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Page 2 of 6 Zheng et al. Plast Aesthet Res 2019;6:2 I http://dx.doi.org/10.20517/2347-9264.2018.76

to harvest and may be associated with significant donor site morbidity. Donor site complications such as
pneumothorax, seroma, scar-related problems, intercostal neuralgia and intensive postoperative pain are
[2]
deterring factors for the use of autologous costal cartilage. Increased surgical time can be another concern .
In that context, although there can be is limited availability and increased cost for purchasing the graft,
the use of homologous costal cartilage in rhinoplasty can be an attractive surgical option as it can avoid
donor morbidity and additional operative time. Homologous costal cartilage is harvested from cadaveric
donors and is processed in various ways. It has been shown to be useful in rhinoplasty. The tissue processing
methods typically involve a high dose of ionizing radiation, osmotic destruction, freeze drying, and chemical
sterilization- either alone or in combination- to eliminate the cellularity of the tissue and to sterilize the
[3-7]
grafts . Numerous surgeons have reported their results of using homologous costal cartilage, treated with
different processing methods in rhinoplasty. However, controversy still exists in the literature regarding
the complications associated with the use of homologous cartilage as a grafting material in rhinoplasty.
Therefore, in this paper, we aim to summarize current understanding of the usefulness and the problems
related with the use of homologous costal cartilage in rhinoplasty.

REVIEW OF CASE SERIES
Published reports have mostly dealt with case series of homologous costal cartilage grafts that have been
[8]
processed in different ways [Table 1]. Mühlbauer et al. reported their experience with the use of L-shaped
homologous costal cartilage grafts for saddle nose correction that were preserved in merthiolate saline
and stored at 4 °C. Thirty out of the 40 reported cases showed no sign of absorption, moderate absorption
was seen in 8 cases and in 2 cases, where syphilis was the underlying pathology, the grafts almost totally
disappeared. They believed that the calcification of homologous cartilage began approximately 1 year after
insertion and, as time passed, the degree of calcification became more complete and contiguous.

[9]
Lefkovits published a retrospective study of 27 augmentation rhinoplasty cases using irradiated homologous
costal cartilage (IHCC). The reported complications included infection in 7.4% (2 of 27) of cases, warping
[10]
14.8% (4 of 27), no resorption was seen. Clark and Cook studied the usefulness of IHCC in immediate
reconstruction of extruded alloplastic nasal implants in 18 patients. They noted that resorption of IHCC was
minimal with a mean follow-up of 26 months. There was only one case of warping that was reported and
[11]
revised by anther IHCC. Strauch and Wallach presented the results of 130 IHCC grafts. There were 2 cases
of graft exposure (1.5%) of immediate complication. Four (3.1%) cases of late complication, including 1 case
of fracture and 2 cases of displacement. There was partial resorption of one graft demonstrated at 6 months
[12]
postoperatively. Kridel et al. published their experience with the long-term use of HICC in a large series
of 357 patients. Among 357 patients, there were 83 primary cases and 274 revision cases. The mean follow-
up period was 13.45 years. The overall complication was 3.25%, including 10 cases of warping (1.06%), 9 cases
of infection (0.86%), 5 cases of non-infectious resorption (0.53%), 5 cases of infectious resorption (0.48%), 3
cases of mobility (0.31%) and there was no extrusion noted.

Tutoplast processing is a specific method of tissue processing developed by Tutoplast over forty years
TM
TM
ago. The process includes, delipidization, osmotic treatment, oxidative treatment, solvent dehydration,
TM
double-sterile packaging, and terminal gamma irradiation (17.8-25.0 kGy). Tutoplast -processed costal
cartilage has very different characteristics than autologous costal cartilage because of its complex chemical
[13]
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process. Demirkan et al. reported their experience with Tutoplast -processed homologous costal cartilage
use in rhinoplasty in 65 patients, with a mean follow-up period of 33 months. There was no significant
resorption detected in any of the cases. However, there were 4 cases (6%) of minor complications such as
[14]
deformity of the dorsal graft, excessive graft length, and erythematous nasal tip. Song et al. studied the
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surgical outcome of rhinoplasty using Tutoplast -processed costal cartilage. They reported a relatively high
complications rate of 31%. These included 6 (17%) cases of partial resorption, 3 (9%) cases of warping, 1 (3%)