IJPS_69_18R6

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2 Original Article 2
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6 Autogenous control augmentation system – A refinement 6
7 in diced cartilage glue graft for augmentation of dorsum of 7
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9 nose 9
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Gambhir Singh Swaroop, J. Sasidhar Reddy, Mahesh Chand Mangal, Anubhav Gupta,
12 Bheem Singh Nanda, Nikhil Jhunjhunwala 12
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Department of Plastic and Cosmetic Surgery, Sir Ganga Ram Hospital, New Delhi, India
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15 Address for correspondence: Dr. J. Sasidhar Reddy, Room No 2325, 3rd Floor, SSRB Block, Old Rajinder Nagar, Sir Ganga Ram Hospital, 15
New Delhi - 110 060, India. E-mail: j.sasidharreddy@gmail.com
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ABSTRACT
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19 Background: In the context of different grafts being used for dorsal augmentation, diced cartilage 19
20 with glue has gained worldwide acceptance. Aims: To develop a system of tools to objectively 20
21 evaluate the desired dimensions of the required graft for dorsal augmentation and to prepare a 21
22 corresponding customized-glued-diced cartilage construct. Materials and Methods: A modification 22
23 of the diced cartilage glue technique called Autogenous control augmentation system (ACAS) 23
24 was used in ten patients. Results: Of the ten patients, in which this technique was used, eight 24
25 underwent primary rhinoplasties and two underwent secondary rhinoplasties between July 2017 25
26 and December 2017 with a follow-up ranging from 3 to 8 months. In all the cases, the dorsum is 26
27 straight, and height is maintained. Conclusion: The technique has all the advantages of the diced 27
28 cartilage glue. The shape resembles alloplastic implant with height and width varying from radix to 28
29 tip. There is tapering of the cephalic and caudal ends for more natural results. The brow tip aesthetic 29
30 lines are better defined. The limitation of this study is short follow up. 30
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32 KEY WORDS 32
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Augmentation rhinoplasty; diced cartilage; fibrin glue
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36 INTRODUCTION desired and more defined shape. Alloplastic implants, 36
such as silicone and medpore, are being used, as they

T
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38 here is a constant endeavour to find an have a more defined shape, but have a risk of extrusion 38
39 ideal material that can be used in the dorsal and infection.[1] To combat this, there is a continuous 39
40 augmentation in rhinoplasty. The material should search for autologous tissue that can fit all the 40
41 be of low cost, easily available, with low risk of infection requirements. 41
42 and extrusion, and it should provide augmentation in a 42
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Website:
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www.ijps.org
47 47
48 How to cite this article: Swaroop GS, Reddy JS, Mangal MC, Gupta A, 48
DOI: Nanda BS, Jhunjhunwala N. Autogenous control augmentation
49 10.4103/ijps.IJPS_69_18 system – A refinement in diced cartilage glue graft for augmentation 49
50 of dorsum of nose. Indian J Plast Surg 2018;XX:XX-XX. 50
1 © 2018 Indian Journal of Plastic Surgery | Published by Wolters Kluwer - Medknow
AQ1 Swaroop, et al.: Autogenous control augmentation system - A refinement in diced cartilage glue graft for augmentation of dorsum of
nose

