Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

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W. Wagner et al.
the pyriform aperture grants a maximum stabiliz-
ing effect if needed (Fig. 33.23 ) [ 22, 23, 28 ] .
Alar batten grafts often measure 10–15 mm in
length and 4–8 mm in width. Application is pos-
sible during closed or opened procedures. If per-
formed via an endonasal approach, the dissected
subcutaneous pocket should fi t the grafts precisely
to avoid shifting of the inserted graft, which will
impair the lateralizing effect. Suturing is not
compulsory during endonasal approach. In case
of an open approach, alar batten grafts should be
sutured to the lateral third of the lateral crura to
Fig. 33.7 Use of spreader grafts for correction of S-shaped deviation of dorsum (procedures performed: septoplasty,
hump removal, spreader grafts, osteotomies, tip sutures, columellar strut, shield tip graft, open technique)

453
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
prevent medial migration [ 22, 28, 30 ] . Depending
on their shape, caliber, and stiffness, alar batten
grafts may affect a mostly slight yet visible wid-
ening of the alar region; on the other hand, an
overly pinched supra-alar crease may need to be
fl attened by the grafts in order to be effective. So
the surgeon and the patient may have to make a
compromise between gain in stability and avoid-
ance of outer perceptibility, which must be
explained to the patient before the operation.
Fig. 33.8 Use of spreader grafts for correction of “hourglass shape” of the dorsum (procedures performed: septoplasty,
spreader grafts, dorsal height reduction, osteotomies, tip sutures, columellar strut, dom excisions, open technique)

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W. Wagner et al.
33.5
Caudal Septal Extension Graft
Caudal septal extension grafts are segments of
perpendicular cartilage, which are secured to the
caudal septum and extend into the columella [ 25,
31, 32 ] (Fig. 33.24 ). The caudal segment of septal
cartilage provides architectural support to the
nasal tip. Loss of that caudal septal support will
substantially affect the stability of the nasal tip
and thereby result in aesthetic as well as functional
Fig. 33.9 Use of spreader grafts in correction of crooked nose (procedures performed: extracorporeal septoplasty,
osteotomies, spreader grafts, tip sutures, open technique)

455
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
problems [ 32 ] . Thus, the main purpose of the cau-
dal septal extension grafts is to stabilize the nasal
base and the tip.
The dimension of the graft may vary from a
medium-sized strut to a large plate of several
centimeters side length [ 23, 28 ] . The graft can
either be secured in an end-to-end fashion to the
caudal septal edge, or it can be sutured to the
caudal septum in an overlapping fashion; how-
ever, the latter method typically grants a fi rmer
Fig. 33.10 Use of unilateral spreader grafts for correction
of unilateral concavity of cartilaginous dorsum (revision
case; procedures performed: revision septoplasty, doubled
spreader grafts on left side, minor dorsal reduction in
supra-tip, small radix onlay graft, lateral crural strut grafts,
tip sutures, scar revision columella, open technique)

456
W. Wagner et al.
connection between septum and graft (Fig.
33.25 ). Deviations in the caudal septum or the
septal extension graft may be used to anatomic
advantage in order to secure a midline position
of septum and graft, e.g., the graft can be
attached to the right side of the septum if the
caudal septum is deviated to the left and vice
versa. Setting the caudal edge of the graft in the
midline is mandatory in order to secure symme-
try of the columella, the nostrils, and the nasal
tip [ 25, 26 ] . This is most reliably achieved by
suturing the graft to the anterior nasal spine by
means of drill holes and/or a drilled groove in
the nasal spine. Serving the same purpose, uni-
lateral or bilateral splints or extended spreader
grafts may be used to stabilize the caudal margin
of the septal extension graft in the midline
(Fig. 33.11 ) and to give additional support to the
medial crura [ 22, 32 ] .
The caudal septal extension graft creates a fi rm
conjunction between the septum and the colu-
mella/tip complex. By suturing the medial crura to
Fig. 33.11 Combination of spreader grafts and caudal
septal extension graft for medialization and stabilization
of nasal tip
Fig. 33.12 Lateral crural strut grafts (septal cartilage)
sutured on the undersurface of the lateral crus
Fig. 33.13 Use of lateral crural strut grafts for correction
of deformed concave asymmetric lateral crura. Left : initial
situation, right : situation after application of lateral crural
strut grafts, interdomal sutures, and conservative cephalic
reduction of lateral crura

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33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
Fig. 33.14 Use of lateral crural strut grafts for correction
of deformed concave asymmetric lateral crura. ( Left )
Preoperative. ( Right ) Twelve months postoperative. The
concavity of the lateral crura is especially visible the fron-
tal and half pro fi le view. The base view demonstrates the
preoperative side difference in projection of the domes;
see light re fl exes on tip de fi ning points (procedures per-
formed: septoplasty, hump removal, osteotomies, lateral
crural strut grafts, spreader grafts, columellar strut, tip
sutures, alar base reduction, open technique)

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W. Wagner et al.
Fig. 33.15 Use of lateral crural strut grafts for correction of overly convex lateral cura (boxy tip) (primary case, open technique)
Fig. 33.16 Use of lateral crural strut grafts for correction of asymmetries and bossae of the lateral crura (revision case,
open technique)
Fig. 33.17 Use of lateral crural strut grafts for correction of asymmetries, concavities, and inward-pointing lateral
ends of lateral crura, causing inspiratory collapse (primary case, open technique)

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33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
the graft in the desired position, the surgeon is
enabled to de fi nitely determine tip and columella
position in terms of projection, rotation, and naso-
labial angle. Initial overcorrection, which is at
times applied in expectance of slow postoperative
loss of projection and rotation [ 33 ] , is deemed
unnecessary. The grafting procedure makes the
nasal tip somewhat stiffer and less mobile in rela-
tion to the rest of the nose, which the patient should
be made aware of before the operation. However,
this trade-off appears well acceptable in the light
of achievement of a stable long-term result.
The caudal septal extension graft is the
most powerful tool to hold the tip in a de fi nitive
position. Therefore, it is especially useful when
the corrected nose must withstand strong trac-
tional and gravitational forces in the long term,
as it is the case in correction of saddle noses
(Fig. 33.26 ), in the short nose (Fig. 33.27 ), and
generally in underprojected and underrotated
nasal tips with heavy soft tissue mantle
(Fig. 33.28 ). The graft proved to be effective
in restoring the lost tip support in patients with
caudal septal de fi ciency. In premaxillary
de fi ciency, combining the graft with premaxil-
lary augmentation using Mersilene mesh helps
to increase support and stability over long-term
follow-up [ 32 ] .
Fig. 33.18 Typical size and shape of lateral crural strut
grafts
Fig. 33.19 Lateral crural strut grafts bridging the dome
area, thus spanning the lateral crura outward, in case of
inspiratory collapse
a
b
Fig. 33.20 ( a ) No breathing. ( b ) Inspiratory collapse located in the outer nasal valve

460
W. Wagner et al.
33.6
Columellar Strut Graft
The columellar strut graft is a rectangular-shaped,
straight segment of cartilage, typically 15–25 mm
long and 3–6 mm wide, that is positioned between
the medial crura (Figs. 33.29 and 33.30 ) [ 26, 31 ] .
Columellar struts can help to secure or slightly
enhance tip projection, to increase tip rotation
(Fig. 33.31 ), to augment the base of the colu-
mella, thereby correcting an “empty” acute naso-
labial angle, and to lend a straight shape to
intrinsically curved medial crura, respectively
(Figs. 33.31 and 33.32 ). As all structural grafts,
columellar struts are especially important in cases
of weak insuf fi cient cartilaginous support. An
“empty” retracted columella, weak support on
digital palpation, as well as underprojection and
de-rotation of the tip all indicate such lack of sup-
port, alerting the surgeon to take advantage of
grafts and sutures to enhance support. The same
is true if delicate crural and septal cartilages are
present, as such noses often lend much of their
intrinsic support to fi brous structures and inter-
cartilagenous ligaments, which are often transected
during rhinoplasty [ 31 ] .
An imperative feature of the graft is suf fi cient
stability. In order to address this prerequisite, thin
cartilage may be used in a double-layer fashion
for composition of the strut. Suture fi xation of the
columellar strut, which can be accomplished via
an endonasal or an open approach, is advisable,
as it grants stability to the position of the graft.
Fig. 33.21 ( Upper ) Alar batten grafts are used to
strengthen the lateral nasal wall and ala, respectively, in
cases of inspiratory collapse. ( Lower ) Their size and posi-
tion vary from caudal, upon, or cephalad to the lateral
crura, depending on the point of maximal lateral wall
collapse. Making the grafts extend laterally toward the
pyriform aperture provides a maximum stabilizing effect

461
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
Fig. 33.22 ( Upper ) Preoperative. ( Lower ) Twelve
months postoperative after treatment with alar batten
grafts for correction of lateral wall inspiratory collapse
(procedures performed: septoplasty, osteotomies, alar bat-
ten grafts, spreader grafts; primary case, open technique)

462
W. Wagner et al.
Fig. 33.23 Alar batten grafts. Because of inspiratory
collapse and status post unsuccessful operation, especially
large and rigid batten grafts made of costal cartilage were
applied in this case. The grafts, which were fi xated on the
lateral crura with PDS, reach down to the bone, the pyri-
form aperture, stabilizing the lateral nasal wall
Fig. 33.24 ( Upper left ) Caudal septal extension grafts
are segments of cartilage, which are ideally harvested
from the septum. ( Upper right and far right ) The graft is
secured to the caudal septum and extends into the colu-
mella. ( Lower ) It creates a fi rm conjunction between the
septum and the columella/tip complex
Fig. 33.25 Caudal septal extension graft. A septal cartilage plate is sutured upon the caudal edge of the septum, build-
ing a fi rm connection between septum and tip

