Ultra Diced Cartilage Graft in Rhinoplasty: A Fine Tool — Suleyman Tas PubMed

Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. COSMETI C www.PRSJournal.com 1 From the TAŞ Aesthetic Surgery Clinic. Received for publication December 30, 2019; accepted September 11, 2020. Presented at the Closed Atraumatic Rhinoplasty Course (endorsed by the Rhinoplasty Society of Europe and the International Society of Aesthetic Plastic Surgery), in Istanbul, Turkey, November 16 through 17, 2019. Copyright © 2021 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000007794 R hinoplasty is the most challenging operation in plastic surgery because of its complexity and both aesthetic and functional purposes. Dorsum hump reduction is one of the main com- ponents of Caucasian rhinoplasty. Even if dorsal hump reduction is done well and reconstructed with spreader grafts or /f_laps to close the open roof deformity, asymmetries or irregularities can occur because of disruption of the anatomy during the dorsum surgery. In contrast, we need to augment the dorsum or radix sometimes, especially in eth - nic and revision rhinoplasties.1–4 The diced cartilage grafting technique is a well-known procedure in plastic surgery. 5 Onur Erol6 re/f_ined this technique and brought it to the rhinoplasty /f_ield with use of Surgicel (Ethicon, Inc., Somerville, N.J.) as a scaffold to keep the diced cartilage together. After Onur Erol’s impressive article (i.e., the Turkish delight) to re/f_ine or to augment the dorsum, diced cartilage has been using frequently in rhinoplasty for the past 20 years. 6 Then, Daniel and Calvert advo - cated using temporal fascia for the scaffold of the diced cartilage to eliminate the reactive resorp - tion.7,8 However, there is some debate in the litera- ture about using diced cartilage free or wrapped in fascia or Surgicel to eliminate the absorption problem. Recently, Kreutzer et al. 9 compared three ways (except Surgicel) and advocated the use of free diced cartilage to smoothen the nasal dorsum as a routine rhinoplasty procedure, and Süleyman Taş, M.D. Istanbul, Turkey

Background: Free diced cartilage smaller than 0.2/uni00A0mm in diameter to smoothen the nasal dorsum is a well-known procedure. However, creating smaller diced cartilage takes a really long time. In contrast, the free diced cartilage technique has some visibility problems, especially in thin-skin patients, although a /f_ine job is done to chop the cartilage. The author aimed to present the “ultra diced carti- lage graft” and the way to achieve it, to eliminate the problems of diced cartilage during rhinoplasty, and compare it with free diced cartilage grafting technique. Methods: Between April of 2015 and December of 2018, the ultra diced carti - lage graft technique in 104 patients and the free diced cartilage graft technique in 113 patients were used to smoothen the dorsum or augment the radix/dor - sum. Operation records, rhinoplasty outcome evaluation questionnaire, palpa- tion test, and evaluation of the immediate postoperative photographs on the table with postoperative 1-year postoperative photographs by two independent blinded plastic surgeons were analyzed. Results: Ultra diced cartilage seemed superior to free diced cartilage grafting with regard to graft visibility and resorption. Conclusions: Ultra diced cartilage graft is an effective and easily reproducible technique in rhinoplasty. There is no extra cost, and it is the easiest and fastest way to have this perfectly pliable cartilage have no dead space. The ultra diced cartilage grafting technique should be known by all plastic surgeons to achieve /f_ineness in rhinoplasty. (Plast. Reconstr. Surg. 147: 00, 2021.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. Ultra Diced Cartilage Graft in Rhinoplasty: A Fine Tool Disclosure: The author declares that he has no con- /f_licts of interest, commercial associations, or intent of /f_inancial gain regarding this research. Related digital media are available in the full-text version of the article on www.PRSJournal.com. AQ2 AQ1 AQ3 AQ13 lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093

Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 2 Plastic and Reconstructive Surgery • April 2021 recommended use of cartilage pieces smaller than 0.2/uni00A0mm in diameter, for free diced cartilage technique. Kreutzer et al. 9 reported a 25 percent revision rate for diced cartilage wrapped in fas - cia, and recommended free diced cartilage tech - nique and reported a 5.2 percent revision rate with 7-month postoperative follow-up. In contrast, creating smaller diced cartilage takes a really long time, which is especially problematic under gen - eral anesthesia. Moreover, the free diced cartilage technique may cause some visibility problems, especially in thin-skin patients, although a /f_ine job is done to chop the cartilage. In this study, the author aims to present the “ultra diced cartilage graft” and the way to achieve it, to eliminate the problems of free diced cartilage in rhinoplasty, and to compare it with free diced cartilage graft - ing technique. PATIENTS AND METHODS The patients included in the study were both primary and revision cases in whom ultra diced cartilage technique or free diced cartilage tech - nique was used; they underwent surgery between April of 2015 and December of 2018 performed by the author and analyzed retrospectively. The study was conducted according to the Declaration of Helsinki for biomedical research on human subjects. Preoperatively, written informed consent was obtained from all patients. In group 1, free diced cartilage graft technique was used in 113 patients, between April of 2015 and December of 2016; in group 2, ultra diced cartilage tech - nique was used in 104 patients, between January of 2017 and December of 2018. These techniques were used to smoothen the dorsum or accomplish radix/dorsum augmentation. During the follow- up period, all patients were photographed from standard views using a digital camera. The imme - diate postoperative photographs on the table and postoperative 1-year photographs were evaluated by two blinded independent plastic surgeons regarding graft visibility and graft resorption. The evaluators were asked to provide scores of 0 to 2 (0, graft resorption in the dorsum; 1, graft visibility in the dorsum; and 2, smooth dorsum). The author performed palpation tests to check for irregularities of the dorsum at postoperative 1 year control. The rhinoplasty outcome evalua - tion questionnaire, validated by Alsarraf et al., 10 was administered to all patients at their 1-year follow-up visit. ( See Appendix, Supplemental Digital Content 1 , which shows the rhinoplasty outcome evaluation questionnaire, administered to the patients at their 1-year follow-up visit, http:// links.lww.com/PRS/E375.) This questionnaire had six questions with a score of 0 to 4, and measured the social, functional, and aesthetic satisfaction of the patients. Patient satisfaction was determined to be 21 to 24 points, and patient dissatisfaction was determined to be 20 points or less or if any question scored 2 points or lower regardless of the total survey score. The chi-square test was used for statistical analysis. Patient Selection The indications for the free or ultra diced cartilage procedure are as follows: dorsum irregu- larities and asymmetries whether in primary rhi - noplasty or secondary rhinoplasty, and radix and dorsum augmentation. There are no exact con - traindications for these techniques. Included in the study were patients who underwent diced car- tilage grafting during the rhinoplasty procedure and completed their 1-year follow-up or rhino - plasty outcome evaluation questionnaire. Surgical Technique All patients underwent surgery under gen - eral anesthesia with a closed technique. During rhinoplasty, the excess cartilage tissues (from the septum surgery, trimming of the lower lateral cartilages, upper lateral cartilages, or conchal ear cartilage/rib cartilage in revision surgery) were collected. In group 1 (free diced cartilage group), these excess cartilage tissues were diced into pieces smaller than 0.2/uni00A0mm in diameter with a no. 15 blade carefully on a plastic platform. In group 2 (ultra diced cartilage group), excess car - tilage tissues were diced roughly into 4- to 5-mm pieces to /f_it the insulin syringe. Following the insertion of roughly diced car - tilage into the insulin syringe, a no. 15 blade is stuck in the tip of the syringe. This blade should be placed just above the connection of the large and narrow parts of the syringe. Another empty insu - lin syringe is prepared in the same fashion. Then, the syringe is /f_illed with cartilage, inserted into the back part of the empty syringe, and injected. During the transportation from one syringe to another, roughly diced cartilage tissue is chopped. Doing so several times can provide ultra diced car- tilage graft, which resembles cartilage paste. The procedure takes less than 2 minutes for 1 cc of ultra diced cartilage. [See Video/uni00A01 (online), which shows all steps of the technique of ultra diced cartilage graft.] The total cartilage volume was decreased from 1 cc to 0.7 cc, which shows that the dead space can be eliminated in this way. The AQ5 AQ4 lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093

Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 147, Number 4 • Ultra Diced Cartilage 3 microscopic evaluation of the ultra diced carti - lage shows the diameter of the cartilage tissue. By the presented technique, very small size cartilage pieces, almost as small as in cartilage paste, can be achieved ( Fig./uni00A0 1). Because electrostatic force keeps these small particles together (Coulomb law), even in the syringe, the ultra diced cartilage graft does not scatter around and demonstrates a shape as a compact curved line during injection. [See Video/uni00A02 (online), which shows the shape of ultra diced cartilage during injection.] RESULTS The results are summarized in Table/uni00A01. A total of 217 patients were subjected to the study; 58 of 217 patients who did not complete their 1-year follow-up or rhinoplasty outcome evaluation questionnaire were not included to the study. Eighty-four of 113 patients [ n = 62 female (73 percent) and n = 22 male (27 percent)] in group 1 and 75 of 104 patients [ n = 65 female (86 per - cent) and n = 10 male (14 percent)] in group 2 completed the /f_irst year of follow-up and the rhi- noplasty outcome evaluation questionnaire, and were analyzed retrospectively. The mean follow- up was 22 months (range, 12 to 48 months) for group 1 and 14 months (range, 12 to 30 months) for group 2. The mean age was 27.3 years (range, 18 to 54 years) for group 1 and 24.8 years (range, 22 to 49 years) for group 2. The rhinoplasty out - come evaluation questionnaire resulted in an 80.9 percent rate of satisfaction in group 1 and a 90.6 percent rate in group 2, according to both aesthetic and functional results. The mean time was 10 minutes (range, 5.6 to 15.4 minutes) for free diced cartilage and 2.5 minutes (range, 1.2 to 4.5 minutes) for ultra diced cartilage graft - ing. The mean amount of graft applied to re/f_ine the dorsum was 0.5 cc (range, 0.2 to 1 cc) for the free diced cartilage and 0.3 cc (range, 0.2 to 0.8 cc) for the ultra diced cartilage. For dorsum augmentation, the amounts were 1 cc and 0.7 cc, respectively (range, 0.6 to 2 cc and 0.5 to 2 cc), for groups 1 and 2. After two independent blinded plastic sur - geons compared immediate postoperative pho - tographs on the table and postoperative 1-year photographs, both surgeons gave 0 points to four patients (4.5 percent), 1 point to six patients (6.8 percent), and 2 points to the remaining patients Fig. 1. The microscopic evaluation of the cartilage paste (below, left), ultra diced cartilage (below, center), and free diced cartilage (below, right). Table 1. Summary of Results Characteristic Group 1 (%) Group 2 (%) No. of patients 84 75 Sex Female 62 65 Male 22 10 Mean age, yr 27.3 24.8 Mean follow-up, mo 22 14 Mean time to provide the diced cartilage, min 10 2.5 Mean amount of the diced cartilage for smoothing, cc 0.5 0.3 Mean amount of the diced cartilage for augmentation, cc 1 0.7 Change in nasal patency score Preoperatively 4.2 4.6 Postoperatively 7.5 7.2 Two independent plastic surgeon scores 0 4 (4.5) 2 (2.6) 1 6 (6.8) 1 (1.3) 2 74 (88.6) 72 (96) ROE score, % satis/f_ied 80.9 90.6 Revision rate, % 4 0 ROE, rhinoplasty outcome evaluation. Fig. 2. The histologic study perfectly demonstrated the viability of the ultra diced cartilage at 1 year after surgery. AQ7 T1 AQ6 F1 AQ8 lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093

Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 4 Plastic and Reconstructive Surgery • April 2021 (88.6 percent) for group 1; and 0 points to two patients (2.6 percent), 1 point to one patient (1.3 percent), and 2 points to the remaining patients (96 percent) for group 2. The interrater reliability for aesthetic result analysis showed perfect agree - ment (100 percent agreement, Fleiss kappa = 1). The palpation test performed by the author revealed irregularities in eight patients (9 per - cent) in group 1 (a revision operation was needed for two of them) and three patients (4 percent) in group 2, (revision was not needed; instead, the patients were just followed). In group 2, one patient had severe trauma to her face at 6 months postoperatively. In that case, a revision operation was performed because of the dorsal deviation at her /f_irst year. The medial and lateral osteotomies were