British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867

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Comparison of different autografts foraesthetic rhinoplasty: is the tragal caralternative?

Max J. Z a, b c, PaMark M tin HRobert A. Mischkowskia Department of Oral and Craniomaxillofacial Surgery, University Cologne, Germanyb Clinic for Facial Surgery, Cologne, Germanyc Department of Plastic Surgery, Clinic Cologne-Merheim, Germanyd Departmente Department

Accepted 1 AAvailable onl

Abstract

Auricular cainvestigationindications,were tragusfor operatiocompared wintraclass coscapha. Thegrafts were pHarvesting tis a good alt 2013 The

Keywords: Tr

Hereby wthe past 5 yeainterest. Thesstock or otherpayments for

CorresponGermany. Tel

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0266-4356/$ http://dx.doi.oof Trauma and Orthopaedics, Clinic Cologne-Merheim, Germanyof Biomedicine, University of Basel, Switzerlandpril 2013ine 21 May 2013

rtilage is an important source of grafts for various reconstructive procedures such as aesthetic rhinoplasty. The purpose of thiswas to compare tragal cartilage with auricular cartilage harvested from the concha and scapha, and describe its clinical viability,

and morbidity in rhinoplasty. A total of 150 augmentation rhinoplasties with a total of 170 grafts were included. The donor sites(n = 136), concha (n = 26), and scapha (n = 8). The time needed to harvest the grafts, the donor site morbidity, and the indicationsn were recorded. The anthropometric changes to 4 auricular variables after the cartilage had been harvested were analysed andith those on the opposite side in 48 patients using Students paired t-test. Intraobserver reliability was assessed using Pearsonsrrelation. The mean (SD) harvesting time was 27 (8) min for the concha, 4.5 (1.4) min for the tragus, and 5.7 (1.6) min for thelargest graft was taken from the concha (28 19 mm), followed by the tragus (20 12 mm), and the scapha (18 6 mm). Thelaced at the following sites: tip grafts (n = 123), columella struts (n = 80), shield (n = 20), rim (n = 17), and dorsal onlay (n = 15).

ragal cartilage is safe, simple, fast, and has a low morbidity, but it can affect the patients ability to wear earphones. Tragal cartilageernative for nasal reconstruction if a graft of no longer than 20 mm is required.British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

agus; Scapha; Concha; Grafts; Rhinoplasty; Morbidity

e disclose any commercial associations, current and withinrs, that might pose a potential, perceived or real conflict of

e include grants, patent licensing arrangements, consultancies,equity ownership, donations, advisory board memberships orconducting or publicising the study.ding author at: Eugen Langen Strasse 12, 50968 Kln,

.: +49 171 8349256.ddress: drmaxzinser@yahoo.de (M.J. Zinser).

Introduction

Since the fundamental work of Ortiz-Monasterio et al.,1Tardy et al.,2 Peck,3 and Sheen,4 autogenous cartilage hasbeen the graft material of choice in nasal surgery in termsof safety, durability, and versatility. Most surgeons preferthe septum as their first choice of donor site, followedby the conchal cartilage.5,6 Only a few surgeons promotethe use of allografts as their first choice in augmentationrhinoplasties.7,8 Cartilaginous grafts can be obtained from the

see front matter 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.rg/10.1016/j.bjoms.2013.04.001inser , Mathias Siessegger , Oliver Thammaegele d, Lutz Ritter a, Matthias Kreppel a, Mar

aaural cartilage intilage graft a viable

nangiotis Theodorou c,. Sailer e, Joachim E. Zller a,

864 M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867

Fig. 1. Distrib

nose, the senal ear provwhen the ssecondaryprefer concplasties, bumainly poshypertrophconchal ca

Cochransince introdgraft-deplehensive stuand scaphaassessed thsibility insite morbideach graft.