1 The autologous tissues that are available are bone and AlloDerm, Tutoplast-processed Allograft fascia lata,[15] 1
2 cartilage. Bone graft has gone out of favour because of rectus fascia and pectoralis major fascia.[16] 2
3 the high resorption rate, requirement of extra fixation 3
4 and hard consistency. Cartilage can be used in solid form Problems of fascia graft 4
5 or diced form. The solid cartilage graft has less resorption Regardless of whatever fascial graft used, the problem is 5
6 than the bone; however, warping is the main problem. that in the end, the graft becomes sausage shaped with a 6
7 Different sources of solid cartilage grafts available are non-anatomical kidney-shaped cross section. There is no 7
8 septum, concha and costal cartilage. The septum is a very control of final height and width. Sometimes, if there is 8
9 common source of the graft. Volume available is adequate less filling of diced cartilage, a depression is noted in the 9
10 in primary rhinoplasties with no donor-site morbidity. dorsum. To circumvent these problems, various designer 10
11 The limitation is inadequate volume in graft-depleted dorsal grafts came into use such as combination of 11
12 patients and secondary rhinoplasties. With conchal graft, bare-diced cartilage and diced cartilage under the fascia. 12
13 the donor scar is hidden, however, the graft is curved and Still, it is very difficult to make anatomically correct 13
14 not straight.[2] Costal cartilage graft, usually taken from crescent-shaped (cross section) graft with tapering sides. 14
15 the 5th, 6th or 7th ribs, is the largest source of cartilage.[3,4] 15
16 The disadvantages are donor-site pain and scar. Fibrin glue 16
17 Tasman has introduced fibrin glue to fix diced cartilage 17
18 How to preventing warping? together as a single unit.[17,18] He moulded it over a 18
19 There are a lot of techniques described to overcome longitudinally cut 2 or 5 ml syringe. Glue stands as a 19
20 warping; one of the techniques is counter-balancing good alternative to the fascia. There are reports of usage 20
21 technique[5] or “Namaste” technique. There is still a of autologous tissue glue such as PRP (platelet gel), 21
22 problem of graft show and firmness with this technique. PPP (fibrin glue) and whole blood.[19] 22
23 Stacking the cartilage slices in a laminated fashion[6] 23
24 in alternate directions can reduce warping. Instead of We, at our institute, have designed a technique to 24
25 suturing, people have tried to use cyanoacrylate in a objectively evaluate the desired dimensions of the 25
26 porcine model, but found to have a strong foreign body required graft and to prepare a customized-diced 26
27 reaction and resorption of grafts. Warping and resorption cartilage graft. 27
28 with cartilage crushing are uncontrolled.[7] In allografting 28
29 with irradiated rib, the donor-site problem and warping MATERIALS AND METHODS 29
30 can be avoided, but the revision rate is high (26%).[8,9] 30
31 A modification of the diced cartilage glue technique 31
32 Diced cartilage with Surgicel®/fascia called Autogenous Control Augmentation System (ACAS) 32
33 Erol, in the year 2000, published his technique of diced was used in ten patients. 33
34 cartilage wrapped in Surgicel®, calling it as “Turkish 34
35 delight” and latter published his 26 years’ experience Technique 35
36 in 2017.[10,11] The long-term results were satisfactory Open rhinoplasty approach was used and the augmentation of 36
37 with partial resorption in 0.4% and excessive resorption the dorsum was the last step of the operative procedure. For 37
38 in 0.05%. Daniel and Calvert tried to replicate the this, we used the Tasman technique with few modifications 38
39 method[12] but found the higher resorptive rate which of our own [Figures 1-6]. The harvested cartilage is diced 39
40 was attributed to the foreign body reaction seen from into 0.2–0.3 mm pieces. They are then transplanted into the 40
41 the histological study. In patients in whom Surgicel 1 ml syringe. The extra saline was then taken out by pressing 41
42 graft was used resorption of cartilage, was higher. So, the syringe into the gauze. The concentrated diced cartilage 42
43 they started using fascia[13] covering over the diced was ready in the syringe for the use. We use reusable sizers 43
44 cartilage and found that the chances of resorption made of silicone (normally available as implants). They are of 44
45 was drastically reduced. They suggested a slight various sizes and shapes. We place them into the pocket in 45
46 overcorrection as some resorption was still present.[14] the nose. We thus select a sizer of the desired height, length 46
47 The disadvantages are an additional incision required and width and sculpt it if necessary. 47
48 in the temporal area and the extra time required to fill 48
49 diced cartilage into the fascia bag. Different alternatives We have made different sizes of moulds in steel plate just 49
50 available to the fascia are hyaluronic acid membrane, like the sizers. We call it autogenous control augmentation 50
Indian Journal of Plastic Surgery Volume XX Issue XX Month 2018 2
 Swaroop, et al.: Autogenous control augmentation system - A refinement in diced cartilage glue graft for augmentation of dorsum of AQ1
nose

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AQ2 Figure 1: Placement of sizer in the pocket over the dorsum of the nose Figure 2: Finding the appropriate mould for the sizer to fit in
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Figure 3: Placing diced cartilage in the mould Figure 4: Placing fibrin glue in the diced cartilage
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45 Figure 5: Placing the glued-diced cartilage graft onto a carrier Figure 6: Introducing the graft in the pocket of the nasal dorsum 45
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47 system [Figure 2]. The diced cartilage from the syringe for 20–30 s. The mould is ready in 3–5 min [Figure 4]. 47
48 is then put into the mould corresponding to the sizer A pocket over the dorsum has to be dissected prior. We 48
49 used [Figure 3]. First, thrombin is put and mixed with gently lift the mould into the carrier [Figure 5] and then 49
50 freer elevator then we put fibrin and let it polymerise place it into the dorsum carefully by retracting the skin 50
3 Indian Journal of Plastic Surgery Volume XX Issue XX Month 2018
AQ1 Swaroop, et al.: Autogenous control augmentation system - A refinement in diced cartilage glue graft for augmentation of dorsum of
nose

