The use of autologous and cadaveric cartilage grafts in rhinoplasty: an Australian survey study

Introduction

Rhinoplasty is considered one of the most complex and challenging procedures in facial plastic surgery. The nose represents the defining focal point of the midface, thus small imbalances, deformities and irregularities, are easily detectable by the patients and their family. The functional consequences of a lack of structural support, or prior reductive rhinoplasty surgery, can have a huge impact on a patient’s health and quality of life (1,2).

In primary rhinoplasty, the surgeon will frequently utilize the quadrangular septal cartilage for reconstruction, given its abundance, convenience and structural qualities. But even in primary cases, the surgeon will require extra-nasal cartilage harvest in 13% (3). In the context of prior trauma, and especially in revision surgery, the rate of extra-nasal cartilage requirement is considerably higher (24%) (3).

Autologous auricular cartilage and autologous rib grafts (ARGs) provide suitable options for structural grafts and contouring purposes, but while abundant, have their own limitations. For ARG’s the disadvantages include the risk of donor site morbidity, the additional procedural time, and the potential for graft related complications.

In 2023, Chen et al. provided an updated meta-analysis evaluating the complications associated with the use of ARG in rhinoplasty, in 1,648 cases across 20 studies, with an overall complication rate of 15.13% (4). Graft warping (3.1%) was the most common complication, followed by donor site hypertrophic scaring (2.3%), contour irregularities (1.5%), and graft resorption (1.2%). The overall revision rate was 2.3% and overall, there was a low rate of pneumothorax (<0.05%) (4). While subject to reporting bias and study heterogeneity this remains the most comprehensive description of complication relating to ARG in rhinoplasty to date.

Cadaveric rib grafts (CRGs) have been widely utilized in revision rhinoplasty, for many years and has the advantage of off the shelf availability, no donor site morbidity and reduced operative time. CRG is allograft cartilage that has been frozen following irradiation, reducing its allogeneic potential. Some have suggested that processing may alter its mechanical properties, and there have been concerns regarding the risk of resorption and infection (5). Other studies found that irradiated cartilage warps at the same rate as non-irradiated (6). Donor age may be the key factor in determining mechanical properties of rib cartilage grafts, with grafts from donors >36 years of age demonstrating less warping, likely relating to increased cartilage calcification (7).

Numerous studies have investigated the complication rates associated with CRG and ARG. The reported rates of warping, resorption and infection vary significantly. Factors including reporting and publication bias, study heterogeneity, in case complexity and surgical technique, have likely contributed to this variability. A recent meta-analysis comparing the complication rates of CRG and ARG found no significant differences in terms of warping, resorption, infection, contour irregularity, or the necessity for revision surgery (8). However, this meta-analysis could only analyse warping and resorption with regards to dorsal on lay rib cartilage grafts, which is of less relevance than structural graft complications. Kridel et al. found comparable complication rate (3.25%) when using CRG as structural grafts versus ARG in 25-year experience (n=357) (9). Similar resorption (1% vs. 1.4%), low infection rate (0.2%) and similar graft warping was observed, within limitations of subjective palpation of graft abnormalities. When considering functional outcomes, assessed by NOSE score, there appears to be no difference at up to 12 months follow-up (10). Nevertheless, there is still no clear consensus on which graft option is more reliable.

With regards to cost, a North American observational study performed a cost utility analysis for rhinoplasty at a single center and found that when revision rhinoplasty was performed without complication, there was an almost negligible difference in the cost between ARG and CRG, with average of an additional $266 (USD) when ARG was used (11). However, this study found that if ARG harvest was complicated by pneumothorax, the subsequent extended length of stay and medical interventions, increased the cost difference substantially to $5577 (USD) (11).

