Grafting in Modern

Rhinoplasty
Steven Halepas, DMDa, Kevin C. Lee, DDS, MDa, Charles Castiglione, MD, MBAb,
Elie M. Ferneini, MD, DMD, MHS, MBAc,d,e,*

KEYWORDS
 Rhinoplasty  Grafting materials  Rhinoplasty grafting techniques

KEY POINTS
 Grafts are applied for structural or cosmetic purposes to augment the existing nasal substructure.
Stable clinical outcomes are achieved when the osseocartilaginous framework maintains its geom-
etry and permits passive draping of the soft tissue.
 Autogenous cartilage, harvested as septal, costal, and auricular grafts, is the most biocompatible
material.
 Commercially available grafts include processed homografts and synthetic implants. Although
these can be obtained in abundant supply, they are known to cause long-term complications
that are not seen with autogenous cartilage.
 Certain grafts are routinely used by all rhinoplasty surgeons, and these common configurations are
discussed. To a certain extent, the choice of grafting technique depends on surgeon preference
and experience.

INTRODUCTION palate. The remaining bulk of the nasal septum de-

rives from the frontonasal process, which grows
Rhinoplasty is the third most commonly performed inferiorly to fuse with the palatal shelves of sec-
invasive cosmetic surgical procedure behind ondary palate and the anterior septum of the pri-
breast augmentation and liposuction.1 It is consid- mary palate. The result is a complete separation
ered one of the most technically demanding of the right and left nasal chambers. Like other
cosmetic surgeries because of its limited access craniofacial structures, the nasal septum is
and complex 3-dimensional anatomy. Further- composed of a neural crest core that can differen-
more, even with adequate experience, many sur- tiate into a variety of skeletal and connective tissue
geons often have difficulty predicting and precursors. The septum is completely cartilagi-
accounting for subtle long-term postoperative nous at birth; however, beginning at birth and
changes. continuing through puberty, the bony septum un-
Embryologically, the developing nasal septum dergoes endochondral ossification. This process
has 2 components that mirror the pattern of palatal shapes the vomer and the perpendicular plate of
development. The lesser anteroinferior segment of the ethmoid. The anterior septum persists as the
the septum arises as a continuation of the medial quadrangular cartilage, which is a smooth, elastic
nasal processes after they fuse to form the primary hyaline cartilage that is composed of a type II
oralmaxsurgery.theclinics.com

a
Division of Oral & Maxillofacial Surgery, Columbia University Medical Center, New York-Presbyterian,
622West 168th Street, Suite 7-250, New York, NY 10032, USA; b Division of Plastic Surgery, Hartford Hospital
and Connecticut Children’s Medical Center, University of Connecticut School of Medicine, 399 Farmington
Avenue, Suite 210, Farmington, CT 06032, USA; c Beau Visage Med Spa, Cheshire, CT, USA; d Department of
Surgery, Frank H Netter MD School of Medicine, Quinnipiac University, Hamden, CT, USA; e Division of Oral
& Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
* Corresponding author. 435 Highland Avenue, Suite 100, Cheshire, CT 06410.
E-mail address: eferneini@yahoo.com

Oral Maxillofacial Surg Clin N Am 33 (2021) 61–69

https://doi.org/10.1016/j.coms.2020.09.003
1042-3699/21/Ó 2020 Elsevier Inc. All rights reserved.
62 Halepas et al

