CARTILAGE GRAFTS AND

PREASSEMBLED AUTOGRAFTS
FOR RHINOPLASTY AND
AURICULAR RECONSTRUCTION
Part I :
Endoscopy-Assisted
Extranasal Rhinoplasty
Part II:
Auricular Reconstruction
Professor François DISANT
Edouard Herriot Hospital
Otolaryngology-Head and Neck Surgery Unit
Lyon, France
4 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular

Reconstruction
Part I : Endoscopy-Assisted Extranasal Rhinoplasty
Part II : Auricular Reconstruction
Professor François DISANT
Edouard Herriot Hospital, Otolaryngology – Head and Neck Surgery Unit
Pavilion U
Lyon, France

Address for correspondence :

Prof François Disant
Hôpital Edouard Herriot
Service ORL et CCF – Pavillon U
Place d’Arsonval
69437 Lyon Cedex 03, France
Phone: +33 04 72 11 05 32
E-mail: [email protected]

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 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 5

Table of Contents
Part I: Endoscopy-Assisted Extranasal Rhinoplasty
1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6
2.0 Clinical Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6
3.0 State of the Art . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7
4.0 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7
5.0 Outcomes of Clinical Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12
Deviated Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12
Tension Nose with Thin, Retractile Skin . . . . . . . . . . . . . . . . . . . . . . . . . . .  12
6.0 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13
7.0 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13
8.0 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13
Part II: Auricular Reconstruction
1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14
2.0 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14
Instrument Sets for Endoscopy-Assisted Extranasal Rhinoplasty
and Auricular Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18–29
6 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

Endoscopy-Assisted Extranasal Rhinoplasty

1.0 Introduction
Endoscopy-assisted extranasal rhinoplasty is another advancement in ­septoplasty
procedures involving extraction, shaping/assembly and reimplantation in that
it ­integrates the major reconstruction grafts commonly used in augmentation
­rhinoplasty:
Spreader graft
Dorsal onlay graft
Columellar strut

The various grafts are fashioned and recombined on a board. The assembled
­autograft, ­fashioned in this way, is reimplanted under endoscopic vision, once its
stability and position in relation to the patient’s anatomical structures have been
confirmed:

Nasal bones
Lateral nasal cartilage
Anterior nasal spine

1 Lateral view of the anticipated position of 2 Model of the assembled graft and its
the assembled autograft resting on the stability in all directions.
nasion and anterior nasal spine.

2.0 Clinical Data

Successful rhinoplasty requires good coaptation between the new osteocartilaginous
framework and the cutaneous covering. Even though a variety of factors account for
optimum coaptation, the following are of crucial importance:

Smoothness of the reconstructed osteocartilaginous framework.

Normal development of the skin during the wound healing process, that is, no
fibrosis or dermal sclerosis that would reveal any irregularities of the new osteo-
cartilaginous framework.
 Endoscopy-Assisted Extranasal Rhinoplasty 7

3.0 State of the Art

Rhinoplasty is currently performed using two techniques; each has its advantages
and drawbacks:

Endonasal (closed) rhinoplasty involves minimal dissection, thus the duration of

wound healing is shortened. However, using this technique, it is more difficult to
control changes related to the osteocartila­ginous framework and graft stability,
thereby increasing the risk of secondary irregularities, which is particularly visible
if the skin is susceptible to retraction or atrophic alterations.
External (open) rhinoplasty allows for precise visual control over the reduction
or augmentation of the osteocartilaginous framework. However, the extensive
skin dissection inherent to the technique can lead to delayed healing and post-
operative complications, involving the risk of dermal fibrosis and secondary
impairment of the morphological results.

Endoscopy-assisted extranasal rhinoplasty is an alternative treatment option when

the primary technical challenge lies in the dorsum or the middle third of the nasal
pyramid.
However, the endonasal technique is not supposed to replace the external approach
in ­advanced cases of nose tip correction.

The procedure combines the advantages of the open standard approach:

Fashioning of the cartilaginous autograft outside the nasal cavity is facilitated,
­considerably contributing to a regular morphological and mechanical outcome
of the graft.
Simplicity of the endonasal approach, which favors normal wound healing.
Endoscopic visualization allows the position and stability of the reconstructed
anatomical configuration to be assessed.

4.0 Surgical Technique

In the following, the surgical technique will be described step-by-step:

1. Hemitransfixion, inter-septo-columellar incision, then en bloc removal of

septal (quadrangular) cartilage and cartilaginous dorsum by subperichondrial
­dissection.

2. Dorsal bone slotting by creation of an open roof at the dorsum and lateral
­osteo­tomy using green-stick type fractures, to partially reduce the open roof and
maintain stability of the bone flaps.

3 4
8 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

3. Skeletonization of the anterior nasal spine while preserving integrity of the base
of the ­bony septum (to the extent possible) to provide a stable native unit.

