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

503
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
0.2–0.5 mm cubic of ultra fi ne rib cartilage. A
hubless syringe can be made by using a No. 10
blade to cut off the hub. A hubless syringe helps
insertion of the diced rib cartilage into the nasal
dorsum. Diced cartilage was injected into the
nasal dorsum with the hubless syringe, and the
ideal contour of nose was made with manual dig-
ital molding (Fig. 36.11 ). The harvested cartilage
amount and the volume of inserted cartilage were
each recorded.
36.4.2.2 Insertion technique
The diced cartilage can be inserted in the nose
without a wrapping material like fascia or
Surgicel due to less irregularity of the ultra fi ne
dicing particulate. Ultradiced rib cartilage graft is
inserted using a 1-mL hubless syringe into a dis-
sected pocket of the nose with digital molding
manually without fascia or Surgicel. Digital
molding is then necessary to contour the ideal
nasal line
a
b
c
Fig. 36.9 A Dicing machine. ( a ) Carved cartilage can be diced with ( b ) manual dicing machine that has ( c ) multiple
rotating blades. The blades rotate with 22.5° in a turn with one stroke

504
P.C. Kim and D.H. Park
a
b
c
Fig. 36.10 Ultra fi ne diced cartilage can be made by a dic-
ing machine. ( a ) Big particle (10 strokes) can be particulated
into ( b ) fi ne diced cartilage (50 strokes), and ( c ) ultra fi ne
diced cartilage can be achieved with over 100 strokes
a
b
c
Fig. 36.11 Diced cartilage can be mold by fi ngers. Prepared
diced cartilage in ( a ) hubless syringes can be ( b ) inserted
into the nasal dorsum with ( c ) manual digital molding

505
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
c
d
Fig. 36.12 Sequence of repair external marginal incisions. ( a , b ) Both sutures on domal incisional area in nostril are
performed fi rst to check nostril asymmetry. ( c , d ) Medial and lateral incisional area can be repaired with Vicryl 5-0
Fig. 36.13 Preparation of postoperative dressing materials. In sequence from left side, Denver splint with adhesive
bandage, antibiotic ointment with cottons, Merocel®, and a gauze
36.4.3 Repair: Closure and Splinting
Technique
The opened area is all closed by Vicryl 5-0 which
are resorbable sutures. A double hook helps
closure of the wound because a double hook can
expose the wound to the visual fi eld (Fig. 36.12 ).
Interrupted closure is preferred because continu-
ous running suture may be ruptured and
dehiscenced on some occasions. Before com-
pletion of the whole operation, postoperative
materials should be prepared (Fig. 36.13 ). External

506
P.C. Kim and D.H. Park
c
a
b
Fig. 36.14 Sequence of external nose dressing with a
splint immediate postoperatively. ( a ) Strips of different
lengths are carefully applied over the nose. ( b ) Denver
splint fi tted on the nose. ( c ) triangular gauze for absorp-
tion of the blood
dressings consist of soft tissue taping and applica-
tion of an external splint (Denver splint). Strips of
different lengths are then carefully applied over
the nose. An additional piece with a triangular
gauze is applied along the caudal aspect of the
nasal lobule to provide the nasal tip and has role
of absorption of the blood (Fig. 36.14 ).
36.5
Results and Case Review
Case 1: Short Nose (Figs. 36.15 and 36.16 )
A 49-year-old male who underwent rhinoplasty a
year ago disliked the outcome and severe compli-
cated short nose. Rib cartilage graft was necessary to

507
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
c
d
Fig. 36.15 Preoperative four series photos. ( a ) Frontal, ( b ) three quarters, ( c ) right lateral, and ( d ) high basal

508
P.C. Kim and D.H. Park
lengthen his short nose. Transcolumellar incision
was not used, so as to obtain a better cosmetic result.
Surgery Technique (Figs. 36.17 and 36.18 )
1. Infracartilaginous extension approach without
transcolumellar incision
2. Excision of previous old scar and the material
in dorsum
3. Exposure of nasal framework
4. Tip plasty – intercrural and intracrural sutures
with PDS 5-0 for tip enhancement
5. Caudal rotation suture and carved rib cartilage
graft (CRCG) for tip caudal rotation
6. DRCG into the dorsum (1.3 cc)
7. Suture – repair all incisions
Outcome Analysis and Critique (Fig. 36.19 )
In this patient, the nasal tip has been extremely
restored by DRCG (1.3 cc) and caudal rotation
with the CRCG to correct his short nose. He was
satis fi ed with the restoration of his nasal line. No
scar was made on the columella.
Case 2: Saddle Nose with Lower Height Dorsum
(Figs. 36.20 and 36.21 )
A 47-year-old female wanted correction of her short
nose. She was admitted in the neurosurgical depart-
ment to treat C5 ossi fi cated posterior longitudinal
ligament. A lengthening procedure (CRCG and
detoration graft) in rhinoplasty was done to correct
her short nose and lower the height of the dorsum.
Mandible contouring surgery was done simultane-
ously. She had not had previous nasal surgery.
Surgery Technique (Figs. 36.22 and 36.23 )
1. Mandible contouring using lateral cortectomy
and T genioplasty
2. Infracartilaginous extension approach without
transcolumellar incision
3. Exposure of nasal framework
4. Paranasal augmentation with bone graft from
resected mandibular bones
5. Tip plasty – intercrural and intracrural sutures
with PDS 5-0 for tip enhancement
a
b
Fig. 36.16 The patient’s facial analysis. ( a ) Frontal and ( b ) pro fi le were analyzed

509
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
c
d
e
f
Fig. 36.17 Intraoperative procedures. ( a ) Exposure of
nasal framework. ( b ) Removal of previous car tissue. ( c )
Creation of new tip with carved cartilage graft. ( d ) Harvest
of rib cartilage. ( e ) The diced rib cartilage graft. ( f ) Check
immediate postoperative pro fi le with a pro fi le template
6. Caudal rotation suture and carved rib cartilage
graft (CRCG) for tip caudal rotation
7. DRCG into the dorsum (1.4 cc)
8. Suture – repair all incisions

510
P.C. Kim and D.H. Park
11
12
13
14
15
16
17
18
21 22
23
24
25
26
27
28
31 32 33
34
35
36
37
38
41
42
43
44
45
46
47
48
1.3cc
G
Anesthesia
S/A
M49
Operation Diagram - Dentofacial Surgery
EFIL maxillofacial, Korea
ID
Name
Dept: PS
Site
Date.
Diagnosis
Operation
Nose
Short Nose
Lenghtening Rhinoplasty
10−05−31
remove of
Scar tissue
OPD/Adm
Fig. 36.18 Standard brief operation note is visualized with diagram. It is not only for rhinoplasty but also for whole
facial procedures (dentofacial surgery)

511
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
c
d
Fig. 36.19 Postoperative four series photo (2 years postoperatively). ( a ) Frontal, ( b ) three quarters, ( c ) right lateral,
and ( d ) high basal

512
P.C. Kim and D.H. Park
a
b
c
d
Fig. 36.20 Preoperative four series photos. ( a ) Frontal, ( b ) three quarters, ( c ) right lateral, and ( d ) high basal

513
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
Fig. 36.21 The patient’s facial analysis. ( a ) Frontal and ( b ) pro fi le were analyzed
Outcome Analysis and Critique (Fig. 36.24 )
In this patient, a more favorable nasal tip and dor-
sum have been achieved using DRCG (1.4 mL)
and tip plasty with a CRCG to correct her short
nose. The nasolabial fold was improved by par-
ticulate mandibular bone graft. She was satis fi ed
with her facial contour and nasal line. Unfortunately,
there is still an acute nasolabial angle. On the basal
view, a better tip enhancement is seen. No scar
was made on the columella.
Case 3: Cleft Nose Deformity with Upturned Nose
(Figs. 36.25 and 36.26 )
A 21-year-old patient with cleft lip nose defor-
mity came to visit my clinic with her mother for
consultation about surgical correction of her short
nose. She did not have functional nasal obstruc-
tion. She previously underwent reconstructive rhi-
noplasty cheiloplasty twice elsewhere to correct
her cleft lip and nose. On the basal view, a surgical
scar on columella is noticed. For better facial con-
tour, zygoma reduction and mandible contouring
surgery were recommended by consultation.
Surgery Technique (Figs. 36.27 and 36.28 )
1. Zygoma reduction and reduction T genio-
plasty. Lateral cortectomy of mandible was
then performed.
2. Infracartilaginous extension approach without
transcolumellar incision.
3. Exposure of nasal framework.
4. Removal of scar tissue and previous conchal
cartilages.
5. Tip plasty – cephalic trim, intercrural and intra-
crural sutures with PDS 5-0 for tip enhance-
ment.
6. Carved rib cartilage graft (CRCG) was
onlay – grafted on alar cartilages.
7. Derotation graft was done behind CRCG to
prevent cephalic rotation of tip unintentionally.
8. DRCG into the dorsum (2.0 cc).
9. Suture – repair all incisions

