Yang AN ,Jianfang ZHAO ,Lu LU ,Yonghuan ZHEN ,Xiaojie TAN ,Dong LI,2*

1 Department of Plastic Surgery,Peking University Third Hospital,49 North Garden Road,Haidian District,Beijing,100191,China

2 Department of Plastic Surgery,Peking University International Hospital,Beijing,102206,China

3 School of Life Sciences,College of Medical,Veterinary and Life Sciences,University of Glasgow,Glasgow,G12 8QQ,United Kingdom

ABSTRACT Background The corresponding author's experience and recent methods employed in autologous costal cartilage grafts combined with expanded polytetrafluoroethylene (ePTFE)in Asian rhinoplasty were presented in this study.Objectives The purpose of this study was to assess the outcomes of rhinoplasty performed on patients using autogenous costal cartilage grafts combined with an ePTFE implant.Methods Seventy-five rhinoplasty cases with autologous costal cartilage grafts and an ePTFE implant were retrospectively reviewed.Graft types,complications associated with the graft itself or graft harvesting,surgical outcomes,and patient satisfaction were assessed.Results The mean follow-up time post-operation was 13.5 months.A total of 42/75 patients underwent revision surgeries.Graft-related complications were found in 8%of cases,including two warped graft and four infection cases.Three individuals with infections had mild graft resorption.One patient with an infection removed the implant.Graft exposure,mobility,and substantial resorption were not recorded.A total of two cases underwent revision procedures for infection and perforation,respectively.Chest incision lengths for graft harvesting averaged 2.1 cm.No pneumothorax or significant donor-site pain was found.Donor-site scars were negligible,although two cases had hypertrophic chest scars.In general,functional and esthetic outcomes were mostly satisfactory among the assessed patients.Conclusions Rhinoplasty using autologous rib cartilage provides adequate support and sufficient cartilage amounts for correcting nasal contouring.Meanwhile,ePTFE alone for nasal dorsum augmentation safely achieves satisfactory outcomes.Rib cartilage rhinoplasty performed by an experienced surgeon yields excellent,long-lasting results with minimal risk; however,the potential for infection should be considered following revision surgery.

KEY WORDS Asian rhinoplasty; autologous costal cartilage; ePTFE; implant

INTRODUCTION

Asian rhinoplasty is a unique procedure due to anatomic and ethnic differences.The typical Asian nose possesses a low and flat nasal dorsum,with reduced nasal tip projection,thickened lobular skin,broad lobules,large subcutaneous adipose tissue amounts,alar flaring,columella retraction,and an overall petite osteocartilaginous structure[1].Among multiple rhinoplasty methods,dorsal augmentation and tip alterations are the most common,especially due to an overwhelming,widespread,Westernized notion of beauty.Since an adequate tip projection is hardly achieved due to the weak nasal framework,the costal cartilage is preferentially employed as an autologous source of material for Asian nasal tip.Additionally,with more and more revision rhinoplasties due to complications associated with septal and/or conchal cartilage depletion,the remarkably strong rib cartilage is considered the most optimal graft for the nasal tip[2-4].

However,rib cartilage utilization for dorsal augmentation is heavily criticized since it tends to warp,with a high risk of morbidity at the donor site[5-6].With recent advances in rib cartilage handling methods,the incidence of the above drawbacks begin to decrease[7-9].However,warping remains a major problem for rib cartilage used for nasal augmentation.Recently,alloplastic grafts have been preferred in Asia for augmentation in rhinoplasty as they are readily available and are used with ease to achieve desired nasal contouring.Silicone grafts and expanded polytetrafluoroethylene (ePTFE) represent the major alloplasts[10-11].In general,alloplastic products are indicated for nasal dorsum augmentation; however,placing them at the nasal tip (mainly silicone materials)could be detrimental[12].The purposes of this study were to present the corresponding author (Y.A.)'s experience and recent methods employed in autologous costal cartilage grafting combined with expanded polytetrafluoroethylene(e-PTFE),and to describe post-operative outcomes and complications in Asian rhinoplasty.

METHODS

Seventy-five individuals who underwent rhinoplasty with autologous costal cartilage graft materials combined with ePTFE implant between November 2015 and June 2019 at Peking University Third Hospital were included in this study; the population comprised of 20 (26.7%) men and 55 (73.3%) women.Follow-up was between 6 and 33 months.The corresponding author (Y.A) performed all the surgeries.A retrospective analysis of the medical records was performed.The types and sites of the grafts,operative outcomes,and complications (warping,infections,graft resorption or extrusion,and morbidity at the donor site) were comprehensively assessed based on patient charts and serial 3D facial images.The study was performed according to the Declaration of Helsinki.All participants provided informed consent.