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33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
Fig. 33.26 Use of a large caudal septal extension graft made from costal cartilage in a case of traumatic saddle nose.
( Left ) Preoperative. ( Right ) Thirteen months postoperative. A dorsal onlay graft was brought in additionally

464
W. Wagner et al.
Fig. 33.27 Use of a caudal septal extension graft made of
septal cartilage for lengthening of a short nose with too
great nasolabial angle, also correction of nasal deviation.
( Left ) Preoperative. ( Right ) Eleven months postoperative
following septoplasty, caudal septal extension graft, osteot-
omies, dorsal height reduction, and closed technique

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33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
Fig. 33.28 Use of a caudal septal extension graft made of
costal cartilage for increasing projection and tip de fi nition
in a patient with heavy nasal soft tissues. ( Left ) Preoperative.
( Right ) Fifteen months postoperative after septoplasty,
caudal septal extension graft, osteotomies, dorsal onlay
graft from rib, tip sutures, and open technique

466
W. Wagner et al.
Especially in noses with heavy soft tissue man-
tle and structural insuf fi ciency, a columellar strut
may not prevent de-rotation and de-projection of
the tip as effective as a caudal septal extension
graft does; however, anchorage to the caudal sep-
tum contributes to stability [ 25, 31, 35 ] . When
the graft is sutured directly to the premaxilla,
either to the periosteum or to a drill hole in the
anterior nasal spine (Fig. 33.33 ), control of the
strut’s position and effect is more reliably
achieved. If the nasal spine is missing, fi xation at
the premaxillary bone may be alleviated by fabri-
cation of a W-shaped or V-shaped base fi tting into
a groove [ 22 ] .
33.7
Alar Rim Grafts
Traditionally, structural and/or contour deformi-
ties of the alar rim have been addressed with
batten grafts, strut grafts, composite grafts, and
suture techniques. Over the last two decades,
more emphasis on controlling nasal tip contouring
Fig. 33.29 ( Upper ) The columellar strut graft is a rect-
angular-shaped, straight segment of cartilage, typically
15–25 mm long and 3–6 mm wide, that is positioned
between the medial crura ( top ). ( Lower left ) If conchal
cartilage is used as a columellar strut, ( Lower middle ) two
curved pieces can be sutured together in an opposing
manner to create ( Lower right ) a straight and stable piece
of cartilage
Fig. 33.30 Columellar strut sutured in between medial
crura

467
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
Fig. 33.31 Use of columellar strut graft to increase tip rota-
tion, secure tip projection, and straighten intrinsically devi-
ated medial crura. ( Left ) Preoperative. ( Right ) Twelve
months postoperative following extracorporeal septoplasty,
doubled spreader grafts because of thin septal cartilage,
hump removal, tip sutures, osteotomies, and open technique

468
W. Wagner et al.
Fig. 33.32 Use of columellar strut graft to straighten
intrinsically deviated medial crura. ( Left ) Preoperative.
( Right ) Sixteen months postoperative after extracorporeal
septoplasty, doubled spreader grafts because of thin septal
cartilage, hump removal, tip sutures, osteotomies, and
open technique

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33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
has elevated the understanding of structural sup-
port mechanism at the alar rim. The contour and
strength of the alar rim are primarily determined
by the semirigid lateral crus of the lower lateral
cartilage. As the lower lateral cartilage transitions
from the intermediate crus to the lateral crus, it
diverges away from the alar margin to a more
cephalic position. As a consequence, the posterior
half of the alar is devoid of any rigid support. This
particular anatomic relationship between the lower
lateral cartilage and the alar margin has several
structural implications [ 25, 34, 36, 37 ] . A greater
degree of cephalic rotation of the lateral crus
leaves more of the alar without rigid support.
Overresection of the cephalic margin of the lower
lateral cartilage reduces its support of the alar rim.
A weak lateral crus will result in static or dynamic
collapse of the alar rim during inspiration.
According to overresection, dome-suturing tech-
niques commonly used in narrowing broad nasal
tips often interrupt the alar margin. The suture
may result in descent of the caudal margin of the
lateral crus below the cephalic margin and con-
cavity of the lateral crus. When the caudal margin
of the lateral crura is displaced below the cephalic
margin, the alar lobule may lose support, giving
the tip a pinched appearance with an isolated
nasal tip lobule [ 25 ] (Fig. 33.34 ).
Alar rim grafts are placed along the caudal alar
margin. These grafts have been shown to offer
suf fi cient support to the alar rim and valve area [ 37 ] .
The alar rim graft is placed in a non-anatomic fash-
ion in a subcutaneous pocket along the alar margin
[ 25, 36, 37 ] . The rim graft must span the length of
the alar deformity and is therefore capable of directly
altering the contour and strength of the alar margin
and improving the function and aesthetic harmony
of the nasal tip. Alar rim grafts typically are thin,
soft cartilage grafts that measure approximately
12–15 mm in length and 2–3 mm in width. With
converse scissors, a pocket is made along the caudal
margin of the marginal incision with Converse scis-
sors. The more severe the problem, the longer and
wider the graft will need to be [ 23, 25 ] .
Alar rim grafting is a simple and versatile
approach to providing additional support to the
external nasal valve and improving nasal base
Fig. 33.33 Suture fi xation of columellar strut at drill hole through nasal spine (5–0 mono fi le, non-resorbable).
Meanwhile, the authors changed to using clear suture for this procedure
Fig. 33.34 Overresection of the lower lateral cartilages
or dome division used for narrowing broad nasal tips often
weaken tip support or interrupt the alar margin. These
maneuvers may give the tip a pinched appearance with an
isolated nasal tip lobule, as shown in this example

470
W. Wagner et al.
Fig. 33.35 ( Upper ) Alar rim grafts are placed along the
caudal alar margin to give support to the alar rim and
valve area. These grafts are placed in a non-anatomic
fashion in a subcutaneous pocket along the alar margin.
( Lower left to right ) The placement is shown. Alar rim
grafts help to alter contour and strength of the alar margin
and improve the function and aesthetic harmony of the
nasal tip
harmony (Fig. 33.35 ) [ 36 ] . It should be consid-
ered in primary or secondary rhinoplasties
when nasal tip analysis reveals malpositioned
lower lateral cartilages, alar fl aring, overprojected
nasal tips, mild alar retraction or collapse, and
contour asymmetries (Fig. 33.36 ). This proce-
dure appears to be as effective as currently
available reconstructive alternatives while being
technically uncomplicated [ 36, 37 ] . Alar rim
grafts are not as effective as lateral crural strut
grafts in patients with signi fi cant alar scarring,
loss of vestibular skin, or absent lower lateral
cartilages [ 36 ] . An alternative to correct moder-
ate to severe alar retraction or notching is the
use of a composite alar rim graft. This is a com-
posite skin-conchal cartilage graft harvested
from the cymba conchae or cavum conchae and
placed along the intranasal alar rim. It is also
used to treat asymmetries in alar rim height and
to combat nostril or vestibular stenosis [ 36 ] .

471
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
Fig. 33.36 ( Upper ) Preoperative. ( Lower ) Thirteen
months postoperative after ( Middle ) alar rim grafts in
combination with alar batten grafts to treat inspiratory
alar collapse septoplasty, hump reduction, septal exten-
sion graft; spreader grafts, allar rim grafts, alar batten
grafts, tip onlay graft; primary case, open technique

472
W. Wagner et al.
Fig. 33.37 Extracorporeal septoplasty. Severely devi-
ated cartilaginous portion of the septum (lamina quadran-
gularis) seen from ( Upper left ) front and ( Upper middle )
above. ( Right ) Preparation of straight L-strut from dis-
sected segments of the septum, including spreader grafts
and double-layered caudal edge of neo-septum. Neo-
septum seen from ( Left middle ) front and ( Middle ) above.
( Lower left ) Insertion of neo-septum, three-point suture
fi xation at upper lateral cartilages on both sides and nasal
spine, respectively

473
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
Fig. 33.38 Extracorporeal septoplasty. Severely deviated
septum ( Upper left ) in situ and ( Upper middle ) from front.
( Upper right and lower left ) New L-strut composed of seg-
ments of the septum. Note that in this case not only parts of
the cartilaginous septum were used but due to lack of suit-
able cartilage also parts of the bony septum. The bone was
supplied with drill holes to allow suture fi xation. ( Lower
right ) Insertion of neo-septum, three-point suture fi xation
33.8
Extracorporeal Septoplasty
(Septal Replacement Graft)
Surgical correction of a deviated nasal septum is
one of the most frequently performed surgical
procedures. An estimated 90% of these septal
surgery procedures are routine, and standard sep-
toplasty is adequate to improve the patient’s nasal
airway. Key elements of a standard septoplasty
include cartilage and bone resection, cartilage
scoring, release of tensions, and possibly free
reimplantation of cartilage between the mucoper-
ichondrial fl aps. However, if the septum diplays
massive deviation in all three levels [ 38 ] , which
can occur congenitally as well as posttraumatic
or after surgery [ 4 ] , such standard techniques are
often insuf fi cient to solve the problem. This is
especially true when the deviations that need to
be corrected involve the caudal and/or the ante-
rior septal portion (often referred to as septal
roof). The reason for this is that the named seg-
ments of the cartilaginous septum need to be pre-
served to grant suf fi cient stability of the nasal
frame. In other words, an L-shaped remainder of
the lamina quadrangularis of at least 10 mm is
not suitable for cartilage resection or excessive
scoring. Furthermore, in some patients, the cause
of nasal airway obstruction includes a narrow
valve angle and high septal de fl ection. Such cases
require more complex correction [ 40 ] . External
septoplasty or extracorporeal septum reconstruc-
tion can be an appropriate in such cases [ 38 – 41 ] .
The principle of this procedure is the entire devi-
ated septum is resected to be replaced by a new
septal structure, which is prepared on the back
table (Figs. 33.37 , 33.38 , 33.39 , and 33.40 ). The

