Complications of the nasal dorsum reconstruction using autologous or alloplastic grafts: evidence from systematic review and meta-analysis

Jibril Y. Hudise Saud A. Aldhabaan Badi F. Aldosari About the authors

Abstract

Introduction

Augmentation rhinoplasty depends mainly on intact stable bony and cartilaginous parts. Many trials have used different materials as a graft to perform the operation and support the nose. Debate exists whether alloplastic or autogenic grafts are more appropriate. Common available alloplastic grafts include silicone, medpor, and gore-tex. Autogenic grafts are usually derived from costal cartilages. Warping, infection, and hypertrophic scars are the main complications of the procedure. Yet no subgroup analysis has been performed to investigate the effect of different risk factors.

Objective

To investigate the effect of different types of grafts and the association of the income level of the country on surgery complications.

Methods

A comprehensive literature search of articles was conducted in PubMed, Cochrane Library, Web of Science, and SCOPUS databases through October 2019. We included articles that used autologous or alloplastic grafts in nasal dorsum reconstruction surgery. We performed subgroup analysis according to the type of graft used, region, and income level of the country. A meta-regression analysis model was carried out from the period of 1999-2018, to study the incidence of these complications over time.

Results

The overall complication rate was 7.1%, which was higher in the alloplastic group (7.8%) than the autogenic group (6.9%). The most common complications were secondary surgery for re-correction (4.1%), infection (2.1%), warping (1.6%), and hypertrophic scars (1.6%). All outcomes were homogeneous (I2 < 50%).

Conclusion

Patients with autogenic grafts are less liable to develop complications than their peers reconstructed with alloplastic grafts. Moreover, Asian patients are less susceptible to overall rhinoplasty complications. Attention should be noted for low-income countries in which surgical complications are more prone to occur.

Keywords
Complication; Nasal dorsum; Reconstruction; Autologous; Alloplastic grafts

Resumo

Introdução

A feitura de uma rinoplastia de aumento depende principalmente das partes ósseas e cartilaginosas intactas. Muitos estudos usaram enxertos de diferentes materiais para a feitura da cirurgia e como apoio da estrutura nasal. Ainda existem controvérsias em estudos prévios sobre quais tipos de enxertos, se materiais aloplásticos ou autogênicos, seriam os mais adequados. Os enxertos aloplásticos comuns incluem silicone, medpor e gore-tex. Os enxertos autogênicos são geralmente derivados de cartilagens costais. Deformações, infecção e cicatrizes hipertróficas são as principais complicações do procedimento. No entanto, nenhuma análise de subgrupo foi feita para investigar o efeito de diferentes fatores de risco.

Objetivo

Investigar o efeito de diferentes tipos de enxertos e o nível de renda do país nas complicações cirúrgicas

Método

Uma pesquisa abrangente de artigos na literatura foi feita nas bases de dados PubMed, Cochrane Library, Web of Science e SCOPUS até outubro de 2019. Foram incluídos artigos que usaram enxertos autólogos ou aloplásticos em cirurgias de reconstrução do dorso nasal. Foi feita uma análise de subgrupos de acordo com o tipo de enxerto usado, região e nível de renda do país. Um modelo de análise de metarregressão foi feito de 1999 a 2018, para estudar a incidência dessas complicações ao longo do tempo.

Resultados

A taxa global de complicações foi de 7,1%, a qual foi maior no grupo aloplástico (7,8%) do que no grupo autogênico (6,9%). As complicações mais comuns foram cirurgia secundária para recorreção (4,1%), infecção (2,1%), deformidade (1,6%) e cicatrizes hipertróficas (1,6%). Todos os resultados foram homogêneos (I2 < 50%).

Conclusão

Os pacientes com enxertos autogênicos são menos propensos a desenvolver complicações, em comparação com seus pares com enxertos aloplásticos. Além disso, pacientes asiáticos são menos suscetíveis a complicações gerais da rinoplastia. Merece atenção o fato de que em países de baixa renda as complicações cirúrgicas são mais propensas a ocorrer.

Palavras-chave
Complicação; Dorso nasal; Reconstrução; Autólogo; Enxertos aloplásticos

Introduction

Rhinoplasty is the most common cosmetic surgery. Correction of nasal septal deformity is a challenge for aesthetic surgeons to provide the best shape of both the bony and cartilaginous frameworks of the nose with minimal complications.11 Loghmani S, Loghmani S, Baghi H, Hoghoughi MA, Dalvi F. Demographic characteristics of patients undergoing rhinoplasty: a single center two-time-period comparison. World J Plast Surg. 2017;6:275-9. Materials for reconstruction include autogenic and alloplastic grafts.22 Gunter JP, Cochran CS, Marin VP. Dorsal augmentation with autogenous rib cartilage. Semin Plast Surg. 2008;22:74-89. Autogenic transplantation of costal cartilage grafts is characterized by fewer infections, patient safety, and mild immunological response.33 Moretti A, Sciuto S. Rib grafts in septorhinoplasty. Acta Otorhinolaryngol Ital. 2013;33:190. However, alloplastic grafts are better in terms of less warping, unlike costal cartilage grafts, which may absorb or warp during the period after surgery.44 Balaji SM. Costal cartilage nasal augmentation rhinoplasty: study on warping. Ann Maxillofac Surg. 2013;3:20-4. To overcome these difficulties, several techniques are used to minimize graft-related warping, the most frequent of which is delay grafting or immersing the graft in a solution before shaping or insertion.55 Adams JW, Rohrich RJ, Gunter JP, Clark CP, Robinson JJ. The rate of warping in irradiated and nonirradiated homograft rib cartilage: a controlled comparison and clinical implications. Plast Reconstr Surg. 1999;103:265-70.

Rhinoplasty is becoming more common among patients over 40 years.11 Loghmani S, Loghmani S, Baghi H, Hoghoughi MA, Dalvi F. Demographic characteristics of patients undergoing rhinoplasty: a single center two-time-period comparison. World J Plast Surg. 2017;6:275-9. For a cosmetic purpose, many women have been seeking for a diversity of beauty patterns. Although autogenic grafts are more commonly used than alloplastic grafts,66 Sajjadian A, Rubinstein R, Naghshineh N. Current status of grafts and implants in rhinoplasty: part I. Autologous grafts. Plast Reconstr Surg. 2010;125, 40e-9e. alloplastic grafts are widely preferable in Asia over autogenic grafts.77 Jin HR, Won TB. Rhinoplasty in the Asian patient. Clin Plast Surg. 2016;43:265-79.