514
P.C. Kim and D.H. Park
a
b
c
d
e
f
Fig. 36.22 Intraoperative procedures in rhinoplasty. ( a )
Exposure of nasal framework. ( b ) Creation of new tip
with CRCG. ( c ) Tip plasty was done fi rst and checked
with postoperative pro fi le template which was fi t with
nasal tip area. ( d ) DRCG (1.4 mL) was then inserted to
nasal dorsum. ( e ) Fits in all with the pro fi le template. ( f )
Immediate postoperative nose, which is attractive and
favorable

515
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
11
12
13
14
15
16
17
18
21 22
23
24
25
26
27
28
31 32
33
34
35
36
37
38
41
42
43
44
45
46
47
48
1.4cc
G
Anesthesia
S/A
F47
Operation Diagram - Dentofacial Surgery
ID
Name
Dept: PS
Site
Date.
Diagnosis
Operation
Nose, Squre Mandible
Nose, Mandible
T Genioplasty, DRCG (1.4cc piezo with Tipplaty, Lat Cortectomy)
09−11−12
OPD/Adm
EFIL maxillofacial, Korea
Fig. 36.23 Standard brief operation note is visualized with diagram. It is not only for rhinoplasty but also for whole
facial procedures (dentofacial surgery)

516
P.C. Kim and D.H. Park
a
b
c
d
Fig. 36.24 Postoperative four series (3 years postoperatively). ( a ) Frontal, ( b ) three quarters, ( c ) right lateral, and ( d )
high basal

517
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
c
d
a
b
Fig. 36.25 Preoperative four series photo. ( a ) Frontal, ( b ) three quarters, ( c ) right lateral, and ( d ) high basal

518
P.C. Kim and D.H. Park
Outcome Analysis and Critique (Fig. 36.29 )
In this patient, a more favorable nasal tip and dor-
sum have been achieved using DRCG (2 cc) and
tip plasty with a CRCG. From an aesthetic point of
view, the nasal dorsal contour was lined well and
the short nose was well corrected. Unfortunately,
her upper lip was not corrected at this moment,
and on the basal view, there is a nostril notch on
the right nostril and nostril asymmetry. However,
the noticeable columellar scar was hidden by
redraping the nasal columellar skin. She was
satis fi ed with her facial contour and nasal line. She
is supposed to have proposed cheiloplasty and
subapical augmentation in the next operation.
Case 4: Problem Nose (Figs. 36.30 and 36.31 )
A 63-year-old woman had previously been sub-
jected to negligent rhinoplasty more than fi ve times.
The patient really wanted removal of the ugly
hump, removal of unknown material such as sili-
cone liquid and cartilage, and she wanted a higher
nasal tip. She did not have a functional problem. A
lengthening procedure was necessary, and a skin
envelope had an important role in lengthening.
Surgery Technique (Figs. 36.32 and 36.33 )
1. Zygoma reduction and reduction T genio-
plasty. Lateral cortectomy of mandible was
then performed.
2. Infracartilaginous extension approach without
transcolumellar incision.
3. Exposure of nasal framework.
4. Removal of scar tissue and previous conchal
cartilages.
5. Tip plasty – cephalic trim, intercrural and intrac-
rural sutures with PDS 5-0 for tip enhancement.
6. Carved rib cartilage graft (CRCG) was onlay –
grafted on alar cartilages.
7. Derotation graft was done behind CRCG to
prevent cephalic rotation of tip unintentionally.
8. DRCG into the dorsum (2.0 mL)
9. Suture – repair all incisions
b
a
Fig. 36.26 The patient’s facial analysis. ( a ) Frontal. ( b ) Pro fi le

519
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
c
d
e
f
g
h
Fig. 36.27 Intraoperative procedures in rhinoplasty. ( a )
Exposure of nasal framework. ( b ) All scar was resected
and CRCG(B) was onlayed on nasal tip to correct short
nose without transcolumellar incision. ( c , d ) Rib cartilage
was harvested from the chest and CRCG was applied for
new tip. ( e ) DRCG (1.3 mL) was inserted in his nasal dor-
sum. ( f ) Preoperative nose. ( g ) After creation of new tip.
( h ) Immediate postoperative after DRCG was checked
with life-sized pro fi le template which fi t

520
P.C. Kim and D.H. Park
11
12
13
14
15
16
17
18
21 22
23
24
25
26
27
28
3132 33
34
35
36
37
38
41
42
43
44
45
46
47
48
2.0cc
6mm adv.
remove of
scar tissue
Gereral − endo
Anesthesia
S/A
F21
Operation Diagram − Dentofacial Surgery
EFIL maxillofacial, Korea
ID
Name
Dept: PS
Site
Date.
Diagnosis
Operation
Short Nose, Protruced Zygoma, Squre Mandible
Cleft lip & Nose deformity, Mandible, Nose, Zygoma
Rhinoplasty with DRCG (2.0cc), Facial Contouring (ZR, MR, TR)
11−01−31
OPD/Adm
Fig. 36.28 Standard brief operation note is visualized with diagram. It is not only for rhinoplasty but also for whole
facial procedures (dentofacial surgery)

521
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
c
d
Fig. 36.29 Postoperative four series (6 months postoperatively). ( a ) Frontal, ( b ) three quarters, ( c ) right lateral, and ( d )
high basal

522
P.C. Kim and D.H. Park
a
b
d
c
Fig. 36.30 Preoperative four series photos. ( a ) Frontal, ( b ) three quarters, ( c ) right lateral, and ( d ) high basal

523
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
Fig. 36.31 The patient’s facial analysis. ( a ) Frontal. ( b ) Pro fi le
Outcome Analysis and Critique (Fig. 36.34 )
In this patient, a more favorable nasal tip and dor-
sum have been achieved using DRCG (2 cc) and
tip plasty with a CRCG. From an aesthetic point
of view, the nasal dorsal contour was lined well
and the short nose was well corrected.
Unfortunately, her upper lip was not corrected at
this moment, and on the basal view, there is a
nostril notch on the right nostril and nostril asym-
metry. However, the noticeable columellar scar
was hidden by redraping the nasal columellar
skin. She was satis fi ed with her facial contour
and nasal line. She is supposed to have proposed
cheiloplasty and subapical augmentation in the
next operation.
36.6
Complications
36.6.1 Donor Scar and Possible
Morbidity
36.6.1.1 Donor scar
The donor scar is almost undetectable in females,
as an inframammary scar. For men, it is still short
and barely visible. Scar therapy should start at
2 weeks postoperatively (Fig. 36.35 ).
36.6.1.2 Hematoma
Hematoma can easily occur in hypertensive
patient. Therefore, bleeding control is very impor-
tant, and meticulous hemostasis is mandatory. To

524
P.C. Kim and D.H. Park
a
b
c
d
e
f
Fig. 36.32 Intraoperative procedures in rhinoplasty.
( a ) All scar and silicone were resected in a block. ( b )
The nose was checked with postoperative pro fi le tem-
plate to predict how much the amount of DRCG is nec-
essary. ( c ) Rib bone and cartilage were harvested with
the piezosurgery system. ( d ) New tip was created with
CRCG. ( e ) DRCG (2.0 mL) was prepared for dorsal
augmentation. ( f ) Immediate postoperative pro fi le was
checked with life-sized pro fi le template which fi t