474
W. Wagner et al.
new septum is often composed of usable cartilage
segments of the existing septum, in other cases it
is constructed out of auricular or costal cartilage,
or even bony parts. The critical aspect of the neo-
septum is that is has to include a suf fi ciently sta-
ble L-strut, building the new caudal septal edge
and septal roof. The height of the caudal portion
of the neo-septum depends on the desired projec-
tion of the tip and supra-tip; however, the typical
length of the caudal edge is 22–24 mm. The
length of the new septal roof is less critical. After
insertion of the new septal plate, it needs to be
Fig. 33.39 ( First and second row ) Extracorporeal septo-
plasty in the treatment of pollybeak deformity due to pre-
vious rhinoplasty. ( Third and fourth row ) After harvesting
cavum cartilage, preparation of a straight L-strut from
dissected segments of the septum was performed, includ-
ing spreader grafts sutured to the L-strut and lateral crural
grafts from the auricular cartilage. ( Fifth row ) Final result
(revision case, open technique)

475
33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
reliably anchored in the nose [ 42, 43 ] , which is
accomplished by suturing it to the nasal spine
caudally and to the upper lateral cartilage bilater-
ally. This principle has been referred to as three-
point fi xation. Suf fi cient fi xation of the newly
created septum is mandatory to support the nasal
dorsum, tip, and columella for long-term aes-
thetic and functional success. Stripes of cartilage
can be sutured to the new upper septum border as
a spreader graft to strengthen the dorsal support
and widen the inner nasal valve [ 42 ] . The proce-
dure can be performed via closed or an open
approach; however, many authors advocate the
open approach for greater ease of preparation and
fi xation.
33.9
Suture Material
For suture fi xation of stabilizing cartilage grafts, the
authors of this article prefer either slowly resorb-
able (PDS) or non-resorbable mono fi lam entous
Fig. 33.40 ( Upper ) Preoperative. ( Lower ) Eleven months postoperative

476
W. Wagner et al.
clear suture material of 4–0 or 5–0 size. One aspect
when selecting the appropriate suture material for
graft fi xation is how much traction and gravitation
forces the graft will have to withstand. Also impor-
tant is how much of the graft stands in direct con-
tact with another stable structure of the nose, which
supports the graft in its structural purpose. For
instance, a lateral crural strut graft does not carry as
much mechanic load as a caudal septal extension
graft does, and it has tight contact to the surface it is
sutured upon, while the septal extension graft rests
on the nasal spine with only a small contact surface.
Hence, in the authors’ hands, the greater the forces
acting on the graft are and the more the graft has to
bear these forces alone, the longer lasting and stron-
ger the suture will be.
Conclusions
Many of the secondary abnormalities of the
nose seen after rhinoplasty can be prevented by
minimizing resection of the support structures
of the nose and by using structural grafting.
The incidence of many complications is greater
in patients with certain nasal anatomy. It is the
responsibility of the surgeon to identify these
anatomic variants and make necessary adjust-
ments in surgical technique to avoid complica-
tions. Thus, rhinoplasty techniques have moved
away from excisional methods and focused
more on repositioning and restructuring
existing tissues. Conservative reduction and
thoughtful preservation of support structures
will maximize functional and aesthetic results.
Structural grafting with autologous cartilage
can help to increase nasal support. The rhino-
plasty surgeon can choose from numerous
grafts. A key understanding of the bene fi ts and
limitations of each graft commonly used in rhi-
noplasty surgery is the prerequisite for suc-
cessful aesthetic and functional results.
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33 Stabilizing Cartilage Grafts in Functional-Aesthetic Rhinoplasty
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23. Riedel F, Bran G (2008) Cartilage grafts in functional
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29. Tardy ME, Garner ET (1990) Inspiratory nasal
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DOI 10.1007/978-3-642-28053-5_34, © Springer-Verlag Berlin Heidelberg 2013
34
34.1
Introduction
The aesthetic and functional implications of an
appropriate dorsal contour are immense and con-
tribute signi fi cantly to the overall rhinoplasty
results. Spanning from the nasion to the tip, the
dorsal contour and its integrity play a key role in
pro fi le, function, and tip projection. This chapter
will focus on the principles and techniques com-
monly utilized for dorsal nasal augmentation.
34.2
Anatomy
Prior to any discussion of dorsal augmentation,
one must gain a fi rm knowledge of the anatomy
of the nose, the various bony and cartilaginous
relationships, and their collective roles in attain-
ing both an aesthetically pleasing and functional
form. Failure to reconstitute or reinforce the sup-
port mechanisms of the nasal dorsum during rhi-
noplasty can lead to disastrous outcomes – some
of which may not manifest until years later.
Moreover, failing to adequately re fi ne the dorsal
pro fi le will surely lead to an unhappy patient and
higher rates of revision rhinoplasty.
34.2.1 The Upper Third of the Nose
The junction of the nasal and frontal bones
de fi nes the upper third of the nose at its most
cephalic portion. On pro fi le, this contributes to
the depth of the radix and inferiorly the rhinion
as the nasal bone transitions to the cartilaginous
portion of the nasal dorsum. When observing the
nose from an anterior view, a soft concave line
from the medial brow extending to the nasal tip
is initiated by the contour of the nasal bones [ 1 ] .
The degree of contribution from the nasal bones
to the dorsal pro fi le is dependent on the length
of the nasal bones. Short nasal bones will typi-
cally have less of a signi fi cant effect on dorsal
pro fi le and function than a nose with longer nasal
bones. The keystone area, de fi ned as the articula-
tions between the upper lateral cartilages-septal
Costal Cartilage Grafting
for Dorsal Augmentation
Waleed H. Ezzat and Babak Azizzadeh
B. Azizzadeh , M.D., FACS
Center for Advanced Facial Plastic Surgery ,
Beverly Hills , CA , USA
The Center for Advanced Facial Plastic Surgery ,
9401 Wilshire Blvd., Suite 650 ,
Beverly Hills , CA 90212 ,
USA
W. H. Ezzat , M.D. (*)
Facial Plastic and Reconstructive Surgery ,
Boston Medical Center ,
Boston , MA , USA
Department of Otolaryngology/Head and Neck Surgery ,
Boston University School of Medicine ,
820 Harrison Ave., 4FGH ,
Boston , MA 02118 , USA
e-mail: waleed.ezzat@bmc.org;

480
W.H. Ezzat and B. Azizzadeh
complex and caudal nasal bones, is paramount for
the overall integrity of the nasal dorsum. These
connections are reinforced via fi brous muco-
periosteal and mucoperichondrial attachments.
Anatomic studies have shown that this point of
articulation should be preserved or reconstituted
during any type of nasal surgery [ 2 ] .
34.2.2 The Middle Third of the Nose
The foundation of the middle third of the nose
rests on the strength of the cartilaginous nasal
septum. Articulating with the bony septum
cephalically, the septum serves to maintain the
overall dorsal pro fi le and position of the upper
lateral cartilages (ULCs) – thereby serving as a
support beam for the middle nasal vault [ 3 ] . The
ULCs ride underneath the nasal bones cephalad
and articulate with the septum medially to con-
tribute the internal nasal valve, an area bound by
the septum, ULCs, and the anterior head of the
inferior turbinate. The internal nasal valve func-
tionally provides the majority of resistance to
nasal air fl ow, contributing up to 50% of the total
resistance [ 4 ] . Minor contributions to the middle
nasal vault and internal nasal valve are made by
the fi brous attachments of the mucoperichon-
drial tissue internally and the soft tissue enve-
lope externally.
34.2.3 The Lower Third of the Nose
The most caudal aspect of the septum lends sup-
port to the nasal tip and contributes to its projec-
tion. While Tardy et al. [ 5 ] have described many
factors that develop and support the nasal tip,
one cannot omit the septum’s integral role in
maintaining nasal projection. This is best
exempli fi ed by the saddle nose deformity where
the loss of dorsal cartilaginous support allows
the roof of the middle vault to collapse leading
to de-projection and over-rotation of the nasal
tip. Furthermore, determining the appropriate
height of the cartilaginous dorsum plays a key
role in de fi ning an aesthetically pleasing tip pro-
jection point.
34.3
Goals for Augmentation
The shape of the nasal dorsum should be tailored
appropriately for gender and ethnicity. Ideally,
the nasofrontal angle should be between 115°
and 130°, keeping in mind that the extent of gla-
bellar projection and initial height of the nasal
dorsum can signi fi cantly impact this measure-
ment. Other adjunctive maneuvers, such as a
radix grafts, may be necessary to bring this angle
into its ideal range. In females, a straight dorsal
line that transitions into a subtle, re fi ned supratip
break compliments the delicacy of the nose. For
the male patient, a straight to slightly convex
nasal dorsum confers a stronger, more masculine
look. In ethnic patients with platyrrhine noses,
one should avoid the temptation to heighten the
dorsum excessively – as this tends to elevate the
tip and give the nose a more leptorrhine appear-
ance. The length of the dorsum is typically used
to help set the position of the nasal tip. If more
projection or counter-rotation is desired, length-
ening the nose can be accomplished by way of
extended spreader grafts [ 3 ] . Conversely, resec-
tion of the most caudal aspect of the septum can
shorten the nose and result in rotation of the tip.
34.4
Materials Used for Dorsal
Nasal Augmentation
34.4.1 Alloplastic Materials
As early as the nineteenth century, alloplastic
materials were utilized to contour the nasal dor-
sum [ 6 ] . Some surgeons initially turned to rigid
plastics, relying on the graft’s non-immunogenic
properties, as these were well tolerated in the
body [ 7 ] . Their major drawback lay within the
fact that once infected, they tended to extrude.
Silicone implants remain in wide use for dorsal
augmentation, especially in Asia. A fi brous cap-
sule surrounds these smooth implants, which do
not integrate with the adjacent tissue and are
therefore prone to shifting and buckling [ 8 ] .
Proponents of these implants refer to their ease of
use and, if necessary, ease of removal. Tham et al.
[ 9 ] retrospectively analyzed 355 patients in which

