Crushed cartilage grafts

What repeats

Five findings that hold across the literature.

The degree of crushing sets the survival rate

Human septal cartilage from 15 patients was left intact, then slightly, moderately, significantly and severely crushed. Day 1 chondrocyte viability was 96%, 92%, 82%, 72% and 54% across those five states, and day 10 viability was 93%, 90%, 84%, 75% and 68%. Ear and rib cartilage behave the same way. Across 10 auricular and 10 costal grafts taken during secondary rhinoplasty, day 1 viability ran 70%, 67%, 65%, 58% and 45% for ear, and 65%, 63%, 59%, 55% and 53% for rib, with no significant difference between the two sources at the same crush level.

Rests on: Cakmak et al., cultured human septal chondrocytes · Buyuklu et al., auricular and costal chondrocytes.

Lightly crushed cartilage keeps growing, heavily crushed cartilage turns to scar

Six graft states were implanted in 29 rabbits and examined at 2, 5 and 10 months. Intact and slightly crushed grafts showed significant chondrocyte proliferation. That fell as crushing rose, and the severely crushed grafts showed almost no peripheral chondrocyte proliferation with extensive necrosis. A four-month rabbit study comparing sliced against crushed cartilage found the crushed specimens lost significantly more chondrocytes than sliced ones and showed fibrosis, multiple fracture lines and ossification.

Rests on: Cakmak et al., crushed and diced grafts in rabbits · Ergun et al., sliced against crushed.

Crushing costs about a quarter of the volume

In a rabbit model, fresh uncrushed cartilage retained 94.54% of its volume at three months and fresh crushed cartilage retained 69.73%. Preserved uncrushed cartilage retained 91.34% and preserved crushed 74.19%. In the clinical companion series of graft pieces used in revision septorhinoplasty, the success rate was 93.8% for uncrushed fresh cartilage and 87.5% for crushed fresh, with follow-up averaging 44.71 months.

Rests on: Rudderman et al., rabbit model · Guyuron and Friedman, preserved autogenous cartilage.

It is a camouflage material, not a support material

The published role is filling small defects, softening contours and hiding irregularities under thin skin. A systematic review of autologous cartilage in tip surgery screened 253 articles and selected 39, and places crushed, minced and diced cartilage in the group used for noses with thin soft tissue. Structural jobs go to solid grafts.

Rests on: Gentile and Cervelli, systematic review · Cakmak et al. · and spreader grafts.

Patient-reported results are not uniformly better with it

In 93 septorhinoplasty patients, appearance scores improved overall, and the group that received crushed cartilage onlay grafts had lower Rhinoplasty Outcome Evaluation and visual analogue scores at 12 months than the group without them (p < 0.05). A separate series using crushed septal cartilage mixed with fat measured a mean dorsal height change of 0.0 mm (p = 0.91) at a final mean follow-up of 28.9 months, with a mean dorsal volume change of 0.02 cm3.

Rests on: Haci and Sen, with and without crushed camouflage · Gowda et al., crushed cartilage and fat.

By where the graft is placed

The same crushed material does different jobs in different parts of the nose.

On the dorsum, over a hump reduction

Contour irregularities on the bridge are the classic indication. Crushed septal cartilage mixed with autologous fat held its dorsal height across a mean 28.9 months of follow-up. In a 38-patient comparison, a crushed septal cartilage cover over a diced cartilage glue graft scored better for palpable irregularity than the diced graft alone, 4.15 +/- 0.75 against 3.56 +/- 0.92 (p = 0.04).

Rests on: Gowda et al. · Lee et al., crushed cover over diced graft · component dorsal hump reduction.

On the tip, over structural grafts

A free crushed cartilage filler graft was used to hide the edges of tip grafts, at a mean follow-up of 16.3 months. Nasal length was 8.3% greater than before surgery and tip height 12.7% greater. Aesthetic review found visible tip grafts in 4.5% of patients, an irregular or asymmetric tip in 3.0% and an amorphous tip in 6.1%. Aesthetic dissatisfaction was expressed by 12.1%, and no patient pursued revision.

Rests on: Chang et al., free crushed cartilage filler graft · and the pinched tip.

In the soft triangle, at the rim of the nostril

The soft triangle is the point where skin meets skin with no tissue in between. Significantly or severely crushed cartilage has been placed there to prevent notching and support the rim.

Rests on: Bayram et al., the soft triangle · and alar retraction.

As a dorsal augmentation in its own right

Crushed rib cartilage has been used to raise the whole bridge. Across 38 patients followed a mean 36.1 months, surgeons rated the result excellent in 15 and good in 18, and complications on the dorsum occurred in 11 cases (28.9%): four surface irregularities, five resorptions and two short nose deformities. The authors describe it as an alternative for selected situations rather than a first choice.

