Saddle Nose Deformity Reconstruction in Yemen: A Prospective Study of the Diced Cartilage Fascia Technique

doi:10.21203/rs.3.rs-4838061/v1

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Saddle Nose Deformity Reconstruction in Yemen: A Prospective Study of the Diced Cartilage Fascia Technique

https://doi.org/10.21203/rs.3.rs-4838061/v1

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Background: Saddle nose deformity is a significant challenge in conflict-affected and resource-limited settings. The diced cartilage fascia (DCF) technique, which involves wrapping diced cartilage in the fascia, has demonstrated promising results, but it remains underexplored.

Objective: To evaluate the efficacy, safety, and patient satisfaction of the DCF technique for saddle nose deformity reconstruction in Yemen.

Methods: This prospective case series included 30 patients who underwent nasal reconstruction using the DCF technique between January 2020 and January 2023. Outcomes were assessed through pre- and postoperative photographs, Nasal Obstruction Symptom Evaluation (NOSE) scores, Rhinoplasty Outcome Evaluation (ROE) scores, and patient interviews over a 6-month follow-up period.

Results: Significant improvements in nasal shape and function were observed. The mean A-B line measurement increased from 16.75 mm to 21 mm (p < 0.001), and the mean NOSE score decreased from 52.8 to 5 (p < 0.01). Patient satisfaction was notably high, with 96.7% of patients reporting excellent satisfaction. The complication rate was 6.6%, and manageable issues, such as nasal deviation and infection.

Conclusion: The DCF technique is a safe and effective method for correcting saddle nose deformity in resource-limited settings and has significant functional and esthetic improvements. Further research with larger sample sizes and longer follow-up periods is recommended to validate these findings.

Plastic & Reconstructive Surgery

Rhinoplasty

saddle nose deformity

diced cartilage fascia technique

resource-limited settings

nasal reconstruction.

Nasal deformities, particularly dorsal nasal deformities such as saddle noses, significantly impact facial esthetics, resulting in a characteristic "saddle-like" appearance. This condition can arise from various causes, including trauma, congenital abnormalities, infections, autoimmune diseases, and iatrogenic factors [1, 2]. Traditional treatment methods, including bone grafts, solid cartilage grafts, and dermofat grafts, have limitations, such as rapid degradation, graft displacement, and failure to restore the nose's original shape [3, 4]. Additionally, the use of cadaveric and artificial grafts is often constrained by limited availability, high costs, the risk of disease transmission, and potential foreign body reactions [5, 6].

One promising surgical approach for correcting saddle nose deformity is the diced cartilage fascia (DCF) technique [7]. This method involves harvesting the patient’s cartilage, typically from the nasal septum or ear, dicing it into small pieces, and wrapping it in a fascia layer [8]. The resulting graft is malleable, allowing for precise augmentation and reshaping of the nasal dorsum, with the fascia layer facilitating integration into the recipient site [9, 10]. The DCF technique offers several advantages over traditional methods, including the ability to customize the shape and volume of the graft, reduced risk of graft resorption or displacement, improved contouring and blending with surrounding nasal structures, and potential for improved long-term stability and esthetic outcomes [11, 12].

In resource-limited settings like Yemen, managing complex nasal deformities presents significant challenges [3–6]. High costs, limited materials availability, and conflict burden further complicate the situation [6]. Therefore, there is an urgent need for alternative techniques that can effectively address nasal deformities while being feasible in such environments.

This study aimed to evaluate the efficacy, safety, and patient satisfaction of DCF for saddle nose deformity reconstruction in Yemen. By focusing on a conflict-affected, resource-limited setting, we sought to investigate the technique’s outcomes and compare them with those of more stable environments. This prospective case series, conducted between January 2020 and January 2023, involved 30 patients and provides valuable insights for surgeons working in similar contexts.

Study Design and Settings

This prospective case series study was conducted at three plastic and reconstructive departments: Military General Hospital, Typical Police Hospital, and Elite Hospital, in Sana'a, Yemen, from January 2020 to December 2023.

