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Background: Rib cartilage growth is closely related to age and determines the feasibility and outcomes of auricular reconstruction. Ear reconstruction is performed as early as age 6 in efforts to treat children before school matriculation while allowing for sufficient rib growth. But there is controversy over the optimal timing of microtia reconstruction. This study employs CT imaging and surface scanning to guide the timing of auricular reconstruction in children., Methods: A retrospective analysis was performed on 6-year-old microtia patients between January 2016 and June 2016. A total of 37 patients were underwent preoperative 3D rib-cage CT measurements and normal auricle scanning measurement including: the length of 6th, 7th, and 8th costal cartilage, the width of 6th,and 7th costal cartilage, and the length of normal auricle. Then the data of costal cartilage were compared with the data of the auricle., Results: The average length of the 6th, 7th, and 8th rib cartilage on the right was 76.1 ± 9.2 mm (range, 61.1-94.9 mm), 102.6 ± 9.9 mm (range, 84.5-119.1 mm), and 75.4 ± 19.3 mm (range, 47.3-118.5 mm), respectively, and the the average helical length was 90.5 ± 6.8 mm (range, 76.9-101.5 mm). Comparing the above data, it was revealed that the age of 6 years was an optimal time for ear reconstruction with tissue-expanding technique., Conclusions: 3D rib-cage CT for preoperative measurement of costal cartilage could be a useful method for planning microtia reconstruction. According to our study, the amount of costal cartilage of almost all 6-year-old microtia patients is enough for ear reconstruction. So age 6 years is the optimal timing of auricular reconstruction with tissue-expanding method.

Background: Binder syndrome is a rare congenital malformation with a flat facial profile especially a depressed nose. Rhinoplasty plays an important part in the multidisciplinary surgical protocol. Different materials have been proposed to reconstruct nasal framework. But fewer evidence concerns which graft can achieve more stable and appreciated nasal contour. In this article, the authors reported surgical details and experience of nasal framework reconstruction of Binder syndrome, compare the esthetic outcomes of 2 grafts: autologous costal cartilage and L-shaped silicone covered with auricular cartilage., Methods: A retrospective study of 25 Binder syndrome patients (9 with silicone and 16 with costal cartilage) was managed. Anthropometric method was used to evaluate nasal profiles preoperatively and postoperatively. Surgical techniques, complications were reviewed. Statistics analysis was managed. Probability (P) of <0.05 was considered significant., Results: Tip proportions (angle of convexity of the face with nose, nose tip-length quotient, tip projection anterior glabellar line quotient) improved in silicone group, but cartilage group achieved superior esthetic outcomes than silicone in tip projection, subnasal protrusion, and nasal labial angle., Conclusion: Autologous costal cartilage is more favorable to reconstruct the nasal framework and regain nasal esthetics of Binder syndrome.

Background: Recreating the complex architecture of the auricle poses one of the most demanding challenges for the plastic surgeon. The fabrication of the prominent helix is crucial to the final contour of the constructed ear. The success of helix carving depends greatly on the complicated characteristics of the cartilage used, which is commonly the eighth costal cartilage. The authors elaborate on the relevant details for helix sculpting based on different qualities of cartilage., Methods: A series of 415 microtia patients underwent autogenous costal cartilage auricular reconstruction between 2012 and 2015. Because the cartilage used for helix reconstruction is always imperfect or insufficient for the fabrication of anatomical structures, they have devised perfect helix duplication by using individualized eighth rib cartilage with different cartilage lengths, widths, and flexibilities. Four possible scenarios in helix fabrication have been elaborated, and the corresponding methods were introduced., Results: Selective methods for different scenarios in helix fabrication have been shown to produce favorable results. The results reveal that a harmonious helix was achieved and provide a cohesive framework for the integrity of a reconstructed ear., Conclusions: A new classification of helix fabrication methods with autogenous costal cartilage is elaborated, and a favorable framework with harmonious proportions is achieved by precise carving using corresponding measures for different cartilage characteristics. This approach enhances helix aesthetics and helps attain a satisfactory contour of the auricle., Clinical Question/level of Evidence: Therapeutic, IV.