A recent survey of American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members demonstrated a high rate of use of CRG use (76%) amongst its respondents, with over half (56%) utilising ARG. Most respondents employed rib cartilage for structural grafts including spreader grafts (91%) and septal extension grafts (86%). The factors positively affecting CRG use were concerns regarding patient comorbidities [odds ratio (OR) 4.83, 95% confidence interval (CI): 2.03–12.3], and the number of rhinoplasties performed per year, with high volume surgeons utilizing CRG more frequently (OR 3.19, 95% CI: 1.35–7.86). Concern for CRG related complications including warping, infection and resorption, had the greatest negative impact on CRG usage amongst respondents (OR 0.16, 95% CI: 0.06–0.40), followed by concerns regarding CRG cost (OR 0.16, 95% CI: 0.06–0.40).

This study aims to provide a comprehensive understanding of how surgeons in Australia are utilizing this cadaveric and ARGs in rhinoplasty and compare that to practices in North America. By capturing and presenting this data, our goal is to contribute to the broader body of knowledge on CRG use and to highlight variations in practice that could inform future discussions, research, and potential standardization efforts. We surveyed current members of the Australasian Academy of Facial Plastic Surgery (AAFPS), regarding their current practice, preferences and experience in ARG and CRG. By describing a snapshot of the current practice and documenting expert opinions regarding the utility and relevant concerns, we aim to further the discussion about the use of ARG and CRG in rhinoplasty surgery.

Methods

An 18-question survey (Appendix 1) assessing the practice and opinions relating to autologous and cadaveric cartilage grafts in rhinoplasty was created for distribution to members of the AAFPS members between 15 May and 30 June 2024 (n=90). The AAFPS defines a member as an Australian Health Practitioner Regulation Agency (AHPRA) registered specialist surgeon in one of Otolaryngology Head and Neck Surgery, Plastic and Reconstructive Surgery, Ophthalmology and Oral and Maxillofacial Surgery, who practices within the field of facial plastic surgery, in the Australasian region. Fellow members are defined as existing AAFPS members who have provide evidence of at least 50 surgical interventions/procedures of the face and neck in a 2-year period. Members are admitted following a process of application review. Respondents accessed the survey via a unique link embedded in an email describing the survey, sent to active AAFPS members. Survey responses were collected anonymously via RED-Cap (REDCap 9.7.1 Ó 2020 Vanderbilt University). The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-24-66/rc).

Questions numbered 1–4, 6–8, and 12–16, allowed a single response. All other questions allowed respondents to select multiple responses. Respondents who selected ‘other please specify’, were provided a text box for further comment. Descriptive statistics were first employed to summarize surgeons’ practices with cadaveric rib in rhinoplasty, highlighting common techniques, preferences, perceptions, and complications.

Multivariate logistic regression analysis was performed to assess predictive factors for frequency of using CRG, while controlling for independent variables including number of rhinoplasties per year, patient and surgeon preference, graft complications, graft availability, cost, procedure duration and patient age, to identify significant factors relating to frequency of CRG usage amongst AAFPRS respondents. Significance was set at P≤0.05 (95%). Frequency of performing rhinoplasties was grouped as less than 50 per year and more than 50 per year to divide low and higher volume surgeons and allow comparison with the AAFPRS study. All analysis were conducted, and figures were created with GraphPad Prism version 9.1.0 for Mac, La Jolla, California, USA. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments with implied consent from all individual participants. The project was reviewed by the Hunter New England Local Health District Research Ethics Board (No. AU202404-06) under a non-Human Research Ethics Committee (HREC) pathway for low-risk projects and was deemed to be consistent with the principles and values outlined in the National Statement on Ethical Conduct in Human Research [2007]. As a low-risk survey project, exemption was granted from HREC approval, in line with NSW Health policy.