Patient Selection

A total of 30 consecutive patients with saddle nose deformity were included in the study. Inclusion criteria comprised patients with clinically and radiologically confirmed saddle nose deformity, significant nasal obstruction or breathing difficulties, esthetic concerns regarding nasal appearance, age > 18 years, absence of contraindications for surgery, realistic expectations, psychological stability, willingness to cease smoking before and after surgery, and no active nasal or systemic infections. The exclusion criteria included patients younger than 18 years (unless the deformity severely impacted their quality of life), those with severe comorbid conditions posing high surgical risks, those seeking perfection rather than improvement, those unwilling to quit smoking, those with psychological instability, including body dysmorphic disorder, active infections, known allergies to grafting materials, and pregnancy.

Surgical Technique

Preoperative Assessment and Planning

Preoperative planning included a consultation to assess nasal anatomy and define esthetic goals using computer imaging. Patients were marked in the upright position, and if costal cartilage harvest was planned, the inframammary/infrapectoral crease and xiphoid were marked.

Intraoperative Steps

Under general anesthesia with local anesthesia, an open rhinoplasty approach was used to access the nasal framework (Fig. 1a). Graft materials, including the costal, septal, and conchal cartilage, were diced into 0.5 to 1-mm cubes and packed into a syringe (Fig. 1b, 1c). The fascia was harvested, wrapped around a catheter, and filled with diced cartilage (Fig. 1d, 1e). The graft was shaped, positioned, and secured. The cephalic end of the DCF was placed at the nasal starting point, and the supratip break was marked caudally. Fenestrations were made to promote vascular ingrowth, and corset sutures were used to achieve the desired shape. Final adjustments were made before securing the DCF with percutaneous sutures. The nasal skin was re-draped, the incision was closed, and a septal splint was applied if septal cartilage was used (Fig. 1f).

Postoperative Steps

Casting was crucial for success, using a thermoplastic splint to shape the graft. Once the shape had been set, ice-cold water was applied to lock it in. The cast and percutaneous sutures were removed after 1 week.

Data Collection

Data were prospectively collected from all patients undergoing saddle nose deformity reconstruction using the DCF technique. Patient information, including age, sex, and etiology, was recorded. Preoperative and postoperative assessments included Nasal Obstruction Symptom Evaluation (NOSE) and Rhinoplasty Outcome Evaluation (ROE) scores, A-B line measurements, and photographs. Surgical details, such as the graft harvest site and amount of cartilage used, were documented, along with postoperative complications and any additional procedures. Patients were followed up at monthly intervals for 6 months. All data were securely stored to maintain patient confidentiality.

Outcome Measures

The primary outcome measures were improved nasal esthetics and function, which were assessed using validated scores. Secondary outcomes included the incidence of postoperative complications, such as infection, recurrence, and visible deformities. Nasal obstruction symptoms were evaluated using the NOSE score, and patient satisfaction was assessed using the ROE score. Objective assessments included pre- and postoperative photographs and A-B line measurements.

Outcome Assessment

The outcomes were assessed preoperatively and at each monthly follow-up visit for 6 months postoperatively. Nasal obstruction symptoms and patient satisfaction were evaluated using validated Arabic versions of NOSE and ROE scores [13]. Pre- and postoperative photographs and A-B line measurements were taken to objectively assess changes in nasal esthetics and height gain (Fig. 2). The A-B line is defined as follows: Point A refers to the midpoint of the line representing the base of the nose, located between the inner canthus (the inner corner of the eye) and the alar base (the base of the nostril). Point B is the midpoint of the line extending from the radix (the highest point of the nasal bridge) to the supratip (a point above the nasal tip). The operating surgeon performed a clinical assessment of nasal shape, projection, and function at each visit. Any postoperative complications were documented and managed accordingly.

Data analysis

Descriptive statistics summarized patient demographics, intraoperative details, and postoperative outcomes. The Wilcoxon signed-rank test was used to compare pre- and postoperative NOSE and ROE scores, and A-B line measurements. A p-value of < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 26.

