Graf ting in Rhinoplasty

Michael J. Brenner, MDa,*, PeterA. Hilger, MD, FACSb

KEYWORDS
 Rhinoplasty  Graft  Grafting
 Structure  Framework  Cartilage

PHILOSOPHICAL CONSIDERATIONS long-term results, emphasis is placed on the use of

autogenous cartilage grafts, which are associated
Traditional practice in rhinoplasty has tended to with more favorable outcomes and lower compli-
rely on resection of the nasal osseocartilaginous cation rates than other, alternative grafting
framework to achieve aesthetic or functional ob- materials.1,2 This topic alone can justify an inde-
jectives. Most successes using this approach pendent text, and we are sensitive to the con-
have proved short lived because the weakened straints associated with this publication.
nasal scaffold remaining after reductive surgery Therefore, we have provided concise descriptions
often has inadequate strength to withstand the and illustrations of the relevant surgical techniques
contractile forces of healing. The classic stigmata and appended a detailed bibliography for readers
of an overresected nose, including alar retraction, seeking further discussion.
internal and external nasal valve collapse, midvault The soft tissue skin envelope and its underlying
collapse, loss of tip support and projection, and osseocartilaginous framework are intimately re-
unnatural sharp contours such as bossae forma- lated, together influencing the external appear-
tion, have become all too familiar to the revision ance and functionality of the nose.3 In primary
rhinoplasty surgeon. The loss of structural integrity rhinoplasty, suboptimal surgical outcomes com-
observed in patients who have saddle nose defor- monly result from the buckling of a weakened na-
mity is frequently an iatrogenic complication sal skeleton that lacks sufficient structural rigidity
caused by failure to preserve an adequate dorsal to withstand the contracture forces generated by
strut at the time of surgery. The resulting pattern the healing soft tissue skin envelope. In revision
of dorsal and middle vault depression, tip overro- rhinoplasty, the limiting factor in correcting a previ-
tation, loss of tip projection, retraction of the colu- ously operated nose is frequently the quality, de-
mella, and unnatural contours in these patients is gree of contraction, and lack of elasticity of the
disfiguring and functionally crippling. The poor du- soft tissue skin envelope and the intranasal lining.4
rability of aesthetic outcomes and the progressive It is therefore imperative that the surgeon be able
functional impairment associated with reductive to understand and conceptualize the dynamics
surgery have provided a major impetus for the de- of postoperative healing while manipulating the
velopment of grafting approaches in rhinoplasty. nasal framework. Moreover, the surgeon must
This article details the role of structural and aes- possess the requisite skill and intellectual dexterity
thetic grafting in rhinoplasty with the objective of to modify the proposed surgical plan, because dis-
promoting reproducible and durable surgical out- torted anatomy is frequently encountered during
comes. A review of the various grafting materials surgery. Virtually all techniques designed to pro-
available to the rhinoplasty surgeon is followed vide focal alteration of form or function will have
by a discussion of the relevant anatomy, terminol- secondary effects in other areas of the nose. The
ogy, and indications for each grafting approach. In skilled rhinoplasty surgeon anticipates these alter-
keeping with the objective of achieving predictable ations and adjusts the procedure appropriately.
facialplastic.theclinics.com

a
Division of Otolaryngology–Head & Neck Surgery, Department of Surgery, Southern Illinois University School
of Medicine, 747 North Rutledge Street, P.O. Box 19649, Springfield, IL 62794-9649, USA
b
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery,
University of Minnesota School of Medicine, 7373 France Avenue South, Minneapolis, MN 55435-4534, USA
* Corresponding author.
E-mail address: mjbrenner@gmail.com (M.J. Brenner).

Facial Plast Surg Clin N Am 17 (2009) 91–113

doi:10.1016/j.fsc.2008.09.009
1064-7406/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
92 Brenner & Hilger

Conservative resection, framework remodeling,

and judicious use of grafts for augmentation com-
prise the basis for a structural approach to grafting
in rhinoplasty.5 In primary rhinoplasty, major and
minor support mechanisms are often weakened
by surgical maneuvers. Grafts are used to recon-
stitute support elements thus compromised and
to effect desired changes. In contrast, revision rhi-
noplasty often involves rebuilding nasal framework
in the setting of significant structural deficiency.
Excessive resection involving the lower lateral
crura, the caudal septum, and the nasal dorsum
is often compounded by disruption of other tip
support elements. The resulting weakening of the
nasal architecture is further exacerbated by scari-
fication of the nasal lining and external soft tissue
covering. The surgeon can use appropriately se-
lected grafting techniques to correct problematic
anatomy or to protect at-risk areas. A systematic
approach to grafting makes it possible to achieve
lasting improvement in aesthetic appearance and
nasal function, always taking care not to compro-
mise function in the pursuit of aesthetic gain.

