Section 4 Plastic and Reconstructive Problems

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B

Figure 1. A 3-mL syringe cut in a taper along the long axis creates a trough that serves as a mold for diced cartilage.

cartilage to augment the dorsum as a free graft without the use of fascia. 9 He used a modified 3-mL syringe to serve as a trough in which he placed diced cartilage cut to 0.5 mm or smaller. The syringe was cut in a diagonal fashion along its long axis to create a sloping trough measuring approximately 1.0 cm wide and 3.0 to 4.0 cm long. He solidified the diced cartilage by using a few drops of human tissue sealant. This cre- ated a graft that was sufficiently rigid to enable trans- ferring the graft from its plastic mold to the nasal dorsum. I was fascinated with this unique method of prepar- ing a cartilaginous graft and decided to use it in patients who required augmentation of the dorsum of greater than 3 mm. I would like to share my early experience and some helpful suggestions for surgeons who might wish to use this technique. I have used the Tasman technique for dorsal augmentation using cos- tal cartilage as well as septal and auricular cartilage. First, it is difficult to use a scalpel to diagonally cut a plastic 3-mL syringe longitudinally. A handheld battery-operated heat cautery device used for ophthal- mological surgery is more effective in cutting the syringe than using a scalpel ( Figure 1 ). However, I am in the process of working with a surgical instru- ment company to develop variable sizes of metal troughs that can be used as a mold for the diced carti- lage. Recently, I used the trough of an Aufricht retrac- tor (10 mm 45 mm, solid blade) as the mold for the diced cartilage. Another instrument that could be used is a Cobb gauge (9.5 mm). Cartilage used for the graft should be cut into 0.5-mm pieces or smaller. This is most effectively accomplished using a number 10 scalpel blade and a cutting block. The diced cartilage is then placed within the plastic mold and compacted using a freer elevator so that the cartilage assumes the shape of the trough with an outer curvature equal to the circumfer- ence of the trough ( Figure 2 A). This is approxi- mately 1 cm and corresponds nicely with the ideal width of the nasal dorsum. In the center along the long axis of the trough filled with diced cartilage, a shallow groove is created if the recipient site on the dorsum has a convex contour. This groove will accom-

Figure 2. A, Diced costal cartilage compacted in syringe mold; B, diced costal cartilage graft solidified by tissue sealant.

modate the convexity and possibly help prevent side- to-side movement of the graft once it is placed over the dorsum. If the recipient dorsum is a flat plateau, the plastic trough is completely filled with diced cartilage and no groove is created. I use a 2-mL pack- age of Evicel (Omrix Biopharmaceuticals Ltd) tissue sealant as the solidifying agent when preparing the diced cartilage. This material is provided as a single- use kit consisting of 2 vials: one vial contains Throm- bin, which is a sterile solution containing highly puri- fied human thrombin and calcium chloride, and the other vial contains Biological Active Component 2 (BAC2), which consists mainly of a concentrate of human fibrinogen. Fibrinogen is a protein from human blood that forms a clot when combined with Thrombin. Each vial is transferred to an individual 3-mL syringe. The syringe is attached to a 21-gauge needle. Two or 3 drops of Thrombin are applied to the trough first, and then the diced cartilage is added. If the cartilage is too saturated with the Thrombin, the cartilage is held in place with a freer elevator while tilting the trough slightly to drain off excess Throm- bin. The excess may also be eliminated by touching the graft material with nonadherent surgical dressing (Telfa; Covidien). The cartilage is then compacted and molded into the desired shape with a freer elevator. Then, 2 or 3 drops of fibrinogen (BAC2) are distrib- uted evenly over the entire surface of the diced cartilage. The quantity of fibrinogen should be just sufficient to fill the spaces between the fragmented cartilage. It is gently massaged into the cartilage with a freer elevator. The fibrinogen rapidly diffuses through the pieces of cartilage to react with the Thrombin. Within 3 to 5 minutes, the diced cartilage is solidified into a semirigid graft conforming to the size and shape of the plastic trough (Figure 2B). It can be gently lifted

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