Modified Turkish delight: morcellized polyethylene dorsal graft for rhinoplasty

Abstract

Rhinoplasty is one of the most challenging facial aesthetic procedures. Achieving a desirable result depends on correct planning and execution and the tissue characteristics of the patient. Dorsal augmentation has been performed extensively using cartilage grafts harvested from the septum, alar cartilage, conchal artilage and costal cartilages as well as from bone harvested from the ilium or tibia. Carved or crushed cartilage used as a graft might be perceptible through the nasal skin when tissue resolution is complete. Graft warpage and displacement are potential complications. The use of finely diced cartilage wrapped in one layer of Surgicel mixed with 1 ml of the patient’s blood, popularly known as Turkish delight, was suggested by Erol in 2000. The use of cartilage from the septum and ala might not suffice and conchal and costal cartilage harvesting requires a second surgical site. Also, considering the increasing demand for revision rhinoplasty, it might not always be feasible to harvest an adequate quantity of graft. The authors suggest the use of finely diced Medpor implant material wrapped in Surgicel, mixed with 1 ml of the patient’s blood for dorsal augmentation during rhinoplasty. Preliminary results are encouraging.

Rhinoplasty is one of the most challenging facial aesthetic procedures. Dorsum modification is an integral part of rhinoplasty. It can be done using autologous, homologous or alloplastic materials. Autologous cartilage grafts harvested from the patient’s septum, rib or pinna are the most commonly used grafts. Bone grafts may be harvested from the ilium or tibia. Except for the septal graft, harvesting other grafts requires a second surgical site. Carved or crushed cartilage, used as a graft in rhinoplasty, has some disadvantages such as perceptibility after oedema subsides or graft displacement . To overcome these potential complications, the Turkish surgeon Erol, in 2000, suggested a procedure for dorsal augmentation of the nose using a Surgicel mesh and finely diced autologous cartilage graft. Although, cartilage graft harvesting is a commonly performed procedure, it has many disadvantages. Harvesting the costocondral graft is a major surgical procedure. Its complications include haemothorax, pneumothorax, infection and haematoma. Potential complications associated with block grafts include graft visibility, distortion and occasionally displacement and resorption. This procedure was modified by V elidedeoglu et al. in 2005. They used diced, preserved costal cartilage homograft wrapped in Surgicel for nasal augmentation .

High density polyethylene implants (Medpor, Porex Surgical Inc., Newnan, GA, USA) offer an excellent alternative to autogenous and other alloplastic materials for the reconstruction of many facial defects and deformities . Medpor, a biomaterial composed of porous high-density polyethylene, has proven to be a dependable implant and has been widely used in craniofacial reconstruction and rhinoplasty surgery , but block implants present with a potential problem of later visibility and distortion.

The authors modified the Turkish delight graft with reasonable success. They used finely diced chips of Medpor within the oxidized cellulose (Surgicel) mesh and used it for dorsal augmentation. They have found this procedure to be quite satisfactory with respect to its feasibility and effectiveness. Patient compliance is also better owing to the lack of a second surgical site and its associated complications.

Surgical technique

This technique can be used either with an endonasal or open approach. The authors used the open technique. A slice of Medpor was cut from the block and diced into small pieces sized 0.5–1.0 mm with a surgical knife or a pair of scissors. 1–2 ml of parenteral blood was obtained from the patient and added to this diced mass to form a homogenous mass. This pliable mass was wrapped in a single sheet of Surgicel and moulded into a cylindrical form by finger manipulation ( Fig. 1 ). This was inserted under the dorsal skin of the nose extending the length of the dorsum up to the nasal tip, taking care to maintain its integrity. This provided the necessary dorsal augmentation and support to the lower lateral cartilages. After insertion, the mass is moulded with finger pressure from the outside to create the desired shape of the dorsum. Closure was then performed. External nasal taping with Steristrips and internal nasal packing with paraffin gauze was done. External splinting was performed using a custom-made plaster of Paris cast only for cases that required nasal osteotomies. The packing and splinting was removed after 7 days and the patient was instructed to avoid manipulation of the nose for 3–4 weeks. The quantity of Medpor used has to be tailored to the individual patient’s needs. The authors have used this technique in 25 rhinoplasty cases with encouraging results ( Fig. 2 ).

Fig. 1
(a) Diced Medpor. (b) Medpor mixed with blood. (c) Mass being wrapped in Surgicel. (d) Modified Turkish delight graft ready for use.

Feb 5, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Modified Turkish delight: morcellized polyethylene dorsal graft for rhinoplasty
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