4. Fashioning of a standardized septal cartilage autograft that combines:

a) A sagittal ‘set square’, where the anterior part rests on the anterior nasal
spine, made from the thick posterior part of the removed septal (quadrangular)
­cartilage (acts as a strut and supports the nasal base).
b) Two spreader grafts that extend posteriorly, beyond the posterior edge of the
septal ‘set square’, and act as a tenon over their entire length (lateral nasal
a cartilage and nasal bone).
5 Fixation of the spreader graft onto the c) An onlay graft that is sutured to the posterior extension of the spreader grafts;
septal ‘set square’. the height of the spreader graft is reduced in this segment to accomodate the
onlay graft; the latter’s thickness exactly makes up for this reduction.
The resulting projection of the dorsum is perfectly linear.

b c d
Fixation of the onlay graft onto the spreader Assembled graft, three-quarter view. Profile view of the autograft.
graft and septal ‘set square’.

e f a
View of the autograft from below. View of graft from above. 6 Measurement of graft length.

b c d
Measurement of graft height. Measurement of graft width. Measurement of nasal length.
Endoscopy-Assisted Extranasal Rhinoplasty 9

a b c
7 Implantation of the assembled autograft using an endonasal (closed) approach through an inter-septo-columellar incision (a–f).

d e f

5. Dissection of an interposed columellar bed in front of the anterior nasal spine

designed to accomodate the anterior part of the septal ‘set square’.

6. Implantation of the assembled autograft through the inter-septo-columellar route

­using a long grasping forceps and a transcolumellar guiding / traction suture.

7. “Push down” maneuver to lock in the dorsum. The assembled autograft is the
matching part (tenon) of a mortise, corresponding to the open roof of the native
nasal dorsum.

a b c
8 “Push-down” maneuver used to insert the assembled autograft in the open roof of the nasal dorsum, as in a mortise and tenon joint (a–c).
10 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

8. Assessment of the autograft’s position on the anterior nasal spine; if deemed

necessary, the height of the septal ‘set square’ may be reduced to make sure
that it snugly fits on the anterior spine and forms a stable compound.

9. Endoscopic assessment of the match between the projection of the spreader

grafts and that of the lateral nasal cartilages, including the option to reduce any
excess lateral cartilage.

10. Endoscopic assessment to make sure that the onlay graft is flush with the nasal
bones; finger palpation to confirm that the dorsum is even and the onlay graft
does not efface the nasofrontal angle.

a
9 Endoscopic view of the implanted 10 External view during endoscopic
autograft. assessment.

b c d e f
10 Open roof after resection of the nasal Locking of the autograft into the open roof. The autograft is locked in place similarly to a
dorsum and prior to lateral osteotomies. mortise and tenon joint.
Endoscopy-Assisted Extranasal Rhinoplasty 11

11. Closure of the inter-septo-columellar incision and placement of a bivalve ­(Reuter

type) septal external splint.

12. Stabilization of the skin layer with multiple layers of Steri-strips and a h ­ eat-
malleable splint. The threedimensional stability of the autograft is maintained in
the following planes:
a) Vertically, as it rests on the anterior nasal spine.
b) Sagittally, as it rests against the nasion, the engaged nasal bones and the
anterior nasal spine.
c) Transversally, through the mortise and tenon type joint in the neo-dorsum.
11

a b
12 Model of the assembled autograft engaging into the nasal bones by applying the mortise
and tenon principle (a–d).

c d
12 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

5.0 Outcomes of Clinical Cases

Deviated Nose

a b c d
13 Frontal aspect, preoperative (a) and post-operative (b) views. Lateral aspect, preoperative (a) and post-operative (b) views.

Tension Nose with Thin, Retractile Skin

a b c d
14 Frontal aspect, preoperative (a) and post-operative views (b). Lateral aspect, preoperative (a) and post-operative (b) views.

e f
Alar region, preoperative (a) and post-operative (b) submental views.
 Endoscopy-Assisted Extranasal Rhinoplasty 13

6.0 Limitations
The technique can be routinely applied by senior and novice surgeons and features a
short learning curve. Thus, it is not reserved for experienced surgeons only. However,
the technique is contraindicated when attempting to elongate a short nose, since the
vertical skin retraction could raise the graft and cause effacement of the nasofrontal
angle.
The ‘expanded septal graft’ technique is preferable in such a case, as it leaves the
septum in place. Secondary septorhinoplasty involves the risk of a septal cartilage
defect. The bony part of the perpendicular plate of the ethmoid or the vomer can be
used to reconstruct the osteocartilaginous graft.
The spreader grafts require a sufficiently large cartilage fragment. Cartilaginous
auto­graft may also be harvested from the auricular concha to reconstruct the nasal
dorsum.

7.0 Indications
The following are the major indications for this technique:
Deviated nose, especially when the septum exhibits complex deformities.
In our hands, it has always been feasible to construct a completely linear g ­ raft
on the board.
The stability of the assembled autograft provides reproducible results.
The tension nose with thin, retractile skin requires the dorsum to be p ­ erfectly
smooth to prevent the occurrence of secondary irregularities. Having a
large piece of septal (quadrangular) cartilage allows the construction of a
­well-nourished, completely even graft, which is assembled and implanted using
the very ­reliable ­mortise and tenon principle.