GRAFT MATERIALS
Various grafts and implants are available for use in
primary and revision rhinoplasty. Although no ideal
grafting material exists, with appropriate graft se-
lection and sound surgical technique, dependable
outcomes can be achieved. Grafts can be broadly
categorized into autogenous, homologous, and
alloplastic types. Injectable agents such as
hyaluronic acid fillers are occasionally used for
refinements.6

Autogenous Grafts
Autogenous grafts are harvested from the patient
and include cartilage, bone, and various soft tis-
Fig.1. Autogenous grafting materials. (A) Septal carti-
sues, such as perichondrium and temporalis
lage. (B) Conchal cartilage. (C) Costochondral graft
fascia. Autogenous cartilage is the structural graft- (‘‘floater rib’’).
ing material of choice because of its ease of carv-
ing and reliable long-term outcome, with low rates
of infection, resorption, and extrusion.7–9 Autoge-
nous grafts also avoid the potential risk for an im- and has reliable long-term results. It is useful for
mune response or viral contamination. Cartilage spreader grafts, columellar struts, alar battens,
grafts are useful for providing structural scaffold- dorsal augmentation, and alar rim grafts. Septal
ing and creating contour. Representative septal, cartilage can also be crushed to provide volume
auricular, and costochondral grafts are shown in augmentation or to soften contour transitions.
Fig. 1. When crushed, cartilage remains viable When harvesting septal cartilage, it is important
and supports the growth of surrounding that a 1.0- to 1.5-cm L-shaped caudal and dorsal
cartilage.10 strut is maintained. Septal cartilage is often limited
Septal cartilage is the most commonly used in the revision rhinoplasty setting. For major revi-
grafting material in primary rhinoplasty, owing to sions, we prefer to harvest cartilage using an
its straightforward harvest and lack of functional open rhinoplasty approach in which bilateral sub-
or cosmetic donor site morbidity. Furthermore, mucoperiosteal and submucoperichondrial flap el-
septal cartilage is particularly versatile in grafting evation is combined with division of the upper
 Grafting in Rhinoplasty 93

lateral cartilages. With this approach, the septum the use of continuous infusion anesthetic pumps
and nasal dorsum are ‘‘ouvert au ciel’’ (open to with 0.25% bupivacaine to be a simple and effec-
the sky), achieving unparalleled exposure for diag- tive method for managing postoperative pain and
nosis, harvest of residual structural material, and decreasing the need for systemic analgesia.
treatment of structural deformities. Autogenous bone grafts for rhinoplasty are most
Auricular cartilage is usually harvested for use in useful for grafting of the upper third of the nose
revision rhinoplasty when septal cartilage is inade- and are obtained from the calvarium, the rib, or,
quate. The auricular cartilage is more malleable less frequently, the iliac crest. Calvarial bone,
than septal cartilage and has a curved shape. which is membranous bone, resists resorption
This curvature and pliability make auricular carti- and maintains contour more effectively than iliac
lage a less desirable grafting material for certain bone, which is of endochondral origin.11 Calvarial
purposes, such as when spreader grafts are bone is also associated with less donor site mor-
needed or a thin columellar strut is desired. It is bidity, although complications of cerebrospinal
useful to determine preoperatively if one ear is fluid leakage, sagittal sinus laceration, intracranial
more prominent than the other, because conchal injury, and subdural hematoma have been de-
harvest may confer a subtle decrease in the prom- scribed.12 Calvarial bone is harvested as a split
inence of the donor ear. Alternatively, the surgeon calvarial bone graft through a hemicoronal incision
may ask the patient if he or she prefers to sleep on over the parietal skull. Rib cartilage is much pre-
a given side (a ‘‘sleep crease’’ is often discernible ferred to rib bone grafts. Although autogenous
in the preauricular region on this side) and then use bone grafting is well established in the rhinoplasty
the contralateral ear. We prefer to harvest auricular literature,13 we seldom use these donor sites be-
cartilage grafts from a postauricular approach be- cause of susceptibility to fracture, greater difficulty
cause the dissection is straightforward and the in- of carving and securing grafts, tendency for a rigid
cision is hidden. When the conchal bowl is tip or visible graft step-off, and the potential for
harvested, care is taken to preserve the antihelical significant donor site morbidity.
fold and a strut of cartilage projecting from the Various other autogenous materials are also
crus helicis, which divides the concha cymba useful for soft tissue augmentation in rhinoplasty,
and concha cavum. These measures avoid defor- principally as adjuncts to structural grafting. Ex-
mity of the auricle. The soft tissue dead space of amples include costal perichondrium (collected
the donor site is eliminated by a Betadine ointment at the time of costochondral graft harvest), tempo-
bolster that is secured with through-and-through ralis fascia, and fibroadipose tissue from the post-
3-0 nylon sutures. The concha cymba has dimen- auricular region that can be flattened into a thin
sions, contour, and structural characteristics sim- sheet with an otologic fascia press. Each of these
ilar to the lower lateral cartilage, making it tissues can be harvested with little or no additional
a favorable donor site for reconstruction of this donor site morbidity. These grafts may confer
structure. Composite grafts from this site may significant aesthetic benefit by softening the
prove particularly useful in the correction of alar re- framework–soft tissue interface. Most commonly,
traction. The concha cavum has a concave shape these tissues are used to camouflage cartilage
that makes it advantageous for tip grafts, alar bat- grafts or to correct minor contour irregularities. In
tens, and dorsal onlay grafts. revision rhinoplasty, soft tissue may be used to un-
Costochondral grafts afford the rhinoplasty sur- derlay skin that is thin and atrophic secondary to
geon ample grafting material for the structurally scarring, contracture, or steroid injection. This
deficient nose. Rib cartilage is most likely to be re- soft tissue decreases the risk for graft extrusion,
quired either after a disfiguring traumatic injury or prevents bossae formation, protects the overlying
following overzealous resection during prior re- soft tissue skin envelope, and improves the overall
ductive rhinoplasty. The excellent quality and quality of the skin envelope.14 Tragal cartilage or
quantity of costal cartilage make this the donor perichondrium may also be used for small grafts.
site of choice when septal and auricular cartilage
is insufficient. The principal disadvantages of rib
Homologous Grafts
cartilage are the tendency for warping, the donor
site scar and postoperative pain, the potential for The most commonly used homografts are irradi-
rigidity and calcification of the cartilage in the ma- ated rib for structural grafting and acellularized
ture patient, and the added operative time. The pa- dermal matrix for soft tissue augmentation. Histor-
tient must also be counseled regarding the small, ically, these grafts, derived from human cadavers,
yet well-established, risks for infection, hema- have proved less predictable than autogenous tis-
toma, postoperative splinting, and pneumothorax sue in their ability to resist resorption and warping;
associated with this donor site. We have found however, experience has been mixed.15–18 The
94 Brenner & Hilger

