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Complications Associated with the Use of Autologous Costal Cartilage

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Complications Associated with the Use of Autologous Costal Cartilage Rhinoplasty Aesthetic Surgery 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 Rhinoplasty: [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 pneumothorax (0.1%), pleural tear (0.6%), infection (0.6%), seroma (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).
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