6 0 3 4 0 28 (67) 14 (33) 0 Caudal septal replacement 24 9 2 0 2 5 0 2 4 0 13 (54) 11 (46) 0 Shield or tip graft 27 12 2 0 3 4 1 2 3 0 17 (63) 9 (33) 1 (4) Dorsal or nasofrontal onlay 40 16 3 0 10 5 0 3 3 0 29 (72) 11 (28) 0 Alar batten 30 7 0 0 7 0 0 9 7 0 23 (77) 7 (23) 0 Spreader graft 4 0 0 0 2 0 0 2 0 0 4 (100) 0 0 Side wall onlay 3 1 0 0 0 2 0 0 0 0 1 (33) 2 (67) 0 Alar rim graft 2 2 0 0 0 0 0 0 0 0 2 (100) 0 0 Columellar onlay 4 1 0 0 1 1 0 1 0 0 3 (75) 1 (25) 0 Maxilla augmentation graft 1 0 0 0 1 0 0 0 0 0 1 (100) 0 0 Total, No. (%) 177 (100) 64 (85) 11 (15) 0 35 (59) 23 (39) 1 (2) 22 (51) 21 (49) 0 121 (68) 55 (31) 1 (1)

Abbreviations: C, complete (Ͼ50%); M, moderate (25%-50%); N, none (0%-25%). a Follow-up, 18 to 44 months. b Follow-up, 45 to 70 months. c Follow-up, 71 to 96 months.

through an external approach. In all cases, the response gested that the original grafts are replaced in time by fi- was characterized by localized erythema and edema of brous tissue, resulting in a loss of support function with- the soft-tissue envelope without purulent discharge or out a loss of volume.8 This phenomenon, and relatively fever. Five of the 6 patients were treated with oral sys- short follow-up periods, may also explain the more fa- temic broad-spectrum antibiotics (amoxicillin/ vorable outcomes regarding the rate of resorption in some clavulanic acid, 500/125 mg every 6 hours). The other other studies.1,2,4,5,11-17 patient was treated with a topical antibiotic ointment. More specifically for rhinoplasty, Kridel and Konior2 None of the implants needed to be removed, and no re- described the largest series so far, with 122 rhinoplastic current or chronic infections were observed. The onset procedures in which 306 IHRGs were used. In their study, of the inflammation occurred within 1 month after im- the follow-up ranged from 1 to 84 months, with an av- plantation in all cases. On average, the clinical signs started erage of 15 months. Complete resorption was noted for on the 13th day. The inflammation was localized in the 2 grafts (both in the same patient). This total resorption nasal tip in 1 patient, in the dorsum in 1 patient, and in was found early in the postoperative phase and resulted the columella in 3 patients. The erythema was located from a localized infection at the graft site. Partial resorp- in the tip and columella region in 1 patient. No association (0%-25%) was seen in 2 patients, both cases involv- tion was found between inflammation and a higher re- ing a dorsal onlay graft. Murakami et al4 described a se- sorption rate. There was no extrusion of implants. Mini- ries of 18 patients with saddle nose deformities. mal warping of a dorsal onlay graft was observed in 2 of Reconstruction was performed using IHRGs, a dorsal on- 40 cases (5%). In 2 other cases (5%), also with dorsal onlay graft attached to a collumelar strut. Follow-up ranged lay grafts, the patients complained of mobility in the cra- from 1 to 6 years (mean, 2.8 years), and none of the IHRGs nial part of the implant at the site of the frontonasal groove showed infection, extrusion, or noticeable resorption. during palpation. In 7 of the 66 patients (11%), reac- Burke et al10 studied 118 patients who had undergone tions were observed in the overlying soft-tissue enve- nasal reconstruction in which a total of 177 IHRGs were lope. Diffuse chronic redness of the skin was detected in used. Four of 13 patients (30%) with follow-up of 5 to 3 patients (5%), 2 of whom had an inflammatory re- 10 years had severe to complete loss of graft volume (51%- sponse in the postoperative period (2 of 6 patients [33%]). 