Diced cartilage grafts

What repeats

Five findings that hold across the literature.

It was invented so the graft would stop showing through the skin

The original description states the problem directly: carved or crushed cartilage may be perceptible through the nasal skin once swelling settles. The answer was cartilage cut into pieces of 0.5 to 1 mm with a number 11 blade, wrapped in one layer of oxidised cellulose and moulded under the skin. The series covered 2,365 patients over ten years, 1,850 of them primary rhinoplasties, 350 post-rhinoplasty deformities and 165 traumatic deformities. Excessive resorption occurred in 11 patients and persistent overcorrection from fibrosis in 16.

Rests on: Erol, the Turkish delight · and crushed cartilage grafts.

The complication rates are known and the numbers are small

A meta-analysis pooled 14 studies and 2,380 patients having dorsal augmentation with diced cartilage. Overall complications ran 11.5% and revision surgery 5.3%. The individual rates were infection 4.5%, visible irregularity 5.3%, overcorrection 0.7% and absorption 0.5%.

Rests on: Li et al., meta-analysis.

What the pieces are packed in does not change those rates

The same meta-analysis compared wrapped, glued and free diced cartilage and found no significant difference in visible irregularity (p = 0.23) or revision surgery (p = 0.71). A 98-patient comparison of cartilage wrapped in fascia, laid under fascia, and used free found no significant difference in nasion projection, rhinion projection or the width of the dorsal aesthetic lines.

Rests on: Li et al. · Golpayegani et al., projection and width.

The height holds for at least a year, measured three separate ways

Sonographic measurement of glued diced cartilage grafts in 10 patients showed cross-section change of 8% to -7%, median -2%, between 3 and 15 months after insertion. Three-dimensional scanning in 23 patients showed a significant increase in dorsal height at one year without dorsal widening, and no significant reduction between 3 months and 1 year. High-frequency ultrasound in 15 patients found the framework fully intact at one year with no migration.

Rests on: Tasman et al., morphometric evidence · Yoo et al., molded glued graft · Kofler et al., ultrasound.

Some of the cartilage stays alive, and the wrapper affects how much

Biopsies of glued diced grafts showed viable cartilage with signs of regeneration. Colour Doppler found new blood vessels in the graft in 7 of 15 patients. In rabbits, diced cartilage wrapped in oxidised regenerated cellulose showed almost no peripheral chondrocyte proliferation, and in a separate rabbit comparison fascia-wrapped diced cartilage had the greatest volume loss and the lowest survival rate of five graft preparations.

Rests on: Tasman et al. · Kofler et al. · Cakmak et al., rabbit study · Ozturk et al., graft preparation comparison.

By what holds the pieces together

The cartilage is the same. The carrier is the decision.

Oxidised cellulose

The original wrapper. It is now rarely used, because of severe foreign body reactions reported with it and because it reduces cartilage viability.

Rests on: Erol · Dong et al., wrapping materials review · Cakmak et al..

Fascia

A sheet of the patient's own fascia is rolled into a sleeve and filled with the diced pieces. Temporal fascia was used in 18 secondary endonasal cases with no resorption at a minimum of 15 months, with 3 complications and 1 revision for contour. Retroauricular fascia takes the wrapper and the cartilage through one incision behind the ear, at the cost of less cartilage and 6 to 8 weeks of swelling. The listed drawbacks of fascia in general are the second donor site, the quantity available and the time it takes.

Rests on: Harel and Margulis, temporal fascia · Campiglio et al., retroauricular fascia · Dong et al..

Fibrin glue

Glue replaces the sleeve. Prepared in a mould, it shortens the operation and lets the graft be shaped before it goes in. A single-institution series of 108 patients reports rare resorption, and the unfavourable outcomes were corrected with minor revisions.

Rests on: Tasman, diced cartilage glue graft · Tasman, advances review.

The patient's own blood products

Platelet-rich plasma and platelet-poor plasma were combined into an autologous glue in 68 patients, with dorsal height maintained and no graft removed over a mean 15 months. A three-arm study of 30 saddle nose patients compared fibrin glue, platelet-rich plasma and warm blood, 10 patients each, and found significant improvement in appearance score and dorsal height (p < 0.001) with no difference between the three in resorption at 12 months.

Rests on: Bullocks et al., autologous tissue glue · Rabie et al., three scaffolds · and the saddle nose.

