Complications Associated with the Use of Autologous Costal Cartilage in Rhinoplasty: a Systematic Review

Background: Autologous costal cartilage grafts are common in rhinoplasty. To date, no formal systematic review of complications associated with autol-ogous costal cartilage grafting in rhinoplasty exists. Objectives: The authors review current literature to examine the rates of donor and recipient site complications associated with autologous costal cartilage in rhinoplasty. find studies evaluating rates of complications with autologous costal cartilage grafting in rhinoplasty. These studies were then screened with specific inclusion/exclusion criteria, and data were extracted from included studies and pooled for analysis. Results: A total of 21 eligible studies were included. Pooled donor site complication incidence was pneumothorax (0.1%), pleural tear (0.6%), infection (0.6%), seroma (0.6%), scar-related problems (2.9%), and severe donor site pain (0.2%). Pooled recipient site complications were as follows: warping (5.2%), infection (2.5%), displacement/extrusion (0.6%), graft fracture (0.2%), and graft resorption (0.9%). Conclusions: Autologous costal rhinoplasty remains a safe procedure, but is associated with not insignificant rates of minor recipient site complications, such as warping. Autologous costal cartilage is a commonly employed graft for rhinoplasty. It is particularly favored as an abundant source of cartilage in cases of revision rhinoplasty in which more local sources (septal and conchal) are depleted. 1 Despite being a common source of cartilage, evidence is scarce pertaining to complication rates associated with its implementation and the various techniques of harvest and placement. In this systematic review, our goal was to determine the rate of donor and recipient site complications associated with autologous costal cartilage grafting in rhinoplasty. Cochrane Register of Controlled Trials using the key terms " rhinoplasty, " " autologous, " and " costal cartilage. "

Articles published between January 1980 and July 2014 were included.
Inclusion criteria were articles written in English, human patients, rhinoplasty with autologous costal cartilage, and complication rates (donor and recipient site).Exclusion criteria included case studies with sample sizes fewer than 15 and studies not translated into English.
Two reviewers independently screened titles and abstracts of retrieved articles and references for relevant articles.Any disagreements were resolved by discussion with the senior author.
Studies were quality assessed and screened for biases using the critical appraisal checklist of the American Society of Plastic Surgeons. 2This checklist assesses bias in 4 domains: selection bias (appropriate case selection, cases consecutive, assessment of confounders); intervention bias (intervention performed similarly in all patients, all procedures performed by the same surgeon); measurement bias (outcomes have valid defined criteria, appropriate followup times to assess outcome); and conflicts of interest (study should not have conflicts of interest). 2

Data Extraction and Analysis
For each article that was included, the following outcomes were extracted (see Table 1): patient demographics; followup times; donor site complications (including pneumothorax, infection, chest wall pain, scarring, and chest wall deformity); and recipient site complications (warping, infection, displacement, or extrusion of graft).Complication rates were pooled for analysis.

Study Retrieval and Characteristics
The initial search yielded 63 citations.A total of 42 articles were excluded and 21 articles were included for review and analysis (see Table 2 for study characteristics).All included studies were case series with no control groups, thus no statistical analysis could be performed.
The included studies were all case series with varying study protocols (surgical techniques and follow-up times) and no control groups, thus meta-analysis was not viable.

Complication Rates
A summary of included studies and pooled complication rates is shown in Table 2.All studies reported individual complications.The overall pooled donor site complication rate was 3.2% (n = 1545), and recipient site complications were 11.4% (n = 1259; 1 large paper was excluded from analysis because a combination of a heterologous graft with autologous costal cartilage was utilized in 1 group, but the authors did not report individualized recipient complication rates in the autologous costal cartilage group alone).No mortality was reported in any of the studies.A summary of individual recipient and donor site complications is shown in Table 3.

Donor Site Complications
The only serious complication noted was pneumothorax that occurred in 2 cases. 3,4One of these cases was treated with a chest tube, and the patient was discharged 2 days postoperatively 3 ; no information was available regarding the management and outcome of the other case. 46][7] Only 3 studies routinely performed postoperative chest radiographs to assess for pneumothorax. 3,7,8A diagram of a pleural tear is shown in Figure 1.
Only 1 case of severe persistent chest pain was noted, and this was treated with intercostal nerve blocks.

Graft resorption
Another study found that 2 patients required more than 1 g of diclofenac per day. 9Three studies reported the injection of local anesthetic into the donor site. 8,10,11he most common long-term donor site complication was scarring, which occurred in 45 cases. 3,4,8,12,13There were no cases of chest wall deformity.

