Aesth Plast Surg DOI 10.1007/s00266-014-0344-0
ORIGINAL ARTICLE
GENERAL RECONSTRUCTION
Saddle-Nose Deformity Repair with Microplate-Adapted Costal Cartilage ¨ ksu¨z • Cenk Melikog˘lu Fikret Eren • Sinan O ¨ lku¨r Hu¨seyin Karago¨z • Ersin U
•
Received: 15 February 2014 / Accepted: 26 May 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Nasal deformities affecting the bone and lower two-thirds of the nose due to the loss of septal height and tip support are defined as ‘‘saddle-nose’’ deformity. Reconstruction of a saddle-nose deformity essentially necessitates structural grafting. This article presents an alternative approach for correction of saddle-nose deformity using a microplate and costal cartilage. The results are compared with those of the previously applied costal cartilage repair methods. Between 2004 and 2013, 16 patients were treated with costal cartilage autografts. Of these 16 patients, 7 were treated with a microplate and costal cartilage autograft combination, 4 were treated with a costal cartilage autograft and Kirschner (K)-wire, and 5 were treated with onlay costal cartilage grafts. The mean follow-up periods were 16 months for group treated with microplate-adapted autologous costal cartilage, 12 months for the group treated with K-wire and autologous costal cartilage, and 16 months for the group treated with onlay costal cartilage. The patients treated with K-wire inserted cartilages and the patients treated onlay dorsal costal cartilages encountered complications such as extrusion of the wire and warping,
¨ ksu¨z (&) H. Karago¨z E. U ¨ lku¨r F. Eren S. O Department of Plastic, Reconstructive and Aesthetic Surgery, Haydarpasa Training Hospital, Gulhane Military Medical Academy, Istanbul, Turkey e-mail: [email protected]; [email protected] ¨ ksu¨z S. O Department of Plastic Surgery, McGowan Institute of Regenerative Medicine, University of Pittsburg Medical Center, Pittsburgh, PA, USA C. Melikog˘lu Department of Plastic, Reconstructive and Aesthetic Surgery, Sifa University Hospital, Izmir, Turkey
respectively. The seven patients treated with microplate and dorsal onlay costal cartilage graft did not experience any infection, warping, or extrusion complication. The warping tendency of the costal cartilage autograft can be efficiently prevented without a prominent complication risk by using microplate-adapted costal cartilage grafts. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords
Costal cartilage Microplate Saddle nose
Introduction Nasal deformities affecting the bone and lower two-thirds of the nose due to the loss of septal height and tip support are defined as ‘‘saddle-nose’’ deformity. Some of the main problems to be treated are underprojected nasal dorsum, underprojected and broad nasal tip, retracted columella, and wide alar base. Reconstruction of a saddle-nose deformity essentially necessitates structural grafting [1]. Major saddle-nose deformities cause an obvious aesthetic deficit and an equally disturbing functional impairment. Widening of the bony bridge and dropping of the tip are observed clinically. Trauma and excessive resection of the nasal dorsum are the main etiologies for the deformity [2]. In the analysis of saddle nose, lateral nasal length, dorsal projection, tip projection, tip rotation, and septal support should be assessed [3]. Cartilage grafting of the dorsum and columella offers a satisfactory correction option for the deformity [2].
123
Aesth Plast Surg Fig. 1 a Saddle-nose deformity and volume loss to be addressed at the dorsum of the nose. b Subcutaneous precise pocket dissection for the cartilage graft by the external approach
This article presents an alternative approach for correction of saddle-nose deformity in which the warping of the costal cartilage is prevented and an effective fixation is provided by use of a microplate. The results obtained from this new approach are compared with those of the previously applied costal cartilage repair methods.
Materials and Methods The study analyzed the medical records of 16 patients with saddle-nose deformities treated between the years 2004 and 2013 using costal cartilage autografts. The middle and upper thirds of the nasal dorsum were deficient in support, and all the patients in the study had insufficient nasal tip support and projection. The patients presented with underprojected and broad nasal dorsums. The etiologies for the saddle-nose deformities included in this study were either nasal trauma or previous surgery. The patients treated with alloplastic materials and allografts or autologous tissues other than costal cartilages were excluded from the retrospective review. The surgical approach, follow-up outcomes, and complications observed in saddle-nose patients treated with onlay autologous costal cartilage alone and those treated with Kirschner (K)-wire or microplate combined with costal cartilage autografts were reviewed. Surgical Exposure The external approach was used to provide sufficient exposure, thorough assessment, and diagnosis of the saddle-nose deformities for all cases. Thus, the nasal bones and cartilages of all the patients were skeletonized by a standard external rhinoplasty approach.