Costal cartilage grafting is increasing in popularity with increased demand for augmentation rhinoplasty and increased need for grafting material for structure rhinoplasty techniques. Use of costal cartilage for dorsal grafting is both art and science. The art is demonstrated in the act of carving a dorsal graft that will reflect the actual contour of the nasal dorsum. The science is linked to the methodology of how the grafts are contoured to match the patient's desires and how the graft is fixed to the bony dorsum to minimize the risk of warping and displacement. Variations in dorsal graft design and methods of fixation are described. Use of the perichondrial interface between dorsal graft and perforated/rasped nasal dorsum acts to ossify the dorsal graft to the underlying bone, creating an immobile and natural appearing nasal dorsum. The fixation of the dorsal graft limits movement and hence decreases the likelihood of warping or deformity. Use of microfat in rhinoplasty has tremendous potential for camouflage and to promote healing of compromised tissues. Using microfat-infused soft tissue augmentation (MISTA), the surgeon is able to deliver microfat to an open surgical field, promote healing, and provide soft tissue augmentation. In this technique, microfat is injected into soft tissue carriers (perichondrium, temporalis fascia, etc.) and then implanted into the surgical field. MISTA has tremendous potential utility in many areas of cosmetic and reconstructive surgery., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: In cases of congenital chest wall deformities, it is important to maintain the flexibility of the chest wall after rib cartilage resection. In this study, we aimed to determine the regeneration capability of cartilage and the effects of platelet-rich plasma (PRP) on the regeneration process., Methods: A total of 16 four-week-old New Zealand rabbits were used in this study. In the 4th-5th right costal cartilages, the perichondrial sheaths were dissected and costal cartilages were excised. Then, the perichondrial sheaths were closed with absorbable material in the sham group (n = 8), and this was done after replacing PRP in the PRP group (n = 8). The left costal cartilages of the animals were used as controls. The volumes of the costal cartilages and their perichondrial sheaths were estimated using Cavalieri's principle. In addition, the mean numerical densities of the chondroblasts and chondrocytes per square millimetre were estimated using unbiased counting frames., Results: In the PRP and sham groups, the volumes of the cartilages and perichondrial sheaths were higher than those of the control group (p < 0.05). The numerical densities of the chondroblasts and chondrocytes increased more in the PRP group than in the sham group (p < 0.05)., Conclusions: Applying PRP after resection may provide better healing and faster regeneration of cartilage.

