Advances in Plastic & Reconstructive Surgery © All rights are reserved by Rui Filipe Meneses de Lima et al.

Matos Eduardo C1, Lima Rui2, Medeiros Rui3, Fernandes Victor4

1Assistant of Plastic Reconstructive and Aesthetic Surgery (Hospital Santa Maria - Lisbon)2Plastic Reconstructive and Aesthetic Surgery Resident (Hospital Santa Maria - Lisbon)3Plastic Reconstructive and Aesthetic Surgery Resident (Hospital Santa Maria - Lisbon)4Chair, Department of Plastic Surgery (Hospital Santa Maria - Lisbon)

AbstractIntroduction: The cleft lip/palate incidence in white newborns is high. The cleft side maxilla deformity causes lack of projection and an asymmetric piriform rim that provides an asymmetric base to the entire nose. Bone grafts are the gold standard surgical treatment to correct the piriform rim bony defect. In this study we pretend to demonstrate that free diced cartilage grafts can have an important role on the correction of the bony nasal base, being a good alternative to bone grafts. The use of free diced cartilage can also be an option in patients who already had bone graft but still lack support of the piriform rim.

Material and Methods: We present a clinical case of a 33 year old patient operated to cleft lip during childhood. The patient showed an asymmetric nose caused by the absent support of the asymmetric piriform rim but the patient refused the harvest of bone graft. In this way we proposed a new surgical treatment, that consists in augmenting the existing space in the piriform aperture with diced cartilage in order to correct the asymmetric bony base.

Results: It was verified that the increased projection of the nasal base was long lasting and without functional deficits. The analysis of the results by surgeons and patient was evaluated as good or excellent.

Discussion: Cleft patients usually require several surgical interventions. The use of free diced cartilage in rhinoplasty to augment the dorsum is well known, however to augment the piriform rim in order to give projection and symmetric nasal base, was not previously described. The technique described is also simple and safe and can provide a reliable result achieving a symmetric nasal base.

Conclusion: This study provides a new surgical technique that proves that the use of free diced cartilage to correct the piriform rim asymmetry is a surgical option that has the advantages of avoiding iliac scar and iliac deformity necessary to harvest iliac bone and provides long lasting results with the well known use of autologous cartilage.

Keywords: Cleft; Rhinoplasty; Diced Cartilage; Piriform Rim; Cartilage Graft

Research Article ISSN: 2572-6684

A Role of Diced Cartilage in Nasal Base Symmetry - Cleft Rhinoplasty

Introduction Genetic and epigenetic factors play important roles in clefts´s

etiology, and this is supported by the varying incidence of clefting in function of the ethnicity, geographic location and socioeconomic conditions [1, 2].

The incidence of cleft lip/palate in white newborns is approxi-mately 1 in 1000 [1].

Cleft pathology has a large diversity of deficiencies of soft tissue, cartilage and bone. Computed tomographic scans can show a wide spectrum of bone deficiency in maxilla, alveolus and piriform defici-ency. Gassner et al. has identified the bony nasal base has a important role in the results of secondary cleft rhinoplasty, because an asymmetric piriform rim and crest provides an asymmetric base to the entire nose,

being a contributing factor to the overall deformity. The cleft side maxilla has a deficit in volume and projection, which characterize this type of bony base [3].

Osteotomies and bone grafts are used to correct bony nasal base [3]. Although the bone grafts are the gold standard surgical treatment to correct the piriform rim bony defect, some patients refuse to have an additional scar. In several cases is not possible to achieve the volume and the pretended support because of bone reabsorption. Another option is the correction of the bony nasal base using diced cartilage graft. Other authors have used diced cartilage grafts wrapped in surgicel or fascia (with or without fibrin sealant) for dorsal augmentation on rhinoplasty [4] but the use of free diced cartilage for augmenting the piriform rim (without a cover and without fibrin sealant) has not been described. We believe that we can reach good results avoiding scars necessary to harvest iliac bone and this technique can be included in patients who already had alveolar bone graft previously but still need further piriform rim augmentation.