525
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
11
12
13
14
15
16
17
18
21 22
23
24
25
26
27
28
3132 33
34
35
36
37
38
41
42
43
44
45
46
47
48
2.3cc
G
Anesthesia
S/A
F63
Operation Diagram - Dentofacial Surgery
EFIL maxillofacial, Korea
ID
Name
Dept: PS
Site
Date.
Diagnosis
Operation
Hump Nose, Silicon removal, Problem Nose
Nose
Corrective rhinoplasty, DRCG, CRCG
11−01−20
OPD/Adm
Fig. 36.33 Standard brief operation note is visualized with diagram. It is not only for rhinoplasty but also for whole
facial procedures (dentofacial surgery)

526
P.C. Kim and D.H. Park
a
b
c
d
Fig. 36.34 Postoperative four series photo (2 months postoperatively). ( a ) Frontal. ( b ) Three quarters. ( c ) Left lateral.
( d ) High basal view

527
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
prevent hematoma, it is necessary to insert a
catheter into the chest before closure.
36.6.1.3 Wound Dehiscence
Possible causes of wound dehiscence include
aggressive motion of the chest or exercise. Most
wound dehiscence can be repaired with re-suture.
If there is in fl ammation on the chest, preventive
antibiotics should be administered regularly.
36.6.2 Hypertrophic Scar
Hypertrophic scars are cutaneous condition char-
acterized by excess scar tissue, but not to the
degree observed with keloids. Scar therapy with a
compressive band is bene fi cial (Fig. 36.36 ).
36.6.3 Recipient Complication
36.6.3.1 Infection
A 52-year-old female underwent rhinoplasty, and
she was discharged without problem at the time.
After 8 days postoperatively, when she came to
visit our clinic for removal of the external splint,
I detected pus from the incisional site of the left
nostril. This was the fi rst and the last case of
infection from a diced rib cartilage graft. The
cause was hospital infection from other patients
in the same room (Fig. 36.37 ).
36.6.3.2 Partial Resorption
Partial resorption is one complication in diced rib
cartilage graft. This complication comes from
habitual stimulation from the patient’s fi ngers
a
b
c
d
Fig. 36.35 Donor scar on chest. ( a ) Scar in female
breast with inframammary fold is almost undetectable
(2 years postoperatively). ( b ) Scar on male chest
(6 months postoperative). ( c ) Scar in female 1 year
postoperatively. ( d ) Scar in male 1 year postoperatively

528
P.C. Kim and D.H. Park
(Fig. 36.38 ). It can be corrected by minor revi-
sion with fi ller material.
36.6.3.3 Dorsal Deviation
A nasal dorsum with grafted diced rib cartilage
can be deviated also from habitual stimulation
(Fig. 36.39 ). It can be corrected with mini rasp.
36.7
Discussion
The ideal nasal implant is a prosthesis which
contributes to aesthetic and functional results,
with minimized donor morbidity and without
postoperative complication. Many surgeons con-
sider their choice of ideal material for augmenta-
tion rhinoplasty. The authors want to discuss the
advantages and disadvantages of our methods,
and surgical key points, with the readers.
Several papers report that a diced rib cartilage
graft (DRCG) wrapped with fascia results in a
better graft survival rate than for a graft without
fascia. Because the diced particles are big (more
than 1 mm) and inconstant in size and shape,
wrapping fascia should be considered to help
prevent dorsal irregularity and risk of leaking.
However, if ultradiced cartilage can be prepared,
fascia is not necessary to prevent particle leakage
to another site or to prevent dorsal irregularity
because the ultradiced cartilage particles (0.2–
0.3 mm in diameter) can be packed and stabilized
in the dorsal canal with fi brin glue.
The scar is a major sequelae in DRCG. However,
the size is in 2 cm and the scar is hidden in the
skinfold under the breast, especially in women.
DRCG in the authors’ case has the advantage of no
pneumothorax and minimizing of the incision size.
Also, the graft site can be con fi ned, and there is no
need to enclose the particles using fascia.
Excoriating the anterior portion at the exposed
rib cartilage and scooping by the rib are the most
important point in DRCG.
Rib cartilage is a popular donor site for saddle
nose correction or in cases where abundant carti-
lage is necessary. The traditional rib cartilage har-
vesting technique has the disadvantage of serious
complications such as pneumothorax, a long scar,
and severe pain, and the harvesting of a whole
block of rib cartilage is not ef fi cient for light aug-
mentation. The author did not dissect the posterior
part of the rib cartilage for a whole block harvest,
but rather just dissected the anterior part of the rib
cartilage for a small amount. This operation is
simple, can be performed in a short duration due to
the harvesting of only a small amount of cartilage,
and only a small incision is necessary. Safe harvest
of the outer layer of cartilage can be achieved with
minimal pain in the chest area. Due to the pliabil-
ity of the graft, any minor deformity on the nasal
dorsum can be corrected manually within 2 weeks.
Our simple method of rib cartilage harvesting
should be considered for rhinoplasty.
Acknowledgment
We gratefully acknowledge and
thank Gemma Seung Jung Son, B.A., medical illustrator
in our department, and Letitia An, B.Sc., a good friend of
from New Zealand. Gemma Seung Jung Son, B.A., dedi-
cated all the illustration in this article to make this book a
work of art as only she can do. Letitia An, B.Sc., gave us
continued and tireless dedication to make this book a
high-quali fi ed publication. They were instrumental in
transforming this text from a dream to reality.
Fig. 36.36 Hypertrophic scar on chest 6 month postopera-
tively

529
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
c
d
Fig. 36.37 ( a , b ) Infection in diced rib cartilage graft
noticed 8 days postoperatively. The cause was concluded
as hospital infection from other patients in the same room.
( c – f ) Preoperative photo, four series. ( g – j ) Postoperative
after treatment of infection. Even though there was infec-
tion in diced rib cartilage graft, the result was not horrible.
This case was the author’s fi rst and last case of infection
so far

530
P.C. Kim and D.H. Park
e
f
g
h
Fig. 36.37 (continued)

531
36 Ultradiced Rib Cartilage Graft Without Wrapping for Augmentation Rhinoplasty
a
b
Fig. 36.38 Partial resorption. ( a ) This 46-year-old male had partial resorption on supratip break. ( b ) The fi ller
(Juvederm) was injected to correct depression area
i
j
Fig. 36.37 (continued)

532
P.C. Kim and D.H. Park
References
1. Calvert J, Brenner K (2008) Autogenous dorsal recon-
struction: maximizing the utility of diced cartilage
and fascia. Semin Plast Surg 22(2):110–119
2. Bergeron L, Chen PK (2009) Asian rhinoplasty tech-
niques. Semin Plast Surg 23(1):16–21
a
b
Fig. 36.39 Dorsal deviation. ( a ) This 24-year-old female had dorsal deviation after diced rib cartilage graft. ( b )
Revision was done with mini rasp and undermining of the cartilage

533
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_37, © Springer-Verlag Berlin Heidelberg 2013
37
37.1
Introduction
The cartilage framework of the nose plays an
important role in the mechanical support of shape
and airway patency. Consideration of biomec-
hanics of nasal cartilages is important during
reconstruction of the nasal airway or cosmetic
rhinoplasty. Native cartilages of the nose are
often enhanced via various cartilaginous free
grafts which serve either a load bearing, struc-
tural, or volume occupying function, in many
cases counteracting the forces of contraction
produced by remodeling of the skin-soft tissue
envelope. Cartilage grafts can be harvested from
the nasal septum, auricular concha, or costal mar-
gin. The indication for use of each of these
sources depends upon tissue availability, surgeon
experience, and patient expectations. More
importantly, however, the surgeon must compare
the mechanical properties of cartilage harvested
from each source to the ideal properties desired at
the recipient site and determine appropriate size,
shape, and type of cartilage graft appropriate for
use. To make this determination, the surgeon
must have a basic understanding of the mechani-
cal properties of native facial cartilage and carti-
lage obtained from orthotopic sites. The following
chapter reviews work related to the biomechani-
cal behavior of cartilage used in surgery of the
face (with particular emphasis on nasal carti-
lages), and we hope this provides useful informa-
tion that may aid surgeons in better selection and
use of surgical techniques.
37.2
Mechanical Properties
of Native Facial Cartilages
The mechanical response of cartilage to external
forces and deformation is determined by complex
interactions within the constituents of its solid but
porous, permeable matrix consisting of collagen
and proteoglycans and interstitial fl uid. While the
mechanical behavior of articular cartilage has
been examined in detail [ 1 ] , the biomechanics of
Biomechanical Properties of Facial
Cartilage Grafts
Sepehr Oliaei , Cyrus Manuel , Dmitriy Protsenko ,
and Brian J. F. Wong
S. Oliaei , M.D.
Department of Otolaryngology- Head and Neck Surgery ,
University of California Irvine ,
19182 Jamboree Road ,
Irvine , CA 92697 , USA
e-mail: soliaei@uci.edu
C. Manuel , B.S. • D. Protsenko , Ph.D.
Beckman Laser Institute and Medical Clinic,
University of California Irvine ,
1002 Health Sciences Road East , Irvine ,
CA 92617 , USA
e-mail: cmanuel@uci.edu ; dprotsen@uci.edu
B. J. F. Wong , M.D., Ph.D. ()
Department of Biomedical Engineering,
Facial Plastic Surgery, University of California Irvine ,
1002 Health Sciences Road East,
Irvine, CA 92617, USA
Division of Facial Plastic Surgery, Department of
Otolaryngology- Head and Neck Surgery ,
University of California Irvine ,
19182 Jamboree Road , Irvine , CA 92697, USA
e-mail: bjwong@uci.edu

