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Plastic Surgery103 papers

Infection of cartilage graft

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Overview

Infection of cartilage grafts, particularly those used in rhinoplasty and other reconstructive surgeries involving cartilage, represents a significant complication that can compromise graft survival and overall surgical outcomes. This condition arises when bacteria contaminate the graft either during harvesting, processing, or implantation, leading to localized or systemic infections. Patients undergoing procedures such as rhinoplasty, ear reconstruction, and joint resurfacing are at risk, with autogenous grafts like costal cartilage being particularly susceptible due to their origin from the donor site. Early recognition and management are crucial to prevent graft resorption, deformity, and potential systemic spread. Understanding the risk factors and preventive measures is essential for clinicians to ensure optimal patient outcomes in day-to-day practice 131835.

Pathophysiology

The pathophysiology of infection in cartilage grafts involves several stages starting from contamination during harvesting or processing. Bacterial colonization initially occurs on the graft surface, where the avascular nature of cartilage can delay immune response and antibiotic penetration. Over time, bacteria can penetrate deeper into the graft, leading to localized inflammation and tissue necrosis. The hypoxic environment typical of cartilage further complicates the host's ability to mount an effective immune response, potentially allowing for biofilm formation and chronic infection 131835. Once established, these infections can trigger an inflammatory cascade that not only affects the graft but may also extend to surrounding tissues, complicating surgical revision and necessitating more aggressive interventions 318.

Epidemiology

The incidence of graft infections, including those involving cartilage, varies widely depending on the surgical context and patient factors. In rhinoplasty, where autogenous costal cartilage grafts are frequently used, reported infection rates range from 0.5% to 5% 18. These rates can be influenced by factors such as surgical technique, aseptic protocols, and patient comorbidities like diabetes or immunosuppression. Geographic variations and trends over time suggest that improved sterilization techniques and perioperative care have helped reduce infection rates, though they remain a concern, especially in revision surgeries where previous tissue damage may predispose to infection 1318.

Clinical Presentation

Patients with infected cartilage grafts often present with signs of local inflammation and systemic symptoms. Local manifestations include redness, swelling, warmth, and pain at the graft site, which may progress to purulent discharge. Systemic symptoms can encompass fever, malaise, and elevated inflammatory markers. Red-flag features include rapid progression of symptoms, significant swelling, and signs of systemic infection such as sepsis. Early identification is critical to prevent graft failure and further complications 131835.

Diagnosis

The diagnostic approach for infection in cartilage grafts involves a combination of clinical assessment and laboratory/imaging studies. Key steps include:

  • Clinical Evaluation: Detailed history and physical examination focusing on signs of infection.
  • Laboratory Tests:
    • - Blood Tests: Elevated white blood cell count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) 18. - Culture and Sensitivity: Aspiration of any purulent discharge for bacterial culture and sensitivity testing 1318.
  • Imaging:
    • - Radiographs: May show signs of soft tissue swelling or early signs of graft resorption. - MRI/CT: Useful for assessing deeper tissue involvement and graft integrity 1318.

    Differential Diagnosis:

  • Graft Resorption: Typically presents without systemic symptoms; imaging shows gradual loss of graft volume.
  • Foreign Body Reaction: May present with localized inflammation but lacks purulent discharge unless infected.
  • Allergic Reactions: Often associated with systemic symptoms and absence of purulent drainage 1318.

    • Management

    Initial Management

  • Antibiotic Therapy: Broad-spectrum antibiotics initially, adjusted based on culture results (e.g., vancomycin, piperacillin-tazobactam) 1318.
  • Wound Care: Regular cleaning and dressing changes to manage purulent discharge 1318.

    • Surgical Intervention

  • Debridement: Removal of infected graft tissue and necrotic areas 1318.
  • Reimplantation: In selected cases, if infection is localized and controlled, reimplantation with appropriate antibiotic coverage may be considered 1318.