Currently, there is a debate relating to the effect of rhinoplasty on quality of life. A prospective study of Hosseinzadeh et al., 2017 found that cosmetic rhinoplasty improves the quality of life of the patients.88 Hosseinzadeh K, Hamadzadeh H, Khorasani M, Jamshidi M. Health-related quality of life of persons after rhinoplasty: a longitudinal study among iranian population. J Clin Diagn Res. 2017;11:ZC60-2. Another study by Zojaji et al. 2014 reported that cosmetic rhinoplasty has no significant effect on general health and quality of life except for its psychological health advantages, independently on sex, age, marital, or educational status.99 Zojaji R, Keshavarzmanesh M, Arshadi HR, Baf MM, Esmaeilzadeh S. Quality of life in patients who underwent rhinoplasty. Facial Plast Surg. 2014;30:593-6.

Complications of rhinoplasty are different according to ethnic and regional factors. Rhinoplasty of the bulbous and saddle nose is a standard aesthetic procedure in Asian countries.1010 Lin J, Tan X, Chen X, Lin J, Shi S, Tian F, et al. Another use of the alar cartilaginous flap. Aesthetic Plast Surg. 2006;30:560-3. The Asian nose is characterized by tight skin, with weak and scant cartilage. This results in increased frequency of the bulbous tip, small nose, and a short nose. It is not easy to shape straight cartilage from a curved rib.1111 Lopez MA, Shah AR, Westine JG, O’Grady K, Toriumi DM. Analysis of the physical properties of costal cartilage in a porcine model. Arch Facial Plast Surg. 2007;9:35-9. The conventional way to correct saddle noses is to insert an implant into the subperiosteal pocket, which can lead to a severe postoperative complication.1010 Lin J, Tan X, Chen X, Lin J, Shi S, Tian F, et al. Another use of the alar cartilaginous flap. Aesthetic Plast Surg. 2006;30:560-3.

The systematic review of Varadharajan and his colleagues found that autologous costal cartilage rhinoplasty is associated with significant side effects as pneumothorax, pleural tear, and most commonly, warping.1212 Varadharajan K, Sethukumar P, Anwar M, Patel K. Complications associated with the use of autologous costal cartilage in rhinoplasty: a systematic review. Aesthetic Surg J. 2015;35:644-52. In another review, Lee et al.,1313 Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg. 2011;128:538-50. found that the use of alloplastic materials leads to more extrusion and displacement. These side effects are more evident in the pediatric population; a recent review1414 Gupta A, Svider PF, Rayess H, Sheyn A, Folbe AJ, Eloy JA, et al. Pediatric rhinoplasty: a discussion of perioperative considerations and systematic review. Int J Pediatr Otorhinolaryngol. 2017;92:11-6. found that young children experience more revisions than adults.

A previous retrospective study compared two alloplastic grafts; gore-tex and medpor and found an increase in infection rates in the latter group; however, the topic lacks research about essential factors that may play a role in modifying surgery results. These factors may include ethnic factors, as the Asian nose is more common for rhinoplasty than other non-caucasian noses.1515 Matory WE, Falces E. Non-Caucasian rhinoplasty: a 16-year experience. Plast Reconstr Surg. 1986;77:239-52. Another factor is the type of graft used, whether alloplastic or autogenic. The income of the country may play a role in the quality of surgery on an individual basis.

Therefore, we present this systematic review and subgroup analyses to investigate the effect of different types of grafts and the income of the country on surgery complications and to compare patients in terms of study setting to explore if the people living in Asia will show different results than people from Europe. We also investigated the time factor from 1999 to 2018 through a meta-regression model to examine if the complications of surgeries have improved over time.

Methods

Search strategy and study selection

The study process was conducted following the accepted methodology recommendations of the PRISMA checklist for systematic review and meta-analysis where registration of the protocol is not mandated.1616 Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62. We searched PubMed, Scopus, Web of Science, Virtual Health Library (VHL), Google Scholar, and Cochrane databases. The search was done using the following search strategy “(nasal reconstruction OR rhinoplasty OR nasal augmentation OR nasal reconstruction OR nasal dorsum reconstruction OR nasal plastic surgery) AND (alloplastic implant OR nasal implants silicone OR Medpor OR Gore-Tex) AND (costal OR costal cartilage OR rib OR osteocartilaginous rib graft).

We marked studies as included if they met the following criteria: 1) Study design: Clinical trials: comparative or non-comparative; randomized or not randomized clinical trials; 2) Population: patients who underwent nasal dorsum reconstruction; 3) Intervention: rhinoplasty using autologous graft (autologous costal cartilage) or alloplastic grafts; 4) Outcome: at least one of the surgery-related complications. We excluded studies in the following conditions: 1) Observational or retrospective studies; 2) Studies of homologous rib graft; 3) Animal studies, in vitro studies, review articles, case reports, conference abstracts, and duplicate publications.

Data extraction

Two authors performed the extraction sheet on Microsoft Excel file by pilot extraction of at least three papers. Three reviewers independently extracted data from included studies using the excel sheet. The fourth reviewer performed data checking for checking the accuracy of the extracted data. All the disagreements and discrepancies were resolved by discussion and consultation with a senior member when necessary.

Risk of bias assessment

We performed the risk of bias assessment using ROBINS-1 (Risk of bias in non-randomized studies of interventions) tool. It includes the following domains: 1) Bias due to confounding; 2) Bias in selection of participants into the study; 3) Bias in classification of interventions; 4) Bias due to deviations from intended interventions; 5) Bias due to missing data; 6) Bias in the measurement of outcomes, and 7) Bias in the selection of the reported result. Studies are marked to either low, moderate, or high risk of bias according to each domain.

Statistical analysis

We used OpenMeta [Analyst] Software (Center of Evidence-Based Medicine, Brown University, School of Public Health, Rhode Island State, USA) to perform the meta-analysis of all outcomes. The mean proportions of complication rates were pooled in a meta-analysis model, using the Mantel-Haenszel method. The analysis was performed under the fixed-effects model for homogeneous data, and the random-effects model for heterogeneous data. The corresponding 95% Confidence Intervals (95% CI) of pooled effect size were calculated using a random-effects due to the presence of heterogeneity.

