Rhinoplasty

Aesthetic Journal 2015, Vol 35(6) 644–652 Complications Associated With the Use © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: of Autologous Costal Cartilage in : [email protected] DOI: 10.1093/asj/sju117 A Systematic Review www.aestheticsurgeryjournal.com

Kiran Varadharajan, MRCS, DOHNS; Priya Sethukumar, MRCS (ENT); Mohiemen Anwar, MRCS, DOHNS; and Kalpesh Patel, FRCS

Abstract Background: Autologous costal cartilage grafts are common in rhinoplasty. To date, no formal systematic review of complications associated with autol- ogous costal cartilage grafting in rhinoplasty exists. Objectives: The authors review current literature to examine the rates of donor and recipient site complications associated with autologous costal carti- lage in rhinoplasty. Methods: Databases (EMBASE, PubMed, MEDLINE, and Cochrane Database of Systematic Reviews) and references of pertinent articles were searched between January 1980 to July 2014 to find studies evaluating rates of complications with autologous costal cartilage grafting in rhinoplasty. These studies were then screened with specific inclusion/exclusion criteria, and data were extracted from included studies and pooled for analysis. Results: A total of 21 eligible studies were included. Pooled donor site complication incidence was (0.1%), pleural tear (0.6%), (0.6%), (0.6%), scar-related problems (2.9%), and severe donor site pain (0.2%). Pooled recipient site complications were as follows: warping (5.2%), infection (2.5%), displacement/extrusion (0.6%), graft fracture (0.2%), and graft resorption (0.9%). Conclusions: Autologous costal rhinoplasty remains a safe procedure, but is associated with not insignificant rates of minor recipient site complications, such as warping.

Level of Evidence: 4

Accepted for publication December 5, 2014. Therapeutic

Autologous costal cartilage is a commonly employed graft for Cochrane Register of Controlled Trials using the key rhinoplasty. It is particularly favored as an abundant source of terms “rhinoplasty,”“autologous,” and “costal cartilage.” cartilage in cases of revision rhinoplasty in which more local sources (septal and conchal) are depleted.1 Despite being a common source of cartilage, evidence is scarce pertaining to complication rates associated with its implementation and the Dr Varadharajan is a Core Surgical Trainee, Department of ENT, West Middlesex University Hospital, London, UK. Dr Sethukumar is a various techniques of harvest and placement. Research Fellow ENT, Dr Anwar is a Specialist Registrar ENT, and Dr In this systematic review, our goal was to determine the Patel is a Consultant ENT, Department of ENT, St. Mary’s Hospital, rate of donor and recipient site complications associated London, UK. with autologous costal cartilage grafting in rhinoplasty. Corresponding Author: Dr Kiran Varadharajan, Department of ENT, West Middlesex METHODS University Hospital, Twickenham Rd, Isleworth, Middlesex, TW7 6AF, London, United Kingdom. Search Criteria E-mail: [email protected]

An electronic search was conducted in July 2014 of the fol- Presented at: The 25th Congress of the European Rhinologic Society, in lowing databases: EMBASE, MEDLINE, PubMed, and the Amsterdam, Netherlands in June 2014. Varadharajan et al 645

Articles published between January 1980 and July 2014 Table 1. Data Extracted From Articles were included. Extracted Data Inclusion criteria were articles written in English, human patients, rhinoplasty with autologous costal carti- Study information lage, and complication rates (donor and recipient site). Authors and affiliated institutions Exclusion criteria included case studies with sample sizes fewer than 15 and studies not translated into English. Dates data collected Two reviewers independently screened titles and ab- Patient characteristics stracts of retrieved articles and references for relevant arti- cles. Any disagreements were resolved by discussion with Sample size the senior author. Gender Studies were quality assessed and screened for biases Age (mean, range) using the critical appraisal checklist of the American Society of Plastic Surgeons.2 This checklist assesses bias in Follow-up periods 4 domains: selection bias (appropriate case selection, cases Technique of autologous costal cartilage harvest consecutive, assessment of confounders); intervention bias (intervention performed similarly in all patients, all proce- Donor site complications dures performed by the same surgeon); measurement bias Pneumothorax/pleural tear (outcomes have valid defined criteria, appropriate follow- up times to assess outcome); and conflicts of interest Infection 2 (study should not have conflicts of interest). Seroma

