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Irradiated Cartilage Grafts in the Nose A Preliminary Report Page 01 Page 02 Page 03 Page 04 Page 05 Page 06 Page 07

Kridel and Konior ¹ describe results in 306 irradiated homograft costal cartilage (IHCC) grafts used in 122 surgi cal procedures. Of these, 83 irradiated cartilage grafts were used as columellar struts, and 74 were used as dorsal onlays. The authors view this article as "preliminary," citing the short-term follow-up period. (One patient was followed up 7 years, but the distribution of follow-up period in the rest of the series was not clarified.) I would agree that con tinued good results after a longer follow-up periodwould appear necessary before a return to widespread usage of IHCC is advised.

Irradiated homograft cartilage has been used exten sively in nasal surgery for many years. Animal studies, however, have shown that long-term intact survival of irra diated homograft cartilage is minimal. ^2,3 The excellent investigation by Donald ⁴ demonstrated complete resorp tion in 87.7% of irradiated cartilage grafts in dogs and sheep, while only 43.8% of control animals treated with thimerosal (Merthiolate) underwent complete resorption. ⁴ In that study, viable host chondrocytes were found in some of the thimerosal-treated grafts, but not in the irradiated ones. Hence it would appear that irradiation interfered somehow with population of IHCC by living host cells.

Several prior clinical reports have described excellent results with IHCC in humans. Schuller et al ⁵ noted satisfac torily low resorption rates in 1977. Forty-two of these same 107 patients were subsequently reviewed and reported on again by Welling et al ⁶ in 1988. This landmark article, with follow-up periods from 5 to 16 years, confirmed that the high resorption rates noted previously in animal studies were also present in humans after long-term follow-up. Fifty-three of the 62 grafts demonstrated more than 50% resorption, and 29 were completely resorbed. For many surgeons, the Welling et al ⁶ report resolved the prior con flict between animal and human data was resolved. Many surgeons began using auricular and costal autogenous cartilage in reconstructive and aesthetic nasal surgery, par ticularly with the growing threat of the human immunode ficiency virus and lack of information (at the time) as to whether the virus was universally destroyed by highdose irradiation. This clinical series does little, in this reviewer's opinion, to negate the above.

Since switching to autogenous cartilage in 1988, I have not experienced the phenomenon reported by the authors regarding harvesting of autogenous cartilage, "patient refusal to accept donor site morbidity from the auricle or costo-chondral region." As many surgeons are currently satisfied with usage of autografts, a subsequent review (say in another 4 to 5 years) of this series of irradi ated cartilage homografts would be a most welcome con tribution to the literature, particularly since this report dis cusses only nasal grafts, unlike that of Welling et al ⁶ and Schuller et al ⁵ and because it is certainly more convenient to use homograft cartilage material.

It is possible that the fate of grafts placed in the nasal dorsum is different from those placed as tip grafts or as columellar struts. The columellar strut particularly would seem to be subjected to muscular forces accompanying smiling, eating, talking, etc, and may be more quickly resorbed than grafts placed in the less active nasal dorsal space. Additional studies may clarify whether fibrous tis sue replacing a resorbed cartilage graft may continue to provide tissue contour and aesthetic enhancement. The 74 dorsal grafts in this series should be an ideal source for long-term resorption data, while those in the columella may present more difficulty in ascertaining subsequent graft viability. It is possible that serial measurements, over time, of nasal tip projection in patients with columellar struts would yield further information as to the fate of these grafts. The authors are complimented on a large series and are encouraged to continue follow-up observa tion and reporting as discussed.

ROGER L. CRUMLEY, MD
Department of Otolaryngology
Head and Neck Surgery
University of California Irvine Medical Center
Orange, Calif

REFERENCES

1. Kridel RWH, Konior RJ. Irradiated catilage grafts in the nose: a prelim inary report. Arch Otolaryngol Head Neck Surg. 1992;118:31-38.
2. Maves MD. Facial plastic analysis and discussion: nasal reconstruction with articulated irradiated rib cartilage. Arch Otolaryngol Head Neck Surg. 1991,11 7:331.
3. Babin RW, Ryu JH, Gantz BJ, Maynard JA. Survival of implanted irradi ated cartilage. Otolaryngol Head Neck Surg. 1982;90:75-80.
4. Donald PJ. Cartilage grafting in facial reconstruction with special con sideration of irradiated grafts. Laryngoscope. 1986;96:786-807.
5. Schuller DE, Bardach J, Krause CJ. Irradiated homologous costal carti lage for facial contour restoration. Arch Otolaryngol. 1977,103 :12-15.
6. Welling DB, Maves MD, Shuller DE, 8ardach J. Irradiated homologous cartilage grafts, long term results. Arch Otolaryngol Head Neck Surg. 1988; 114:291 -295.