potential risk for transmission of human pathogens throughout the life of the patient. Not all synthetic
also remains a concern for patients. Nonetheless, agents have withstood the test of time. Polyamide
these grafting materials are useful in selected pa- mesh (Supramid), which exhibited excessive deg-
tients who are poor candidates for harvest of au- radation and resorption in animal models, is now of
togenous tissue or who are unwilling to have an historic interest only. Polytetrafluoroethylene (Pro-
additional donor site. These situations occur only plast) demonstrated fragmentation with mechani-
rarely. Costal cartilage homografts are harvested cal stress in temporomandibular joint surgery,
from prescreened cadavers and are subjected to leading to its removal from the United States
at least 30,000 Gy of radiation to decrease antige- market.
nicity. These grafts are associated with low infec-
tion and extrusion rates, although soaking in SPECIFIC GRAFTING TECHNIQUES
antibiotic solution before use is still recommen-
ded. Acellularized dermal matrix has been shown Many grafting techniques have been described for
to have significant resorption within the first year, use in primary and revision rhinoplasty. These
although this tendency for resorption may stabilize techniques are categorized by anatomic site in
thereafter.19,20 Because of this limitation, acellular- the discussion that follows. Although the descrip-
ized dermal matrix is more appropriately used for tions are intended to reflect common uses of par-
graft camouflage and smoothing contour under ticular grafts, many techniques are versatile and
thin skin than for volume augmentation. can be adapted to suit the particular deformity en-
countered. Furthermore, this article covers only
Alloplasts the more common grafts used in rhinoplasty.
In recent years, alloplasts have become more pop- Many of these grafts may be placed by either en-
ular because of their relative ease of use, limitless donasal or external rhinoplasty approaches. The
supply, predesigned or easily adaptable shape, endonasal approach avoids a columellar scar
and lack of donor site morbidity. Most alloplasts and may reduce postoperative edema; however,
are polymers, which are long chains of molecular in the severely overresected nose, an external rhi-
subunits. The more commonly used implants in- noplasty approach should be considered. The ex-
clude expanded-porous polytetrafluoroethylene ternal approach allows for improved diagnosis and
(e-PTFE; Gore-Tex),21 porous high-density poly- is most conducive to reconstructing major frame-
ethylene (PHDPE; Medpor),22 polyester fiber work deficiencies, performing precise graft place-
mesh (Mersilene),23 and silicone, which is used pri- ment, and correcting asymmetries.
marily in Asian patients who have thick skin.24 The
Grafts of the Nasal Tip
biologic response elicited by the host after use of
an allograft is influenced by the chemical composi- Columellar struts
tion and the physical characteristics of the graft. The columellar strut provides structural support to
The implantation of all alloplasts causes an inflam- the nasal tip and improves tip projection. It has be-
matory response. In the acute phase, neutrophils come one of the workhorse grafts in rhinoplasty. As
and macrophages are recruited, and protein mate- shown in Fig. 2, the graft is placed between the
rial coats the implant. Fibroblasts deposit colla- paired intermediate and medial crura, using either
gen, and phagocytosis occurs for implant an endonasal or open rhinoplasty approach. The
particles smaller than 60 micrometers; particles need for a strong columellar strut is most evident
larger than 20 micrometers cause macrophage in noses with short, weak, or flared medial and in-
death and secondary release of local inflammatory termediate crura. For endonasal positioning, an in-
mediators.24 cision may be made in the columella, usually caudal
The presence and size of pores influence the to the medial crura.27 Alternatively, an incision may
tendency for fibrovascular ingrowth and the risk be made either through a small vertical incision be-
for infection.25 Alloplasts with pores that are tween the medial crura or through the skin of the na-
greater than approximately 50 micrometers will sal vestibule and medial crura on one side. When
exhibit tissue ingrowth, with larger pores support- using an open rhinoplasty approach, the graft is su-
ing correspondingly greater ingrowth. PHDPE has tured to the medial crura. Care should be taken to
large pores that permit soft tissue and limited bony avoid unintended distortion of the nasal tip contour
ingrowth. These PHDPE grafts are difficult to re- or the infratip lobule. The graft must be placed short
move, but they are also more resistant to infec- of the domes to avoid excessive prominence with
tion.26 In contrast, e-PTFE has smaller pores, a ‘‘unidome’’ configuration. Preserving a small
making it more readily removable after implanta- amount of soft tissue over the nasal spine prevents
tion. Silicone forms a fibrous capsule without in- clicking and displacement of the graft with lip
growth and carries a persistent risk for extrusion movement. For greater stability, the columellar
 Grafting in Rhinoplasty 95

Fig. 2. Columellar strut. The columellar strut, one of the ‘‘workhorse’’ grafts of structural rhinoplasty, is placed be-
tween the paired intermediate and medial crura. (A) Lateral view. (B) Placement of graft. (C) Columellar strut in
position.