Heterogeneity was assessed with Q statistics and I2 test considering it significant with I2 value > 50%.1717 Cakmak O. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch Facial Plast Surg. 2002;4:172-6. Publication bias could not be assessed using Egger’s regression test due to the small number of included studies (less than 10).1818 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.,1919 Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey A. Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction. J Craniofac Surg. 2007;18:47. The publication bias was assessed using Egger’s regression test1818 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.,1919 Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey A. Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction. J Craniofac Surg. 2007;18:47. and represented graphically by Begg’s funnel plot2020 Al-Qattan MM. Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg. 2007;59:642-4. when there were ten or more studies. Egger’s regression test p-value <0.10 was considered significant. Whenever publication bias was found, the trim and fill method of Duvall and Tweedie was applied to add studies that appeared to be missing2121 Baek RM, Eun SC, Heo CY, Min KH. Rhinoplasty using rib chondro-osseous graft in asian patients. J Craniofac Surg. 2010;21:1122-5. to enhance the symmetry. A meta-regression model was done to correlate the time of surgery and the occurrence of different complications.

Results

Results of the literature search

Our search yielded a total of 789 studies. Following screening and excluding duplicates, 40 studies remained that entered full-text screening. We excluded 10 studies due to either lack of outcomes or studies of non-human species. Finally, 30 studies were included in the meta-analysis, as reported in the PRISMA flow diagram, Fig. 1.

Figure 1
PRISMA flow diagram.

Summary of included studies

We included 30 studies, two of which were controlled trials; therefore, we treated each group as a separate study for feasibility in performing a single-arm meta-analysis. Autogenic grafts were used in 21 studies, while 10 studies used alloplastic grafts. One study used a combination of alloplastic and autogenic grafts.2222 Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6. A total of 1013 patients were enrolled in this meta-analysis, with a mean age of 27.7 years, and a mean duration of follow-up after surgery of 22 months. Table 1 shows a summary of baseline characteristics for each study.

Table 1
Summary of included studies.

Results of risk of bias assessment

We reported an overall low risk of bias according to the ROBINS-1 tool. All studies had a low risk of confounding bias, the bias in classification of interventions, bias due to deviations from intended interventions, the bias in the measurement of outcomes, and bias in the selection of the reported result. Nine studies2323 Draf W, Bockmühl U, Hoffmann B. Nasal correction in maxillonasal dysplasia (Binder’s syndrome): a long term follow-up study. Br J Plast Surg. 2003;56:199-204.

24 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.

25 Kayabasoglu G, Nacar A, Yilmaz MS, Altundag A, Cayonu M, Guven M. A novel method for nasal dorsal reconstruction: permanent fixation using Kirschner wire-guided hidden sutures. J Craniofac Surg. 2015;26:881-4.

26 Lee SJ, Rho BI, Nam SM, Lee SJB, Park ES. Changes in implant thickness after rhinoplasty using surgiform. Arch Aesthetic Plast Surg. 2018;24:1.

27 Swaroop GS, Reddy JS, Mangal MC, Gupta A, Nanda BS, Jhunjhunwala N. Autogenous control augmentation system a refinement in diced cartilage glue graft for augmentation of dorsum of nose. Indian J Plast Surg. 2018;51:202.

28 Tastan E, Sozen T. Oblique split technique in septal reconstruction. Facial Plast Surg. 2013;29:487 91.

29 Turegun M, Acarturk TO, Ozturk S, Sengezer M. Aesthetic and functional restoration using dorsal saddle shaped medpor implant in secondary rhinoplasty. Ann Plast Surg. 2008;60:600 3.

30 Türegün M, Engezer M, Güler M. Reconstruction of saddle nose deformities using porous polyethylene implant. Aesthetic Plast Surg. 1998;22:38 41.
-3131 Taştan E, Yücel ÖT, Aydın E, Aydoğan F, Beriat K, Ulusoy MG. The oblique split method: a novel technique for carving costal cartilage grafts. JAMA Facial Plast Surg. 2013;15:198 203. did not report enough baseline data about patients such as sex and mean age. Therefore, these studies marked a moderate risk of bias.

Regarding missing data, eight studies2525 Kayabasoglu G, Nacar A, Yilmaz MS, Altundag A, Cayonu M, Guven M. A novel method for nasal dorsal reconstruction: permanent fixation using Kirschner wire-guided hidden sutures. J Craniofac Surg. 2015;26:881-4.,2727 Swaroop GS, Reddy JS, Mangal MC, Gupta A, Nanda BS, Jhunjhunwala N. Autogenous control augmentation system a refinement in diced cartilage glue graft for augmentation of dorsum of nose. Indian J Plast Surg. 2018;51:202.,2828 Tastan E, Sozen T. Oblique split technique in septal reconstruction. Facial Plast Surg. 2013;29:487 91.,3030 Türegün M, Engezer M, Güler M. Reconstruction of saddle nose deformities using porous polyethylene implant. Aesthetic Plast Surg. 1998;22:38 41.,3232 Moher D, Liberati A, Tetzlaff J, Altman DG, Altman DG, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement (Chinese edition). Chin J Integr Med. 2009;7:889 96.

33 Kim YH, Kim BJ, Jang TY. Use of Porous High-Density Polyethylene (Medpor) for spreader or extended septal graft in rhinoplasty: aesthetics, functional outcomes, and long-term complications. Ann Plast Surg. 2011;67:464 8.
-3434 Li J, Huang Y, Zhang Y, Pu Z. Application of a porous polyethylene spreader graft for nasal lengthening in asian patients. Aesthetic Surg J. 2018;38:491 9. did not report necessary outcome endpoints to be included in a meta-analysis. We did not find any data for important complications of the surgery such as infection, therefore these studies were put to a high risk of bias. The risk of bias summary was of included studies was reported in Fig. 2.

Figure 2
Summary of risk of bias for included trials using ROBINS-1 tool.

Overall complication rates

The overall complication rate was 7.1% (95% CI 4.9%−9.3%) which was higher in the alloplastic grafts group 7.8%, (95% CI 4.1%−11.5%) than the autogenic group 6.9%, (95% CI 4.3%− 9.6%). There was no heterogeneity among the included studies (I2 = 47.6%) (Fig. 3). One study2222 Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6. used combined alloplastic and autogenic graft, therefore, it removed from the subgroup analysis by graft type.

Figure 3
Forest plot of total complications rate.

Prevalence of warping

The overall warping rate as reported by fifteen studies (530 participants) was 1.6% (95% CI 0.5%−2.6%). Four studies1616 Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62.,2424 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.,3535 Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.,3636 Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11. used alloplastic grafts and reported a prevalence rate of 1.6% (95% CI −0.5% to 3.7%), while in the autogenic group, the pooled proportion of warping as reported by ten studies1818 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.

19 Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey A. Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction. J Craniofac Surg. 2007;18:47.