123
The nasal-tip skin and the nasal-dorsum skin were undermined subperichondrially and subperiosteally. However, to prevent movement of the graft, the dissected pocket for both exposure of the deformity and future placement of the costal cartilage was no larger than the costal cartilage. The exposure of the septal cartilage in almost every case showed inadequate cartilage tissue at the caudal portion of the septum deteriorating tip projection. The whole nasal dorsum, including the nasal tip, indicated cartilage support for all the patients (Fig. 1). The patients treated with onlay costal cartilage grafts alone and those treated with K-wire or microplate combined with costal cartilage grafts underwent surgery by the same open rhinoplasty approach for exposure of the defect and subcutaneous pocket. Reconstruction with Costal Cartilage Autologous costal cartilage was obtained from the fifth and sixth ribs of the patients’ left side. The cartilages were carved symmetrically, and the central parts were used in each case to repair the deficient nasal structures (Fig. 2). In the cases treated with a titanium microplate (Ucmed Medical Ltd. Co. Trimed, Ankara Turkey), a groove along the long axis of the cartilage was carved under the dorsal component of the graft (Fig. 3). The plate was settled in the groove under the onlay dorsal cartilage graft and fastened to the cartilage by polypropylene sutures (Fig. 4). Microplate-implanted costal cartilage was placed into the previously prepared precise pocket under the skin at the dorsum and the columella of the nose in a manner to keep the microplate over the nasal bone but embedded under the costal cartilage (Fig. 5).A second transverse stab incision was made at the radix of the nose, and the proximal end of
Aesth Plast Surg Fig. 2 a Costal cartilage harvest. b Symmetric cartilage carving. c Evenly carved central portion of the cartilage
In the onlay costal cartilage group, an evenly carved costal cartilage was placed into the precise nasal subcutaneous pockets of the patients as an onlay graft without any additional intervention. The onlay costal cartilage grafts were located just over the deficient nasal dorsum as in the microplate and K-wire groups (Fig. 8).
Results
Fig. 3 a Microplate used in reconstruction. b Groove carved for the microplate under the costal cartilage. c Lateral view of carving
the plate was anchored to the nasal bone with screws (Fig. 6). The costal cartilages used for the K-wire-combined group and the group treated with onlay costal cartilage alone were carved from the central parts of the cartilages much the same as for the microplate-adapted costal cartilage group. The K-wire was placed in the center of the cartilage along the long axis of the graft. After placement of the K-wire-applied graft under the skin at the deficient nasal dorsum, the proximal end of the K-wire was fixed to the radix of the nasal bone (Fig. 7).
Seven patients with a mean age of 23 years were treated with the microplate and costal cartilage autograft combination. Four patients with a mean age of 25 years were treated with a costal cartilage autograft and K-wire. Five patients with a mean age of 24 years were treated with onlay costal cartilage grafts alone. The mean follow-up period for the patients treated with microplate-adapted autologous costal cartilage was 16 months postoperatively. The mean follow-up period for the patients treated with K-wire and autologous costal cartilage was 12 months. The mean follow-up period for the patients treated with onlay costal cartilage alone was 16 months (Table 1). The volume gain at the dorsum was satisfying for all three types of autograft application. However the patients treated with K-wire-inserted cartilages and those treated with dorsal onlay cartilages alone encountered complications such as extrusion of the wire and warping, respectively. The patients treated with costal cartilage in combination with K-wire did not present with warping. However, one of the four patients had an infection complication at
123
Aesth Plast Surg
Fig. 4 Microplate-adapted costal cartilage. a Figure from a top and schematic view. b Figure from a bottom and schematic view. c Figure from a lateral and schematic view of the sutures
Fig. 6 Schematic view of the screw fixation for the microplateadapted costal cartilage through the stab incision Fig. 5 Schematic view of the microplate-adapted costal cartilage placed into the subcutaneous pocket at the deficient nasal dorsum site of the saddle-nose deformity
postoperative month 4, and the costal cartilage graft with K-wire was extirpated. All three remaining patients with K-wires experienced extrusion of the wire at different follow-up periods. The patients treated with dorsal onlay costal cartilage autografts alone presented with warping at an average of 4 months postoperatively (Fig. 9). The seven patients treated with the microplate and the dorsal onlay costal cartilage grafts did not experience any infection, warping, or extrusion complications (Fig. 10).
123
The microplate settled into the groove under the costal cartilage autograft, provided an efficient fixation, and prevented warping (Figs. 11, 12, 13, 14).
Discussion Saddle-nose deformities necessitate restoration of support and contour of the nasal dorsum. The missing or collapsed structures of the nose have to be replaced. The choice of implant or graft to augment inadequate volume still is an area of controversy.
Fig. 8 Schematic view of the saddle-nose deformity repair with only an onlay costal cartilage graft
The restoration of saddle-nose deformity can be achieved by using alloplastic materials, allografts, or autologous tissues [1, 2]. However, materials other than autografts are subject to some complications over time. Infection, extrusion, and displacement are the most prominent complications reported with such materials [3–
None
Complications
Female
25
Trauma surgery
K-wire-costal cartilage
18
K-wire extrusion
Age
Etiology
Reconstruction method
Follow-up (months)
Complications
K-wire extrusion
12
K-wire extrusion
14
Warping
24
Onlay costal cartilage
Previous surgeries
32
Female
12
None
10
Micro plate-costal cartilage
Surgical overresection
21
Male
4
K-wire-costal cartilage
Surgical overresection
21
Male
11
None
12
Micro plate-costal cartilage
Surgical overresection
24
Male
3
K-wire-costal cartilage
Trauma
21
Male
10
None
16
Micro plate-costal cartilage
Trauma surgery
21
Male
Gender
9
12
Follow-up (months)
Case no.
Surgical overresection
Micro plate-costal cartilage
32
Age
Reconstruction method
Male
Gender
2
Warping
18
Onlay costal cartilage
Surgical overresection
25
Male
13
None
18
Micro plate-costal cartilage
Trauma surgery
20
Male
5
Fig. 7 Schematic view of the saddle-nose deformity repair with a K-wire-combined costal cartilage graft
Etiology
1
Case no.
