FIXATION OF NASAL BONE GRAFTS WITH INTEROSSEOUS WIRE: OUR TECHNIQUE - Dr. Nilam Sathe (Assistant Professor, Dept of ENT) - Dr. Ninad Gaikwad (Associate Professor, Dept of ENT) - Dr. Gaurav Wadkar (Senior ENT Resident) - Dr. Samir Thakare (Senior ENT Resident)

NAME OF AUTHOR DR. NILAM SATHE Department of ENT. Seth G. S. Medical College & K. E. M hospital, Parel, Mumbai ADDRESS FOR CORRESPONDENCE: DR. NILAM SATHE Yash Co-Op. Soceity 66/1748, Kannamwar Nagar No.2, Vikhroli (E) Mumbai – 400083 Ph. No. 02225782801 Mobile No. : 9821309298 E-mail ID : [email protected]

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STRUCTURED ABSTRACT Background:

Use of interosseous wire for bone graft fixation is

well known. We hereby describe a technique of fixation of iliac crest bone graft for nasal augmentation using a stainless steel wire. Method:

A hole in the cancellous part of the graft guides the

wire exactly in the groove in the cortical part, preventing slippage and ensuring rigid fixation. Secondly, as the wire is threaded through a hollow spinal needle passed underneath the skin envelop, a dorsal incision is avoided minimizing scarring, reducing the chances of graft exposure and improving the aesthetic result. Results:

This technique has two distinct advantages; preventing

slippage of the wire and avoiding a dorsal incision on the nose. Conclusions:

The method describes the use of an interosseous

wire for rigid bone graft fixation without a dorsal incision and also preventing slippage. It achieves good cosmetic results by improving the nasal contour with a cantilever effect that acts to raise the nasal tip. KEY WORDS: TECHNIQUE; NASAL BONE GRAFTS FIXATION; INTEROSSEOUS WIRE 2

TEXT INTRODUCTION:

Contour defects of the nose requiring dorsal augmentation are seen in patients with septal collapse following submucous resection (SMR), post traumatic defects and congenital deformities. Dorsal augmentation can be performed using alloplastic implants, cartilage grafts or bone grafts. However the material used for augmentation needs either a structural support or a stable bed to rest upon. For this reason depressions arising following submucous resection (SMR) are difficult to correct, as this structured support is missing in the lower half of the dorsum: the lack of structural support can be easily diagnosed as the supratip area sinks when pressed by the examining finger (Fig. 1). A bone graft fixed at the upper end is a reasonable solution for these deformities.

Graft fixation plays an important role in the final cosmetic outcome. Along with internal shaping it controls the 3

position of the graft and maintains a good alignment. It has been proved that to decrease the risk of resorption the fixation must be rigid with good bone-to-bone apposition1,

5,6,7,8,9,10.

Further the

recipient site should provide a good blood supply, immobility and functional stress on the graft4.

TECHNIQUE: The technique described below highlights the important aspects of preparation of the recipient site and graft, and graft fixation. Recipient Site Preparation For the preparation of the platform to receive the graft, bilateral alar rim incisions are taken. Through these incisions the skin - soft tissue envelop of the nose is degloved. Once the inferior edge of the nasal bones is reached, subperiosteal undermining is performed up to a slightly beyond the nasofrontal angle, so that the implant can be easily inserted upto that site and then manipulated retrogradely towards the nasal tip. The bony dorsum is rasped to 4

remove the remaining bits of periosteum and superficial layer of bone; thus providing a raw bed for bone-to-bone contact. Shaping the Graft Bone graft is harvested from the iliac crest. Carving of this cortico-cancellous iliac crest graft is done in such a fashion that the cortex is preserved on one side (the dorsal side) while the cancellous side is shaped to fit the defect using a no. 10 scalpel. With complementarily carving and shaping good bone-to-bone apposition is achieved avoiding a dead space. The now boat shaped graft should extend up to the tip and, depending on the nasal length, will be approximately 4 to 4.5 cm in length, 4 –6 mm in width with a thickness of 3-4 mm at the critical area where wire fixation is to be done (5 – 10 mm inferior to nasofrontal angle). At the site for wire fixation a groove is made on the anterior cortical aspect of the graft and just below this, a parallel hole is then bored into the cancellous portion using a 20-gauge needle. (Fig.2) The sculpted and prepared graft is inserted in the pocket for a trial of shape and stability. Pressure is placed cephalically in the radix area to replicate the eventual fixation and judge the cosmetic 5