481
34 Costal Cartilage Grafting for Dorsal Augmentation
silicone implants were utilized for nasal augmen-
tation and concluded that silicone was effective,
economical, and safe for surgical correction of
the Asian nose with its thicker soft tissue enve-
lope. Unfortunately, follow-up averaged just over
4 months, and removal or replacement of the
implant was necessary in 7.8% of patients.
Longer-term studies have also reported higher
extrusion and infection rates [ 10, 11 ] .
Medpor (Porex Surgical, Newnan, USA) is a
porous high-density polyethylene material which
allows the ingrowth of connective tissue and
more complete integration of the implant into the
soft tissue [ 8 ] . A stable, fi rm surface must be
present to permit incorporation, and initial sterile
handling of the implant is critical in lowering
long-term infection risks [ 12 ] . However, the pos-
sibility of infection and subsequent extrusion
makes this option less ideal, and the authors dis-
courage its use in favor of autologous materials.
The tissue ingrowth also makes this material
extremely hard to remove (Fig. 34.1 ).
34.4.2 Homografts
Homografts are harvested from cadaveric
sources. Prior to harvesting, donors are screened
for systemic diseases and local infectious pro-
cesses. They are then stored in solution and sub-
jected to gamma irradiation at 30,000–40,000 Gy
in order to sterilize and reduce the antigenicity
of the graft. Homografts display good tissue
compatibility and low rate of infection [ 13 ] .
Other bene fi ts include availability of large vol-
umes of cartilage and avoidance of donor-site
morbidity. Gunter et al. found no difference in
the rate of warping of irradiated cadaveric carti-
lage and fresh cadaveric cartilage in vitro over a
4-week period [ 14 ] . In both groups, those grafts
carved from the periphery of the cartilage tended
to warp at a higher rate than those from more
central portions of the rib.
The degree of homograft resorption when
used in facial reconstructive surgery remains
controversial [ 15 ] . Early studies demonstrated
that the rate of resorption was highly dependent
on the implanted region [ 16 ] . Kridel and Konior
[ 13 ] published a series of 122 procedures using
the irradiated costal cartilage for nasal augmenta-
tion. Over the average follow-up of 15 months,
four (3.3%) of the homografts showed signi fi cant
resorption. In two of these four cases, resorption
was attributed to infection from the use of braided
sutures. This resorption rate was much lower than
that of previously reported studies which failed to
speci fi cally address nasal reconstruction [ 15, 16 ] .
A larger follow-up study was later published by
the same group, totaling 357 patients. Although
they advocate irradiated cartilage is well-toler-
ated and had a decreased number of complica-
tions from their prior study, over 40% of the
a
b
Fig. 34.1 ( a ) A porous high-density polyethylene
(PHDPE) implant, used as a dorsal implant, has become
infected and is extruding. ( b ) The PHDPE implant
removed; the ingrowth of the surrounding tissue makes
removal dif fi cult during revision surgery

482
W.H. Ezzat and B. Azizzadeh
subjects were followed for 1 year or less and
almost 15% required revision surgery [ 17 ] .
Non-cartilaginous, processed homografts are
also available. Acellular dermis (AlloDerm®,
LifeCell Corporation, Branchburg, NJ) utilizes
human donor skin dermal tissue matrix, which can
be placed over a stable existing structural frame-
work to augment the nasal dorsum. Although the
biocompatibility of the graft is suitable, long-term
results have shown high resorption rates and the
need for overcorrection when the graft is used for
augmentation [ 18 ] . The lack of rigidity of the
material limits its use as a camou fl age onlay graft.
34.4.3 Autografts
Autografts utilize the patient’s own tissue and are
the gold standard for rhinoplasty and nasal recon-
struction. They offer complete tissue immunoge-
nicity and the lowest rates of resorption and
extrusion [ 19 ] . Donor sites for grafts include septal,
auricular (concha), and rib cartilage, as well as cal-
varial and iliac bones. Because of its structural
rigidity and ease of harvest [ 20 ] , septal cartilage is
frequently preferred for reconstruction [ 21 ] .
However, this often cannot be utilized in cases of
revision rhinoplasty, when signi fi cant dorsal aug-
mentation requires large grafts or in cases where
prior trauma or surgery has compromised the
amount of available cartilage. The ear and rib have
been used extensively as secondary sources of car-
tilage [ 5, 20 ] . Conchal cartilage can be obtained
without postsurgical deformity if one maintains the
antihelical integrity; however, it lacks structural
rigidity. In observance of this fact, the authors pre-
fer to retain the use of auricular cartilage for cases
that do not require extensive structural support.
Given the frequent lack of suf fi cient septal
cartilage in rhinoplasty and the absence of rigid-
ity of conchal cartilage, costal cartilage grafts
provide an ample, readily available, and reliable
source of cartilage for nasal dorsal augmentation.
Rib is utilized for grafting material as a cartilagi-
nous or as an osseocartilaginous graft.
The most common concern when using rib as
a cartilaginous graft is its tendency to warp. This
phenomenon has been noted since the early 1900s
when Gilles noted the propensity for cartilage to
warp toward the side where the perichondrium
was left intact. This initially led to the belief that
it was the perichondrial layer that induced warp-
ing of the cartilage [ 22 ] . This theory was dis-
proven decades later when Gibson and Davis [ 23 ]
reported that costal cartilage appears to be in a
state of constant counterbalanced tension. They
hypothesized that imprecise carving of the grafts
could lead to an imbalance of these forces, which
results in eventual dis fi gurement. Gibson and
Davis have proposed four main con fi gurations
for sculpting the graft that balance the forces of
tension and resist warping.
Despite Gibson’s initial reports of cross-bal-
anced carving, he later states that the most criti-
cal factor in reducing warping is to minimize the
amount of shaping required, which is still advo-
cated today [ 24 ] . Gunter et al. [ 24, 25 ] report
overcoming this by fi xation of costal cartilage
grafts using internal K-wires, using a 0.035-in.
K-wire placed down the central aspect of the graft
as a technique to resist warping. Studies have
shown that the majority of cartilage warping
takes place within 15–30 min after immersion in
saline [ 23, 26 ] , although some warping can con-
tinue for up to 4 weeks postoperatively [ 27 ] .
The authors recommend immersing costal
grafts in saline for at least 20 min prior to its use
in order to allow any warping of the cartilage to
take place before sculpting occurs. Moreover, the
authors agree that concentrically carved cartilage
grafts warp far less than eccentrically carved
pieces [ 28, 29 ] .
Osseocartilaginous costal grafts are an alterna-
tive to cartilaginous grafts for the nasal dorsum.
Early reports of signi fi cant bony reabsorption lead
to a tendency to avoid its use for nasal reconstruc-
tion [ 30, 31 ] . However, the nose has been shown to
have low rates of resorption of bony grafts, such as
calvarial and costal grafts when used for dorsal
augmentation [ 32, 33 ] . Although the use of osseo-
cartilaginous costal grafts avoids the potential for
warping, the incision tends to be less concealed
due to the more inferolateral position of the 10th
and 11th ribs. This typically is an issue in females,
where an inframammary incision provides the per-
fect concealment under a bra wire or bikini top.

483
34 Costal Cartilage Grafting for Dorsal Augmentation
34.5
Evaluation of the Patient
The overall evaluation of the rhinoplasty patient
is a complex process and beyond the scope of this
chapter. However, there are a few key points that
require addressing when attempting to correct the
nasal dorsum. A complete history of the patient
should always be elicited to help identify the
potential causes of deformities of the nose and
the patient’s motivation for corrective surgery.
A variety of pathological conditions can lead
to a dorsal deformity requiring augmentation, but
trauma and prior surgical procedures account for
the majority of causes in the reported literature
[ 34– 36 ] . Nasal trauma may result in mechanical
disruption of the septum or in hematoma forma-
tion leading to necrosis of the cartilaginous sep-
tum and loss of support [ 37 ] . Surgical disruption
of septal attachments to the nasal fl oor, bony sep-
tum, and nasal bones as well as injudicious resec-
tion of the septal cartilage may result in a loss of
support of the nasal dorsum. Such effects may be
delayed for months or years following the proce-
dure [ 38 ] . Destruction of the septal mucoper-
ichondrium and subsequent perforation of the
septum by prolonged topical use of vasoconstric-
tive agents such as cocaine and oxymetazoline are
also common causes of saddle nose deformity.
Septal perforations unrelated to above-men-
tioned etiologies require further workup. A thor-
ough serological evaluation and nasal biopsy is
required to exclude conditions such as Wegener’s
granulomatosis, sarcoid, Crohn’s disease, and
relapsing polychondritis [ 39, 40 ] . Such illnesses
usually result in damage to the septal and mid-
dle vault cartilages while involving the bone to
a lesser extent [ 41 ] . These conditions should be
under medical control and in remission prior to
reconstructive rhinoplasty. Despite fears of an
immunosuppressive regimen’s effect on graft
take rate, studies have failed to show increased
rates of failure in this patient population and
is not a contradiction to surgery [ 42 ] . Directed
nasal biopsy permits evaluation for neoplas-
tic processes such as inverted papillomas and
squamous cell carcinomas in which direct growth
of the lesion is locally destructive [ 20 ] . Prior to
the popularization of septorhinoplasty, infectious
processes were frequent causes of septal perfo-
rations and included syphilis, leprosy, or septal
abscesses [ 38, 43 ] .
In addition to dorsal contour and septal evalu-
ation, tip support and functional integrity of the
internal nasal valves must also be ascertained
preoperatively in order to determine whether
these areas need to be addressed simultaneously
with dorsal augmentation. Finally, the skin-soft
tissue envelope (S-STE) should always be exam-
ined to determine its thickness as grafting in thin-
ner skin will be more transparent to irregularities,
and thus more likely to require onlay camou fl age
material. Rigid costal grafting may also be unten-
able for patients who have S-STE with poor vas-
cularity and/or signi fi cant cicatricial contracture.
The surgical approach for dorsal augmenta-
tion is dependent on the surgeon’s determination
of the needs for dorsal reconstruction. Endonasal
and external approaches need to be both utilized
depending on the nature of the dorsal augmenta-
tion as well as the need for tip reconstruction.
34.6
Harvesting Grafts
34.6.1 Cartilaginous Rib Grafts
The ribs are marked by palpation of their medial
articulation with the sternum starting with the
manubrioclavicular joint, which marks the sec-
ond rib. The fi fth, sixth, and seventh ribs are typi-
cally chosen for harvesting, but one should be
familiar with the overall anatomy of the ribs as
certain ribs, such as the ninth rib, can provide two
ample straight segments of grafts (Figs. 34.2 and
34.3 ). In females, an incision is marked at the
inframammary fold centered just medial to the
midclavicular line and measures approximately
2.5–5 cm in length. Care should be taken not to
extend this line beyond the medial border of the
inframammary fold in order to avoid an obvious
scar when wearing low-cut clothing. In males,
the scar is placed above the rib to be harvested,
ideally within a hair-bearing area for better
concealment.
After ensuring a sterile fi eld, the skin is
injected with a lidocaine solution containing