redone and spreader grafts were used to stabilize the dorsum, the excessive part of the ultra diced cartilage graft was excised to re/f_ine the dorsum, and excision Fig. 3. A 34-year-old female primary rhinoplasty patient with thin skin, hump, and severe left deviated nose and bulbous tip. Preoperative frontal ( above, left) and pro/f_ile (above, right) views, and postoperative 1-year frontal ( below, left) and pro/f_ile (below, right) views. The left nasal passage was totally obstructed by the deviated nasal septum. The surgical procedure included the /f_ix-down technique to align the nose, eliminate the hump, and allow for corrective septoplasty. Tip-plasty was performed, including the superior-based transposition /f_lap with lateral crural steal and medial crural overlapping, interdomal and intradomal sutures, and anatomical columellar strut grafting through the nondelivery technique. Dorsum-radix pass was camou/f_laged by the 0.4-cc ultra diced cartilage graft injection. lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093

Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 147, Number 4 • Ultra Diced Cartilage 5 material was sent for histologic evaluation, which perfectly demonstrated the viability of the ultra diced cartilage graft (Fig./uni00A02) This procedure represents no additional cost to the operation, because the cartilaginous remnants are used to provide ultra diced carti - lage graft with two no. 15 blades and two insulin syringes. See Figures/uni00A03 and 4 for the case studies of group 2. [See Video/uni00A03 (online), a turning video which allows us to observe the result of the patient in Fig./uni00A03, from frontal, oblique, and side views with a dynamic effect on her smiling.11] DISCUSSION In the /f_ield of plastic surgery, our philosophy for reshaping the nose during rhinoplasty must consist not only of preservation but also of sup - port to prevent complications and provide long- lasting results. 12 In addition, we still need more advanced techniques for camou/f_laging the recon- structed areas and performing augmentation. To do that, diced cartilage is frequently used, which is a very nice and pliable tool for correcting irregu - larities and for augmentation; however, there are three problems that need to be solved: Fig. 4. A 32-year-old man secondary rhinoplasty patient with thin skin. The dorsum was quite asymmetric and irregular. Preoperative frontal ( above, left) and pro/f_ile (above, right) views, and postoperative 2-year frontal ( below, left) and pro/f_ile (below, right) views. The surgical procedure included dorsum reconstruction with right spreader /f_lap and left spreader graft and closing the open roof deformity with asymmetric lateral and medial osteotomies and stabilization of the nasal bones, each other with trans-bone suture. Following this severe reconstruction, the dorsum was re/f_ined by a 0.5-cc ultra diced cartilage injection. AQ9 F3, F4 F2 lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093

Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 6 Plastic and Reconstructive Surgery • April 2021 1. Diced cartilage needs a scaffold to keep it together and to be able to shape it.6,13 2. This scaffold needs more time and cost, and it may act as a barrier to prevent the diffu - sion of nutrients to the chondrocytes.9,14,15 3. The visibility of the diced cartilage, espe - cially in thin skin patients, is another main problem, which is why pieces smaller than 0.2/uni00A0 mm in diameter are recommended in the literature.9 The viability of diced carti - lage was compared with crushed or mor - selized cartilage graft in several studies. 16 Diced cartilage has shown superior results with more viable chondrocytes compared with the other two methods of graft prepa - ration. Thus, pieces of cartilage should be diced smaller than 0.2/uni00A0mm in diameter with sharp blades, and this takes a really long time but is a good investment to prevent complications. According to the author’s experience, car - tilage paste can be used to eliminate these side effects of diced cartilage grafting. Cartilage paste can be achieved classically by rasping the thick surfaces with a no. 15 blade while the non - dominant hand is holding the cartilage. [ See Video/uni00A04 (online) , which demonstrates the clas - sic way to achieve cartilage paste.] However, this method is also time consuming, and only a very small amount of the cartilage paste can be achieved, especially from the septal and ear cartilage]. The ultra diced cartilage technique presented