Diced cartilage and fluid cartilage in the nasal dorsum deficit

The saddle nose is a deformity of the nasal pyramid characterized by a reduction of the dorsal height due to an osteocartilaginous deficit. Most saddle noses are acquired, even though there are congenital causes, such as syphilis or intrauterine traumas. The acquired deformities are caused by previous traumas at the level of the septum or the nasal pyramid, from pathologies such as Wegener's granulomatosis and recurring polychondritis, cocaine abuse or the outcome of previous septorhinoplasties. An iatrogenic origin, due to the removal of an excessive quantity of osteocartilaginous hump during a previous operation, is the most frequent. The saddle nose is one of the morpho-functional alterations of the nose most difficult to correct. The correction does not aim only to camouflage the deformity with a graft but consists of an anatomical reconstruction plan of all the inadequate structures. After reconstructing a solid cartilaginous support framework of the nasal pyramid, a better definition and height of the dorsum can be obtained by making use of various types of graft for the purpose of obtaining functional and aesthetic results that are stable over time. Of the numerous autologous and heterologous materials described in the literature, each with advantages and disadvantages, autologous cartilage is currently the first choice. Heterologous materials, such as Medpor, are habitually used for refilling certain areas of the face, such as the zygoma or chin, but their application in the nose is often associated with serious complications of an infective nature, including long-term. Autologous cartilage “block” grafts, that is, used as a single segment, were used for many years, enabling creating even significant deformities to be corrected. However, over time the skin thins and adheres to them, making them visible in many cases, even when they were well modelled in order not to leave superficial irregularities. In the case of costal cartilage block grafts, moreover, there is also the problem of “warping”. The use of “crushed” (morselized) autologous or “diced” (cut into cubes) cartilage can prove invaluable for the purpose of preventing these complications, both to regularize and to raise the nasal dorsum. Diced cartilage (fig. 1) can be prepared by cutting it into larger cubes (1) or smaller ones (less than 0.2 mm) (2) wrapped or otherwise in the muscular fascia (DCF) (deep temporal, fascia lata or rectus abdominis) or otherwise in Surgicel (oxidized regenerated cellulose – polyanhydroglucuronic acid, commonly used as a hemostatic agent, reabsorbable in 48 hours) or in the acellular matrix (Allorderm, LifeCell Corp., Branchburg, N.J.). Sometimes, to aggregate the cartilage cubes, fibrin glue or the venous blood of the patient is used. It has been demonstrated in various studies that the vitality of the chondrocytes is greater than the "crushed” or “morsellised” cartilage. For many small defects, crushed cartilage still remains a valid alternative, if obtained with the right degree of morsellisation, known as "crocodile skin", that enables minimum reabsorption (fig. 2) (3). However, it must always be borne in mind that the degree of reabsorption of this cartilage is inversely proportional to the degree of morsellisation and the predictability of the long-term result is not so high as in diced cartilage (3).