Therefore the purpose of this study is to evaluate the efficiency and the clinical application of the augmentation of the piriform rim with free diced cartilage and subsequent correction of the nasal base.

*Address for Correspondence: Eduardo Craveiro Matos, Avenida Professor Egas Moniz, 1649-035 Lisboa, PORTUGAL, Tel: + 351 966734692; E-Mail: eduardomcmatos@gmail.com

Received: May 22, 2019; Date Accepted: July 17, 2019; Date Published: July 18, 2019.

Adv Plast Reconstr Surg, 2019 Page 252 of 255

Lima R, Matos E, Medeiros R, Fernandes V. Tuga Grafter: Low Cost Fat Harvesting, Processing and Infiltration System. Adv Plast Reconstr Surg, 2019; 3(1): 252-255.

Material and Methods

Clinical Case

Female, 33 years old, operated to cleft lip three decades before and without other surgeries performed. The patient showed an asymmetric nasal tip and an asymmetric position of the nostrils and wings, caused by the typic deformation of the inferior lateral cartilage and the absent support of the nasal base [Figure 1 & Figure 2]. She also showed a broad nasal dorsum.

Surgical Technique The senior author (Matos et al.) has developed a surgical technique

to correct the bony asymmetry of the piriform aperture through the use of free diced cartilage, in order to enhance the results of the primary/secondary rhinoseptoplasty. The key idea was to fill the existing space in the piriform aperture [Figure 4], in order to re-establish the nasal base symmetry (improving lower lateral cartilage support). Cephazolin 2g was given intravenously at induction.

In first place, the surgeon performed the open rhinoseptoplasty [Figure 3] which was realized through the classical trans-columellar incision. Through this approach we harvested septal cartilage retaining a L-Strut. It was used an unilateral spreader graft on the left side, a columellar strut graft and was performed a cephalic trim, interdomal and transdomal stitches.

Figure 4: a) The surgeon filling the piriform aperture with diced cartilage; b) Superior vestibular incision with the exposure of piriform rim; c) Syringe previously cut and filled with diced cartilage

Figure 1: pre-operative basal view - is possible to verify the asymmetric nasal bony base with contraction of the left vestibule and deficit in the tip projection on the left side;

Figure 2: Pre-operative frontal view - asymmetric nose with less projection of the left side;

The patient refused the treatment of the dorsum, lateral osteoto-mies and also refused the harvest of iliac bone. After discussing other options with the patient, including other bone grafts donor sites that the patient refused, the authors planed an alternative surgical technique for augmentation of the piriform rim with free diced autologous cartilage harvested from the septum. The surgical option was presented and accepted by the patient and the informed consent was discussed and obtained.

Figure 3: Open primary rhinoseptoplasty with exposure of the nasal septum;

a

b c

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The excess cartilage was diced in pieces (smaller than 1 mm cubes) using a 24 blade and soaked in NaCl 0.9‰ solution. The cartilage obtained was placed in 1ml syringes and the syringe tip was cut [Figure 4].

Lima R, Matos E, Medeiros R, Fernandes V. Tuga Grafter: Low Cost Fat Harvesting, Processing and Infiltration System. Adv Plast Reconstr Surg, 2019; 3(1): 252-255.

Figure 5: Comparison between pre and pos surgical intervention (9 months later) - anterior posterior and lateral views

Finally the piriform aperture was exposed through upper vesti-bular incision and the piriform rim was reached through sub periosteal approach taking care to undermine only the area intended to augment. The piriform aperture was then augmented with 1 ml of cartilage previously obtained [Figure 4]. Lastly we closed the incision layer by layer. In post operative period the patient used an upper lip constriction bandage and soft diet to avoid upper lip movement and migration of the cartilage. Oral antibiotics were given for 7 days.

Figure 6: comparison between pre and post surgical intervention (9 months later) - basal view

The results were evaluated through subjective analysis by the author, patient and one other non-involved surgeon during the follow up visits of the patient. The evaluation was performed in the third month, sixth month and first year post-operative consultations.

The patient authorized and signed the informed consent for the use of her clinical case in this scientific work after one year of follow up.

