|Year : 2016 | Volume
| Issue : 1 | Page : 3-8
Diced cartilage under perichondrial carpet with reinforcement (DCUP) technique for nasal dorsal augmentation
Kapil Agrawal, Raghav Shrotriya, Manoj Bachhav
Department of Plastic and Reconstructive Surgery, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||9-Feb-2016|
Department of Plastic Surgery, King Edward Memorial Hospital, Gynae Wing, 2nd Floor, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Correction of the secondary cleft lip nasal deformity is a real challenge for the esthetic surgeons. Grafts are an integral part of modern rhinoplasty with costal cartilage being increasingly used in the secondary case. The use of costal cartilage is fraught with problems like visibility and warping. Introduction: We propose an innovative alternative technique, "Diced Cartilage Under perichondrial carpet with reinforcement (DCUP) technique" keeping in mind, the Indian noses which usually do not support the liquid (filler) or semisolid (diced cartilage in fascia [DCF]) augmentation due to thick skin and weak structural support. Aims and Objective: To introduce a technique which can provide both a softer and natural looking dorsum and a strong framework to withstand the stress of healing forces in early postoperative period. Materials and Methods: Over the past 3 years we have used this technique in 25 patients with primary as well as secondary rhinoplasties including posttraumatic and secondary cleft lip nose deformity. Postoperative follow-up was done with clinical examination and photography. Results: In our study, a total of 25 patients were operated, there were 9 males and 16 females, giving a male:female ratio of about 1:2. Mean follow-up was 18 months. All patients had rounded, well contoured, and smooth dorsum. There was no incidence of fracture, warping, visibility or extrusion of graft, or palpable or visible sutures. Conclusion: Proposed technique of "Diced Cartilage Under Perichondrial carpet with reinforcement (DCUP) technique" is a very good alternative especially in Indian setting to keep the good effects of DCF that is, smoother, softer, and natural looking dorsum and also able to withstand postoperative contracting forces owing to its stable base of costal cartilage graft.
Keywords: Diced cartilage, rhinoplasty, secondary cleft lip nasal deformity, warping, costal cartilage graft
|How to cite this article:|
Agrawal K, Shrotriya R, Bachhav M. Diced cartilage under perichondrial carpet with reinforcement (DCUP) technique for nasal dorsal augmentation. J Cleft Lip Palate Craniofac Anomal 2016;3:3-8
|How to cite this URL:|
Agrawal K, Shrotriya R, Bachhav M. Diced cartilage under perichondrial carpet with reinforcement (DCUP) technique for nasal dorsal augmentation. J Cleft Lip Palate Craniofac Anomal [serial online] 2016 [cited 2021 Apr 14];3:3-8. Available from: https://www.jclpca.org/text.asp?2016/3/1/3/175996
| Introduction|| |
Correction of the secondary cleft lip nasal deformity is a real challenge for the esthetic surgeons. ,,, The most difficult part of secondary cleft lip nose is the tip deformity. To get an esthetically pleasing and normally breathing nose, one needs to give equal importance to tip, septum, and dorsum. Grafts are an integral part of modern rhinoplasty with costal cartilage being increasingly used in secondary cases. A secondary cleft lip nose requires plenty of cartilage grafts for supporting and designing tip, septal strengthening with spreader grafts and if needed, to design dorsum. Use of grafts comes with several problems-donor site morbidity, limited availability, visibility, warping, and long-term survival.  Diced cartilage provides a solution to all these. Recently, the use of finely diced surgicel wrapped cartilage by Erol has ushered in a new era in rhinoplasty.  Later Rollin Daniel came with the idea of diced cartilage in fascia (DCF).