Results

The REDCap survey was sent via email to all 90 active AAFPS members and completed by 39 members for a total response rate of 43.3% (n=39/90). Of those that complete the survey, 41% were fellow members (n=16), and 59% were non-fellow members (n=23). The response rate for fellow members was 80% (n=16/20) compared and for non-fellow members was 33% (n=23/70). Most respondents held primary fellowships (n=33) in Otolaryngology, Head and Neck Surgery (respondents/members =33/62), the remaining respondents were from Plastic and reconstructive surgery (n=5/15) and Oral and Maxillofacial Surgery (n=1/7). None of the Ophthamology members responded (n=0/6 members).

Most of the respondents (64.1%, n=25) perform more than 50 rhinoplasties per year, all of which were from the field of Otolaryngology, Head and Neck Surgery (Figure 1). High volume surgeons performing >100 rhinoplasties per year made up 38.5% (n=15) of the total respondents.

Figure 1 The AAFPS respondents’ number of rhinoplasties performed per year and the proportion of revision rhinoplasties performed per year [labels; category, % (n)]. AAFPS, Australasian Academy of Facial Plastic Surgery.

All respondents reported performing both primary and revision rhinoplasties. For 46% of respondents (n=18), revision rhinoplasty comprises more than 20% of the surgeon’s rhinoplasty practice (Figure 1).

The most commonly utilized graft types by respondents were septal cartilage (100%, n=39), CRG (95%, n=37), ARG (79.5%, n=31) and auricular cartilage (64.1%, n=25). Over half (56.4%, n=22) of the respondents use perpendicular plate of ethmoid grafts. Of those that reported ‘Other’ graft types; written responses included autologous fascia (n=4), autologous fat (n=3), dermis (n=1) and Medpor^® allogenic implant (n=1) (Table 1).

With regards to costal cartilage usage, 41% utilise costal cartilage grafts weekly to biweekly (n=16), or a few times per year (33.3%, n=13). Only one respondent (2.6%, n=1) reported never using costal cartilage and only 2 respondents (5.1%, n=2) reported using ARG but never using CRG (Table 2). Most respondents use CRG regularly, with over half (59%, n=23) using CRG weekly to monthly (Figure 2). The majority of respondents that reported using costal grafts offer patients a choice between ARG and CRG (81.6%, n=31) (Table 1).

Figure 2 Frequency using cadaveric rib graft [labels; category, % (n)].

Respondents mostly commonly utilized CRG for spreader grafts (94.6%, n=35), septal extension/replacement grafts (91.9%, n=34) and lateral support grafts; articulated rim grafts/batten/lateral crural strut grafts (78.4%, n=29). There was relatively low usage of CRG for non-structural grafts including columella strut grafts (45.9%, n=17) and dorsal onlay grafts (45.9%, n=17).

CRG was mostly prepared at room temperature after thawing (91.9%, n=34). Alternatively, grafts were prepared when the cartilage was incompletely thawed (2.7%, n=1) or whilst frozen (5.4%, n=2). The majority of respondents fashioned grafts that were 1–3 mm at their smallest dimension (89.2%, n=33) (Table 3). Most respondents (67.6%, n=25) preferred to prepare grafts from a 40 mm donor segment and prefer a single piece of donor cartilage rather than pre-cut strips (97.3%, n=36). Most of the respondents (70%, n=26) regularly utilize at least half of the CRG provided, and half (51.4%, n=19) regularly utilize CRG perichondrium (Table 3). Experience with pre-cut CRG strips was low (16.2%, n=6). Of those with experience only one respondent preferred pre-cut strips to a complete CRG segment (Table 3).

Respondents were asked what they regarded were the indications for use of CRG over ARG, and what factors if any, prevented the use of CRG in their practice.

Advanced patient age (82.1%, n=32), length of procedure (82.1%, n=32), patient preference (79.5%, n=31), surgeon preference (76.9%, n=30) and reduced risk donor site morbidity (74.4%, n=29) were reported most as indications for CRG over ARG.

Concern for ARG infection (5.1%, n=2) and resorption (7.7%, n=3) was low, relative to concern for ARG warping in all patients (12.8%, n=5) and warping in young adult patients (33.3%, n=13) (Table 4).