534
S. Oliaei et al.
facial and costal cartilage have largely been
ignored in the literature. Functionally, articular
cartilage is a weight-bearing and stress-tolerant
tissue capable of sustaining high-impact loads
with prolonged duty cycles, while facial cartilage
serves primarily as structural support for the air-
way and does not undergo repeated high stress
and strain deformations, but responds to small
static loads which act over prolonged time frames.
However, the differences in mechanical response
in these tissues are re fl ected mainly on the macro-
scopic level of organization. At molecular and
microscopic levels, nasal, auricular, and costal
cartilages share largely the same biochemical and
structural components and basic biomechanical
principles as articular cartilage, and the theories,
models, and simulations governing the mechani-
cal behavior of articular cartilage can be applied
to cartilage tissues elsewhere. Notably, auricular
cartilage (along with tracheal and laryngeal carti-
lage) is replete with elastin fi bers, making it dis-
tinct from hyaline cartilage tissue such as those in
the nose.
Mow and colleagues have developed triphasic
theory, the most comprehensive model for carti-
lage mechanical behavior [ 2 ] . They proposed the
concept of a tertiary mixture including two fl uid–
solid phases and an ion phase, representing cat-
ion and anion of a single salt, to describe the
deformation and stress fi elds for cartilage under
chemical and/or mechanical loads. Triphasic the-
ory combines the physiochemical theory for ionic
and polyionic (proteoglycan) solutions with the
biphasic theory for cartilage. Triphasic theory
assumes the fi xed charge groups to remain
unchanged and that the counterions are the cat-
ions of a single salt of the bathing solution. For
the con fi ned-compression swelling problem, it
predicts that the applied compressive stress is
shared by three load support mechanisms: (1) the
osmotic pressure, (2) the chemical-expansion
stress, and (3) the solid matrix elastic stress. All
three mechanisms are important in determining
the overall compressive stiffness of cartilage.
In more practical terms, cartilage in simple
tension or compression can be approximated by a
classic nonlinear stress–strain curve including a
toe region, a linear region, and a failure region
(Fig. 37.1 ). When cartilage is compressed, there
is an increase in repulsive coulombic forces
between individual charged proteoglycan moi-
eties as they are brought closer in approximation
to one another. Once the load is removed, electro-
static repulsion by these same negative charges
leads to restoration of initial geometry. The
unconstrained expansion is balanced by the col-
lagen meshwork of the tissue matrix which resists
this expansion and also provides resistance to any
tensile deformation acting upon this tissue. An
increase in the collagen/proteoglycan ratio leads
to an enhanced tensile modulus of the solid
matrix. Additionally, the interaction between the
fl uid and solid phases of the cartilage plays a
signi fi cant role in the mechanical behavior of car-
tilage. The fl ow of water out of the tissue and the
drag created by the interaction with solid phase
are major determinants of the compressive behav-
ior of the tissues. Swelling, an important interac-
tion between the liquid/solid phase and the ionic
forces, is accounted for in triphasic theory. It
arises from the need to maintain electrical neu-
trality (charge balance) between fi xed negatively
charged proteoglycan molecules and mobile cat-
ions in the interstitial fl uid. The electric balance
created by excessive concentration of mobile
positive ions results in an osmotic gradient and
hence results in the net fl ux of water into the
matrix and generation of swelling pressure. At
Young’s modulus = s /e
Strain, e
Tensile stress, s
Fig. 37.1 Stress–strain graph

535
37 Biomechanical Properties of Facial Cartilage Grafts
equilibrium physiological conditions, this pres-
sure is counteracted by the stresses generated
within solid collagen-proteoglycan matrix.
Dissection of grafts from physiologically sta-
ble cartilage reservoirs disturbs this equilibrium
between solid and fl uid/ionic phases and often
results in uncontrolled warping and distortion of
the cartilage graft. This phenomenon is discussed
in greater detail in the next section.
Analysis of nasal septal cartilage has demon-
strated 77% water/7.7% collagen composition
with collagen/proteoglycan ratio of 2.7 and 2.4
million cells per gram of tissue [ 3 ] . These num-
bers indicate a comparable water content to artic-
ular cartilage but lower collagen/proteoglycan
ration and a higher cellularity [ 3, 4 ] . These dif-
ferences in composition likely re fl ect the func-
tional distinctions between these two classes of
cartilage.
Similar functional differences exist between
the septal cartilage and the lower lateral carti-
lages (LLCs). The nasal septum serves a major
structural support for the nasal dorsum, is a shock
absorber for trauma, divides the two nasal cavi-
ties, and is important in the growth and develop-
ment of the surrounding midfacial structures
[ 5, 6 ] . The septum provides rigid support to
project the nose and airway and must still have
the ability to deform and absorb blunt trauma.
The LLCs, on the other hand, serve to support the
nasal tip, prevent external nasal valve, and par-
ticipate in cosmetic de fi nition of the nose.
Ultrastructural analysis of these two cartilage
structures has revealed differences in organiza-
tion of collagen fi bers. The collagen fi bers of sep-
tal cartilage were found to be arranged in a mesh
framework, with larger lacunae and thicker fi bers,
while LLC fi bers were arranged in less-organized
sheets, with fi brous extensions, and had fewer,
narrower lacunae [ 6 ] .
Attention to form and function of the native
cartilage in the nose is of paramount importance
in rhinoplasty. Variations in biochemical compo-
sition and structural arrangement are dictated by
the functional role served by the particular carti-
lage. These variations must be considered in
selecting appropriate graft material in reconstruc-
tive or cosmetic surgery of the nose.
37.3
Mechanical Properties
of Autologous Grafts
Septal cartilage has long been the ideal source of
cartilage for use in rhinoplasty surgery due to
accessibility and ease of harvest. Auricular carti-
lage is also a frequently used source of cartilage
grafts due to proximity, low incidence of donor
site morbidity, and ease of harvest. When auricu-
lar and septal cartilage sources have been depleted
or if they are otherwise unsuitable, costal carti-
lage grafts provide ample tissue for purposes of
transplantation, provided ossi fi cation has not
occurred. It is important to note that rib behaves
differently than its nasal and auricular counter-
parts. Costal tissue lacks the same degree of elas-
ticity as septal or conchal cartilage and is more
suitable for certain applications in rhinoplasty
that demand rigid structural support rather than
pliability or contouring. Uses include spreader
grafting, dorsal augmentation, and columellar
support. Consideration of mechanical parameters
of each of these graft material is important in
appropriate selection of suitable tissue.
The elastic modulus of costal cartilage may be
estimated using a cantilever fl exure test setup. A
fl exure test jig may be constructed to hold fl at
and rectangular pieces of cartilage that can then
be tested. A probe can then be used to depress the
graft while measuring the reaction force of the
fl exure (Fig. 37.2 ). The fl exure is then modeled
as a cantilever beam with a fi xed support. The
following equation is used to determine the elas-
tic modulus:
Tissue
Cross-section
Probe
L
F
y
b
h
Fig. 37.2 Cantilever model. F reaction force, y displace-
ment, L distance from fulcrum where the probe displaces
the tissue, b width of the tissue, and h tissue thickness