Materials

This retrosplasties do(Table 1); 1primary, 35cleft lip rep

Only paconcha, orwhom septcartilage grscaphal grawere donegal cartilagwomen (68(32%), mea

The grastructure odefects, sm

. Technd at the

ur (assynd

and thsigne

inki pr

ssmensis

r siteded focomp

that rts inclonor s

48 phad besite uneerdaangleeen th

andopomperatiution of donor sites and properties of auricular cartilage grafts.

ptum, the rib, and the external auricle.2 The exter-ides a viable alternative in graft-depleted patients

eptal cartilage had already been used, ideally forand tertiary rhinoplasties.913 Most surgeons stillhal grafts for augmentation-reconstruction rhino-t Grobbelaar et al.14 reported a morbidity of 2.2%,toperative deformities of the ear, haematomas, andic scarring. The mean time needed to harvest thertilage ranges between 25 and 30 min.2,11,13

and DeFatta9 and Kotzur and Gubitsch10 haveuced the tragal cartilage as a viable alternative in

ted patients. The purpose of the present compre-dy was to compare tragal cartilage with conchall cartilage for augmentation rhinoplasty. We havee different clinical indications, viability, and fea-cluding the time taken to harvest the graft, donority, and anthropometric changes of the ear for

and methods

pective study comprised 150 augmentation rhino-ne between February 2001 and April 201140 were done for aesthetic reasons, and 100 were

Fig. 2marke

contoroofskinjectsHels

Asseanaly

Donorecor

earlypainplainthe d

Inlageoppoby Wsionbetwsuredanthrpostosecondary, and 5 tertiary. Ten patients had had aair and required reconstruction of the cleft nose.tients who had auricular cartilage grafts (tragus,scapha) were included (Fig. 1, Table 1). Patients inal cartilage was used were excluded. A total of 170afts (136 tragal (80%), 26 conchal (15%), and 8fts (5%)) were harvested (Fig. 1). All operationsby 3 experienced surgeons. In 10 patients, tra-e was harvested from both sides. There were102%), mean (SD) age 25 (5) years, and 48 menn (SD) age 26 (5) years.fts were used to: reconstruct the cartilaginousf cleft noses, cover bony and cartilaginousooth out irregularities, stabilise (as batten grafts),

Grafting te

The scaphaccording t

The mingal cartilagtragal rimto the antersection witfacilitates t1012 mmthe whole2 mm wideique for harvesting tragal cartilage. The incision line must beposterior border of the edge of the tragus.

shield grafts), refine the nasal tip, avoid openrome, and prevent formation of scars between thee bone, particularly if the skin was thin. All sub-d consent forms according to the Declaration ofeoperatively.

t of donor site morbidity and anthropometric

morbidity and harvesting time of each graft werer each patient. This included documentation oflaints, including haematoma and perioperativeesolved within 3 weeks, and irreversible com-uding scarring, sensory disturbances, and pain atites.atients the anthropometric changes after carti-en harvested were compared with those from theaffected ear according to the protocol described

.15 The width, length of the auricles, the protru-of the mastoidauricular plane, and the distancee tragus and the lateral canthus, were mea-

compared with those of the unaffected side. Theetric measurements were made at least 6 monthsvely when the swelling had completely resolved.chniques

al and conchal cartilage grafts were harvestedo the technique described by Nolst Trenit.16imally invasive approach to the harvesting of tra-e is shown in Fig. 2.10 From an incision in the

at the inner border, we dissect subperichondrallyior and posterior of the tragal cartilage. Hydrodis-h local anaesthetic solution containing adrenalinehe preparation. The facial nerve is located aboutanterior to the lower end of the cartilage. Nearlytragus can be removed, leaving only a small rimat the site of the incision for structural support.