We propose an innovative alternative keeping the Indian noses in mind which usually donot support the liquid (filler) or semisolid (DCF) augmentation due to thick skin and weak structural support. Diced cartilage under perichondrial carpet with reinforcement (DCUP) technique is the perfect answer to the Indian noses as it is a combination of both solid and diced cartilage. Solid plate of cartilage provides structural support as well as keeps the thick skin envelope supported while diced cartilage on top of it gives a soft contour and perichondrium over this keeps the unit intact and helps in maintaining the natural rounded shape of dorsum, softens the graft edges and helps in minimizing the visibility of the graft. Warping of the base plate is controlled by senior author's counterbalancing technique  in which concave surfaces of two warped pieces sutured together which keeps the plate straight [Figure 1]. Authors use "DCUP" technique when costal cartilage is chosen as augmentation material.
|Figure 1: (a) Technique of harvesting a strip of perichondrium before harvesting the costal cartilage; (b) Costal cartilage marked in midline; (c and d) Opposing pieces sutured together to prevent warping|
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| Materials and methods|| |
Over the past 3 years, we have used this technique in total 25 patients of primary as well as secondary rhinoplasties including posttraumatic and secondary cleft lip nose deformity (SCLND). Results were evaluated according to patient satisfaction, clinical evaluation and serial photographic documentation every 3 months for the 1 st year and then yearly, longest follow-up being 3 years.
Patients are operated by standard open rhinoplasty technique. The septum is opened from the caudal end and medial osteotomies if needed, performed. Septal correction is carried out with the scoring of septum on the concave side and/or with suturing technique. More severely deformed septum needs removal of deformed part of cartilage as well as bone, leaving 8-10 mm of dorsal and caudal L strut. Splinting of L strut is performed with bilateral spreader grafts and dorsum is closed. Tip is rebuilt and reshaped using columellar strut, suturing techniques and tip and alar grafts. Authors first build and reshape the tip complex and accordingly decide the height/thickness of dorsal augmentation. The decision of final height/thickness of DCUP unit is dictated by the height of reshaped tip complex. Frequently, unilateral secondary cleft lip nose cases need alar base or pyriform augmentation to match with normal side. Percutaneous lateral osteotomies, unilateral or bilateral are performed according to the need after the closure of all incisions. After the completion of procedure, nasal packing is done with paraffin soaked ribbon gauze. Plaster of Paris splint is applied and removed after 2 weeks.
Preparation of the DCUP unit
Usually, 6 th or 7 th or both costal cartilages are harvested as per requirement. We harvest strip of anterior perichondrium leaving 2-3 mm rim on either side which helps in subperichondrial dissection while harvesting graft and also facilitates perichondrial closure [Figure 1]a.
A dorsal strut of costal cartilage is prepared from 2 curved pieces by suturing their concave surfaces together to get single straight plate over which strip of perichondrium is fixed to its three corners with 5-0 vicryl, keeping one of its lateral sides opened to fill diced cartilages [Figure 1]c, d and [Figure 2].
Cartilage is diced up to 2-3 mm size using no. 11 knife. Pieces of diced cartilage are swept underneath the perichondrial carpet closed from three sides with back of the knife handle or scoop [Figure 2]a and b. In case still larger volume is required, the perichondrium may be fixed circumferentially around the dorsal cartilage to provide two surfaces wherein to fill diced cartilage [Figure 2]c and d. Once the desired volume and shape is achieved, the open end is closed with 3-4 sutures keeping the knots down toward posterior aspect of cartilage graft. In case the width of perichondrial sleeve is inadequate, two strips can be sutured together using 5-0 vicryl. The DCUP construct is then inserted through the open rhinoplasty exposure to provide smooth looking dorsal augmentation. The final height or thickness of a complete DCUP unit is decided according to the difference of height between reconstructed tip complex and dorsum. The amount of diced cartilage needed in a DCUP unit is dictated by thickness of solid cartilage plate. Other grafts are placed as required. Closure is done by standard technique.
|Figure 2: Technique of preparation of DCUP unit (a) Filling of diced cartilage under the perichondrial carpet sutured over the stable cartilage base; (b) Schematic representation of DCUP unit; (c) Formed sandwich DCUP; (d) Schematic representation of sandwich DCUP|
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In some cases of secondary cleft lip nasal deformity, patient has severe maxillary hypoplasia for which midface augmentation and alar base augmentation is performed by using costal cartilage grafts.
| Results|| |
Out of total 25 patients in the study, there were 9 males and 16 females. Out of which 15 patients had secondary cleft lip nasal deformity, 8 patients had a secondary deformity, and 2 patients were operated for primary augmentation one of which was having a milder variety of Binder's syndrome. Mean follow-up was 18 months. All patients were satisfied with the nasal profile. There was no incidence of fracture, warping, visibility or extrusion of graft, or palpable or visible sutures.