Recipient Site Complications
The most common recipient site complication was warping of the graft, with a pooled incidence of 5.2%.Overall, warping rates ranged from 0% [13][14][15] to as high as 26.1%. 16he overall rate of need for further revision rhinoplasty was 5.4%.
Recipient site infection (2.5%) was much more common than donor site infection (0.60%).[19] Other modalities of antibiotic coverage included immersion of the graft in antibiotic solution prior to insertion 8,10 and packing of the nose with antibiotic cream for 2 days postoperatively. 19

Operative Techniques
Most papers reported the typical techniques that were employed in the studies (see Table 4); however, 2 compared methods of graft harvest.

Graft Harvest
The typical intraoperative technique for costal cartilage harvesting (from the right sixth costal cartilage) is shown in Figure 2. In those studies that provided details regarding graft harvest, grafts were taken between the fifth to 11th costal cartilages (see Table 3).The typical site for a costal cartilage harvest is shown in Figure 3.An inframammary incision was also selected in females in several studies 3,5,7,8,10,14,17,20,21 for cosmetic benefit in concealing the scar.0,11 Several other studies reported checking for pneumothorax; however, the specific details were not provided. 16,17,22 few papers reported novel techniques of graft harvest.Ag ȃog lu et al (2000) 20 employed a gouge to minimize the amount of cartilage harvested (they reported no cases of pneumothorax or pleural breech).A conservative harvesting technique, whereby only a central segment of costal cartilage is removed, has been described. 5,14

Graft Preparation and Placement
Costal cartilage was employed for a wide range of grafts (see Table 5), including dorsal, septal, spreader, columellar tip, and alar.
A variety of grafting techniques was described to minimize warping.A common technique was to soak the harvested cartilage in saline 5,8,10,15,17 or to observe a period of delay prior to shaping and placement of the graft. 3,6,11,12,16oshaver et al 17 utilized Kirschner wires to prevent warping.
Ozturan et al 6 compared the standard autologous cartilage graft with the accordion graft (a costal cartilage graft that has been scoured); all 7 cases of warping in this study were found in the standard cohort.

Other Factors
The average age of patients was 29.1 years; the youngest patient was 3.8 years old and the oldest 82 years old (in studies that provided a demographic breakdown).
Among the nine studies that reported accurate follow-up time information (not all), the pooled mean follow-up was 24.8 months (range, 3 to 73 months).