Table 1 Characteristics of saddle-nose deformity patients
Warping
12
Onlay costal cartilage
Surgical overresection
20
Male
14
None
24
Micro plate-costal cartilage
Trauma
21
Female
6
Warping
14
Onlay costal cartilage
Trauma
21
Male
15
None
20
Micro plate-costal cartilage
Surgical overresection
22
Male
7
Warping
12
Onlay costal cartilage
Surgical overresection
22
Male
16
Infection-K-wire extrusion
4
K-wire-costal cartilage
Surgical overresection
33
Male
8
Aesth Plast Surg
123
Aesth Plast Surg
Fig. 11 Anterior view before and 7 months after the reconstruction
Fig. 9 Warping of the onlay costal cartilage
Fig. 12 Lateral view before and 7 months after reconstruction
Fig. 10 Radiographic postoperatively
image
of
the
microplate
12 months
5]. Homologous costal cartilage also is reported to have a higher resorption rate [2]. Thus, autografts are frequently used because of their high biocompatibility and low risk of infection or extrusion. Septal cartilage, conchal cartilage, temporalis fascia, bone grafts, and costal cartilage are the most preferred autografts [4]. An ideal graft material for nasal reconstruction should have pliability, stability over time, a low rate of extrusion,
123
Fig. 13 Anterior view before and 10 months after reconstruction
and a low risk for triggering an inflammatory response. The graft also should be in adequate supply with a low risk of donor-site morbidity [3]. Particularly, costal cartilage grafts usually are the treatment of choice for saddle-nose deformity reconstruction due to the aforementioned necessary graft features [3, 6].
Aesth Plast Surg
Fig. 14 Lateral view before and 10 months after reconstruction
Costal cartilage with its abundant source has the potential to meet the requirement of large volume deficiencies in saddle-nose deformity [4]. The foremost disadvantage of costal cartilage graft is its unpredictable tendency to warp. Conflict about measures to prevent warping is the main ongoing problem of costal cartilage grafts to be overcome. Some preventive measures are suggested to prevent this tendency [6, 7]. Balanced cross-sectional carving of the cartilage along its long axis is a well-accepted precaution against warping [7, 8]. However symmetric carving from both sides and use of only the central part of the cartilage is technically challenging and cannot essentially prevent warping alone. The natural curve of a costal cartilage cannot be modified into a single straight dorsal graft without violating the balanced cross-sectional carving principle for the cartilage [1]. Harvesting the costal cartilage before the definitive surgery or at the beginning of the definitive surgery and storing the cartilage in sterile saline respectively for a few days or hours to allow initial warping of the graft and then carving the cartilage is another method applied by some authors. However, warping is an ongoing process for more than 4 weeks after the harvest [1, 9]. For all the cases described in this report, all the costal cartilages were harvested at the beginning of the operation to let them bend to their full extent until the period of carving. The authors also used the technique of carving evenly as far as possible to avoid warping. However, all the patients treated with dorsal onlay costal cartilage grafts alone without any additional fixation method presented with marked warping. The warping of the cartilage could be prevented only for the patients treated with K-wires or microplates. The reason for warping in the cases treated with dorsal onlay cartilage graft alone may be explained by insufficiently even carving of the cartilage, which is technically challenging.
In our reported cases, we compared three different costal cartilage reconstruction methods, and all of the saddle-nose reconstructions addressed by the traditional onlay costal cartilage treatment experienced warping. The warping rate for costal cartilage was reported to have a wide range in previous studies. A recent study investigating saddle-nose deformity repair using traditional measures of costal reconstruction reported the warping rate to be 39 % (7 of 18 patients) [10]. Gibson and Davis [8] reported warping for 61 of 91 patients (67 %) in Kilner’s costal cartilage reconstruction series during a follow-up period of more than 2 years. In an experimental study of human costal cartilages, the warping tendencies of irradiated and nonirradiated costal cartilages and of centrally and peripherally cut cartilages were compared. In this study, Adams et al. [9] reported that all 43 costal cartilage grafts (100 %) in their study demonstrated warping within a 4-week period. The warping was observed in both the radiated and nonirradiated cartilages, and even the centrally and balanced-cut cartilages exhibited warping. However, the warping in the centrally cut cartilages was significantly less than in the peripherally cut cartilages, whereas the difference in warping between the irradiated and nonirradiated cartilages did not differ statistically. Thus, Adams et al. [9] recommended adopting extra preventive measures against warping. Placing a K-wire through the dorsal onlay costal cartilage graft is a well-known adapted measure to prevent warping. Wire can partially secure the cartilage, but prevention of warping is not always guaranteed [11]. Besides K-wire extrusion is an almost inevitable problem arising from insufficient fixation, thereby resulting in displacement or warping of the cartilage as well [12]. The K-wire applied patients in our cases did not encounter warping. However, infection and extrusion of the wire were inevitable in our series. Bent spreader grafts also have been used previously by clinicians to overcome subsequent warping. For this purpose, the midportion of the costal cartilage is carved equally on each side to form the neoseptum. The outer aspects carved from each side warps away from the designated costal neoseptum. These shaved-off outer strips then are incorporated into the costal neoseptum in a mirror image fashion to form two spreader grafts to neutralize the warping. These spreader grafts also are expected to restore the deficient height to the middle third of the nose with this technique [1]. This procedure may provide some projection to the middle third of the nose above the alar cartilages via the help of spreader grafts. Septal deficiency also may be restored. However, a major nasal dorsum projection loss cannot be sufficiently restored by this technique. In our cases, the deficiencies necessitated excessive volume replacement. Thus dorsal onlay costal cartilage
