DISCUSSION Discussion: Free Diced Cartilage: A New Application of Diced Cartilage Grafts in Primary and Secondary Rhinoplasty O. Onur Erol, M.D. Istanbul, Turkey
T
he authors share their experience with the use of diced cartilage for rhinoplasty in three groups: group I, 325 patients with fine diced cartilage as the only onlay; group II, 73 patients in which the dorsal onlay consisted of fascia either alone or in combination with fine diced cartilage; and group III, 48 patients with diced cartilage wrapped in fascia. In their comparative study, they found revision rates of 5.2, 8.2, and 25 percent for dorsal irregularities within a 7-month observation period for groups I, II, and III, respectively. After I developed the Turkish delight technique, I conducted a literature review and, to my surprise, discovered that the experimental and clinical use of diced cartilage goes far back into medical history.1 In the past, even though several authors had shown the viability of diced cartilage, it stopped being used for 50 years, probably because of the impossibility of shaping and keeping those cartilages together. Dr. Guerrerosantos, after seeing my presentation of the Turkish delight technique at the 1992 International Society of Aesthetic Plastic Surgery meeting in Guadalajara,2,3 liked the idea very much and began using the same technique by using deep temporal fascia instead of Surgicel (Ethicon, Inc., Somerville, N.J.) to wrap the diced cartilage. The credit for this modification should be given completely to him. Whether the diced cartilage is wrapped with Surgicel or with fascia, the goal is the same: to keep cartilages together and obtain a pliable, moldable cartilage graft mass. It is well known that edema is 90 to 95 percent resolved at the end of the first year. Complete resolution continues until the end of 4 years postoperatively. However, the authors’ revision rates for dorsal irregularities within the 7-month observation period appear to be inadequate, as, in a longer term follow-up, the revision rate would probably be higher. In their short follow-up, the revision rates for all groups seemed From ONEP Plastic Surgery Science Institute. Received for publication April 24, 2017; accepted May 5, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003658
redundant. In my last article, which described my results after a 25-year follow-up of patients treated with the Turkish delight technique,4 the complication rates were far less. I understand that the authors did not use Surgicel because they could not create a control group for comparison; however, as I have longterm experience with diced cartilage use,4,5 they might discuss the use of Surgicel in their article. With respect to diced cartilage wrapped in fascia, I use it only for select patients showing extensively damaged skin; thus, I have limited experience on which to base my opinion. However, I know that the revision rates in articles published by Daniel and others are far below those reported by these authors. In rhinoplasty, the role of Surgicel is to keep the diced cartilage together, and its use has resulted in over 9000 documented satisfactory primary and secondary rhinoplasties.1 In some instances, large or small pockets were filled with diced cartilage in the nose, without wrapping materials. In the beginning, diced cartilage was injected using a standard commercial 1-cc syringe (2003). For small areas, this approach works fairly well. However, in large areas, such as the dorsum and radix, or in small areas, such as the columella and tip region, I needed a stronger syringe to inject the diced cartilages with force. By using specially designed syringes, it was possible to fill the pouch evenly with diced cartilage.6–11 This technique saves time, as injections take only 5 minutes. Good results can be obtained with negligible complication rates. However, it should be used only in select cases, in which a closed pocket can be developed (Fig. 1). I have seen many plastic surgeons using free diced cartilage in rhinoplasty similar to authors. An advantage of their technique, as others, is the plasticity of the fine granulated fine diced Disclosure: The author discloses that the syringe presented in this Discussion is patented and manufactured by Micrins. Royalties from this product are donated to a local cleft palate and birth defect charity.
www.PRSJournal.com
471
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • September 2017
Fig. 1. Secondary nasal deformity with short nose and alar rim deficiency treated with compressed diced cartilage injection. (Above, left) Preoperative frontal view; (above, right) 8-year postoperative frontal view; (below, left) preoperative lateral view; (below, right) 8-year postoperative lateral view.
cartilage mass, enabling a large variety of shapes, and allowing the graft to fit perfectly in various recipient sites of the nose. Moreover, the production and application of fine diced cartilage is quicker and easier, thereby saving precious operating time. I agree completely with the above findings of the authors. However, if it is not used in areas where a closed pocket is not obtained, there will be a loss of diced cartilage, resulting in a higher revision rate. In conclusion, they state that because of the relatively short postoperative observation period in the current study, the results should be considered
preliminary and further studies should be performed to evaluate long-term results. To conclude: 1. Fine diced cartilage is an effective and easily reproducible method for camouflage and augmentation in aesthetic and reconstructive rhinoplasty and should have a permanent place among the wide array of techniques available to the rhinoplasty surgeon. 2. After hump excision, there is often an open roof, and fine diced cartilage injection is not recommended. For these cases, the use of wrapped diced cartilage is suitable.