Scar (hypertrophic/keloid) Data Extraction and Analysis Persistent/severe pain For each article that was included, the following outcomes were extracted (see Table 1): patient demographics; follow- Chest wall deformity up times; donor site complications (including pneumotho- Recipient site complications rax, infection, chest wall pain, scarring, and chest wall Warping deformity); and recipient site complications (warping, in- fection, displacement, or extrusion of graft). Complication Infection rates were pooled for analysis. Graft extrusion/displacement/visible contour RESULTS Graft fracture Graft resorption Study Retrieval and Characteristics The initial search yielded 63 citations. A total of 42 articles were excluded and 21 articles were included for review and rates in the autologous costal cartilage group alone). No analysis (see Table 2 for study characteristics). All included mortality was reported in any of the studies. A summary of studies were case series with no control groups, thus no individual recipient and donor site complications is shown statistical analysis could be performed. in Table 3. The included studies were all case series with varying study protocols (surgical techniques and follow-up times) Donor Site Complications and no control groups, thus meta-analysis was not viable. The only serious complication noted was pneumothorax 3,4 Complication Rates that occurred in 2 cases. One of these cases was treated with a chest tube, and the patient was discharged 2 days A summary of included studies and pooled complication postoperatively3; no information was available regarding rates is shown in Table 2. All studies reported individual the management and outcome of the other case.4 Breach of complications. The overall pooled donor site complication the pleura without pneumothorax was more common and rate was 3.2% (n = 1545), and recipient site complications reported in 10 cases.5-7 Only 3 studies routinely performed were 11.4% (n = 1259; 1 large paper was excluded from postoperative chest radiographs to assess for pneumotho- analysis because a combination of a heterologous graft with rax.3,7,8 A diagram of a pleural tear is shown in Figure 1. autologous costal cartilage was utilized in 1 group, but the Only 1 case of severe persistent chest pain was noted, authors did not report individualized recipient complication and this was treated with intercostal nerve blocks.3 646 Aesthetic Surgery Journal 35(6)

Table 2. Included Studies

Study Year Type of Sample Mean Age Donor Site Recipient Site Study Size Complications (%) Complications (%)

Lee et al14 2011 Case series 322 – 0.3 0.0

Miranda et al10 2013 Case series 286 32 10.1 – a

Balaji et al16 2013 Case series 157 24.4 (4.9) 0.0 26.1

Moon et al3 2012 Case series 108 33 12.0 16.7

Park et al8 2012 Case series 83 28.8 (9.4) 8.4 6.0

Boyaci et al5 2013 Case series 65 35.5 1.5 0.0

Saeed et al4 2012 Case series 60 – 10.0 1.7

Moretti et al12 2013 Case series 54 34 3.7 16.7

Riechelmann et al9 2004 Case series 43 36 (12) 9.3 39.5

Tastaņ et al15 2013 Case series 43 33 0.0 2.3

Ozturan et al6 2013 Case series 41 25.5 (5.54) 2.4 24.4

Yilmaz et al22 2007 Case series 38 27.7 0.0 0.0

Moshaver et al17 2007 Case series 37 Median 42 2.7 21.6

Cervelli et al18 2006 Case series 33 – 0.0 6.1

Gurley et al7 2000 Case series 32 8.8 25.0 37.5

Agaoğ lŭ et al20 2000 Case series 30 – 0.0 0.0

Ullah et al19 2012 Case series 28 – 0.0 7.1

Chait et al24 1980 Case series 25 – 0.0 16.0

Al-Qattan13 2007 Case series 21 30 23.8 9.5

Cakmak et al11 2002 Case series 20 30 5.0 20.0

Song et al21 1991 Case series 19 – 0.0 36.8

aRecipient site complications were not assessed as study included a cohort in which autologous costal cartilage was combined with an allograft (no individualized recipient site complication rates were reported for the autologous costal cartilage group alone).

Another study found that 2 patients required more than 1 g Other modalities of antibiotic coverage included immersion of diclofenac per day.9 Three studies reported the injection of the graft in antibiotic solution prior to insertion8,10 and of local anesthetic into the donor site.8,10,11 packing of the nose with antibiotic cream for 2 days postop- The most common long-term donor site complication eratively.19 was scarring, which occurred in 45 cases.3,4,8,12,13 There were no cases of chest wall deformity. Operative Techniques Most papers reported the typical techniques that were em- Recipient Site Complications ployed in the studies (see Table 4); however, 2 compared The most common recipient site complication was warping methods of graft harvest. of the graft, with a pooled incidence of 5.2%. Overall, warping rates ranged from 0%13-15 to as high as 26.1%.16 Graft Harvest The overall rate of need for further revision rhinoplasty was The typical intraoperative technique for costal cartilage 5.4%. harvesting (from the right sixth costal cartilage) is shown Recipient site infection (2.5%) was much more common in Figure 2. In those studies that provided details regard- than donor site infection (0.60%). Routine postoperative ing graft harvest, grafts were taken between the fifth to antibiotics were administered in several studies.6,8,11,17-19 11th costal cartilages (see Table 3). The typical site for a Varadharajan et al 647

