Viability of diced and crushed cartilage with different supportive sleeve material

Diced and crushed cartilage can be wrapped in different sleeve material. One of the main purposes for this is to camouflage irregular firm jagged edges of cartilage for a smoother cosmetic result especially in those with thin skin. Nose Revision Specialists have used the following materials as sleeves or fillers: Autogenous deep temporal fascia, Perichondrium, Surgicel (oxidized methylcellulose), dermal grafts, synthetic material and  esterified hyaluronic acid (HYAFF). A couple of study's have indicated the superiority of using deep temporal fascia or  esterified hyaluronic acid over surgicel (The Turkish delight method). I haven't come across any clinical experimental study's on Perichondrium  viability- reabsorption rate comparisons .  Dr. Eugene  A. Chu of John Hopkins University Dept. of Otolaryngology makes a recommendation to remove the perichondrium completely from the costal cartilage to limit warping, however Dr. Dean Toriumi, has claimed years of success with using perichondrium which will make the skin thicker and more importantly  help prevent graft visibility and deformity. Apparently it has given him a better long term outcome. Even though a few Surgeons have claimed success on long term follow up's with the Turkish delight method, most clinical studies indicate it is an inferior material to use, due to higher reabsorption rate of the contained cartilage.

According to Dr. Ozcan Cakmak and Dr. Fuat Buyuklu:

Some authors have stated that autogenous soft tissue grafts, such as dermal grafts³ or temporalis fascia grafts,⁵ are satisfactory for covering underlying dorsal irregularities. However, those materials have disadvantages of possible partial resorption and donor-site morbidity. Although some authors have suggested that temporalis fascia grafts are among the most reliable materials and are associated with reasonably low resorption rates,^{5, 8, 23} those grafts are difficult to manipulate because they are thin and slippery.^23-24 Alloplastic materials, such as gelatin film,⁴ polyglactin 910 (Vicryl suture; Johnson & Johnson Gateway LLC, Piscataway, New Jersey),⁶ and Gore-Tex (W. L. Gore & Associates Inc, Newark, Delaware),⁷ have also been advocated for that purpose. However, absorbable synthetics do not last long, and of all graft materials, nonabsorbable synthetics are associated with the highest rates of infection and extrusion.^{2, 11} A soft-tissue filler, AlloDerm (LifeCell Corp, Branchburg, New Jersey), which is derived from cadaveric skin, is another material frequently used to achieve a smoother nasal dorsum. However, AlloDerm has the definite disadvantage of partial graft resorption, especially when it is positioned over the dorsum in patients with thin skin.

Although the maintenance of typical cartilage viability and a high graft survival rate have been reported with the use of this material, harvesting the temporalis fascia adversely affects the donor site, where either permanent or transient alopecia can develop after surgery.

Many authors have used bare crushed cartilage grafts to conceal dorsal irregularities and to achieve a smoother nasal surface.

http://archfaci.ama-assn.org/content/9/5/352.full

http://www.eclips.consult.com/eclips/article/Plastic-and-Aesthetic-Surgery/S1535-1513%2808%2970595-2

http://www.ncbi.nlm.nih.gov/pubmed/17690607

http://emedicine.medscape.com/article/881443-treatment

http://deantoriumi.com/faq1.asp

Crushed vs Diced Cartilage: Similarities and Differences

Looking at some forums I noticed some people are using the words crushed and diced cartilage interchangeably as if they are same thing. Another important  issue i would like to address here is correlation between  the degree of crushed cartilage and how it effects the long term outcome (re absorption rate) of the surgery.

Crushing cartilage is procedure that takes pieces of cartilage and crushes it in a device called Cottle cartilage crusher and/or using a mallet. They can be crushed to varying degree's from slightly crushed to severely crushed. They are then inserted in the desired area of the nose using a medical tweezer.

Dicing cartilage is procedure where the cartilage is sliced using a straight edge razor blade into small fine pieces.  The cartilage is normally diced into <0.5mm squares, using two #11 blades avoiding, not being morselized or crushed. . Then it is placed in a syringe to be later injected in the desired area and molded/shaped accordingly. Usually diced cartilage  is wrapped in soft material preferably deep temporal fascia.

Both crushed and diced cartilage is used to smoothen out or camouflage nasal surface area's where cartilage is placed in the nose , like the dorsum, to conceal any irregularities. Both can be wrapped or combined with different material as well.

Crushed cartilage grafts can be used for the following purposes: (1) to cover the sharp edges of an irregular nasal framework after hump resection    (2) to serve as an underlying padding material to prevent skin adhesion   (3) to fill pit holes and, thus, mask irregularities   (4) as a filler to mask asymmetries and depressions on the side walls  (5) for tip grafting   (6) to camouflage the edges of solid onlay grafts  , (7) to supply minor dorsal augmentation for the correction of an overresected dorsum, and (8) to increase the thickness and natural color of the overlying skin where skin atrophy had occurred. I believe diced cartilage can be used in most of the above situations as well.

Crushed Cartilage Grafts for Concealing Irregularities in Rhinoplasty

1. Ozcan Cakmak, MD;
2. Fuat Buyuklu, MD

Our current clinical series confirmed our previous animal⁹ and human cell culture¹³ studies that the degree of crushing applied is important to the long-term clinical outcome of crushed cartilage grafts used in rhinoplasty.

The results showed a correlation between the degree of crushing applied and the resorption rate of the crushed graft, especially in grafts applied at the dorsum. The resorption rate was zero in slightly crushed grafts, 2.1% in moderately crushed grafts, and 13.1% in significantly crushed grafts. Our results show that slight or moderate crushing of the autogenous cartilage produces an outstanding graft material that is effective in concealing irregularities, filling defects, and creating a smoother surface, with excellent long-term clinical outcome and predictable esthetic result. We suggest that intact cartilage should be used to correct major deformities and that moderately crushed grafts should be used for smaller depressions to minimize resorption. The severely crushed form of cartilage should not be used as filler except to correct negligible depressions in atrophic skin.

The edges of solid onlay grafts might be softened by placing small pieces of moderately crushed grafts on or around the solid graft. The tiny pieces of moderately or significantly crushed grafts might be successfully used in final contouring at the conclusion of surgery. In patients with thin skin or in whom revision is required, a thin layer of moderately or significantly crushed cartilage would be the proper option as a padding material to prevent the adhesion of skin and to camouflage the sharp edges of the nasal skeleton that might be visible after edema has subsided.

From the above study,  one would presume that  thinner and smaller diced cartilage would also have higher resorption rates then thicker larger pieces, but I haven't seen any clinical studies to support or contradict that conclusion. 

http://archfaci.ama-assn.org/content/9/5/352.full