Section 4 Plastic and Reconstructive Problems

cartilage to augment the dorsum as a free graft without

the use of fascia.

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-

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

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.

Figure 2.

A, Diced costal cartilage compacted in syringe mold; B, diced

costal cartilage graft solidified by tissue sealant.

ARCH FACIAL PLAST SURG/VOL 14 (NO. 6), NOV/DEC 2012