strut may be secured to the nasal spine or premax- These grafts are used primarily to camouflage ir-
illa. Septal or costal cartilage is preferable, although regularities or to achieve subtle increases in tip
double-layered auricular cartilage will often provide projection or contour. Beveling or morselization
sufficient strength. Using the perpendicular plate of of the edges minimizes the likelihood of visibility
the ethmoid or other bone grafts is also effective but or palpability. The Peck graft (see Fig. 3) is
requires perforation before suturing. In the patient a type of onlay tip graft that is made from conchal
who has a dependent caudal septum requiring or septal cartilage. It is classically rectangular and
increased projection, establishing a tongue-in- abuts on the domes. The contoured auricular pro-
groove relationship between the medial crura and jection graft is a saucer-like disc of cartilage taken
the nasal septum will achieve stability similar to a col- from the concha cymba or concha cavum29 and is
umellar strut without the need for graft placement. useful in rhinoplasty on Asian patients. Cap grafts
are classically derived from remnant cartilage af-
Onlay tip grafts ter cephalic volume reduction of the lower lateral
These grafts are placed over the alar domes as cartilage (see Fig. 3). These cap grafts are small
single or multilayer grafts (Figs. 3 and 4), using ei- nasal tip grafts used to soften or fill areas of cleft-
ther an endonasal or an external approach.28 ing at the nasal tip. They are helpful in improving
96 Brenner & Hilger

Fig. 3. Tip grafting. (A) Base view, showing beveled edges of graft that minimize visible edges. (B) Peck graft, with
its classically rectangular shape. (C) Cap graft. Cephalic volume reduction of the lower lateral cartilage provides
donor cartilage that may be used as a cap graft of the nasal tip.

the contour of the nasal tip in patients who have positioned over the medial crura, extending from
thin skin. The graft is placed in the space between the medial crural footplates to the nasal tip.31 Ex-
the tip-defining points and the medial crura. The amples of these grafts are shown in Fig. 6. Initial
term ‘‘umbrella graft’’ is used to describe the enthusiasm for these grafts was considerable be-
use of an onlay tip graft in conjunction with a col- cause of their usefulness in increasing tip projec-
umellar strut; the columellar strut is the umbrella tion, defining the nasal tip, and improving the
shaft and the tip onlay graft secured to it forms contour of the infratip region. However, the ten-
the top of the umbrella (Fig. 5).30 Placement of dency of these grafts to leave a visible ‘‘tomb-
tip grafts over the tip-defining points will increase stone’’ impression on the overlying skin
tip projection and definition, whereas placement subsequently led to much more selective usage.
of these grafts at and below the tip-defining These grafts are best reserved for patients who
points will increase projection and add volume have thick skin, and the edges should be exten-
to the infratip lobule. Whenever possible, it is de- sively beveled to minimize visibility. Morselization
sirable to stabilize the grafts within a precise may be beneficial. The extended shield graft,
pocket. Securing the grafts with fine sutures, par- sometimes termed an ‘‘extended columellar
ticularly with stacked grafts, also minimizes the strut-tip graft’’, extends anteriorly beyond the
risk for graft displacement. domes to provide added tip projection.32 In such
cases, a small cartilage block placed beneath the
Shield grafts graft at the level of the nasal tip may be helpful
Shield grafts, sometimes termed Sheen or infra- to increase stability and projection, as shown in
lobular grafts, are shield-shaped grafts that are Fig. 6. These grafts provide the added benefit of
 Grafting in Rhinoplasty 97

Fig. 4. Multilayer tip grafts. Two or more cartilage grafts, usually secured together with suture, may be stacked to
achieve greater projection than is possible with a single graft. (A) Frontal view. (B) Frontal view of tip graft shown
in cadaver with soft tissue skin envelope removed. (C) Lateral view.

derotation of the overrotated nose. The use of con- (Fig. 7). It is carved from auricular cartilage and
chal cartilage for this graft improves its pliability is used to replace or reinforce the lateral crura,
and confers a softer contour, thereby decreasing thereby enhancing tip support or projection.33,34
the risk for a visible graft silhouette after resolution The subdomal graft, which is placed transversely
of edema. as a bar under the domes, is used to correct
dome asymmetry.35 It has found application in
Other grafts of the nasal tip the correction of the pinched nasal tip and in
Other, less common, grafts also warrant mention. stabilizing the vertical and horizontal orientation
The anchor graft, so named for its shape, has of the domes. Various autogenous materials
paired transversely oriented curved wings are useful in softening the appearance of
98 Brenner & Hilger

Fig. 5. Umbrella graft. This graft integrates an onlay tip graft with a columellar strut; the columellar strut is the
umbrella shaft and the tip onlay graft is the top of the umbrella. (A) Frontal view. (B) Lateral view. (C) Base view
of umbrella graft in anatomic position.

cartilaginous grafts and in camouflaging subtle Grafts of the Alar Region

irregularities that may become unmasked in the
Alar batten grafts
weeks to months after surgery, as the edema
Aesthetic and functional impairment may arise
resulting from the operation gradually resolves
from deformity of the external nasal valve or inter-
(Fig. 8). Fibroadipose tissue or temporalis fascia
nal nasal valve, or deepening of the alar-nasal
are readily harvested from the postauricular
groove (Fig. 9).36 Alar batten grafts, shown in
region, often at the time of conchal cartilage har-
Fig. 10, are placed in a pocket that extends from
vest. Use of perichondrium, crushed cartilage, or
the piriform aperture to the paramedian position.
connective tissue should always be considered
The exact position of the graft is determined by
when performing rhinoplasty on patients who
the site of maximal collapse. Therefore, the graft
have thin skin.