Background: Warping remains a primary issue in the use of autologous costal cartilage for nasal augmentation. To mitigate such issues, diced cartilage in fascia (DCIF) has been proposed as an alternative for use in rhinoplasty. The objective of this study was to assess the efficacy of DCIF in nasal dorsal augmentation for Asian patients, with particular focus on the strengths and weaknesses of this material., Materials and Methods: Fifteen patients who underwent major dorsal augmentation with DCIF during the last 2 years were retrospectively reviewed. Diced cartilage wrapped in deep temporal fascia was used., Results: Costal cartilage was used as the dicing material in 11 cases, while a mixture of septal and conchal cartilage was used in the other four cases. In the majority of cases, DCIF was inserted from the radix to the supratip. In 10 of the 15 cases, acceptable aesthetic and functional results were obtained; at a mean follow-up of 13.3 months, no complications were observed in these patients. In the remaining five cases, complications such as mild deviation, mild supratip depression, irregularities of the nasal dorsum, considerable resorption, and hair loss at the fascial harvesting site were observed., Conclusions: This study suggests that DCIF is useful in major nasal dorsal augmentation; however, it involves certain complications. Although obvious warping can be avoided, irregularity and mild deviation may still occur, potentially requiring technical refinement., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Purpose: Slipping rib syndrome (SRS) is an elusive diagnosis. Previous reports have been single cases or small series. We previously reported a small multicenter review with encouraging early results. We now describe our matured experience., Methods: This is a follow-up study of patients with SRS from 2006 to 2015. Included are 5 previously analyzed patients and 25 new patients. Patients were called to review current symptoms, course, and satisfaction., Results: From 2006 to 2015, 30 patients underwent 38 operations. Eight underwent re-operation. All had reproducible pain localized to the costal margin, 60% had a popping sensation, and 23% were bilateral. 86% were female. Median age of symptom onset was 14 (IQR 13.75-15) years, while median age at diagnosis was 16 (IQR 15-17). Contact was possible with 18/30 patients, and mean follow up time was 1.3years. 72% of those felt they were cured, and 44% rated satisfaction a 10/10 (mean 7.84). Of those not cured, all reported significant improvement., Conclusions: Costal cartilage excision is an effective treatment for SRS and should be considered early in the workup of costal margin pain in a normally active population. Case Series with no Comparison Group - Level IV., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objective: Laser reshaping of cartilage is a prospective technique which can be applied for manufacturing the natural implants for otolaryngology and reconstructive surgery. Optical properties and optimal laser settings for laser reshaping of costal cartilage depend on its thickness, water content, and structural anisotropy of the tissue, in particular, the distinct orientation of collagen packing. The aim of the work is to study the effect of different collagen orientation, thickness, and drying of costal cartilage on its interaction with laser radiation., Materials and Methods: Costal cartilage was cut along and crosswise the distinct collagen orientation. The dried and normal cartilage was used for the comparative analysis. The collagen package was studied using atomic force microscopy. The dried tissue was analyzed with thermogravimetry-differential scanning calorimetry (TG-DSC) analysis to reveal the residual water content. The optical transmittance was measured for two wavelengths λ: 1,560 and 532 nm. The reshaping of cartilage of 1-3 mm in thickness was performed with infrared laser with λ = 1560 nm while, the radiation with λ = 532 nm was used to determine the location of the IR beam., Results: The transmittance of 532 nm radiation does not depend on collagen orientation and tissue drying. The IR radiation transmits better along the distinct collagen direction in dried cartilage while in normal cartilage the intensity of transmitted IR radiation increases intermittently passing crosswise and does not change dramatically with time along the collagen orientation., Conclusions: The effect of structural anisotropy of costal cartilage reveals itself in the increasing scattering of IR radiation with λ = 1,560 nm passing crosswise the collagen orientation when tissue water content is decreased. The radiation with λ = 1,560 nm is effective to perform the reshaping for cartilage of 1-3 mm in thickness; however, for 3 mm, the residual mechanical stress should be taken into account. Lasers Surg. Med. 48:887-892, 2016. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Importance: Reconstructive rhinoplasty often requires the use of cartilage grafts. Full-thickness autologous costal cartilage grafts provide a large amount of cartilage in a single uncarved block and are often used for major reconstructions. Warping is frequently described as a complication of rib cartilage use in rhinoplasty., Objective: To describe an approach to cartilage carving whereby a single block of cartilage is carved in a multiplanar manner to mimic or redefine the anatomic relationships and resist warping., Design, Setting, and Participants: A retrospective review of reconstructive rhinoplasty cases using multiplanar costal cartilage grafting technique was performed. A consecutive sample of 11 patients with complex nasal deformity underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions to address complex deformities at the University of New Mexico Hospital between January 2010 and December 2014. The follow-up period ranged from 3 to 36 months., Interventions: Autologous rib cartilage harvest was performed to obtain a full-thickness segment of rib cartilage. The deficient or malformed nasal cartilage is defined and soft tissue prepared using an open rhinoplasty approach. Rib cartilage graft curvature is removed to create a uniform, symmetric, solid block of cartilage. A cartilage graft is carved in a multiplanar fashion to simulate normal nasal anatomy., Main Outcomes and Measures: Postoperative evaluation of nasal airway function, cartilage graft warping, and aesthetic outcomes were reported in the follow-up period. Nasal Obstructive Symptom Evaluation (NOSE) scores are documented in the majority of cases and were obtained at least 3 months postoperatively., Results: Overall, 11 patients with complex nasal deformity underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions. The most common use was for reconstruction of the septum with the upper lateral cartilage. There were no major complications. No patients experienced graft warping in the follow-up period. Several patients required minor revision procedures. All patients reported improved nasal airway and improved aesthetic appearance of the nose., Conclusions and Relevance: Multiplanar costal cartilage grafting is a useful surgical technique for complex reconstructive rhinoplasty that yields optimal and predictable results., Level of Evidence: 4.