1 flap with an Aufricht retractor. The radix point or the and height is maintained [Figures 7-9]. In one case, 1
2 planned cephalic end of the mould is marked earlier. The slight deviation was observed at the cephalic end of 2
3 caudal end of the mould reaches the supratip area. the graft in the 3rd week, which got corrected by gentle 3
4 massage. The average dimensions of the grafts used 4
5 All the three dimensions length, width and height of were 33.2 mm (length), 8.7 mm (maximum width) and 5
6 each mould are fixed and different. We can even prepare 4.5 mm (maximum height) [Table 1]. 6
7 a glued cartilage graft of less length and height of each 7
8 corresponding mould. DISCUSSION 8
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10 RESULTS Ideal tissue or material for dorsal augmentation is yet 10
11 to be found, but diced cartilage has gained worldwide 11
12 Of the ten patients, in which this technique was acceptance for its ability to survive with or without fascia 12
13 used, eight underwent primary rhinoplasties and two graft. 13
14 underwent secondary rhinoplasties between July 2017 14
15 and December 2017 with a follow-up ranging from The disadvantages with using a fascia graft are another 15
16 3 to 8 months. In all the cases, the dorsum is straight donor site added and the extra time consumed in 16
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AQ2 Figure 7: (a) Patient 1-pre-operative. (b) Patient 1-pre-operative. (c) Patient 1-post-operative. (d) Patient 1-post-operative
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AQ2 Figure 9: (a) Patient 3-pre-operative. (b) Patient 3-pre-operative. (c) Patient 3-post-operative. (d) Patient 3-post-operative 50
Indian Journal of Plastic Surgery Volume XX Issue XX Month 2018 4
 Swaroop, et al.: Autogenous control augmentation system - A refinement in diced cartilage glue graft for augmentation of dorsum of AQ1
nose

1 Table 1: Dimensions of the grafts used Though the initial clinical outcome is promising the long 1
2 Case Length (mm) Width (mm) Height (mm)
term results remains to be seen. 2
1 35 7 3
3 3
2 29 8 4
4 3 37 10 3 CONCLUSION 4
5 4 30 8 4 5
6 5 33 8 6 The technique has all the advantages of the diced cartilage 6
7 6 32 8 5 glue. As well, it is more alloplastic implant shaped with 7
8 7 35 10 6 8
height and width varying from radix to tip. There is
8 34 10 5
9 tapering of the cephalic and caudal ends for more natural 9
9 33 8 4
10 10 34 10 5 results. The brow tip aesthetic lines are better defined. 10
11 The limitation of our study is short follow up. 11
12 12
13 preparing the sleeve and putting diced cartilage into Financial support and sponsorship 13
14 it. Using Tutoplast (Alloplastic fascia lata), we can solve Nil. 14
15 these problems but still end up having a sausage-shaped 15
16 bag.[20] This shape is not anatomical, and there may be Conflicts of interest 16
17 depression in long term if diced cartilage is not filled There are no conflicts of interest. 17
18 tightly. They are not very predictable. 18
19 REFERENCES 19
20 The ideal shape to attain is a crescent-shaped cross 20
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24 It is already proven that fibrin glue (tisseel) used to form perichondrial attachment in rhinoplasty. Plast Reconstr Surg 24
2015;135:1545-53.
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3. Lee M, Inman J, Ducic Y. Central segment harvest of costal
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Surg 2010;125:214e-5e.
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postoperative twisting complications. Arch Facial Plast Surg
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39 evaluate the desired dimensions of the required graft 10. Erol OO. The Turkish delight: A pliable graft for rhinoplasty. Plast
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40 and to prepare a corresponding customized-glued-diced Reconstr Surg 2000;105:2229-41. 40
41 cartilage construct. The technique which we have 11. Erol OO. Long-term results and refinement of the Turkish delight 41
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45 Reconstr Surg 2006;118:230-6. 45
the cephalic and caudal ends for more natural results. 13. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty
46 The brow tip aesthetic lines are better defined. It can surgery. Plast Reconstr Surg 2004;113:2156-71. 46
47 be moulded by manual pressure in the 1st post-operative 14. Kim EK, Daniel RK. Operative techniques in Asian rhinoplasty. 47
48 Aesthet Surg J 2012;32:1018-30. 48
weeks, and there is no dead space present as in fascia
15. Jang YJ, Song HM, Yoon YJ, Sykes JM. Combined use of crushed
49 graft. The main advantage of this technique is that it cartilage and processed fascia lata for dorsal augmentation in
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50 is more objective and controlled to give better results. rhinoplasty for Asians. Laryngoscope 2009;119:1088-92. 50
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14 Author Query??? 14
15 AQ1: Kindly check and confirm the article title and running title are seems to be same 15
16 AQ2: Please ensure that the patient consent form has been obtained. 16
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