M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867 865

Table 1Morbidity of donor and recipient sites of external cartilage of the ear (n = 170). Data are number (%) of patients.Variable Tragus (n = 136) Concha (n = 26) Scapha (n = 8) Total (n = 170)Rhinoplasty 8 150

Primary 8 100Secondary 8 5Tertiary 5Cleft nose 10

Recipient site Tip/onlay g 6 123Dorsum on 15Rim/batten 2 17Columella 80Shield graf 20

Donor site moEarly (reve 1 7(4)

Haemato 5Perioper 2

Late (not re 1 10 (7)Scarring 5Pain on p 2Hypoaes 2Clicking 1 1Unable t

Harvesting timDressing

Properties ofSize (mm)ShapeQuality

The woundto prevent a

Statistical a

All data wcal PackagInc., ChicKolmogorosoft tissuedistributedto assessanthropomvested comassess interthe anthrotified usinProbabilitiecant.

Results

The types oIt was possIt was necewho requir(such as a

e for srtilage

r site126 2689 930 66 21 9

raft 100 17lay graft 4 11graft 9 6

strut 60 20t 10 10rbidity

rsible) 2 (1) 5ma 1 4ative pain 1 1versible) 5 (4) 6

1 4ressure 1 1

thesia 1 1sensation

o wear earplugs 2 e (min) 5 27

45cartilage

20 20 28 19Thin, straight ConvexFirm Stiff

can be closed with a transtragal mattress suturehaematoma. No additional dressing is needed.

nalysis

choictal ca

Donoere analysed with the help of the Statisti-e for the Social Sciences (version 17.0, SPSSago). The distribution was assessed by thevSmirnov test and found to be normal. Allvariables of the external ear were normally

, allowing the use of Students paired t-testthe significance of the difference between theetric variables after the graft had been har-pared with those on the unaffected side. To

observer reliability, two different surgeons madepometric measurements. Reliability was quan-g Pearsons intraclass correlation coefficient.s of less than 0.05 were accepted as signifi-

f graft and their distribution are shown in Table 1.ible to use the tragal cartilage in 136 cases (80%).ssary to use conchal cartilage in 26 patients (15%)ed extensive reconstruction of the cartilage framecleft nose). Grafts from the ears were our first

The early awhose scarposterior au

There wgrafts (Figwere nearl

Fig. 3. Technprepared andtragal border

6

18 6 Straight Flexible

econdary and tertiary rhinoplasties when the sep-had already been used.

morbiditynd late morbidity are shown in Table 1. One patientretracted and who had an adhesion between thericle and the mastoid skin required revision.as less early morbidity after harvest of tragal

. 3, Table 1). Following tragal harvest, the scarsy invisible (Fig. 3) and were of better quality

ique for harvesting tragal cartilage. An anterior flap must bea strip of cartilage 1.52 mm wide preserved at the posteriorto ensure structural support.

866 M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867

Fig. 4. Technique for harvesting tragal cartilage: almost the entire cartilagecan be harvested.

than the chonchal grafts (Fig. 4). The tragal cartilage alsoshowed superior results as far as late morbidity was concerned(Table 1 and Fig. 5).

Harvesting time and properties of the grafts

A further focus of this study was the time taken to harvest thegraft, including the size and shape of the monolayer cartilage(Fig. 1 and Table 1), and tragal grafts took less time, and didnot require dressing. Fig. 1 illustrates the properties of eachcartilage graft.

Fig. 5. Appeagraft.

Anthropometric analysis

Four soft tissue variables were chosen to evaluate the anthro-pometric charvested,there was aharvesting(p < 0.45).(p < 0.52).gus and thmean variaThe inter-o

Discussion

Numerousfunctionalmost recenhigh-densitsimilar toever, the firUnfortunatularly in sefrom differproblem wture, their cand cannotcartilage grThe conchamultiple, b

plastiesectiurrellamewephalowo eaHowegrafthologectedsonabrhinoand r

Mlar frthe cthe tlage.auralmorpunaffis rearance of the almost invisible scar after harvest of the tragal

the ears.20Murrell

frameworkcartilage btion, the hplacementoperative dforming.

