鼻中隔软骨联合耳软骨雕塑鼻尖在假体隆鼻中应用效果

目的:探讨假体隆鼻时应用鼻中隔软骨联合耳软骨雕塑鼻尖的临床效果。方法:选取2013年1月至2014年3月在我院进行隆鼻术的患者98例,按照随机数表法将其分成对照组和实验组,每组49人。对照组患者采用单纯的假体隆鼻,实验组患者采用假体隆鼻并使用鼻中隔软骨联合耳软骨雕塑鼻尖。评价手术的满意程度及手术前后患者的鼻长、鼻尖高度、鼻尖角的变化情况。结果:实验组患者的治疗满意度为91.84%,明显高于对照组的40.82%,差异具有统计学意义(P0.05)。实验组患者术后鼻长、鼻尖高度、鼻尖角均优于手术前(P0.05),且显著优于对照组,差异均有统计学意义(P0.05)。结论:应用鼻中隔软骨联合耳软骨雕塑鼻尖在假体隆鼻中具有良好的应用效果,满意度较高,值得在临床上推广使用。     

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty

Augmentation rhinoplasty of the Asian nose may be effectively accomplished with alloplastic materials. However, certain circumstances mandate the use of autologous grafts (e.g., dorsal augmentation that exceeds 8 mm and patient intolerance of alloplastic implants). Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. The use of costal cartilage for autologous augmentation in select Asian patients has proven to be a reliable method in more than 500 operative cases during a 10-year period. This study was designed to evaluate the ideal costal cartilage graft for augmentation rhinoplasty. Forty-two preserved cadavers were studied for the relationship of the individual rib cartilages to the surrounding tissue and for the length and caliber of each costal cartilage. The seventh rib was found to be the ideal rib graft by virtue of its safe location and overall size for grafting. The seventh rib is situated over the abdominal cavity, so the risk of pneumothorax is insignificant. The internal thoracic artery and vein descend in close apposition behind the first to sixth ribs but begin a course medial to the ribs inferior to this point, and therefore vascular injury during seventh-rib harvesting is unknown. The seventh rib also provides the greatest overall available length (90.7 mm, right; 89.6 mm, left) and thickness (17.6 mm, right; 17.5 mm, left). Despite the more conspicuous location of the incision required to harvest the seventh rib, the limited 3-cm incision that is used has healed favorably in almost all cases. The other major drawback for seventh-rib harvesting is the dissection required through the overlying rectus abdominis muscle, but little technical difficulty or postoperative morbidity is added with muscle dissection. The seventh rib is advocated as the ideal choice for augmentation rhinoplasty and potentially other recipient sites.     

Costal cartilage sculpturing as an adjunct to augmentation mammaplasty

Costal cartilage irregularities are a major component of most congenital thoracic-wall deformities. A significant number of patients with these cartilage irregularities may either refuse major reconstruction or in fact have disorders of insufficient magnitude to justify such endeavors. In patients undergoing augmentation mammaplasty, recontouring or sculpturing of these abnormal costal cartilages may correct or improve the underlying chest-wall deformity and thus enhance the final aesthetic result. This method has had application in mild to moderate asymmetrical cases of both pectus excavatum and pectus carinatum, thoracic hypoplasia (Poland's syndrome), isolated cartilage deformities, and spinal scoliosis. In our hands, the combination of cartilage sculpturing with submuscular augmentation mammaplasty is performed as an outpatient local anesthetic procedure requiring not more than 90 minutes.     

Reconstruction of the nose damaged by cocaine

Nasal snorting of cocaine crystals causes destruction of the septal and nasal mucosa, which eventually provides exposure of the septal cartilage and nasal bones. This exposure eventually leads to septal chrondritis and nasal bone osteomyelitis. As this process continues, the severe loss of cartilage and bone allows gradual to total collapse of the nose. Correction of this deformity is best achieved by supplying new lining; this is possible by turning nasolabial flaps into the nasal vestibule to replace the lost and released lining. Once this has been accomplished, costal cartilage grafts can be inserted along the bridge and alae to maintain the structural integrity of the reconstruction.     