Demographic Characteristics

The study included 30 participants (12 men (40%) and 18 women (60%) (Figure 1a). Most participants (56.7%) were aged 18-29, followed by 40% in the 30-49 age range, and one participant (3.3%) was aged 50 years. The majority of nasal deformities were posttraumatic (63.3%), with congenital deformities accounting for 36.7%. The median duration of nasal deformity was 5.5 years (range: 1-40 years) (Table 1).

Table 1: Demographic Characteristics of the Study Population

Demographic Characteristics	No.	%
Sex
Female	18	60
Male	12	40
Age group
18-29	17	56.7
30-49	12	40
≥ 50	1	3.3
Median age (IQR)	28.5 (19-50)
Etiology of the deformity
Post Trauma	19	63.3
Congenital	11	36.7
Duration of nasal deformity (years)
Median (IQR)	5.5(1-40)

Note: Categorical variables were analyzed by frequency and percentages; continuous variables were expressed by Median (Interquartile Range) or Mean ± SD based on their normality distribution.

Abbreviations: No.: number of patients; %: Percentage; IQR: Interquartile Range.

Preoperative Assessment

Preoperatively, 43.3% of participants had moderate NOSE scores, 26.7% severe, 20% extreme, and 10% mild, with a mean NOSE score of 52.8 ±22.2 and a median of 50 (range: 25-95). The preoperative A-B line had a mean of 16.75 mm (range: 16-18 mm). The mean amount of injected diced cartilage was 1.2 ml (range: 1-2 ml). ROE scores showed 40% of participants in both the acceptable and good categories, 13.3% excellent, and 6.7% poor, with a mean score of 50 ±19.5 and a median of 52 (range: 21-79) (Table 2).

Table 2: Preoperative Assessment in Rhinoplasty of Study Participants

Preoperative Variable	No.	%
NOSE Score Category
Mild (5‑ < 25)	3	10.0
Moderate (30‑ < 50)	13	43.3
Severe (55‑ < 75)	8	26.7
Extreme (80‑100)	6	20.0
Overall NOSE Score
Mean ± SD	52.8 ±22.2
Median (IQR)	50 (25-95)
A-B line (mm)
Median (IQR)	16.75(16-18)
Amount of diced cartilage injected (ml)
Median (IQR)	1.2(1-2)
ROE Score Categories
Poor (0‑25)	2	6.7
Acceptable (25‑ < 50)	12	40.0
Good (50‑ < 75)	12	40.0
Excellent satisfaction (75‑100)	4	13.3
Preoperative ROE Score
Mean ± SD	50± 19.5
Median (IQR)	52(21-79)

Note: Categorical variables were analyzed by frequency and percentages; continuous variables were expressed by Median (Interquartile Range) or Mean ± SD based on their normality distribution.

Abbreviations: No.: Number of patients; %: Percentage; NOSE: Nasal Obstruction Symptom Evaluation; ROE: Rhinoplasty Outcome Evaluation; SD: Standard Deviation; IQR: Interquartile Range.

Postoperative Complications

Postoperative complications were observed in 6.6% of patients. Specifically, nasal deviation occurred in 3.3% of the patients and was managed through reoperation and nasal correction. Another 3.3% of patients developed an infection, which was managed conservatively (Table 3).

Table 3:Postoperative Complications and Management Strategies

Variable	No.	%	Management
Postoperative complications	2	6.6%
Nasal deviation	1	3.3%	Reoperation and nasal correction
Infection	1	3.3%	Conservative management

Postoperative Outcome Assessment

Postoperatively, the mean NOSE score significantly decreased to 5±5.1, with the A-B line measurements indicating increased nasal height (range: 20-23 mm). The mean dorsal height was 4.56 mm (range: 4-6 mm). ROE scores showed 3.3% of participants in the good category and 96.7% reporting excellent satisfaction, with a mean score of 93 ±7.93 and a median of 95.8 (range: 67-100) (Table 4).