in this article is a perfect tool for solving all of these problems. First, because of the system using two no. 15 blades and two insulin syringes, ultra diced cartilage is achieved in a very fast manner, less than 2 minutes [ see Video/uni00A0 1 (online) ], and achieves a 50-fold reduction, from 4 to 5/uni00A0 mm to less than 0.1/uni00A0mm. Second, because the presented system provides a cartilage paste, graft visibility is not going to be possible. Third, the ultra diced cartilage technique creates very small particles (<0.1/uni00A0 mm) and resembles a powder rather than diced cartilage and, as we all know, small particles are kept together by electrostatic force (Coulomb law), and this force eliminates the need for using a scaffold or liquid. The following are limitations of the study: his- tologic support to prove the viability of the ultra diced cartilage, although clinical observation of over 50 patients with at least 2-year follow-up was uneven; the technique is not comparative with other techniques; and the study is based on a single surgeon’s experience. The limitation of the technique is the tight pose needed for augmen - tation rhinoplasty to control the volume in the application side. CONCLUSIONS Ultra diced cartilage grafting is an effective and easily reproducible technique in rhinoplasty. There is no extra cost and it is the easiest and fastest way to have this perfectly pliable carti - lage, which has no dead space. The ultra diced cartilage grafting technique should be known by all plastic surgeons to achieve /f_ineness in rhinoplasty. Süleyman Taş, M.D. TAŞ Aesthetic Surgery Clinic Hakkı Yeten Cad, No. 11 Terrace Fulya, Center 1, Apt 97 Şişli, Istanbul 34349, Turkey drsuleymantas@live.com Instagram: @drsuleymantas Twitter: @drsuleymantas PATIENT CONSENT Patients provided written consent for the use of their images. REFERENCES 1. Taş S. Closed atraumatic rhinoplasty course. Available at: https://drsuleymantas.com/course/. Accessed August 11, 2019. 2. Taş S. The use of bone dust to correct the open roof defor - mity in rhinoplasty. Plast Reconstr Surg. 2018;142:629–638. 3. Taş S. A new technique to correct saddle nose deformity in failure of diced cartilage grafts: Diced cartilage /f_lap. Aesthetic Plast Surg. 2015;39:764–770. 4. Taş S. Dorsal roof technique for dorsum preservation in rhi- noplasty. Aesthet Surg J. 2020;40:263–275. 5. Peer LA. Extended use of diced cartilage grafts. Plast Reconstr Surg (1946) 1954;14:178–185. 6. Erol OO. The Turkish delight: A pliable graft for rhino - plasty. Plast Reconstr Surg. 2000;105:2229–2241; discussion 2242–2243. 7. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg. 2004;113:2156–2171. 8. Brenner KA, McConnell MP, Evans GR, Calvert JW. Survival of diced cartilage grafts: An experimental study. Plast Reconstr Surg. 2006;117:105–115. 9. Kreutzer C, Hoehne J, Gubisch W, Rezaeian F, Haack S. Free diced cartilage: A new application of diced cartilage grafts in primary and secondary rhinoplasty. Plast Reconstr Surg. 2017;140:461–470. 10. Alsarraf R, Larrabee WF Jr, Anderson S, Murakami CS, Johnson CM Jr. Measuring cosmetic facial plastic surgery out- comes: A pilot study. Arch Facial Plast Surg. 2001;3:198–201. 11. Safaryan D, Santareno S, Ta ş S. Dynamic video-photograph studio: A new rhinoplasty documentation. Aesthetic Plast Surg. 2020;44:1093–1096. AQ12 AQ11 AQ10 lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093

Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 147, Number 4 • Ultra Diced Cartilage 7 12. Taş S. Response to commentary on: Dorsal roof technique for dorsum preservation in rhinoplasty. Aesthetic Plast Surg. 2020;44:1102–1105. . 13. Baker SR. Diced cartilage augmentation: Early experience with the Tasman technique. Arch Facial Plast Surg. 2012;14:451–455. 14. Bullocks JM, Echo A, Guerra G, Stal S, Yuksel E. A novel autologous scaffold for diced-cartilage grafts in dorsal aug - mentation rhinoplasty. Aesthetic Plast Surg. 2011;35:569–579. 15. Fatemi MJ, Hasani ME, Rahimian S, Bateni H, Pedram M, Mousavi SJ. Survival of block and fascial-wrapped diced carti- lage grafts: An experimental study in rabbits. Ann Plast Surg. 2012;69:326–330. 16. Trivisonno A, Cohen SR, Magalon G, et al. Fluid cartilage as new autologous biomaterial in the treatment of minor nose defects: Clinical and microscopic difference amongst diced, crushed, and /f_luid cartilage. Materials (Basel) 2019;12:1062. lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093lww 18/2/21 15:49 4 Color Fig(s): F1-4 Art: PRS-D-20-00093