Fig. 6. Shield grafts. Sometimes termed ‘‘Sheen’’ or ‘‘infralobular’’ grafts, these shield-shaped grafts are carved in
various shapes and then positioned over the medial crura, extending from the medial crural footplates toward
the nasal tip. (A) Frontal view, showing examples of various types of shield grafts. (B) Base view of shield graft.
Note beveling of edges to avoid a visible ‘‘tombstone’’ appearance through skin. (C) Extended shield graft with
small cartilage block (green) to improve stability and projection.
 Grafting in Rhinoplasty 99

Fig. 7. Anchor graft. This modified infratip shield graft, named for its characteristic shape with curved wings, is
used to enhance tip projection, improve alar rim position, and augment the infratip region. (A) Frontal view.
(B) Base view. (C) Anchor graft shown in cadaver with soft tissue skin envelope removed.

may extend inferior to the caudal aspect of the lat- When placed through an external rhinoplasty
eral crus or even toward the alar rim for correction approach, we suture fixate the graft to the surface
of an overresected lateral crura or external nasal of the lateral crura in at least two locations to en-
valve collapse. More cephalad positioning allows sure adequate stability. Precise pocket prepara-
for treatment of internal nasal valve collapse. tion is necessary for endonasal placement. In
Care must be taken with the grafts to avoid crea- either approach, we routinely place a 5-0 absorb-
tion of a bulbous appearance or visible promi- able suture from the vestibular lining, through the
nence. In patients who have thin skin, lateral lower lateral cartilage in the hinge area, and
crural strut grafts (discussed below) may be used through the graft and alar skin. A small cutaneous
to achieve improved airway patency with minimal stab incision is then made adjacent to the projec-
risk for distortion. Auricular cartilage and septal ting needle tip to avoid dimpling, and the suture is
cartilage are most commonly used, although brought back through the tissues as a simple stitch
PHDPE grafts are also available. and tied intranasally.
100 Brenner & Hilger

cephalic malposition of the lower lateral cartilages.

Additional uses include correction of alar flare and
treatment of alar contour irregularity. Cartilaginous
alar grafts are nonanatomic grafts that are placed
in a subcutaneous pocket immediately above the
alar rim. They can be placed through an external
rhinoplasty approach, a marginal incision, or
a small stab incision just inside the alar margin.
Alar rim grafts should be placed so that they do
not cross the soft tissue triangle, and the leading
edge can be softened to avoid bossae formation.
When we place these grafts through an external
approach, we stabilize them with a 6-0
absorbable suture anteriorly, thereby avoiding mi-
gration superiorly. These grafts are typically capa-
ble of achieving 1 to 2 mm of inferior displacement
of ala. A large alar batten that extends caudally
functions as a combined alar batten and alar rim
graft.

Composite grafts
In cases of severe alar retraction, where a rim graft
will not achieve adequate correction, a composite
graft is necessary (Fig. 12).38 Composite grafts
typically consist of skin, cartilage, and the inter-
vening perichondrium and connective tissue ele-
ments. These grafts may be harvested from
various locations, including the concha cymba,
concha cavum, or auricular root. Usually, the car-
tilaginous portion of the graft is larger than the
overlying skin to maximize the structural augmen-
tation. These grafts are also beneficial in the treat-
ment of vestibular stenosis.

Lateral crural strut graft

The lateral crural strut graft, shown in Fig. 13, is
well suited to the thin-skinned patient who has
a moderate degree of alar collapse and in whom
an unfavorable aesthetic result would be expected
with alar batten grafting. Lateral crural strut grafts
allow for correction of alar rim collapse, deformed
Fig. 8. Autogenous camouflage grafts. These grafts lateral crura, and mild alar retraction.39 These
can camouflage subtle contour irregularities and grafts, like alar batten grafts, are effective for
soften the appearance of cartilaginous grafts. They straightening the lateral crus, especially when re-
are particularly useful in patients who have thin curvature of the lower lateral crura is present.
skin. (A) Perichondrium. (B) Postauricular incision for These grafts are also useful in providing support
harvest of conchal cartilage allows access to plentiful
to the nasal tip when cephalic malposition is pres-
fibroadipose tissue. (C) Crushed cartilage.
ent and the alae must be repositioned. These
grafts require dissection of the vestibular skin
from the undersurface of the lower lateral cartilage
Alar rim grafts and are placed between the lateral crus and the
Alar rim grafts, sometimes referred to as alar con- vestibular skin. The lateral aspect of the rim graft
tour grafts, are useful in the prevention or correc- is usually positioned superficial to the piriform ap-
tion of alar retraction (Fig. 11).37 These grafts erture and caudal to the alar groove. Although ex-
also afford the alae sufficient rigidity to resist col- tremely useful, these grafts are more technically
lapse, as would otherwise occur in cases of difficult than batten grafts. They also tend to
 Grafting in Rhinoplasty 101

Fig. 9. Sites of nasal collapse. (A) Internal and external nasal valve collapse occurs in the purple region, which
spans the lower third of the nose and caudal aspect of the nasal midvault, including the hinge area. Alar batten
grafts can be placed anywhere in this region. The midvault (blue region) is classically stented with spreader grafts.
Nasal bones (green) denote upper third of nose. (B) Recurvature of the lower lateral crura (green) narrows the
nasal airway and can be corrected with cartilaginous grafting. (C) Collapse at hinge area on cadaveric
specimen is denoted by the broken line ellipse.