Rests on: Lee et al., crushed costal cartilage augmentation · rib cartilage grafts · the saddle nose.

Back inside the septum during septoplasty

Crushed septal cartilage has been returned to the septum instead of being discarded. In 500 patients, NOSE scores improved significantly at two months (p < 0.001), with intranasal infection or crusting in 7 patients (1.4%) and late nosebleed in 3 (0.6%) over one year of follow-up.

Rests on: Mutlu, crushed septal cartilage in septoplasty · and nasal airway obstruction.

What to ask about crushed cartilage

Questions the evidence supports asking.

How hard is it going to be crushed

Slight and moderate crushing keep most of the cells alive. Significant and severe crushing drop viability to 72% and 54% on day 1 and produce unpredictable volume loss. Ask the surgeon where on that scale they work.

Rests on: Cakmak et al. · Cakmak et al., rabbits.

Where is the cartilage coming from

Septum, ear and rib all crush to similar viability at the same force. The choice is driven by what is left after previous surgery.

Rests on: Buyuklu et al. · ear cartilage grafts · costal cartilage harvest.

What happens to it after a year

Volume retention in the rabbit model is 69.73% for crushed against 94.54% for uncrushed. Clinical series report both stable dorsal height at 28.9 months and resorption in 5 of 38 rib cases. Ask what the surgeon does if the graft flattens.

Rests on: Rudderman et al. · Gowda et al. · Lee et al. · and revision rhinoplasty.

Is something else better for this spot

Diced cartilage wrapped in fascia, sliced cartilage and thin sliced grafts are the direct alternatives. Sliced cartilage kept its thickness and normal histology at four months where crushed cartilage did not, and an ultra-thin sliced graft showed greater chondrocyte proliferation than crushed, diced or fascia-wrapped diced grafts at eight weeks.

Rests on: Ergun et al. · Ozturk et al., fish-scale grafts · diced cartilage grafts.

Why is it being used at all

It is being used to hide something. Ask what irregularity it is covering, and whether that irregularity can be avoided instead of camouflaged.

Rests on: Erol, the Turkish delight · and open versus closed rhinoplasty.

The terms, defined

The words used about this graft.

• Crushed cartilage: cartilage flattened in a crusher until pliable, graded in the literature as slightly, moderately, significantly or severely crushed. [16301462]
• Chondrocyte: the living cell inside cartilage; its survival is what the viability percentages count. [16301462]
• Camouflage graft: a graft placed to hide an edge or a ridge rather than to hold a shape. [35596979]
• Onlay graft: a graft laid on top of the existing framework, most often on the dorsum. [33821313]
• Diced cartilage: cartilage cut into pieces of roughly 0.5 to 1 mm, the alternative preparation. [10839424]
• Sliced cartilage: partial-thickness slices cut with a slicer, which keep their thickness and structure at four months. [34546396]
• Resorption: loss of graft volume over time as the cartilage is replaced by scar. [33443780]
• Soft triangle: the apex of the nostril, where skin meets skin with nothing between. [27428918]
• ROE score: Rhinoplasty Outcome Evaluation, the patient-completed appearance questionnaire. [35596979]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what the surgeon should assess before operating and what should be recorded afterwards, whichever graft is chosen.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a chapter on this graft and chapters on the preparations it competes with. They are written for surgeons and go further into technique than a patient page should.

• The use of crushed cartilage grafts for camouflage and contouring in rhinoplasty
• Use of The Diced Cartilage Glue Graft in Rhinoplasty
• Management of the middle vault

The operation on video

The same archive hosts a recorded operation by Ozcan Cakmak, who published the viability work.

• Crushed cartilage

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

What is not settled

• Nearly all the survival data come from rabbits and cell culture. The human numbers are chondrocyte viability in a dish, not graft volume in a nose. [16301462] [15655170] [20418106]
• No trial randomises patients to crushed against uncrushed camouflage. The one comparison with a control group found lower satisfaction at 12 months in the crushed group. [35596979]
• Crushed specimens measured thicker at four months than at implantation, which the authors put down to measurement error on a soft graft rather than growth. [34546396]
• Platelet preparations have been added to improve survival with mixed results. Platelet-rich plasma gave no statistically significant benefit, and in one rabbit study crushed cartilage still showed marked degeneration even with platelet-rich fibrin. [26114532] [41612064]
• Whether crushed cartilage or a fascia-wrapped diced graft gives the smoother dorsum at five years has not been measured in a comparative series. [42557455] [34799765]