Quick and Easy Autologous Filler for Rhinoplasty

INTRODUCTION

The autologous diced cartilage as a filler for contouring and augmenting of the nasal dorsum, known since 1943,¹ although widely used, is not without drawbacks. The major one is the fluidity, which necessitates wrapping the graft to create a “sausage” that is able to maintain the desired shape, volume, and location. This formation is not injectable. The second problem is the necessity of chopping cartilage into pieces of 0,5- 1,0 mm³, which is tedious and time consuming. We seem to overcome these problems with our way to prepare the filler.

METHODS

We never discard even the tiniest fragment of whatever is being removed from the nose: bone, cartilage, and soft tissues of any sort, with the exception of epithelium. Instead of dicing with the scalpel, we put everything into the Cottle Bone-Cartilage Crusher (Karl Storz, Tuttlingen, Germany) and with heavy hummer strokes, mince the tissue fragments into a homogenous paste. We collect the paste into the barrel of a 1.0-mL insulin syringe, and we are ready to administer the filler in less than 1 minute after the first hummer stroke. The consistency is not fluid, but rather clay like (Fig. 1). This obviates the graft wrapping and allows injection of the filler through the small residual opening in the suture line (Fig. 2), which is closed on the syringe withdrawal. The texture of this graft enables the surgeon to give a final shape to the nasal dorsum manually before taping and splinting.

Fig. 1.

The filler compound can be easily expelled from the syringe, yet maintain the mechanical integrity.

Fig. 2.

The syringe loaded with the filler is inserted under the rectangular temporal fascia sheet sutured at 4 angles to the underside of the dorsal skin with 4 knots visible outside. The surgeon’s thumb and index finger follow the withdrawal of the syringe alongside the dorsum with simultaneous filler discharge, to keep the uploaded mass strictly within the dorsum aesthetic unit.

DISCUSSION

The game changer in our grafting technique appeared to be the Cottle Cartilage Crusher. Its multiple fine sharp teeth easily mince tissue, enabling the resulting compound to pass through the syringe nozzle. We managed to find mention of the Cottle Crusher usage in the “Turkish delight” method.² However, the authors still wrapped their minced cartilages with Surgicel (Ethicon, Johnson & Johnson Medical Ltd., Somerville, N.J.), which could have been totally avoided, to our mind. There was no mention of the Cottle Crusher in the original description.³ Others avoided wrapping by gluing with blood the bone dust obtained by rasping.⁴ But the authors added the chopped cartilage for bulk, making injection through the syringe impractical, and they had to place the mixture as a solid graft. The simplicity of our method and the absence of donor-site morbidity are particularly appealing. Donor material is available in the same surgical field as a mixture of cartilage fragments with soft tissue. If more volume is needed, one can easily harvest from ears and/or any site where scars could be excised. This makes the technique especially valuable for secondary, nasal cartilage-depleted patients.