In our experience, the major indication for the external approach is advanced nasal
tip surgery. Conversely, the middle third of the nose can be addressed by extranasal
rhinoplasty, avoiding tip dissection which is only needed for creating the surgical
­access, but not for managing an advanced-level nasal tip correction.

8.0 Conclusion
Endoscopy-assisted extranasal rhinoplasty allows to precisely manage nasal ­dorsum
deformities through a minimally invasive approach, facilitating post-operative recovery
and avoiding secondary deformities related to the reconstructed osteocartilaginous
framework or to skin healing.
14 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

Auricular Reconstruction
1.0 Introduction
The external ear, an aerated structure that projects from both sides of the skull, plays
a mostly esthetic role. When missing, either due to a congenital defect related to
microtia or as a result of amputation, the face looks unbalanced, which is poorly toler-
ated by school-aged children.
The goal of auricular reconstruction is to restore the main features of the ear: ­delicate
contours, symmetry relative to the contralateral ear and stable retroauricular sulcus.
Auricular reconstruction is based on the interposition of a sculptured rib cartilage
autograft. This procedure was first described by Radfort Tanzer in the late 1950s and
then improved upon by Burt Brent; it is now considered well-established. Although
the first reconstruction procedures were accomplished in at least three stages, today
most surgeons employ a two-staged approach. The first stage involves harvest,
sculpturing and implantation of the assembled cartilage framework; the second stage
consists of lateral transposition of the auricle itself. However, the outcomes of the
second stage procedure are unpredictable, notably because of scar retraction at the
new retroauricular sulcus, leading to a loss of ­auricular contour.

2.0 Surgical Technique

Auricular reconstruction is performed in two stages, usually scheduled four months
apart. Occasionally, a third stage is needed to refine the results.

First Stage:
The key elements contributing to the anticipated auricular framework are harvested,
assembled and implanted during the first stage.
Cartilage is harvested from the sixth to eighth ribs contralateral to the ear in
question. The procedure is facilitated by use of bipolar scissors, allowing for a
bloodless, extra-perichondrial harvest. Always make sure to maintain integrity of
the parietal pleura. The muscle and skin layers are carefully closed over a suction
drain, followed by post-operative lung X-rays for reassessment purposes, and
removal of the chest drain on the second day to rule out pneumothorax.
The costal cartilage is carved and assembled with 3-0 metal sutures to form
a three-dimensional auricular framework. The size of this graft must match the
contralateral ear. Cartilage harvested from the sixth and seventh ribs are used
to support those grafts that will make up the helix and antihelix. The front part
of the cartilage is hollowed-out to form the cavum conchae. The inferior part is
used to build the structure of the lobule. A cartilage graft is attached in front to
form the tragus.

a b c
1 Harvesting of cartilage from the sixth to Assembly of the helix and antihelix scapha Fully assembled right auricular graft (c).
eight ribs. block.
 Auricular Reconstruction 15

d e f g
1 Oblique view (d) and posterior view (e) Auricular graft and crescent-shaped cartilage Auricular graft shown in front of the
of the auricular graft framework using used for lateral transposition of the auricle temporo­mastoid recipient site (g).
fine-gauge wire suture. during the second stage procedure (f).

The retroauricular region must be carefully prepared and shaved a few

­centimeters. A small (3 to 4 cm), sloping V-shaped retroauricular incision is made
and the subcutaneous-adipose tissue released in the temporomastoid area
overlying the anticipated position of the auricle. Detachment of the skin is done
over the temporoparietal fascial flap in a plane below the super­ficial adipocuta-
neous system (SACS). If undermining is carried too deep, the delicate contours
are at risk of being c ­ ompromised. The cartilage of the patient’s remnant ear /
lobule is ­carefully mobilized and removed making sure not to transfix the skin.

a b c
2 Undermining is performed carefully in a Removal of cartilage of the patient’s remnant Probing of skin laxity after subcutaneous
plane below the superficial adipocuta­- ear / lobule. dissection and cartilage resection.
neous system (SACS) in the temporomastoid
area.

In the first stage, a small, crescent-shaped costal cartilage graft is placed,

­concave side facing down, under the temporoparietal fascial flap above and
behind the ­neo-auricle. The graft will serve as a wedge to elevate the auricle
during the second stage of surgery.
The graft is positioned, angled upwards and backwards, with the superior margin
at the same level as the brow line. A gentle suction drain, which is kept in place
for seven days, coapts the skin to the cartilage framework.

a b
3 Neo-auricle presenting in the temporo­ 4 Suction drain used to ensure skin- 5 Skin-cartilage coaptation showing the contours
mastoid plane following insertion of the cartilage coaptation for one week. typical of the auricle (a).
graft in the subcutaneous pocket. Excess lobule skin and early lateral transposition of
the inferior margin of the neo-auricle (b).
16 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

The lower part of the retroauricular sulcus is fashioned during the first stage to
allow the lobule to be laterally repositioned on the spot. We favour a ­primary
lateral transposition of the microtic ear lobule and cartilage over a s­ econdary
approach with the same intent, which is always challenging because the lower
part of the graft is susceptible to become trapped between the anterior edge of
the sternocleidomastoid muscle and the mastoid.