536
S. Oliaei et al.



F = reaction force, y = displacement, L = distance
from fulcrum where the probe displaces the
tissue, b = width of the tissue, and h = tissue
thickness.
Using our proposed model, we have deter-
mined costal cartilage grafts have an approximate
stiffness of 1.70E+07 +/– 9.54E+05 Pa [ 7 ] .
Grellmann et al. investigated the elastic prop-
erties of human cartilage and demonstrated elas-
tic modulus of 7.2 ± 3.4 MPa for septal cartilage
and a fl exion modulus of 8.8 ± 2.9 MPa for rib
cartilage. In their report, the microhardness val-
ues fl uctuate for septum from 1 to 4 N/mm 2 and
for the rib from 0.5 to 1.3 N/mm 2 . The micro-
hardness measurement evidences a decrease of
the plastic deformation capacity and an increase
in the stiffness of the cartilage tissue with increas-
ing age of patient [ 8 ] . Watson and colleagues
reported on the effects of orientation on the equi-
librium compression modulus of human septal
cartilage with vertical (0.7 ± 0.12 MPa) and cau-
dal-cephalic (0.66 ± 0.01 MPa) orientations being
signi fi cantly stiffer ( p = 0.05) than the medial ori-
entation (0.44 ± 0.04 MPa) [ 9 ] . The same group
reported separately on the tensile biomechanics
of septal cartilage con fi rming that septal carti-
lage has weaker tensile properties compared to
articular cartilage, while they found no differ-
ence in strength with respect to age, gender, or
axis of tension [ 10 ] . They reported the following
tensile results for septal cartilage: equilibrium
modulus 3.01 ± 0.39 MPa, dynamic modulus
4.99 ± 0.49 MPa, strength 1.90 ± 0.24 MPa, and
failure strain 0.35 ± 0.03 mm/mm. Comparative
examination of porcine cartilage has determined
bending modulus of auricular cartilage (4.6 MPa)
to be found to be statistically lower ( p < 0.05)
than that of costal cartilage (7.1 MPa) [ 11 ] . In a
1979 master’s dissertation, Vasudevan focused
on experiments characterizing the viscoelastic
behavior by placing costal cartilage under ten-
sion, torsion, or compression [ 12 ] . A linear
mechanical model based on the Boltzmann
superposition principle was used to calculate the
stress from the strain measurements. The out-
come of these tests shows numerically that the
strain behaves linearly with stress for small defor-
mations. Although the tests assumed the tissue to
behave isotropically, the report shed light into
characterizing tissue with complex and time-
dependent behavior of cartilage. Variability of
these reports indicate probable subjective variabil-
ity and the signi fi cance of testing conditions, size,
shape, orientation of the cartilage, as well as the
age and gender of subjects among other factors.
Although costal cartilage remains the work-
horse when septal cartilage is depleted for creat-
ing strong grafts to augment or support the nasal
dorsum, tip, or septum, it does present additional
donor site morbidity as well as the risk of carti-
lage warping, fi rst described by Gillies in 1920
[ 13 ] . This distortion of the graft may result in
deformity of the nasal dorsum or tip. These
changes are thought to result from the induction
of internal tensile strength from protein polysac-
charides within cartilage, leading to warping as
reported fi rst by Fry [ 14, 15 ] . Warping is seen as
early as 30 min after carving and may continue
for weeks afterward. Gibson and Davis [ 16 ] theo-
rized that this immediate and delayed warping of
costal cartilage grafts is due to inherently
increased tautness in peripheral regions and there-
fore advocated cutting balanced cross sections to
minimize these forces. To this end, a mechanical
slicer has been invented to create costal cartilage
grafts of reproducible size and shape, as shown in
Fig. 37.3 [ 17 ] . Warping can be minimized by
simply carving the central region of the cartilage
with the cutter.
Given the disadvantages of relying solely on
slicing perfectly balanced central cross sections,
several additional techniques have been used or
attempted to prevent or reduce warping. Adams
et al. [ 18 ] irradiated cartilage with ionizing energy
before cutting the grafts in an attempt to mini-
mize warping but observed that both the irradi-
ated and the nonirradiated samples warped to
approximately the same degree. Erol [ 19 ] intro-
duced the “Turkish delight” method in which
diced cartilage was wrapped in Surgicel (Ethicon,
Inc, Johnson & Johnson, Somerville, New Jersey).
3
3
4
/
E
FL
ybh
=

537
37 Biomechanical Properties of Facial Cartilage Grafts
Fig. 37.3 Mechanical cartilage cutter for obtaining accurate slices of the central portion of costal cartilage

538
S. Oliaei et al.
However, a subsequent report by Daniel and
Calvert [ 20 ] discounted Erol’s method through
histological methods that demonstrated a high
rate of cartilage absorption and the presence of
in fl ammatory in fi ltrates caused by the Surgicel.
They resolved this problem by abandoning the
use of Surgicel and instead wrapped the diced
cartilage in temporalis fascia. The method of
using diced cartilage provides volumetric aug-
mentation but cannot provide grafts for structural
purposes. In an attempt to mechanically arrest
warping, Gunter et al. [ 21 ] placed Kirschner wire
through longitudinally carved costal cartilage
slices. However, this method can result in extru-
sion of the wire long after surgery.
The use of laser irradiation to reshape carti-
lage has been extensively studied. Helidonis et al.
[ 22 ] fi rst reported laser-assisted cartilage reshap-
ing of rabbit ear cartilage grafts with the use of a
carbon dioxide laser, and this technique was later
demonstrated using other wavelengths and carti-
lage sources [ 23– 27 ] Laser reshaping has also
been used clinically in septoplasty operations and
to perform otoplasty [ 28– 31 ] . Laser irradiation of
costal cartilage is an effective method for rapidly
stabilizing acute shape change by accelerating
the warping process [ 32 ] . Additionally, electro-
mechanical stabilization of the carved cartilage
graft may be achieved without subjecting the tis-
sues to laser thermal energy (unpublished data).
Postoperative warping of implanted costal
cartilage in cosmetically sensitive regions such as
the nose can lead to serious cosmetic deformity.
Steps taken to minimize cartilage warping includ-
ing meticulous carving technique, laser, and elec-
tromechanical treatment of grafts prior to
implantation are crucial in preventing adverse
outcomes.
37.4
Estimation of Threshold
Mechanical Stability
The goal of cartilage grafting in rhinoplasty is to
provide a framework for enhancing the aesthetic
features of the nose while maintaining adequate
mechanical stability to resist the forces of wound
contracture, gravity, and dynamic airway col-
lapse. To this end, a method for estimation of
threshold mechanical stability of cartilage grafts
would be useful in proper selection of size, shape,
and harvest site for the graft while also being
applicable in the development of tissue engi-
neered cartilage grafts.
Three major classes of structural cartilage
grafts are utilized in majority of rhinoplasty pro-
cedures: columellar struts, L-strut replacements
(including spreader grafts), and lateral crural
strut grafts (alar struts). The columellar strut is
used for both structural and cosmetic purposes
to support of the tip of the nose and control pro-
jection. A cartilage graft used to support or
replace the L-strut should require a higher stiff-
ness relative to the other grafts because it sup-
ports the dorsum and prevents collapse of the
nasal vault, as described previously. Alar struts
require minimal stiffness because they are almost
exclusively used for cosmetic modi fi cations of
alar shape.
Estimation of minimum acceptable thresholds
for these structural grafts has been performed (see
Table 37.1 ) [ 33 ] . Previous reports have described
the process for the manufacture of polyurethane
blocks with varying stiffness that can be used as
comparisons for approximation of the stiffness of
harvest cartilage grafts. From research standpoint,
this estimation technique is useful in assessing
the ultrastructure of modi fi ed cartilage (i.e., via
laser or electromechanical deformation) or tissue
engineered grafts to ensure that they meet the
threshold mechanical stability prior to implanta-
tion. However, this method of assessing mechani-
cal behavior is imprecise and prone to subjective
Table 37.1 Estimated minimum stiffness of human carti-
laginous grafts, with average stiffness of septal and articu-
lar cartilage listed for comparison
Actual stiffness Desired Stiffness
Septal cartilage
0.8 MPa
Articular cartilage 60–85 MPa
Columellar graft
0.56 MPa
L-strut graft
0.59 MPa
Alar graft
0.49 MPa

