Is Fresh Frozen Homologous Costal Cartilage a Suitable Substitute for Autologous Costal Cartilage in Rhinoplasty?

Costal cartilage is commonly used as a graft material to revise and reconstruct the nasal framework during both primary and revision rhinoplasty. Although autologous costal cartilage has long been considered a gold standard, it carries the disadvantages of donor site morbidity, increased surgical time and cost, and necessity of general anesthesia.1, 2 Consequently, cadaveric costal cartilage grafts are commonly employed as an alternative solution. Traditionally, sterilization of these grafts was achieved through irradiation; however, studies have demonstrated higher rates of resorption, warping, and infection using irradiated homologous costal cartilage.1 More recently, fresh frozen homologous costal cartilage (Musculoskeletal Tissue Foundation, Edison, N.J.) has been made commercially available as a nonirradiated option for cadaveric cartilage.1 This allograft is harvested from the seventh to ninth ribs, debrided of surrounding soft tissue, rinsed with surfactant, soaked in antibiotic solution, stored frozen at −80 to −40°C, and defrosted just prior to use.1, 3 Although several recent studies have summarized single institution experiences with fresh frozen cartilage use, no formal guidelines exist regarding the safety and efficacy of its use compared with more established options. This review summarizes the outcomes of recent literature describing clinical outcomes and complication rates associated with primary and revision rhinoplasty using fresh frozen homologous costal cartilage grafts as compared with autologous costal cartilage (Table I). 6 mo–8 yr (Mean = 12.2 mo) 2.7% Infection 2.7% Warping 0% Displacement 2.2% Revision 2–38 mo (Mean = 15.0) 0% Infection 0% Warping 4.8% Resorption 10% Revision 12–46 mo (Mean = 20.3) 2.1% Infection 0% Warping 0% Resorption 0% Displacement 2.1% Revision 1–47 mo (Mean = 14.8) Increased post-op satisfaction 0% Infection 8% Warping 8% Resorption 2% Scarring 16% Revision Smaller change in deviation, nasolabial angle Lower cost, less opioid requirement N/A 9 studies In 2022, Rohrich et al. published a retrospective review of the senior author's 9-year experience with 226 patients who underwent revision rhinoplasty using fresh frozen cartilage.3 This study provided a continuation of preliminary data published in 2019 as the earliest report of fresh frozen cartilage grafts in the literature.1 Graft uses included alar contour, septal extension, columellar strut, dorsal onlay, and nasal side wall/batten grafting. Patients were followed for at least 6 months. They reported a 2.7% infection rate (six cases, one requiring explantation), 4.0% nasal tip erythema, 2.7% graft warping, 2.2% revision, and no graft displacement or extrusion. These rates were found to be consistent with those reported for autologous and irradiated homologous cartilage from prior meta-analyses. They also reported an anecdotal advantage of customizing allograft selection based on desired graft properties; specifically, specimens with a yellowish hue offer greater structural rigidity while those with a whitish hue offer greater flexibility likely due to differences in calcification. Milkovich and Ahmad similarly reported on a single surgeon’ experience with 21 patients followed for 2.0–37.8 months receiving primary and secondary rhinoplasty using fresh frozen cartilage predominantly for alar contour, septal extension, spreader, columellar strut, splinting, and lateral crural strut grafts.4 The authors reported that 90% of the patients were “very satisfied” with cosmetic results while 10% were “satisfied” but still requested additional revision surgery. They reported no cases of infection or warping and found one case of resorption (4.8%). Hanna et al. published the largest single-surgeon case series to date, with 282 primary and secondary rhinoplasties using fresh frozen costal cartilage.5 They did not report which graft types were performed. Patients were followed for at least 12 months. They noted a 2.1% infection rate, 2.1% revision, and no cases of warping, resorption, explantation, or displacement, which are comparable to rates for autologous cartilage reported in the literature. Like the Rohrich group, they also comment on differences between yellow versus white fresh frozen cartilage specimens. Additionally, while they did not directly compare mechanical properties with those of autologous costal cartilage, they did note that fresh frozen costal cartilage does not respond as well to scoring and has a greater risk of fracture during suturing when compared with autologous septal cartilage. Wan et al. described the first prospective nonrandomized clinical trial comparing fresh frozen with autologous costal cartilage grafts in 50 primary and revision rhinoplasties, all performed by the senior author.2 Both groups included spreader, nasal tip, septal extension, dorsal onlay, columellar strut, and alar grafts. Patients were followed for 1–47 months. To assess warping, resorption, and displacement, the authors compared the deviation angle, nasofrontal angle, total facial convexity, nasofacial angle, and nasolabial angle as measured on photographs taken 6 versus 12 months postoperatively. They found that autologous cartilage was associated with a significantly greater change in deviation and nasolabial angles. Both groups reported increased satisfaction with nasal appearance after surgery with no statistically significant differences in subjective cosmetic outcomes between the two groups as measured by the FACE-Q patient-reported outcome measure. The fresh frozen group had no infections, an 8% resorption rate, 8% warping, 2% scarring, and 16% revision; the autologous group had a 4% infection rate (representing one case which required explantation), 8% resorption, 12% warping, 16% scarring, 12% revision, and no pneumothoraces. A statistical comparison was not performed for complication rates. This group also reported a lower overall surgical cost associated with using fresh frozen rather than autologous cartilage even accounting for cost of shipment and storage, as well as reduced opioid requirement. Most recently, Salzano et al. conducted a narrative review summarizing nine articles published between 2019 and 2023 describing the use of homologous costal cartilage in rhinoplasty, including the four above articles, four additional case series, and one in vitro study.1 Of note, none of the studies reviewed represented randomized controlled trials, and only one included a control group.2 In addition to the above findings, they cited an association of fresh frozen cartilage with reduced structural support, similar warping, and shorter operative times when compared with autologous cartilage.1 They conclude that fresh frozen cartilage represents a valid alternative to autologous rib cartilage that provides similar outcomes while avoiding donor site morbidity and reducing operative time. Fresh frozen homologous costal cartilage in rhinoplasty represents an alternative approach that has been described mostly through single surgeon case series in the existing literature. Many of these studies are modest in size, and while they demonstrate comparable rates of infection, warping, resorption, and revision as historically reported for autologous cartilage, there remains a lack of randomized controlled trials to provide statistical comparisons and inform best practices. Further research is needed to quantify differences in mechanical properties, long-term aesthetic and clinical outcomes, and overall costs associated with fresh frozen costal cartilage, autologous costal cartilage, and other alternative cartilage graft sources. However, these early studies suggest that fresh frozen homologous costal cartilage is a safe, effective, and potentially customizable alternative to the conventional gold standard of autologous costal cartilage, particularly among patients who may not tolerate the risks associated with harvesting from the donor site. The current literature is limited. This best practice guideline reviews one nonrandomized prospective cohort study (Level III), three case series (Level IV), and one narrative review (Level IV).