Second Stage:
Four months later, in the course of this stage, lateral transposition of the auricle is
accomplished by interposing a wedge of crescent-shaped cartilage in the retro­
auricular sulcus; the wedge was banked under the temporoparietal fascial flap
during the first stage.
The skin incision is made along the contour of the neo-auricle and is completed
by a horizontal incision extended posteriorly, towards the banked, crescent-
shaped graft.
The temporoparietal fascial flap (TPF) with anterior pedicle, which is used to
mobilize the head of the crescent-shaped cartilage, is inset into the retroauricular
neo-sulcus.
The lateral side of the auricle and TPF that wrap the crescent-shaped graft
are covered by a thin, 0.3 mm skin graft, while the medial side is covered by
­advancement of two temporomastoid scalp flaps.

a b
6 Dissection of a cartilage fascia flap four Transposition of the cartilage fascial flap (b).
months after a crescent-shape cartilage
piece was banked under the superficial
temporal fascia (a).

c d
Insertion of the crescent-shaped cartilage into The crescent-shaped cartilage graft is affixed to
the posterior aspect of the reconstructed the bottom of the retroauricular sulcus (d).
auricle (c).
 Auricular Reconstruction 17

e f g
Coverage of the medial side Coverage of the lateral side of the retroauricular
of the retroauricular sulcus by sulcus with a free skin graft (g).
advancement of temporo­
mastoid scalp flaps (e, f).

a b
7 Retroauricular sulcus after six months of 8 Postoperative results of two patients
normal wound healing. demonstrated in various views (a–f).

c d e f
18 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

Instrument Set for Endoscopy-Assisted Extranasal Rhinoplasty

7230 AA

7230 AA HOPKINS® Straight Forward Telescope 0°,

enlarged view, diameter 4 mm, length 18 cm, autoclavable,
fiber optic light transmission incorporated,
color code: green

7230 BA HOPKINS® Forward-Oblique Telescope 30°,

enlarged view, diameter 4 mm, length 18 cm, autoclavable,
fiber optic light transmission incorporated,
color code: red

403655 479408 494500 498000 536909

403655 COTTLE Nasal Speculum, 498000 JOSEPH Retractor,

blade length 55 mm, length 13 cm length 15.5 cm
479408 COTTLE Raspatory, 536909 Dissecting and Ligature Forceps,
slightly curved, width 8 mm, length 19.5 cm straight, smooth jaws, length 9.5 cm
494500 JOSEPH Knife,
curved, backward cutting, double beveled,
length 15 cm

It is recommended to check the suitability of the product for the intended procedure prior to use.
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 19

Instrument Set for Endoscopy-Assisted Extranasal Rhinoplasty

465001

465002

200900 465001 484800 486223

465002

200900 HEANLEY Rongeur,

straight, length 19 cm
465001 BRÜNINGS-LUC Septum Forceps,
size 1, working length 11 cm
465002 Same, size 2
484800 MASING Chisel,
straight, with rounded guard, straight, length 18 cm
486223 BEHRBOHM-WALTER Micro-Osteotome,
extra delicate, long, flat blade, double-edged
grinding, with round ergonomic handle and finger
grip plate, width 3 mm, length 19 cm
498809 AIACH Osteotome for Hump Removal,
with lateral guiding rod, width 10 mm
498810 Same, width 13 mm
498810 F Guide Rod,
for 498809 and 498810, only
498809
174200 COTTLE Metal Mallet, 498810
length 18 cm
498810 F 174200
20 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

Instrument Set for Endoscopy-Assisted Extranasal Rhinoplasty

791803 792013 DS 791600 511814

791803 JAMESON Scissors,

curved, pointed, delicate tips, length 15.5 cm
792013 DS MAYO Dissecting Scissors,
with tungsten carbide inserts, curved, length 15 cm,
color code: one black handle ring,
one gold-plated handle ring
791600 Scissors,
for suture, curved, sharp/sharp, length 12.5 cm
511814 KILNER Scissors,
curved, flat end, length 14 cm
791202 DS Scissors,
curved, sharp/blunt, length 14.5 cm,
color code: one gold-plated handle ring
513612 FOMON Lower Lateral Scissors,
strongly curved, length 12 cm

791202 DS 513612
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 21

Instrument Set for Endoscopy-Assisted Extranasal Rhinoplasty

533212 792320 532013 534015

533212 ADSON-BROWN Tissue Forceps,

atraumatic, fine side grasping teeth, length 12 cm
792320 Atraumatic Tissue Forceps,
tungsten carbide inserts, serrated, length 20 cm
532013 Tissue Forceps,
straight, with 7 x 8 fine teeth, length 13 cm
534015 COTTLE Lower Lateral Forceps,
bayonet-shaped, with set screw,
serrated tips and teeth on the inside, length 15 cm
22 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