Results

The authors verified that the increase projection of the piriform rim lasted through the follow up consultation. As a consequence of the increased projection of the piriform rim, the tilt to the cleft side was corrected on the basal view. Furthermore, a bigger tip projection, tip and alar base symmetry were achieved.

During evaluations both surgeons and patient classified the results as good or excellent.

It is important to mention that the patient was very satisfied with the aesthetic result of surgery, and in addition she remained without functional deficits.

Discussion The failure of fusion of the frontonasal and maxillary processes

gives rise to the cleft of the primary palate, which includes the lip, alveolar process, and the hard palate anterior to the incisive foramen. These patients have a characteristic phenotype which provoques difficulties on social integration, and also they have limitations on the speech, swallow, feeding and consequently on their growth [2, 5, 6]. Advances on Plastic Surgery techniques have allowed surgeons to offer a normal speech, a regular growth and a sociable acceptable appearance.

Cleft patients usually require several surgical interventions since their childhood. At a later stage, that is, after the cessation of growth of the nose (age 11 or 12 in females and 13 or 14 in males), these patients can be candidates to rhinoplasty to correct associated defo-rmities.

Generically, in patients with secondary cleft nose deformities, surgery objectives are the optimization of nasal tip projection, bony dorsum projection, alar base position, alar rim contour, alar facial relationship, nasolabial angle and achieve nasal airway patency. In the case reported, the patient showed asymmetric nasal tip, alar base position and alar rim contour. She also showed a broad nasal dorsum. The surgical planning was designed focusing on these deformities with the limitation of not reducing the dorsum respecting patients desire. The nasal tip was corrected through widely used techniques aiming to obtain a tip proportional to the untouched dorsum.

The use of free diced cartilage in rhinoplasty to augment the dorsum is well known [7].

However its use was not previously described to augment the piriform rim in order to give a projected and symmetric nasal base. This technique is a valid alternative that uses established techniques of free diced autologous cartilage with a new objective aiming to correct piriform rim deformities. It’s an option in patients who refuse autolo-gous bone graft or even in patients who have already been submitted to autologous bone graft but still lack projection.

The harvest of iliac autologous bone graft is not exempt from problems and can create a visible scar, deformity in the iliac area and can promote disabling gait disorder or even dysesthesia by nerve damage. It has also the disadvantage of operating in another surgical field. For minor autologous bone grafts, the bone can be harvested from other sites. In similar cases the donor area is usually the mandible

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but that may also cause endodontic and nerve damage.

The free diced cartilage described has the advantages of using autologous cartilage harvested from the same surgical site and avoids other scars, deformities, endodontic and nerve damage caused by autologous bone graft harvest.

It has been shown that cartilage cut into cubes has viability and stability four and a half years after its insertion, and that diced cartilage has lasted longer compared to other preparations, such as cartilage wrapped in surgicel [9].

We evaluated the patient for more than one year after the surgery and the result produced by the diced cartilage was kept with maintained projection of the nasal base.

One limitation of the study is the report of only one clinical case. However, this study allowed us to verify that diced cartilage can achieve satisfactory and long lasting results in the correction of asymmetry of the nasal base. Further studies should be done in order to confirm and evaluate histological features that comprove viability of the grafts or more objective analysis with 3D imaging technology or other.

This surgical technique does not replace the techniques well described in the literature for the correction of the piriform rim, such as the bone graft, but it presents itself as a good alternative.

As future prospects, it would be important to carry out a prospe-ctive study comparing the bone graft and cartilage graft in similar cases.

Conclusion

The asymmetric piriform rim contributes to the overall deformity

of the nose and should be addressed before or during the rhinoplasty in cleft lip patients. The use of diced cartilage to correct the piriform rim asymmetry is a surgical option that has the advantage of avoiding iliac scar and deformity necessary to harvest iliac bone. It´s a simple and safe technique that can provide a reliable result and a symmetric nasal base.

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Adv Plast Reconstr Surg, 2019 Page 255 of 255

Lima R, Matos E, Medeiros R, Fernandes V. Tuga Grafter: Low Cost Fat Harvesting, Processing and Infiltration System. Adv Plast Reconstr Surg, 2019; 3(1): 252-255.