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Outcomes Following Rhinoplasty Using Autologous Costal Cartilage

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Outcomes Following Rhinoplasty Using Autologous Costal Cartilage ORIGINAL ARTICLE Outcomes Following Rhinoplasty Using Autologous Costal Cartilage Byoung Jae Moon, MD; Ho Jun Lee, MD; Yong Ju Jang, MD, PhD Objective: To describe the aesthetic and clinical out- ter than they did preoperatively; and 19 patients were dis- comes following rhinoplasty using autologous costal car- satisfied. The independent surgeons judged that 43 tilage, which is considered the best graft material for rhi- patients had excellent outcomes, 37 patients had good noplasty requiring major reconstruction. Few studies have outcomes, 24 patients had fair outcomes, and 4 patients examined outcomes following rhinoplasty using autolo- had poor outcomes. There were 13 donor site compli- gous costal cartilage. cations: 9 seromas, 1 pneumothorax, 2 keloid forma- tions, and 1 persistent pain. There were 19 recipient site Methods: A retrospective review of the data from 108 pa- complications: 9 infections, 5 resorptions, 2 visible graft tients who underwent rhinoplasty using autologous cos- contours, 2 graft fractures, and 1 warping. tal cartilage between April 2006 to May 2011. The study population consisted of 81 male and 27 female patients Conclusions: The use of autologous costal cartilage in (mean age, 33.0 years). Each patient self-assessed their aes- rhinoplasty was found to be associated with a relatively thetic outcomes for subjective satisfaction, and 2 indepen- high complication rate and relatively poor aesthetic out- dent surgeons assessed aesthetic outcomes from photo- comes. Considering our results, autologous costal car- graphs. Associated complications were also analyzed. tilage should be used with the possibility of complica- tions in mind. Results: The patient self-assessment showed that 73 pa- tients were satisfied; 16 patients stated that they felt bet- Arch Facial Plast Surg. 2012;14(3):175-180 UPO1 REPORTS THAT AUTOLO- thermore, those studies were confined to gous cartilage was first used dorsal grafts or enrolled only a small num- in rhinoplasty in 1900 by Von ber of patients. The present study exam- Mangoldt for syphilitic noses. ines the outcomes of 108 rhinoplasty cases Although debate continues that involved the use of autologous cos- Lregarding the optimal graft material, au- tal cartilage. tologous grafts such as septal cartilage, con- chal cartilage, and costal cartilage are gen- METHODS erally accepted as the gold standard for 2 rhinoplasty. Some clinicians believe that PATIENTS only autologous grafts should be used for 3 nasal augmentation and reconstruction. We retrospectively analyzed data from 108 pa- However, each autologous cartilage has its tients who underwent rhinoplasty using autolo- advantages and disadvantages. gous costal cartilage between April 2006 to May While septal and conchal cartilage can 2011. The study population consisted of 81 male be easily harvested without significant con- and 27 female patients (mean age, 33.0 years; age cerns of donor site morbidity, a relatively range, 11-63 years). The postoperative fol- limited quantity of those 2 types of carti- low-up period ranged from 8 to 60 months lage can be harvested. This restricts their (mean, 19 months). The study was approved by the institutional review board of the Asan Medi- use in cases where a large graft is re- cal Center, and written informed consent was ob- quired, such as in reconstruction of se- tained from all patients. vere deformities or in graft-depleted revi- sion rhinoplasty. In such cases, autologous SURGERY costal cartilage may be a viable alterna- Author Affiliations: 4,5 Department of Otolaryngology, tive. However, despite the increasing use All rhinoplasties were performed by a single Asan Medical Center, University of autologous costal cartilage in rhino- surgeon (Y.J.J.) while the patients were under of Ulsan College of Medicine, plasty, few studies have examined the re- general anesthesia. An open rhinoplasty tech- Seoul, South Korea. lated outcomes and complications. Fur- nique was used in all cases. A transcolumellar ARCH FACIAL PLAST SURG/ VOL 14 (NO. 3), MAY/JUNE 2012 WWW.ARCHFACIAL.COM 175 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 1. Patient Diagnoses Table 2. Use of Cartilaginous Grafts Patients, No. Patients, No. Diagnosis (N = 108) Graft Usage (N = 108) Deviated nose 40 Dorsal augmentation 80 (69, laminated; 11, mono-unit) Saddle nose 29 Septal extension 78 Flat nose 25 Shield 73 Short nose 4 Spreader 75 Contracted nose 3 (1 burn, 2 postrhinoplasty cases) Columellar strut 38 Postmaxillectomy deformity 2 Tip onlay 25 Cleft lip nose 3 Backstop 22 Hump nose 1 Extracorporeal septal 15 Intramuscular hemangioma 1 reconstructions of nasal dorsum