Two blinded rhinoplasty surgeons independently assessed standardized images acquired preoperatively and 12 months postoperatively.Postoperative result grading employed a 4-point scale (1,worse; 2,no change; 3,improved; 4,much improved).The subjective esthetic and functional satisfactions were also evaluated by reviewing charts and phone calls.The telephone survey encompassed nasal function parameters (such as smelling and nasal obstruction symptoms) and self-assessment of postsurgical nasal appearance (1,worse; 2,no change; 3,improved; 4,much improved)[13].

Surgical Procedure

Autologous Costal Cartilage Graft Harvesting

Graft harvesting was essentially performed as previously reported3.Briefly,the costal cartilage was obtained from the seventh rib.After local anesthesia,an incision was made over the selected rib to help dissection.Then,a 1.2-2.5 cm incision was made along the cartilaginous part.Upon skin incision,subcutaneous fat,fascia,and the external oblique muscle underwent layer by layer retraction until rib exposure was achieved.Next,two parallel incisions were made through the rib perichondrium along both superior and inferior borders to preserve the anterior perichondrium,which would be further employed as a camouflage graft.Following multiple cuts perpendicular to the above incision,perichondrium dissection was performed from the rib,without touching the central perichondrium strip.The cartilage underwent cutting at the costochondral junction,with subsequent perichondrium dissection under the cartilage,avoiding pleural injury.A 3-4 cm section of the costal cartilage with overlying perichondrium was obtained (Fig.1).Positive-pressure hyperventilation was applied to assess air leakage after the dissection pocket was filled with saline.In case of no air leakage,layer by layer wound closure was performed.A compression dressing was then applied for 72 hours.

Nasal Dissection

The open transcolumellar approach via an inverted-V incision was employed.For secondary rhinoplasty,the previous uppermost incision line was employed.The columella and dorsal skin flap were brought to the level of the lower lateral cartilage (LLC)'s perichondrium using tenotomy and Converse right-angle scissors,respectively.In cases with thin skin,the LLC underwent clear separation.Subcutaneous soft tissue remaining on the LLC in cases with thick skin should be removed.The LLC was separated from the upper lateral cartilage (ULC)to displace the tip for lengthening the nose.The LLC was pulled caudally,with the ligamentous structure between the LLC and ULC removed while avoiding nasal mucosa tearing.The septum was approached by incising the medial crura for caudal septum exposure.The septum's caudal aspect was graded,followed by sharp dissection for identifying the subperichondrial plane,and bilateral mucoperichondrial flaps were elevated for septum exposure.ULC separation from the septum (midline) was performed.

Autologous Costal Cartilage Graft Carving

The obtained graft underwent carving into multiple forms based on its planned purpose.Because flat cartilage pieces were required for broad grafts,batten grafts,columellar struts,and septal extension grafts,cartilage specimens were sliced in longitudinal or tangential directions,with peripheral parts left symmetrically on both sides,counteracting the distortion (Fig.2).This cartilage piece(width of 6-10 mm) can resist warping.Cartilage carving was performed with a number 10 blade.Three to five cartilage immersions in warm saline (≥20 minutes)between carvings could help predict and minimize warping following the last carving.The spreader grafts measured 2.5-3 cm in length and 3 mm in width.They were positioned along both septum sides from the keystone region to the septal angle,with at least 5 mm from the septal angle.Further spreader grafts were employed to extend the nasal tip (Fig.3A).Columellar strut grafts underwent sequential carving(3 mm×5-7 mm×25-30 mm) with a flared base notch to fix the septal caudal bottom as shown in Fig.3B-C.Costal cartilage shield grafts were used for achieving desirable tip projection and they were covered with perichondrium to prevent visibility (Fig.3D).The remaining costal cartilage pieces were employed for generating diced maxillary or premaxilla grafts in 1-ml syringes.Based on the degree of premaxilla defect,two diced maxillary grafts in a 1 ml syringe were injected into the pregenerated pocket surrounding the anterior nasal spine without fixation.