20 Al-Qattan MM. Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg. 2007;59:642-4.
-2121 Baek RM, Eun SC, Heo CY, Min KH. Rhinoplasty using rib chondro-osseous graft in asian patients. J Craniofac Surg. 2010;21:1122-5.,2323 Draf W, Bockmühl U, Hoffmann B. Nasal correction in maxillonasal dysplasia (Binder’s syndrome): a long term follow-up study. Br J Plast Surg. 2003;56:199-204.,2828 Tastan E, Sozen T. Oblique split technique in septal reconstruction. Facial Plast Surg. 2013;29:487 91.,3333 Kim YH, Kim BJ, Jang TY. Use of Porous High-Density Polyethylene (Medpor) for spreader or extended septal graft in rhinoplasty: aesthetics, functional outcomes, and long-term complications. Ann Plast Surg. 2011;67:464 8.,3737 Agrawal KS, Bachhav M, Shrotriya R. Namaste (counterbalancing) technique: overcoming warping in costal cartilage. Indian J Plast Surg. 2015;48:123 8.

38 Shubailat GF. Cantilever rib grafting in salvage rhinoplasty. Aesthetic Plast Surg. 2003;27:281 5.
-3939 Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137:43-51. was 1.5% (95% CI 0.3%−2.8%) (Fig. 4).

Figure 4
Forest plot of warping outcome according to graft type.

Pooling the results from four studies of high-income countries,2121 Baek RM, Eun SC, Heo CY, Min KH. Rhinoplasty using rib chondro-osseous graft in asian patients. J Craniofac Surg. 2010;21:1122-5.,2323 Draf W, Bockmühl U, Hoffmann B. Nasal correction in maxillonasal dysplasia (Binder’s syndrome): a long term follow-up study. Br J Plast Surg. 2003;56:199-204.,3333 Kim YH, Kim BJ, Jang TY. Use of Porous High-Density Polyethylene (Medpor) for spreader or extended septal graft in rhinoplasty: aesthetics, functional outcomes, and long-term complications. Ann Plast Surg. 2011;67:464 8.,3737 Agrawal KS, Bachhav M, Shrotriya R. Namaste (counterbalancing) technique: overcoming warping in costal cartilage. Indian J Plast Surg. 2015;48:123 8. nine studies of middle-income countries,1616 Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62.

17 Cakmak O. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch Facial Plast Surg. 2002;4:172-6.

18 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.
-1919 Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey A. Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction. J Craniofac Surg. 2007;18:47.,2222 Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6.,2424 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.,2828 Tastan E, Sozen T. Oblique split technique in septal reconstruction. Facial Plast Surg. 2013;29:487 91.,3535 Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.,3636 Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11. and two low income studies revealed a prevalence rate of 1.7% (95% CI −0.5% to 3.9%), 1.7% (95% CI 0.3%−3.1%), and 1.0% (95% CI −1.0% to 2.9%), respectively (Fig. 5). Similarly, the mean proportion of warping rate from Asian studies1616 Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62.,2020 Al-Qattan MM. Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg. 2007;59:642-4.

21 Baek RM, Eun SC, Heo CY, Min KH. Rhinoplasty using rib chondro-osseous graft in asian patients. J Craniofac Surg. 2010;21:1122-5.
-2222 Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6.,3333 Kim YH, Kim BJ, Jang TY. Use of Porous High-Density Polyethylene (Medpor) for spreader or extended septal graft in rhinoplasty: aesthetics, functional outcomes, and long-term complications. Ann Plast Surg. 2011;67:464 8.,3535 Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.

36 Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11.

37 Agrawal KS, Bachhav M, Shrotriya R. Namaste (counterbalancing) technique: overcoming warping in costal cartilage. Indian J Plast Surg. 2015;48:123 8.
-3838 Shubailat GF. Cantilever rib grafting in salvage rhinoplasty. Aesthetic Plast Surg. 2003;27:281 5. was 1.3% (95% CI 0.2%−2.4%), while in European studies1616 Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62.

17 Cakmak O. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch Facial Plast Surg. 2002;4:172-6.

18 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.
-1919 Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey A. Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction. J Craniofac Surg. 2007;18:47.,2323 Draf W, Bockmühl U, Hoffmann B. Nasal correction in maxillonasal dysplasia (Binder’s syndrome): a long term follow-up study. Br J Plast Surg. 2003;56:199-204.,2424 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.,2828 Tastan E, Sozen T. Oblique split technique in septal reconstruction. Facial Plast Surg. 2013;29:487 91.,3636 Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11. was 2.4% (95% CI 0%−4.8%) (Fig. 6). Pooled studies, in all analyses, did not show any significant heterogeneity.

Figure 5
Forest plot of warping outcome according to country income level.

Figure 6
Forest plot of warping outcome according to the study sitting.

Prevalence of infection

The prevalence of infection was reported by 17 studies (578 patients). The overall infection rate of the nasal dorsum reconstruction surgery was 2.1% (95% CI 1.0%−3.3%). The alloplastic grafts were associated with higher infection rates of 3.7% (95% CI 0.4%−7.0%), compared to only 2.1% (95% CI 0.8%−3.4%) among autogenic grafts (Fig.7).

Figure 7
Forest plot of infection outcome according to graft type.

Rates of infection were lowest in high income countries with 1.8% (95% CI −0.3% to 3.9%), followed by middle, and low income countries, with 2.3% (95% CI 1%−3.3%), and 2.1% (95% CI −0.5% to 4.7%), respectively (Fig. 8). The results showed that according to patients’ regional country, nine Asian studies1616 Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62.,2020 Al-Qattan MM. Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg. 2007;59:642-4.

21 Baek RM, Eun SC, Heo CY, Min KH. Rhinoplasty using rib chondro-osseous graft in asian patients. J Craniofac Surg. 2010;21:1122-5.
-2222 Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6.,3535 Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.,3737 Agrawal KS, Bachhav M, Shrotriya R. Namaste (counterbalancing) technique: overcoming warping in costal cartilage. Indian J Plast Surg. 2015;48:123 8.,3838 Shubailat GF. Cantilever rib grafting in salvage rhinoplasty. Aesthetic Plast Surg. 2003;27:281 5.,4040 Riechelmann H, Rettinger G. Three-step reconstruction of complex saddle nose deformities. Arch Otolaryngol Neck Surg. 2004;130:334.,4141 Yazar M, Yazar SK, Sevim KZ, Kozanoglu E, Sirvan SS, Karsidag S, et al. Key and keyhole model for dorsal onlay cartilage grafts in correcting nasal deformities. Ann Plast Surg. 2015;75:418-23. showed lower infection rates of 1.8% (95% CI 0.4%−3.2%), compared to Eight European studies1717 Cakmak O. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch Facial Plast Surg. 2002;4:172-6.