Patient concerns regarding CRG (56.4%, n=22), cost of CRG (51.3%, n=20) and limited supply of CRG (43.6%, n=17) were the most cited reasons preventing surgeons from using CRG in their practice. Concern regarding CRG warping (5.1%, n=2) and resorption (5.1%, n=2) were low and concern for CRG infection (10.3%, n=4) was slightly higher. ‘Other’ reported factors included inconsistencies in CRG calcification (2.6%, n=1) (Table 4).

Multivariate logistic regression model compared key predictive factors with the frequency of CRG use, with respondents placed into two groups: regular users (weekly to monthly use) versus respondents with infrequent use or who never used CRG (Figure 3). Multivariate logistic regression demonstrated a significant positive relationship between number of rhinoplasties performed and frequency of use of CRG (OR 10.58, P=0.03, 95% CI: 1.4–64.8). The other factors did not reach statistical significance in either direction (Figure 3).

Figure 3 Factors associated with frequency of cadaveric rib graft use on multivariate logistic regression analysis. *, P<0.05. CI, confidence interval; OR, odds ratio.

Discussion

Our results document the current practice regarding the use of costal cartilage grafts amongst Australian facial plastic surgeons. Over a third (38.5%) of respondents reported performing more than 100 rhinoplasties per year, with the majority of respondents (64%) reported performing more than 50 rhinoplasties per year. This is similar to the respondents in the AAFPRS survey (65.7%), and demonstrates that most respondents have a large amount of experience (11).

Almost all the respondents in this survey reported using CRG (95%) and 25% reported that nothing prevented them from using CRG in their practice. Inexperience with CRG was a factor limiting use of CRG for only one respondent, so overall respondents were comfortable and familiar with using CRG in rhinoplasty. Of the respondents that never used CRG a lack of supply and concern for infection were the reported factors.

Compared to the AAFPRS survey, the rate of CRG usage in this survey was considerably higher (95% vs. 76.8%). Thus, multivariate logistic regression analysis could not identify predictive factors for CRG usage as was performed in the former study (11). Rather, frequency of CRG usage was compared with similar predictive factors. Frequency of CRG usage was divided into two groups: regular users (using CRG weekly to every 4 weeks) and infrequent or never users. Multivariate logistic regression demonstrated performing more than 50 rhinoplasties per year was the only statistically significant predictive factor relating to frequency of CRG use in this study (OR 10.58, P=0.03, 95% CI: 1.4–64.8). Respondents that reported performing more than 50 rhinoplasties per year were over 10 times more likely to be regular CRG users (at least every four weeks) than those who perform less than 50 rhinoplasties per year. For 64% of respondents, revision rhinoplasty makes up at least 20% of their practice. With such a high proportion of revision rhinoplasties performed by respondents, this finding is understandable. Thus, this may simply be a reflection of a higher number of rhinoplasties or perhaps the use of more advanced grafting techniques requiring robust extra-nasal cartilage. Patient selection, by the lower volume surgeon, may also be a factor. Although CRG supply was not a statistically significant factor on multivariate logistic regression, 44% of respondents reported that CRG supply impacted usage. Institutional factors such as CRG consignment at high volume centers could be a contributing factor but this was not confirmed by our results and more data is required.

One option to address a lack of supply is the use of pre-cut strips of CRG. However, experience with pre-cut strips in Australia was low, with only 16.2% of respondents having used them and only one of those respondents preferring pre-cut strips to a single CRG segment. Respondents generally preferred a single piece of donor cartilage to prepare their grafts from and mostly utilized at least 50% of the CRG segment, often also using the perichondrium from the graft.

