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Irradiated homologous costal cartilage is durable, well tolerated, and safe for use in rhinoplasty, long-term follow-up showed.

The total complication rate during 24 years of follow-up was 3.25%, with the major event being warping, which occurred in 10 cases (1.06%), according to Russell W.H. Kridel, MD, of the University of Texas in Houston, and colleagues.

Six of those 10 grafts were replaced and showed no warping during follow-up ranging from five months to 15.25 years, the authors wrote in the November/December Archives of Facial Plastic Surgery.

Septal cartilage is generally the preferred grafting material for rhinoplasty, but, in some patients, especially with revision procedures, there is inadequate tissue for reconstructive purposes.

Other approaches that have been used include harvesting the patient's own auricular cartilage, but the size and shape of ear cartilage may limit its suitability.

The patient's own rib cartilage also has been used, but this leaves the patient with a scar, postoperative pain, and the potential for adverse events such as pneumothorax and hemothorax.

In contrast, homografts using rib cartilage salvaged from previously healthy donors such as lethal trauma victims has many of the advantages of autologous grafting without the donor site morbidity.

The salvaged tissue is screened for systemic diseases including hepatitis and HIV, exposed to 30,000 to 50,000 Gy of gamma radiation to remove antigenicity, and stored in saline in tissue banks.

In 1993, Kridel and colleagues published a preliminary report detailing their use of irradiated homologous costal cartilage for rhinoplasty in 117 patients.

They continued to follow those patients, and their series now includes 357 patients who underwent primary or secondary rhinoplasty and have been followed for a mean of 13.45 years.

Patients' mean age was 37 years, ranging from a five-year-old child who had repair of a congenital defect to a 95-year-old man who required repair after cancer surgery.

Females comprised 63.02% of the cohort, and 79.27% were white.

Among the reasons for surgery in these patients were nasal breathing difficulties, septal perforation, and loss of nasal tip support.

A total of 83 were primary cases and the remainder were revisions.

Multiple grafts were often required in individual patients. In all, there were 1,025 irradiated homologous costal cartilage grafts and 373 grafts using other materials such as septal cartilage or Mersilene mesh, for a total of 1,398 grafts.

There were nine cases of postoperative infection, occurring 21 days to 7.16 years after the surgery, seven of which were in patients who received the irradiated costal cartilage plus other types of graft materials.

If all nine were presumed to have occurred in the homologous cartilage grafts the infection rate would be 0.87%, but the actual infection rate based on the total of 1,398 grafts was 0.64%, according to the investigators.

All patients with infections had preexisting risk factors, including recurrent sinus infections and multiple previous nasal surgeries.

In five of the nine cases infection was followed by resorption two months to 4.08 years later, for a rate of infective resorption of 0.48%, while the rate of noninfective resorption was 0.53%.

Complications also were seen in the 218 cases where autogenous cartilage was used in addition to the homologous cartilage, including three cases of noninfective resorption of the autogenous cartilage.

"The rate of noninfective resorption of [autogenous cartilage] was 1.37%, which was 2.58-fold higher than the overall 0.53% noninfective resorption rate of [irradiated homologous costal cartilage]," they wrote.

"We counsel all of our patients about potential resorption of any cartilage grafts we use, whether they are autogenous or homologous."

The complication rate for repair of 53 cases of septal perforation, involving 162 homologous cartilage grafts, was 2.46%, with one case of infective resorption (0.61%).

Among the 25 cases of septal perforation repaired with autogenous cartilage there were two cases of noninfective resorption (8%).

The overall complication rate fell by 1.05%, from 4.3% in the 1993 report to 3.25% in the current one. The authors credited the drop in complications to their improved techniques and experience.

Among 42 patients who rated their satisfaction with the procedure, 91.31% reported short-term satisfaction and 94.18% reported long-term satisfaction.

The authors concluded that, although the search for an ideal nasal implant is ongoing, irradiated homograft costal cartilage fulfills many of the desirable qualities needed, including ease of carving, availability in large sizes, and the ability to resist infection and absorption.

An accompanying editorial by the journal's editor Wayne F. Larrabee, MD, refers to this as a "landmark study," which "is important not only for the standard it sets in careful clinical evaluation but also for the importance of the subject."

The findings are likely to cause many working in this field to reevaluate the use of irradiated cartilage in their practices, according to Larrabee.