Handheld ultrasound devices can be used in revision rhinoplasty to evaluate the calcification of costal rib cartilage that is to be harvested for grafting. This article provides instructions on how to perform this technique. Laryngoscope, 134:651-653, 2024

Dilley, Katelyn K

Gedeon, David N

Hernandez, Kelly

Hutchison, Dana M

Park, Asher C

Prasad, Karthik R

Wong, Brian J‐F

eScholarship - University of California

UC IrvineUC Irvine Previously Published WorksTitleCostal Cartilage Considerations: Novel Use of Handheld Ultrasound Device in RhinoplastyPermalinkhttps://escholarship.org/uc/item/2952w9pnJournalThe Laryngoscope, 134(2)ISSN0023-852XAuthorsPark, Asher CHutchison, Dana MPrasad, Karthik Ret al.Publication Date2024-02-01DOI10.1002/lary.30760Copyright InformationThis work is made available under the terms of a Creative Commons Attribution License, available at https://creativecommons.org/licenses/by/4.0/ Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaHOW I DO ITCostal Cartilage Considerations: Novel Use of Handheld UltrasoundDevice in RhinoplastyAsher C. Park, BS ; Dana M. Hutchison, MD, MSc; Karthik R. Prasad, MD; Kelly Hernandez, BS;Katelyn K. Dilley, BS; David N. Gedeon, MD; Brian J-F Wong, MD, PhDKey Words: calcification, cartilage, point-of-care ultrasonography, rhinoplasty, ultrasound.Laryngoscope, 134:651–653, 2024INTRODUCTIONPrimary and secondary rhinoplasty frequently requirestructural augmentation of the nasal framework to provideadequate airway support and also achieve aestheticallydesirable results. At times, this requires the use of graftmaterial. Although septal remains the ideal material ofchoice, conchal and costal cartilage are also used. Autolo-gous costal cartilage is considered by many as the idealsource of cartilage for revision rhinoplasty where other res-ervoirs are often depleted. However, calcification of costalrib cartilage can be problematic, as it can be difficult toharvest, cut, and fashion.1 Although the prevalence of cos-tal cartilage calcification increases with age, it is not negli-gible in younger populations.2 Identifying calcified graftmaterial and thereby avoiding harvesting of a heavily ossi-fied rib in favor of another rib or use of allograft is impor-tant. Other studies have shown that preoperativecomputed tomography (CT) scans provide insight into thepresence and patterns of calcification.3,4 However, CTscans expose patients to radiation, albeit modestly, andare an additional cost. For these reasons, there is a needfor an inexpensive, efficient, and easy-to-use means for thesurgical team to evaluate costal cartilage quality in theperioperative period.Point-of-care ultrasonography (POCUS) refers to theuse of ultrasound at the patient’s bedside by cliniciansother than a radiologist or cardiologist.5 In recent years,there has been increased practice of POCUS and subse-quently, an increased demand for ultrasound devices thatcomplement this practice.5 In response, recent advance-ments have made handheld ultrasound devices (HUD)even more compact, affordable, and easy to operate.5 Toour current knowledge, there is limited literature onHUD in facial plastic surgery and rhinoplasty. With thisstudy, we hope to show that HUD can be utilized by indi-viduals with minimal training as a convenient, inexpen-sive, and effective means of perioperative evaluation ofcostal cartilage quality for rhinoplasty.METHODSThis study was conducted in accordance with institutionalreview board approval (IRB #20152490). The charts of patientswho underwent revision rhinoplasty and had perioperative HUDwere reviewed. HUD images were compared with pre-operativeCT images or intra-operative images of harvested costal cartilagerib graft when available.HUD Training and ExaminationPerioperative examinations with the HUD were conductedby members of the surgical team with minimal to moderate HUDtraining and experience (D.M.H., K.R.P., K.H., and B.R.P.).Three of these US operators were medical students although onewas a facial plastic surgery fellow. Experience with US devicesranged from approximately 3 to 30 h of formal HUD trainingacross the operators performing US examination in this study.Operators were trained in general ultrasound anatomy and phys-iology. For our study, operators were shown representativetransverse and longitudinal ultrasound images of rib cartilageThis is an open access article under the terms of the CreativeCommons Attribution-NonCommercial-NoDerivs License, which permitsuse and distribution in any medium, provided the original work is prop-erly cited, the use is non-commercial and no modifications or adaptationsare made.From the Feinberg School of Medicine (A.C.P.), NorthwesternUniversity, Chicago, Illinois, USA; Beckman