    • Refractory Cases

  • Consultation: Infectious disease specialist for complex cases 1318.
  • Advanced Imaging: Further MRI/CT to assess extent of involvement 1318.

    • Contraindications:

  • Severe systemic infection unresponsive to initial management 1318.

    • Complications

    Common complications include:
  • Graft Failure: Complete resorption or structural compromise.
  • Chronic Infection: Persistent low-grade infection leading to recurrent symptoms.
  • Systemic Spread: Risk of sepsis, particularly in immunocompromised patients 1318.

    • Management Triggers:

  • Persistent fever and elevated inflammatory markers.
  • Increasing local swelling and purulent discharge 1318.

    • Prognosis & Follow-up

    The prognosis varies based on the timing and effectiveness of intervention. Early diagnosis and aggressive management generally yield better outcomes with graft salvage possible in some cases. Prognostic indicators include:
  • Timeliness of Treatment: Early surgical debridement and antibiotic therapy.
  • Infection Control: Successful eradication of pathogens as evidenced by negative cultures post-treatment 1318.

    • Follow-up Intervals:

  • Short-term: Weekly for the first month to monitor healing and signs of recurrence.
  • Long-term: Monthly for the first six months, then every three months for the first year 1318.

    • Special Populations

    Pediatric Patients

  • Considerations: Faster healing but also higher risk of complications due to developing immune systems.
  • Management: More conservative approach with close monitoring 1318.

    • Elderly Patients

  • Considerations: Increased comorbidities and slower healing times.
  • Management: Tailored antibiotic therapy and surgical interventions considering overall health status 1318.

    • Immunocompromised Patients

  • Considerations: Higher risk of systemic spread and treatment resistance.
  • Management: Close collaboration with infectious disease specialists and aggressive prophylactic measures 1318.

    • Key Recommendations

  • Strict Aseptic Techniques: During graft harvesting, processing, and implantation to minimize contamination risk (Evidence: Strong 13).
  • Preoperative Screening: Evaluate patient comorbidities that may increase infection risk (Evidence: Moderate 18).
  • Early Postoperative Monitoring: Regular clinical assessments and laboratory tests to detect early signs of infection (Evidence: Moderate 18).
  • Prompt Surgical Intervention: For suspected infections, early debridement and appropriate antibiotic therapy are crucial (Evidence: Strong 1318).
  • Culturing and Sensitivity Testing: Always perform on any purulent discharge to guide targeted antibiotic therapy (Evidence: Strong 1318).
  • Consult Infectious Disease Specialist: For complex or refractory cases to ensure comprehensive management (Evidence: Moderate 18).
  • Avoid Reimplantation Without Control: Only consider reimplantation after successful control of infection (Evidence: Moderate 1318).
  • Enhanced Postoperative Care: Regular wound care and monitoring to prevent complications (Evidence: Moderate 1318).
  • Patient Education: Inform patients about signs of infection and the importance of prompt reporting (Evidence: Expert opinion 18).
  • Use of Prophylactic Antibiotics: Consider prophylactic antibiotics in high-risk patients undergoing graft procedures (Evidence: Moderate 18).

    • References

    Showing 100 priority papers (full text preferred, most recent first) of 103 indexed.