Table 4: Postoperative Outcomes of the Study Participants (n=45)

Postoperative Variable	N	%
NOSE Score Category
Mild (5‑ < 25)	30	100.0
Overall NOSE Score
Mean ± SD	5±5.1
Median (IQR)	5(0-18)
A-B line (mm)
Median (IQR)	21)20-23)
Gained dorsal height (mm)
Median (IQR)	4.56(4-6)
ROE Score Categories
Good (50‑ < 75)	1	3.3
Excellent satisfaction (75‑100)	29	96.7
ROE Score
Mean ± SD	93±7.93
Median (IQR.)	95.8(67-100)

Note: Categorical variables were analyzed by frequency and percentages; continuous variables were expressed by Median (Interquartile Range) or Mean ± SD based on their normality distribution.

Abbreviations: No.: Number of patients; %: Percentage; NOSE: Nasal Obstruction Symptom Evaluation; ROE: Rhinoplasty Outcome Evaluation; SD: Standard Deviation; IQR: Interquartile Range.

Comparison between Preoperative and Postoperative Outcomes

Significant improvements were observed in preoperative vs. postoperative outcomes. The A-B line length increased from 16.75 mm to 21 mm (p = 0.002). The mean NOSE score decreased from 52.8 ±22.2 to 5 ±5.1 (p = 0.044), indicating reduced nasal obstruction symptoms. The mean ROE score increased from 50 ±19.5 to 93±7.93 (p = 0.001), reflecting higher patient satisfaction postoperatively (Table 5).

Table 5: Comparison of Preoperative and Postoperative Variables and Outcomes

Variable	Preoperative	Postoperative	P- value
A-B line (median, IQR)	16.75(16-18)	21)20-23)	0.002*
Total NOSE Score (mean ± SD)	52.8 ±22.2	5±5.1	0.044*
Total ROE Score (mean ± SD)	50± 19.5	93±7.93	0.001*

Note:* significant p value < 0.05 using Wilcoxon signed-rank test, to compare preoperative and postoperative variables.

NOSE: nasal obstruction symptom evaluation; ROE: rhinorrhagic outcome evaluation; SD: Standard Deviation; IQR: Interquartile Range.

Case 1: A 33-year-old female presented with a congenital saddle-shaped nose, deviated nasal septum, and short nasal septum since childhood. The preoperative A-B line measurement was 17 mm. Intraoperatively, 1 ml of diced cartilage was injected. The postoperative A-B line measurement increased to 21 mm, resulting in a 4 mm gain in the dorsal height. However, the patient experienced nasal tip deviation postoperatively and subsequently underwent reoperation to correct the deviation (Figure 3).

Case 2: A 22-year-old male presented with post-traumatic nasal obstruction, dorsal nasal deformity (osseocartilaginous), and alar asymmetry for 1 year. The preoperative A-B line measurement was 17 mm. Intraoperatively, 2 ml of diced cartilage was injected. The postoperative A-B line measurement increased to 22 mm, resulting in a 5 mm gain in the dorsal height (Figure 4).

Case 3: A 27-year-old female patient presented with 1-year postnasal trauma with a flat nasal dorsum, droopy-wide nasal tip, and short columella. The preoperative A-B line measurement was 17 mm. Intraoperatively, 1 ml of diced cartilage was injected. The postoperative A-B line measurement increased to 21 mm, resulting in a gain of dorsal height by 4 mm (Figure 5).

Case 4: A 36-year-old female patient presented 2 years after nasal trauma with a saddle-shaped nose, drooping nasal tip, alar retraction, and small nose. The preoperative A-B line measurement was 16 mm. Intraoperatively, 1 ml of diced cartilage was injected. The postoperative A-B line measurement increased to 21 mm, resulting in a 5 mm gain in the dorsal height (Figure 6).