Laser Institute (A.C.P., D.M.H.,K.H., K.K.D., B.J-F.W.), University of California Irvine, Irvine, California,USA; Department of Otolaryngology, Head and Neck Surgery (K.R.P.),Yale University, New Haven, Connecticut, USA; Department ofRadiology (D.N.G.), University of California Irvine, Orange, California,USA; Department of Otolaryngology, Head and Neck Surgery (B.J-F.W.),University of California Irvine, Orange, California, USA; and theDepartment of Biomedical Engineering, Samueli School of Engineering(B.J-F.W.), University of California Irvine, Irvine, California, USA.Editor’s Note: This Manuscript was accepted for publication onMay 08, 2023.Presented as a poster at the Triological Society 2022 Combined Sec-tions Meeting, Coronado, CA on January 10th, 2022.The authors have no funding, financial relationships, or conflicts ofinterest to disclose.Send correspondence to Brian J.F. Wong, MD, PhD, BeckmanLaser Institute, 1002 Health Sciences Road, Irvine, CA 92697, USA.Email: bjwong@uci.eduDOI: 10.1002/lary.30760Laryngoscope 134: February 2024 Park et al.: Handheld Ultrasound Imaging of Rib Cartilage651The Laryngoscope© 2023 The Authors. The Laryngoscopepublished by Wiley Periodicals LLC onbehalf of The American Laryngological,Rhinological and Otological Society, Inc.from a previous study that also included ossification patternsand also practiced obtaining control images on each other. Train-ing sessions were less than 20 min.These examinations were performed with a portable ultra-sound device (iQ+, Butterfly Network, Guilford, CT) paired with acommercial tablet device (4th Generation iPad Pro, Apple, Cuper-tino, CA) as seen in Figure 1. The HUD utilized a smartphone/tablet application-based interface that allows the user to selectbetween 22 tissue-type presets across six different imaging modes:B-mode, M-mode, Color Doppler, Power Doppler, Pulsed WaveDoppler, Biplane, and Fetal Heart Sounds. For this study, weselected the Musculoskeletal (MSK)-Soft Tissue preset that utilizesB-mode for ultrasound imaging. Perioperatively, the patient’s fifth,sixth, or seventh ribs were identified via palpation and anatomicallandmarks. Each rib was imaged transversely via the HUD,starting laterally and sweeping medially along the rib to the cos-tochondral junction. Upon HUD examination, the costochondraljunction was clearly visible; the costal cartilage appeared as a hyp-oechoic region with a more hyperechoic boundary surrounding thecartilage peripherally as shown in the representative images inFigure 2C. Calcifications are hyperechoic areas with posterioracoustic shadowing located on the central (Figure 2A) or peripheral(Figure 2B) areas of the rib cartilage. Video obtained during HUDexamination was recorded in the patient’s chart. Chart reviewincluded evaluation of ossification presence and correlation withpreoperative CT and/or images of gross pathology when available.This HUD evaluation method is highlighted in SupplementalVideo 1 which can be used in a comprehensive instructionalresource for those looking to learn this method (Audio 1).Surgical ProcedureThe ribs were palpated and counted, with either the fifth,sixth, or seventh rib selected as the rib graft harvest site. A 2 cmincision was created directly over the rib selected for harvest inmales. For females, the incision site was marked at theinframammary fold. The incisions were then made and subse-quently, the skin and subcutaneous layers were dissected toaccess the muscle fascia. Fascia was divided, muscles bluntlyseparated, and the rib was exposed for dissection. The perichon-drium was carefully dissected off the rib, and the cartilaginousrib was cut on both ends and then subsequently harvested. Therib was then placed on the sterile operating room table and care-fully cut, photographed in cross-section, and then prepared forsubsequent use as graft material.RESULTSAfter minimal training, all four of the HUD operatorswere able to successfully perform ultrasound and identifyboth the presence or absence of calcification in costal ribcartilage for all 10 patients. Of the 10 patients, nine hadFig. 1. Preoperative ultrasound setup with iPad and Butterfly probe.Fig. 2. (A) Central calcification-Left 7th costal cartilage of 50-year-old male showing central calcification on cross-sectional ultrasound(US) and gross pathology. (B) Peripheral calcification-Left 6th costalcartilage of 59-year-old male showing peripheral calcification oncross-sectional US and sagittal computed tomography scan.