Acrylamide gel electrophoresis of acid glycosaminoglycans for the study of molecular size distribution

Chondroitin sulfates from bovine nasal septum and lamprey cartilage and keratan sulfate from human costal cartilage show a wide molecular size polydispersity by acrylamide gel electrophoresis. The number of fractions were limited only by the number of slices obtained from gel slabs after electrophoresis. The polysaccharides are probably distributed in a continuum of varying chain lengths.For the study of the size distribution of sulfated glucosaminoglycan by acrylamide gel disc electrophoresis, several buffer systems were formulated according to a general guide.     

The Turkish delight: a pliable graft for rhinoplasty

In nose surgery, carved or crushed cartilage used as a graft has some disadvantages, chiefly that it may be perceptible through the nasal skin after tissue resolution is complete. To overcome these problems and to obtain a smoother surface, the authors initiated the use of Surgicel-wrapped diced cartilage. This innovative technique has been used by the authors on 2365 patients over the past 10 years: in 165 patients with traumatic nasal deformity, in 350 patients with postrhinoplasty deformity, and in 1850 patients during primary rhinoplasty. The highlights of the surgical procedure include harvested cartilage (septal, alar, conchal, and sometimes costal) cut in pieces of 0.5 to 1 mm using a no. 11 blade. The fine-textured cartilage mass is then wrapped in one layer of Surgicel and moistened with an antibiotic (rifamycin). The graft is then molded into a cylindrical form and inserted under the dorsal nasal skin. In the lateral wall and tip of the nose, some overcorrection is performed depending on the type of deformity. When the mucosal stitching is complete, this graft can be externally molded, like plasticine, under the dorsal skin. In cases of mild-to-moderate nasal depression, septal and conchal cartilages are used in the same manner to augment the nasal dorsum with consistently effective and durable results. In cases with more severe defects of the nose, costal cartilage is necessary to correct both the length of the nose and the projection of the columella. In patients with recurrent deviation of the nasal bridge, this technique provided a simple solution to the problem. After overexcision of the dorsal part of deviated septal cartilage and insertion of Surgicel-wrapped diced cartilage, a straight nose was obtained in all patients with no recurrence (follow-up of 1 to 10 years). The technique also proved to be highly effective in primary rhinoplasties to camouflage bone irregularities after hump removal in patients with thin nasal skin and/or in cases when excessive hump removal was performed. As a complication, in six patients early postoperative swelling was more than usual. In 16 patients, overcorrection was persistent owing to fibrosis, and in 11 patients resorption was excessive beyond the expected amount. A histologic evaluation was possible in 16 patients, 3, 6, and 12 months postoperatively, by removing thin slices of excess cartilage from the dorsum of the nose during touch-up surgery. This graft showed a mosaic-type alignment of graft cartilage with fibrous tissue connection among the fragments. In conclusion, this type of graft is very easy to apply, because a plasticine-like material is obtained that can be molded with the fingers, giving a smooth surface with desirable form and long-lasting results in all cases. The favorable results obtained by this technique have led the authors to use Surgicel-wrapped diced cartilage routinely in all types of rhinoplasty.     

Grafting the nasal dorsum with tandem ear cartilage

A technique for autogenous grafting of the nasal dorsum with ear cartilage is suggested based on the results of 25 consecutive cases. The technique involves (1) harvesting the entire cymba conchae and cavum conchae of the ear; (2) separating them and suturing them to each other in tandem fashion; (3) filling the underside concavity of the cymba conchae part of the graft with scraps of cartilage; (4) avoiding any bruising or crushing of the graft; and (5) filling any minor residual irregularities of the dorsum with soft tissue or cartilage from the cephalic trim of the lateral crus. The results suggest a consistent augmentation of the nasal dorsum for deficiencies from 3 to 6 mm in size. Four of the 25 cases did require secondary correction for dorsal convexity, inadequate augmentation, and surface irregularities. The technique, however, has been helpful in that ear cartilage is invariably available, allowing septum to be used for more important grafts. The procedure is easily performed under local anesthesia with no significant distortion to the donor site.     