123
Aesth Plast Surg
autografts were used for all cases in combination with a columellar graft when required. Apart from the choice of reconstruction material, fixation of the tissue used to prevent both malpositioning and movement also is a challenging problem. Malpositioning is the most common complication associated with the cartilage grafts due to insufficient anchoring. The ideal fixation method should retain the tissue at its desired location by hindering any distortion or displacement [13, 14]. Stowing the graft inside the soft tissue pocket in a manner that hinders the warping and movement is an accepted method for overcoming malpositioning. For this purpose, the dissected pocket for the costal cartilage should be no larger than the graft to prevent movement of the graft [6]. In our series, the authors also placed the grafts in a precise pocket in all cases. Moreover, for the cases treated with microplate-adapted autografts, the costal cartilages and the plates were fixed to the bony segment of the nose with a micro screw. Using a micro screw and microplate provided a more efficient fixation compared with the other groups. Plate fixation systems are securely used for the treatment of many different bone fractures in the body. Rigid internal fixation of maxillofacial fractures has evolved from the principles established in orthopedics and has been the standard of care for years. Titanium plates currently are used in fixation of facial bone fractures as in orthopedics due to their biocompatible properties. In maxillofacial region reconstructions, micro- and miniplates are used depending on the location, fracture type, and weightbearing properties of the fractures. Non–weight-bearing fractures of midfacial, periorbital, or frontal bones can be fixed by microplates after reduction [15–17]. The weight-bearing properties of titanium plates are not necessary to prevent the warping of the costal cartilage. Thus microplates are ideal to fit in a narrow groove carved for the plate on the cartilage and strong enough to prevent warping. In our series, the aim in using titanium microplates was to prevent warping of the costal cartilage and fix the cartilage to the nasal vault. The microplate-adapted costal cartilage technique defined in this report can be applied for any indication of saddle-nose deformities with a need of massive volume replacement. The limitations can be absence of bone at the radix of the nose for fixation of the screws and insufficient skin to cover the graft. The microplate-adapted costal cartilage graft has the major advantages of secure fixation and no warping complications. Adaptation of the microplate to the cartilage does not significantly increase the surgery time. The additional cost for the surgery is limited to the cost of the microplate. The second stab incision at
123
the radix of the nose for the screws does not cause a visible scar and is well hidden at the radix. The only disadvantage of the technique can be the presence of permanent foreign material in the body. However, titanium plates have been used in several locations of the body, including the maxillofacial region, as biocompatible materials without any adverse reactions for years.
Conclusion Microplates are magnetic resonance imaging (MRI) compatible and pliable materials, providing sufficient costal cartilage support and fixation. Application of a microplate, hidden and embedded deep under onlay costal cartilage for saddle-nose repair as described in this report, yields a secure fixation of the cartilage. The warping tendency of the costal cartilage autograft can be efficiently prevented without a prominent complication risk by using microplateadapted costal cartilage grafts. Conflicts of interest The authors declare that they have no conflicts of interest to disclose.
References 1. Ahmed A, Imani P, Vuyk HD (2010) Reconstruction of significant saddle-nose deformity using autogenous costal cartilage graft with incorporated mirror image spreader grafts. Laryngoscope 120:491–494 2. Andrade M, Fernandes VS, Bole´o-Tome´ JP (1999) Saddle nose: our approach to the problem. Aesthet Plast Surg 23:403–406 3. Young K, Rowe-Jones J (2011) Current approaches to septal saddle-nose reconstruction using autografts. Curr Opin Otolaryngol Head Neck Surg 19:276–282 4. Sajjadian A, Rubinstein R, Naghshineh N (2010) Current status of grafts and implants in rhinoplasty: part I. Autologous grafts. Plast Reconstr Surg 125:40e–49e 5. Sajjadian A, Naghshineh N, Rubinstein R (2010) Current status of grafts and implants in rhinoplasty: part II. Homologous grafts and allogenic implants. Plast Reconstr Surg 125:99e–109e 6. Al-Qattan MM (2007) Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg 59:642–644 7. Daniel RK (1994) Rhinoplasty and rib grafts: evolving a flexible operative technique. Plast Reconstr Surg 94:597–609 8. Gibson T, Davis WB (1958) The distortion of autogenous cartilage grafts: its cause and prevention. Br J Plast Surg 10:257–274 9. Adams WP Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JB Jr (1999) The rate of warping in irradiated and non-irradiated homograft rib cartilage: a controlled comparison and clinical implications. Plast Reconstr Surg 103:265–270 10. Ozturan O, Aksoy F, Veyseller B, Apuhan T, Yıldırım YS (2013) Severe saddle nose: choices for augmentation and application of accordion technique against warping. Aesthet Plast Surg 37:106–116
