In 1961, Dingman and Grabb 8 were the first to report success using IHCC for restoring contour defects of the face. Eleven years later, they reported continued success and minimal resorption of IHCC grafts in more than 600 patients. 9 A national clinical survey organized by Donald and Col 14 reported IHCC to be a useful graft material that appeared to undergo less resorption than similarly placed autogenous cartilage grafts. Schuller et al 10 reported a 1.4% partial resorption rate in 145 IHCC grafts used in a variety of locations for facial contour restoration; their longest follow-up was 36 months. Welling et al 11 pursued that study and reported the long-term follow-up on 62 of the original 145 grafts. They noted that the average resorption rate rose to 75% in patients 9 years after implantation.
Although those previous studies examined the average resorption rates for IHCC grafts located in various regions about the face, they did not specifically focus on the fate of IHCC implanted into the nose. Resorption rates and clini cal success rates appeared to vary with graft location on the face. Donald 12 identified regional discrepancies regard ing IHCC resorption. He noted that grafts placed over the dorsum of the nose and the malar eminence showed little resorption, while grafts placed in other facial areas exhibit ed higher resorption rates. It was hypothesized that vari able, location-dependent resorption rates may occur sec ondary to local conditions at the implantation site. Grafts subjected to regular muscular activity or significant overly ing pressure appeared more susceptible to resorption.
Chaffoo and Goode 15 reported a series of 35 IHCC nasal grafts in 13 patients. They noted no evidence of resorption in patients followed up for at least 1 year post operatively. Murakami et aI 16 studied the use of IHCC for reconstructing complex and compound saddle-nose defor mities in 18 patients. In each case an articulated dorsal and caudal graft was used to restore nasal contour and support. They reported no cases of infection, extrusion, or resorption during an average follow-up period of 2.8 years. Despite the optimistic results reported by these two groups, Maves 17 continued to discourage the use of IHCC in humans.
This article reports the largest series of IHCC grafts used specifically for nasal reconstruction to date. Irradiated homograft costal cartilage was used throughout the nose to correct a variety of functional and cosmetic problems. On follow-up examinations extending up to 84 months, most patients with IHCC nasal grafts were found to maintain their cosmetic and functional corrections (Figs 5 and 6). Regional variances in resorption were not rec
ognized; that is, IHCC nasal grafts, regardless of location, appeared to maintain the correction intended. Resorption was found to be a definite risk in cases of infection, espe
cially when treatment was delayed. Only two of 306 grafts (both in the same patient) were completely resorbed. In that case, total resorption was found in the early postoper
ative period and resulted from a well-localized infection at the graft site. On long-term follow-up, two of 117 patients were found to have experienced partial resorption of their IHCC nasal grafts, both of those being dorsal onlay grafts. Resorption was minimal in both patients.
This study, along with prior clinical studies, 8,9 conflicts with the results of irradiated cartilage graft longevity in experimental animal studies. In experimental animals, irra diated cartilage appears to undergo progressive and even tually complete resorption 18,19 In contrast to animal studies where grafts can be surgically removed at any time for close inspection, clinical studies such as this are limited because of the difficulty involved in directly measuring the exact amount of graft remaining at the implantation site. Despite clinical evidence of reliable nasal augmentation and support following IHCC grafting, there is no guarantee that the previously placed IHCC grafts are actually intact (unless the patient is brought back to surgery for a second look). Several investigators 11,14,16 have documented experi ences where good long-term facial augmentation resulted despite clinical evidence of IHCC graft resorption. Welling et al 11 noted that approximately half of patients with com plete graft resorption maintained the original augmentation effect. If long-term IHCC resorption is inevitable, propor tionate fibrous tissue replacement may be responsible for the clinical successes reported by Dingman and Grabb 9 and by Donald and Col. 14 Resorption therefore would not be a factor in nasal surgery if trie overall cosmetic and func tional results were preserved.
Complications following the use of IHCC occur infre quently in nasal surgery. Short-term complications includ ed three patients (2.5%) with graft-related infections. Delayed treatment, as was observed in one patient, can result in complete and rapid graft resorption. Two patients witil early postoperative infections were treated promptly and never showed evidence of graft loss. As previously noted by Dingman and Grabb, 9 the early utilization of antibiotics and prompt, aggressive local wound care gen erally results in the successful management of localized infections without loss of graft material. Long-term com plications were limited and included one case (0.8%) of a localized, suture-related, wound infection. Dorsal onlay grafts were responsible for the other long-term complica tions. Among the 74 patients with dorsal onlay grafts, three patients (4.0%) demonstrated persistent graft mobil ity and two patients (2.7%) experienced graft warping. Precise, well-tailored pockets and sutured grafts are rec ommended to reduce the risk of graft mobility. The low rate of graft warping is consistent with that of other reports. 9 This contrasts greatly with the rate of warping seen with fresh autogenous rib cartilage and is probably a consequence of irradiation processing.
Although resorption has not emerged as a problem on patients followed up to 84 months postoperatively, the fol-low-up period is still regarded as short term and these results are considered preliminary. Even if minimal anti genic stimulation exists on the surface of the IHCC grafts, the potential for progressive resorption certainly exists. If graft resorption does emerge as a problem, the role of fibrous tissue replacement and its ability to maintain aug mentation will need documentation. Continued long-term follow-up will be maintained with this patient population to further delineate the exact fate of the IHCC nasal grafts.