collagen. Although cartilage is metabolically Other sources of cartilage are available in rare cir-
active, it is avascular and relies on diffusion to cumstances. For example, during facial feminiza-
obtain adequate nutrition. Therefore, following tion surgery the use of cartilage from a
injury, cartilage has a limited capacity for repair concurrent thyroid chondroplasty has been
and regeneration. Grafting the nasal region with described.7 Secondary extranasal sources of
cartilage is a technical and biologic challenge grafting are more than twice as likely to be
because long-term graft survival is less reliable required with revision rhinoplasties.8 Homografts
compared with skin and bone.2 and alloplastic biomaterials are available if autog-
Although the entire nose was originally consid- enous donor sites are exhausted or undesirable.
ered a single unit of the face,3 authors have long Each material described serves a purpose, but
come to appreciate the complexities of functional some materials are more versatile than others.
and aesthetic nasal anatomy. Burget and Menick4
first described the principles of nasal aesthetic Septal Cartilage
subunits, which divided the external nose into a
Septal cartilage is widely accepted to be the best
tip, dorsum, sidewalls, alar lobules, and soft tissue
grafting material whenever it is available. The
triangles. Other authors have since offered their
septum is always part of the surgical field, and
modifications and even created separate classifi-
septoplasty is often simultaneously planned for
cations based on skin quality, light shadows, and
many patients. Septal cartilage is straight and
underlying support. The nasal framework is best
resilient, and the biochemical composition is iden-
studied by dividing the nose into horizontal thirds.
tical to that of the rest of the nose. Septal cartilage
The upper third is supported by a bony vault,
is less firm than costal cartilage, and some sur-
whereas the middle and lower thirds overlie a so-
geons may prefer the later when a high value is
phisticated cartilaginous substructure.5
placed on structural integrity. Graft size is the pri-
Grafting is an essential component of primary
mary limiting factor, because a minimum 1 cm of
and revision rhinoplasties and is performed for
septal cartilage needs to be preserved dorsally
structural and/or cosmetic purposes. The rein-
and caudally to serve as an L-shaped strut. The
forcement provided by structural or functional
amount of available septal cartilage is subject to
grafts permits the nose to resist static gravitational
individual variability and is estimated with preoper-
forces and dynamic forces that are applied during
ative imaging. Postoperatively, septal perforation
animation and respiration. There is tremendous
may require secondary surgical correction if the
variation in graft nomenclature, and this is often a
mucoperichondrial flaps are injured through and
source of confusion. Grafts are classified by their
through.
material, shape, number, location, or function.
Furthermore, grafts are globally categorized as be-
Auricular Cartilage
ing either viable or nonviable. A nonviable graft has
no direct contact to skin and is frequently used to The conchal bowl is accessed through either an
provide structure. A viable graft has direct contact antihelical or postauricular approach. The poste-
with the skin and is typically used for cosmetic rior approach has the benefit of a well-hidden inci-
purposes.6 Unfortunately, the evidence supporting sion, but proper technique results in
individual graft selection is limited. To a certain inconspicuous scaring with either technique.9 Dur-
extent, the choice of graft for a given purpose is ing harvest, care must be taken to preserve the
subject to provider preference and comfort. No antihelix and the crus helix, the latter of which di-
randomized clinical trials have been conducted vides the conchal bowl into the cymba and cavum.
comparing graft materials and techniques for spe- Conchal cartilage is generally thicker and more
cific indications. Luckily, different grafts are pliable than the septal cartilage. The entire
deployed reliably with successful outcomes. In segment possesses a curvature that may be ad-
this review, we describe the most popular grafting vantageous for certain locations. The cymba
materials and introduce common techniques used concha is wider and thinner than the cavum
in the modern rhinoplasty. concha.10 Because of its 3-dimensional contour
and resemblance, the concha is the optimal
GRAFTING MATERIALS choice for lower lateral cartilage and alar recon-
struction. The firmness, thickness, and concave
Whenever grafting is necessary, the septal carti- shape of the cavum concha make it favorable for
lage is the preferred donor site because it is readily use as a shield graft. The intervening extension
available and easy to access. When septal carti- of the helical root is the most robust portion of
lage is unavailable or insufficient, acceptable the conchal graft, and as such it is used as a colu-
autogenous alternatives include rib or concha. mellar strut.11
 Grafting in Modern Rhinoplasty 63