The effect of calcification on the structural mechanics of the costal cartilage

The costal cartilage often undergoes progressive calcification with age. This study sought to investigate the effects of calcification on the structural mechanics of whole costal cartilage segments. Models were developed for five costal cartilage specimens, including representations of the cartilage, the perichondrium, calcification, and segments of the rib and sternum. The material properties of the cartilage were determined through indentation testing; the properties of the perichondrium were determined through optimisation against structural experiments. The calcified regions were then expanded or shrunk to develop five different sensitivity analysis models for each. Increasing the relative volume of calcification from 0% to 24% of the cartilage volume increased the stiffness of the costal cartilage segments by a factor of 2.3–3.8. These results suggest that calcification may have a substantial effect on the stiffness of the costal cartilage which should be considered when modelling the chest, especially if age is a factor.     

Augmentation rhinoplasty: dorsal onlay grafting using shaped autogenous septal cartilage

We describe our experience with autogenous septal cartilage onlay grafts for augmentation of the nasal dorsum in primary and secondary rhinoplasty cases. After careful nasofacial analysis, the grafts are custom-shaped into inverted-V-frame, A-frame, or inverted-U-frame grafts, depending on the type and degree of augmentation desired. The dorsal elevation is thus tailored to fit the imperfection at hand, resulting in a smooth, natural-looking nasal contour. The indications for each type of graft are reviewed, and the surgical technique of graft harvesting and carving is detailed and illustrated.     

Segmental bone and cartilage reconstruction of major nasal dorsal defects

This article describes the results of segmental bone and cartilage reconstruction of significant nasal dorsal defects. Solid bone graft reconstructions frequently lead to an unnatural hardness of the nasal tip. Rib cartilage reconstructions are pliable and soft but are a problem because they easily undergo warpage. The operation is performed using the open approach. Outer cranial bone graft is used for the bone component and extends at least two-thirds of the length of the dorsum. It is secured in place with a compression screw and a Kirschner wire. The cartilage component consists of an abbreviated L strut constructed of septal or conchal cartilage. It is slotted into the cranial bone in a tongue-in-groove manner and is sutured to it through a drill hole in the bone. The dorsal profile is completed with a single cartilage onlay graft or multiple sagittal cartilage grafts secured to the sides of the L strut. Twelve patients underwent segmental reconstruction of nasal deformities. Within this group, five patients underwent secondary rhinoplasty, five underwent posttraumatic rhinoplasty, and two underwent nose augmentation for Oriental features. There were seven men and five women. In all cases, good nasal tip mobility was maintained, and the nasal tips were soft. The interface between the bone graft and cartilage graftwas well camouflaged. The two did not separate. This procedure follows the principle of replacing lost tissue with like materials.     

Modeling costal cartilage using local material properties with consideration for gross heterogeneities

Contemporary computer models of the thorax designed to predict injury in automobile collisions model the costal cartilage as a homogeneous material using properties derived from local material characterization tests. No studies have validated the accuracy of these models in predicting the structural mechanics of costal cartilage. Two heterogeneities - the perichondrium and calcified regions - may affect the behavior of costal cartilage in a manner not accounted for by current models. This study sought to investigate the predictive ability of subject-specific models of whole costal cartilage segments, with the calcified regions modeled distinctly and with the perichondrium removed (from the physical specimens as well as from the simulations). Finite element models were developed in the case of five cadaveric costal cartilage segments. The properties of the cartilage were derived from indentation testing of each specimen, where the characteristic average instantaneous elastic moduli ranged from 8.7 to 12.6 MPa. Matched simulations and experiments were then performed, subjecting each specimen to cantilever-like loading with a dynamic posterior displacement of the sternal boundary (all other boundary degrees-of-freedom fixed). The models predicted the resulting peak anterior-posterior forces generated on the costal boundary with a minimum error of 1% and a maximum error of 36%. These results provide support to the previous implicit assumption that insight can be gained into the structural behavior of costal cartilage by observing the local material properties (when calcified regions are included and the perichondrium is removed). Future work includes the addition of the perichondrium, so as to model the whole costal cartilage composite structure.     

Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases

Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the nasal framework. The technique described by Erol ( 105: 2229, 2000) uses Surgicel-wrapped diced cartilage grafts in rhinoplasties. The advantages include its ease of preparation, the large volume of graft substrate available for use, and the avoidance of contour irregularities in the areas of placement. A retrospective case review of 67 consecutive patients who were treated with a Surgicel-wrapped diced cartilage graft as part of an aesthetic and/or functional rhinoplasty, in a 5-year period between 1995 and 2000, was performed in this study. All cases of congenital nasal deformities or deformities caused by trauma or tumors in which the technique was used were excluded. The charts were reviewed to determine demographic variables, the surgical procedures performed, prior operations, the rhinoplasty approach used, and the graft donor and recipient sites. Preoperative and postoperative photographs were examined, and the results were assessed. Data on the donor and recipient sites, complications, and the necessity for revisionary procedures were tabulated. There were two complications, namely, an infection, which resolved with aspiration and oral antibiotic therapy, and a recurrence of a dorsal depression, which necessitated repeated augmentation within 6 months. The technique of using Surgicel-wrapped diced cartilage proved to be effective for the augmentation of various areas of the nose. The complication and revision rates were acceptable and comparable to those of other techniques. Patient satisfaction with the aesthetic results was rated highly, with no reports of graft extrusion or contour irregularities. This technique is recommended for nasal augmentation and contouring for selected rhinoplasty patients.     

Effect of neonatal head X-irradiation on growth of costal and tibial cartilage in rats: a histochemical and electron microscopic study

Long-Evans rats were exposed to a single dose of head X-irradiation (600 rads) at 2 days of age. Experimental and sham irradiated rats were sacrificed at 14, 20-21, 23, 41-45, and 70-71 days. Tibial epiphyseal width and the number of cells in the epiphyseal plate were determined. Histochemical and electron microscopic studies were carried out on both costal and epiphyseal cartilage. Histochemical techniques revealed a reduction in chondroitin sulfate at 14 days in both costal and epiphyseal cartilage of X-irradiated rats. Epiphyseal cartilage demonstrated recovery subsequently, and this was followed by a normal decrease of chondroitin sulfate with increasing age, but costal cartilage did not recover. Collagen synthesis was also reduced in both costal and epiphyseal cartilage, but not as dramatically as chondroitin sulfate. Except for some electron dense cells and reduced scalloping of the cell membrane, costal chondrocytes from irradiated rats did not show major ultrastructural alterations. In contrast, epiphyseal chondrocytes demonstrated radiation induced alterations in organelles, in enhanced glycogen deposition, and in retardation of chondrocyte maturation. Extracellularly in both costal and epiphyseal cartilage of irradiated rats, collagen density and matrix granules were reduced, while calcification of the matrix was enhanced. Beyond 45 days, the effects of irradiation were markedly reduced. Comparisons of the histochemical results with metabolic studies carried out previously in cartilage from the same animals indicated a more direct concordance of the histochemical results with the pattern of physical growth and supported the usefulness of morphologic and histochemical techniques in the analysis of the growth disorder in the head-irradiated rat.     

In situ split costal cartilage graft harvesting through a small incision using a gouge

A costal cartilage graft is one of the most useful materials in reconstructive plastic surgery. In this article, a technique of in situ split costal cartilage graft harvesting through a small incision (2 to 3 cm) using a gouge is described. The technique used has many advantages: it is a simple technique, is easy to learn, and can be performed quickly through a small incision. By avoiding complete costal cartilage graft harvesting, the associated potential complications such as pleural perforation, chest wall deformities, long-lasting postoperative pain, and incisional scar length are reduced. This technique will be useful in selected cases for which a complete block of costal cartilage graft is not needed.     