Instrument Set for Auricular Reconstruction

786003

208000 786004 801706 801910 525515

801708 801911

208000 Surgical Handle,

Fig. 3, length 12.5 cm,
for Blades 208010 – 15, 208210 – 15
786003 Retractor,
sharp, 3 prongs, length 17 cm
801706 KOCHER-LANGENBECK Retractor,
size 55 x 11 mm, length 21.5 cm
801708 Same, size 65 x 14 mm
801910 MICCOLI Retractor,
double-ended, size 35 x 10 mm and 21 x 10 mm,
length 16 cm (2 pcs. recommended)
801911 Same, size 45 x 10 mm and 21 x 10 mm
525515 CASTROVIEJO Skin Measurement Caliper,
measurement range 0 – 150 mm, length 14 cm
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 23

Instrument Set for Auricular Reconstruction

798718

533112 533022 533214 511814 798618

533112 ADSON Tissue Forceps,

1 x 2 teeth, length 12 cm
533022 ADSON Dressing Forceps,
serrated, tungsten carbide inserts, length 12 cm
533214 ADSON-BROWN Tissue Forceps,
atraumatic, fine side grasping teeth,
tungsten carbide inserts, width 1.5 mm,
length 12 cm
511814 KILNER Scissors,
curved, flat end, length 14 cm
798718 HEGAR-MAYO Needle Holder,
robust, tungsten carbide inserts, length 18 cm
516012 HALSEY Needle Holder,
tungsten carbide inserts, length 12 cm 516012
24 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

VITOM® n
Visualization System for Open Surgery with Minimal Access
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 25

VITOM® n
Visualization System for Open Surgery with Minimal Access

The KARL STORZ VITOM® system represents a re­vo­lu­­ best possible recording and playback in FULL HD
tio­nary and innovative way of displaying open surgery quality.
with minimal access in a high quality and ergonomic
manner. The first-class enhanced imaging can be observed via
a FULL HD monitor from a convenient distance by the
VITOM® is based on the renowned HOPKINS® rod lens surgeon, the assistant as well as the entire OR team.
system from KARL STORZ. With the help of a holding
system, VITOM® is placed at a working distance of The VITOM® system has proven to be an excellent
25 – 75 cm above the surgical field. This gives the alternative to OR illumination cameras, loupes or
surgeon more room to work. op­erating microscopes in various surgical disciplines.
The small size of the VITOM® reduces space The VITOM® is equipped with an integrated fiber optic
re­quirements in the OR to a minimum. Due to its slim light transmission that enables the connection of cold
and compact design, the surgical field is not obstructed light sources used in endoscopy.
and even long instruments can be used with ease. The
VITOM® system provides great depth of field, optimal The system allows the further use of existing units. A
magni­fication, good contrast and excellent color FULL HD endoscope imaging solution from KARL STORZ
re­production, which are the ideal prerequisites for the can also be used with the VITOM® system.

The VITOM® system offers:

## Excellent FULL HD image quality ## Compact design requiring minimal space in the OR
## Great depth of view ## Useof existing KARL STORZ FULL HD endoscopy
## Large working distance system possible
## Ergonomic monitor work

Use of the VITOM® system in ENT surgery.

OR photographs courtesy of: Prof. Dr. Gero Strauss, Director of the International Reference and Development Center (IRDC),
Leipzig, Germany.
26 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

VITOM® n
System Overview

Exoscope

Camera System,
Monitor and Illumination

Mechanical
Holding System

VITOM® System Overview

Documentation System

Equipment Cart
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 27

VITOM® n
System Components

Exoscope and Illumination – 2nd Generation VITOM® Telescopes

Length 11 cm

8100 AA

8100 AA VITOM® Telescope 0° with Integrated Illuminator,

VITOM® HOPKINS® Straight Forward Telescope 0°,
working distance 25 – 75 cm, length 11 cm,
autoclavable, with fiber optic light transmission
incorporated and condensor lenses,
color code: green

Fiber Optic Light Cables 495 TIP or 495 NVC recommended

495 TIP 495 NVC

495 TIP Fiber Optic Light Cable,

highly heat resistant,
diameter 4.8 mm, length 300 cm
495 NVC Fiber Optic Light Cable,
with 90° deflection to the instrument,
very narrow radius of curvature,
diameter 4.8 mm, length 300 cm
28 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

VITOM® n
System Components

Exoscope and Illumination – 2nd Generation VITOM® Telescopes

Length 11 cm

8100 DA

8100 DA VITOM® Telescope 90° with Integrated Illuminator,

VITOM® HOPKINS® telescope 90°, working distance
25 – 75 cm, length 11 cm, autoclavable,
with fiber optic light transmission incorporated and
condensor lenses,
color code: blue

Fiber Optic Light Cable 495 TIP recommended

495 TIP

495 TIP Fiber Optic Light Cable,

highly heat resistant,
diameter 4.8 mm, length 300 cm
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 29