DISCUSSION
In this systematic review, we have demonstrated that a wide variety of complications can occur at both the donor and recipient sites with autologous costal cartilage grafting   in rhinoplasty.The incidence of these complications varies greatly.
The most serious donor site complication is pneumothorax.No meta-analyses or systematic reviews were found reporting figures on pneumothorax rates in autologous costal cartilage harvesting in rhinoplasty or other procedures.In this review, frank pneumothorax was reported in only 2 cases; however, iatrogenic pleural tear was more common.Pleural tears can be managed with primary closure, whereas a pneumothorax requires the insertion of a chest drain with admission and discharge once it has cleared.
Many studies reported preserving the posterior perichondrium during graft harvest. 3,5,8,11,14,16,17,20Of these studies, only 1 case of pleural tear 5 and 1 case of pneumothorax 3 were reported, respectively.0,11 Routine postoperative chest radiographs are usually not required, although they were performed in some of the studies included in this systematic review. 3,7,8If pleural tears are excluded intraoperatively, then a postoperative chest x-ray is not necessary in most cases.
Chest wall deformities and scoliosis are a potentially severe long-term complication resulting from harvesting costal cartilage; 23 however, we found no reported cases associated with autologous costal cartilage in rhinoplasty.To address the deficiency in costal cartilage, studies have reported filling this potential dead space with fat 3 and unused cartilage. 6eromas are collections of serous fluid that can occur in any potential space created intraoperatively.One study found that by modifying their technique to maintain the integrity of the perichondrium at the donor site, seroma rates could be reduced (9 cases of seroma were initially reported and none occurred after modifying the technique), suggesting that limiting dead space and vessel leakage can reduce the risk of seroma. 3arvest technique appears to influence the rate of donor site complications.The classic harvest technique can be modified to obtain a conservative central segment harvest, which has been shown to result in low donor site morbidity in a large case series. 14However, a conservative harvest may not provide sufficient cartilage for rhinoplasty.
Scarring at the donor site was also a common issue.However, this complication can be treated with steroid injection, 3,8,12,13 silastic gel, 8 or silicon sheets. 13he most commonly reported complication is warping, with a pooled rate of almost 10%.Warping refers to distortion of graft material, which can later present with structural deformity.A variety of techniques have been utilized to minimize warping.
The most frequently applied techniques were to delay grafting or to immerse the graft in solution prior to shaping or insertion.Warping rates with these techniques varied substantially, ranging from 0% 15 to 26.1%. 16ilizing the central segment of costal cartilage is thought to minimize warping, therefore this method was employed in many studies. 4,8,11,12,14,16,17,19he majority of studies utilizing this technique reported warping rates less than 10%, 8,12,14,17 with 2 reporting rates greater than 10%, 11,16 suggesting this technique may be efficacious in reducing warping rates.
Several novel techniques were utilized in some studies.Ozturan et al 6 compared a standard grafting technique with the accordion technique (scouring the cartilage prior to insertion), with no reported cases of warping in the latter technique (in 23 patients).In a small series, researchers performed no carving on harvested grafts, instead place them with the convex edge of the graft oriented superiorly to utilize the natural curvature of the graft for shaping the nose 13 (no cases of warping were reported).Moshaver et al 17 combined the use of central segment cartilage with Kirschner wires, but still reported an 8.1% warping rate in addition to Kirschner wire extrusion in 3 patients.
A large case series combined autologous costal cartilage with an allogenic material (expanded polytetrafluoroethylene) to form a heterologous graft that the authors theorized would reduce warping rates. 10The overall warping rating in this study was very high (25.8%); 10 however, the study did not report individualized complication rates for this intervention compared with the use of autologous costal cartilage alone.
An overt increase in incidence of warping in studies with longer follow-up was not found.One study with a mean follow-up time of 48 months reported no cases of  warping, 13 and another with a mean follow-up time of 21 months reported a warping rate of 17.1%. 6 study assessing the properties of costal cartilage grafts noted that a greater mineral content in the cartilage, straighter grafts, and older age of the patient are associated with a lower incidence of warping. 16he rate of graft resorption with autologous costal cartilage in rhinoplasty is very rare, with a pooled rate of less than 1%.Donor and recipient infection were also uncommon, with many studies routinely administering antibiotics.
Major advantages of autologous cartilage are its abundance and versatility, permitting the derivation of a range of graft types and its use as the predominant source of cartilage in major nasal reconstructions. 7,9Autologous costal cartilage remains an all-purpose "workhorse" graft, with dorsal and septal as the most frequent types.
To date, 1 meta-analysis has assessed complication rates associated with autologous costal cartilage use in rhinoplasty. 25This review only included 10 studies and reported a not dissimilar rate of graft resorption, graft displacement, or pneumothorax; however, it noted a lower rate of warping (3.08%), a lower rate of recipient site infection (0.56%), and a higher rate of scarring (5.45%) 25 in comparison with the present systematic review.

Limitations
It should be noted that current best evidence for techniques and complication rates in costal cartilage associated with rhinoplasty are based on case series.A wide variety of techniques intending to minimize complication rates have been reported; however, to our knowledge, no well-designed controlled study compares 1 technique with another.
The ability to provide definitive recommendations on specific techniques for minimizing complication rates remains limited by the level of evidence available.

CONCLUSION
Autologous costal cartilage is an abundant and versatile graft material that is effective in rhinoplasty.The rates of reported associated complications vary greatly.Whereas severe complications such as pneumothorax are rare, warping appears to be much more common.In this study, we have provided a thorough review of the overall complication rates and surgical techniques.We hope that surgeons can avail themselves of this information to guide their choice of technique, to recognize complications, and to counsel patients preoperatively.Future studies should focus on comparing various techniques, with a particular emphasis on complication rates.

Figure 1 .
Figure 1.A diagram of a pleural tear.

Figure 2 .
Figure 2. (A) Incision over marked costal cartilage site, (B) exposure of costal cartilage through dissection of intercostal muscles, (C) exposed costal cartilage, and (D) excision of graft from exposed costal cartilage are demonstrated in a typical intraoperative technique for costal cartilage harvesting (from the right sixth costal cartilage) on a 38-year-old male patient.

Figure 3 .
Figure 3.A diagram showing the typical site for costal cartilage harvest.

Table 1 .
Data Extracted From Articles

Table 2 .
Included Studies a Recipient site complications were not assessed as study included a cohort in which autologous costal cartilage was combined with an allograft (no individualized recipient site complication rates were reported for the autologous costal cartilage group alone).

Table 3 .
Complication Rates a One large paper was excluded from analysis as the authors used a combination of a heterologous graft with autologous costal cartilage in 1 group, but did not report individualized recipient complication rates in the autologous costal cartilage group alone.

Table 4 .
Summary of Operative Techniques