18 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.
-1919 Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey A. Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction. J Craniofac Surg. 2007;18:47.,2323 Draf W, Bockmühl U, Hoffmann B. Nasal correction in maxillonasal dysplasia (Binder’s syndrome): a long term follow-up study. Br J Plast Surg. 2003;56:199-204.,2424 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.,3939 Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137:43-51.,4242 Green S, Higgins JP, Alderson P, Clarke M, Mulrow CD, Oxman AD. Cochrane handbook for systematic reviews of interventions: cochrane book series. Naunyn-Schmiedeberg’s Arch Exp Pathol Pharmakol. 2008;5:S38.,4343 Lee Y, Ham SB. Use of a temporoparietal fascia-covered silastic implant in nose reconstruction after foreign body removal. Plas Reconstr Surg. 1999;104. that showed an infection rate of 2.8% (95% CI 0.9%−4.8%) (Fig. 9). Pooled studies, in all analyses, did not show any significant heterogeneity.

Figure 8
Forest plot of infection outcome according to country income level.

Figure 9
Forest plot of infection outcome according to study sitting.

Hypertrophic scar

Eleven studies (405 patients) reported the prevalence rates of all scars. The overall pooled rate was 1.7% (95% CI 0.5%−2.9%), for both nose and chest scars. Subgroup analysis showed that prevalence of scars in autogenic grafts reported by six studies1818 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.,2020 Al-Qattan MM. Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg. 2007;59:642-4.,2323 Draf W, Bockmühl U, Hoffmann B. Nasal correction in maxillonasal dysplasia (Binder’s syndrome): a long term follow-up study. Br J Plast Surg. 2003;56:199-204.,3737 Agrawal KS, Bachhav M, Shrotriya R. Namaste (counterbalancing) technique: overcoming warping in costal cartilage. Indian J Plast Surg. 2015;48:123 8.,3939 Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137:43-51.,4242 Green S, Higgins JP, Alderson P, Clarke M, Mulrow CD, Oxman AD. Cochrane handbook for systematic reviews of interventions: cochrane book series. Naunyn-Schmiedeberg’s Arch Exp Pathol Pharmakol. 2008;5:S38. was 1.8% (95% CI 0.2%−3.4%), while in the alloplastic grafts, reported by four studies,2424 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.,3535 Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.,3636 Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11.,4444 Khorasani M, Janbaz P, Rayati F. Maxillofacial reconstruction with Medpor porous polyethylene implant: a case series study. J Korean Assoc Oral Maxillofac Surg. 2018;44:128. the scarring rate was 1.5% (95% CI −0.4% to 3.5%) (Fig. 10).

Figure 10
Forest plot of hypertrophic scars outcome according to graft type.

Stratifying studies according to countries, the scarring rate was the highest in low income countries with 9.8% (95% CI 1.6%−18%), followed by high income countries with 2.8% (95% CI −0.1% to 5.7%), and middle-income countries with 1.2% (95% CI −0% to 2.5%) (Fig. 11). The Asian studies reported higher scarring rates of 1.8% (95% CI 0.2%−3.4%) as reported in six studies.2020 Al-Qattan MM. Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg. 2007;59:642-4.,2222 Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6.,3535 Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.,3636 Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11.,3939 Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137:43-51.,4444 Khorasani M, Janbaz P, Rayati F. Maxillofacial reconstruction with Medpor porous polyethylene implant: a case series study. J Korean Assoc Oral Maxillofac Surg. 2018;44:128. European patients experienced 1.4% scar rates (95% CI −0.2% to 4.8%) as reported in five studies1818 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.,2323 Draf W, Bockmühl U, Hoffmann B. Nasal correction in maxillonasal dysplasia (Binder’s syndrome): a long term follow-up study. Br J Plast Surg. 2003;56:199-204.,2424 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.,3939 Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137:43-51.,4242 Green S, Higgins JP, Alderson P, Clarke M, Mulrow CD, Oxman AD. Cochrane handbook for systematic reviews of interventions: cochrane book series. Naunyn-Schmiedeberg’s Arch Exp Pathol Pharmakol. 2008;5:S38. (Fig. 12). Pooled studies, in all analyses, did not show any significant heterogeneity.

Figure 11
Forest plot of hypertrophic scars outcome according to country income level.

Figure 12
Forest plot of hypertrophic scars outcome according to study sitting.

Need for a second surgery for re-correction

A total of 19 studies (613 participants) reported the need for a second surgery. The overall rate of re-correction surgery was 4.1% (95% CI 2.5%−5.6%). Subgroup analysis showed that the need for a second surgery was higher in the autogenic grafts with 4.2% (95% CI 2.4%−6.1%), compared to the alloplastic grafts with 3.7% (95% CI 1.0%−6.4%) (Fig. 13).

Figure 13
Forest plot of need for a second surgery outcome according to graft type.

The middle-income countries reported the lowest need for second surgery with only 1.2% (95% CI 0%−25%),1616 Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62.,1818 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.,2222 Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6.,2424 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.,2525 Kayabasoglu G, Nacar A, Yilmaz MS, Altundag A, Cayonu M, Guven M. A novel method for nasal dorsal reconstruction: permanent fixation using Kirschner wire-guided hidden sutures. J Craniofac Surg. 2015;26:881-4.,2929 Turegun M, Acarturk TO, Ozturk S, Sengezer M. Aesthetic and functional restoration using dorsal saddle shaped medpor implant in secondary rhinoplasty. Ann Plast Surg. 2008;60:600 3.,3131 Taştan E, Yücel ÖT, Aydın E, Aydoğan F, Beriat K, Ulusoy MG. The oblique split method: a novel technique for carving costal cartilage grafts. JAMA Facial Plast Surg. 2013;15:198 203.,3232 Moher D, Liberati A, Tetzlaff J, Altman DG, Altman DG, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement (Chinese edition). Chin J Integr Med. 2009;7:889 96.,3434 Li J, Huang Y, Zhang Y, Pu Z. Application of a porous polyethylene spreader graft for nasal lengthening in asian patients. Aesthetic Surg J. 2018;38:491 9.