There was no incidence of chest wall deformity.
Following complications were noted:
- One patient had infection of the banked costal cartilage which had to be removed
- One patient had infection of the tip which got settled by intravenous antibiotics for 5 days
- One patient had necrosis of tip of columella which got settled spontaneously with minor scarring on the suture line. The postoperative results of some of the patients of this series are as shown in [Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8] and [Figure 9].
|Figure 3: (a) Case of secondary cleft lip nose deformity, preoperative frontal photo; (b) 18 month postoperative|
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|Figure 4: (a) Case of secondary cleft lip nose deformity, preoperative frontal photo; (b) 2 years postoperative|
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|Figure 5: Case of posttraumatic crooked nose (a) Preoperative frontal view; (b) 15 months postoperative|
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|Figure 6: (a) Case of secondary cleft lip nose deformity, preoperative frontal photo; (b) 3 years postoperative|
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|Figure 7: (a) Case of secondary cleft lip nose deformity, preoperative frontal photo; (b) 8 months postoperative|
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|Figure 8: (a) Case of esthetic rhinoplasty, preoperative frontal photo; (b) 16 months postoperative|
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|Figure 9: (a) Esthetic rhinoplasty in a case of Binder Syndrome, preoperative frontal photo; (b) 6 months postoperative|
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| Discussion|| |
Various grafts have been used in recent times for augmentation in all types of rhinoplasties. Synthetic materials seem to give good results in primary rhinoplasties but in revision and secondary cleft lip nasal deformities the danger of exposure and infection is much more.  Cartilage grafts have been widely used to improve the contour of the nose, including the dorsum, lateral wall, and nasal tip. , Among autogenous grafts, bone onlay grafts are difficult to shape and often undergo an unpredictable degree of resorption. Similarly, autogenous auricular cartilage must be harvested through a separate incision and is usually not enough to be used for both skeletal support as well as augmentation. Though septal cartilage is the best but for secondary septo-rhinoplasties septal cartilage is usually inadequate. The volume of cartilage harvested from conchal and septal sites might be deemed inadequate for the need of the procedure.
Authors devised this technique after experiencing problems with DCF technique in two cases where after 2-3 months there was a severe contraction of skin envelope [Figure 10]a-c. Now we are using this particular technique in the noses where the thickness of skin and weak cartilage support demand solid augmentation material.
|Figure 10: (a) Use of diced cartilage in fascia: Preoperative photo; (b) 1 month postoperative photograph; (c) 3 months postoperative photograph shows poor long-term results due to severe postoperative contraction|
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History of diced cartilage
The viability of diced cartilage grafts was demonstrated first by Coster and Galbraith  and later confirmed by others.  Peer conducted extensive research on moulded diced cartilage into ear framework and for cranioplasties. Tovey  used diced cartilage to fill posterior cavity before insertion of the dorsal bone graft. It was forgotten for almost 50 years when Erol reintroduced the diced cartilage by his "Turkish Delight" technique. 
In a new technique of use of diced cartilage, Daniel and Calvert had critically analyzed the Turkish delight technique and described the use of fascia wrapped diced cartilage. 
In Daniel's study, use of Turkish delight technique (diced cartilage wrapped in surgicel), there was 100% evidence of resorption of the graft and therefore failure to correct the clinically malady.
Kawamoto et al. used diced cartilage to correct tip deformities in cleft lip noses by closed approach. 
In a much similar technique, Chang et al., have used finely diced cartilage injected over a thin dorsal cartilage strut without using any sleeve of fascia etc. Effectively in this technique, diced cartilage remains directly under the dorsal skin.  Though this technique takes care of postoperative skin contraction due to the presence of a solid thin piece of dorsal strut but visibility of grafts, dorsal irregularities, and need of frequent moulding remain a concern.
In earlier studies, the size of diced cartilage has been taken as 0.5-1 mm. In his paper on DCF, Daniel and Calvert  comments that the smaller the size of diced cartilage, higher is the rate of resorption. To avoid probable resorption of fine pieces we have used slightly larger size of diced cartilage (2-3 mm). Though larger pieces may have visibility or palpability but in our technique, we cover the cartilage with thick perichondrium and set them properly before final insertion of the unit for dorsal augmentation.
