Medical Minute 5-20: Rebuilding Noses

By: Vanessa Welch Email
By: Vanessa Welch Email

Pat Villafranca never liked her nose growing up.

"I never really had good airways, and I always had a hump right between the eyes," said Pat Villafranca.

In her twenties, she went to a doctor to have that hump fixed, but he left Pat with a face she didn't recognize.

"The tip of my nose is gone. There's nothing supporting that skin, and now my nose droops," she said.

Over the years, several doctors told her they couldn't fix her droopy nose. Then, she met Doctor Russell Kridel.

"Patients who had previous surgery on their nose or who had significant trauma to their nose shouldn't give up hope," said Russell Kridel, M.D., Facial Plastic Surgeon UT Health Science Center at Houston Houston, TX.

Doctor Kridel gives patients reason to get excited with this: Donor rib cartilage. It's irradiated first to virtually eliminate rejection risk and to keep the cartilage from warping.

"If we take rib cartilage, it's straight, and we can get a very nice contour on the bridge of the nose."

Kridel's study shows using donor cartilage instead of a patient's own cartilage reduces cost, pain, surgery time and recovery. The before and after pictures tell the story.

"Since we wrote this paper, there's been a huge demand for it. The tissue banks have been unable to keep up with the demand because it's so easy to use."

As an FBI agent, Pat does on camera interviews for big cases.

"I probably would have never volunteered for this job if I felt that I didn't like the way I looked. I feel like I have my old nose back."

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

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MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: Rhinoplasty, or nose surgery, is often referred to as "nose reshaping" or a "nose job." This procedure can improve the appearance and proportion of a person's nose, while enhancing facial harmony. Surgery of the nose can also correct impaired breathing that is sometimes caused by structural abnormalities in the nose. Rhinoplasty can change the nose size, the nose width, the nose profile, the nasal tip, the nostrils that are large, and the nasal asymmetry. Patients who are candidates for this procedure must be physically healthy, nonsmokers, and be at least 13 years of age or older.
(SOURCE: www.plasticsurgery.org)

GRAFTING MATERIAL: Septal cartilage is generally the preferred grafting material for rhinoplasty, but in some patients, there is inadequate tissue, especially for revision procedures. Other approaches have included harvesting the patient's own ear cartilage, but the size and shape of the cartilage may limit its suitability.
(SOURCE: www.medicalnewstoday.com)

DONATED RIB CARTILAGE: Now, some doctors are using irradiated rib cartilage as part of the rhinoplasty procedure. Homografts using rib cartilage salvaged from previously healthy donors such as lethal trauma victims may offer advantages. The salvaged tissue is screened for diseases and exposed to 30,000 to 50,000 Gy of gamma radiation to remove antigenicity. It is stored in saline in tissue banks. The donor cartilage has a long shelf life. It's good for five years from the time it's harvested.

RESULTS: Russell Kridel, M.D., a facial plastic surgeon from UT Health Science Center at Houston, conducted a study and found that using donor cartilage instead of a patient's own cartilage reduces cost, pain, surgery time and recovery. He says there is ongoing research to explore the possibility of using artificial cartilage in plastic surgery procedures like rhinoplasty.

FOR MORE INFORMATION, PLEASE CONTACT:
Cindy Romeo
Patient Coordinator for Dr. Kridel
(800) 621-7531