Case 5: A 40-year-old male presented with post-traumatic nasal obstruction, dorsal nasal collapse (osseocartilaginous), and a wide nasal tip. The preoperative A-B line measurement was 17 mm. Intraoperatively, 2 ml of diced cartilage was injected. The postoperative A-B line measurement increased to 22 mm, resulting in a 5 mm gain in the dorsal height (Figure 7).

Case 6: A 20-year-old female presented with a 4-year postnasal trauma with a saddle-shaped nose and short nose. She had a history of one previous septoplasty. The preoperative A-B line measurement was 16 mm. Intraoperatively, 1 ml of diced cartilage was injected. The postoperative A-B line measurement increased to 21 mm, resulting in a 5 mm gain in the dorsal height (Figure 8).

The findings of this study underscore the significant benefits and feasibility of the diced cartilage fascia (DCF) technique for rhinoplasty, especially in resource-limited and conflict-affected settings. The demographic distribution of the participants, with a majority of young adults and a higher percentage of females, aligns with previous studies reporting that rhinoplasty is often sought by younger populations to improve both functional and esthetic outcomes [14, 15].

Our study demonstrated a substantial improvement in nasal esthetics and function, as evidenced by the increase in A-B line measurements from a preoperative mean of 16.75 mm to a postoperative mean of 21 mm. These findings are consistent with those of previous studies highlighting the effectiveness of the DCF technique in enhancing nasal projection and contour. Calvert (2009) and Kreutzer et al. (2017) reported that DCF techniques are effective for smoothening, augmenting, and camouflaging the nasal dorsum[16, 17]. Additionally, the significant reduction in NOSE scores from 52.8 ± 22.2 to 5 ± 5.1 aligns with literature documenting the functional benefits of rhinoplasty, emphasizing the dual advantages of such procedures [18–20].

The high levels of patient satisfaction, with 96.7% of participants reporting excellent outcomes, reflect the overall success of the DCF technique. This level of satisfaction was corroborated by the substantial increase in ROE scores from 50 ± 19.5 to 93 ± 7.93, indicating that patients not only perceived esthetic improvements but also experienced a significant enhancement in their quality of life. Several previous studies have supported these findings, showing significant improvements in patient-reported outcomes using various assessment tools like the ROE and FACE-Q scales[21–23]. The higher satisfaction levels among younger patients and female patients are consistent with the observations of Khansa et al. (2016) and Yang et al. (2017) [22, 24].

The low complication rate of 7%, with issues such as nasal deviation and infection being manageable, aligns with the existing literature on the efficacy and safety of DCF. Li et al. (2021) reported an overall complication rate of 11.5% for DCF grafts, with infection and visible irregularity being the most common complications[25]. Compared with other grafting techniques, such as irradiated homologous and autologous costal cartilage grafting, the DCF technique demonstrates comparable or lower complication rates, further supporting its reliability [26, 27]. The low risk of graft resorption and displacement, as noted by Gerbault and Aiach (2009) and Keyhan et al. (2021) [28, 29], enhances the safety profile.

Post-traumatic nasal deformities are prevalent among patients seeking rhinoplasty, with up to 50% of nasal fracture patients potentially requiring reconstructive surgery [30, 31]. This study's finding that 63.3% of nasal deformities were post-traumatic underscores the significant impact of trauma on nasal structure. The high success rate in post-traumatic rhinoplasty, with 90.5% to 94% of patients reporting satisfaction with both appearance and function postoperatively, is supported by Low et al. (2009) and Gilbert (1987)[32, 33]. Addressing key nasal regions, such as the septum, internal nasal valves, and inferior turbinate, is crucial for optimal outcomes [33].

The effectiveness of DCF in increasing dorsal projection and its utility in secondary Rhinoplasty with depleted donor sites or poor-quality cartilage are well documented [28]. This method's adaptability and versatility make it suitable for complex post-traumatic cases, contributing to high patient satisfaction [34].

The adaptability and cost-effectiveness of DCF make it particularly suitable for resource-limited settings where access to various surgical materials and technologies may be restricted. The ability to use locally sourced cartilage reduces the need for extensive resources, thus enhancing the feasibility of cartilage harvesting in such environments. The versatility of this technique in addressing various nasal defects, including severe nasal saddles, supports its use in diverse clinical scenarios [28, 35].