result. Any additional modifications to the graft can then be made at this time. Graft Fixation Taking a small stab incision in the right medial canthal region a hole is drilled using a hand drill and a 16 no. spinal needle is then inserted in lieu of the drill bit.(Fig.3) The needle passes through the nasal bones and exits through the skin of at the opposite medial canthal region. A 24-gauge pre-stressed stainless steel wire; approximately 25 cm long, is then threaded through the needle while the needle is slowly withdrawn. (Fig.4) The spinal needle is now inserted underneath the skin envelop through the right side of the rim incision to the left medial canthal region. The leading end of the wire is guided through the spinal needle so that it now comes out through the rim incision on the right side of the columella. (Fig.5). The graft is then mounted onto the wire by passing the wire through the hole in the cancellous bone and the wire is then bent and passed over the groove on the anterior cortical surface that has been previously cut (Fig.6). The spinal needle is now bent to a minimum curvature and again passed 6

from the right stab incision in the right medial canthal region to the right alar rim incision and the wire guided through it (Fig.7). The wire is then slowly pulled through the medial canthal stab incision. Both ends of the wire are gradually pulled while the graft is inserted into the pocket and positioned on the nasal bone bed (Fig.8 a). The beveled graft tip projects beyond the nasal bones thus providing tip projection. The wire is then tightened putting stress on the graft in order to ensure adequate graft fixation - and the cut ends are buried in the soft tissue in the medial canthal region. (Fig.8 b) Wound Closure and Splintage The stab incisions do not require any suturing. The rim incision is sutured with a 4/0 absorbable suture. The nose is taped and a plaster of Paris splint is placed on the nose for protection and in order to ensure that there is no hematoma formation. It is removed after 3 weeks. The graft wire was not palpable. There was no infection. The wire is not submucosally located in the nose and may enter the nasal cavity: therefore it is not

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prone to infection in the long term. The patients were given antibiotics for two weeks. The wire did not fatigue in time.

RESULTS:

The technique has so far been used in 16 patients with post SMR supratip depression. The first 10 patients have a 5-year follow up. During this time augmentation has been maintained and a straight dorsal line has persisted. Routine plain x rays have shown no resorption of bone (Fig.9). The remaining patients have only a 2 year to 4 month follow up but there have been contour changes thus far. In all these patients we were able to achieve the desired aesthetic result; correcting the deformity and establishing a pleasant profile (Fig.10). As the graft projects beyond the nasal bones; the cantilever effect raises the tip (Fig.11).

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DISCUSSION:

Supratip depression following SMR presents a specific challenge, as there is no structural support for the augmentation material in the cartilaginous part. Cartilage graft or boat shaped implants cannot be used, as there is no underlying support to secure them. This necessitates the use of a bone graft fixed at one end or an L graft or implant1. The implants however cannot be rigidly fixed and have a chance of extrusion -especially in a previously operated and scarred nose 2, 3,5,6,14,15. Various methods have been described for fixation of a graft using lag screws, mini plates and screws, interosseous wiring and K wires. These techniques however are complicated, time consuming and have the potential for failure, be it early malposition, late resorption or poor contour restoration. Kirschner wires or no. 30 needles can be passed percutaneously through the bone graft and into the nasal bones. These are then incorporated in the dressing to be removed after a specified time period. However inadvertent removal in the early 9

post operative period leads to malposition of the graft and nonunion. Thus K wires are usually not used alone and are used along with another method of fixation2, 6, and 9. Ultra mini screws and plates are a popular method of graft fixation. They do produce a rigid fixation but they require a small incision on the dorsal skin for their insertion and the screws may occasionally be palpable in the frontonasal region5, 9. Lag screws have been used for cantilever grafts. However a single screw cannot provide a rigid fixation, as rotation around this screw is possible. Also it is a poor method of fixation for iliac crest bone grafts where the bone is fragile and the screw causes micro fractures and horizontal cracking of the bone as the screw tightens. In addition if the head is countersunk into the bone it weakens the bone further and has a risk of entry into the nasal cavity7. The use of interosseous wire for fixation has been previously described but the details of the technique are lacking. To negotiate a wire percutaneously from one canthal region, over the bone graft to the other canthal region and making it sit exactly in the groove is extremely difficult without a dorsal skin incision2. Thus this 10