Aesth Plast Surg 11. Gunter JP, Clark CP, Friedman RM (1997) Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping. Plast Reconstr Surg 100:161–169 12. Sheen JH (1998) The ideal dorsal graft: a continuing quest. Plast Reconstr Surg 102:2490–2493 13. Sheen JH (1993) Tip graft: a 20-year retrospective. Plast Reconstr Surg 91:48–63 14. Endo T, Nakayama Y, Ito Y (1991) Augmentation rhinoplasty: observations on 1,200 cases. Plast Reconstr Surg 87:54–59 15. Jensen J, Sindet-Pedersen S, Christensen L (1992) Rigid fixation in reconstruction of craniofacial fractures. J Oral Maxillofac Surg 50:550–554
16. Evans GR, Clark N, Manson PN, Leipziger LS (1995) Role of mini- and microplate fixation in fractures of the midface and mandible. Ann Plast Surg 34:453–456 17. Champy M, Blez P (2009) Anatomical aspects and biomechanical considerations. In: Haerle F, Champy M, Terry B (eds) Atlas of craniomaxillofacial osteosynthesis: microplates, miniplates, and screws. Thieme, New York, pp 1–7
123
ORIGINAL ARTICLE
GENERAL RECONSTRUCTION
Saddle-Nose Deformity Repair with Microplate-Adapted Costal Cartilage ¨ ksu¨z • Cenk Melikog˘lu Fikret Eren • Sinan O ¨ lku¨r Hu¨seyin Karago¨z • Ersin U
•
Received: 15 February 2014 / Accepted: 26 May 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Nasal deformities affecting the bone and lower two-thirds of the nose due to the loss of septal height and tip support are defined as ‘‘saddle-nose’’ deformity. Reconstruction of a saddle-nose deformity essentially necessitates structural grafting. This article presents an alternative approach for correction of saddle-nose deformity using a microplate and costal cartilage. The results are compared with those of the previously applied costal cartilage repair methods. Between 2004 and 2013, 16 patients were treated with costal cartilage autografts. Of these 16 patients, 7 were treated with a microplate and costal cartilage autograft combination, 4 were treated with a costal cartilage autograft and Kirschner (K)-wire, and 5 were treated with onlay costal cartilage grafts. The mean follow-up periods were 16 months for group treated with microplate-adapted autologous costal cartilage, 12 months for the group treated with K-wire and autologous costal cartilage, and 16 months for the group treated with onlay costal cartilage. The patients treated with K-wire inserted cartilages and the patients treated onlay dorsal costal cartilages encountered complications such as extrusion of the wire and warping,
¨ ksu¨z (&) H. Karago¨z E. U ¨ lku¨r F. Eren S. O Department of Plastic, Reconstructive and Aesthetic Surgery, Haydarpasa Training Hospital, Gulhane Military Medical Academy, Istanbul, Turkey e-mail: [email protected]; [email protected] ¨ ksu¨z S. O Department of Plastic Surgery, McGowan Institute of Regenerative Medicine, University of Pittsburg Medical Center, Pittsburgh, PA, USA C. Melikog˘lu Department of Plastic, Reconstructive and Aesthetic Surgery, Sifa University Hospital, Izmir, Turkey
respectively. The seven patients treated with microplate and dorsal onlay costal cartilage graft did not experience any infection, warping, or extrusion complication. The warping tendency of the costal cartilage autograft can be efficiently prevented without a prominent complication risk by using microplate-adapted costal cartilage grafts. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords
Costal cartilage Microplate Saddle nose
Introduction Nasal deformities affecting the bone and lower two-thirds of the nose due to the loss of septal height and tip support are defined as ‘‘saddle-nose’’ deformity. Some of the main problems to be treated are underprojected nasal dorsum, underprojected and broad nasal tip, retracted columella, and wide alar base. Reconstruction of a saddle-nose deformity essentially necessitates structural grafting [1]. Major saddle-nose deformities cause an obvious aesthetic deficit and an equally disturbing functional impairment. Widening of the bony bridge and dropping of the tip are observed clinically. Trauma and excessive resection of the nasal dorsum are the main etiologies for the deformity [2]. In the analysis of saddle nose, lateral nasal length, dorsal projection, tip projection, tip rotation, and septal support should be assessed [3]. Cartilage grafting of the dorsum and columella offers a satisfactory correction option for the deformity [2].
123
Aesth Plast Surg Fig. 1 a Saddle-nose deformity and volume loss to be addressed at the dorsum of the nose. b Subcutaneous precise pocket dissection for the cartilage graft by the external approach
This article presents an alternative approach for correction of saddle-nose deformity in which the warping of the costal cartilage is prevented and an effective fixation is provided by use of a microplate. The results obtained from this new approach are compared with those of the previously applied costal cartilage repair methods.
Materials and Methods The study analyzed the medical records of 16 patients with saddle-nose deformities treated between the years 2004 and 2013 using costal cartilage autografts. The middle and upper thirds of the nasal dorsum were deficient in support, and all the patients in the study had insufficient nasal tip support and projection. The patients presented with underprojected and broad nasal dorsums. The etiologies for the saddle-nose deformities included in this study were either nasal trauma or previous surgery. The patients treated with alloplastic materials and allografts or autologous tissues other than costal cartilages were excluded from the retrospective review. The surgical approach, follow-up outcomes, and complications observed in saddle-nose patients treated with onlay autologous costal cartilage alone and those treated with Kirschner (K)-wire or microplate combined with costal cartilage autografts were reviewed. Surgical Exposure The external approach was used to provide sufficient exposure, thorough assessment, and diagnosis of the saddle-nose deformities for all cases. Thus, the nasal bones and cartilages of all the patients were skeletonized by a standard external rhinoplasty approach.
