Irradiated homograft costal cartilage was used as the principal nasal augmentation material in 117 patients between January 1, 1984 and December 31, 1990.
Fig 1.-Top, A large irradiated homeograft costal cartilage (IHCC) block taken directly from the bottle with perichondrium intact. Since many saddle deformities require lengths of greater than 4 cm, the IHCC block should measure at least 5 to 7 cm in length. A single block of IHCC this size is usually sufficient to provide enough graft material for an entire nasal reconstruction. Bottom, A piece of IHCC that will be used as a dorsal onlay graft. The perichondrium was removed and the graft is being contoured with a cutting burr.
Fig 2.-Top, A dorsal onlay graft is being prepared to correct a saddlenose deformity using the open rhinoplasty dpproach. Bottom, A closeup view of the completely contoured graft being positioned into a precise pocket over the nasal dorsum. At least two sutures are used for stabilization to prevent postoperative displacement.
A total of 122 surgical procedures were performed during that time. Forty patients underwent primary nasal surgery and 82 patients underwent revision procedures (Table 1). Four patients in the primary surgery group eventually required revision nasal surgery for supplemental nasal augmentation with IHCC; three of those patients underwent a single revision procedure while one patient required two revision procedures. Graft material other than autogenous cartilage was required in all patients because of limited donor availability (eg, a previously operated-on septum) or because of patient refusal to accept donor site morbidity in the auricle or costochondral region.
All IHCC grafts were obtained from the University of Texas Health Science Center at Dallas or from the Northern California Tissue Bank, San Francisco. At the time of surgery the IHCC graft was aseptically removed from its container and placed in 500 mL of a sterile saline solution with 80 mg of gentamicin sulfate. Prior to sculpting, a scalpel was used to remove all perichondrial remnants from the graft’s outer surface.
Each graft was initially shaped with a fresh scalpel. Residual irregularities were smoothed with a hand-held drill and cutting burr or by gently shaving the graft’s surface with a sharp scalpel blade (Fig 1). All cases were managed using the open rhinoplasty approach. The open approach is advantageous because it allows for exact graft positioning and it minimizes the need for extensive intranasal incisions (Fig 2). This approach also maximizes the distance between the incision lines and the graft sites. Multilayered grafts were generally unnecessary because of the large blocks of IHCC available. Whenever possible, dorsal onlay grafts were stabilized using precisely created pockets over the nasal dorsum. Early in the series, braided polyester or braided polyglycolic acid sutures were used to sew grafts into place. Following a few well-localized suture infections, absorbable 6-0 polydioxanone and permanent 6-0 polypropylene monofilament sutures were substituted to secure the IHCC grafts whenever mobility or stability was a concern. All patients received antibiotics 12 hours prior to and for 1 week following surgery.
Fig 3.-Top left, center left, and bottom left, Preoperative views of a 44-year-old man injured 20 years earlier playing basketball. There is marked dorsal saddling and loss of tip support secondary to absence of the caudal septum. Top right, center right, and bottom right, Irradiated homograft costal cartilage was used to repair the nose. An onlay graft corrected the dorsal saddle deformity and a large caudal septal replacement graft was used to resupport the tip.
Fig 4.-Intraoperative photographs of the patient in Fig 3. This patient had a traumatic nasal injury that resulted in a dorsal saddle deformity and loss of the caudal nasal septum. Top left, Loss of the caudal septum has severely weakened support in the nasal tip. Light digital pressure collapses the lower lateral cartilages. Top right, Base view of the nose with the medial crura separated demonstrating the absent caudal septum. Bottom left, right, Base view of the caudal septum replacement graft between the medial crura prior to suture stabilization.
Clinical factors were used to evaluate the degree of graft resorption and the maintenance of nasal augmentation. For consistency, standard preoperative and postoperative photographs were taken of each patient using the same lighting, background, patient positioning, and photographic equipment. High-quality profile views were deemed essential for accurate preoperative and postoperative comparisons.13 Early postoperative photographs were taken at 6 weeks to document the amount of augmentation achieved at the time of surgery. Earlier photographs were not used for comparison because of the anticipated postoperative edema that occurs with nasal surgery. Whenever possible, subsequent postoperative photographs were taken on a semiannual basis. Each nose was carefully palpated prior to surgery and on all following postoperative visits to assess for graft integrity and degree of graft resorption. Graft resorption was classified as none (O%), minimal (O% to 25%), moderate (25% to 50%), near complete (50% to 75%), or complete (75% to 100%). Resorption patterns were further classified as short term (<3 months) or long term (>3 months).
Fig 5.-Top left, center left, and bottom left, Preoperative views of a 43-year-old man with a posttraumatic saddle deformity deformity of the nasal dorsum and loss of tip support. Top right, center right, and bottom right, Postoperative views 30 months following nasal reconstruction with irradiated homograft costal cartilage (IHCC) dorsal onlay and caudal septal replacement grafts. There has been no postoperative IHCC graft resorption noted.
Fig 6.-Top left and bottom left, Preoperative view of a 35-year-old woman. An unsuccessful septorhinoplasty done elsewhere resulted in marked dorsal saddling, bilateral nasal valve collapse, bilateral alar rim retraction, and columellar show. Top right and bottom right, Postoperative views 18 months after nasal reconstruction. Multiple irradiated homograft costal cartilage graft,5 were used as onlays to augment the dorsum and the collapsed alar rims. Irradiated homograft costal cartilage spreader grafts were used to reconstruct the collapsed nasal valve regions.