100% resorption), whereas 2 of 3 patients (66%) with fol- In 4 of the 66 patients (6%), there were signs of telangi- low-up of more than 10 years showed this volume re- ectasia of the soft-tissue envelope overlying a dorsal on- duction. Loss of structural support with compromised lay graft (4 of 40 patients [10%]). nasal function or aesthetics for the same follow-up periods occurred in 3 of 14 patients (21%) and in 1 of 3 COMMENT patients (33%), respectively. Burke and colleagues10 also studied the long-term outcome of IHRGs for auricular Our data showed that the incidence of graft resorption reconstruction and found resorption in 5 of 7 patients of IHRGs increased with the duration of follow-up. Clini- (71%). The typical appearance was an amorphous mass, cally, the most important finding was that resorption of which was probably due to the replacement of the origi- IHRGs was characterized by a loss of support function nal grafts by fibrous tissue. The IHRGs from our series rather than by a reduction of volume. These findings were were obtained from Tutoplast. Because these grafts were in agreement with other long-term follow-up studies8,10 chemically processed with peroxide and acetone before and animal data.6,7,9 In the literature, it has been sug- irradiation, they might not behave the same as nonchemi-

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 cally processed irradiated rib grafts. Irradiated homolo- in cases in which shield grafts were needed. Auricular gous rib grafts from the same manufacturer were used cartilage is probably more resistant to resorption caused to augment the nasal dorsum as dorsal onlay grafts, or by microtrauma and stresses from the overlying soft- they were diced and wrapped in oxidized cellulose (Sur- tissue envelope in the nasal tip area than irradiated and gicel; Johnson & Johnson, New Brunswick, New Jer- autogenous costal cartilage. Localized erythema and edema sey). With a mean follow-up of 36 months, recurrence of the skin in the postoperative phase was the most fre- of dorsal depression was observed in 5 of 23 patients quently noted complication (6 of 66 cases [9%]). This (22%). This recurrence was probably attributable to par- symptom, however, completely disappeared with the use tial resorption.18 Song et al19 noted partial resorption of of orally and/or locally administered antibiotics. Fre- dorsal onlay grafts in 6 of 35 cases (17%). Our study was quent postoperative assessments after surgery with IHRGs intended to assess which types of nasal grafts were reli- are therefore essential to avoid progression of the inflam- able for a favorable long-term functional and aesthetic mation response and/or infection. At the site of the in- outcome. In the evaluation of the resorption rate, the flammatory response, however, 2 of the 6 patients de- amount of volume and support function were taken into veloped a diffuse chronic redness of the skin. In our series, account. Both parameters were evaluated in a subjective minimal warping was observed in 2 of 40 dorsal onlay manner, but with the use of the classification system de- grafts (5%). Warping can be prevented by using only the scribed in the “Methods” section, we studied and ana- centrally cut pieces of rib cartilage. In a controlled ex- lyzed the results as objectively as possible. As we stated perimental study, the rate of warping in irradiated and earlier, the rate of complete resorption in our series was nonirradiated costal cartilage proved to be similar for at low. Only a shield graft was completely resorbed. In that least 4 weeks.21 Two patients in our series had under- case, palpation confirmed the presence of graft tissue un- gone previous surgery elsewhere involving a silicone im- derneath the overlying soft-tissue envelope, with a re- plant. Both patients developed a chronic infection that duction of tissue consistency compared with the origi- did not respond to antibiotic therapy. In these patients, nal IHRG graft. The incidence of moderate resorption, immediate reconstruction with IHRGs was performed. on the other hand, increased with duration of follow-up Immediate reconstruction has advantages over recon- to levels of 49% in patients with follow-up of 71 to 96 struction at a later date after a period of resolution of the