539
37 Biomechanical Properties of Facial Cartilage Grafts
variability. More objective measurement tech-
niques are therefore warranted.
37.5
Computer Modeling
for Determination of Ideal
Mechanical Properties
The fi nite element modeling (FEM) is a tech-
nique developed for numerical solution of sys-
tems of differential equations describing physical
processes. This method gives us a powerful tool
for accurate evaluation of complex mechanical
problems such as emulation of the behavior of a
nasal tip under an external load. FEM allows us
to assess mechanical outcomes of speci fi c surgi-
cal maneuvers using virtual cartilage grafts before
actually implementing them in the operating
room. There are limits to using this modeling
technique: (1) modeling anatomically accurate
structures remains a challenge, (2) the material
properties of most biologic materials are complex
(generally nonlinear and anisotropic) and poorly
understood, and (3) simple and intuitive software
packages aimed at end user are not available.
With that in mind, this subsection will review
previous studies that have used FEM of the nasal
tip and related supporting structures.
In an effort to enhance the functional de fi nition
of nasal septal mechanics, Lee et al. used FEM to
see the effects of anteroposterior load applied to
the nasal tip and identi fi ed maximum stress areas
[ 34 ] . They concluded that the septum acts as a
crumple zone to absorb most of the impact and
impeding further transmission to the skull. The
same group of investigators further re fi ned their
model in a second study where they demonstrated
that the bony-cartilaginous junction and the nasal
spine to be the consistent points of maximum
stress regardless of material properties [ 35 ] . Their
model demonstrated that the preservation of an
arc of cartilage and a wider dorsal strut increase
the stability of the structure. Other groups have
used FEM to demonstrate that the intrinsic elas-
ticity of the septal cartilage, the mucoperichon-
drial fl ap, and overlap with the bony vault all
contribute to the stability of the L-strut, which is
enhanced by preserving a small triangular seg-
ment of cartilage at the bony-cartilaginous junc-
tion of the dorsal L-strut.
Recent efforts to develop an “incision-less” tech-
nique for septoplasty include electromechanical
reshaping as well as laser septoplasty [ 22, 23, 28 ] .
To predict mechanical behavior of nasal airway and
septal cartilage prior to application in human sub-
jects, our group has developed a similar numerical
model to assess stress fi elds in laser-reshaped devi-
ated septum [ 36 ] .
FEM also has applications in the study of
mechanics of nasal tip, such as the evaluation of
lower lateral cartilage stability. For instance,
while it is widely accepted that cephalic trim of
the lateral crura should be limited such that it pre-
serves an intact 6–9-mm strip, the basis for this
strategy has been empirically derived based upon
trial and error and is a useful rubric to keep in
mind. That being said, numerous counterexam-
ples of bossa formation, retraction, etc., have
been observed despite adherence to this numeri-
cal yardstick. Both noncadaveric and numerical
models of LLC mechanical behavior are useful to
better understand and re fi ne rules to govern the
surgical treatment of this important aesthetic and
functional cartilage. Using curved alar tissue har-
vest fashioned from porcine alar cartilage, we
have developed a surgical model that represents
the lateral crura and can be used to examine a
variety of crural maneuvers.
We have developed a rudimentary FEM of the
LLC which we have implemented in the
COMSOL Multiphysics programming environ-
ment. Figure 37.4 shows an example of a typical
stress distribution of the LLC with a normal force
placed 8 mm from the midline. In this model, the
mechanical stress is greatest at the midline where
both crura and septum meet. This model was
used to calculate the reaction force to a given
deformation and then compared it to actual force
measurements obtained from experiments. The
resistance force calculated with the FEM came in
agreement with the force measured from this
mechanical testing. The resistance force of the
crura was signi fi cantly lower when the strut width
was reduced beyond 6 mm, which supports the

540
S. Oliaei et al.
notion that the crura aids as a supporting struc-
ture of the nasal airway [ 37 ] .
Our understanding of the mechanics of nasal
mechanics has improved in the recent years with
development of new computer modeling tools for
assessment of nasal mechanics. As models con-
tinue to develop for assessment of post-interven-
tion mechanics, surgeons will soon be armed
with the ability to predict outcomes of existing
surgical techniques in a particular subject (i.e.,
cephalic trim maneuver) or assess the feasibility
of novel cartilage deformation technologies (i.e.,
electromechanical reshaping, laser cartilage
reshaping) and determine if a graft composed of
bioengineered cartilage or a novel polymer would
be suitable for their particular application.
Conclusions
Nasal tip aesthetics and the integrity of the
internal and external nasal valves are governed
largely by the complex mechanical relation-
ships of the underlying cartilaginous skeleton.
Maintenance or improvement of the structural
integrity of this cartilaginous foundation is an
essential part of any aesthetic or functional
rhinoplasty procedure. Various autologous and
cadaveric cartilage grafts have long been used
for the purpose of reconstituting the proper
stability of nasal framework. Subjective esti-
mation of the threshold stability of these grafts
has long been the norm. With the advent of
noninvasive cartilage deformation techniques,
tissue engineered grafts, and novel synthetic
implants, objective assessment of the integrity
of these grafts via computer modeling or
preclinical mechanical studies will be pivotal.
As these technologies progress, rhinoplasty
surgeons can rely more and more on objective
assessment of cartilage graft function to ensure
predictable long-term functional and aesthetic
results.
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DOI 10.1007/978-3-642-28053-5_38, © Springer-Verlag Berlin Heidelberg 2013
38
38.1
Introduction
Structural grafts and suture techniques play an
essential role in rhinoplasty. Over the decades,
numerous innovations and modi fi cations in graft
techniques and sutures have been described. Many
long-established techniques have stood the test of
time with minor modi fi cations [ 1 ] . In this chapter,
we intend to discuss the grafts and suture techniques
that are most frequently described and employed.
A review of all grafts and suture techniques would,
of course, be beyond the scope of this chapter.
38.2
Choice of Graft Material
Various graft materials are available for rhino-
plasty. Important factors determining the choice
of the graft material include adequate integration
of the graft at the recipient site, suf fi cient
fl exibility, and/or structural stiffness for the
intended purpose as well as relatively simple and
safe harvest of the graft.
Autologous transplants unite many favorable
features and represent the most frequently utilized
graft source in rhinoplasty. Among the autologous
grafts, septal cartilage is most frequently utilized
because of its ready availability and easy access
within the surgical fi eld. The biochemical and bio-
mechanical properties of septal cartilage have been
researched in multiple studies and are relatively
well understood [ 2, 3 ] . In case of inadequate avail-
ability of septal cartilage, conchal cartilage repre-
sents a good alternative graft source. Relatively
large transplants may be obtained from the cavum
conchae. The area of the cymba conchae and of the
tragus provides smaller but straight pieces of carti-
lage. Overall the typically more curved structure of
auricular cartilage represents a substantial draw-
back of this grafting material. Scoring and weaken-
ing of this cartilage and suture fi xation on PDS foil
have been discussed more recently as an approach
to generate straighter transplants. Calci fi cation of
auricular cartilage presents another clinical prob-
lem which is typically more pronounced in elderly
patients when compared to septal cartilage.
Another alternative graft source is costal carti-
lage. A larger volume of cartilage or a composite
of cartilage and bone is obtained at the expense of
an additional remote donor site with its associ-
ated morbidity. The propensity of costal cartilage
to warp may be recognized early after explanta-
tion when the cartilage is split and placed in a
sterile liquid. Donor site morbidity and compli-
cations may include injury of the pleura and
deformities of the chest wall. Techniques to
reduce these risks include the preservation of a
Structural Grafts and Suture
Techniques in Rhinoplasty
Uwe Mueller-Vogt and Holger G. Gassner
U. Mueller-Vogt , M.D. (*)
Private Clinic , Center for Otorhinolaryngology
and Facial Plastic Surgery ,
Marktstr. 59, 83646 , Bad Toelz, Germany
e-mail: uwe@mueller-vogt.de
H. G. Gassner , M.D.
Facial Plastic Surgery ,
Department of ORL, University of Regensburg ,
Regensburg 93042 , Germany
e-mail: info@dr.gassner.eu