A cover of crushed cartilage

A crushed septal cartilage sheet laid over a glued diced graft scored better for palpable irregularity than the glued graft alone in 38 patients, 4.15 +/- 0.75 against 3.56 +/- 0.92 (p = 0.04).

Rests on: Lee et al., crushed cover · crushed cartilage grafts.

Nothing at all

Free diced cartilage with no carrier is still used. In the 98-patient comparison it produced the same projection and width as the wrapped versions, and the two graft infections and one malposition in that study were all in the fascia-wrapped group.

Rests on: Golpayegani et al. · Pincet et al., with and without fascia.

What to ask about diced cartilage

Questions the evidence supports asking.

What is going to hold the pieces

Fascia, glue, blood product or nothing. The pooled figures show no difference in irregularity or revision between them, so the answer is about the operation rather than the result: a fascia sleeve needs a second incision and glue does not.

Rests on: Li et al. · Dong et al..

Where is the fascia coming from

Temple, behind the ear, or the thigh. Behind the ear uses the same incision as a conchal harvest. The temple is a separate site with its own scar.

Rests on: Campiglio et al. · Harel and Margulis · ear cartilage grafts.

How much of the height will still be there next year

Measured by ultrasound and 3D scanning, most of it. Median change in graft cross-section between 3 and 15 months was -2%, and pooled absorption across 2,380 patients was 0.5%. Ask what your surgeon measures and when.

Rests on: Tasman et al. · Li et al. · what recovery looks like.

What happens if the bridge ends up lumpy or crooked

Visible irregularity is the second most reported complication at 5.3%, and pooled revision runs 5.3%. A glued or moulded graft can be adjusted after placement. Ask what the revision would involve and who pays for it.

Rests on: Li et al. · Yoo et al. · revision rhinoplasty · what rhinoplasty costs.

Would a solid block do this better

Diced cartilage fits the shape of the dorsum and resorbs less than block cartilage in one published comparison, and the trade named there is lower predictability of the final height. Ask which one your nose calls for.

Rests on: Suh, dorsal augmentation with autogenous tissues · rib cartilage grafts.

The terms, defined

The words used about this graft.

• Diced cartilage: cartilage cut into pieces of roughly 0.5 to 1 mm. [10839424]
• Diced cartilage in fascia: the pieces packed into a sleeve of the patient's own fascia. [23855009]
• Diced cartilage glue graft: the pieces bonded with fibrin glue and shaped in a mould, with no sleeve. [28388795]
• Free diced cartilage: the pieces laid on the dorsum with no carrier at all. [35346544]
• Oxidised regenerated cellulose: the original wrapper, sold as Surgicel, now rarely used. [34731262]
• Dorsal augmentation: raising the bridge of the nose rather than lowering it. [30005786]
• Radix: the root of the nose, between the eyes, a common site for a small diced graft. [23634447]
• Resorption: loss of graft volume over time. [34357798]
• Neovascularisation: new blood vessels growing into the graft, seen on colour Doppler in 7 of 15 patients at one year. [39151282]

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 the glue graft, a chapter on the deformity it is most often used for, and a chapter on the crushed alternative. They are written for surgeons and go further into technique than a patient page should.

• Use of The Diced Cartilage Glue Graft in Rhinoplasty
• Saddle Nose Deformity: Selection of Augmentation Materials and Management
• The use of crushed cartilage grafts for camouflage and contouring in rhinoplasty

The operation on video

The same archive hosts a recorded operation.

• Diced Cartilage Glue Graft in Rhinoplasty

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

• No randomised trial compares the carriers. The meta-analysis pools separate observational studies, and its finding of no difference between wrapped, glued and free grafts inherits their design. [34357798]
• Animal work and clinical work disagree about fascia. Fascia-wrapped diced cartilage had the lowest survival of five preparations in rabbits, while clinical series report no resorption at 15 months. [42557455] [23855009]
• Follow-up in most series ends at 12 to 15 months. Behaviour at five and ten years is not measured. [23634447] [35877941]
• The infection rate of 4.5% is pooled across studies with different antibiotic and preparation routines, and the studies do not report which step is responsible. [34357798]
• Whether platelet products add anything is untested against a control. The three-scaffold saddle nose study found no difference between fibrin glue, platelet-rich plasma and warm blood. [40311642] [21487909]