(C) No calcification-Left 6th costal cartilage of 23-year-old withoutevidence of calcification on cross-sectional US or gross pathology.Laryngoscope 134: February 2024 Park et al.: Handheld Ultrasound Imaging of Rib Cartilage652 15314995, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/lary.30760 by University Of California - Irvine, Wiley Online Library on [13/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licensecalcification that was identified through ultrasound andwas then correlated with gross pathology and/or prior CTscans. Three of these patients had peripheral calcification,five had central calcification, and one had both peripheraland central calcification patterns present. Only one patienthad no calcification indicated on ultrasound which was cor-related with gross pathology (Figure 2C).DISCUSSIONThe presence and extent of rib cartilage calcificationhave historically been evaluated with preoperative CTscans and standard ultrasound, or with the interrogationof the rib quality using a needle translated across the ribsurface percutaneously.3,4 However, both modalities havelimitations. Some patients have pre-existing CT scansobtained for unrelated purposes, and these ought to bereviewed. Many surgeons order CT scans for patients thatthey deem more likely to have heavily ossified costal car-tilage, and in general this is more common in olderpatients. This can be expensive, time-consuming, and canunnecessarily expose patients to ionizing radiation, albeitmodest. In a study by Bozzato et al., standard US wasvalidated as an effective means of evaluating the costalmargin.4 However, compared to HUD, standard USdevices are far more expensive and may require extensivetraining to develop expertise.In this study, we found that the Butterfly iQ+ HUDcan be used to effectively evaluate the costal cartilagequality of patients preoperatively, helping the surgeonidentify and select ideal options for tissue harvest. HUDreadily detects calcification and provides information onspatial distribution. As mentioned, a major advantage ofthis proposed method is the low cost. The Butterfly iQ+ultrasound device is priced at $2,399 with annual sub-scription costs ranging from $199/year at the most basicto $420/year for the most advanced; this is far more inex-pensive compared to standard US devices. There are alsomany devices at an even more economical price point, butthe Butterfly and devices like it are being used and issuedto medical students on admission at many medicalschools.This application-based HUD was paired with eithera tablet device or smartphone device, adding to its’ easeof use and economy, along with compact size. Like mosttablet/smartphone devices or apps, the software is intui-tive and easy to use. Clinicians with minimal to moderateexpertise with ultrasonography are able to successfullyultrasound rib cartilage and evaluate images for calcifica-tion presence and patterns as validated with CT scansand/or gross pathology.In summary, we have found that HUD can be used asan economical, convenient, and easy-to-use method forevaluating the presence and patterns of calcification on ribcartilage prior to surgery. Our HUD findings correlatedwith CT scan/gross pathology results.BIBLIOGRAPHY1. Salinger S. Cartilage homografts in rhinoplasty: a critical evaluation. AnnOtol Rhinol Laryngol. 1952;61(2):533-541. https://doi.org/10.1177/000348945206100225.2. Hawellek T, Beil FT, Hischke S, et al. Costal cartilage calcification: preva-lence, amount, and structural pattern in the general population and itsassociation with age: a cadaveric study. Facial Plast Surg Aesthet Med.2021. https://doi.org/10.1089/fpsam.2021.0063.3. Rejtarova O, Slizova D, Smoranc P, Rejtar P, Bukac J. Costal cartilages—aclue for determination of sex. Biomed Pap Med Fac Univ PalackyOlomouc Czech Repub. 2004;148(2):241-243. https://doi.org/10.5507/bp.2004.050.4. Bozzato A, Bumm K, Hertel V, Wurm J. Ultrasonographic evaluation of calci-fication patterns in costal cartilage: implications for rib graft harvesting.JAMA Facial Plast Surg. 2013;15(6):457-460. https://doi.org/10.1001/jamafacial.2013.128.5. Diaz-Gomez JL, Mayo PH, Koenig SJ. Point-of-care ultrasonography. N EnglJ Med. 2021;385(17):1593-1602. https://doi.org/10.1056/NEJMra1916062.Video 1. Costal cartilage evaluation with a handheld ultrasounddevice.Video content can be viewed at https://onlinelibrary.wiley.com/doi/10.1002/lary.30760Laryngoscope 134: February 2024 Park et al.: Handheld Ultrasound Imaging of Rib Cartilage653 15314995, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/lary.30760 by University Of California - Irvine, Wiley Online Library on [13/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Costal Cartilage Considerations: Novel Use of Handheld Ultrasound Device in Rhinoplasty

Costal Cartilage Considerations: Novel Use of Handheld Ultrasound Device in Rhinoplasty

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