method is complicated by the possibility of slippage of the wire resulting in a malposition of the graft .If a dorsal incision is taken to expose the nasal bones that would certainly facilitate passage of the wire but may also result in increased scarring, more chances of graft exposure and an inferior cosmetic result. Our method of graft fixation involves the use of interosseous wires too; however we avoid a dorsal incision by entangling the graft in the wire and by threading the wire through a hollow needle. As the graft has a parallel hole underneath the groove, it ensures that the wire sits exactly in the slot. The wire is not simply passed through the hole for fixation; as after tightening the wire, it would cut through the cancellous bone. Thus the hole is meant not to hold, but to guide the wire exactly in the groove above, and preventing slippage. As the wire is bent over into the groove, the brunt of compressive forces is borne by the strong cortical bone thus preventing the wire from cutting through. This rigid fixation of the bone graft allows better take. A second wire 5-6 mm distal to the first may also be used to increase stability. 11

Though calvarial bone grafts are superior in terms of lack of resorption4,

11, 13,

they have restricted shaping possibilities8. The

iliac crest provides an abundant source of cortico-cancellous bone graft. The graft can be surprisingly easily carved by a number 10 and 15 scalpel just like a wooden pencil is sharpened by a knife and sculptured into any desired shape and contour. It can also be polished by a number 15 blade to make the dorsum absolutely smooth. However a major problem with the use of an iliac crest bone graft is unpredictable resorption leading to loss of the initial augmentation, shape and volume. This can be prevented by rigid fixation and good bone-to-bone apposition. All other complications related to donor site morbidity are minimal.

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CONCLUSIONS:

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Thus use of interosseous wire is a good way of graft fixation and our technique describes how exactly to do it with ease; without a dorsal incision and preventing slippage.

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Although it has so far been used only for post SMR supra tip depressions with lack of support; its use can be extended for correction of saddle nose and posttraumatic deformities as well

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The long-term results of most of the patients are still awaited, yet the technique is easy, follows the principles of bone grafting and is associated with few complications.



It achieves good cosmetic results by improving the nasal contour, establishing a pleasing profile line and supporting and shaping the nasal tip.

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ACKNOWLEDGEMENT

We are thankful to our Dean and Director ME & MH, DR. SANJAY OAK for permitting us to publish this paper & to DR.D.S Grewal for his support.

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LIST OF REFRENCES: 1.

Sullivan P K , Varna M , Rozzelle A A ,Optimizing bone-graft nasal reconstruction: a study of nasal bone shape and thickness Plast Reconstr Surg. 1996 ; 97:327-35

2.

Stuzim J M , Kawamoto H K, Saddle nasal deformity Clin Plast Surg 1988;15:83

3.

Baser B , Shahani R , Khanna S, Grewal D S, Calvarial bone grafts for augmentation rhinoplasty J Laryngol Otol. 1991; 105:1018-20

4.

Smith J D , Abramson M , Membranous versus endochondral bone autografts Arch Otolaryngol ,1974;99:203

5.

Posnick J C, Seagle M B, Armstrong D, Nasal reconstruction with full- thickness cranial bone grafts and rigid internal skeleton fixation through a coronal incision. Plast Reconstr Surg 1990; 86:894-902

6.

Wheeler E S , Kawamoto H K, Zarem H A, Bone grafts for nasal reconstruction Plast Reconstr Surg 1982; 69:9-18

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7.

Gruss J S, Cantilever nasal bone grafting with miniscrew fixation Plast Reconstr Surg. 1989; 84:1014-5

8.

Daniel R K, Rhinoplasty and rib grafts: evolving a flexible operative technique. Plast Reconstr Surg 1994; 94:597-609

9.