protrude slightly into the nasal airway and impart These grafts are among the most commonly
less structural rigidity than alar batten grafts. used and versatile grafts in both primary and revi-
sion rhinoplasty. They are frequently used to re-
Other grafts of the alar region construct an open roof deformity and to smooth
Several other, less common, alar grafts have also the brow–tip aesthetic line. Spreader grafts pre-
been described. The lateral crural spanning graft, vent or correct midvault collapse by stenting
also referred to as an alar spreader graft, is a trans- open the internal nasal valve, thereby avoiding
verse graft that spans the intercrural space medial displacement of the upper lateral carti-
(Fig. 14).40 This graft allows for correction or pre- lages.42 Occasionally, grafts with asymmetric
vention of an overly narrowed or pinched nasal width are helpful in managing pre-existing mid-
tip. It is secured to both lateral crura for stabiliza- vault irregularities. We usually place these grafts
tion and must be beveled to avoid being discern- through an external approach to facilitate suture
able postoperatively. These grafts may make the fixation after the upper lateral cartilages and sep-
tip more bulbous if not carefully contoured. Lateral tum are separated. We seldom place spreader
crural turnover grafts are used to create thicker grafts beneath intact lower lateral cartilages be-
and stronger lateral crura. Longitudinal scoring or cause this method produces less reliable
partial-thickness incision along the undersurface outcomes.
of the lateral crura is followed by suturing of the ce- Several adaptations to the spreader grafts have
phalic portion of the lateral crura to its caudal rem- been described. The term ‘‘pistol grafts’’ refers to
nant.41 The lateral crural onlay graft is used to spreader grafts that extend above the dorsal sep-
strengthen and shape alae that are weakened or tum to augment the dorsum. When performing this
have irregular contour. The grafts are placed over maneuver, it is important to appropriately camou-
the lateral crus to improve external nasal valve flage the irregularity that is produced. When
function. This graft has some similarity to the alar spreader grafts project caudally to lengthen the
batten graft, although it more closely mirrors alar nose or increase tip projection, they are referred
cartilage anatomy. Care must be taken to bevel to as extended spreader grafts or septal extension
these grafts so as to avoid a ‘‘step-off’’ deformity. grafts.43 The caudal ends of the grafts are sutured
to the medial surfaces of the intermediate crura of
Grafts of the Nasal Dorsum and Midvault
the lower lateral cartilages, thereby providing tip
Spreader grafts (and extended spreader grafts) derotation. The dynamic adjustable rotational tip
Spreader grafts, shown in Fig. 15, are longitudi- (DART) grafts are long spreader grafts used to cor-
nally oriented grafts, usually paired, that are se- rect tip deprojection and overrotation in patients
cured deep to the mucoperichondrium between who have overly resected, weakened cartilage
the nasal septum and upper lateral cartilages. frameworks.44 Spreader grafts may also extend
102 Brenner & Hilger

Fig. 10. Alar batten grafts. These grafts extend from the piriform aperture to the paramedian position and are
positioned at the site of maximal collapse. (A) Frontal view showing standard position of alar batten grafts in
blue. Purple indicates the larger range of possible placement for these grafts, depending on the site of collapse.
(B) Three-quarter view showing a large alar batten graft carved from auricular conchal cartilage. The graft con-
vexity will promote nasal airway patency. (C) Graft in position.

cephalically to slightly widen the bony nasal pyra- that span from the nasal septum, beyond the ante-
mid, although widening at this site is only occa- rior septal angle, and into the interdomal region
sionally indicated. (Fig. 16). A second type of septal extension graft
involves cartilage grafts that run diagonally from
Septal extension grafts and septal the septal angle to the tip–lobule complex. The
replacement grafts third type of graft, sometimes termed a ‘‘caudal
Septal extension grafts include various grafts that septal extension graft’’, is a direct extension from
are used to enhance nasal tip dynamics by build- the caudal septum that can control the projection,
ing stable framework onto the existing septal scaf- rotation, and strength of the tip (Fig. 17). This graft
fold.45,46 The size and position of septal extension confers considerable strength and stability be-
grafts are varied to influence projection, to dero- cause of its rigid foundation. The medial crura
tate the tip, or to fill out the columella-labial angle, can be repositioned along this augmented sep-
thereby suggesting tip rotation. Some septal ex- tum, and lateral crural steal may be used to opti-
tension grafts are actually long spreader grafts mize tip projection. In cases in which a caudal
 Grafting in Rhinoplasty 103

Fig.11. Alar rim grafts. Also referred to as alar contour grafts, these grafts are used to correct alar retraction and
to provide support to the external nasal valve. (A) Frontal view. (B) Lateral view. (C) Alar rim graft in anatomic
position.

septum is weak or missing, resulting in alar-colu- sufficient for refinement of the nasal dorsum, cos-
mellar disproportion, a septal extension graft or tal cartilage is indicated in those cases where ma-
caudal septal replacement graft (Fig. 18) will im- jor augmentation is required. Examples include
prove tip support and correct columellar severe saddle nose deformity, traumatic compres-
retraction.47 sive fractures, or other major structural deficits. Al-
ternatives are e-PTFE, PHDPE, and silicone (in
Dorsal onlay graft patients who have thick skin), although autoge-
The dorsal onlay graft, shown in Fig. 19, is used to nous material is preferred. If e-PTFE is used, we
correct minor and major deformities of the nasal avoid dissection that communicates to dorsal
dorsum. Commonly, we design these grafts to and septal surgical sites because we believe that
span the entire length of the nasal dorsum, from doing so increases the risk for alloplast infection.
the radix to the septal angle, to minimize the risk We routinely harvest a ‘‘floater’’ rib, which is
for palpable irregularities.7 Smaller refinement straighter and less prone to warping than the sixth
grafts may be used as beveled or crushed grafts or seventh rib. This floater rib is harvested as half
to address contour irregularities or asymmetries. bone and half cartilage, thereby mirroring the nat-
Although septal or conchal cartilage is usually ural osseocartilaginous anatomy of the nasal
104 Brenner & Hilger