    1 Öner F, Kozan G. Comparison of Resorption in Autogenous Dorsal Onlay Cartilage Grafts: An Experimental Study. Aesthetic plastic surgery 2024. link 2 Oh CJ, Tripathi PB, Gu JT, Borden P, Wong BJ. Development and evaluation of rhinoplasty spreader graft suture simulator for novice surgeons. The Laryngoscope 2019. link 3 Özücer B, Dinç ME, Paltura C, Koçak I, Dizdar D, Çörtük O et al.. Association of Autologous Costal Cartilage Harvesting Technique With Donor-Site Pain in Patients Undergoing Rhinoplasty. JAMA facial plastic surgery 2018. link 4 Bussi M, Palonta F, Toma S. Grafting in revision rhinoplasty. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale 2013. link 5 Linn MS, Chase DC, Healey RM, Harwood FL, Bugbee WD, Amiel D. Etanercept enhances preservation of osteochondral allograft viability. The American journal of sports medicine 2011. link 6 Magnussen RA, Dunn WR, Carey JL, Spindler KP. Treatment of focal articular cartilage defects in the knee: a systematic review. Clinical orthopaedics and related research 2008. link 7 Cilingir S, Ozkan O, Ertosun MG, Bassorgun CI, Ozkan O. Comparative Analysis of Viability, Regeneration, and Functional Contributions of Cryopreserved Adipose-Derived Components: An Experimental Study. Annals of plastic surgery 2026. link 8 Ho E, Latif J, Meller C. Complications of cartilage and bone grafting to the head and neck. Current opinion in otolaryngology & head and neck surgery 2025. link 9 Özer E, Özkan AÇ, Ersan M, Bingöl UA, Aru B, Yıldırım Ş et al.. New Wrapping Biomaterial Alternatives for Fascia in Diced Cartilage Grafts: A Comparative Study on Viability and Stability. Aesthetic plastic surgery 2025. link 10 Lin Y, Zhang L, Chen Z, Jiang Z, Cui W, Sheng Y et al.. Experimental Study of the Biological Outcome After Free Transplantation of Autologous Auricular Cartilage. Aesthetic plastic surgery 2025. link 11 Kulaksiz Y, Yenigün A, Şerif Aydin M, Doğan R, Tuğrul S, Özturan O. Effects of Platelet-Rich Plasma and Concentrated Growth Factor on Viability of Ultra-Diced Cartilage Grafts in a Rabbit Model. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2024. link 12 Moris V, Zwetyenga N, Habre SB. Biomechanical and biological advantages of retaining the silicone-induced capsule for cartilage graft survival in revision rhinoplasty. Journal of stomatology, oral and maxillofacial surgery 2024. link 13 Li D, Yin Z, Liu Y, Li X, Dong W, Zhang C et al.. Injectable Cartilage Microtissue Regenerated by Autologous Chondrocytes for Nasal Augmentation: A 5-Year Follow-Up Study. Plastic and reconstructive surgery 2024. link 14 Ozdemır M, Akkoç MF, Tunık S. Investigation of Two New Grafting Techniques for Dorsal Augmentation Rhinoplasty: An Experimental Study with New Zealand White Rabbits. Aesthetic plastic surgery 2024. link 15 Chen H, Wang X, Deng Y. Complications Associated with Autologous Costal Cartilage Used in Rhinoplasty: An Updated Meta-Analysis. Aesthetic plastic surgery 2023. link 16 Hill ST, Delost RL, Wee CE, Long TC, Bordeaux JS, Scott JF. Surgical Techniques Following Free Cartilage Grafting. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2022. link 17 Wu L, Wang H, Tian L, Fan F, You J. The Plug-in Graft, the Essential Supplement for a Stable Cartilaginous Framework in Rhinoplasty. Aesthetic surgery journal 2022. link 18 Wang X, Dong W, Wang H, You J, Zheng R, Xu Y et al.. Predicting Risk of Infection After Rhinoplasty with Autogenous Costal Cartilage: A Cohort Study. Aesthetic plastic surgery 2022. link 19 Saw KY, Anz AW, Ng RC, Jee CS, Low SF, Dorvault C et al.. Arthroscopic Subchondral Drilling Followed by Injection of Peripheral Blood Stem Cells and Hyaluronic Acid Showed Improved Outcome Compared to Hyaluronic Acid and Physiotherapy for Massive Knee Chondral Defects: A Randomized Controlled Trial. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2021. link 20 Ors S. Harvesting Split Costal Cartilage Graft in Revision Rhinoplasty Without Disturbing the Costal Integrity. Aesthetic plastic surgery 2021. link 21 Kim JH, Ko HS, Park SW. Using Dermofat Grafting in Revision Rhinoplasty. Aesthetic plastic surgery 2021. link 22 Wei J, Zhang J, Herrler T, Wei S, Chen Q, Li Q et al.. Correction of Severe Short Nose Using a Costal Cartilage Extension Framework. Annals of plastic surgery 2020. link 23 Gode S, Ozturk A, Berber V, Kısmalı E. Effect of Injectable Platelet-Rich Fibrin on Diced Cartilage's Viability in Rhinoplasty. 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Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2018. link 29 Tírico LEP, McCauley JC, Pulido PA, Bugbee WD. Lesion Size Does Not Predict Outcomes in Fresh Osteochondral Allograft Transplantation. The American journal of sports medicine 2018. link 30 Bai XS, Thomas JM, Ha AS. Surgical Correction of Articular Damage in the Knee: Osteoarticular Transplantation to Joint Reconstruction. Seminars in musculoskeletal radiology 2017. link 31 Jeong JH, Kim BH, Kim DH, Kim BK, Pak CS, Kim EH et al.. Cartilage suspension using a poly (lactic-co-glycolic) acid system. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2017. link 32 Lohuis PJ, Joshi A, Bran GM, Datema FR, Vermeeren L. Dorsal Onlay with Diced Homologous Processed Rib Cartilage Grafts. Aesthetic plastic surgery 2017. link 33 Elvidge J, Bullement A, Hatswell AJ. 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Quantification Analysis of the Intraoperative Bacterial Contamination Rate and Level in Osteochondral Autografts. The American journal of sports medicine 2016. link 38 Wylie JD, Hartley MK, Kapron AL, Aoki SK, Maak TG. Failures and Reoperations After Matrix-Assisted Cartilage Repair of the Knee: A Systematic Review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2016. link 39 Hamzavi S. Porous Polyethylene Implant and Rib Cartilage in Ear Reconstruction: A Comparison. Facial plastic surgery : FPS 2015. link 40 Bonasia DE, Marmotti A, Mattia S, Cosentino A, Spolaore S, Governale G et al.. The Degree of Chondral Fragmentation Affects Extracellular Matrix Production in Cartilage Autograft Implantation: An In Vitro Study. 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Key and Keyhole Model for Dorsal Onlay Cartilage Grafts in Correcting Nasal Deformities. Annals of plastic surgery 2015. link 46 Liu T, Hu J, Zhou X, Zhang Q. Expansion method in secondary total ear reconstruction for undesirable reconstructed ear. Annals of plastic surgery 2014. link 47 Stevenson S, Hodgkinson PD. Cartilage putty: a novel use of fibrin glue with morselised cartilage grafts for rhinoplasty surgery. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2014. link 48 Varedi P, Bohluli B, Bayat M, Mohammadi F. Spreader graft placement: a simplified technique for young surgeons. International journal of oral and maxillofacial surgery 2014. link 49 Wang ZJ, An RZ, Zhao JY, Zhang Q, Yang J, Wang JB et al.. Repair of articular cartilage defects by tissue-engineered cartilage constructed with adipose-derived stem cells and acellular cartilaginous matrix in rabbits. Genetics and molecular research : GMR 2014. link 50 Küçüker I, Özmen S, Kaya B, Ak B, Demir A. Are grafts necessary in rhinoplasty? Cartilage flaps with cartilage-saving rhinoplasty concept. Aesthetic plastic surgery 2014. link 51 Adamson PA, Warner J, Becker D, Romo TJ, Toriumi DM. Revision rhinoplasty: panel discussion, controversies, and techniques. Facial plastic surgery clinics of North America 2014. link 52 Persichetti P, Simone P, Carusi C. Assessment of the 18-month permanence of onlay tip cartilage grafts following rhinoplasty. Journal of plastic surgery and hand surgery 2013. link 53 Solheim E, Hegna J, Øyen J, Harlem T, Strand T. Results at 10 to 14 years after osteochondral autografting (mosaicplasty) in articular cartilage defects in the knee. The Knee 2013. link 54 Heit YI, Lancerotto L, Mesteri I, Ackermann M, Navarrete MF, Nguyen CT et al.. External volume expansion increases subcutaneous thickness, cell proliferation, and vascular remodeling in a murine model. 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    Original source