months. However, the clinical consequences of resorp- inflammation.22 When reconstruction is performed im- tion were different for the distinct types of nasal IHRGs mediately, patients need not wait for a secondary recon- used. Nasal IHRGs with a need for structural support were struction, and this is emotionally beneficial. Also, there more likely to lose their function. Shield grafts for in- will be less change caused by retraction of the pocket un- creasing nasal tip projection were most at risk. In cases derneath the soft-tissue envelope as a result of scar tis- of moderate resorption, these grafts showed less tissue sue formation. In both patients, there were no compli- consistency during palpation. Clinically, the nasal tip in cations in the postoperative period and, in particular, no these cases showed a loss of tip definition and refine- signs of infection or extrusion. These findings were in ment and became more bulbous in comparison with the line with similar observations in a series of 18 patients situation 3 months after surgery. Consequently, there was described by Clark and Cook.23 Impregnation of the minimal loss of nasal tip projection. Columellar struts IHRGs with antibiotics could conceivably result in a fur- and caudal septal replacement grafts were clearly less rigid ther reduction of the risk of postoperative infection in on palpation, but, in general, there was little to no loss cases in which the implant bed is already infected.24 of projection. In time, IHRG dorsal onlay grafts were also In conclusion, in our study, the use of IHRGs in rhi- found to have lost tissue consistency on palpation, but noplasty resulted in relatively low complication rates. The the contour was generally well preserved. In all cases in- resorption rate increased with duration of follow-up. Re- volving alar batten grafts, the implants were palpable and sorption was characterized by a loss of structural sup- showed some reduction of tissue consistency. However, port rather than by a loss of volume. This phenomenon improvement of nasal breathing was achieved in 37 of was probably the result of the replacement of the origi- 40 cases (92%). Improved nasal passage with spreader nal grafts by fibrous scar tissue. Complete resorption re- grafts was found in 4 of 4 cases (100%). quiring revision surgery was uncommon. There was mod- In our study, we found that nasal IHRGs underwent erate resorption in half of the cases with a follow-up period no or minimal reduction in volume, but it is possible that of 71 to 96 months. For most types of nasal grafts, mod- some structural support might be lost over time. For most erate resorption did not negatively influence the func- types of grafts, this loss in tissue consistency did not nega- tional or aesthetic result. However, in cases of moderate tively influence the functional or aesthetic result. How- resorption of IHRG shield grafts, there was loss of nasal ever, with the use of IHRG shield grafts, tip definition tip definition and nasal tip projection. In cases in which and refinement were at risk in the long term. For shield a shield graft is a clinical necessity, we recommend the grafts, therefore, we recommend the use of autologous use of autogenous auricular cartilage grafts. cartilage grafts such as auricular or costal cartilage. In a previous study involving patients with leprosy,20 auto- Accepted for Publication: November 11, 2009. genous costal cartilage shield grafts underwent more re- Correspondence: Dirk J. Menger, MD, Department of sorption (55%) than auricular grafts (23%). The lower Otorhinolaryngology–Head and Neck Surgery, Center for resorption rate and more favorable physical properties Facial Plastic and Reconstructive Surgery, Academic Medi- owing to the natural flexibility of auricular cartilage made cal Center, University of Amsterdam, Meibergdreef 9, 1105 this the material of first choice in the lower nasal third AZ Amsterdam, the Netherlands ([email protected]).