472 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 3 • Discussion 3. To obtain an accurate result, the follow-up period should be at least 1 to 4 years. 4. In my opinion, each surgeon’s results may be different; for this reason, one surgeon’s results would be more accurate for standard investigation. 5. The authors should be congratulated for their comparative study. O. Onur Erol, M.D. ONEP Plastic Surgery Science Institute Manolyali Sk. No:15 Levent 34330 Istanbul, Turkey [email protected]
PATIENT CONSENT
The patient provided written consent for the use of her images. REFERENCES 1. Erol OO. The Turkish delight: A pliable graft for rhinoplasty. Plast Reconstr Surg. 2000;105:2229–2241; discussion 2242–2243. 2. Erol OO. Chopped cartilage graft wrapped with Surgicel in nose surgery (plasticine-like graft). Paper presented at: 11th Biennial Congress of the International Society for Aesthetic and Plastic Surgeons; February 29–March 4, 1992; Guadalajara, Mexico. 3. Erol OO. Chopped cartilage graft wrapped with Surgicel in nose surgery (plasticine-like graft). Paper presented at:
Third European Association of Plastic Surgeons Meeting; May 14–16, 1992; Pisa, Italy. 4. Erol OO. Long-term results and refinement of the Turkish delight technique for primary and secondary rhinoplasty: 25 years of experience. Plast Reconstr Surg. 2016;137:423–437. 5. Erol OO. Tip rhinoplasty in broad noses in a Turkish population: Eurasian noses. Plast Reconstr Surg. 2012;130:185–197. 6. Erol OO. Injection of compressed diced cartilage via “author’s design syringe” in secondary rhinoplasty (new technique). Paper presented at: Rhinoplasty Society Meeting; May 1, 2009; Las Vegas, Nev. 7. Erol OO. Injection of compressed diced cartilage via “author’s design syringe” in secondary and primary rhinoplasty (new technique). Paper presented at: American Society for Aesthetic Plastic Surgery Meeting; May 2–7, 2009; Las Vegas, Nev. 8. Erol OO. Injection of compressed diced cartilages in correction of primary & secondary rhinoplasty: A new technique. Paper presented at: 20th Annual Meeting of the European Association of Plastic Surgeons; June 2–4, 2011; Mykonos, Greece. 9. Erol OO. The role of diced cartilage in tip augmentation. Paper presented at: Istanbul International Rhinoplasty Course; June 22–24, 2011; Istanbul, Turkey. 10. Erol OO. Injection of compressed diced cartilages in correction of primary & secondary rhinoplasty: A new technique. Paper presented at: Plastic Surgery 2012: Annual Meeting of the American Society of Plastic Surgeons; October 26–30, 2012; New Orleans, La. 11. Erol OO. Injection of compressed diced cartilages in correction of primary & secondary rhinoplasty: 12 years’ experience and refinement of technique. Paper presented at: The Aesthetic Meeting 2016; April 2–7, 2016; Las Vegas, Nev.
473 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
T
he authors share their experience with the use of diced cartilage for rhinoplasty in three groups: group I, 325 patients with fine diced cartilage as the only onlay; group II, 73 patients in which the dorsal onlay consisted of fascia either alone or in combination with fine diced cartilage; and group III, 48 patients with diced cartilage wrapped in fascia. In their comparative study, they found revision rates of 5.2, 8.2, and 25 percent for dorsal irregularities within a 7-month observation period for groups I, II, and III, respectively. After I developed the Turkish delight technique, I conducted a literature review and, to my surprise, discovered that the experimental and clinical use of diced cartilage goes far back into medical history.1 In the past, even though several authors had shown the viability of diced cartilage, it stopped being used for 50 years, probably because of the impossibility of shaping and keeping those cartilages together. Dr. Guerrerosantos, after seeing my presentation of the Turkish delight technique at the 1992 International Society of Aesthetic Plastic Surgery meeting in Guadalajara,2,3 liked the idea very much and began using the same technique by using deep temporal fascia instead of Surgicel (Ethicon, Inc., Somerville, N.J.) to wrap the diced cartilage. The credit for this modification should be given completely to him. Whether the diced cartilage is wrapped with Surgicel or with fascia, the goal is the same: to keep cartilages together and obtain a pliable, moldable cartilage graft mass. It is well known that edema is 90 to 95 percent resolved at the end of the first year. Complete resolution continues until the end of 4 years postoperatively. However, the authors’ revision rates for dorsal irregularities within the 7-month observation period appear to be inadequate, as, in a longer term follow-up, the revision rate would probably be higher. In their short follow-up, the revision rates for all groups seemed From ONEP Plastic Surgery Science Institute. Received for publication April 24, 2017; accepted May 5, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003658
redundant. In my last article, which described my results after a 25-year follow-up of patients treated with the Turkish delight technique,4 the complication rates were far less. I understand that the authors did not use Surgicel because they could not create a control group for comparison; however, as I have longterm experience with diced cartilage use,4,5 they might discuss the use of Surgicel in their article. With respect to diced cartilage wrapped in fascia, I use it only for select patients showing extensively damaged skin; thus, I have limited experience on which to base my opinion. However, I know that the revision rates in articles published by Daniel and others are far below those reported by these authors. In rhinoplasty, the role of Surgicel is to keep the diced cartilage together, and its use has resulted in over 9000 documented satisfactory primary and secondary rhinoplasties.1 In some instances, large or small pockets were filled with diced cartilage in the nose, without wrapping materials. In the beginning, diced cartilage was injected using a standard commercial 1-cc syringe (2003). For small areas, this approach works fairly well. However, in large areas, such as the dorsum and radix, or in small areas, such as the columella and tip region, I needed a stronger syringe to inject the diced cartilages with force. By using specially designed syringes, it was possible to fill the pouch evenly with diced cartilage.6–11 This technique saves time, as injections take only 5 minutes. Good results can be obtained with negligible complication rates. However, it should be used only in select cases, in which a closed pocket can be developed (Fig. 1). I have seen many plastic surgeons using free diced cartilage in rhinoplasty similar to authors. An advantage of their technique, as others, is the plasticity of the fine granulated fine diced Disclosure: The author discloses that the syringe presented in this Discussion is patented and manufactured by Micrins. Royalties from this product are donated to a local cleft palate and birth defect charity.
