REVIEW
CURRENT
OPINION Advances in nasal dorsal augmentation with
diced cartilage
Abel-Jan Tasman
Purpose of review
The quest for the ideal method for augmenting the nasal dorsum continues to be a matter of debate, with
alloplastic materials and autologous tissues each having distinct advantages. This review focuses on the use
of autologous tissues, diced cartilage in particular.
Recent findings
In the western world, the preferred tissue has been autologous cartilage with diced cartilage in a sleeve of
fascia having become the dominant technique in the last decade. This review highlights the characteristics
of different augmentation techniques, giving particular attention to a recent modification of a diced
cartilage graft, described as the Tasman technique. The technique bonds the cartilage with fibrin glue,
greatly improving the ease of graft preparation and its versatility. A morphometric study has shown this
graft to be stable over a 15-month follow-up period.
Summary
Using autologous tissue for nasal dorsal augmentation meets the preference of most patients and surgeons.
The diced cartilage glue graft is a welcome addition to the rhinoplasty armamentarium.
Keywords
diced cartilage, dorsal augmentation, fibrin glue, rhinoplasty
INTRODUCTION &&
[1 ,4,5]. Optimal biocompatibility and a low risk
The ideal tissue or material for dorsal augmentation of infection or extrusion are considered to be
should be readily available, biocompatible, harvested the decisive advantages of autologous tissue grafts
with low donor site morbidity and should have a low that must be weighed against the disadvantages of
cost and a low risk of infection or extrusion [1 ].
&&
available graft volume, shape, absorption, donor site
Alloplastic materials, such as silastic, expanded morbidity, and aesthetic results [6,7].
polytetrafluorethylene, and porous polyethylene, Septal cartilage, having low absorption rates, is
continue to be the material of choice for many traditionally considered first choice for most graft-
surgeons. In Asia, for example, alloplastic implants ing purposes. It has a limited value in dorsal
continue to be widely perceived as a viable option augmentation because of its available volume and
&&
for dorsal augmentation [2 ]. In the United States, size, especially in so-called graft-depleted patients,
however, even Asian rhinoplasty is said to be charac- in whom most of the septal cartilage has been taken
&&
terized by a growing preference for autogenous in previous operations [1 ,8]. In addition, it is
grafts with the rhinoplasty surgeon confronting difficult to carve the straight septal cartilage graft
the conundrum ‘high complication rate with allo- to fit the contour of the dorsum. Likewise, solid
plastic implants versus the aesthetic limitations of conchal cartilage grafts tend to be ill-fitting because
autogenous techniques’ [3]. What are the compli- of their curvature and small size. In an attempt to
cation rates of alloplastic implants, what are the
aesthetic limitations of autologous tissues, and which Rhinology and Facial Plastic Surgery, Department of Otolaryngology,
new techniques may improve their versatility? Cantonal Hospital St. Gallen, St. Gallen, Switzerland
Correspondence to Abel-Jan Tasman, Hals-Nasen-Ohrenklinik,
Kantonsspital St. Gallen, Rorschacherstr 95, CH-9007 St. Gallen,
AUTOLOGOUS AND HOMOLOGOUS Switzerland. Tel: +41 71 494 1693; fax: +41 71 494 6179; e-mail:
TISSUES FOR DORSAL AUGMENTATION abel-jan.tasman@kssg.ch
More recent trends in dorsal augmentation have Curr Opin Otolaryngol Head Neck Surg 2013, 21:365–371
strongly favoured the use of autologous tissues DOI:10.1097/MOO.0b013e3283627600
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Facial plastic surgery
with intact or mildly crushed cartilage faring better
KEY POINTS in retrospective clinical and animal studies [20,21].