Nasal Dorsum

A pocket was generated subcutaneously in a conservative fashion using an I-shaped ePTFE alloplast (Tisuthes;Shanghai Suokang Medical Implants Co,200331,Shanghai,China),which was further tailored as needed.Generally,the dorsum was filled at a thickness of 2-6 mm.Close to the tip,implant tailoring was performed to achieve the ideal thickness.Alloplasts were immersed in a bacteriostatic solution before insertion into the generated dorsal pocket (Fig.4),avoiding curves or folds.During ePTFE positioning,the no-touch method was applied to minimize the odds of contamination,also ensuring satisfactory cosmetic results and avoiding surface asymmetries or step-off defects.A strip of the harvested perichondrium covering the ePTFE implant was employed for camouflaging potential asymmetries and further preventing step generation on the sidewall,nasal end because of thin dorsal skin for revision cases.A permanent suture by 5-0 nylon was required for securing the ePTFE position.6-0 polypropylene sutures were used to close the incision.Nasal packing was inserted and then removed after 7 days or less.Prophylactic oral antibiotic treatment was administered for 3 days postoperatively.

RESULTS

Of the 75 cases,42 (56.0%) were revision cases,including rhinoplasty (n=37) and septoplasty (n=5).The most frequent external deformities were saddle nose (n=25),flat nose (n=22),and deviated nose (n=12)(Table 1).In 27 of the 42 cases,previously placed dorsal alloplasts (silicone) underwent removal with the capsule and surrounding granulation tissue.One patient had a septal perforation after the operation,which was surgically repaired during the follow-up period.Chest incision lengths for grafts were 2.1±0.5 cm on average.

Autologous costal cartilage grafts were utilized for tip grafting in all 75 patients,for septum in all 75,and for alar surgery in 22 (Table 2).A total of 32 cases with acute nasolabial angle and premaxilla retrusion underwent premaxilla augmentation using autologous costal cartilage grafts (Fig5-7).Graft-associated complications were found in six cases,including two and four warping and infection cases,respectively (Table 3).Graft exposure,mobility,and severe resorption were not observed.Among the four patients with infection (all among revision cases),three showed localized disease to the tip or dorsum; one case demonstrated infection in both (Table 4).Amongthe four infection cases,three were well-managed with intravenously administered antibiotics,drainage,and irrigation using povidone-iodine solution.The remaining case had a small abscess (tip),which subsided after oral antibiotic treatment and drainage.

Table 1 Patient Diagnoses

Table 2 Sites and Types of Autologous Costal Cartilage Grafts

Significant costal cartilage graft resorption on the nasal tip requiring revision surgery because of infection occurred in only one patient.Three cases with postoperative infectionhad mild cartilage resorption and slightly reduced tip projection.There was no report of pneumothorax or intense pain at the donor site.Although,all cases experienced minor pain at the donor site,which was effectively alleviated by oral analgesics.Postoperative scars were negligible; however,two cases developed hypertrophic chest scars.

Table 3 Complications Following Rhinoplasty with Autologous Costal Cartilage Grafts and ePTFE

Table 4 Cases with Postoperative Infections

No patients complained of functional issues postoperatively.According to the patients,the appearance of their nose post-surgery was much improved in 42 cases (56%),improved in 27 (36%),and unchanged or worse in 6 (8%).The leading cause of subjective dissatisfaction was nasal tip graft resorption.Objective assessment of presurgical and 1-year post-surgical images was performed for 48 patients.Great improvement was found in 25 cases (52%),with improvement in 22 (46%) and no improvement or aggravation in 3 (6%).All cases with post-surgical infection eventually showed satisfactory results.Septal perforation repair failed in one patient.

DISCUSSION

The present authors preferentially use autologous costal cartilage grafts for nasal tip contouring and an ePTFE implant for dorsal augmentation procedures in Asians.Such preference has multiple motives.In several Asian countries,individuals seeking primary augmentation rhinoplasty are mainly in their twenties.Rib cartilages employed in the nasal dorsum are prone to warping and lead to distortion of the nasal dorsum in such cases.Avoiding such a risk constitutes the primary reason for selecting alloplastic implants for nasal augmentation.Secondly,the rib cartilage provides ample material for tip operation compared to that in the septum.In multiple patients,efficient tip modification in Asian rhinoplasty requires substantial amounts of strong cartilage;septal cartilage is weak and found in small amounts.Thirdly,with an increasing number of rhinoplasty procedures being performed in Asia and elevated patient expectations,revision surgery rates are going up[3].Without rib cartilage's superb strength supporting flaccid alar cartilage,it is hard to achieve the desired results.Fourthly,the rib is abundant in cartilage,which could be used in virtually all aspects of rhinoplasty,thus making it the favored donor site when a firm support and large amounts of graft are required (e.g.,in individuals with congenital or posttraumatic defects,or those with a severe low-profile nose).Therefore,autologous costal cartilage grafts with alloplastic implants are increasingly used in Asian rhinoplasty,and graft collection and carving methods continue to improve[2-3].