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Russell Kridel, M.D., a facial plastic surgeon at UT Health Science Center at Houston discusses a new way to rebuild noses.
So tell me, what are some of the reasons people need to have or want to have their noses surgically altered or reconstructed?
RK: Some reasons are cosmetic. Some of us are born with a short nose or a low bridge on the nose and want to have it augmented. In our study we looked at patients who had previous surgery or injury to their nose and we had to rebuild their noses.
And how normally would, let’s say before we get into the irradiated rib cartilage, how in the past, normally would a nose be rebuilt?
RK: If a nose is missing some parts, often after trauma or after surgery, there may be a dip in the bridge of the nose or the cartilage that makes up the tip is deficient. In the past we would take cartilage from the ear or sometimes from the structure between the nostrils called the septum and use that as graft material.
Ok is there any other? Pat, the patient, happened to mention taking it from the collar bone, is that ever done?
RK: No, collarbone you wouldn’t normally use.
Ok, ok.
RK: Normally we don’t use bone for the nose except in some very severe conditions, because bone requires a lot of blood supply. Cartilage is normally what we use for the nose to rebuild it.
What are the negatives with using ear cartilage from the person's own ear or the septum?
RK: We like to use those first if we can, but sometimes people have already had previous surgeries and those grafts have already been utilized, there’s nothing left to graft elsewhere. You look at the nose, it’s straight, your ear is curved, so sometimes the ear is not a good graft material because of its shape and structure.
Oh, ok so if you needed a large piece of cartilage or a larger amount, maybe the ear might not be.
RK: Might not be enough, plus if you have to sew it together make it long enough, you can see irregularities. Where if we take a rib cartilage, it’s a straight piece and we can get a very nice contour on the bridge of the nose.
So that’s why it’s rib, I wondered that, So that’s why because it’s straight. Interesting. Ok, so when you reconstruct the nose why is the extra cartilage needed, why can’t you rebuild, cartilage is necessary for a good structured nose right?
RK: Right, the nose has to breathe, not only look good, but breathe and to breathe it has to have an open airway, So you need structure, you need architecture there to hold the nose open, and you also need structure there to look good but in a nice contour. Soft grafts wouldn’t work; the nose would be very floppy.
Ok, ok got it. So explain the rib cartilage procedure.
RK: For years people were using the patient’s own rib. They would make an incision in the rib cage and take that piece of rib and they would use that in the nose, but the problem is that, that hurts. Sometimes there are scars and there are some possible complications using someone’s own rib cartilage. Plus, as an individual gets older the cartilage in their ribs calcifies or gets hard and so we thought of an alternative to use donor cartilage from a tissue bank instead from people unfortunately who are usually in an accident, who passed away at an early age before there was any calcification in their ribs. This saves an individual from having to have another incision on their chest, which is especially important in ladies who don’t want a scar, and it saves time in the operating room.
And how do you ensure that there won’t be any rejection?
RK: Cartilage is very inert, and all of the individual patients who are donors are screened for multiple diseases and problems and also the cartilage is irradiated, and it doesn’t mean it glows in the dark, it just means that it’s made inert, totally inert, so rejection is not a problem.
How important is that, the irradiation part?
RK: We found that it decreases warping because the rib expands when you breathe and so it has a little curve to it, but the actual irradiation may decrease any attempt for it to want to warp. So it stays straight in most cases.
So, it’s not necessarily, I thought the irradiation was to prevent any rejection, is it also helpful in that arena?
RK: Yes
Oh it is, ok.
RK: Helpful in both ways.
Ok, does that virtually eliminate the chance of rejection with irradiation or is there still some risk?
RK: Cartilage in these cases is not rejected.
I think that is something people hear, oh it’s from a donor, you automatically think that there’s a risk of rejection, so people might even just tune it out, let’s say they are watching the story, I want to make sure that that’s clear, So there’s not a high risk in the first place and the irradiation lowers it even more?
RK: That’s correct.
Ok, so I’ll have you explain that a little bit to me.
RK: Cartilage is one of those tissue structures that we have that’s almost never rejected and cartilage has been used from one person to another for many, many years. With the irradiation it even decreases the chance of rejection even further and additionally we found the irradiation helps decrease the possibility of the graft warping or bending.
And when you compare this donor rib cartilage to let’s say cartilage from the ear or cartilage from the septum what are the results?
RK: Well we were fascinated to see that the rate of complications using donor rib cartilage that’s been irradiated was no more than using the patient’s own ear or septum cartilage or their own rib cartilage. In fact, in certain instances they were even less.
When you say complications, what kind of complications?
RK: Well we have a complication rate of less than 4% from over 1000 grafts, 370 patients, and what we’re talking about with complication is one would be infection, one would be resorption where the body is eating away at the graft over time, and the other one was warping.
From the surgeons point of view is it easier for you to use a donors rib that to say take a piece of the person's own ear cartilage, is it an easier procedure, quicker procedure or better looking procedure?