Dicing cartilage for dorsal augmentation makes
grafting with autologous tissue more predictable
and versatile. DICED CARTILAGE
Experience with diced cartilage, which is cleanly cut
The long-term success of the diced cartilage fascia graft
and not crushed, dates back to the 1940s. Long
has been studied extensively.
after Peer’s first description of diced cartilage grafts
Bonding diced cartilage with fibrin glue instead of in 1954, the concept received much attention after
placing it in a fascia sleeve further improves versatility, the publication of remarkable long-term success
especially for partial dorsal augmentation. after augmentation with diced cartilage wrapped
Clinical follow-up and sonographic morphometric and in oxidized regenerated cellulose [22]. Enthusiasm
histological data have shown diced cartilage glue for this new graft called ‘Turkish Delight’ was not
grafts to be stable for more than 1 year. shared by other authors, who found a foreign body
reaction induced by the wrapper with cartilage
absorption. If autologous fascia was used to hold
the cartilage instead, good long-term survival of the
overcome these drawbacks, conchal cartilage has graft in over 300 cases in 9 years was reported,
&&
been slightly crushed and cut into segments that obviating the need for overcorrection [1 ]. The role
were fixed to retroauricular fascia in varying of the fascial sleeve for cartilage survival was initially
patterns [9]. Still, conchal cartilage in one piece is considered crucial [5], but was later questioned by
currently less popular for augmentation of the two studies comparing survival of solid block and
&&
dorsum than in the form of diced cartilage [1 ]. diced cartilage wrapped in fascia in rabbits [23,24].
Solid costal cartilage grafts have been used exten- Today, for many surgeons, the diced cartilage
sively for dorsal augmentation but postoperative fascia (DCF) graft is the standard for dorsal aug-
donor site pain, stiffness, suboptimal shape of the mentation, as it combines versatility with the use
graft, and a high percentage of warping continue to of autologous tissues, preferred by many patients
be a matter of concern [10]. Harvesting the central and surgeons alike. One obvious drawback is the
rib segment only and preserving the continuity of need to harvest a 5 5 cm sheet of deep temporal
the rib by leaving an inferior strip have been fascia for a sleeve [3] and sewing a recipient pocket
suggested to reduce donor site morbidity [11,12]. adding time to the procedure. Numerous attempts
Homologous irradiated costal cartilage grafts have have been made to simplify the procedure. Auto-
properties that come close to autologous rib grafts, logous temporalis fascia has been replaced by Allo-
obviate donor site morbidity and have been Derm (LifeCell EMEA Ltd, Langford Business
proposed as a good alternative. Favourable long- Park, Kidlington, UK) [25] and a hyaluronic acid
term outcomes in a large patient series [13] but also membrane that was also found to improve cartilage
revision rates of up to 26% have been reported for survival compared to oxidized regenerated cellulose
dorsal augmentation with solid costal cartilage [26]. Diced cartilage has also been injected over a
grafts [14]. Warping of costal cartilage en-bloc grafts cartilage framework without a sleeve [27] or bonded
continues to be a major drawback. Laminating the with autologous tissue glue created from platelet-
cartilage followed by stacking and suturing the slices rich plasma (platelet gel) and platelet-poor plasma
in an alternating orientation has been proposed (fibrin glue) [28]. As the controversy on the optimal
[15]. Cyanoycrylate glue has also been used for this substance or scaffold for delivering diced cartilage is
purpose in a porcine model but was found to induce ongoing, new studies have recently been called for
&&
a strong foreign body reaction and partial loss of [2 ].