Fig.12. Composite grafts. These grafts are useful in the Fig.13. Lateral crural strut grafts. These inconspicuous
treatment of vestibular stenosis and correction of se- grafts are placed deep to the alar cartilage and allow
vere alar retraction not amenable to rim grafting. for correction of moderate alar collapse, lower lateral
(A) Base view shows composite graft in nasal vesti- cartilage recurvature, and mild alar retraction. (A)
bule. Note that the structural cartilaginous compo- Vestibular lining is dissected away from the undersur-
nent of the graft (green) is larger than the overlying face of the lower lateral cartilage, creating a pocket
skin component (stippled pink). (B) Composite graft. for graft placement. (B) Placement of graft. (C) Lateral
(C) Auricular cartilage showing common sites of graft crural strut graft in anatomic position.
harvest, including concha cymba (red), concha cavum
(blue), and auricular root (green).
 Grafting in Rhinoplasty 105

Fig.14. Lateral crural spanning graft. Also referred to as an alar spreader graft, this graft allows for correction of
an overly narrowed or pinched nasal tip. (A) Frontal view. (B) Base view. (C) Graft shown in anatomic position.

dorsum. The bony portion of the graft is positioned fixation and minimizes the risk for warping.48
cephalically, and the undersurface is carved in The K-wire is easily removed in the office in
a gently curving concave contour to ensure that 3 weeks.
the graft will be seated firmly and to expose the Rarely, it is necessary to articulate the dorsal
cancellous trabecular bone. Before securing the graft and a columellar strut. This approach is
graft, the surgeon then rasps down the bony foun- most useful when a profound loss of structural
dation where the graft will sit until punctuate support in the lower third of the nose occurs. For
bleeding is encountered. The contact of raw example, in patients who have significant saddle
bone to raw bone thus achieved promotes effec- deformity, the lower third of the nose is usually
tive osseointegration of the cantilevered graft to poorly supported, and a strong cartilaginous colu-
the underlying bony foundation. The dorsal onlay mellar strut is required, along with an integrated
graft obviates the need for spreader grafts cartilaginous premaxillary graft. The columellar
because the upper lateral cartilages are sutured strut and premaxillary graft are placed through
to the lateral cartilaginous aspects of the graft. an open rhinoplasty approach with dissection be-
The graft is then rigidly fixated with a percutaneous tween the medial crura. The premaxillary graft is
Kirschner wire (K-wire) that further promotes rigid fixated with a percutaneous K-wire.
106 Brenner & Hilger

Fig.15. Spreader grafts. These grafts, which have become the workhorse for midvault reconstruction, are used to
correct or prevent collapse of the middle third of the nose, to reconstruct open roof deformity, and to smooth the
brow-tip aesthetic line. (A) This axial section through the midvault demonstrates how spreader grafts can expand
the nasal airway. (B) Frontal view. (C) Spreader grafts in anatomic position.

Skoog technique modification correction of the open roof deformity, preservation

In patients who have short nasal bones and long of the middle vault, and restoration of the natural
upper lateral cartilages, a modification of the contouring of the nasal dorsum while obviating
Skoog technique for dorsal reduction may be ad- the need for osteotomies.49
vantageous (Fig. 20). In this procedure, the osseo-
cartilaginous dorsal convexity is removed as Radix graft
a unit, the underlying nasal dorsum is reduced, Radix grafts, shown in Fig. 21, are used to reposi-
and the osseocartilaginous unit is then sculpted tion the radix in a more cephalic and anterior posi-
by shaving off the residual septal remnant on the tion. This maneuver provides the perception of
undersurface and replaced in it is original ana- lengthening the nose and can also be used to aug-
tomic location. The upper lateral cartilages are ment an inadequate nasofrontal angle.50 Precise
subsequently secured to this anatomic osseocarti- subperiosteal pocket preparation minimizes the
laginous graft with suture fixation. This approach is risk for graft displacement. The grafts may be sin-
attractive from aesthetic and functional aspects gle or layered, and beveling or crushing of the
because it accomplishes dorsal reduction, sides of the grafts will decrease perceptibility.
 Grafting in Rhinoplasty 107

Fig.16. DART grafts stabilized with columellar strut. These elongated spreader grafts extend into the dome as sep-
tal extension grafts and can increase projection and derotate the tip. Stability is optimized when they are inte-
grated with a columellar strut, as depicted in these figures. (A) Frontal view. (B) Lateral view. (C) Grafts in
anatomic position.