www.PRSJournal.com
471
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • September 2017
Fig. 1. Secondary nasal deformity with short nose and alar rim deficiency treated with compressed diced cartilage injection. (Above, left) Preoperative frontal view; (above, right) 8-year postoperative frontal view; (below, left) preoperative lateral view; (below, right) 8-year postoperative lateral view.
cartilage mass, enabling a large variety of shapes, and allowing the graft to fit perfectly in various recipient sites of the nose. Moreover, the production and application of fine diced cartilage is quicker and easier, thereby saving precious operating time. I agree completely with the above findings of the authors. However, if it is not used in areas where a closed pocket is not obtained, there will be a loss of diced cartilage, resulting in a higher revision rate. In conclusion, they state that because of the relatively short postoperative observation period in the current study, the results should be considered
preliminary and further studies should be performed to evaluate long-term results. To conclude: 1. Fine diced cartilage is an effective and easily reproducible method for camouflage and augmentation in aesthetic and reconstructive rhinoplasty and should have a permanent place among the wide array of techniques available to the rhinoplasty surgeon. 2. After hump excision, there is often an open roof, and fine diced cartilage injection is not recommended. For these cases, the use of wrapped diced cartilage is suitable.
472 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 3 • Discussion 3. To obtain an accurate result, the follow-up period should be at least 1 to 4 years. 4. In my opinion, each surgeon’s results may be different; for this reason, one surgeon’s results would be more accurate for standard investigation. 5. The authors should be congratulated for their comparative study. O. Onur Erol, M.D. ONEP Plastic Surgery Science Institute Manolyali Sk. No:15 Levent 34330 Istanbul, Turkey [email protected]
PATIENT CONSENT
The patient provided written consent for the use of her images. REFERENCES 1. Erol OO. The Turkish delight: A pliable graft for rhinoplasty. Plast Reconstr Surg. 2000;105:2229–2241; discussion 2242–2243. 2. Erol OO. Chopped cartilage graft wrapped with Surgicel in nose surgery (plasticine-like graft). Paper presented at: 11th Biennial Congress of the International Society for Aesthetic and Plastic Surgeons; February 29–March 4, 1992; Guadalajara, Mexico. 3. Erol OO. Chopped cartilage graft wrapped with Surgicel in nose surgery (plasticine-like graft). Paper presented at:
Third European Association of Plastic Surgeons Meeting; May 14–16, 1992; Pisa, Italy. 4. Erol OO. Long-term results and refinement of the Turkish delight technique for primary and secondary rhinoplasty: 25 years of experience. Plast Reconstr Surg. 2016;137:423–437. 5. Erol OO. Tip rhinoplasty in broad noses in a Turkish population: Eurasian noses. Plast Reconstr Surg. 2012;130:185–197. 6. Erol OO. Injection of compressed diced cartilage via “author’s design syringe” in secondary rhinoplasty (new technique). Paper presented at: Rhinoplasty Society Meeting; May 1, 2009; Las Vegas, Nev. 7. Erol OO. Injection of compressed diced cartilage via “author’s design syringe” in secondary and primary rhinoplasty (new technique). Paper presented at: American Society for Aesthetic Plastic Surgery Meeting; May 2–7, 2009; Las Vegas, Nev. 8. Erol OO. Injection of compressed diced cartilages in correction of primary & secondary rhinoplasty: A new technique. Paper presented at: 20th Annual Meeting of the European Association of Plastic Surgeons; June 2–4, 2011; Mykonos, Greece. 9. Erol OO. The role of diced cartilage in tip augmentation. Paper presented at: Istanbul International Rhinoplasty Course; June 22–24, 2011; Istanbul, Turkey. 10. Erol OO. Injection of compressed diced cartilages in correction of primary & secondary rhinoplasty: A new technique. Paper presented at: Plastic Surgery 2012: Annual Meeting of the American Society of Plastic Surgeons; October 26–30, 2012; New Orleans, La. 11. Erol OO. Injection of compressed diced cartilages in correction of primary & secondary rhinoplasty: 12 years’ experience and refinement of technique. Paper presented at: The Aesthetic Meeting 2016; April 2–7, 2016; Las Vegas, Nev.
473 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