544
U. Mueller-Vogt and H.G. Gassner
thin sliver of costal cartilage on top of the parietal
perichondrium as well as the reconstruction of
the rib contour with pieces of residual cartilage
wrapped in a Vicryl net [ 4, 5 ] .
An alternative to the harvest of costal cartilage
and bone may be the harvest of calvarial bone.
After a trichophytic incision over the parietal
bone, a trough is drilled around the intended
graft. The graft is then harvested with an angled
oscillating saw which separates the external table
from the internal table. External table can pro-
vide osseous grafts of substantial size a low mor-
bidity [ 6 ] . The use of homologous preserved
human cartilage is infrequently reported. It seems
to be mainly useful for the correction of minor
contour deformities while the use of preserved
bank cartilage seems not to be suitable for struc-
tural and load-bearing purposes [ 7 ] .
Another allogenic material is acellular dermis.
This commercially available material is produced
from human cadaveric skin and has been utilized
to correct contour irregularities. Reported resorp-
tion of this material is up to 50% of the originally
placed volume. This freeze-dried material is typi-
cally rehydrated prior to insertion. Some authors
report insertion in the frozen, stiff state and rehy-
dration in situ [ 8 ] .
Among the synthetic implant materials, pre-
dominantly porous polyethylene and expanded
polytetra fl uoroethylene have seen a longer-term
acceptance. Porous polyethylene allows for tis-
sue ingrowth. This relatively rigid material seems
to be associated with a lower rate of extrusion
and
infection
than
polytetra fl uoroethylene.
However the risk of extrusion seems to be con-
siderable with any synthetic material implanted
in the nose [ 9 ] .
38.3
Surgery of the Nasal Tip
Correction of the nasal tip typically requires com-
bination of multiple different techniques. The
anatomic structures predominantly responsible
for the shape of the nasal tip are the alar cartilage,
the caudal septum, and the surrounding soft tis-
sues. Accordingly most corrections of the nasal tip
intend to modify these structures. The intradomal
suture is a suture technique frequently utilized to
narrow the dome of the alar cartilage. This mat-
tress suture may be placed at different heights of
the dome. Various effects may be achieved accord-
ing to the exact placement of the suture, including
a modi fi cation of the transition to the supratip
and the shape and width of the nasal tip itself
(Fig. 38.1 ). The intended effect may be modi fi ed
by varying the tying force of the suture. The alar
spanning suture may be regarded as a variation of
the intradomal suture. The alar spanning suture
runs between the medial aspects of the lateral alar
crura and through the medial crura . The narrow-
ing effect of the alar spanning suture is more pro-
nounced than that of the intradomal sutures.
Medial crura sutures have a similar narrowing
effect. These are placed as simple interrupted
sutures between the medial crura of the alar carti-
lage. Their effects may include enhanced support
of the nasal tip and derotation of the lateral crus of
the alar cartilage (Fig. 38.1 ).
Fig. 38.1 From top to bottom: fl aring suture, high inter-
domal suture, lateral mattress suture, interdomal suture,
intradomal suture, medial crural suture

545
38 Structural Grafts and Suture Techniques in Rhinoplasty
Conservative resections and suture techniques
are often adequate to correct the nasal tip. If these
measures are insuf fi cient, cartilaginous trans-
plants may be required. A cap graft is placed on
top of the domes in order to correct asymmetries,
contour irregularities, or insuf fi cient projection
of the nasal tip (Fig. 38.2 ). Additional crushed
cartilage or soft tissue transplants may be placed
on top of a cap graft in order to further camou fl age
the typically fi nely shaved edges of the trans-
plant. The natural bi fi dity of the nasal tip is typi-
cally abolished with the placement of a cap graft.
The nasal tip appears more round. This so-called
unitip deformity is rarely noticeable or bother-
some to the patient. An important feature deter-
mining the shape of the nasal tip is the transition
from the tip over the infratip lobule to the colu-
mella. Dissection of an intercrural pocket and
suture fi xation of the columella to the caudal end
of the septum is termed the tongue-in-groove
technique (Fig. 38.3 ). This advancement of the
Fig. 38.2 From top to bottom: spreader grafts, intercarti-
laginous grafts, cap graft, shield-type graft
a
b
Fig. 38.3 ( a ) Tongue-in-groove technique: rotation of
the nasal tip. ( b ) Tongue-in-groove technique: fi xation of
the columella and nasal tip to the caudal end of the
septum

546
U. Mueller-Vogt and H.G. Gassner
columella along the caudal end of the septum and
subsequent suture fi xation allows effective pro-
jection and deprojection of the nasal tip as well as
modi fi cation of columella show [ 10 ] . The place-
ment of a columella strut graft may also substan-
tially change the infratip lobule and associated
structures. The columella strut may be inserted
through a retrograde pocket or from above
between the domes. It is suture- fi xated between
the medial crura of the lower lateral cartilages
(Fig. 38.4 ). The columella strut may enhance tip
support and correct a rounded columella. It
should not reach all the way to the interior nasal
spine as movement of the spine may then result in
a bothersome clicking sensation over the spine. A
more effective tool to control the position of the
columella and the projection of the nasal tip is the
caudal septal extension graft. This graft may be
fi xed to the caudal end of the septum with an end-
to-end suture or a side-to-side mattress suture
(Figs. 38.5 , 38.6 , and 38.7 ). The caudal septal
extension graft may be combined with a colu-
mella pocket and a tongue-in-groove technique.
In addition to good control over the projection of
the nasal tip, caudal end deviations and
de fi ciencies of the nasolabial angle may be cor-
rected through this graft as well. Care must be
taken to fashion the graft thin in order to prevent
thickening of the columellar base [ 11 ] .
A shield-type tip graft may be placed to change
the infratip lobule to tip transition, to derotate the
nasal tip, and to increase projection (Fig. 38.2 ).
After it is fashioned with the edges shaved to
paper-thin, it is suture- fi xated to the medial crus
bilaterally. The shield-type tip graft carries the
long-term risk of migration and perception of its
edges. It seems to be less frequently used because
of these de fi cits. One technique to reduce the risk
of visible edges is to connect alar rim grafts with
the anterior corners of the shield-type tip
(Figs. 38.2 and 38.4 ). The shield graft is typically
placed through the open approach. On the other
Fig. 38.4 From top to bottom: vertical alar batten grafts,
alar strut grafts, alar rim grafts, columellar strut graft
Fig. 38.5 Caudal septal extension graft: side-to-side mat-
tress suture fi xation of a caudal septal extension transplant

547
38 Structural Grafts and Suture Techniques in Rhinoplasty
a
b
Fig. 38.6 ( a ) Preoperative young female patient with ptotic and underprojected nasal tip. ( b ) Postoperative, after
placement of a caudal septal extension graft and bilateral spreader grafts