35 Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.
-3636 Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11.,3939 Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137:43-51.,4343 Lee Y, Ham SB. Use of a temporoparietal fascia-covered silastic implant in nose reconstruction after foreign body removal. Plas Reconstr Surg. 1999;104.,4545 Ma J, Wang K, Zhao X. Diced costal cartilage for augmentation rhinoplasty. Chin Med J. 2015;128. followed by high income country studies3333 Kim YH, Kim BJ, Jang TY. Use of Porous High-Density Polyethylene (Medpor) for spreader or extended septal graft in rhinoplasty: aesthetics, functional outcomes, and long-term complications. Ann Plast Surg. 2011;67:464 8.,4040 Riechelmann H, Rettinger G. Three-step reconstruction of complex saddle nose deformities. Arch Otolaryngol Neck Surg. 2004;130:334.,4242 Green S, Higgins JP, Alderson P, Clarke M, Mulrow CD, Oxman AD. Cochrane handbook for systematic reviews of interventions: cochrane book series. Naunyn-Schmiedeberg’s Arch Exp Pathol Pharmakol. 2008;5:S38.,4444 Khorasani M, Janbaz P, Rayati F. Maxillofacial reconstruction with Medpor porous polyethylene implant: a case series study. J Korean Assoc Oral Maxillofac Surg. 2018;44:128. 2.3% (95% CI 2.8%−9.5%), and low income countries 9.8% (95% CI 6.3%−27.8%), respectively (Fig. 14). Asian studies reported second surgery rates of 1.8% (95% CI 0.2%−3.4%) as reported by 11 studies,1616 Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62.,2222 Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6.,3232 Moher D, Liberati A, Tetzlaff J, Altman DG, Altman DG, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement (Chinese edition). Chin J Integr Med. 2009;7:889 96.,3333 Kim YH, Kim BJ, Jang TY. Use of Porous High-Density Polyethylene (Medpor) for spreader or extended septal graft in rhinoplasty: aesthetics, functional outcomes, and long-term complications. Ann Plast Surg. 2011;67:464 8.,3535 Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.,3636 Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11.,3838 Shubailat GF. Cantilever rib grafting in salvage rhinoplasty. Aesthetic Plast Surg. 2003;27:281 5.,4040 Riechelmann H, Rettinger G. Three-step reconstruction of complex saddle nose deformities. Arch Otolaryngol Neck Surg. 2004;130:334.,4444 Khorasani M, Janbaz P, Rayati F. Maxillofacial reconstruction with Medpor porous polyethylene implant: a case series study. J Korean Assoc Oral Maxillofac Surg. 2018;44:128.,4545 Ma J, Wang K, Zhao X. Diced costal cartilage for augmentation rhinoplasty. Chin Med J. 2015;128. while a lower rate was observed in the European studies 1.5% (95% CI 0.3%−2.7%) as reported by eight studies1818 Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.,2424 Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.,2525 Kayabasoglu G, Nacar A, Yilmaz MS, Altundag A, Cayonu M, Guven M. A novel method for nasal dorsal reconstruction: permanent fixation using Kirschner wire-guided hidden sutures. J Craniofac Surg. 2015;26:881-4.,2929 Turegun M, Acarturk TO, Ozturk S, Sengezer M. Aesthetic and functional restoration using dorsal saddle shaped medpor implant in secondary rhinoplasty. Ann Plast Surg. 2008;60:600 3.,3131 Taştan E, Yücel ÖT, Aydın E, Aydoğan F, Beriat K, Ulusoy MG. The oblique split method: a novel technique for carving costal cartilage grafts. JAMA Facial Plast Surg. 2013;15:198 203.,3939 Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137:43-51.,4242 Green S, Higgins JP, Alderson P, Clarke M, Mulrow CD, Oxman AD. Cochrane handbook for systematic reviews of interventions: cochrane book series. Naunyn-Schmiedeberg’s Arch Exp Pathol Pharmakol. 2008;5:S38.,4343 Lee Y, Ham SB. Use of a temporoparietal fascia-covered silastic implant in nose reconstruction after foreign body removal. Plas Reconstr Surg. 1999;104. (Fig. 15). Pooled studies, in all analyses, did not show any significant heterogeneity.

Figure 14
Forest plot of need for a second surgery outcome according to country income level.

Figure 15
Forest plot of need for a second surgery outcome according to study sitting.

Meta-regression

A meta-regression model was performed to correlate the date of surgery (from 1999 to 2018) with the occurrence of complications. We found no significant effect of surgery date on warping rates (p= 0.6), infection rates (p= 0.2), hypertrophic scars (p= 0.1), or the need for a second surgery showed (p= 0.1) (Fig. 16).

Figure 16
Meta-regression analysis.

Publication bias

This meta-analysis reported a significant publication bias in two outcomes: the need for a second surgery and hypertrophic scars (Fig. 17). The rest of the outcomes and subgroup comparisons did not show any similar funnel plot asymmetry, hence no risk of bias (Fig. 18).

Figure 17
Begg’s funnel plot shows significant publication bias.

Figure 18
Begg’s funnel plot shows non-significant publication bias.

Discussion

The present meta-analysis provides class 1 scientific evidence that the overall complications rate is less common in patients from Asia than in people living in Europe and that autogenic grafts have lower prevalence rates of overall complications. Moreover, patients from low income countries showed increased rates of infection, warping, and need for reoperation, in contrast to high income and middle income countries.

The literature is full of studies that support our results. A previous meta-analysis which included 10 studies found that alloplastic grafts are associated with an increased incidence of infection, warping, hypertrophic chest scarring, and resorption.4444 Khorasani M, Janbaz P, Rayati F. Maxillofacial reconstruction with Medpor porous polyethylene implant: a case series study. J Korean Assoc Oral Maxillofac Surg. 2018;44:128. They reported that the low number of included studies was their main limitation. In our study, we reported the results from 30 studies (1013 patients) and revealed that the rate of infection, warping, hypertrophic chest scarring, and resorption were 2.1%, 1.5%, 1.6%, and 4.1%, respectively.

Another meta-analysis of observational studies compared alloplastic with autogenic grafts in terms of complications. The study found that autogenic grafts carry the most benefits and least side effects.4646 Wee JH, Park MH, Oh S, Jin HR. Complications associated with autologous rib cartilage use in rhinoplasty: a meta-analysis. JAMA Facial Plast Surg. 2015;17:49. This supports our findings; we reported that the alloplastic grafts have a higher infection rate, compared to autogenic grafts (2.1%). Besides, the autogenic grafts require more frequent second surgeries (4.2%) than alloplastic grafts (3.7%).