the graft [16]. Homologous lyophilized bone and Regardless of what is used for a sleeve, the graft
fascia lata have also been used [17,18]. Tutoplast- will tend to acquire an oval or kidney-shaped cross-
processed fascia lata had been used successfully section, depending on the size of the sleeve and
in combination with diced cartilage with high the degree of filling. This shape is not anatomic,
patient satisfaction rates and predictable outcomes as the side of the graft will not smoothly blend with
for dorsal augmentation [19]. the nasal dorsum. The consequence may be a visible
To overcome the incongruent shape of solid depression or groove parallel to the dorsum on
cartilage grafts, septal cartilage in particular, either side of the graft. This is often seen with solid
weakening of grafts by crushing has been widely rib transplants and tightly packed DCF grafts. It has
used in the past. The degree of crushing is now been suggested to camouflage this incongruence by
known to have a strong impact on resorption rates inserting cartilage dices alongside the graft, between
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Advances in nasal dorsal augmentation with diced cartilage Tasman
&&
the dorsum and the graft [1 ]. This additional made from a 2-ml or 5-ml disposable syringe that is
manoeuvre adds complexity to the operation and cut into half along its axis. The diced cartilage
may have a negative impact on its predictability. is then moulded into the desired shape and
Doing so, a ‘designer dorsal graft’, may be fashioned care is taken to eliminate any avoidable dead space
using a combination of bare diced cartilage, diced between the cartilage fragments. These are then
&&
cartilage under fascia, or in a fascia sleeve [1 ]. bonded by adding a few drops of the fibrinogen-
Still, using the techniques described so far, it is containing component and compressing the graft
difficult to obtain an anatomically correct with two fingertips, squeezing out excessive
crescent-shaped cross-section with tapered sides. fibrinogen. The technique is described in detail in
Also, one of the most challenging grafts is the afreelyaccessiblevideo(http://archfaci.jamanetwork.
half-length dorsal graft, which fills the radix area com/multimediaPlayer.aspx?mediaid=5132635).
&&
and upper dorsum [1 ], again because of difficulties The whole dorsum (Fig. 1), parts of the dorsum
in tapering the cranial and caudal end of the (Fig. 2), and the radix (Fig. 3) have been augmented
segmental graft. by 2 10 mm and the longevity of the graft has been
studied using morphometry of sonographic cross-
sections and histological examination of graft biop-
THE DICED CARTILAGE GLUE GRAFT sies taken more than 1 year after transplantation
&
Recently, a technique based on bonding of [30 ]. During the clinical follow-up, ranging from
diced cartilage with commercially available two- 6 to 22 months in a group of 24 patients, the grafts
component fibrin glue has been presented as the were found to heal uneventfully in all patients and
&
Tasman technique [29 ]. The rationale behind to be stable when comparing standardized photo-
this modification was an attempt to simplify the graphs and sonographic cross-sections of the graft.
laborious preparation of a DCF graft, improve the Volume loss of the graft was seen during the early
versatility, especially for partial dorsal augmenta- postoperative phase with diameters of the grafts
&
tion and creating an anatomical shape [30 ]. Fibrin decreasing up to 16%, except for early cases in which
as a scaffold for cartilage tissue engineering had more fibrin sealant had been used. Minor but visible
received substantial attention in recent years with irregularities of the caudal end of the graft were
reports commenting favourably on chondrocyte resected in two patients 14 and 20 months after
viability in different fibrin-based carriers both transplantation. Intact cut edges of the cartilage
in vitro and in vivo. Using fibrin gel as a cell delivery dices with no or minimal signs of absorption were
system had been found to result in higher cell seen in histological sections (Fig. 2). The dices
seeding efficiency, more even cell distribution, were embedded in a sleeve of fibrous connective
and increased retention of newly synthesized tissue. All chondrocytes appeared to be vital and
glucosaminoglycans (GAGs), compared with seed- formation of small clones, consisting of clusters of
ing without fibrin [31,32]. Chondrocyte prolifer- more than four chondrocytes was seen, indicating
ation and cartilaginous tissue formation with cartilage regeneration.