484
W.H. Ezzat and B. Azizzadeh
epinephrine. Adequate time is allowed for vaso-
constriction, and the incision is made through the
skin using a scalpel blade. Electrocautery is uti-
lized to dissect the subcutaneous fat, fascia, and
muscle layers. Muscle-sparing approach is almost
always utilized in order to minimize postopera-
tive pain. Maintaining the dissection directly over
the rib targeted for harvesting is aided by direct
palpation. The cartilaginous portion of the rib is
isolated. The goal is to harvest the largest seg-
ment capable of producing long, straight seg-
ments. The bony-cartilaginous junction can be
identi fi ed visually by the change in color from
the off-white cartilage to the reddish-gray bone.
The perichondrium is incised along the superior
and inferior length of the rib. Blunt subperiosteal
dissection then ensues around the superior, infe-
rior, and posterior cartilaginous portion of the rib,
thus minimizing the risk of violating the pleura
and allowing perichondrium to be available for
closure if required. Freer and pediatric doyen rib
elevators are used to maintain a subperichondrial
dissection. Once the cartilage is isolated, a #15
blade is used to make the medial and lateral cuts
with freer elevator protecting the pleura to com-
plete the harvesting of the graft. Using the same
technique, osseocartilaginous grafts can also be
harvested if desired. The internal oblique strongly
adheres to the periosteum overlying the rib, and
dissecting this layer requires spreading parallel to
the direction of the muscle fi bers to avoid inad-
vertent cautery of the underlying bone. If there is
dif fi culty de fi ning the osseocartilaginous junc-
tion, a 22-guage needle can be used to differenti-
ate the softer cartilage from the bony rib. The
graft is immediately immersed in saline for at
least 20 min to account for any warping that may
take place. The perichondrium/periosteum is har-
vested with the graft and can be separated from
the bone and/or cartilage to take the place of tem-
poralis fascia as a camou fl age onlay graft [ 33 ] .
The donor site is fl ooded with saline, and
Valsalva maneuver is performed to check for
pleural defects. If one is found, a 14-french red
rubber catheter is threaded into the defect and
connected to continuous suction. The closure is
performed in layers to ensure a watertight closure.
Once the muscular layers are closed, positive
pressure up to 40 mmHg is maintained while the
red rubber catheter is withdrawn. Failure to main-
tain appropriate ventilation volumes and pressures
may require placement of a chest tube and appro-
priate postoperative care – although this is typi-
cally not needed. A long-acting local anesthetic is
in fi ltrated in the surrounding area for pain man-
agement prior to closure of the skin with suture.
Fig. 34.2 A segment of autologous rib cartilage har-
vested for use in dorsal reconstruction
Fig. 34.3 Harvesting of the ninth rib cartilage takes
advantage of the natural curvature of the rib cage. Both a
dorsal graft and a dorsocaudal septal strut can be easily
carved using this one rib. The disadvantage to harvesting
this rib is due to its more inferolateral position and cannot
be harvested from an inframammary incision

485
34 Costal Cartilage Grafting for Dorsal Augmentation
34.7
Determining the Needs of the
Dorsum
34.7.1 Contour Deformities
The success of any nasal surgery lies in the ability
to accurately diagnose the type of dorsal deformity
and anticipate which type of grafts are required to
attain the desired outcome. Onlay grafting will
typically be necessary in a structurally stable nose
with contour depression due to overresection of
the dorsum. The restoration of the dorsal pro fi le
may proceed without concern for strengthening or
rebuilding the septal/middle nasal vault. Injectable
fi ller materials may be employed to correct rela-
tive supratip depressions, but lasting corrections
generally require the use of onlay and support
grafts. As previously described, allografts may be
used successfully but can result in delayed infec-
tion and extrusion. In general, autografts are
favored by the authors for dorsal augmentation.
Bare diced cartilage grafts from the septum,
concha, or rib have been used but are associated
with the possibility of shifting despite placement
in a secure pocket of tissue and of palpable irreg-
ularities, especially in thinner-skinned individu-
als (Fig. 34.4 ). Out of these drawbacks, Erol
established the method of wrapping diced carti-
lage in Surgicel® (ETHICON, West Somerville,
NJ) for correction of defects of the nasal dorsum –
coined The Turkish Delight [ 44 ] . He published a
series of 2,365 patients treated over the course of
a 10-year period. In addition to the ability to uti-
lize this graft in both endonasal and open
approaches, the graft was moldable by manipula-
tion for up to 3 weeks postoperatively. The need
for revisions secondary to overcorrection and rate
of resorption were both under 1%.
Daniel and Calvert attempts to duplicate these
results, however, were unsuccessful due to
signi fi cant resorption of the grafts [ 45 ] . Upon
revision, the Surgicel® wrapped grafts were his-
tologically compared to diced cartilage wrapped
in temporalis fascia. The specimens wrapped in
Surgicel® displayed evidence of signi fi cant for-
eign body reaction, the primary means of
Surgicel® degradation, leading to the resorption
of the underlying cartilage [ 46 ] In comparison,
the temporalis fascia wrapped grafts had minimal
evidence of resorption and retained the regenera-
tive capacity of the cartilage [ 45 ] . A smooth con-
tour was attained, and no evidence of mobility
was observed. These grafts may be inserted into
the dorsum through an intercartilaginous or exter-
nal incision and do not require overcorrection.
Furthermore, diced cartilage grafts may be the
only alternative for patients with extremely com-
promised S-STE due to the lack of rigidity.
34.7.2 Contour Deformity with Middle
Nasal Vault Collapse
Some patients present with contour deformities
in conjunction with internal nasal valve collapse
and loss of tip projection. In this setting, middle
Fig. 34.4 Cartilage diced and prepared for placement
along the nasal dorsum as a camou fl age graft. These can
be used alone or wrapped in fascia

486
W.H. Ezzat and B. Azizzadeh
nasal vault reconstruction is required in addition
to reestablishing the nasal dorsal contour [ 46– 48 ] .
In this setting, despite the possibility of the patient
having adequate septal cartilage, the surgeon
should anticipate the likelihood of having to har-
vest costal cartilage. The authors will always pre-
consent the patient for costal cartilage grafting
and maintain a separate set of instruments and
surgical fi eld for sterility.
Dorsal augmentation in conjunction with
middle vault reconstruction will typically require
the surgeon to utilize extended spreader grafts,
consisting of two longitudinal struts of cartilage
typically measuring 20–25 mm × 3 mm. These are
placed between the upper lateral cartilages and
the septum. They serve to widen the internal nasal
valve, thereby improving the functionality of the
internal nasal valve. The grafts are supported by
the remaining dorsal septal cartilage and a septal/
columellar strut caudally in a tongue-in-groove
fashion (Fig. 34.5 ). This caudal strut is placed at
the nasal spine with its maximal width and weight
bearing strength at the columellar-labial angle
[ 49 ] . This con fi guration will also provide lobular
support and help increase tip projection as well as
counter-rotate the tip if desired. Once the desired
dorsal pro fi le is set, the extended spreader grafts
are secured to the existing ULCs to reconstitute
the middle nasal vault and to the septal/columellar
strut by 5-0 polydioxane sutures. The LLCs are
also reattached to this new scaffolding in a tongue-
in-groove fashion order to reset the nasal tip.
34.7.3 Contour Deformities with
Signi fi cant Loss of Structural
Support
Signi fi cant dorsal contour deformity will almost
always lead to signi fi cant functional de fi cits due
to the loss of structural support in the middle
nasal vault and tip. Augmenting these defects
with camou fl age onlay grafts without addressing
the underlying framework will result in a poorly
functioning nose. The dorsal contour should be
restored with structurally supporting grafts.
Two alternative approaches can be utilized to
address signi fi cant dorsal deformities. The most
common approach involves utilizing a canoe-
shaped dorsal cartilage or osseocartilaginous
grafts secured to the bony dorsum and to a dorso-
caudal septal strut. The upper lateral cartilages
can be secured to the undersurface or lateral
aspect of these dorsal grafts, thereby improving
the internal nasal valve.
An alternative composite approach popular-
ized by Daniel involves augmenting the dorsal
contour after reestablishing of a stable middle
nasal vault and tip support with extended spreader
a
b
Fig. 34.5 ( a ) Dorsal modi fi cation using two dorsal struts
( dark green ) secured to the remaining septal cartilage at
the keystone area. This is secured to a caudal septal strut
( light blue ) anteriorly and to the nasal spine posteriorly.
( b ) The caudal septal strut placed in a tongue-in-groove
fashion over the nasal spine and secured with sutures. This
serves as support but can also be used to reset the lower
lateral cartilages, thus adjusting tip height