Our results revealed a high rate of second surgery in patients from Asia; this is supported by the efforts of Matory and Falces1515 Matory WE, Falces E. Non-Caucasian rhinoplasty: a 16-year experience. Plast Reconstr Surg. 1986;77:239-52. in their research in 1986, where they show that Asian individuals have a weak osteocartilaginous framework that does not easily support grafting. A meta-analysis included autologous costal cartilage grafts showed that rhinoplasty is significantly associated with the incidence of pneumothorax, extrusion, seroma, and persistent donor site pain.1212 Varadharajan K, Sethukumar P, Anwar M, Patel K. Complications associated with the use of autologous costal cartilage in rhinoplasty: a systematic review. Aesthetic Surg J. 2015;35:644-52. In fact, from the 30 included trials, only two studies reported pain as a significant side effect. Lee et al. reported that synthetic silicone grafts show higher rates of complications.1313 Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg. 2011;128:538-50.

As expected, low income countries suffer from significant complications of surgery. Consistent with previous literature, middle income countries, that usually do not suffer from such complications,4747 Liang X, Wang K, Malay S, Chung KC, Ma J. A systematic review and meta-analysis of comparison between autologous costal cartilage and alloplastic materials in rhinoplasty. J Plast Reconstr Aesthetic Surg. 2018;71:1164-73.,4848 Iyer KS. Pediatric cardiac surgery in lowand middle-income countries - Fighting the odds. Ann Pediatr Cardiol. 2019;12:1-2. showed less complications compared to low income ones.

The age of patients plays an important role in the incidence of complications because the procedure is more difficult in the pediatric population than adults. Gupta et al. reported that pediatric rhinoplasty is associated with increased revision rates than adults.1414 Gupta A, Svider PF, Rayess H, Sheyn A, Folbe AJ, Eloy JA, et al. Pediatric rhinoplasty: a discussion of perioperative considerations and systematic review. Int J Pediatr Otorhinolaryngol. 2017;92:11-6.

Several limitations were observed in the previous meta-analyses: the relatively low number of included trials, lacked subgroup analysis to isolate different factors, low evidence of included studies, and significant heterogeneous outcomes. We considered these critical limitations during the preparation of our meta-analysis.

Our study has many strong points, mainly derived from the limitations of previous works. We performed a comprehensive search that included a large number of studies to provide stronger evidence. Additionally, we included only clinical trials for this meta-analysis. The analyzed data were homogeneous as assessed by I2 test. Finally, we added new evidence through our subgroup analyses and meta-regression.

The main limitation we encountered was a lack of data in some studies. Many included studies lacked reporting of important outcomes as warping and infection. Other studies provided data in a manner not suitable for entering in a meta-analysis. The low sample size for each study is an important limitation that should be taken into consideration as well. The studies from low income countries were limited so, it may bias the results and gives underestimation of the actual rates. We recommend future trials with large sample size to adequately assess all relevant outcomes.

In conclusion, patients with autogenic grafts are less liable to develop complications, when compared to their peers with alloplastic grafts. Moreover, Asian patients are less susceptible to overall rhinoplasty complications. Attention should be noted to the fact that in low income countries, surgical complications are more prone to occur.

Acknowledgement

We would like to thank King Saud university, College of Medicine. and King Faisal Medical City of Southern Region for their great support of the scientific researches.

  • Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.