Background: External compression is used for pectus carinatum (PC) treatment, but many patients are noncompliant. Costal cartilage resection (CCR) has been described as an alternative, but these approaches sacrifice the internal thoracic arteries (ITA). We aim to assess the feasibility of CCR sparing ITA comparing thoracoscopic and subcutaneous endoscopic approaches., Methods: Twelve pigs were used as models for surgical PC correction and randomized for 2 groups: thoracoscopy (T) and subcutaneous (subpectoralis) endoscopy (SP). In both groups, CCR from 3rd 4th and 5th ribs was performed avoiding ITA damage. ITA preservation was confirmed by Doppler-ultrasound as well as postmortem injection of methylene blue. Four persons evaluated the procedures being difficult, using a 6-item modified validated scale., Results: In both techniques, the procedure was accomplished in all animals sparing ITAs. CCR was faster in T than in SP (49±5 vs. 65±16minutes, p<0.05). T was classified as easier than SP (p<0.001) with a significantly higher score for all items, especially better image and tissue handling., Discussion: Sparing the ITAs during CCR for correction of PC is feasible in a porcine model and might be a goal in humans. The thoracoscopic approach allows for a faster and easier procedure., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Costal cartilage is an important reconstructive tissue for correcting nasal deformities. Warping of costal cartilage, a recognized complication, can lead to significant functional and aesthetic problems. The authors present a technique to prevent warping that involves transverse slicing of the sixth-seventh costal cartilaginous junction, that when sliced perpendicular to the long axis of the rib, provides multiple long, narrow, clinically useful grafts with balanced cross-sections. The aim was to measure differences in cartilage warp between this technique (TJS) and traditional carving techniques., Methods: Costal cartilage was obtained from human subjects and cut to clinically relevant dimensions using a custom cutting jig. The sixth-seventh costal cartilaginous junction was sliced transversely leaving the outer surface intact. The adjacent sixth rib cartilage was carved concentrically and eccentrically. The samples were incubated and standardized serial photography was performed over time up to 4 weeks. Warp was quantified by measuring nonlinearity of the grafts using least-squares regression and compared between carving techniques., Results: TJS grafts (n = 10) resulted in significantly less warp than both eccentrically (n = 3) and concentrically carved grafts (n = 3) (P < 0.0001). Warp was significantly higher with eccentric carving compared with concentric carving (P < 0.0001). Warp increased significantly with time for both eccentric (P = 0002) and concentric (P = 0.0007) techniques while TJS warp did not (P = 0.56)., Conclusion: The technique of transverse slicing costal cartilage from the sixth-seventh junction minimizes warp compared with traditional carving methods providing ample grafts of adequate length and versatility for reconstructive requirements.

Objective: The present study aims to elucidate whether or not scoring deformed cartilages reduces postoperative pain after the Nuss procedure for pectus excavatum patients., Methods: A total of 46 pectus excavatum patients for whom the Nuss procedure was conducted were included in the study. The patients were categorized into two groups, depending on whether or not the supplementary maneuver of scoring deformed cartilages was performed in addition to the Nuss procedure. Patients for whom deformed costal cartilages were scored were categorized as the Scoring Group (n = 24); those who received no such scoring were categorized as the Non-Scoring Group (n = 22). After evaluating the maximum stresses occurring on the thoraces by means of dynamic simulation using finite element analyses, intergroup comparison of the maximum von-Mises stress values was performed. Furthermore, after quantifying postoperative pain as the frequency with which patients injected anesthetics through an epidural pain-control system within 2 postoperative days, the degree of pain was compared between the two groups., Results: The maximum stresses occurring on the thorax were significantly greater for the Non-Scoring Group than for the Scoring Group; injection frequency was also greater for the Non-Scoring Group (average 4.9 times for 2 days) than for the Scoring Group (average 2.5 times for 2 days)., Conclusion: High stresses occur due to the performance of the Nuss procedure, causing postoperative pain. The stresses can be reduced by performing supplementary scoring on deformed cartilages. Accordingly, postoperative pain is reduced., (Georg Thieme Verlag KG Stuttgart · New York.)

We have developed a handheld-level multichannel electromechanical reshaping (EMR) cartilage device and evaluated the feasibility of providing a means of cartilage reshaping in a clinical outpatient setting. The effect of EMR on pig costal cartilage was evaluated in terms of shape change, tissue heat generation, and cell viability. The pig costal cartilage specimens (23 mm × 6.0 mm × 0.7 mm) were mechanically deformed to 90 degrees and fixed to a plastic jig and applied 5, 6, 7, and 8 V up to 8 minutes to find the optimal dosimetry for the our developed EMR device. The results reveal that bend angle increased with increasing voltage and application time. The maximum bend angle obtained was 70.5 ± 7.3 at 8 V, 5 minutes. The temperature of flat pig costal cartilage specimens were measured, while a constant electric voltage was applied to three pairs of electrodes that were inserted into the cartilages. The nonthermal feature of EMR was validated by a thermal infrared camera; that is, the maximum temperate of the flat cartilages is 20.3°C at 8 V. Cell viability assay showed no significant difference in cell damaged area from 3 to 7 minutes exposure with 7 V. In conclusion, the multichannel EMR device that was developed showed a good feasibility of cartilage shaping with minimal temperature change., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: In this study, we aimed to present a novel application and use of Kirschner wire-guided suturing that is less invasive and allows permanent fixation for nasal dorsal reconstruction., Methods: A total of 23 patients, who underwent surgery between 2009 and 2013, were included in this study: 19 with saddle nose deformity and 4 patients with keystone area damage, or collapse of the dorsal nasal support during primary septoplasty or rhinoplasty. The patients were asked to fill out a nasal obstruction symptom evaluation (NOSE) scale preoperatively and at the postoperative sixth month to assess breathing quality. The patients were followed up for complications such as nasal dorsal contour irregularity, dorsal collapse, as well as graft malposition and infections. The results of the surgeries were assessed on the basis of preoperative and postoperative examinations, septal support test, NOSE scale results, and photographic comparison., Results: The mean (SD) NOSE scales were 78.91 (10.09) and 30.48 (10.71) in the preoperative and postoperative periods, respectively. The difference of mean NOSE scale was statistically significant (P < 0.001). None of the patients experienced nasal dorsal collapse or graft malposition. Two patients had nasal dorsal irregularity complaints owing to inadequate costal cartilage edge beveling. None of the patients had complications of suture reaction, suture visibility, or suture extrusion. All of the patients stated that they were happy with the cosmetic outcome., Conclusions: Permanent sutures introduced through channels made with the Kirschner wire provide a less invasive, cosmetically pleasing, and functional solution, promising more reliable results in the long term.