VITOM® n
System Components

20 9180 20

20 9180 20 V
 ITOM® 25 Distance Rod, length 25 cm

39501 A2

39501 A2 Wire Tray for Cleaning, Sterilization and Storage

of two rigid endoscopes and one light guide cable,
including holder for light post adaptors, silicone telescope
holders and lid, external dimensions (w x d x h):
352 x 125 x 54 mm, for rigid endoscopes up to
diameter 10 mm and working length 20 cm
30 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

VITOM® n
Specifications

Working distance: 25 – 75 cm

Depth of view at working distance of: 25 cm 50 cm 75 cm

Depth of view: approx. 3.5 cm approx. 7 cm approx. 10 cm

Field of view at working distance of: 25 cm 50 cm 75 cm

H3-Z camera zoom 1x 5 cm 10 cm 15 cm
H3-Z camera zoom 2x 3.5 cm 7 cm 10.5 cm

Reproduction scale at working distance of: 25 cm 50 cm 75 cm

26" Monitor:
H3-Z camera zoom 1x approx. 8x approx. 4x approx. 3x
H3-Z camera zoom 2x approx. 16x approx. 8x approx. 6x
42" Monitor:
H3-Z camera zoom 1x approx. 14x approx. 7x approx. 5x
H3-Z camera zoom 2x approx. 28x approx. 14x approx. 10.5x
52" Monitor:
H3-Z camera zoom 1x approx. 17x approx. 8x approx. 6x
H3-Z camera zoom 2x approx. 34x approx. 16x approx. 12x

Technical specifications are subject to change.

Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 31

VITOM® n
System Components

Cold Light Fountain XENON 300 SCB

Special Features:
## Extremely high light intensity due to 300 Watt ## Withintegrated KARL STORZ Communication Bus
Xenon lamp (KARL STORZ-SCB)
## Built-in antifog pump

20 1331 01-1 Cold Light Fountain XENON 300 SCB

power supply 100 – 125/220 – 240 VAC, 50/60 Hz

including:
Mains Cord
Silicone Tubing Set, length 250 cm
SCB Connecting Cable, length 100 cm

Specifications:
Lamp type XENON 15 V, 300 Watt Dimensions 305 x 165 x 335 mm
Color temperature 6000 K wxhxd
Light outlets 1 Weight 7.96 kg
Light intensity continuously adjustable via a membrane Certified to: IEC 601-1 and UL 544,
adjustment keyboard or KARL STORZ Communication protection class 1/CF
Bus Signal
32 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

IMAGE1 S Camera System n

Economical and future-proof
## Modular concept for flexible, rigid and ## Sustainable investment
3D endoscopy as well as new technologies ## Compatible with all light sources
## Forward and backward compatibility with video
endoscopes and FULL HD camera heads

Innovative Design
## Dashboard: Complete overview with intuitive ## Automatic light source control
menu guidance ## Side-by-side view: Parallel display of standard
## Live menu: User-friendly and customizable ­image and the Visualization mode
## Intelligent icons: Graphic representation changes ## Multiple source control: IMAGE1 S a ­ llows
when settings of connected devices or the entire the simultaneous display, processing and
system are adjusted ­documentation of image information from
two c ­ onnected image sources, e.g., for hybrid
operations

Dashboard Live menu

Intelligent icons Side-by-side view: Parallel display of standard image and

Visualization mode
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 33

IMAGE1 S Camera System n

Brillant Imaging
## Clear and razor-sharp endoscopic images in ## Reflection is minimized
FULL HD ## Multiple IMAGE1 S technologies for homogeneous
## Natural color rendition illumination, ­contrast enhancement and color
­shifting

FULL HD image CLARA

FULL HD image CHROMA

FULL HD image SPECTRA A *

FULL HD image SPECTRA B **

* SPECTRA A : Not for sale in the U.S.

** SPECTRA B : Not for sale in the U.S.
34 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

IMAGE1 S Camera System n

TC 200EN

TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to

3 link modules, resolution 1920 x 1080 pixels, with integrated
KARL STORZ-SCB and digital Image Processing Module,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz
including:
Mains Cord, length 300 cm
DVI-D Connecting Cable, length 300 cm
SCB Connecting Cable, length 100 cm
USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US
* Available in the following languages: DE, ES, FR, IT, PT, RU

Specifications:
HD video outputs - 2x DVI-D Power supply 100 – 120 VAC/200 – 240 VAC
- 1x 3G-SDI Power frequency 50/60 Hz
Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib
LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm
USB interface 4x USB, (2x front, 2x rear) Weight 2.1 kg
SCB interface 2x 6-pin mini-DIN

For use with IMAGE1 S

IMAGE1 S CONNECT Module TC 200EN

TC 300

TC 300 IMAGE1 S H3-LINK, link module, for use with

IMAGE1 FULL HD three-chip camera heads,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz,
for use with IMAGE1 S CONNECT TC 200EN
including:
Mains Cord, length 300 cm
Link Cable, length 20 cm

Specifications:
Camera System TC 300 (H3-Link)
Supported camera heads/video endoscopes TH 100, TH 101, TH 102, TH 103, TH 104, TH 106
(fully compatible with IMAGE1 S)
22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3,
22 2200 54-3, 22 2200 85-3
(compatible without IMAGE1 S ­technologies CLARA, CHROMA, SPECTRA*)
LINK video outputs 1x
Power supply 100 – 120 VAC/200 – 240 VAC
Power frequency 50/60 Hz
Protection class I, CF-Defib
Dimensions w x h x d 305 x 54 x 320 mm
Weight 1.86 kg

* SPECTRA A : Not for sale in the U.S.