Table 3. Complication Rates

Complications Total Cases (n) %

Donor Site (n = 1545)

Pneumothorax 2 0.1

Pleural tear 10 0.6

Infection 9 0.6

Seroma 10 0.6

Scar 45 2.9

Persistent/severe pain 3 0.2

Chest wall deformity 0 0.0

Recipient sitea (n = 1259)

Warping 139 5.2

Infection 53 2.5

Displacement/ 6 0.6 extrusion/ exposure of graft Figure 1. A diagram of a pleural tear.

Graft fracture 3 0.2 pneumothorax or pleural breech). A conservative harvest- Visible contour 2 0.2 ing technique, whereby only a central segment of costal Resorption 11 0.9 cartilage is removed, has been described.5,14

Other (persistent 23 mucosal swelling, Graft Preparation and Placement Kirschner wire/steel Costal cartilage was employed for a wide range of grafts suture extrusion, other (unable to breakdown), (see Table 5), including dorsal, septal, spreader, columellar transcolumellar tip, and alar. necrosis, , A variety of grafting techniques was described to mini- transient columellar swelling, exposure, mize warping. A common technique was to soak the har- partial graft loss, nare vested cartilage in saline5,8,10,15,17 or to observe a period of stenosis, nonsolidified delay prior to shaping and placement of the graft.3,6,11,12,16 graft, curvature of the 17 graft. Moshaver et al utilized Kirschner wires to prevent warping. Ozturan et al6 compared the standard autologous carti- a One large paper was excluded from analysis as the authors used a combination of a lage graft with the accordion graft (a costal cartilage graft heterologous graft with autologous costal cartilage in 1 group, but did not report individualized recipient complication rates in the autologous costal cartilage group alone. that has been scoured); all 7 cases of warping in this study were found in the standard cohort. costal cartilage harvest is shown in Figure 3. An inframam- Other Factors mary incision was also selected in females in several The average age of patients was 29.1 years; the youngest studies3,5,7,8,10,14,17,20,21 for cosmetic benefit in concealing patient was 3.8 years old and the oldest 82 years old (in the scar. studies that provided a demographic breakdown). The most common technique described to check for a Among the nine studies that reported accurate follow-up pneumothorax entailed filling the wound with saline or time information (not all), the pooled mean follow-up was water and inducing positive pressure ventilation to check 24.8 months (range, 3 to 73 months). for bubbling (see Table 3).3,6-8,10,11 Several other studies re- fi ported checking for pneumothorax; however, the speci c DISCUSSION details were not provided.16,17,22 A few papers reported novel techniques of graft harvest. In this systematic review, we have demonstrated that a Ağaoğlu et al (2000)20 employed a gouge to minimize the wide variety of complications can occur at both the donor amount of cartilage harvested (they reported no cases of and recipient sites with autologous costal cartilage grafting 648 Aesthetic Surgery Journal 35(6)

Table 4. Summary of Operative Techniques

Authors Level of Costal Cartilage Harvest and Special Technique for Testing for Pneumothorax Graft Preparation Techniques Techniques if Utilized

Lee et al14 Right seventh rib; incision at inframammary crease in Not specified Not specified females and inferior border of pectoralis major in men; conservative central segment harvest utilized.

Miranda Fifth intercostal space; inframammary crease in Valsalva maneuver Grafts soaked in saline/clindamycin solution prior to insertion et al10 females. A total of 30% of patients had an allograft (ePFTE) combined with autologous costal cartilage

Balaji et al16 Right fifth through seventh rib (straightest selected) Not specified Grafts curved sequentially over a long unspecified time period

Moon et al3 Right sixth to seventh costal cartilage (inframammary Donor site filled with water and Valsalva 15-minute delay prior to insertion of graft crease in females with large breasts). Donor site filled maneuver applied; postoperative chest with harvested fat to reduce dead space radiograph in all patients

Park et al8 Right sixth to eighth ribs; women inframammary crease Donor site filled with saline and positive Harvested grafts soaked 2 to 3 times in saline prior to insertion pressure ventilation applied; first 23 (at least 10 minutes per soak). patients had a Dorsal augmentation grafts (central segment selected). Flat piece of cartilage required (spreader graft, batten graft, columellar, strut, or septal extension graft) then graft laminated with longitudinal or tangential incisions leaving peripheral portions symmetrically on both sides)

Boyaci et al5 Right fifth rib; in males inferior border of pectoralis Not specified Grafts soaked in saline for 1 hour prior to insertion major, in females inframammary crease; conservative central segment harvest utilized.