In the graft-depleted patient, the tragal cartilage The disadvantages of harvesting costal cartilage
graft is considered a salvage procedure. One include donor site morbidity, graft warping, and
cadaver study determined that the mean graft graft calcification. The donor site scar is typically
size that could be reliably harvested without visible well hidden. However, before closure, the wound
deformities was 21.6 mm by 15.3 mm.12 Those should be filled with saline and examined for
grafts were approximately 1 mm thick and similarly bubbling during Valsalva maneuver.15 Chest tubes
curved along the long axis. As with conchal carti- are not needed for most small pleural tears. Costal
lage, a stacked configuration or other modification cartilage has an inherent and unpredictable ten-
is required to create a straight graft. dency to warp over time, and this can cause resid-
ual deformity in the reconstructed nose. Strategies
Costal Cartilage to reduce warping include increasing graft thick-
ness,16 performing balanced cross-sectional carv-
The costal cartilage graft is the procedure of ing with central harvest,17 including a chimeric
choice for total nasal reconstruction because of osseous framework,18 and using internal fixation
its volume and strength.13 A tremendous amount with Kirschner wires or screw fixation.19 Older pa-
of cartilage can be harvested from the rib’s attach- tients have greater calcification of their costal
ment to the sternum, and this abundance of mate- cartilage. This calcified cartilage is less prone to
rial is sufficient to reconstruct even the most deformation, but it is also more difficult to harvest
deficient dorsum. Costal cartilage has more than and carve and is less predictably resorbed by the
4 times the average surface area of auricular carti- body.
lage,9 and donor segments up to 5 cm in length are
possible.14 Exposure of the fifth or sixth rib is Homograft Costal Cartilage
straightforward; however, the greatest care must
be taken during dissection of the cartilaginous Nonautogenous grafts are composed of either
cap away from the underlying parietal pleura synthetic or nonsynthetic materials, the latter of
(Fig. 1). Whenever possible, the left ribs are pre- which include homografts. Irradiated homograft
served to avoid masking cardiac pain costal cartilage provides the option for structural
postoperatively. grafting without the requirement of a separate
donor site. These grafts are obtained from pre-
screened donor cadavers and subjected to
60,000 Gy of radiation. As with all donor tissue
transfers, disease transmission is a theoretic pos-
sibility that is almost nonexistent in clinical prac-
tice. The primary concerns with irradiated
homografts are the increased tendency to experi-
ence warping, resorption, and infection compared
with autografts.20 Resorption is particularly prob-
lematic because the graft is often applied as a
load-bearing graft. Newer processing techniques
have been described to overcome the limitations
with irradiated grafts. Fresh frozen, nonirradiated
costal cartilage is decontaminated using light sur-
factant to remove blood, lipid, and cellular compo-
nents and antibiotic solution to remove donor
pathogens.21 Because there is no irradiation, this
processing technique theoretically sterilizes the
graft without affecting its viability. A recent study
of 50 patients who underwent secondary rhino-
plasty reported satisfactory outcomes without sig-
nificant graft resorption.21 The one case of
infection that the authors encountered was treated
effectively with light debridement and antibiotics.

Alloplastic Materials
Fig. 1. Intraoperative dissection for harvesting a
costal cartilage graft. Note the osseocartilaginous The ideal facial implant is biocompatible, inert, be-
junction, which marks the lateral extent of available comes well integrated, and is easily contoured.
cartilage. Synthetic implants have many advantages
64 Halepas et al

including the lack of additional donor site, abun- Medpor, Gore-Tex, and combined materials,
dant supply, and the ability to be patient specific respectively.23 As a general rule, oversized im-
and maintain a reliable shape without concern for plants should be avoided, and recipient tissues
resorption. Commonly used alloplastic materials should be thick, well vascularized, and closed
include silicone, porous high-density polyethylene with minimal tension.
(Medpor, Stryker, Kalamazoo, MI), and expanded
polytetrafluoroethylene (Gore-Tex, W.L. Gore and GRAFT USE IN RHINOPLASTY
Associates, Newark, DE). It is our opinion that
the use of synthetic implants be restricted to Grafts are performed for functional and/or
immobile areas, such as the nasal dorsum. In gen- aesthetic purposes. Grafting techniques are orga-
eral, alloplastic materials are often avoided in rhi- nized by their location.
noplasty because of safety concerns. It should
be noted that silicone is still commonly used in Nasal Tip
Asian rhinoplasties because of its low cost, easy Each lower lateral cartilage is divided into a
availability, and familiarity among providers and medial, intermediate, and lateral crus. The medial
patients. crura contact the nasal septum, whereas the
The physical characteristics of alloplastic im- lateral crura follow curvilinear courses cephalically
plants determine their biologic behavior. Medpor, toward the piriform aperture. The intermediate
Gore-Tex, and silicone are all commercially avail- crura lie between the medial and lateral crura,
able as sheets or preformed blocks. In addition, and its apex is the tip defining point.24 The lower
Medpor is thermoplastic and can be molded in lateral cartilage connects to the upper lateral carti-
situ to the desired shape and contour. Both Med- lage in a union that is referred to as the “scroll
por and Gore-Tex are porous implants that allow area.”25 According to the tripod theory, the nasal
for soft tissue ingrowth. Pores as narrow as 1 mm tip derives its support from the paired lower lateral
permit the translocation of bacteria, whereas cartilages. The 2 lateral crura each represent a leg
macrophages require pore diameters of 30 to of the tripod with the conjoined medial crura and
50 mm. Because the pore size of Gore-Tex im- caudal septum acting as the third leg. Maneuvers
plants is between 10 and 30 mm, there is theoret- that increase or decrease the length these limbs
ically an increased risk of infection because of its in turn alter tip projection and rotation.26
semipermeability to bacteria. Medpor implants The columellar strut graft is the workhorse graft
have pore sizes between 100 and 300 mm, and for stabilizing the nasal tip (Fig. 3). For reference, a
this feature is thought to reduce their incidence strut graft is a generic mechanical term describing
of infection.22 Smooth, nonporous implants, any functional graft that provides outward-facing
such as silicone, rely on fibrous encapsulation support. The columellar strut graft is placed be-
for stabilization. All synthetic implants are prone tween the medial crura and secured to the caudal
to migration and extrusion; however, silicone im- septum (Fig. 4). Septal and costal cartilage are the
plants seem to carry the greatest risk of both preferred donor sites for the columellar strut
(Fig. 2). Implant retrieval rates have been esti- because of their stiffness. Auricular cartilage is
mated at 12%, 4.5%, 3.6%, and 2% for silicone, used when arranged as a double layer. When there

