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Original Investigation
May 30, 2019

Characterization of Injury Induced by Routine Surgical Manipulations of Nasal Septal Cartilage

Author Affiliations
  • 1Department of Otorhinolaryngology–Head & Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia
  • 2McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia
  • 3Surgical Service, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
  • 4Praxis am Hanse Viertel, Hamburg, Germany
  • 5Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
JAMA Facial Plast Surg. 2019;21(5):393-401. doi:10.1001/jamafacial.2019.0169
Key Points

Question  What is the optimal surgical manipulation for cartilage autografts in rhinoplasty?

Findings  In this in vitro investigation of 4 distinct surgical manipulations compared with a control group using cartilage from bovine snouts, the crushing manipulation was statistically significantly worse than all other manipulations with shaving, dicing, and scoring following, respectively, by various quantitative assays.

Meaning  When clinical needs dictate the use of cartilage grafts, surgeons should consider the least damaging, yet adequate cartilage manipulation to enhance clinical outcomes.


Importance  This study characterizes and compares common surgical manipulations’ effects on septal cartilage to understand their implications for rhinoplasty outcomes based on cell viability and cartilage health.

Objective  To illustrate distinct differences in the impact of various surgical manipulations on septal cartilage in an in vitro septal cartilage model. A secondary objective is to better understand the chondrocyte’s response to injury as well as how alterations in the extracellular matrix correspond to chondrocyte viability.

Design, Setting, and Participants  In this bench-top in vitro porcine model using juvenile bovine septal cartilage from bovine snouts, easily obtainable septal cartilage was used to generate large numbers of homogenous cartilage specimens. Quantitative outcomes at early and late time points were cell viability, cell stress, matrix loss, and qualitative assessment through histologic examination. The study was performed at a single academic tertiary care research hospital.

Interventions  Four common surgical manipulations were contrasted with a control group: crushed cartilage, scored cartilage, diced cartilage, and shaved cartilage.

Main Outcomes and Measures  Following the manipulation of the cartilage, the quantitative outcomes were glycosaminoglycan release to the media, lactate dehydrogenase release to the media, and cell death analysis through apoptosis staining. The qualitative outcomes were histologic staining of the manipulated cartilage with safranin-O/fast green stain to identify proteoglycan loss.

Results  The crushing followed by shaving manipulations were the most damaging as indicated by increased levels of lactate dehydrogenase release, glycosaminoglycans loss, and cell death. Matrix loss did not increase until after 48 hours postinjury. Furthermore, chondrocyte death was seen early after injury and accelerated to the late time point, day 9, in all manipulations. Conversely, cell stress was found to be greater at 48 hours postinjury, which then declined to the late time point, day 9.

Conclusions and Relevance  The crushing manipulation followed by shaving and then dicing were the most destructive methods of cartilage manipulation relative to control specimens. Collectively, these outcomes demonstrate the range of injury which occurs with all septal cartilage manipulations and can inform rhinoplasty practice to use the least damaging effective surgical manipulation to obtain the desired outcome.

Level of Evidence  NA.