** SPECTRA B : Not for sale in the U.S.
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 35

IMAGE1 S Camera Heads n

For use with IMAGE1 S Camera System
IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300
and with all IMAGE 1 HUB™ HD Camera Control Units

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head,

50/60 Hz, IMAGE1 S compatible, progressive scan,
soakable, gas- and plasma-sterilizable, with integrated
Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x),
2 freely programmable camera head buttons,
TH 100 for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-Z
Product no. TH 100
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 114 mm
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head,

50/60 Hz, IMAGE1 S compatible, autoclavable,
progressive scan, soakable, gas- and plasma-sterilizable,
with integrated Parfocal Zoom Lens, focal length
f = 15 – 31 mm (2x), 2 freely programmable camera head
TH 104 buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-ZA
Product no. TH 104
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 100 mm
Weight 299 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
36 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

Monitors
9619 NB 19" HD Monitor,
color systems PAL/NTSC, max. screen
resolution 1280 x 1024, image format 4:3,
power supply 100 – 240 VAC, 50/60 Hz,
wall-mounted with VESA 100 adaption,
including:
External 24 VDC Power Supply
Mains Cord
9619 NB

9826 NB 26" FULL HD Monitor,

wall-mounted with VESA 100 adaption,
color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image fomat 16:9,
power supply 100 – 240 VAC, 50/60 Hz
including:
External 24 VDC Power Supply
Mains Cord

9826 NB
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 37

Monitors

KARL STORZ HD and FULL HD Monitors 19" 26"

Wall-mounted with VESA 100 adaption 9619 NB 9826 NB
Inputs:
DVI-D l l
Fibre Optic – –
3G-SDI – l
RGBS (VGA) l l
S-Video l l
Composite/FBAS l l
Outputs:
DVI-D l l
S-Video l –
Composite/FBAS l l
RGBS (VGA) l –
3G-SDI – l
Signal Format Display:
4:3 l l
5:4 l l
16:9 l l
Picture-in-Picture l l
PAL/NTSC compatible l l

Optional accessories:
9826 SF Pedestal, for monitor 9826 NB
9626 SF Pedestal, for monitor 9619 NB

Specifications:
KARL STORZ HD and FULL HD Monitors 19" 26"
Desktop with pedestal optional optional
Product no. 9619 NB 9826 NB
Brightness 200 cd/m2 (typ) 500 cd/m2 (typ)
Max. viewing angle 178° vertical 178° vertical
Pixel distance 0.29 mm 0.3 mm
Reaction time 5 ms 8 ms
Contrast ratio 700:1 1400:1
Mount 100 mm VESA 100 mm VESA
Weight 7.6 kg 7.7 kg
Rated power 28 W 72 W
Operating conditions 0 – 40°C 5 – 35°C
Storage -20 – 60°C -20 – 60°C
Rel. humidity max. 85% max. 85%
Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm
Power supply 100 – 240 VAC 100 – 240 VAC
Certified to EN 60601-1, EN 60601-1, UL 60601-1,
protection class IPX0 MDD93/42/EEC,
protection class IPX2
38 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

VITOM® n
System Components

Mechanical Holding System

28272 UGN

28272 HC

28172 HR

28172 HM

28272 HC Articulated Stand, L-shaped, long, reinforced version, only,

especially large swivel range, with one mechanical central clamp
for all five joint functions, height 48 cm, swivel range 66 cm,
with quick release coupling KSLOCK (female)

28172 HR Rotation Socket, to clamp to the operating table,

with one mounted Butterfly Nut 28172 HRS, for European
and US standard rails, with lateral clamp for height and angle
adjustment of the articulated stand

28172 HM Extension Rod, 50 cm, with lateral clamp for height adjustment
of the articulated stand, for use with articulated stands 28272 HA,
28272 HB or 28272 HC and socket 28172 HK or 28172 HR

28272 UGN Clamping Jaw, metal, clamping range 16.5 up to 23 mm,

with quick release coupling KSLOCK (male),
for use with all square-headed KARL STORZ HOPKINS® telescopes

28272 UGK Clamping Jaw, with ball joint, large, clamping range 16.5 to 23 mm,
with quick release coupling KSLOCK (male),
for use with all square-headed KARL STORZ HOPKINS® telescopes
28272 CN Clamping Cylinder, folding, for flexible mounting of 10 mm telescopes
on the telescope sheath, autoclavable. The clamping cylinder allows
vertical movement and rotation of the telescope.
 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 39

