Frozen Cadaveric Rib Grafts in Primary or Revision Rhinoplasty: A Systematic Review and Meta-analysis

We read with great interest the recent meta-analysis on frozen cadaveric rib grafts in rhinoplasty.¹ The authors have provided a timely and much-needed synthesis of complication rates associated with this emerging graft material. However, we would like to respectfully raise several methodological concerns that may impact the interpretation of the study’s conclusions.

First, we identified likely patient duplication across 2 included studies: Mohan et al² and Rohrich et al.³ Both studies were conducted at the same institution by overlapping authors, and the smaller Mohan cohort (n = 50) is entirely encompassed within the timeframe and patient population of the Rohrich study (n = 226). Including both datasets without accounting for overlap likely led to double-counting patients, unless the authors verified with Rohrich that these were distinct patient populations. This may have artificially lowered the reported complication rate and increased the apparent sample size.

Second, the inclusion of Rogal et al,⁴ a study of “non- and minimally irradiated homologous costal cartilage,” raises definitional concerns. Although this graft type is described as nonterminally sterilized, it is not confirmed to be fresh frozen. Without clarification of processing protocols or storage temperatures consistent with established definitions of fresh frozen grafts, its inclusion may introduce heterogeneity that challenges the study’s internal validity.

Third, Swanepoel and Fysh⁵ reported outcomes using lyophilized rib cartilage harvested and processed in South Africa. These grafts were not frozen, but rather freeze-dried, and were laminated using a technique not used in other studies. This represents a markedly different graft material and surgical approach, making it an outlier relative to the other included cohorts. Its inclusion in a meta-analysis focused on fresh frozen cartilage appears methodologically inappropriate.

Finally, although the authors state in their methods that they included “all frozen rib grafts (fresh frozen and lyophilized),” their results and conclusions refer specifically to “fresh frozen” cartilage.¹ This conflation may lead readers to infer that the reported 4.4% total complication rate applies exclusively to fresh frozen grafts, when in fact the pooled data include diverse processing methods with different biomechanical and biological profiles.¹

We commend the authors for their contribution to the growing literature on cadaveric grafts in rhinoplasty. However, we encourage future reviews to clearly differentiate graft processing methods and to ensure methodological rigor in cohort selection to preserve the interpretability of pooled outcomes.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.