Abstract
Purpose
Patients having suffered severe nasal trauma or having undergone prior septal surgery present particular problems during open structure septorhinoplasty. Septal cartilage deficient noses often require costal or conchal cartilage grafting or the use of allograft material, resulting in secondary donor site morbidity, longer operative times and variable results. The present study evaluated the utility of cyanoacrylate-based adhesives (CBA) in creating layered septal cartilage grafts from remnant septal cartilage for L-strut reconstruction during open septorhinoplasty.
Study design
A retrospective clinical review was performed at a university-based facial plastic and reconstructive surgical practice, identifying patients undergoing open structure septorhinoplasty performed by the senior authors. Procedures involved construction of a layered caudal or dorsal L-strut graft from at least two smaller autologous septal cartilage grafts. The grafts were adhered together with CBA with 5-0 polydioxanone suture (Ethicon, Somerville, NJ) used for reinforcement. Stability of the final construct was assessed postoperatively.
Results
Fifteen patients were included with mean age of thirty-nine years (range: 15–65). Fifty-three percent of the patients had undergone prior nasal surgery: Seven had undergone at least one prior external septorhinoplasty and one had undergone prior endonasal septoplasty. Median follow-up was 144 days (range: 45–405). Postoperatively, one local infection was noted and two patients complained of post-operative columellar deviation. No other complications were encountered.
Conclusion
CBAs provide a safe technique in the crafting of layered grafts to provide reliable tip/dorsal support when performing open structure septorhinoplasty among patients with cartilage deficient or severely traumatized septa.
1
Introduction
Long-term maintenance of tip support and midvault volume are essential during septorhinoplasty. Patients seeking revision surgery without adequate support often present with irregularities of the middle vault, a malpositioned tip, or internal valve insufficiency. The dorsal and caudal components of the intact septal L-strut provide the necessary support for the optimization of nasal function and cosmesis .
When weakened by prior surgery or trauma, proper reconstruction of the L-strut is critical for an ideal result and there are many potential grafting sources. Autologous grafts include septal, auricular, and costal cartilage as well as alloplastic implants and irradiated homologous costal cartilage (IHCC). These sources all have specific attributes and criticisms. Surgeon familiarity, patient selection, and history of prior nasal surgery or trauma must all be considered when deciding upon graft provenance.
Septal cartilage is often absent or deficient following prior septoplasty or severe nasal trauma. Many techniques have been developed to treat septal cartilage deficient noses. Procedures have been described using either auricular cartilage, rolled mersilene mesh, or bone from the perpendicular plate of the ethmoid to reconstruct either the dorsal or caudal strut . These techniques entail additional donor site dissection and/or intricate and time-consuming suturing.
Here we describe a technique in which an elongated and bolstered caudal or dorsal graft for L-strut reconstruction is created by adhering multiple septal cartilage remnants together with cyanoacrylate glue. The described technique includes off-label, subcutaneous use of cyanoacrylate-based adhesives (CBA). CBA (Indermal®, Dermabond®, Histoacryl®) is a family of liquid monomers that polymerize in an exothermic reaction when in contact with tissue surfaces creating a strong yet flexible binding film. CBA therefore may represent a safe option to simply and quickly construct elongated caudal or dorsal strut grafts with no additional donor site morbidity and minimal added time.
2
Methods
This study was approved by the University of California, San Francisco (UCSF) Committee for Human Research (14-14337). A retrospective chart review was performed identifying patients greater than 18 years of age undergoing primary or revision rhinoplasty from July 2012 to July 2014 at the UCSF Medical Center. All patients underwent the procedure discussed below by the senior authors. Patient demographics, indication for surgery, operative findings, and post-operative course including complications were noted.
2.1
Surgical technique
Standard open septorhinoplasty was performed. The CBAs were only used in 2 settings: septal cartilage deficient noses and noses with severely traumatized septa. During revision cases, as much septal cartilage was harvested as possible, while maintaining the structural integrity of the L-strut, as long as it was not severely deviated and/or causing symptoms of nasal obstruction. If severely deviated and causing obstruction, an extracorporeal septoplasty was performed ( Fig. 1 ). If severely traumatized septal cartilage was encountered, wherein tears in the cartilage prevented the creation of grafts of adequate strength and/or length, the septal cartilage was divided into straight segments, which were adhered together with Indermil® (Medline Corp, Mundelein, IL), Histoacryl® (Aesculap, Center Valley, PA), or Dermabond® (Ethicon, Somerville, NJ), to create sufficiently long, rigid and/or thick grafts ( Fig. 2 ). 5-0 Polydioxanone suture (Ethicon, Somerville, NJ) was then used to reinforce these composite grafts. The newly created, layered cartilage grafts were then used to reconstruct the deficient L-strut ( Fig. 3 ). Other standard maneuvers in open rhinoplasty were used to address rotation and projection, refine the nasal tip, and/or support alar position. Post-operative antibiotics were not provided.