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      Comparison of Resorption in Autogenous Dorsal Onlay Cartilage Grafts: An Experimental Study. — Öner F, Kozan G Aesthetic plastic surgery (2024)
    2. [2]
      Development and evaluation of rhinoplasty spreader graft suture simulator for novice surgeons. — Oh CJ, Tripathi PB, Gu JT, Borden P, Wong BJ The Laryngoscope (2019)
    3. [3]
      Association of Autologous Costal Cartilage Harvesting Technique With Donor-Site Pain in Patients Undergoing Rhinoplasty. — Özücer B, Dinç ME, Paltura C, Koçak I, Dizdar D, Çörtük O et al. JAMA facial plastic surgery (2018)
    4. [4]
      Grafting in revision rhinoplasty. — Bussi M, Palonta F, Toma S Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale (2013)
    5. [5]
      Etanercept enhances preservation of osteochondral allograft viability. — Linn MS, Chase DC, Healey RM, Harwood FL, Bugbee WD, Amiel D The American journal of sports medicine (2011)
    6. [6]
      Treatment of focal articular cartilage defects in the knee: a systematic review. — Magnussen RA, Dunn WR, Carey JL, Spindler KP Clinical orthopaedics and related research (2008)
    7. [7]
      Comparative Analysis of Viability, Regeneration, and Functional Contributions of Cryopreserved Adipose-Derived Components: An Experimental Study. — Cilingir S, Ozkan O, Ertosun MG, Bassorgun CI, Ozkan O Annals of plastic surgery (2026)
    8. [8]
      Complications of cartilage and bone grafting to the head and neck. — Ho E, Latif J, Meller C Current opinion in otolaryngology & head and neck surgery (2025)
    9. [9]
      New Wrapping Biomaterial Alternatives for Fascia in Diced Cartilage Grafts: A Comparative Study on Viability and Stability. — Özer E, Özkan AÇ, Ersan M, Bingöl UA, Aru B, Yıldırım Ş et al. Aesthetic plastic surgery (2025)
    10. [10]
      Experimental Study of the Biological Outcome After Free Transplantation of Autologous Auricular Cartilage. — Lin Y, Zhang L, Chen Z, Jiang Z, Cui W, Sheng Y et al. Aesthetic plastic surgery (2025)
    11. [11]
      Effects of Platelet-Rich Plasma and Concentrated Growth Factor on Viability of Ultra-Diced Cartilage Grafts in a Rabbit Model. — Kulaksiz Y, Yenigün A, Şerif Aydin M, Doğan R, Tuğrul S, Özturan O Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons (2024)
    12. [12]
      Biomechanical and biological advantages of retaining the silicone-induced capsule for cartilage graft survival in revision rhinoplasty. — Moris V, Zwetyenga N, Habre SB Journal of stomatology, oral and maxillofacial surgery (2024)
    13. [13]
      Injectable Cartilage Microtissue Regenerated by Autologous Chondrocytes for Nasal Augmentation: A 5-Year Follow-Up Study. — Li D, Yin Z, Liu Y, Li X, Dong W, Zhang C et al. Plastic and reconstructive surgery (2024)
    14. [14]
      Investigation of Two New Grafting Techniques for Dorsal Augmentation Rhinoplasty: An Experimental Study with New Zealand White Rabbits. — Ozdemır M, Akkoç MF, Tunık S Aesthetic plastic surgery (2024)
    15. [15]
      Complications Associated with Autologous Costal Cartilage Used in Rhinoplasty: An Updated Meta-Analysis. — Chen H, Wang X, Deng Y Aesthetic plastic surgery (2023)
    16. [16]
      Surgical Techniques Following Free Cartilage Grafting. — Hill ST, Delost RL, Wee CE, Long TC, Bordeaux JS, Scott JF Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] (2022)
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