548
U. Mueller-Vogt and H.G. Gassner
hand, the extended columella strut-tip graft is a
transplant designed for the endonasal approach
[ 12 ] . This graft may affect projection, rotation,
and de fi nition of the nasal tip favorably.
Signi fi cant long-term problems have not been
described with this graft.
38.4
Techniques to Correct the
External Nasal Valve
Alar rim grafts may contribute to improvements
in the function of the external nasal valve. Ideally
these transplants are curved. Such curved grafts
may be obtained from deviated or split and warped
septal cartilage. The transplant is inserted into a
pocket anterior to the caudal end of the lateral
crus. The alar rim graft may also be applied to
correct alar retraction and secondary columella
show. For this transplant to ful fi ll any of these
functions, it needs to be of adequate size and
structural strength. When placed through the open
approach, it may be connected to the edges of a
shield-type tip graft as delineated above [ 13 ] .
The lateral crural suture is designed to contrib-
ute to the correction of the external nasal valve as
well. This mattress suture runs through the lateral
crus of the alar cartilage (Fig. 38.1 ). It may be
employed to accentuate the convexity of the lower
lateral cartilage or to correct a concave lower lat-
eral cartilage. These effects may be enhanced by
scoring incisions of the undersurface of the alar
cartilage. A straightening effect of the lower
lateral cartilage may be achieved with the lower
lateral turnover suture. In this case, a wide cephalic
margin of the lower lateral cartilage is incom-
pletely incised and then fl ipped over and suture-
fi xated to the caudal aspect of the lower lateral
cartilage. When the lateral crus is thin and lacks
suf fi cient height but requires correction of its
three-dimensional shape, an alar strut graft may
be employed. This graft is suture- fi xated to the
undersurface of the lateral crus after the vestibular
skin has been dissected off the lateral crus. This
maneuver allows effective straightening of the lat-
eral crus and may contribute to correcting a boxy
tip as well as correcting external nasal valve col-
lapse. The alar strut graft is typically designed to
reach laterally past the lateral crus and to fi t into a
generously dissected pocket lateral to the pyri-
form aperture (Fig. 38.4 ). This technique is also
well suited to correct overprojection of the tip
[ 14 ] . In this case, the entire lateral crus is dis-
sected off the undersurface and completely freed.
It may then slide freely into the lateral pocket and
thus contribute to deprojecting the nasal tip. This
maneuver has worked well in the authors’ hands
to avoid division of the domes or the lateral crus.
Nasal valve collapse may be dif fi cult to treat and
may at times require the combination of multiple
techniques for a best possible result. The lateral
suspension suture may be a helpful adjunct to
treating this dif fi cult problem. This suture grasps
the soft tissue over the pyriform aperture and pulls
it into an anterior superior direction. It may be
fi xated to a transconjunctivally applied bone
Fig. 38.7 Caudal septal
extension graft,
intraoperative

549
38 Structural Grafts and Suture Techniques in Rhinoplasty
anchor or through different suture techniques. In
the authors’ experience, this technique works only
when the soft tissue insertions of the alar base
with the pyriform aperture have been mobilized
and the alar base has been dissected adequately to
move freely and be re fi xated through scarring in
the new position.
38.5
Techniques to Correct the
Internal Nasal Valve and the
Middle Vault
The intercartilaginous graft is suitable to correct
alar retraction and overrotation of the nasal tip.
These two deformities are typically a result of
previous surgical overcorrection. The intercarti-
laginous graft is placed between the caudal end of
the upper lateral cartilage and the cephalic margin
of the alar cartilage (Fig. 38.2 ). In order to achieve
ef fi cient derotation of the alar cartilage, it is typi-
cally necessary to widely undermine and release
the scar tissue in this area. The intent of this
maneuver is to move the alar cartilage down to its
previous more physiologic location [ 15 ] .
The alar batten graft may be placed to correct
internal nasal valve collapse and overaccentuation
of the horizontal alar fold. Both deformities are
frequently a result of prior overresection of the
alar cartilage. The graft is suture- fi xated over the
lateral aspect of the upper lateral cartilage
(Fig. 38.4 ). Determined by the extent of the defor-
mity, the transplant may be extended laterally and
placed into a pocket dissected over the lateral
aspect of the pyriform aperture [ 16 ] . This place-
ment is similar to but more superior to the place-
ment of an alar strut graft. The alar batten graft
may also be placed in a more vertical position.
This results in a more pronounced outward rota-
tion of this graft (Fig. 38.4 ). Extra caution must be
taken to shave the edges of a more vertically
placed alar batten graft very thin to avoid palpable
contour deformities over the pyriform aperture.
An outward rotation of the upper lateral carti-
lages may also be achieved by placement of a
fl aring suture (Fig. 38.1 ). This mattress suture
grasps the lateral aspect of the upper lateral carti-
lage and is tied over the anterior septal angle. The
widening effect of this suture on the internal nasal
valve seems to be more pronounced when the
upper lateral cartilage has been released from the
septal cartilage and spreader grafts have been
inserted [ 17 ] .
The principle of spreader graft placement is
delineated in Figs. 38.2 , 38.6 , 38.8 , 38.9 , and
38.10 . The spreader graft is a frequently utilized
transplant which is placed between the previously
released upper lateral cartilage and the septal car-
tilage. Typically a rectangular transplant of septal
cartilage is inserted. A spreader graft with a trap-
ezoidal cross-sectional area is ideally suited to
reconstruct the nasal valve angle in a more physi-
ologic manner [ 18 ] . When a higher dorsal hump
has been resected and the height of the upper lat-
eral cartilages has been preserved, these carti-
lages may be scored and folded on themselves.
The folded segment may act as an auto turn in
spreader graft and suture fi xated to the septal car-
tilage like a conventional spreader graft. This
elegant method fi nds frequent use in the authors’
routine. Its main advantage is the preservation of
precious septal cartilage. In the typical case of a
cartilaginous saddle nose deformity, the onlay
spreader graft is a useful transplant. This wide
rectangular graft is placed on top of the anterior
edge of the septum and is suture- fi xated to the
remnants of the upper lateral cartilages. This
graft reconstructs the previously destroyed arc
that is physiologically formed by the upper lat-
eral cartilages. Endonasal spreader grafts may be
inserted from the undersurface of the upper lat-
eral cartilages [ 19 ] . A narrow mucosal tunnel is
dissected along the undersurface of the upper lat-
eral cartilage, and an appropriately shaped carti-
laginous graft is inserted into this tight pocket.
This graft is mainly cosmetic and typically con-
tributes to opening the nasal valve only to a mild
degree. The conventional spreader graft may be
extended and articulated with a columella strut
graft. This complex is then termed a septocolu-
mellar interposition graft and allows effective
derotation of an overly rotated and short nose.
Asymmetries of the middle vault may be cor-
rected by placement of asymmetrically fashioned
spreader grafts. Another graft that has been
designed to correct the internal nasal valve is the

550
U. Mueller-Vogt and H.G. Gassner
a
b
c
Fig. 38.8 ( a ) Suture fi xation of standard spreader grafts
may narrow the nasal valve angle, especially when the
mattress suture is placed low. ( b ) Insertion of spreader
graft with more physiologic, trapezoidal cross section
may open the nasal valve angle further. ( c ) Suture fi xation
of autospreader graft after scoring and folding of the
upper lateral cartilage

551
38 Structural Grafts and Suture Techniques in Rhinoplasty
a
b
Fig. 38.9 ( a ) Patient with residual cartilaginous hump and overprojecting tip after previous surgery. ( b ) Surgical result
after hump reduction and placement of autospreader grafts

552
U. Mueller-Vogt and H.G. Gassner
butter fl y graft [ 20 ] . This rectangular graft is
placed on top of the anterior septal angle. It is
suture- fi xated on either side with the lower edge
of the upper lateral cartilage. Through its inher-
ent elasticity, this graft lateralizes the upper lat-
eral cartilages and thus opens the internal nasal
valve angle. Important drawbacks of this trans-
plant include the limited fl exibility and recoil of
the transplanted material and its tendency to frac-
ture when the nose is pinched.
38.6
Techniques to Correct De fi cits
of the Middle Vault and the
Supratip
Augmentation of a saddle nose deformity is chal-
lenging. Successful techniques with long-term sta-
bility typically require substantial transplantation
of a combination of conchal cartilage (Fig. 38.11 ),
costal cartilage (Fig. 38.12 ), costal bone, or calva-
rial bone. A composite graft of cartilage and bone
may be harvested from the rib. When bone is uti-
lized as a transplant, its solid and stable fi xation
appears to be an important factor contributing to a
good, long-term result. Fixation with wire or
screws appears to be more reliable than suture
fi xation. Transplants containing bone typically
result in substantially increased rigidity of the
reconstructed nose. More recently, alternative less-
rigid methods of reconstruction are favored.
Costal cartilage has an inherent tendency to
warp. After explantation of costal cartilage, the
transplant may be cut in slices and placed in ster-
ile saline. After 20–30 min, one may observe the
early tendency of the cartilage to warp. Typically
the more central aspects of the cartilage show a
lesser tendency of warping. As described by
a
b
Fig. 38.10 ( a ) Patient with deviated middle vault. ( b ) Surgical result after placement of bilateral spreader grafts