123
The nasal-tip skin and the nasal-dorsum skin were undermined subperichondrially and subperiosteally. However, to prevent movement of the graft, the dissected pocket for both exposure of the deformity and future placement of the costal cartilage was no larger than the costal cartilage. The exposure of the septal cartilage in almost every case showed inadequate cartilage tissue at the caudal portion of the septum deteriorating tip projection. The whole nasal dorsum, including the nasal tip, indicated cartilage support for all the patients (Fig. 1). The patients treated with onlay costal cartilage grafts alone and those treated with K-wire or microplate combined with costal cartilage grafts underwent surgery by the same open rhinoplasty approach for exposure of the defect and subcutaneous pocket. Reconstruction with Costal Cartilage Autologous costal cartilage was obtained from the fifth and sixth ribs of the patients’ left side. The cartilages were carved symmetrically, and the central parts were used in each case to repair the deficient nasal structures (Fig. 2). In the cases treated with a titanium microplate (Ucmed Medical Ltd. Co. Trimed, Ankara Turkey), a groove along the long axis of the cartilage was carved under the dorsal component of the graft (Fig. 3). The plate was settled in the groove under the onlay dorsal cartilage graft and fastened to the cartilage by polypropylene sutures (Fig. 4). Microplate-implanted costal cartilage was placed into the previously prepared precise pocket under the skin at the dorsum and the columella of the nose in a manner to keep the microplate over the nasal bone but embedded under the costal cartilage (Fig. 5).A second transverse stab incision was made at the radix of the nose, and the proximal end of
Aesth Plast Surg Fig. 2 a Costal cartilage harvest. b Symmetric cartilage carving. c Evenly carved central portion of the cartilage
In the onlay costal cartilage group, an evenly carved costal cartilage was placed into the precise nasal subcutaneous pockets of the patients as an onlay graft without any additional intervention. The onlay costal cartilage grafts were located just over the deficient nasal dorsum as in the microplate and K-wire groups (Fig. 8).
Results
Fig. 3 a Microplate used in reconstruction. b Groove carved for the microplate under the costal cartilage. c Lateral view of carving
the plate was anchored to the nasal bone with screws (Fig. 6). The costal cartilages used for the K-wire-combined group and the group treated with onlay costal cartilage alone were carved from the central parts of the cartilages much the same as for the microplate-adapted costal cartilage group. The K-wire was placed in the center of the cartilage along the long axis of the graft. After placement of the K-wire-applied graft under the skin at the deficient nasal dorsum, the proximal end of the K-wire was fixed to the radix of the nasal bone (Fig. 7).
Seven patients with a mean age of 23 years were treated with the microplate and costal cartilage autograft combination. Four patients with a mean age of 25 years were treated with a costal cartilage autograft and K-wire. Five patients with a mean age of 24 years were treated with onlay costal cartilage grafts alone. The mean follow-up period for the patients treated with microplate-adapted autologous costal cartilage was 16 months postoperatively. The mean follow-up period for the patients treated with K-wire and autologous costal cartilage was 12 months. The mean follow-up period for the patients treated with onlay costal cartilage alone was 16 months (Table 1). The volume gain at the dorsum was satisfying for all three types of autograft application. However the patients treated with K-wire-inserted cartilages and those treated with dorsal onlay cartilages alone encountered complications such as extrusion of the wire and warping, respectively. The patients treated with costal cartilage in combination with K-wire did not present with warping. However, one of the four patients had an infection complication at
123
Aesth Plast Surg
Fig. 4 Microplate-adapted costal cartilage. a Figure from a top and schematic view. b Figure from a bottom and schematic view. c Figure from a lateral and schematic view of the sutures
Fig. 6 Schematic view of the screw fixation for the microplateadapted costal cartilage through the stab incision Fig. 5 Schematic view of the microplate-adapted costal cartilage placed into the subcutaneous pocket at the deficient nasal dorsum site of the saddle-nose deformity
postoperative month 4, and the costal cartilage graft with K-wire was extirpated. All three remaining patients with K-wires experienced extrusion of the wire at different follow-up periods. The patients treated with dorsal onlay costal cartilage autografts alone presented with warping at an average of 4 months postoperatively (Fig. 9). The seven patients treated with the microplate and the dorsal onlay costal cartilage grafts did not experience any infection, warping, or extrusion complications (Fig. 10).
123
The microplate settled into the groove under the costal cartilage autograft, provided an efficient fixation, and prevented warping (Figs. 11, 12, 13, 14).
Discussion Saddle-nose deformities necessitate restoration of support and contour of the nasal dorsum. The missing or collapsed structures of the nose have to be replaced. The choice of implant or graft to augment inadequate volume still is an area of controversy.
Fig. 8 Schematic view of the saddle-nose deformity repair with only an onlay costal cartilage graft
The restoration of saddle-nose deformity can be achieved by using alloplastic materials, allografts, or autologous tissues [1, 2]. However, materials other than autografts are subject to some complications over time. Infection, extrusion, and displacement are the most prominent complications reported with such materials [3–
None
Complications
Female
25
Trauma surgery
K-wire-costal cartilage
18
K-wire extrusion
Age
Etiology
Reconstruction method
Follow-up (months)
Complications
K-wire extrusion
12
K-wire extrusion
14
Warping
24
Onlay costal cartilage
Previous surgeries
32
Female
12
None
10
Micro plate-costal cartilage
Surgical overresection
21
Male
4
K-wire-costal cartilage
Surgical overresection
21
Male
11
None
12
Micro plate-costal cartilage
Surgical overresection
24
Male
3
K-wire-costal cartilage
Trauma
21
Male
10
None
16
Micro plate-costal cartilage
Trauma surgery
21
Male
Gender
9
12
Follow-up (months)
Case no.
Surgical overresection
Micro plate-costal cartilage
32
Age
Reconstruction method
Male
Gender
2
Warping
18
Onlay costal cartilage
Surgical overresection
25
Male
13
None
18
Micro plate-costal cartilage
Trauma surgery
20
Male
5
Fig. 7 Schematic view of the saddle-nose deformity repair with a K-wire-combined costal cartilage graft
Etiology
1
Case no.