487
34 Costal Cartilage Grafting for Dorsal Augmentation
grafts cantilevered to septal/columellar struts and
tip grafts. The extended spreader grafts described
as “pistol” grafts by Gunter should be carved
along the natural curvature of the rib and secured
beneath the bony dorsum [ 50 ] . Caudally, the
grafts are secured to a piece of rib cartilage carved
to serve as a dorsocaudal septal strut and sutured
directly to the nasal spine. The upper lateral car-
tilages may then be attached to this stable support
wall. Adequate nasal lining is critical for the sur-
vival of these grafts. Advancing and securing the
medial crura to the septal/columellar strut can
place the nasal tip at its desired position. If addi-
tional projection is required, onlay or shield tip
grafts are utilized [ 51 ] .
Once the structural framework has been estab-
lished and the tip work completed, dorsal contouring
proceeds secondarily. Either fascia alone, diced car-
tilage, or fascia-wrapped diced cartilage grafts, fash-
ioned from the remaining rib, may be placed along
the dorsum in order to achieve the desired contour
(Fig. 34.6 ) [ 47 ] . Lateral nasal wall collapse can be
corrected through additional cartilage grafts designed
to bolster the compromised internal and external
nasal valve. Segments of cartilage as thin as 1 mm
can be carved and provide adequate support and
aesthetics [ 48 ] .
34.7.4 Defects Encompassing
the Bony Dorsum
Defects of the bony vault that accompanies the
complete loss of dorsal septal support and con-
tracture of the nasal lining represent a signi fi cant
reconstructive undertaking. Composite recon-
structions aimed at rebuilding a septal support
wall are not possible due to the compromised
nasal lining that usually accompanies this type of
defect. A new framework must be fashioned from
a cantilevered dorsal graft and a dorsocaudal sep-
tal/columellar cartilage strut. Tardy et al. reserves
the use of autogenous iliac bone crest for recon-
struction of these major defects [ 5 ] . However,
iliac bone harvesting results in signi fi cant donor-
site morbidity and pain [ 20 ] . Membranous calva-
rial bone grafts have been shown to exhibit
improved resorption rates over the endochondral
bone of the iliac crest. Thomassin et al. reported a
13.5% resorption rate of iliac versus none for cal-
varial bone over a mean follow-up of 4 years when
correcting moderate and major saddle nose defor-
mities [ 51 ] . Calvarial bone has also been utilized
for creation of an L-shaped strut in reconstruction.
Such a graft has advantages of harvesting gener-
ous graft material from the same region of the
body, direct bone to bone contact improving graft
take rate, and a minimal blood supply requirement
[ 32 ] . This option is not ideal for patients who have
thinning hair, are bald, or have a monocortical cal-
varium. In addition, iliac crest and calvarial bone
grafts fail to address support of the ala and lateral
nasal side wall, requiring further harvesting of
cartilage from another donor site.
a
b
Fig. 34.6 When dealing with signi fi cant dorsal defects,
the need for additional grafting should be anticipated. ( a )
A septal columellar strut may be utilized to lengthen the
nose and elevate the tip. ( b ) Further contour deformities
may be addressed through diced cartilage or fascia-
wrapped diced cartilage placed upon the new established
framework

488
W.H. Ezzat and B. Azizzadeh
A cantilevered cartilaginous or osseocartilagi-
nous dorsal graft carved from costal cartilage can
also provide adequate structural support and aes-
thetic contour (Fig. 34.7 ) [ 47 ] . These grafts are
harvested as previously described. If an osseocar-
tilaginous graft is used, the osseous portion can
be aggressively carved out to provide a smooth
dorsal contour without the fear of warping. The
native bony vault in the upper third of the nose is
gently rasped down to accommodate the height
of the bony rib, so as not to create a step-off
deformity, and allow for an ample bone-to-bone
union. If shifting is experienced intraoperatively,
the graft can be secured cephalically with percu-
taneous Kirschner wires, 1.2-mm titanium lag
screws, or a 1.2-mm X- or Y-shaped titanium
fi xation plate to the existing nasal bones
(Fig. 34.8 ). The Kirschner wire, when utilized, is
placed percutaneously and removed in the of fi ce
7 days after the procedure. Titanium plate fi xation
can be performed through a separate incision at a
prominent rhytid at the nasion (Fig. 34.9 ).
A dorsocaudal septal strut is fashioned from
the distal cartilaginous portion of the rib graft.
This is secured with a 4-0 Prolene suture passed
through a drill hole placed in the nasal spine. A
hand drill can be utilized or, more practically
accomplished, with an 18-guage needle twisted
back and forth between the thumb and fore fi nger.
The strut is also vertically incised at its base to
permit it to straddle the nasal spine. Tip projec-
tion and lateral nasal wall reconstruction may
proceed as described above, but results are often
limited by extensive contracture of the skin and
nasal lining [ 47– 49 ] . To account for skin contrac-
ture, composite grafts from the triangular fossa or
concha of the contralateral ear serve as excellent
extenders at the alar rim.
Fig. 34.7 Total nasal reconstruction with an autologous
rib graft. The dorsal and caudal septal struts are support-
ing additional grafts formed from the remaining cartilage
to reconstitute the upper and lower lateral cartilages.
While the primary goal of this particular procedure is
functional, the principles of structural support are best
exempli fi ed by these cases and should be maintained dur-
ing cosmetic cases as well
K-wire
Screws
Fig. 34.8 Fixation of the cephalic portion of either a car-
tilaginous or osseocartilaginous graft can be accomplished
with monocortical screw fi xation or K-wires placed
percutaneously
Fig. 34.9 An X- or Y-shaped titanium miniplate is placed
through an incision placed in a prominent rhytid at the
nasion will secure the graft and prevent shifting

489
34 Costal Cartilage Grafting for Dorsal Augmentation
Conclusions
Augmentation and reconstruction of the nasal
dorsum is a challenging component of rhi-
noplasty. The role of the middle nasal vault
in function and aesthetics is vital, and main-
tenance of the support mechanisms is para-
mount to the ideal dorsal pro fi le. The interplay
between the nasal pyramid, cartilaginous sep-
tum and upper lateral cartilages, and lower third
of the nose must be taken into consideration
during reconstruction. By fi rst ascertaining the
exact nature and extent of the defect, the sur-
geon should be able to anticipate the need for
grafts preoperatively. Autologous material pro-
vides the most reliable source of graft material,
with the most abundant source found in costal
cartilage. Harvesting either a cartilaginous or
osseocartilaginous graft can be accomplished
without signi fi cant morbidity to the patient.
Strict adherences to the basic principles sur-
rounding nasal support will allow the surgeon
to ef fi ciently plan their reconstructive effort
and lead to acceptable surgical outcomes.
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DOI 10.1007/978-3-642-28053-5_35, © Springer-Verlag Berlin Heidelberg 2013
35
35.1
Introduction
Selection of grafting materials in rhinoplasty can
be a challenging problem, particularly in patients
with signi fi cant aesthetic and structural de fi cits
of the nasal dorsum. In appropriately selected
cases, split calvarial bone graft represents an
ideal choice for modi fi cation of this nasal region.
Split calvarial bone graft provides the bene fi ts of
unsurpassed strength, abundant volume, and
long-term resistance to resorption. The latter
property separates this graft from other autoge-
nous materials, such as septal, auricular, and cos-
tal rib cartilage. In this chapter, split calvarial
bone grafting is reviewed in detail, focusing on
indications, harvest technique, and avoidance of
potential pitfalls and complications.
35.2
Grafting Considerations
in Rhinoplasty
Planning of a successful rhinoplasty operation
requires a thorough assessment of all available
grafting options. In a primary setting, or in noses
with modest demands for grafting, native carti-
lage provides an excellent supply of grafting
material. Nasal septal and auricular cartilages are
preferred choices for structural grafting of the
nasal tip and the mid-vault region. These cartilage
sources, however, can be inadequate for large vol-
umetric and structural demands seen in cases of
advanced osseocartilaginous de fi ciencies.
Autogenous or heterologous rib cartilage can
provide an abundant source of grafting material
for rhinoplasty. The downside of rib harvest lies in
donor site morbidity, with potential for a conspicu-
ous scar and regional discomfort from musculosk-
eletal manipulation of the rib cage. Rib cartilage
also possesses elastic memory and propensity for
warping and absorption. Although these undesir-
able properties make it a less predictable graft in
rhinoplasty surgery, they have been recently
addressed by using central core of the costal graft.
Autogenous bone sources include iliac crest,
rib, and calvarium. Membranous bone (facial
skeleton) has a lower resorption rate than endo-
chondral bone (rest of the skeleton). Harvesting
Split Calvarial Bone Grafting
in Rhinoplasty
Babak Azizzadeh and Grigoriy Mashkevich
B. Azizzadeh , M.D., FACS (*)
Facial Plastic and Reconstructive Surgery ,
Cedars-Sinai Medical Center , Los Angeles , CA , USA
The Center for Advanced Facial Plastic Surgery ,
9401 Wilshire Blvd., Suite 650 , Beverly Hills ,
CA 90212 , USA
The Center for Facial and Nasal Plastic Surgery ,
8670 Wilshire Blvd., Suite 200 , Beverly Hills ,
CA 90211 , USA
Division of Head and Neck Surgery , David Geffen
School of Medicine at the University of California, Los
Angeles , 120 South Spalding Drive, Suite 340 ,
Beverly Hills , CA 90212 , USA
e-mail: md@facialplastics.info
G. Mashkevich , M.D.
Division of Facial Plastic and Reconstructive Surgery ,
The New York Eye and Ear In fi rmary ,
310 East 14 Street , New York 10003 NY , USA
e-mail: gmashkevich@nyee.edu;
gmashkevich@yahoo.com