Deficiency of the radix is easily overlooked and the soft tissue skin envelope and increasing pro-
may prompt excessive resection of the nasal dor- jection. Furthermore, the radix graft does not
sum if the dorsum is brought down to the level of pose the risk for introducing asymmetry or other
the radix. Significant iatrogenic deformity can re- deformity to the lower third of the nose.50
sult from this error in judgment. Thoughtful appli-
cation of this simple, yet powerful, grafting Lateral nasal wall grafts
technique can yield satisfying results. The aes- Lateral nasal wall grafts, also referred to as dorsal
thetic perception of nasal lengthening achieved sidewall onlay grafts, are grafts of variable size that
with this graft, although limited, is far more predict- are used to correct focal depression or contour ir-
able than the lengthening achieved by stretching regularity along the lateral nose.51 The grafts are
108 Brenner & Hilger

Fig.17. Caudal septal extension graft. This graft extends directly from the caudal septum to control the projection,
rotation, and strength of the nasal tip. (A) Lateral view, showing columellar strut (green) secured to nasal septum
(red). (B) Placement of graft. (C) Graft in anatomic position.

Fig. 18. Caudal septal replacement graft. This graft is useful when the caudal septum is weak, deformed, or
absent. (A) Lateral view. (B) Frontal view. (C) Graft in anatomic position.
 Grafting in Rhinoplasty 109

Fig. 19. Dorsal onlay graft. Septal and auricular cartilage are useful for improving the contour of the nasal dor-
sum, whereas costal cartilage is indicated in cases where major augmentation is required, as in severe saddle
nose deformity. (A) Frontal view. (B) Lateral view. (C) Graft shown in cadaver with soft tissue skin envelope
removed.

Fig. 20. Modified Skoog procedure. In patients who have short nasal bones and long upper lateral cartilages, the
osseocartilaginous dorsal convexity is removed and sculpted for use as a dorsal onlay graft after appropriate re-
duction of the underlying nasal dorsum. (A) Dashed line denotes osseocartilaginous convexity to be removed
with scalpel and Rubin osteotome. (B) Cadaveric demonstration of regions to be sculpted into onlay graft.
(C) Sculpted onlay graft showing short nasal bones and long cartilaginous component.
110 Brenner & Hilger

Fig. 21. Radix graft. This graft allows for augmentation of the nasofrontal angle and creates the perception of
nasal lengthening by repositioning the radix. (A) Frontal view, with peripheral aspect of cartilaginous graft
crushed (crosshatches) to minimize visibility. (B) Lateral view. Green shading and broken line indicate radix being
repositioned in a more cephalic and anterior position, thereby increasing nasal length, denoted by ‘‘X.’’ (C) Graft
shown in cadaver with soft tissue skin envelope removed.

positioned along the lateral aspect of the nose in and medial crural footplates results in widening of
the area of asymmetry and tend to be most useful the columellar-labial angle. This graft thus creates
in the midvault region. The grafts may be crushed an appearance of nasal tip rotation.52
or rigid, although rigid grafts are more likely to be
discernible when placed over the bony pyramid Premaxillary grafting
of the upper third of the nose. When a cosmetic The premaxillary graft is used to augment an un-
deformity of the midvault is associated with nasal derdeveloped or retrusive premaxilla. It involves
airway obstruction, either spreader grafts or an- grafting of the caudal aspect of the piriform aper-
other grafting technique that simultaneously ad- ture.52 These grafts may be difficult to carve and,
dresses the functional problem should be used. depending on the underlying anatomy, may re-
quire substantial volume. In rhinoplasty in Asians,
Grafts of the Premaxilla and Alar Base
silicone implants are often used and thought to
Columellar plumping grafts be better tolerated because of the thicker skin in
Columellar plumping grafts, shown in Fig. 22, con- this ethnic population.53,54 Costal cartilage is an-
sist of diced or morselized cartilage that is placed other option well suited to this location, particularly
at the posterior aspect of the columella. Placing if the use of costal cartilage for another part of the
graft material in the region between the nasal spine reconstruction is already indicated.
 Grafting in Rhinoplasty 111

Fig. 22. Columellar plumping grafts. Diced or morselized cartilage is placed between the nasal spine and foot-
plates of the medial crura to widen the columellar-labial angle. This technique creates the illusion of tip rotation.
(A) Frontal view. (B) Lateral view. Green shading and broken line indicated widening of the columellar-labial
angle, X . (C) The plumping grafts, shown in figure, are placed subcutaneously.

Alar base grafts SUMMARY

Alar base grafts are used along the lateral piriform
aperture to augment a posteriorly displaced inter- The development of sophisticated grafting tech-
face of the lip and ala.55 The alar base composite niques has played an integral role in achieving
graft is particularly useful in reconstruction of the durable surgical outcomes in rhinoplasty. The
cleft lip nasal deformity. This deformity exemplifies loss of structural integrity often encountered after
how the lack of a stable platform in the premaxilla reductive rhinoplasty illustrates the importance of
precludes a normal relationship between the lip preservation of framework. The structural ap-
and nose. In cases of significant bony deficiency proach to rhinoplasty uses grafts to maintain and
of the premaxilla, a corticocancellous bone graft augment nasal support mechanisms and in doing
may be necessary to reconstruct the underlying so, enables the nasal skeleton to resist contractile
deformity. forces of healing that would otherwise compro-
mise aesthetic and functional results.
112 Brenner & Hilger

ACKNOWLEDGMENTS Center experience. Arch Otolaryngol Head Neck

Surg 2008;134(5):485–9.
The authors wish to thank Eric Dobratz, MD, for 18. Strauch B, Wallach SG. Reconstruction with irradi-
his assistance with the laboratory dissections ated homograft costal cartilage. Plast Reconstr
used for selected figures in this publication. Surg 2003;111(7):2405–11.
19. Gryskiewicz JM, Rohrich RJ, Reagan BJ. The use
of AlloDerm for the correction of nasal contour
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