Table 1 Characteristics of saddle-nose deformity patients
Warping
12
Onlay costal cartilage
Surgical overresection
20
Male
14
None
24
Micro plate-costal cartilage
Trauma
21
Female
6
Warping
14
Onlay costal cartilage
Trauma
21
Male
15
None
20
Micro plate-costal cartilage
Surgical overresection
22
Male
7
Warping
12
Onlay costal cartilage
Surgical overresection
22
Male
16
Infection-K-wire extrusion
4
K-wire-costal cartilage
Surgical overresection
33
Male
8
Aesth Plast Surg
123
Aesth Plast Surg
Fig. 11 Anterior view before and 7 months after the reconstruction
Fig. 9 Warping of the onlay costal cartilage
Fig. 12 Lateral view before and 7 months after reconstruction
Fig. 10 Radiographic postoperatively
image
of
the
microplate
12 months
5]. Homologous costal cartilage also is reported to have a higher resorption rate [2]. Thus, autografts are frequently used because of their high biocompatibility and low risk of infection or extrusion. Septal cartilage, conchal cartilage, temporalis fascia, bone grafts, and costal cartilage are the most preferred autografts [4]. An ideal graft material for nasal reconstruction should have pliability, stability over time, a low rate of extrusion,
123
Fig. 13 Anterior view before and 10 months after reconstruction
and a low risk for triggering an inflammatory response. The graft also should be in adequate supply with a low risk of donor-site morbidity [3]. Particularly, costal cartilage grafts usually are the treatment of choice for saddle-nose deformity reconstruction due to the aforementioned necessary graft features [3, 6].
Aesth Plast Surg
Fig. 14 Lateral view before and 10 months after reconstruction
Costal cartilage with its abundant source has the potential to meet the requirement of large volume deficiencies in saddle-nose deformity [4]. The foremost disadvantage of costal cartilage graft is its unpredictable tendency to warp. Conflict about measures to prevent warping is the main ongoing problem of costal cartilage grafts to be overcome. Some preventive measures are suggested to prevent this tendency [6, 7]. Balanced cross-sectional carving of the cartilage along its long axis is a well-accepted precaution against warping [7, 8]. However symmetric carving from both sides and use of only the central part of the cartilage is technically challenging and cannot essentially prevent warping alone. The natural curve of a costal cartilage cannot be modified into a single straight dorsal graft without violating the balanced cross-sectional carving principle for the cartilage [1]. Harvesting the costal cartilage before the definitive surgery or at the beginning of the definitive surgery and storing the cartilage in sterile saline respectively for a few days or hours to allow initial warping of the graft and then carving the cartilage is another method applied by some authors. However, warping is an ongoing process for more than 4 weeks after the harvest [1, 9]. For all the cases described in this report, all the costal cartilages were harvested at the beginning of the operation to let them bend to their full extent until the period of carving. The authors also used the technique of carving evenly as far as possible to avoid warping. However, all the patients treated with dorsal onlay costal cartilage grafts alone without any additional fixation method presented with marked warping. The warping of the cartilage could be prevented only for the patients treated with K-wires or microplates. The reason for warping in the cases treated with dorsal onlay cartilage graft alone may be explained by insufficiently even carving of the cartilage, which is technically challenging.
In our reported cases, we compared three different costal cartilage reconstruction methods, and all of the saddle-nose reconstructions addressed by the traditional onlay costal cartilage treatment experienced warping. The warping rate for costal cartilage was reported to have a wide range in previous studies. A recent study investigating saddle-nose deformity repair using traditional measures of costal reconstruction reported the warping rate to be 39 % (7 of 18 patients) [10]. Gibson and Davis [8] reported warping for 61 of 91 patients (67 %) in Kilner’s costal cartilage reconstruction series during a follow-up period of more than 2 years. In an experimental study of human costal cartilages, the warping tendencies of irradiated and nonirradiated costal cartilages and of centrally and peripherally cut cartilages were compared. In this study, Adams et al. [9] reported that all 43 costal cartilage grafts (100 %) in their study demonstrated warping within a 4-week period. The warping was observed in both the radiated and nonirradiated cartilages, and even the centrally and balanced-cut cartilages exhibited warping. However, the warping in the centrally cut cartilages was significantly less than in the peripherally cut cartilages, whereas the difference in warping between the irradiated and nonirradiated cartilages did not differ statistically. Thus, Adams et al. [9] recommended adopting extra preventive measures against warping. Placing a K-wire through the dorsal onlay costal cartilage graft is a well-known adapted measure to prevent warping. Wire can partially secure the cartilage, but prevention of warping is not always guaranteed [11]. Besides K-wire extrusion is an almost inevitable problem arising from insufficient fixation, thereby resulting in displacement or warping of the cartilage as well [12]. The K-wire applied patients in our cases did not encounter warping. However, infection and extrusion of the wire were inevitable in our series. Bent spreader grafts also have been used previously by clinicians to overcome subsequent warping. For this purpose, the midportion of the costal cartilage is carved equally on each side to form the neoseptum. The outer aspects carved from each side warps away from the designated costal neoseptum. These shaved-off outer strips then are incorporated into the costal neoseptum in a mirror image fashion to form two spreader grafts to neutralize the warping. These spreader grafts also are expected to restore the deficient height to the middle third of the nose with this technique [1]. This procedure may provide some projection to the middle third of the nose above the alar cartilages via the help of spreader grafts. Septal deficiency also may be restored. However, a major nasal dorsum projection loss cannot be sufficiently restored by this technique. In our cases, the deficiencies necessitated excessive volume replacement. Thus dorsal onlay costal cartilage