Saeed et al4 Sixth rib Not specified Not specified

Moretti Level not specified Not specified 30-minute delay prior to insertion of graft. et al12 Dorsal reshaping/septal reconstruction (central segment used). Alar/tip (peripheral portions used).

Riechelmann Sixth rib Not specified Graft longitudinally divided into 4 layers; medial 2 layers used et al9 for septal/dorsal grafts and outer 2 layers used for shield graft.

Tastaņ Seventh rib; oblique split method Not specified First few patients had the grafts soaked in saline for 1 hour. et al15

Ozturan Right sixth/seventh costal cartilage; accordion graft Donor site filled with saline and positive Delay of 40-180 minutes prior to insertion of grafts. et al6 technique in some patients. pressure ventilation applied. Central segment of cartilage used.

Yilmaz Sixth to 11th costal cartilage used Checked but details not specified Not specified et al22

Moshaver Level not specified Checked but details not specified Graft decorcicated (1-mm tissue shaved off from external et al17 surface) prior to grafting. Graft placed in saline for 30 minutes prior to insertion. Central segment used in 25 patients.

Cervelli Eighth to 11th ribs Not specified Not specified et al18

Gurley et al7 Inframammary incision Donor site filled with water and positive Details not specified pressure ventilation applied; postoperative chest radiograph in all patients

Agaoğ lŭ Sixth to seventh costal cartilage (inframammary crease Not specified Not specified et al20 in females); gouge utilized to harvest costal cartilage

Ullah et al19 Seventh costal cartilage Not specified Only central segment of costal cartilage used

Chait et al24 Fifth costochondral junction Not specified Symmetrical carving to preserve “balanced cross section”

Al-Qattan13 Ninth to 10th costal cartilage; edge on technique utilized Not specified Not specified

Cakmak Seventh rib Donor site filled with water and positive 30-minute delay prior to insertion of grafts. et al11 pressure ventilation applied Both central and peripheral segments used

Song et al21 Straightest costal cartilage (usually fifth); inframammary Not specified Not specified crease can be used for incision in females Varadharajan et al 649

Figure 2. (A) Incision over marked costal cartilage site, (B) exposure of costal cartilage through dissection of intercostal muscles, (C) exposed costal cartilage, and (D) excision of graft from exposed costal cartilage are demonstrated in a typical intraoperative technique for costal cartilage harvesting (from the right sixth costal cartilage) on a 38-year-old male patient.

in rhinoplasty. The incidence of these complications varies were reported, respectively. In studies that reported tech- greatly. niques for assessing pneumothorax, the universal technique The most serious donor site complication is pneumotho- entailed assessing for bubbling after filling the donor site rax. No meta-analyses or systematic reviews were found re- with solution (water or saline) and applying the Valsalva porting figures on pneumothorax rates in autologous costal maneuver or positive pressure ventilation.3,6-8,10,11 Routine cartilage harvesting in rhinoplasty or other procedures. In postoperative chest radiographs are usually not required, al- this review, frank pneumothorax was reported in only 2 though they were performed in some of the studies included cases; however, iatrogenic pleural tear was more common. in this systematic review.3,7,8 If pleural tears are excluded Pleural tears can be managed with primary closure, intraoperatively, then a postoperative chest x-ray is not nec- whereas a pneumothorax requires the insertion of a chest essary in most cases. drain with admission and discharge once it has cleared. Chest wall deformities and scoliosis are a potentially Many studies reported preserving the posterior perichon- severe long-term complication resulting from harvesting drium during graft harvest.3,5,8,11,14,16,17,20 Of these studies, costal cartilage;23 however, we found no reported cases as- only 1 case of pleural tear5 and 1 case of pneumothorax3 sociated with autologous costal cartilage in rhinoplasty. To 650 Aesthetic Surgery Journal 35(6)