492
B. Azizzadeh and G. Mashkevich
from the iliac crest is avoided secondary to pain
at the donor site and long-term resorption of the
endochondral iliac bone. In contrast, there are
several distinct advantages of the calvarial bone
that make it an ideal grafting material in appro-
priately selected cases. The temporoparietal
donor site is well tolerated by patients in terms of
discomfort. In comparison to cartilage, calvarial
bone has a lower risk of warping over time. It
provides a stable segment of potentially large
bone stock, which possesses the necessary inher-
ent strength to support forces of skin-soft tissue
envelope contracture.
While alloplastic materials resist resorption, they
carry an elevated risk of infection and extrusion and
are not preferred by the authors in nasal surgery.
35.3
Clinical Indications for Split
Calvarial Bone Grafting
The most common cosmetic application of split
calvarial bone graft is dorsal nasal augmentation,
typically in a setting of a severe saddle nose defor-
mity. Calvarial bone grafts can also be reliably
used for total or subtotal reconstruction of the
L-shaped strut in large rhinectomy defects. While
limited, clinical presentations requiring consider-
ation of split calvarial bone grafting vary in etiolo-
gies and include traumatic, oncologic, and
iatrogenic nasal deformities. Autogenous costal
cartilage and calvarial bone grafts are the only
options that should be considered in these settings.
These two options should be discussed with the
patients in terms of their advantages and disadvan-
tages. The authors typically use autologous costal
grafts and reserve calvarial bone grafts for patients
who have relapsing polychondritis or do not desire
a visible scar in the chest region (Fig. 35.1 ).
35.4
Surgical Considerations
in Preparation of the Nasal
Recipient Bed
Insertion of a split calvarial bone graft is best per-
formed during an open rhinoplasty approach,
which enables the most optimal visualization of
the nasal bones and the recipient bed. Following
creation of a tight pocket, nasal bones are drilled
down to create a “sticky” raw surface, maximiz-
ing contact points with the undersurface of the
split calvarial bone graft. Fresh surface of the
nasal bones allows the graft to adhere more effec-
tively while promoting contact between surfaces.
This also eliminates the dead space, minimizes
possibility of nonunion, and decreases risk of
postoperative graft dislodgement and mobility.
At its caudal aspect, graft placement is limited to
the caudal margin of the upper lateral cartilages.
An alternative fi xation method consists of
miniplate placement along the nasal sidewall and
by the radix. This technique can be cumbersome
and requires percutaneous stab incisions to intro-
duce instrumentation and screws. Creation of an
appropriately sized pocket of skin-soft tissue
envelope, with a concomitant reduction of the
bony nasal vault, eliminates the need for plate
fi xation in this area and is the preferred method
of fi xation by the authors.
35.5
Surgical Steps in Calvarial
Bone Graft Harvesting
Presence of the diploic space must be con fi rmed
on coronal CT views of the temporoparietal cra-
nium prior to surgery. Incision design can follow
several orientations. For small graft requirements,
an irregular zigzag incision oriented in a coronal
plane provides the most optimal scar camou fl age,
especially if incisional hair loss ensues. However,
such incision would not be appropriately oriented
in patients with existing or anticipated baldness.
Instead, a sagittal incision is placed over the tem-
poral line (and lateral to it in balding patients),
measuring up to 10 cm in length and situated
6–8 cm lateral to the midline (Fig. 35.2 ) . The area
is injected with 1% lidocaine mixed with
1:100,000 units of epinephrine and is sterilely
prepped with Betadine. Following the incision,
the scalp is elevated in a plane above pericranium.
In the forehead, the pericranium is incised and
elevated posteriorly over the bone. This fl ap is
used at the end of bone harvest for coverage of
the donor site, which is described below.

493
35 Split Calvarial Bone Grafting in Rhinoplasty
The site of the graft is then outlined, typi-
cally measuring up to 2 × 5 cm, with the long
axis oriented along the sagittal plane. The donor
graft site is adjusted for positioning above the
temporal line, where cranial curvature is mini-
mal. A cutting bur is then utilized to drill out the
outer table just outside graft periphery, in order
to provide access to the diploic space (Fig. 35.2 ).
a
b
c
Fig. 35.1 Clinical scenarios in which split calvarial bone
grafting can be utilized. ( a ) Patient with recurrent squamous
cell skin carcinoma invading the skin-soft tissue envelope of
the nose. ( b ) Same patient after undergoing total rhinectomy,
showing resection of the quadrangular cartilage and overly-
ing soft tissues. ( c ) Patient with a saddle nose deformity

494
B. Azizzadeh and G. Mashkevich
Graft periphery is saucerized for approximately
1 cm, taking care to avoid approaching the mid-
line on the medial border. This step is performed
under constant saline irrigation to minimize
bone trauma from high temperatures generated
by the rotating bur. While bleeding heralds entry
into the diploic space, drilling is gently contin-
ued until bleeding stops, indicating the inner
cortex.
Saucerized periphery of the graft allows for
entry with straight osteotomes or a sagittal saw
(Fig. 35.2 ). Either one can be utilized to cut
beneath the outlined outer table. This is per-
formed halfway on the lateral and medial aspects
of the graft, thereby minimizing the risk of graft
fracture. Osteotomes are introduced tangential to
the skull to reduce the chance of intracranial pen-
etration. The bone graft is then removed and set
aside for modi fi cation on a separate sterile table.
The graft is drilled with a combination of cut-
ting and diamond burs to create a desired contour
for the nasal dorsum. Care is taken to create a
smooth surface and to bevel graft edges, in order to
minimize transitional visibility. The undersurface
of the graft is given a gentle concave con fi guration
in the middle, which helps with stabilization and
a
b
c
d
Fig. 35.2 Split calvarial bone graft harvesting. ( a )
Midline and planned off-midline incision is outlined. ( b )
The periphery of the bone graft is saucerized with a cut-
ting bur in order to gain access into the medullary space.
( c ) The outer table is delivered after making cuts under-
neath it with a sagittal saw. ( d ) Application of hydroxy-
apatite bone cement into the donor site defect

495
35 Split Calvarial Bone Grafting in Rhinoplasty
prevents displacement. Depending on the need,
dorsal and caudal struts can be created and con-
nected with miniplates and screws.
The donor site is repaired by fi lling its base
with hydroxyapatite bone cement. An example of
such product is HydroSet (Stryker, Portage, MI),
which is an injectable, self-setting calcium phos-
phate cement that converts to hydroxyapatite
(principal mineral component of bone). Filling of
the donor site defect creates a more favorable
external contour (avoids depression) and seals
the open bone wound, thereby minimizing post-
operative hematoma and seroma formation. A
previously created pericranial fl ap is then laid
down and secured over the cement. A suction
drain is placed for 24 h. The wound is closed pri-
marily with deep 3–0 absorbable sutures and
staples super fi cially.
35.6
Complications and Pitfalls
Complications associated with split calvarial
bone grafting can affect both the donor and recip-
ient areas.
Scalp incisions can lead to peri-incisional hair
loss, which can be permanent. In select cases, vis-
ibility of hair loss and incisional scars can be
camou fl aged by creating an irregular, zigzag-like
incision oriented along the coronal axis. All skin
incisions should be made at an angle of hair exit-
ing the scalp, in order to avoid follicular root
transection. In balding patients, incision scars may
become visible as a result of receding frontotem-
poral hair tufts. Placement of incisions inferior to
the temporal line can help in these situations.
Dural exposure, tears, and intracranial pene-
tration represent unlikely events if the technique
outlined above is closely followed. Preoperative
CT scanning allows con fi rmation of the cranial
diploic space. Sagittal sinus penetration is
avoided by placing the medial border of the
graft several centimeters away from the midline.
Contour depression of the harvest site can be
addressed with hydroxyapatite cement or an
autologous fat graft. Hematoma and seroma for-
mations are the most common donor site com-
plications. These are best prevented by active
drain placement and donor site dead space cov-
erage with cement.
Split calvarial bone graft can become visible
on the nose, especially underneath the thin dorsal
skin. This complication is best avoided by metic-
ulously drilling down graft edges prior to inser-
tion. Bone graft can become mobile if it fails to
fuse to the underlying osseocartilaginous frame-
work. This is prevented by preparing a matching
recipient site, thereby eliminating dead space and
allowing optimal contact between the graft and
osseocartilaginous nasal framework. Bone and
hardware exposure is possible with excessive
tension placed by the graft on the overlying skin-
soft tissue envelope. Salvage with local wound
care, antibiotics, and delayed adjacent tissue
transfer can be attempted before considering graft
removal (Fig . 35.3 ).
Conclusions
In appropriately selected rhinoplasty cases,
split calvarial bone graft represents an ideal
material
for
aesthetic
and
structural
modi fi cation of the osseocartilaginous nasal
framework. Understanding of the nuances of
donor site design, graft harvest, and recipient
bed preparation can result in reliable outcomes
and minimal donor site morbidity.