Fig. 2. Previously placed silicone

implant that had migrated. The
implant caused distortion of the soft
tissue (A) and was subsequently
removed (B).
 Grafting in Modern Rhinoplasty 65

Fig. 3. The columella strut graft. Cartilage is placed between the medial crura and secured with sutures to pro-
vide increased tip support. (From Koehler JK. Basic rhinoplasty. In: Fonseca R, editor. Oral and maxillofacial sur-
gery, volume 3. St. Louis: Elsevier; 2017. p. 374; with permission.)

is a lack of tip support, the columellar strut pro- rotation is the shield graft. This trapezoid-shaped
jects and restores the medial crural limb of the graft sits anteriorly over the intermediate crura
tripod. When existing tip support is adequate, the and travels inferiorly to the medial crural foot-
columellar strut may not be the most efficient plates.27 In this position, it provides definition to
means for just increasing nasal projection. To the tip and supports the infratip lobule (Fig. 5).
soften and augment the nasal tip, remnant carti- Extending the graft beyond the nasal dome pro-
lage is used to fill the open spaces and clefts at vides additional projection, but this modification
the nasal tip. If further projection is required, an requires stabilization with a small interpositional
onlay tip graft is placed in either a single or multi- block graft in the posterior dead space.
layered fashion over the alar domes. An onlay graft
is a general term that describes any graft laid Nasal Dorsum and Septum
directly onto its recipient surface. These grafts
can also mask tip asymmetries and should always The spreader graft is a longitudinal graft that is
be beveled along at the edges to blend with the placed often bilaterally between the dorsal septum
surrounding cartilage. The onlay tip graft is termed and the upper lateral cartilages. Spreader grafts
a “peck graft” when it is applied in a transverse are considered the mainstay of treatment of inter-
rectangular configuration. The combination of an nal valve collapse (Fig. 6). These grafts not only act
onlay tip graft with a columellar strut is referred as spacers to prevent narrowing of the internal
to as an “umbrella graft.” Another onlay graft valve angle, but they also widen and straighten
used to increase not only tip projection but also the external appearance of the middle vault
(Fig. 7).24,28 They are often placed following dorsal
hump reduction to close the open roof and recon-
struct the disrupted internal valve. During the
dissection, it is important to completely peel the
mucosa off the deep aspect of the upper lateral
process. Without adequate development of the
submucoperichondrial pocket, graft placement
may actually decrease apical angle and worsen in-
ternal valve obstruction.29 Extended spreader
grafts are designed to project caudally into the
tip-lobule complex, and these longer grafts are
combined with a columellar strut to recreate a
composite L-shaped strut. Extended spreader
can also be used with septal extension grafts to
lengthen the nose. Septal extension grafts are
straight grafts that are sutured end-to-end to the
caudal edge of the septum. They directly lengthen
the deficient septum and can project and derotate
Fig. 4. Columella strut graft placed for tip support. the nasal tip. Tip asymmetry is the main concern
(Courtesy of Michael J. Will, MD, DDS, FACS, Will Sur- when using septal extension grafts, and care
gical Arts, Ijamsville, MD.) should be taken ensure a midline position during
66 Halepas et al

Fig. 5. Shield graft sutured in place.

(Courtesy of Michael J. Will, MD, DDS,
FACS, Will Surgical Arts, Ijamsville, MD.)

fixation. The butterfly graft was first introduced as the radix to the septal angle to reduce the risk of
an alternative to the spreader graft in revisional rhi- introducing additional irregularities. Whenever
noplasty but has gained popularity in addressing alloplastic materials or diced cartilage wraps are
internal nasal valve compromise in primary and used, they are often used for this purpose. Diced
secondary cases.30 It essentially functions like an grafts are useful when there is insufficient cartilage
external nasal dilator strip. The graft is usually to harvest a single block graft, such as in the resid-
shaped from conchal cartilage, placed superficial ual septum of a previously operated nose. They
to the caudal septum, and sutured to the caudal are placed either as a wrap or as free particulate.
margins of the underlying upper later cartilage. Diced cartilage grafts were originally described in
Onlay grafts can also be placed over the upper 1942 but only gained popularity after 2000
lateral cartilages in the form of lateral sidewall following Erol’s31 publication describing his tech-
onlay grafts. Like other onlay grafts, the purpose nique for wrapping them in Surgicel. Because of
of these grafts is to mask uneven contours and ir- issues with graft resorption and foreign body reac-
regularities. The dorsal onlay graft is another tions, Daniel and Calvert32 modified the technique
commonly used midvault onlay graft. They are by wrapping their grafts in temporal fascia. Alter-
often placed over the entire dorsal septum from native protocols have since been described. Tas-
man and colleagues33 impregnated diced
cartilage with thrombin components of fibrin glue