Neu B R , Segmental bone and cartilage reconstruction of major nasal dorsal defects Plast Reconstr Surg.2000; 106:16070

10. Phillips J H , Rahn B A, Fixation effects on membranous and endochondral onlay bone graft resorption Plast Reconstr Surg 1988; 82:872 11. Zins J E , Whitaker L A, Membranous versus endochondral bone: Implications for craniofacial reconstruction Plast Reconstr Surg1983; 72:778 12. Habal M B, Bone grafting in craniofacial surgery Clin Plast Surg , 1994;21:349 13. Tessier P, Aesthetic aspects of bone grafting to face Clin Plast Surg , 1981;8:279 16

14. Tessier P, Autogenous bone grafts taken from the calvarium for facial and cranial applications Clin.

Plast Surg

,1982;9:531 15. Jackson I T, Smith J, and Mixter R C, Nasal bone grafting using split skull grafts Ann. Plast Surg , 1983;11:533

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LIST OF FIGURES Figure 1. “Digital Palpation Test” demonstrating lack of structural support by septum. Figure 2. The Bone Graft. Figure 3. Hole made with a Spinal needle mounted on a Hand drill. Figure 4. A 26 Gauge Stainless Steel wire passed through Spinal needle. Figure 5. The leading edge of Stainless Steel wire brought out through Alar Rim Incision. Figure 6. The Bone Graft mounted with Stainless Steel wire. Figure 7. The leading edge of Stainless Steel wire brought out through medial canthal stab incision. Figure 8a. The Bone Graft In situ (Profile view). Figure 8b. The Bone Graft in situ (Transverse section). Figure 9. X-Ray showing no bone resorption after 3 years. Figure 10.Pre & Post-Op photograph (Profile view). Figure 11. Pre & Post-Op photograph (Basal/ Worms-eye view

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Showing Cantilever effect of bone graft raising the nasal tip).

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Figure 1

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Figure 2

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Figure 3

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Figure 5

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Figure 7

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Figure 8

Figure 9

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Figure 10

Figure 11

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Date:15-03-2010 To, GUY KENYON & ROBIN YOUNGS The Editor of Journal of Laryngology & Otology, Maybank, Quickly Rise, Chorleywood, Hertfordshire WD3 5PE, UK (Tel + 44 (0) 1923 283562) Respected sir, I would like to submit an article. Herewith I am sending our article titled “FIXATION OF NASAL BONE GRAFT WITH INTEROSSEOUS WIRE: OUR TECHNIQUE” for favor of publication in your esteemed journal, Journal of Laryngology & Otology. Please find the copy of manuscript Figures (11) & a letter of copyright (declaration). Kindly do the needful, waiting for the reply. Thanking You, Yours sincerely,

DR. NILAM UTTAM SATHE ASSISTANT PROFESSOR, ENT YASH CO. OP. HSG. SOCIETY 66/1748, KANNAMWAR NAGAR NO. 2, VIKHROLI (EAST), MUMBAI 400 083 MAHARASHTRA, INDIA Tel: 022 25782801 Mob: +91 9821309298 E-mail – ID – [email protected].

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Date:-15 /03 / 2009 To, GUY KENYON & ROBIN YOUNGS The Editor of Journal of Laryngology & Otology, Maybank, Quickly Rise, Chorleywood, Hertfordshire WD3 5PE, UK (Tel + 44 (0) 1923 283562) Respected sir, This is to state that the authors undersigned hereby, assign and otherwise convey all Copyright ownership of the article titled “FIXATION OF NASAL BONE GRAFT WITH INTEROSSEOUS WIRE: OUR TECHNIQUE” to Journal of Latryngology & Otology and the authors do not have any objection reviewing and editing of this by editor. DR. Nilam Sathe is the operating surgeon & has written this article, Dr. Gaurav Wadkar has helped in getting the references, Dr. Samir Thakare has helped in the photographs of this case & Dr. Ninad Gaikwad is the Head of the unit under whose guidance this article is written. Thanking You, Yours sincerely,

NILAM UTTAM SATHE (AUTHOR,

ENT, ASSIST. PROFF)

DR. NINAD GAIKWAD (ENT, ASSOC. PROFF.)

SAMIR THAKARE 27

DR. GAURAV WADKAR (SENIOR ENT RESIDENT )

(SENIOR ENT RESIDENT)

CONSENT FORM DATE: - 1-2-2008

I Mr. Rameshwar Pawar 22years old, Male patient , case of nasal deformity ( depression of nasasl bridge) am fully aware that I am giving my consent to use my photos and case history in any Journal for publication to the author & my operating surgeon , Dr. Nilam Sathe, ENTsurgeon. I will not take any legal action for using this material.

Patient’s Signature Mr. RAMESHWAR PAWAR

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Witness doctor’s Signature Dr. NILAM U. SATHE