Establishment and characterization of chondrocyte cell lines from the costal cartilage of SV40 large T antigen transgenic mice

Complete understanding of the physiology and pathology of the cartilage is essential to establish treatments for a variety of cartilage disorders and defects such as rheumatoid arthritis, congenital malformations, and tumors of cartilage. Although synthetic materials have been used in many cases, they possess inherent problems including wear of the materials and low mechanical strength. Autograft has been considered very effective to overcome these problems. However, the limitation of the transplant volume is a major problem in autograft to be overcome. The costal cartilage is the most serious candidate for donor site transplantation, since it is the largest permanent hyaline cartilage in the body. To investigate the possibility using the costal cartilage as a transplant source, we have established and characterized three mouse chondrocyte cell lines (MCC-2, MCC-5, and MCC-35) derived from the costal cartilage of 8-week-old male SV40 large T-antigen transgenic mice. At confluence, all the cell lines formed nodules that could be positively stained with alcian blue (pH 2.5). The size of nodules gradually increased during culturing time. After 2 and 6 weeks of culture, RT-PCR analysis demonstrated that all three cell lines expressed mRNA from the cartilage-specific genes for type II collagen, type XI collagen, aggrecan, and link protein. Furthermore, type X collagen expression was detected in MCC-5 and MCC-35 but not in MCC-2. Any phenotypic changes were not observed over 31 cell divisions. Immunocytochemistry showed further that MCC-2, MCC-5, and MCC-35 produced cartilage-specific proteins type II collagen and type XI collagen, while in addition MCC-5 and MCC-35 produced type X collagen. Treatment with 1alpha, 25-dihydroxyvitamin D(3) inhibited cell proliferation and differentiation of the three cell lines in a dose-dependent manner. These phenotypic characteristics have been found consistent with chondrocyte cell lines established from cartilage tissues other than costal cartilage. In conclusion, costal cartilage shows phenotypic similarities to other cartilages, i.e., articular cartilage and embryonic limbs, suggesting that costal cartilage may be very useful as the donor transplantation site for the treatment of cartilage disorders. Furthermore, the cell lines established in this study are also beneficial in basic research of cartilage physiology and pathology.     

Redefining the Septal L-Strut to Prevent Collapse

During septorhinoplasty, septal cartilage is frequently resected for various purposes but the L-strut is preserved. Numerous materials are inserted into the nasal dorsum during dorsal augmenation rhinoplasty without considering nasal structural safety. This study used a finite element method (FEM) to redefine the septal L-strut, to prevent collapse as pressure moved from the rhinion to the supratip breakpoint on the nasal dorsum and as the contact percentage between the caudal L-strut and the maxillary crest changed. We designed a 1-cm-wide L-strut model based on computed tomography data. At least 45% of the width of the L-strut in the inferior portion of the caudal strut must be preserved during septoplasty to stabilize the septum. In augmentation rhinoplasty, the caudal L-strut must either be preserved perfectly or reinforced to prevent collapse or distortion of the L-strut. The dorsal augmentation material must be fixed in an augmentation pocket to prevent movement of graft material toward the supratip breakpoint, which can disrupt the L-strut. We conducted a numerical analysis using a FEM to predict tissue/organ behavior and to help clinicians understand the reasons for target tissue/organ collapse and deformation.     

A monoclonal antibody distinguishes growth cartilage from other types of cartilage: a new probe for osteogenic cartilage