Erol refers to his grafts as having a semisoft smooth surface under the skin early on but does not describe their long-term palpability. In our series, the graft remains distinctly palpable for upto 3 years, which is the longest follow-up available to us.
The basic difference is that we have primarily used costal cartilage for most of our rhinoplasties, the reason being that a typical Indian nose is usually smaller in size, requires larger volumes for augmentation to achieve the proportions of esthetic nose as compared to the rhinoplasties carried out for the Caucasians wherein cartilage harvested from the septum suffices.  A Secondary cleft lip nose needs a large amount of cartilage to build the distorted and poorly supported skeleton. While using costal cartilage, perichondrium is readily available to be used as a covering carpet for diced cartilage to be moulded for dorsal augmentation.
Being a natural material unlike surgicel, it has better biological properties to be used as filler implant. Unlike temporalis fascia that is used in similar way, perichondrium is available through the same surgical site and thereby decreases the need of extra incision and the morbidity of the extra donor site.
In our technique, we have sutured the perichondrium on three sides to the bar of costal cartilage being used for dorsal augmentation and diced pieces of cartilage are swept underneath to achieve a uniform, smooth dorsal profile which is much more stable than some of the alternatives described (surgicel or fascia or diced cartilage directly under the dorsal skin), which have high chances of getting displaced and dorsal visibility or dorsal irregularity, as they are just lying in the dead space created and rely upon the natural fibrosis to provide stability. Unlike the alternatives, here the perichondrial strip is sutured to the hard base of costal cartilage which prevents it from rolling off or getting displaced and provides far greater durability and a higher level of patient satisfaction. All components of this reinforced unit have their own importance; (1) The presence of a solid bar of cartilage reduces the chances of postoperative skin contraction requiring lesser chances of resurgery, (2) diced cartilage provides flexibility of changing size and shape of the dorsum according to the need and (3) perichondrial strip keeps the unit intact, softens the edges and keeps the diced cartilages in control and they remain organized leaving very minimal or no chance of change in shape or visibility of graft through dorsum. Unlike other techniques such as covering the diced cartilage with surgicel, fascia or placing it directly under the dorsal skin, this technique doesn't need frequent change of plaster splint or postoperative massage to mould the graft and so no need to keep splint for a long time.
Authors devised this technique originally as a substitute of DCF technique to improve the aesthetic outcome in secondary cleft lip rhinoplasty cases, but now it is being used in all type of rhinoplasties wherever costal cartilage is used. Good carving of solid costal cartilage graft also gives good dorsum, but results with this combined technique are far superior. It gives liberty to the operating surgeon to use even a flat plate of cartilage which can easily be changed into a contoured graft with this technique. Authors, therefore, suggest that instead of carving a single solid strut which may warp, or stacking few cartilages to achieve desired thickness, it is better to suture the concave surfaces of two thin plates of cartilage and then prepare a strut with reinforced diced cartilage technique wherever it is applicable.
| Conclusion|| |
This technique of reinforced diced cartilage (DCUP) produces a natural looking dorsum in all the patients. In the Indian setting, DCUP superior to DCF as it is providing an equally soft and smooth dorsum while keeping the postoperative contracting forces in check. Frequent change of plaster splint is not required to inspect the shape in postoperative period as the unit is very nicely packed. The resultant dorsum with DCUP is far more natural as edges blend with the nasal skin nicely and there is no graft show as compared to well carved solid cartilage graft. Warping of cartilage base plate remains no concern with the use of counterbalancing technique. DCUP technique overcomes the problems of dorsal irregularity, visibility of graft and postoperative skin contraction. A large series and long follow-up may be needed to establish the long-term survival of diced cartilage and a revision of such case may provide an opportunity to see the status of the unit and histology of the graft.
Gone are the days when SCLNDs were usually done just to make patients looking better than earlier, and patients would be happy with whatever improvement they got. Nowadays patients do not accept substandard results, and they demand normalcy. There is no dearth of techniques for surgeons, each case needs to be analyzed thoroughly, and accordingly the surgical steps must be planned. All parts of the nose, be it tip, septum or dorsum need equal attention to get normal breathing and aesthetically pleasing nose with no/minimal stigma of the cleft. At present, it (DCUP) seems to be an ideal augmentation method in this era where the meaning of beauty for younger generation has changed to a more natural look.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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