Tragal chas other eit is both teasier and fneed for sphaematomahanges to the ears after the cartilage had beenand these did not differ significantly. Althoughmean difference in length of the conchal grafts,of scaphal or tragal cartilage had no effectThe difference in width amounted to 2.3 mmThe mean difference in distance between the tra-e lateral canthus was 1.3 mm (p < 0.341) and thetion in the protrusion angle was 2.1 (p < 0.61).bserver reliability (0.814).

materials have been described for grafting inas well as in aesthetic rhinoplasty. Niechajev8tly published excellent long-term results usingy polyethylene implants, which have a morbidityprocedures that involve autologous grafts. How-st choice for most authors is still septal cartilage.17ely, enough of this is not always available, partic-condary rhinoplasty revisions. Auricular cartilageent sites around the ear is the second choice.18 Theith conchal cartilage grafts is their irregular struc-urvature, and the fact that the cartilage is elasticbe crushed. Some authors also combine auricularafts with bone grafts or cartilage from the ribs.19l cartilage is a beneficial source of cartilage when

igger pieces of cartilage are needed, for instance ines for cleft lip or nasal reconstructions after traumaon of tumours.12 reported changes in the aesthetics of the auricu-ork including distortion of the auricle, changes inauricular angle that result in asymmetry betweenrs, or visible scarring after harvest of the carti-ver, our results showed that none of the external

s (tragus, scapha, or concha) showed significantical differences between the operated side and theside. Independently of the surgical intervention, itle to assume that there is normal variation between

12 further stated that changes in the auricularcan be avoided by preserving a central strut of

etween the cymba and cavum concha. In addi-arvesting of conchal cartilage also requires theof a cumbersome and often uncomfortable post-ressing, or bolster, to prevent a haematoma from

artilage avoids many of these complications andssential advantages, the biggest of which is thathin and straight. Harvesting from the tragus isaster than harvesting from the concha. There is noecial postoperative dressings, there is less risk of, and a straight graft can be obtained that is firmer

M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867 867

than one taken from the concha. However, haematomas canbe prevented simply and effectively when harvesting tragalcartilage by insertion of a single transtragal mattress suture,which can be removed 48 h postoperatively.

Tragal cartilage has many different applications in rhino-plasty surgery. Because of its shape it is ideal for the slightaugmentation of the nasal dorsum, to smooth irregularities,and to hide an open roof. It can also be used for alar contour(rim) grafts, for which the cartilage is cut into 3 15 mmpieces and then placed in an undermined pocket to help cor-rect minor alar retraction or to strengthen the alar side wall.For patients with collapsed nasal valves, tragal cartilage issuitable for use as alar batten grafts. It is particularly well-suited for grafts of the nasal tip such as shield grafts, onlaytip grafts, and columella struts, because it is pliable and notparticularlyexcellent sosal augmenor irregularwork. Howcartilage isumellar strgrafts benot the castragal graftwe have noularly thinprevent theskeleton.

A drawbever, the pietypically mquality forcaused usrently useborne in miharvestingearphones.they workwith the pa

The scawe have almlimited amflat quality

corrective measures, and cannot be recommended for casesin which substantial structural change is needed.

References

1. Ortiz-Monasterio F, Olmedo A, Oscoy LO. The use of cartilage grafts inprimary aesthetic rhinoplasty. Plast Reconstr Surg 1981;67:597605.

2. Tardy Jr ME, Denneny III J, Fritsch MH. The versatile cartilage autograftin reconstruction of the nose and face. Laryngoscope 1985;95:52333.

3. Peck GC. Secondary rhinoplasty. Clin Plast Surg 1988;15:2941.4. Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr Surg

1993;91:4863.5. Guerrerosantos J. Nose and paranasal augmentation: autogenous, fascia

and cartilage. Clin Plast Surg 1991;18:6586.6. Rodriguez-Camps S. Augmentative rhinoplasty with an auricular gibbus.