References

  • 1
    Loghmani S, Loghmani S, Baghi H, Hoghoughi MA, Dalvi F. Demographic characteristics of patients undergoing rhinoplasty: a single center two-time-period comparison. World J Plast Surg. 2017;6:275-9.
  • 2
    Gunter JP, Cochran CS, Marin VP. Dorsal augmentation with autogenous rib cartilage. Semin Plast Surg. 2008;22:74-89.
  • 3
    Moretti A, Sciuto S. Rib grafts in septorhinoplasty. Acta Otorhinolaryngol Ital. 2013;33:190.
  • 4
    Balaji SM. Costal cartilage nasal augmentation rhinoplasty: study on warping. Ann Maxillofac Surg. 2013;3:20-4.
  • 5
    Adams JW, Rohrich RJ, Gunter JP, Clark CP, Robinson JJ. The rate of warping in irradiated and nonirradiated homograft rib cartilage: a controlled comparison and clinical implications. Plast Reconstr Surg. 1999;103:265-70.
  • 6
    Sajjadian A, Rubinstein R, Naghshineh N. Current status of grafts and implants in rhinoplasty: part I. Autologous grafts. Plast Reconstr Surg. 2010;125, 40e-9e.
  • 7
    Jin HR, Won TB. Rhinoplasty in the Asian patient. Clin Plast Surg. 2016;43:265-79.
  • 8
    Hosseinzadeh K, Hamadzadeh H, Khorasani M, Jamshidi M. Health-related quality of life of persons after rhinoplasty: a longitudinal study among iranian population. J Clin Diagn Res. 2017;11:ZC60-2.
  • 9
    Zojaji R, Keshavarzmanesh M, Arshadi HR, Baf MM, Esmaeilzadeh S. Quality of life in patients who underwent rhinoplasty. Facial Plast Surg. 2014;30:593-6.
  • 10
    Lin J, Tan X, Chen X, Lin J, Shi S, Tian F, et al. Another use of the alar cartilaginous flap. Aesthetic Plast Surg. 2006;30:560-3.
  • 11
    Lopez MA, Shah AR, Westine JG, O’Grady K, Toriumi DM. Analysis of the physical properties of costal cartilage in a porcine model. Arch Facial Plast Surg. 2007;9:35-9.
  • 12
    Varadharajan K, Sethukumar P, Anwar M, Patel K. Complications associated with the use of autologous costal cartilage in rhinoplasty: a systematic review. Aesthetic Surg J. 2015;35:644-52.
  • 13
    Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg. 2011;128:538-50.
  • 14
    Gupta A, Svider PF, Rayess H, Sheyn A, Folbe AJ, Eloy JA, et al. Pediatric rhinoplasty: a discussion of perioperative considerations and systematic review. Int J Pediatr Otorhinolaryngol. 2017;92:11-6.
  • 15
    Matory WE, Falces E. Non-Caucasian rhinoplasty: a 16-year experience. Plast Reconstr Surg. 1986;77:239-52.
  • 16
    Li Q, Weng R, Gu B, Liu K, Shen G, Xie F, et al. Anchor-shaped nasal framework designed for total nasal reconstruction. J Plast Reconstr Aesthetic Surg. 2010;63:954-62.
  • 17
    Cakmak O. The versatile autogenous costal cartilage graft in septorhinoplasty. Arch Facial Plast Surg. 2002;4:172-6.
  • 18
    Karaaltn MV, Batoglu-Karaaltn A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty. J Craniofac Surg. 2012;23:719-23.
  • 19
    Yilmaz M, Vayvada H, Menderes A, Mola F, Atabey A. Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction. J Craniofac Surg. 2007;18:47.
  • 20
    Al-Qattan MM. Augmentation of the nasal dorsum with autogenous costal cartilage using the ‘‘edge-on’’ technique. Ann Plast Surg. 2007;59:642-4.
  • 21
    Baek RM, Eun SC, Heo CY, Min KH. Rhinoplasty using rib chondro-osseous graft in asian patients. J Craniofac Surg. 2010;21:1122-5.
  • 22
    Wang H, Fan F, You J, Wang S. Combined silicone implant and cartilage grafts for augmentation rhinoplasty. J Craniofac Surg. 2013;24:494-6.
  • 23
    Draf W, Bockmühl U, Hoffmann B. Nasal correction in maxillonasal dysplasia (Binder’s syndrome): a long term follow-up study. Br J Plast Surg. 2003;56:199-204.
  • 24
    Gürlek A, Celik M, Fariz A, Ersöz-Öztürk A, Eren AT, Tenekeci G. The use of high-density porous polyethylene as a custom-made nasal spreader graft. Aesthetic Plast Surg. 2006;30:34-41.
  • 25
    Kayabasoglu G, Nacar A, Yilmaz MS, Altundag A, Cayonu M, Guven M. A novel method for nasal dorsal reconstruction: permanent fixation using Kirschner wire-guided hidden sutures. J Craniofac Surg. 2015;26:881-4.
  • 26
    Lee SJ, Rho BI, Nam SM, Lee SJB, Park ES. Changes in implant thickness after rhinoplasty using surgiform. Arch Aesthetic Plast Surg. 2018;24:1.
  • 27
    Swaroop GS, Reddy JS, Mangal MC, Gupta A, Nanda BS, Jhunjhunwala N. Autogenous control augmentation system a refinement in diced cartilage glue graft for augmentation of dorsum of nose. Indian J Plast Surg. 2018;51:202.
  • 28
    Tastan E, Sozen T. Oblique split technique in septal reconstruction. Facial Plast Surg. 2013;29:487 91.
  • 29
    Turegun M, Acarturk TO, Ozturk S, Sengezer M. Aesthetic and functional restoration using dorsal saddle shaped medpor implant in secondary rhinoplasty. Ann Plast Surg. 2008;60:600 3.
  • 30
    Türegün M, Engezer M, Güler M. Reconstruction of saddle nose deformities using porous polyethylene implant. Aesthetic Plast Surg. 1998;22:38 41.
  • 31
    Taştan E, Yücel ÖT, Aydın E, Aydoğan F, Beriat K, Ulusoy MG. The oblique split method: a novel technique for carving costal cartilage grafts. JAMA Facial Plast Surg. 2013;15:198 203.
  • 32
    Moher D, Liberati A, Tetzlaff J, Altman DG, Altman DG, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement (Chinese edition). Chin J Integr Med. 2009;7:889 96.
  • 33
    Kim YH, Kim BJ, Jang TY. Use of Porous High-Density Polyethylene (Medpor) for spreader or extended septal graft in rhinoplasty: aesthetics, functional outcomes, and long-term complications. Ann Plast Surg. 2011;67:464 8.
  • 34
    Li J, Huang Y, Zhang Y, Pu Z. Application of a porous polyethylene spreader graft for nasal lengthening in asian patients. Aesthetic Surg J. 2018;38:491 9.
  • 35
    Gu Y, Yu W, Jin Y, Chen H, Ma G, Chang SJ, et al. Safety and efficacy of cosmetic augmentation of the nasal tip and nasal dorsum with expanded polytetrafluoroethylene: a randomized clinical trial. JAMA Facial Plast Surg. 2018;20:277 83.
  • 36
    Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome: inferior turbinate reconstruction with medpor. Laryngoscope. 2013;123:1106 11.
  • 37
    Agrawal KS, Bachhav M, Shrotriya R. Namaste (counterbalancing) technique: overcoming warping in costal cartilage. Indian J Plast Surg. 2015;48:123 8.
  • 38
    Shubailat GF. Cantilever rib grafting in salvage rhinoplasty. Aesthetic Plast Surg. 2003;27:281 5.
  • 39
    Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg. 2016;137:43-51.
  • 40
    Riechelmann H, Rettinger G. Three-step reconstruction of complex saddle nose deformities. Arch Otolaryngol Neck Surg. 2004;130:334.
  • 41
    Yazar M, Yazar SK, Sevim KZ, Kozanoglu E, Sirvan SS, Karsidag S, et al. Key and keyhole model for dorsal onlay cartilage grafts in correcting nasal deformities. Ann Plast Surg. 2015;75:418-23.
  • 42
    Green S, Higgins JP, Alderson P, Clarke M, Mulrow CD, Oxman AD. Cochrane handbook for systematic reviews of interventions: cochrane book series. Naunyn-Schmiedeberg’s Arch Exp Pathol Pharmakol. 2008;5:S38.
  • 43
    Lee Y, Ham SB. Use of a temporoparietal fascia-covered silastic implant in nose reconstruction after foreign body removal. Plas Reconstr Surg. 1999;104.
  • 44
    Khorasani M, Janbaz P, Rayati F. Maxillofacial reconstruction with Medpor porous polyethylene implant: a case series study. J Korean Assoc Oral Maxillofac Surg. 2018;44:128.
  • 45
    Ma J, Wang K, Zhao X. Diced costal cartilage for augmentation rhinoplasty. Chin Med J. 2015;128.
  • 46
    Wee JH, Park MH, Oh S, Jin HR. Complications associated with autologous rib cartilage use in rhinoplasty: a meta-analysis. JAMA Facial Plast Surg. 2015;17:49.
  • 47
    Liang X, Wang K, Malay S, Chung KC, Ma J. A systematic review and meta-analysis of comparison between autologous costal cartilage and alloplastic materials in rhinoplasty. J Plast Reconstr Aesthetic Surg. 2018;71:1164-73.
  • 48
    Iyer KS. Pediatric cardiac surgery in lowand middle-income countries - Fighting the odds. Ann Pediatr Cardiol. 2019;12:1-2.

Publication Dates

  • Publication in this collection
    27 June 2022
  • Date of issue
    May-Jun 2022

History

  • Received
    17 Feb 2020
  • Accepted
    04 July 2020
Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br