VITOM® n
System Components

KARL STORZ AIDA® compact NEO advanced

Brilliance in documentation

Data Acquisition
Still images, video sequences and audio comments can easily be recorded
during an examination or intervention by pressing the on-screen button,
activitating the footswitch, or pressing the camera head button.
All captured data are displayed on the right-hand side as a thumbnail
preview to ensure the data have been generated. Patient data can be
AIDA compact NEO:
Recording screen entered via an onscreen or standard keyboard. The system also offers the
possibility to transfer all relevant patient data via a DICOM worklist or a link
to the hospital information system (HIS) without requiring manual entry in
the patient entry screen.

AIDA compact NEO:

Patient data

Flexible Review, Data Storage and Efficient Data Export

Captured still images or video files can easily be viewed, edited, or deleted
on-screen before final storage. KARL STORZ AIDA® compact NEO efficiently
stores all recorded data on DVD, CD, USB stick, external/internal drive,
the relevant network and/or on a FTP server. It is also possible to save the
data directly on the PACS and/or HIS servers via HL7/DICOM. Data that
AIDA compact NEO: cannot be stored successfully remains in a cache until final archiving is
Review screen possible.

Special Features:
## SD and HD signal support:
– Y/C (S-Video)
– Composite input
– DVI-D input
## Picture-in-Picture function:
Display of channel 2 (SD) in channel 1 (FULL HD)
## Resolution:
– Still images 1920 x 1080 and SD
– Videos 1080p, 720p and SD
## Interface package (DICOM/H7) included
## NEO Secure security software
## Recommended applications:
– Universal (cart or OR1™ installation)

20 0409 13-EN* 
KARL STORZ AIDA® compact NEO advanced
Documentation system for digital storage of still images,
video sequences and audio files, power supply 115/230 VAC, 50/60 Hz

*  Available in the following languages:

DE, ES, FR, IT, PT, PL, RU, DK, SE, JP, CN
40 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

VITOM® n
System Components

Documentation System

20 0905 19 19" KARL STORZ Touch Screen, 24V, wall mounting,

RS 232, VGA, resolution max. 1280 x 1024 (SXGA mode),
including RS 232 cable, SVGA cable,
mains cord and external power supply 24 VDC,
power supply 100 – 240 VAC, 50/60 Hz

041265-20* Sterile Cover, for 19“ KARL STORZ touch screen

29005 MSK Monitor Holding Arm, height and side adjustable,

tilting, can be mounted either on the left or on
the right side, swivel range 190°, reach 300 mm,
loading capacity max. 15 kg, with monitor holder
VESA 75/100, for Equipment Carts 29005 xx

This product is marketed by mtp.

For additional information, please apply to:

* mtp medical technical promotion gmbh,

Take-Off Gewerbepark 46,
D-78579 Neuhausen ob Eck, Germany
Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction 41

Equipment Cart

UG 220 Equipment Cart

wide, high, rides on 4 antistatic dual wheels
equipped with locking brakes 3 shelves,
mains switch on top cover,
central beam with integrated electrical subdistributors
with 12 sockets, holder for power supplies,
potential earth connectors and cable winding
on the outside,
Dimensions:
Equipment cart: 830 x 1474 x 730 mm (w x h x d),
shelf: 630 x 510 mm (w x d),
caster diameter: 150 mm
inluding:
Base module equipment cart, wide
Cover equipment, equipment cart wide
Beam package equipment, equipment cart high
3x Shelf, wide
Drawer unit with lock, wide
2x Equipment rail, long
Camera holder
UG 220

UG 540 Monitor Swivel Arm,

height and side adjustable,
can be turned to the left or the right side,
swivel range 180°, overhang 780 mm,
overhang from centre 1170 mm,
load capacity max. 15 kg,
with monitor fixation VESA 5/100,
for usage with equipment carts UG xxx

UG 540
42 Cartilage Grafts and Preassembled Autografts for Rhinoplasty and Auricular Reconstruction

Recommended Accessories for Equipment Cart

UG 310 Isolation Transformer,

200 V – 240 V; 2000 VA with 3 special mains socket,
expulsion fuses, 3 grounding plugs,
dimensions: 330 x 90 x 495 mm (w x h x d),
for usage with equipment carts UG xxx

UG 310

UG 410 Earth Leakage Monitor,

200 V – 240 V, for mounting at equipment cart,
control panel dimensions: 44 x 80 x 29 mm (w x h x d),
for usage with isolation transformer UG 310

UG 410

UG 510 Monitor Holding Arm,

height adjustable, inclinable,
mountable on left or rigth,
turning radius approx. 320°, overhang 530 mm,
load capacity max. 15 kg,
monitor fixation VESA 75/100,
for usage with equipment carts UG xxx

UG 510
 WITH COMPLIMENTS OF
KARL STORZ–– ENDOSKOPE