Aesthetic Plast Surg 1998;22:196205.chajev

l and hichajevedpore)chran Crnative8;138:

tzur A,sthetic Pe M, Ca

versalrrell GLg 2008

ticocheas as a dobbelaatilage gerda Httgart: Tlst Treninoplasu BR.gery. Panovicnt in cinologye Y, Kimed use osal onlaschkownor-site8;121:

thier DDphonesthick. Its uniform, smooth contour makes it anurce of onlay grafts for minimal amounts of dor-tation, or for camouflaging localised depressionsities of contour in the osseocartilagenous frame-ever, Cochran and DeFatta9 reported that the tragalless suitable for structural grafting such as col-

uts, lateral crural strut grafts, and dorsal spreadercause it is not sufficiently strong or thick. This ise according to our experience; we routinely useds as columellar or lateral crural strut grafts, andt found any limitations. In patients with partic-skin it can also be used to camouflage scars andir formation between the skin and the bony nasal

ack of tragal cartilage is its limited supply. How-ce of tragal cartilage that can usually be harvestedeasures 20 12 mm and is usually of sufficientthe applications described. These results have

to change our clinical conception, and we cur-predominantly tragal grafts, although it must bend that Pothier and Charaklias21 found that tragalsignificantly affects the patients ability to wearThis can be an important issue (for example, if

in security or the police) and should be discussedtients.phal cartilage also gave low morbidity. However,

ost completely abandoned its use because of theount that can be harvested and the rather thin and

of the cartilage. It may best be used for small

7. Nieica

8. Nie(M

9. Coalte200

10. KoAe

11. Leand

12. MuSur

13. Orear

14. Grcar

15. WeStu

16. NoRh

17. Nesur

18. JovplaRh

19. Lebindor

20. MiDo200

21. PoearI. Porous polyethylene implants for nasal reconstruction: clin-stologic studies. Aesthetic Plast Surg 1999;23:395402.I. Facial reconstruction by porous high-density polyethylene: long-term results. Aesthetic Plast Surg 2012;36:91727.S, DeFatta RJ. Tragal cartilage grafts in rhinoplasty: a viablein the graft-depleted patient. Otolaryngol Head Neck Surg

1669.Gubisch W. Tragal cartilage grafts in aesthetic rhinoplasty.last Surg 2003;27:2328.llahan S, Cochran CS. Auricular cartilage: harvest techniqueity in rhinoplasty. Am J Otolaryngol 2011;32:54752.. Tragal cartilage grafts in rhinoplasty.OtolaryngolHeadNeck

;139:1767.M. A new method for total reconstruction of the nose: the

onor area. Clin Plast Surg 1981;8:481505.r AO, Matti BA, Nicolle FV. Donor site morbidity post conchalrafting. Aesthetic Plast Surg 1997;21:902.. Basic principles. In: Weerda H, editor. Surgery of the ear.hieme; 2004. p. 110 [in German].it GJ. Grafts in nasal surgery. In: Nolst Trenit GJ, editor.ty. Amsterdam: Klugerer Publications; 1998. p. 4966.Combined conchal cartilageethmoid bone grafts in nasallast Reconstr Surg 2000;106:1715.S, Berghaus A. Autogenous auricular concha cartilage trans-orrective rhinoplasty. Practical hints and critical remarks.1991;29:2739.

J, Lee E. Lengthening of the postoperative short nose: com-f a gull-wing concha composite graft and a rib costochondraly graft. Plast Reconstr Surg 2000;105:2190201.ski RA, Domingos-Hadamitzky C, Siessegger M, et al.morbidity of ear cartilage autografts. Plast Reconstr Surg

7987., Charaklias N. Tragal cartilage harvesting and in the ear

: a pilot study. J Laryngol Otol 2006;120:13.

Comparison of different autografts for aural cartilage in aesthetic rhinoplasty: is the tragal cartilage graft a viable alternative?IntroductionMaterials and methodsAssessment of donor site morbidity and anthropometric analysisGrafting techniquesStatistical analysis

ResultsDonor site morbidityHarvesting time and properties of the graftsAnthropometric analysis

DiscussionReferences