The ideal treatment for pentalogy of Cantrell is neo-sternum reconstruction by using autologous tissues. Although treatment timing varies depending on the degree of deformity and patient's condition, the principle is performing the procedure at the earliest, to prevent blunt or piercing trauma to the heart. However, the challenge is performing the procedure on a neonate, because feasibility of the procedure is affected by the size of the defect, and limitations in utilizable autologous tissues. We used a small biocompatible patch (Permacol) and lower costal cartilage to perform curative neo-sternum reconstruction, which is a simple and safe treatment method.

Objectives: To evaluate long-term results of tracheoplasty using autologous pericardial patch and strips of costal cartilage for relieving severe long-segment tracheal stenosis., Methods: Data were collected retrospectively by clinical chart review. Between 1995 and 2013, 21 patients underwent tracheoplasty. Follow-up was performed by outpatient chart review; otherwise, referring physicians and parents were contacted and asked to fill in a questionnaire., Results: Median age at the time of operation was 0.9 (range 0.5-44) years. Aetiology of tracheal stenosis was double aortic arch in 9 patients, right arch with a left ductus in 3, innominate artery compression in 1 patient, complete tracheal rings in 7, 3 of whom with pulmonary artery sling and 2 with agenesis of one lung, and other causes in 1 patient. Previous surgery was performed in 6 (29%) patients. Patch tracheoplasty was performed using autologous pericardial patch and external stenting using costal cartilage. Major complications were mediastinitis and patch dehiscence in 2 patients, 2 patients needed tracheal cannula and 1 patient had stent implantation. Three (14%) patients died in the late postoperative period: 1 patient died of sepsis, 1 had patch dehiscence and 1 erosion of tracheal stent and consequently intractable bleeding. Follow-up was 6.1±2.7 years (0.75-10 years). At follow-up, 2 (11%) patients were still symptomatic, 4 (22%) had occasionally mild symptoms and 12 (67%) were free of symptoms., Conclusions: Treatment for severe tracheal stenosis remains challenging. With tracheoplasty using autologous pericardial patch and strips of costal cartilage, long and narrow tracheal stenosis can be repaired. There are no limitations as to the length and location and severity of the stenosis. Tracheoplasty is associated with a high complication rate. A multidisciplinary approach is mandatory to ensure favourable long-term outcomes., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background and Objective: To examine the possibilities of laser thermoplasty of whole costal cartilages for correction the human congenital chest wall deformities., Study Design/materials and Methods: Ex vivo the samples of porcine costal cartilages were heated with lasers of differing wavelengths, including a 0.97-μm diode laser, a 1.56-μm erbium-doped quartz fiber laser, and a 1.68-μm fiber Raman laser. The dynamics of the temperature fields and the degradation of collagen in the laser-affected regions of samples were determined by using, respectively, thermometry, trypsin treatment, and light microscopy. Ex vivo the whole mechanically deformed costal cartilages of pigs were treated by laser radiation with wavelength 1.68-μm. The changes of cartilage shape were recorded at certain intervals over a 24-hour period by photographing them in a fixed position with a digital camera., Results: Treatment of costal cartilage samples from 5 to 11 mm in thickness by laser radiation with 0.97, 1.56, and 1.68 μm wavelengths showed that the 1.68-μm radiation could produce the necessary nonuniform bulk heating of the exposed sample. The altered shape of costal cartilage proved to remain stable after treatment when the laser irradiation settings used provided for the heating of a broad region within the tissue to temperatures about 80°C., Conclusion: This study demonstrates the possibilities of laser thermoplasty of whole costal cartilages for treatment of human congenital chest wall deformities. The development of novel approaches based on laser cartilage engineering techniques will enable to treat the human congenital chest wall deformities., (© 2014 Wiley Periodicals, Inc.)