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Discussion: Combined Use of Crushed Cartilage and Fibrin Sealant for Radix Augmentation in Asian Rhinoplasty

301e I the article entitled “Combined Use of Crushed Cartilage and Fibrin Sealant for Radix Augmentation in Asian Rhinoplasty,” the authors describe their technique using fibrin tissue sealant to stabilize a construct of crushed cartilage to augment the radix. They used a pooled blood fibrin tissue sealant (Tisseel, Baxter, Deerfield, Ill.) to glue stacked cartilage grafts that were slightly crushed after beveling the edges. After molding into the proper shape, the constructs were placed onto the radix into a dissected tunnel by means of an endonasal rhinoplasty approach. To account for resorption of the grafts, the augmentation was overcorrected by 15 to 20 percent. Their results were analyzed by independent observers, patient interview, and measurements performed on photographs. Their results showed an observer rating of excellent in 41.2 percent of patients, good in 37.3 percent, fair in 15.7 percent, and poor or unchanged in 5.9 percent. There was no extrusion, infection, or displacement of the grafts. There was one case of partial resorption of the graft and there were two cases of graft visibility and irregular graft contour. A deficiency of the study involved the method of measuring augmentation using preoperative and postoperative photographs. Performing such measurements off of photographs introduces significant variability in magnification and head position. A couple of degrees of rotation of the head can significantly alter the accuracy of measurements performed on radix and dorsal augmentation. Ideally, measurements should be performed off of three-dimensional images taken using stereophotogrammetry and software designed to obtain precise measurements of the face and nose.1–3 Using this method of measurement, changes as small as 0.1 mm can be made accurately from sitting to sitting.4 This is particularly important when obtaining measurements of less precisely defined areas of the nose such as the radix or nasal dorsum. Using stereophotogrammetry and threedimensional software, changes in volume can also be measured, which would be particularly helpful if used over the area of radix augmentation.5 The resorption noted using crushed cartilage and fibrin sealant is likely attributable in part to lack of direct vascular ingrowth into the cartilage at the center of the implant. The layering of the graft likely creates a “zone of hypoxia” between the layers of cartilage and fibrin sealant that is not adequately vascularized. The histologic specimen examined in the study (revision patient) was likely from the periphery of the graft, where maximal survival is expected. To account for potential resorption, the authors overcorrected by approximately 15 to 20 percent when augmenting the radix using the crushed cartilage combined with fibrin sealant. Such overcorrection would suggest that there is less precision in the final degree of augmentation noted in the radix over time. In addition, this would likely introduce a period where the graft needs to stabilize into its final form. Many Asian patients are very particular about the height of their radix and the degree of dorsal augmentation to be achieved. In many Asian patients, the augmentation of the radix or dorsum is the primary reason for undergoing rhinoplasty surgery and therefore precision in augmentation is of utmost importance. Diced cartilage grafts are another popular method for augmenting the radix and nasal dorsum.6,7 One of the disadvantages of using diced cartilage is that it lacks structural stability and can lose its form, leading to less defined dorsal aesthetic lines. I have seen this problem in patients that underwent diced cartilage dorsal augmentation. This is in contrast to the maximally defined dorsal aesthetic lines that can be achieved using a solid cartilaginous dorsal graft. These more defined dorsal aesthetic lines require that the dorsal grafts be nearly perfect to provide a straight and symmetric