Significant augmentative rhinoplasty of the dorsum usually poses a choice between a synthetic implant and a rib cartilage graft. When choosing a rib cartilage graft, the options are to use it as a carved solid graft or to dice it and assemble it as a moldable wrapped cartilage graft. Introduced back in 1989, a finally diced cartilage graft became known as a ‘Turkish Delight’ because of its conceptual introduction by Turkish plastic surgeon.
The original technique description was to dice the cartilage graft into 0.5 to 1mm cubes and then wrap it with resorbable Surgicel collagen mesh. This original rhinoplasty grafting technique has been modified over the years by others using the patient’s own fascia instead of Surgical and moistening the small cartilage cubes with PRP. (platelet rich plasma)
In the February 2016 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘ Long-Term Results and Refinement of the Turkish Delight Technique for Primary and Secondary Rhinoplasty: 25 Years of Experience’. The original developer of this rhinoplasty cartilage grafting technique summarized his experience with it in close to 10,000 patients over a 25 year period. The patients reviewed were anywhere from 4 to 25 years out from their initial surgery. Both primary (7700) and secondary (2300) rhinoplasties had the cartilage grafting technique used. They report very low complication rates with its use including less than 1% incidences of prolonged swelling, overcorrection and resorption. They reported no infections or graft show over the short or long term followup.
Particulating a cartilage graft for nasal implantation into small particles predictably eliminates the issue of graft visibility. The controversial aspect of the diced cartilage graft technique is the material used to contain. Surgicel is the original mesh wrap and is well known as a resorbable hemostatic material. It is made of an oxidized cellulose polymer (polyanhydroglucuronic acid) derived from plant fibers. It works by absorbing fluids which causes platelet plug formation to stop bleeding. The plant cellulose breaks down once it becomes wet and this results in a more acidic pH around it, giving it in contact with moisture which lowers the pH (more acidic). This gives Surgicel a bacteriostatic property. The cellulose material is rapidly eliminated, initially by absorption of the sugar acid uronic acid within the first day after implantation, and then days later by macrophage digestion of the fibrous residue.
Some controversy exists about whether to use Surgicel or the patient’s fascia to contain the diced cartilage graft for placement into the nose. The author stands by his contention based on his experience that Surgicel does not induce cartilage graft resorption. It does, in fact, create a the smooth enveloping fibrocartilaginous layer under the skin that prevents graft visibility.
This paper supports the contention that wrapped diced cartilage grafting has revolutionized the approach to dorsal augmentation in rhinoplasty. In my experience this become really significant in larger rib grafts where warping and cartilage outlien show are not uncommon.
Dr. Barry Eppley