There are mixed reports regarding graft complications, particularly costal cartilage warp rates, infection and resorption for both ARG and CRG in the literature (4,8,9). Respondents in this survey had greater concern for ARG graft warping (ARG 12.8% vs. CRG 5.1%) and resorption (ARG 7.7% vs. CRG 5.1%) whilst slightly more concern for CRG infection (CRG 10.3% vs. ARG 5.1%), although overall concerns for graft complications were low compared to AAFPS respondents.

Surgeons mostly utilized CRG for structural grafts including spreader grafts and septal extension grafts, whereas the use for dorsal onlay grafts was much less common, which was similar to reports in the AAFPRS survey. This demonstrates the confidence respondents have in CRG for structural grafts, in line with the findings of Kridel et al. (9), but further studies are required to assess the long-term structural performance of CRG and ARG.

Respondents preferred CRG to ARG due to shorter length of procedure, in older patients, and when patients or surgeons preferred to avoid autologous rib harvest. This is very similar to the main predictive factors for CRG use identified in the AAFPS study.

Patient concern regarding CRG was considerably higher than the US patient population. 56% of respondents reported patient concern with CRG as a factor limiting use compared to 26.4% in the AAFPRS study. This did not reach significance as predictive factor for frequency of CRG use on multivariate logistic regression and this could reflect the sample size.

A response rate of over 41% is comparable to survey study response rates in the literature, and more than double the response rate of the North American study (11-13). However, by virtue of a smaller membership (n=39/90), the study population in this survey was considerably smaller than that of the AAFPRS survey (n=178/1,015). This is a major limitation of this study. However, considering the aim was to obtain a snapshot of the current practice of facial plastic surgeons in Australia, this does not obviate its relevance in the rhinoplasty literature. Another inherent limitation is the potential source of biases. Since participation was voluntary, the study may be affected by nonresponse bias. It is possible that non-responding members of the AAFPS hold views on the use of ARG and CRG might differ considerably from those who responded. Due to the anonymous data collection process, it was not feasible to identify those who did not respond after the survey closed. We therefore cannot identify if the non-responders differ from responders, e.g., by specialty or experience, and thus we cannot analyse this; 84% of responders were Otolaryngology Head and Neck Surgery specialists, and this reflects the AAFPS membership composition, with the majority (69%) of members from this field (n=62/90).

The response rate of 43% may be considered a major limitation, however there is no established standard for what constitutes an acceptable response rate to ensure representativeness. Moreover, no studies have shown a direct link between response rate and the reduction of nonresponse bias.

Conclusions

Extra-nasal cartilage grafts are frequently required in the setting of revision rhinoplasty. The surveyed Australian facial plastic surgeons are both familiar and comfortable with the use of either ARG or CRG. Respondents were relatively more concerned with CRG infection than rates of warping or resorption compared to ARG. Almost all respondents utilize CRG in their rhinoplasty practice. The greatest predictor of the frequency of CRG usage, is performing more than 50 rhinoplasties per year. It is likely that the increased use of CRG among high-volume surgeons (>50 rhinoplasties annually) is due to a combination of factors, including a preference for more advanced reconstructive techniques and a higher proportion of revision cases, both of which typically necessitate extra-nasal cartilage sources. The respondents preferred CRG over ARG due to reduced donor site morbidity and shorter procedure time amongst other factors. Our findings suggest that higher volume surgeons have a greater confidence in CRG usage in rhinoplasty.

Further research is needed to assess long term structural performance of CRG versus ARG.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-24-66/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-24-66/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-24-66/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-24-66/coif). C.M. serves as an unpaid editorial board member of Australian Journal of Otolaryngology from November 2022 to December 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments with implied consent from all individual participants. The project was reviewed by the Hunter New England Local Health District Research Ethics Board (No. AU202404-06) under a non-Human Research Ethics Committee (HREC) pathway for low-risk projects and was deemed to be consistent with the principles and values outlined in the National Statement on Ethical Conduct in Human Research [2007]. As a low-risk survey project, exemption was granted from HREC approval, in line with NSW Health policy.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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