RK: Well for most of the defects we took care of in the nose, we needed a long straight piece of cartilage and the ear was really not an adequate donor site for us
So, you needed a, really rib was the best option, it was really just whether it was coming from themselves or a donor.
RK: The other possibility would have been septal cartilage, because the septum, that wall between the two nostrils, does have a lot of cartilage that’s straight, but often these cases didn’t have any septal cartilage left. We could have used septal cartilage if we had enough, but in some of these cases we needed a long piece of cartilage, a strong piece of cartilage, and so it was either the patient’s own rib or a donor rib.
Once the cartilage is in there, how do you attach it?
RK: We carve the cartilage to make it exactly the shape that we want and then we place over some of the existing structures and sew it into place with multiple sutures.
Ok. They are totally permanent, there’s not a risk of it coming apart?
RK: The sutures that we use do absorb over time, but by the time the sutures absorb the body has formed fibrosis around it and will keep the graft exactly where we placed it.
Perfect. Ok, great. So is this something that is readily available? It’s approved and available?
RK: Since we wrote this paper there’s been a huge demand for it; the tissue banks have been unable to keep up with the demand because it’s so easy to use and because our studies have showed it is safe. So we would like all the tissue banks around the country to harvest more rib cartilage for us because I get calls from doctors all the time saying “where do I get some? I want some” and there’s a back log at the tissue banks.
Ok, So it’s fine to do this, someone watching this across the country wouldn’t necessarily have to come here, they could try to find someone in their area who could do it.
RK: Yes, there are tissue banks all over the country that process rib cartilage and we’d like it to be irradiated, we don’t like it to be treated with chemicals, we don’t want it to be frozen, and it should be fresh cartilage that is irradiated in a bottle of saline.
So, when you say fresh, how long does it last, how long do you have to get it from the person who’s expired to the patient?
RK: Well that usually happens very quickly because often these individuals donate other organs at the same time.
What’s the benefit to the patient?
RK: Well the benefit to the patient is less time in the operating room, not another incision to take their own rib. When you take someone’s rib there’s a potential for a pneumothorax or punctured lung, because remember the ribs protect the lungs and So if you’re harvesting it, that’s a potential complication. You can get infection at the site, you could get pain, or you could get a scar. So it’s decreasing patient morbidity or discomfort and decreasing time in the operating room; time in the operating room is money and the cost for that extra time to harvest rib cartilage graft from the patient.
How extensive is the procedure, how long does a typical procedure take?
RK: You can’t give a time, because every nose is individual and what damage has been done to it will be different in each patient. Some of these cases can take 4 or 5 hours, some might take just 1 or 2.
So, it’s not a 15 hour, you said you carved it before, do you use previous pictures of the patient or how do you do it?
RK: One of the things that we do now is called computer imaging where we take a picture of the patient prior to surgery and then we put it on a computer screen and then we morph it or change it to try and show a goal for the surgery and then we actually show that picture to the patient and see if they like it. If they do, then we go to surgery with that new picture and have the nurse hold the picture next to the patient as I’m operating, and I try to come as close to it as I can.
Wow, so how do you think you do?
RK: Well you’ll have to ask the patients but we have some pretty happy ones.
And you touched on this a little bit but it’s permanent, it should be permanent.
RK: Well that’s why I mention the small possibility of resorption or of it decreasing in size, but we have patients with up to a 24 year follow up with almost no resorption, a marjority with no resorption, and just a very few with some resorption, so this has not been an issue. For many years it was thought that this cartilage would resorb, but it doesn’t seem to do so in the nose to the same extent that it would in other parts of the body. So the longevity is really quite good. Now if you compare that to the patient’s own cartilage that you take from the ear that can resorb also. So actually, our resorption rates were no different than using the patient’s own cartilage.
Is the use of artificial cartilage on the horizon?
RK: There are a lot of studies growing cartilage in the lab right now. There are many, many different centers doing research and lab studies now, and that certainly is the hope for the future. If we could grow cartilage and mold it and shape it the way we would like to have it, it would be tremendous. But we're’re not there yet.
But it would have to be cartilage that you grow, it can’t be any other artificial material?
RK: Well remember we want structure here, structure and strength and cartilage has structure and strength and that’s a normal structure that’s in the nose.
Ok, so you want to keep as close to original as possible.
RK: Yes.
I think I asked you everything I wanted to ask you, is there anything you want to add?
RK: I would say in general that the patients who had previous surgery on their nose or who had significant trauma to their nose should not give up hope. I think that using this grafting material is a bright spot for these individuals and they should really consult with a facial plastic surgeon to see if maybe they can be helped.


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