Summary Monoclonal antibodies (mAbs) were raised by injection of a homogenate of cultured growth cartilage (GC) cells from young rabbit ribs. These mAbs were examined by immunohistochemical staining for their reactivity to paraffin sections of rabbit tissues. The results showed that an mAb reacted preferentially with late hypertrophic and calcified costal GC zones. The mAb also reacted with hypertrophic GC adjacent to bone that existed in sternum and femur, but not to other cartilages, including resting cartilage, articular cartilage, auricular cartilage, nasal cartilage, tracheal cartilage and meniscus cartilage, or with other tissues, including tendon, skin, muscles, lung, liver, heart, thymus, spleen, eye and gut. It reacted with a wider area of the GC zone when the sections were decalcified, although its reactivity with the extended area was much less intensive than that with late hypertrophic and calcified GC zones. On treatment of the sections with bacterial collagenase, neither the reactive area nor its intensity were changed, while when treated with trypsin the reactivity was lost.These results suggest the existence of a certain molecule which distinguishes GC (osteogenic cartilage) from other (non-osteogenic) cartilage. This mAb is a useful probe for distinguishing osteogenic cartilage from non-osteogenic cartilage, and for studying differentiation steps of cartilage cells in endochondral bone formation. The mAb can also be used as a probe for clinical and stored specimens because it reacts with decalcified and paraffin-embedded human specimens.     

The residual unilateral cleft lip nasal deformity: a three-phase correction technique

The author presents a three-phase correction technique for the residual unilateral cleft lip nasal deformity. This procedure involves a sculpting excision of the alar rim, use of this alar rim as an interpositional flap in lengthening the columella, and augmentation of the nasal tip and perialar sulcus with a free ear conchal cartilage graft. The concept has been incorporated in the revisionary surgery program of 74 patients over a period of 5 years with a minimal follow-up of 2 years. The majority of the patients are operated on between the ages of 5 and 7 years based on the concept of a need for a "tidy appearance" by first grade.     

The use of alloderm for the correction of nasal contour deformities

What rhinoplasty surgeon has not been frustrated by unmet expectations from unreliable graft materials? The quest for an ideal graft continues. Septal cartilage is not always adequate in amount or substance. Ear cartilage may cause unsightly irregularities over time. Cranial bone or rib harvest sites add to the complexity of the procedure and can be intimidating for many operators. This article describes the authors' successful experience with AlloDerm onlay grafts for the correction of nasal contour deformities in 58 primary and secondary rhinoplasty cases by means of the open and endonasal approaches. Forty-two patients received an open-approach procedure; the remaining 16 received grafting through an endonasal or closed approach. Thirty-seven of the patients were secondary rhinoplasty patients, and some underwent multiple nasal corrections. The indications, intraoperative surgical technique of graft placement, and representative results will be discussed. Long-term follow-up showed good results, though partial graft resorption occurred in some patients. Overall, this experience with AlloDerm for nasal augmentation was encouraging.     

The effect of aging on the synthesis of hexosamine-containing substances from rat costal cartilage. A decrease in sulfation of chondroitin sulfate with aging.

The amount of glycosaminoglycan (GAG) in dry costal cartilage tissue of rats decreased with aging, while the GAG content in mg DNA (unit cartilage cell) remained the same with aging. These results can be explained by the finding that the total number of cartilage cells decreased with aging. Electrophoretic analysis showed that chondroitin 4-sulfate was the major GAG in rat costal cartilage of various ages. Rat costal cartilage of different ages was incubated with radioactive precursors, and newly synthesized GAG was prepared and the radioactivity analyzed to determine the biosynthetic activity. As to changes in the radioactivity uptake with aging per mg dry cartilage tissue, aging influenced [35S]sulfate incorporation into GAG more significantly than [3H]glucosamine incorporation into GAG. There was a significant decrease in the specific radioactivity of [35S]sulfate per mg DNA (unit cartilage cell), whereas the specific radioactivity of [3H]glucosamine per mg DNA did not change significantly with aging. Both the total sulfotransferase activity and the specific activity per mg DNA decreased significantly with aging. Analysis of disaccharide units formed after chondroitinase ABC digestion of labeled GAG isolated from young and old cartilage showed that the percentage of incorporation of [3H]glucosamine into deltaDi-OS increased significantly with aging. These results suggested that the appearance of nonsulfated positions in the structure of the chondroitin sulfate chain increased with aging. On the basis of gel chromatography on Bio-Gel A-1.5 m no significant difference in the approximate molecular size of chondroitin sulfate was observed between the young and old GAG samples. The present study indicated that the sulfation of chondroitin sulfate chains from rat costal cartilage decreased with the process of aging.