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Author Contributions: Study concept and design: Menger 11. Donald PJ, Col A. Cartilage implantation in head and neck surgery: report of a and Nolst-Trenite´.Acquisition of data: Menger and Nolst- national survey. Otolaryngol Head Neck Surg. 1982;90(1):85-89. 12. Dingman RO, Grabb WC. Costal cartilage homografts preserved by radiation [fol- Trenite´. Analysis and interpretation of data: Menger and low-up clinic]. Plast Reconstr Surg. 1972;50(5):516-517. Nolst-Trenite´. Drafting of the manuscript: Menger. Criti- 13. Demirkan F, Arslan E, Unal S, Aksoy A. Irradiated homologous costal cartilage: cal revision of the manuscript for important intellectual con- versatile grafting material for rhinoplasty. Aesthetic Plast Surg. 2003;27(3): tent: Menger and Nolst-Trenite´.Statistical analysis: Menger 213-220. and Nolst-Trenite´.Study supervision: Menger and Nolst- 14. Strauch B, Wallach SW. Reconstruction with irradiated homograft costal cartilage. Plast Reconstr Surg. 2003;111(7):2405-2413. Trenite´. 15. Linberg JV, Anderson RL, Edwards JJ, Panje WR, Bardach J. Preserved irradi- Financial Disclosure: None reported. ated homologous cartilage for orbital reconstruction. Ophthalmic Surg. 1980; 11(7):457-462. REFERENCES 16. Lefkovits G. Irradiated homologous costal cartilage for augmentation rhinoplasty. Ann Plast Surg. 1990;25(4):317-327. 17. Strauch B, Erhard HA, Baum T. Use of irradiated cartilage in rhinoplasty of the 1. Dingman RO, Grabb WC. Costal cartilage homografts preserved by irradiation. non-Caucasian nose. Aesthet Surg J. 2004;24(4):324-330. Plast Reconstr Surg Transplant Bull. 1961;28:562-567. 18. Velidedeog˘lu H, Demir Z, Sahin U, Kurtay A, Erol OO. Block and Surgicel- 2. Kridel RWH, Konior RJ. Irradiated cartilage grafts in the nose: a preliminary report. wrapped diced solvent-preserved costal cartilage homograft application for na- Arch Otolaryngol Head Neck Surg. 1993;119(1):24-31. sal augmentation. Plast Reconstr Surg. 2005;115(7):2081-2097. 3. Chaffoo RAK, Goode RL. Irradiated homologous cartilage in augmentation 19. Song HM, Lee BJ, Jang YJ. Processed costal cartilage homograft in rhinoplasty: rginoplasty. In: Stucker FJ, ed. Plastic and Reconstructive Surgery of the Head the Asian Medical Center experience. Arch Otolaryngol Head Neck Surg. 2008; and Neck: Proceedings of the Fifth International Symposium. Philadelphia, PA; 134(5):485-489. BC Decker; 1989:297-300. 4. Murakami CS, Cook TA, Guida RA. Nasal reconstruction with articulated irradi- 20. Menger DJ, Fokkens WJ, Lohuis PJ, Ingels KJ, Nolst Trenite´ GJ. Reconstructive ated rib cartilage. Arch Otolaryngol Head Neck Surg. 1991;117(3):327-331. surgery of the leprosy nose: a new approach. J Plast Reconstr Aesthet Surg. 2007; 5. Schuller DE, Bardach J, Krause CJ. Irradiated homologous costal cartilage for 60(2):152-162. facial contour restoration. Arch Otolaryngol. 1977;103(1):12-15. 21. Adams WP Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JB Jr. The rate of 6. Maves MD. Facial plastic analysis and discussion: nasal reconstruction with ar- warping in irradiated and nonirradiated homograft rib cartilage: a controlled ticulated irradiated rib cartilage. Arch Otolaryngol Head Neck Surg. 1991;117 comparison and clinical implications. Plast Reconstr Surg. 1999;103(1):265- (3):331. 270. 7. Babin RW, Ryu JH, Gantz BJ, Maynard JA. Survival of implanted irradiated cartilage. 22. Raghavan U, Jones NS, Romo T III. Immediate autogenous cartilage grafts in Otolaryngol Head Neck Surg. 1982;90(1):75-80. rhinoplasty after alloplastic implant rejection. Arch Facial Plast Surg. 2004; 8. Welling DB, Maves MD, Schuller DE, Bardach J. Irradiated homologous carti- 6(3):192-196. lage grafts: long-term results. Arch Otolaryngol Head Neck Surg. 1988;114 23. Clark JM, Cook TA. Immediate reconstruction of extruded alloplastic nasal im- (3):291-295. plants with irradiated homograft costal cartilage. Laryngoscope. 2002;112 9. Donald PJ. Cartilage grafting in facial reconstruction with special consideration (6):968-974. of irradiated grafts. Laryngoscope. 1986;96(7):786-807. 24. Tasman AJ, Wallner F, Neumeier R. Antibiotic impregnation of cartilage im- 10. Burke AJC, Wang TD, Cook TA. Irradiated homograft rib cartilage in facial plants: diffusion kinetics of fluoroquinolones. Laryngorhinootologie. 2000; reconstruction. Arch Facial Plast Surg. 2004;6(5):334-341. 79(1):30-33.

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