496
B. Azizzadeh and G. Mashkevich
a
b
Fig. 35.3 ( a ) Preoperative pro fi le view. ( b ) Postoperative pro fi le view following nasal augmentation with a split calva-
rial bone graft

497
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_36, © Springer-Verlag Berlin Heidelberg 2013
36
36.1
Introduction
Silicone or Gore-Tex implant is the most widely
utilized material in dorsal augmentation. However,
secondary rhinoplasty may then be required
because of alloplastic-associated complications
such as infection or extrusion of the implant. Erol
[ 1 ] fi rst published about diced rib cartilage graft.
However, the percentage use of rib cartilage is
not much high because the surgery has complica-
tions such as a warping effect of rib cartilage,
along scar on the chest, the possibility of pneu-
mothorax, and severe pain. Therefore, a scooping
technique for the harvest of rib cartilage was
developed by the author (DWP). Using the tech-
nique, the harvest of outer layer of rib cartilage
2 cm length renders a zero percent possibility of
pneumothorax and decreased pain. Despite no
use of Surgicel or fascia wrapping, because ultra-
diced cartilage graft was utilized, no dorsal irreg-
ularity occurred.
Although most patients do well over their life-
time with alloplastic implants such as silicone or
Gore-Tex, implants can cause signi fi cant problems
due to trauma such as frequent nasal bone fracture
or an in fl ammation condition such as sinusitis or
rhinitis. Patients have to be reminded of the neces-
sary caution they must take in regular life activi-
ties to avoid injury of the nose. There is also risk
of injury to the nose in recreational activity, such
as skiing, or as the result of an unavoidable or
unanticipated event, such as a car accident.
Problems can include infection, in fl ammation,
exposure of implants, displacements, and tissue
necrosis. Because of the issue of these potential
problems, the authors do not use alloplastic
implants in any rhinoplasty and prefer to utilize
autologous cartilage for all grafting in rhinoplasty.
Autologous cartilage grafting material comes
from three main sources: septal, auricular, and rib
cartilages. Of these three sources, the authors pre-
fer to use rib cartilage in the sixth rib area.
36.2
Background for Using
Rib Cartilages
There are three potential donor sites for autolo-
gous graft in rhinoplasty: septal cartilage, auricu-
lar cartilage, and rib cartilage. Septal cartilage is
Ultradiced Rib Cartilage Graft
Without Wrapping
for Augmentation Rhinoplasty
Peter Chanwoo Kim and Dae Hwan Park
P. C. Kim , M.D., Ph.D., M.B.A.
Plastic and Reconstructive Surgery Department ,
Daegu Catholic University Medical Center ,
3056-6 Daemyung 4-Dong , Nam-gu,
Daegu 705-034 , Korea
e-mail: psman007@gmail.com
D. H. Park , M.D., Ph.D., FACS ()
Plastic and Reconstructive Surgery Department ,
Daegu Catholic University Medical Center ,
3056-6 Daemyung 4-Dong , Nam-gu,
Daegu 705-034 , Korea
Department of Plastic and Reconstructive Surgery ,
Catholic University of Daegu ,
Daegu , Korea
e-mail: dhpark@cu.ac.kr

498
P.C. Kim and D.H. Park
the preferred choice for autologous cartilage
grafting because it is straight, requires no addi-
tional incisions, results in invisible donor site
scarring, and is good for simultaneous correction
of septal deviation. However, the average har-
vesting volume of septal cartilage is frequently
insuf fi cient which results in having to use alter-
native donor sites such as auricular cartilage.
From our data, the average volume of septal har-
vest was 0.40 cc despite the average necessary
volume of nasal augmentation being 1.13 mL [ 2 ] .
The average volume of a general silicone nasal
implant is 0.8 mL. Auricular cartilage may be
used occasionally; however, it is limited by its
fl accidity and convolutions, and also is insuf fi cient
for every tip graft or dorsal graft in rhinoplasty.
Rib cartilage provides the most abundant
source of cartilage graft fabrication. However, rib
cartilage is known for having limited indication
when the amount of septal cartilage is inadequate
and is just for secondary or tertiary rhinoplasty
which needs the rigid support of the osseocarti-
laginous framework despite the existence of risky
donor complications like pneumothorax and a
long scar on the chest. However, the proposed
harvest technique of rib cartilage is safe against
risk of pneumothorax. There is no injury to the
posterior layer of costal cartilage; harvest is sim-
ple due to the scooping technique; and only a
short operation time (average 12 min) is needed
for harvest. Therefore, the preferred choice is rib
cartilage (Table 36.1 ).
36.3
Preoperative Planning
A life-sized pro fi le template is a great tool not
only for preoperative planning but also for intra-
operative check and for postoperative change.
The life-sized pro fi le template is made from a
life-sized photo. Facial analysis is one of most
important aspects of preoperative work not only
for rhinoplasty but also for facial bone surgery.
After the life-sized 2D facial photos are printed
out, tracing paper is overlaid on the photos.
Cephalotracing can be performed if there is simul-
taneous facial bone surgery. With Peter’s ana-
lyzer, the ideal line of soft tissue can be outlined.
A facial template made of dental wax is framed
out from the facial analysis. The pro fi le template
is a useful tool for pro fi loplasty (Fig. 36.1 ).
36.4
Operative Technique
(Table 36.2 )
36.4.1 Technique for Measuring
Expected Volume
of the Harvest
Local in fi ltration with 1% lidocaine mixed
1:10,000 epinephrine is necessary. At this time,
local in fi ltration on the nasal dorsum is a useful
tool for predicting what volume of diced cartilage
is necessary. If 2 mL of lidocaine solution is nec-
essary to achieve the appropriate dorsum of the
nose for rhinoplasty, then it is necessary to pre-
pare 2 cc of diced rib cartilage (Fig. 36.2 ). So, it is
easy to predict the proposed amount of cartilage
from the injected volume of lidocaine solution.
There is no need to harvest a wasteful amount of
rib cartilage.
A marginal incision could be sutured back
with Vicryl 5-0. Insertion of the diced cartilage is
the last process for rhinoplasty. One side of the
marginal incision should be closed to prevent
diced cartilage from leaking out. The other side
of the marginal incision should be closed after
insertion of the diced cartilage.
36.4.2 Harvesting Technique
of Costal Cartilage
For the harvest of rib cartilage, the fi ve and/or
sixth rib is typically used. The chest can be
Table 36.1 Preferred use of cartilage
Septal cartilage
Ear cartilage
Rib cartilage
Small amount of graft such as nasal
root graft, polly beak nose, alar
contouring graft, or batten graft
Cartilage graft for lower lateral
cartilage (similar contour with lower
lateral cartilage), contour graft
For short nose, upturned nose, graft
for dorsal augmentation, derotation
graft

499
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
palpated before the incision is made to decide
which rib would be most appropriate. In males,
the fi fth or sixth rib can be chosen for rhinoplasty.
In females, the inframammary fold at the sixth
rib can be chosen for a nonvisible scar. For
females, it is necessary for the patient to be seated
on the operation table for the design for the chest
incision to be performed (Fig. 36.3 ). Before inci-
sion, the intercostal nerve is blocked using 5 mL
of 2.5% bupivacaine and local in fi ltration with
1:100,000 epinephrine mixed – 1% lidocaine is
necessary for pain and bleeding control. The 1.5–
2-cm incision is made through the skin and sub-
cutaneous tissue then the chest tissue is sharply
dissected down to the muscular fascia with long
Metzenbaum scissors. In patients with breast
implants, the incision must be made inferior to
the implants to avoid rupture or potential
in fl ammation around implant. For a fatty chest,
resection of part of the fat tissue helps dissection,
cartilage harvest, and even closure. The fascia is
a
b
Fig. 36.1 Pro fi le template. ( a ) Pro fi le facial template is framed out from the facial analysis and is ( b ) useful for
preoperative planning, intraoperative check, and postoperative comparison
Table 36.2 Operative technique
Measuring expected volume of harvest technique
Harvesting technique of costal cartilage
Dicing technique
Insertion and molding technique
Repair – closure
Splinting and dressing
Profile template
Fig. 36.2 Two milliliter was injected to the dorsal line to fi t the pro fi le template in pink color. About 2 mL of diced
cartilage graft can be predicted to be needed

500
P.C. Kim and D.H. Park
a
b
Fig. 36.4 A cartilage carving
instrument (designed in
Nagata, Japan). ( a ) Rib
cartilage is harvested with a
carving instrument. ( b ) Carved
cartilage with a scoop
Fig. 36.3 Incision on the
chest. Two centimeter
incision is made on
inframammary fold in female
to harvest sixth rib cartilage
1
2
3
4
5
6
incised sharply, and the muscle fi bers are care-
fully spread in the direction of the muscle fi bers.
For postoperative pain control, the muscle fi bers
are not cut and just separated. Once the rib carti-
lage is identi fi ed, cartilage harvest can be started
with a cartilage carving instrument (Fig. 36.4 ).
Rib cartilage is harvested with a carving
instrument using a scooping technique (Fig. 36.5 )
until the predicted volume for augmentation is
achieved without damage of the posterior layer of
the costal cartilage (Fig. 36.6 ).
In aging patients, mostly calci fi ed rib can be
found. It is necessary for the calci fi ed costal car-
tilage, which closely resembles bony solidity, to
be cut with a piezoelectric saw which allows
ultrasonic vibration (Fig. 36.7 ). The absorption
rate of calci fi ed rib cartilage graft is higher
than for fresh cartilage. An angiocatheter is
inserted into the dissected space for drainage.
The donor site is reapproximated with subcuta-
neous sutures using 3-0 Vicryl. The skin is closed
with 2-octylcyanoacrylate (2-OCA, Dermabond®,

501
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
Fig. 36.5 The scooping
method as a harvesting
technique of costal rib
cartilage is like scooping ice
cream
Fig. 36.6 Cross section of sixth rib area including the
lung. The scooping technique prevents injury to the pleura
a
b
c
Fig. 36.7 Piezoelectric saw with handpiece. ( a )
Piezoelectric surgery systems (SurgeryBone, Silfradent,
Italy) are designed to use ultrasonic microvibrations to
create an osteotomy. ( b ) Calci fi ed cartilage can be cut by
ultrasonic microvibration due to bone hardness of
calci fi ed cartilage. ( c ) These microvibrations make
selective the cartilage cuts possible. The Piezosurgery
device does not work on soft tissue, so the device causes
little or no soft tissue (pleura) trauma during harvesting
of rib cartilage and bone