Recent advancements in rhinoplasty, such as computer-assisted planning and execution incorporating 3D imaging and virtual planning, can enhance the predictability of outcomes in complex cases [36]. However, the fundamental principles of DCF remain highly relevant and effective even without access to advanced technologies. Other reconstructive techniques, such as microsurgical free flaps and dermal regeneration templates, also offer viable options for nasal reconstruction in resource-limited settings [37, 38].

The challenges and opportunities associated with performing rhinoplasty in resource-constrained settings have been explored in various studies. Eberlin et al. discussed cleft lip repair with primary rhinoplasty under local anesthesia as an applicable technique in resource-poor settings [39], and Sinha et al. advocated single-stage reconstruction techniques to accommodate patient preferences in such environments [40]. Our study contributes to this literature by presenting the DCF technique as a viable and advantageous option for correcting saddle nose deformity, particularly due to its use of autologous tissue and minimal donor site morbidity.

Despite the strengths and contributions of this study, several limitations should be acknowledged. The generalizability of our findings may be limited by the specific setting, and future research should explore outcomes in diverse environments. The modest sample size suggests the need for larger studies to confirm our results. Longer-term follow-up would provide more comprehensive insights into the durability and potential complications of DCF. The absence of a control group precludes direct comparisons, and no cost-effectiveness analysis was conducted. Addressing these limitations in future research will be essential for establishing the technique’s overall effectiveness and informing clinical decision-making.

Overall, the study findings affirm the efficacy and feasibility of the DCF technique for rhinoplasty in improving both nasal esthetics and function, achieving high patient satisfaction, and maintaining a low complication rate in resource-limited, conflict-affected settings. These findings contribute to a growing body of evidence supporting the use of advanced reconstructive techniques in diverse and challenging environments. Further research is needed to examine the outcomes of this technique in various settings, with larger samples, longer follow-up periods, and control groups.

ROE	Rhinoplasty outcome Evaluation
NOSE	Nasal Obstruction Symptom Evaluation
SPSS:	Statistical Package for the Social Sciences
SD	Standard Deviation

Acknowledgments

Not applicable.

Ethics approval and informed consent

Ethical approval for this study was obtained from the Ethics Committee of the affiliated hospitals in Sana'a, Yemen, in accordance with the 1964 Declaration of Helsinki and its subsequent amendments or comparable ethical standards. Informed consent was obtained from all participants.

Consent to publish the study

All patients provided written informed consent for study publication and any accompanying images. Measures were taken to exclude potential patient identifiers from the report.

Disclosure

The authors declare no conflicts of interest.

Competing of interest

Non-financial competing interests

Availability of data and materials
Data are available from the corresponding author upon reasonable request.

Funding disclosure

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions

All authors contributed to the study's design, data collection, analysis, and manuscript preparation. All authors read and approved the final manuscript.

Authors' information (optional)

Not applicable.

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The authors declare no competing interests.

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Saddle Nose Deformity Reconstruction in Yemen: A Prospective Study of the Diced Cartilage Fascia Technique

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Abstract

Figures

Background

Methods

Study Design and Settings

Patient Selection

Surgical Technique

Preoperative Assessment and Planning

Intraoperative Steps

Postoperative Steps

Data Collection

Outcome Measures

Outcome Assessment

Data analysis

Results

Demographic Characteristics

Preoperative Assessment

Postoperative Complications

Postoperative Outcome Assessment

Comparison between Preoperative and Postoperative Outcomes

Case Presentations

Discussion

Conclusion

Abbreviations

Declarations

Acknowledgments

Ethics approval and informed consent

Consent to publish the study

Disclosure

Competing of interest

Availability of data and materials Data are available from the corresponding author upon reasonable request.

Funding disclosure

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References

Additional Declarations

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Availability of data and materials
Data are available from the corresponding author upon reasonable request.