Fig. 7. Demonstration of the internal and external

nasal valves. A minimum angle of 10 to 15 between
Fig. 6. Placement of a spreader graft between the the septum and upper lateral cartilage is needed to
nasal septum and upper lateral cartilages. (From maintain internal valve patency. (From Koehler JK.
Koehler JK. Basic rhinoplasty. In: Fonseca R, editor. Basic rhinoplasty. In: Fonseca R, editor. Oral and maxil-
Oral and maxillofacial surgery, volume 3. St. Louis: lofacial surgery, volume 3. St. Louis: Elsevier; 2017. p.
Elsevier; 2017. p. 371; with permission.) 371; with permission.)
 Grafting in Modern Rhinoplasty 67

Fig. 8. Revision rhinoplasty for alar

collapse in a patient born with cleft lip
(A). Alar rim reconstructed with onlay
graft (B). Immediate postoperative
result (C).

(TISSEEL, Baxter International, Inc, Deerfield, IL). lateral cartilage concavities and convexities. Un-
They found that their grafts were easier to manip- like other lateral wall grafts, the lateral crural strut
ulate into the desired shapes and sizes while can also alter tip dynamics by repositioning the
demonstrating good long-term histologic viability lateral legs of the nasal tripod. The alar batten graft
and regeneration.33 To limit inflammation and in- is another graft that can fortify the nasal valves and
crease revascularization, Bullocks and col- increase their resistance to collapse. The alar
leagues34 suggested the use of autologous batten graft is a curved rectangular graft that sits
tissue glue created from platelet-rich plasma. on the piriform rim laterally and overlaps the upper
The preliminary outcomes with this approach are or lower lateral cartilage medially. An alar batten
promising; however, the 1-year follow-up is too graft positioned caudally in the alar lobule can
short of a period to adequately assess for compensate for a deficient cartilaginous frame-
resorption. work and correct alar retraction. When the graft
is placed more cephalad, it can provide nasal side-
Alar Region wall support and reduce internal valve collapse. A
final alar graft to consider is the lateral crural onlay
Alar rim contour grafts can correct or prevent alar graft. These grafts resemble alar batten grafts in
retraction while simultaneously reinforcing the that they rest on the surface of the lateral crus;
external nasal value. External valve collapse often however, like other onlay grafts they are designed
results from overzealous resection of the lower to overlie and closely mirror the anatomy of the
lateral cartilages. In addition, alar notching is recipient surface (Fig. 8).
seen postoperatively when scar contracture de-
forms weakened lateral cartilages. Alar rim grafts SUMMARY
are able to address both complications simulta-
neously.35 The conventional rim graft is placed Rhinoplasty is a highly challenging procedure that
as a free-floating graft in a subcutaneous plane requires excellent surgical skills and extensive
parallel to the existing or anticipated alar rim. The experience. The complexity is further emphasized
articulated modification involves securing the graft by the countless number of grafting configurations
to the underlying tip. Composite alar grafts with that are possible. Postsurgical soft tissue changes
skin and cartilage may be inserted to correct se- are often dependent on the underlying bony and
vere retraction and notching when there is insuffi- cartilaginous support in addition to the overlying
cient soft tissue. The lateral crural strut graft is a skin thickness. Many rhinoplasty surgeons use
more aggressive method for correcting alar rim workhorse grafts, such as the spreader graft and
deficiencies. This graft is placed as a supporting the columellar strut, to correct commonly encoun-
structure on undersurface of the lateral crus. By tered problems. Still, many grafting options exist,
providing structural stability to the lower lateral and there are many overlapping indications, such
cartilage, the lateral crural strut prevents alar rim as when grafting the lateral wall. In those situa-
collapse by tenting the adjacent soft tissue. From tions, rhinoplasty surgeons may have individual
the basal view, this straightens out any lower preferences based on their own comfort level
68 Halepas et al

and experiences. The authors have reviewed the an anatomic analysis. Ann Otol Rhinol Laryngol
main sources and configurations of rhinoplasty 2017;126(10):706–11.
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