123
Aesth Plast Surg
autografts were used for all cases in combination with a columellar graft when required. Apart from the choice of reconstruction material, fixation of the tissue used to prevent both malpositioning and movement also is a challenging problem. Malpositioning is the most common complication associated with the cartilage grafts due to insufficient anchoring. The ideal fixation method should retain the tissue at its desired location by hindering any distortion or displacement [13, 14]. Stowing the graft inside the soft tissue pocket in a manner that hinders the warping and movement is an accepted method for overcoming malpositioning. For this purpose, the dissected pocket for the costal cartilage should be no larger than the graft to prevent movement of the graft [6]. In our series, the authors also placed the grafts in a precise pocket in all cases. Moreover, for the cases treated with microplate-adapted autografts, the costal cartilages and the plates were fixed to the bony segment of the nose with a micro screw. Using a micro screw and microplate provided a more efficient fixation compared with the other groups. Plate fixation systems are securely used for the treatment of many different bone fractures in the body. Rigid internal fixation of maxillofacial fractures has evolved from the principles established in orthopedics and has been the standard of care for years. Titanium plates currently are used in fixation of facial bone fractures as in orthopedics due to their biocompatible properties. In maxillofacial region reconstructions, micro- and miniplates are used depending on the location, fracture type, and weightbearing properties of the fractures. Non–weight-bearing fractures of midfacial, periorbital, or frontal bones can be fixed by microplates after reduction [15–17]. The weight-bearing properties of titanium plates are not necessary to prevent the warping of the costal cartilage. Thus microplates are ideal to fit in a narrow groove carved for the plate on the cartilage and strong enough to prevent warping. In our series, the aim in using titanium microplates was to prevent warping of the costal cartilage and fix the cartilage to the nasal vault. The microplate-adapted costal cartilage technique defined in this report can be applied for any indication of saddle-nose deformities with a need of massive volume replacement. The limitations can be absence of bone at the radix of the nose for fixation of the screws and insufficient skin to cover the graft. The microplate-adapted costal cartilage graft has the major advantages of secure fixation and no warping complications. Adaptation of the microplate to the cartilage does not significantly increase the surgery time. The additional cost for the surgery is limited to the cost of the microplate. The second stab incision at
123
the radix of the nose for the screws does not cause a visible scar and is well hidden at the radix. The only disadvantage of the technique can be the presence of permanent foreign material in the body. However, titanium plates have been used in several locations of the body, including the maxillofacial region, as biocompatible materials without any adverse reactions for years.
Conclusion Microplates are magnetic resonance imaging (MRI) compatible and pliable materials, providing sufficient costal cartilage support and fixation. Application of a microplate, hidden and embedded deep under onlay costal cartilage for saddle-nose repair as described in this report, yields a secure fixation of the cartilage. The warping tendency of the costal cartilage autograft can be efficiently prevented without a prominent complication risk by using microplateadapted costal cartilage grafts. Conflicts of interest The authors declare that they have no conflicts of interest to disclose.
References 1. Ahmed A, Imani P, Vuyk HD (2010) Reconstruction of significant saddle-nose deformity using autogenous costal cartilage graft with incorporated mirror image spreader grafts. Laryngoscope 120:491–494 2. Andrade M, Fernandes VS, Bole´o-Tome´ JP (1999) Saddle nose: our approach to the problem. Aesthet Plast Surg 23:403–406 3. Young K, Rowe-Jones J (2011) Current approaches to septal saddle-nose reconstruction using autografts. Curr Opin Otolaryngol Head Neck Surg 19:276–282 4. Sajjadian A, Rubinstein R, Naghshineh N (2010) Current status of grafts and implants in rhinoplasty: part I. Autologous grafts. Plast Reconstr Surg 125:40e–49e 5. Sajjadian A, Naghshineh N, Rubinstein R (2010) Current status of grafts and implants in rhinoplasty: part II. Homologous grafts and allogenic implants. Plast Reconstr Surg 125:99e–109e 6. Al-Qattan MM (2007) Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg 59:642–644 7. Daniel RK (1994) Rhinoplasty and rib grafts: evolving a flexible operative technique. Plast Reconstr Surg 94:597–609 8. Gibson T, Davis WB (1958) The distortion of autogenous cartilage grafts: its cause and prevention. Br J Plast Surg 10:257–274 9. Adams WP Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JB Jr (1999) The rate of warping in irradiated and non-irradiated homograft rib cartilage: a controlled comparison and clinical implications. Plast Reconstr Surg 103:265–270 10. Ozturan O, Aksoy F, Veyseller B, Apuhan T, Yıldırım YS (2013) Severe saddle nose: choices for augmentation and application of accordion technique against warping. Aesthet Plast Surg 37:106–116
Aesth Plast Surg 11. Gunter JP, Clark CP, Friedman RM (1997) Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping. Plast Reconstr Surg 100:161–169 12. Sheen JH (1998) The ideal dorsal graft: a continuing quest. Plast Reconstr Surg 102:2490–2493 13. Sheen JH (1993) Tip graft: a 20-year retrospective. Plast Reconstr Surg 91:48–63 14. Endo T, Nakayama Y, Ito Y (1991) Augmentation rhinoplasty: observations on 1,200 cases. Plast Reconstr Surg 87:54–59 15. Jensen J, Sindet-Pedersen S, Christensen L (1992) Rigid fixation in reconstruction of craniofacial fractures. J Oral Maxillofac Surg 50:550–554
16. Evans GR, Clark N, Manson PN, Leipziger LS (1995) Role of mini- and microplate fixation in fractures of the midface and mandible. Ann Plast Surg 34:453–456 17. Champy M, Blez P (2009) Anatomical aspects and biomechanical considerations. In: Haerle F, Champy M, Terry B (eds) Atlas of craniomaxillofacial osteosynthesis: microplates, miniplates, and screws. Thieme, New York, pp 1–7
123