Autologous costal cartilage grafts face criticisms such as prolonged surgery,morbidity at the donor site,and complications associated with graft warping.With experience,rib cartilage collection could take only 18 minutes,and morbidity could be minimized by careful collection and closure.An actual problem in employing autologous costal cartilage grafts lies in warping,resulting in a deviation appearance along the dorsum.Liang and colleagues performed a meta-analysis on the operative outcomes between autologous costal cartilages and alloplastic materials in rhinoplasty[14],and costal cartilages had more complications.This might be explained by the fact that costal cartilage utilization is more common for the nasal dorsum in revision surgeries.It was proposed that costal cartilage grafts could be prone to warping because of their natural properties,therefore,compromising operative outcomes[15].In this study,warping was found in 2.6% of cases,indicating a reduced value than previously reported.A possible explanation is that warping seldom occurs in tip surgery cases.In addition,silicone implants are broadly employed for dorsum augmentation,nose lengthening,and nasal tip projection in Asia.However,silicone implants could seem unnatural due to the inherent features of this material.Rigid silicone implants could cause multiple problems,including a shrink-wrapped appearance of the nose,a hard feel of the implant,skin depigmentation with changing temperatures,and distal migration of silicone causing skin erosion and extrusion of the implant over the tip[11,16].Therefore,we routinely use ePTFE implants instead of autologous costal cartilages to avoid warping.Adamson[17]proposed using alloplasts solely for filling since extrusion is very frequent when they are used for structural support[12].Routinely,we select Tisuthes (Shanghai SuokangMedical Implants),an ePTFE implant widely used in China,which provides various shape and hardness options.

Thin septal and ear cartilages are found in Asians,with a flimsy lower lateral cartilage supporting the tip,while the soft tissue comprises a thick fibromuscular layer with large amounts of adipose tissue.This does not promote proper nasal tip projection or septal or ear cartilage refinement[18].Additionally,since the nasal spine and the nasal base's premaxilla are inadequately developed,non-corrected columella and midface retrusion would lead to mouth protrusion without facial balance.Since Asians desire a facially harmonized appearance[19],multiple patients might be submitted to ＞2 revision surgeries for correcting or offsetting previous inadequate operations,improper implant utilization,and/or operative complications[20].Often,using rib cartilage and ePTFE for the nasal tip and augmentation,respectively,represents an excellent approach to Asian rhinoplasties.Indeed,the rib cartilage could help transform broad/wide nostrils into oval ones via columella lengthening.In addition,a short nose can be lengthened with sufficient tip projection and a firm nasal structure.Finally,large cartilage amounts could provide premaxilla,maxilla,and paranasal grafts for nasal base reconstruction in cases of retrusion,alongside multiple batten and tip graft materials used to correct various deformities[21-22].

Previous studies[23-25]showed the effectiveness of ePTFE in the nasal dorsum,with infection rates of 0-3.2%.Although this report found an elevated infection rate compared with previous studies4,5,others have published equal or higher rates for revision surgeries[26].In the present study,56% of cases underwent revision surgeries,resulting in four infections.A revision operation is associated with disruption of the soft-tissue envelope and prolonged surgical duration,increasing the nose's susceptibility to infection.Different from alloplastic infections,the majority of infection cases in this study were localized,mostly to the tip,and were well-managed by antibiotic treatment,drainage,and irrigation (except for one case requiring implant removal).Although slightly increased resorption than usual was found on the nasal tip in three patients with prolonged infection before effective treatment,the final esthetic results were satisfactory.

CONCLUSIONS

To achieve success in Asian rhinoplasty,the anatomical features of Asians should be comprehensively assessed,while appreciating the recent trends of ideal beauty.Rhinoplasty with rib cartilage combined with an ePTFE implant in Asians provides substantially reliable and longlasting satisfactory results if performed properly.

ACKNOWLEDGEMENTS

This work was supported by Key Clinical Projects of Peking University Third Hospital (No.BYSYZD2019013)and the Scientific Research Staring Foundation for the Returned Overseas Chinese Scholars,Peking University Third Hospital (No.BYSYLXHG2019001).Illustrations created by Chen Jing.

CONFLICT OF INTEREST

None.