Table 5. Graft Types

Graft Type N

Dorsal 253 (unspecified 217, cantilever 19, onlay 17)

Septal 232 (unspecified 126, extension 78, extracorporeal reconstruction 15, batten 13)

Spreader 99

Columellar strut 92

Tip 91 (unspecified 66, onlay 25)

Shield 73

Alar 22

Backstop 22

Figure 3. A diagram showing the typical site for costal carti- Lateral crural onlay 15 lage harvest.

address the deficiency in costal cartilage, studies have re- Utilizing the central segment of costal cartilage is ported filling this potential dead space with fat3 and unused thought to minimize warping, therefore this method was cartilage.6 employed in many studies.4,8,11,12,14,16,17,19 are collections of serous fluid that can occur in The majority of studies utilizing this technique reported any potential space created intraoperatively. One study warping rates less than 10%,8,12,14,17 with 2 reporting rates found that by modifying their technique to maintain the in- greater than 10%,11,16 suggesting this technique may be tegrity of the perichondrium at the donor site, seroma rates efficacious in reducing warping rates. could be reduced (9 cases of seroma were initially reported Several novel techniques were utilized in some studies. and none occurred after modifying the technique), suggest- Ozturan et al6 compared a standard grafting technique with ing that limiting dead space and vessel leakage can reduce the accordion technique (scouring the cartilage prior to in- the risk of seroma.3 sertion), with no reported cases of warping in the latter Harvest technique appears to influence the rate of donor technique (in 23 patients). In a small series, researchers site complications. The classic harvest technique can be performed no carving on harvested grafts, instead place modified to obtain a conservative central segment harvest, them with the convex edge of the graft oriented superiorly which has been shown to result in low donor site morbidity to utilize the natural curvature of the graft for shaping the in a large case series.14 However, a conservative harvest nose13 (no cases of warping were reported). Moshaver may not provide sufficient cartilage for rhinoplasty. et al17 combined the use of central segment cartilage with Scarring at the donor site was also a common issue. Kirschner wires, but still reported an 8.1% warping rate in However, this complication can be treated with steroid in- addition to Kirschner wire extrusion in 3 patients. jection,3,8,12,13 silastic gel,8 or silicon sheets.13 A large case series combined autologous costal cartilage The most commonly reported complication is warping, with an allogenic material (expanded polytetrafluoroethylene) with a pooled rate of almost 10%. Warping refers to distor- to form a heterologous graft that the authors theorized would tion of graft material, which can later present with struc- reduce warping rates.10 The overall warping rating in this tural deformity. A variety of techniques have been utilized study was very high (25.8%);10 however, the study did not to minimize warping. report individualized complication rates for this intervention The most frequently applied techniques were to delay compared with the use of autologous costal cartilage alone. grafting or to immerse the graft in solution prior to shaping An overt increase in incidence of warping in studies or insertion. Warping rates with these techniques varied with longer follow-up was not found. One study with a substantially, ranging from 0%15 to 26.1%.16 mean follow-up time of 48 months reported no cases of Varadharajan et al 651 warping,13 and another with a mean follow-up time of 21 Acknowledgements 6 months reported a warping rate of 17.1%. The authors would like to thank Medical Illustration UK, Ltd. A study assessing the properties of costal cartilage grafts for the illustrations in this article. noted that a greater mineral content in the cartilage, straighter grafts, and older age of the patient are associated with a lower incidence of warping.16 Funding The rate of graft resorption with autologous costal The authors received no financial support for the research, au- cartilage in rhinoplasty is very rare, with a pooled rate of thorship, and publication of this article. less than 1%. Donor and recipient infection were also uncommon, with many studies routinely administering Disclosures antibiotics. fl Major advantages of autologous cartilage are its abun- The authors declared no potential con icts of interest with dance and versatility, permitting the derivation of a range respect to the research, authorship, and publication of this article. of graft types and its use as the predominant source of carti- lage in major nasal reconstructions.7,9 Autologous costal cartilage remains an all-purpose “workhorse” graft, with REFERENCES dorsal and septal as the most frequent types. 1. Sajjadian A, Rubinstein R, Naghshineh N. Current status To date, 1 meta-analysis has assessed complication of grafts and implants in rhinoplasty: part I. Autologous rates associated with autologous costal cartilage use in rhi- grafts. Plast Reconstr Surg. 2010;125(2):40e-49e. noplasty.25 This review only included 10 studies and report- 2. American Society of Plastic Surgeons. 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