Lateral crural onlay 15 Total 108 Septal batten 13 inverted V-shape incision was connected to a bilateral mar- constructions. An upright chest radiogram was obtained for all ginal incision. The osseocartilaginous skeleton was exposed, patients after surgery. and the septal mucoperichondrial flaps were elevated, begin- ning at the anterior septal angle. The upper lateral cartilages were separated and mobilized from the septum. The septal de- POSTOPERATIVE ASSESSMENT viation was corrected, and the cartilage was harvested if there was available remnant septal cartilage. The procedure may have Two rhinoplastic surgeons not involved in the procedures included medial and/or lateral osteotomies and placement of (Jin-Young Min, MD, and Gye Song Cho, MD) assessed the aes- septal batten grafts, septal extension grafts, spreader grafts, colu- thetic outcomes by comparing the earliest preoperative pho- mellar struts, tip onlay grafts, dorsal onlay grafts, and/or shield tograph with the postoperative photograph taken at the final grafts. When autologous costal cartilage was used for dorsal aug- follow-up. Outcomes were classified as excellent, good, fair, or mentation, a mono-unit graft or a laminated graft was used, as poor. In addition, patients’ subjective evaluations were ob- previously described.6 tained, and the classifications were satisfied, better than pre- operation, or dissatisfied. Postoperative records were re- TECHNIQUES FOR COSTAL viewed to assess surgical morbidity, including graft resorption, CARTILAGE HARVEST postoperative infection, visible graft contour, fracture due to trauma, warping, seroma, pneumothorax, keloid formation, and For men and women with small breasts, a 3- to 4-cm incision persistent pain at the donor site. was made over the right sixth-seventh costal cartilage. For women with large breasts, the incision was made under the breast RESULTS crease over the fifth rib. The rib number was identified through palpation. After the skin incision was made and the subcuta- Of the 108 study subjects, 73 patients had undergone pre- neous tissue divided using electrocautery, the fascia over the external oblique muscle was opened and the fibers elevated to vious surgery, including rhinoplasty (n=34), septoplasty expose the underlying costal cartilage. (n=37), medial maxillectomy with septoplasty (n=1), and Two methods were used to harvest costal cartilage. In the total maxillectomy (n=1). The most frequent external de- first method, the cartilage was harvested with the perichon- formities were deviated nose (n=40), saddle nose (n=29), drium. Soft tissues and muscles around the costal cartilage and flat nose (n=25) (Table 1). Autologous costal carti- were dissected using electrocautery. A rectangular-shaped lage was used for dorsal grafts (n=80), septal extension grafts incision was made through perichondrium along the outer (n=78), shield grafts (n=73), spreader grafts (n=75), colu- surface of the selected costal cartilage, and dissection was per- mellar struts (n=38), tip onlay grafts (n=25), backstop grafts formed. Once elevation was complete, the desired section of (n=22), extracorporeal septal reconstructions (n=15), lat- costal cartilage was harvested with the perichondrium. In sec- eral crural onlay grafts (n=15), and septal batten grafts ond method, a longitudinal incision was made through the perichondrium, and a subperichondrial dissection was per- (n=13) (Table 2). Of the 80 dorsal grafts that used au- formed. The desired section of costal cartilage was harvested tologous costal cartilage, 69 were laminated grafts, and 11 and the perichondrium was preserved at the donor site. The were mono-unit grafts. first method was used prior to October 2010 (86 patients), The assessment by 2 independent surgeons found that and the second method, which preserved the perichondrium, the rhinoplasty outcomes were excellent in 43 cases was used thereafter (22 patients). (Figure 1), good in 37 cases, fair in 24 cases, and poor in After the graft was removed, the donor site was filled with 4 cases. The patient subjective satisfaction assessments water, and sustained positive pressure was then used to check showed that 73 patients were satisfied; 16 stated that the for air bubbles, which would indicate a pleural tear. Subcuta- results made them feel better than they did preopera- neous fat was harvested to fill the dead space at the cartilage tively; and 19 patients were dissatisfied. The reasons given harvest site. A Jackson-Pratt drain was inserted to the supra- muscular layer in some cases. The donor site was closed layer for dissatisfaction were columellar scar (n=6), low radix by layer. The harvested costal cartilage was shaped as a verti- and dorsum (n=5), nostril asymmetry (n=3), remnant na- cal strip using a dermatome blade. We waited at least 15 min- sal deviation
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