development of cartilage-specific extracellular
matrix components GAG and collagen type II
increased up to five-fold with excellent chondrocyte COMMENT
viability if fibrin was added to hybrid scaffolds Alloplastic materials continue to be considered first
[33–37]. Fibrin appeared to be an excellent carrier choice by many surgeons in Asia, whereas the use of
of chondrocytes for tissue engineering and the autologous tissue, cartilage in particular, is standard
author set out to use it as a binder for diced cartilage. of care in the western world. The DCF graft
has greatly expanded the spectrum of autologous
cartilage augmentation and is the preferred method
TECHNIQUE for many surgeons today. The diced cartilage glue
Autologous nasal septal, auricular, or costal cartilage (DCG) graft widens the field of autologous cartilage
pieces are set aside in a solution of 3 mg/ml augmentation even further, while reducing operat-
ciprofloxacin solution, which is known to diffuse ing time. One advantage of the DCG graft compared
into the cartilage obviating the need for systemic with the DCF graft is its superior versatility,
antibiotics [38]. The cartilage is then diced or cut especially for augmentation of segments of the
into fine slivers and impregnated with a few drops of dorsum only, which is considered to be the most
&&
the thrombin component of the two-component challenging form of dorsal augmentation [1 ].
fibrin sealant TISSEEL DUO S (Baxter International Another advantage is its relative speed and ease of
Inc., Newbury, Berkshire, UK). A mould is prepared preparation. Also, thin, finely tapered grafts less
according to the desired shape of the graft, typically than 2-mm-thick can be fashioned. Finally, the graft
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Facial plastic surgery
(a) (b) (c) (d)
(e) (f)
(g) (h)
FIGURE 1. A patient with a posttraumatic saddle-nose deformity before (a; c) and 5 months after dorsal augmentation (b; d).
The diced cartilage glue graft was fashioned using remnants of septal cartilage and auricular cartilage from one ear using a
5-ml syringe as a mould (e; f). The tapering of the graft at the cranial and caudal ends, the concavity of the posterior surface
(e) and the convexity of the anterior surface (f) can be seen. Sonographic cross-sections of the graft at the sixth postoperative
day (g) and 5 months after surgery (h) revealed stability of the graft. This figure is reproduced with permission from [30 ].
&
can easily be given an anatomical shape with a a current market price of 1 ml Tisseel of less than
crescent-shaped cross-section. Several limitations 150 Euro. This additional cost may be more than
of the DCG graft deserve being highlighted. First, compensated for by the time saved compared
the tissue glue adds to the cost of the procedure with with the alternative of harvesting temporalis fascia
368 www.co-otolaryngology.com Volume 21 Number 4 August 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Advances in nasal dorsal augmentation with diced cartilage Tasman
(a) (b) (c) (d)
(e) (f)
(g) (h)
FIGURE 2. An iatrogenic cartilaginous polly-beak deformity and an overresected bony dorsum (a; c) were revised by
lowering the cartilaginous dorsum and augmenting the bony dorsum with a diced cartilage glue graft (e; f). Fifteen months
later an irregularity that sonographically could be attributed to the insufficiently tapered caudal end of the graft ( on d; e; f)
was resected. Hematoxylin eosin (g) and Elastica van Gieson (h) stained sections revealed vital cartilage, no signs of
absorption and several small clones of regenerating chondrocytes showing basophilia (HE 100) (g). Groups of clones in a
red collagenous matrix (EvG 200) (h). This morphology and chondrocyte clusters are indicative of cartilage regeneration.
This figure is reproduced with permission from [30 ]. HE, hematoxylin–eosin; EvG, Elastica van Gieson.
&
and preparing a sleeve for a DCF graft. Second, technical aspect is the need for a wide surgical access
because of its fragility the graft lends itself to aug- to the recipient bed with a pocket large enough to
mentation only. It is not a structural graft. This, accommodate the graft without compression by the
however, is also true for the DCF graft. An important inserting instrument. This is of much less concern
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Facial plastic surgery
(a) (b) (c)
(d)
(e)
FIGURE 3. A minor aesthetic improvement without osteotomies was requested by a patient with a posttraumatic septal
deformity with saddling of the cartilaginous dorsum and a nasal hump (a). The septum was rotated and the hump
camouflaged with a diced cartilage glue radix graft, moulded in a 2-ml syringe (c, d). Four months after surgery (b) the graft
measured 7.2 1.8 mm (e). This figure is reproduced with permission from [30 ]. &
when using a DCF graft. Third, migration of cartilage REFERENCES AND RECOMMENDED
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&& of outstanding interest
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