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Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 185
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inch threaded K-wire inserted longitudinally in the strut. (A K-wire cannot be
placed in septal cartilage because it is too thin.) e K-wire should be inserted up
to three-fourths the length of the strut, leaving mm exposed at the base. is
is then placed in a mm drill hole just lateral to the maxillary midline, parallel
and inferior to the nasal oor. When xed with a K-wire, the medial crura can
be advanced and sutured to the strut to control projection, and rotation can be
controlled by the angle made in the K-wire at the base of the strut.
Extended Columellar Strut–Tip Gra (Extended Shield Gra)
An extended columellar strut–tip gra is an elongated shield-shaped gra that
lies caudal to or between the medial crura and extends anteriorly to project beyond the domes and posteriorly toward the medial crural footplate. e gra
provides tip support, projection, denition, and fullness caudal to the medial
crura to aid in shaping the columella. It is stabilized in a tight pocket in the precrural space (endonasal approach), or it is placed caudal to or between the me
dial crura and sutured in place to the crura (open approach). e anterior end of
the gra is rounded and shaved extremely thin to prevent visibility. e further
the tip of the gra extends above the tip-dening points, the more it will tend to
bend backward. If the bending is more than desired, a small rectangular block of
cartilage can be sutured to the domes behind the gra. is results in increased
stability and a barrier against bending upward with loss of tip projection and increased infratip lobular show.
-
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Onlay Tip Gra
An onlay tip gra is a single-layered or multilayered gra placed horizontally over the alar
domes. It is placed in a tight pocket if the endonasal approach is used, or sutured for stabi
lization in the open approach. e gra functions to minimally increase tip projection but
mainly to camouage tip irregularities. e
edges of the gra may be beveled or crushed
to prevent postoperative visibility.
An onlay tip gra acts as the transverse component of an umbrella gra.
-
Shield Gra (Sheen or Infralobular Gra)
is shield-shaped gra is placed adjacent to the caudal edges of the anterior
middle crura, extending into the tip.
A shield gra is used to increase tip projection, dene the tip, and improve contour of the infratip lobule.
Additional tip projection is obtained by moving the gra more anteriorly above
the tip. If used with the endonasal approach, it is placed in a tightly undermined
pocket for stabilization. If the open approach is used, it is sutured to the caudal
Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 187
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margins of the cartilage. To prevent excessive cephalad tilting of the gra, a
small block gra can be sutured to the alar domes to increase stability. e gra
edges should be beveled or lightly morselized to make them soer and less visible.
Subdomal Gra
A subdomal gra is a bar-shaped gra placed in a pocket under the dome. It
corrects dome asymmetry by controlling the horizontal and vertical orientation
of the domes. It may also be used to correct a pinched nasal tip deformity. Septal
cartilage is the preferred gra material.
Umbrella Gra
An umbrella gra is composed of a vertical columellar strut combined with a
horizontal onlay gra. is gra is used in patients with both inadequate tip
projection and support. e edges of the gra’s transverse component should be
beveled or morselized to prevent postoperative visibility. It is usually stabilized by
placing the transverse component in a small, tight pocket (endonasal approach)
or by suturing it to the domes of the lateral crura (open approach).
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GRAFTS OF THE ALAR REGION
Alar Batten Gras
Alar batten gras are nonanatomic gras placed in a pocket that extends from
the piriform aperture to a paramedian position in the alar sidewall at the site of
maximal lateral nasal wall collapse during inspiration.
tended caudal to the area of the lateral crus to correct external valve dysfunction
caused by loss of support from overresected lateral crura. Alternatively, it can be
placed cephalad to the lateral crus to correct internal valve collapse.
,
e gra can be ex-
Alar Contour Gras (Alar Rim Gras)
Alar contour gras are used to correct or prevent alar retraction or collapse.
ey are placed in a subcutaneous pocket immediately above and parallel to the
alar rim and must span the length of the alar deformity. e more severe the
problem, the longer and wider the gra will need to be. Alar contour gras are
not as eective as lateral crural strut gras in patients with signicant alar scarring, loss of vestibular skin, or absent lower lateral cartilages.
ontour gras are used to correct or prevent alar retraction or collapse.
Alar c
Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 189
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Alar Spreader Gra (Lateral Crural Spanning Gra)
An alar spreader gra is a single bar gra
that bridges the intercrural space, with the
ends of the gras placed in an undermined
pocket between the lateral crura and ves
tibular skin. e gra is sutured to the
lateral crura for stabilization. It is used
to correct or prevent a pinched nasal tip
deformity by controlling the distance between and providing support to the lateral
crura.
An alar spreader gra improves both external and internal valve dysfunction by
correcting crural collapse.
-
e shape (triangular or bar-shaped) and size of the gra will vary depending
on the severity of the deformity.
Composite Alar Rim Gra
A composite alar rim gra is a composite skin–conchal cartilage gra that is harvested from the concha cymba or concha cavum and placed along the intranasal
alar rim.
severe alar retraction or notching that is not amenable to other techniques, and
to combat nostril or vestibular stenosis. e skin of the gra should be sutured to
the edges of the defect in the vestibule. Percutaneous sutures are oen employed
to stabilize the gra. If the donor site cannot be closed primarily, it is closed with
a full-thickness postauricular skin gra.
,
It is used to correct asymmetries in alar rim height and moderate to
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Lateral Crural Onlay Gras
A lateral crural onlay gra is placed over the existing lateral crus. It is used to
correct alar contour irregularities caused by a deformed, intact lateral crus. ese
gras strengthen and shape the ala and may improve external valve dysfunction.
However, gra placement supercial to the lateral crus may be visible as a “stepo” at the anterior end and cephalic margin of the gra. e edges of the gra
need to be carefully beveled.
e edge of a lateral crural onlay gra must be carefully beveled to prevent a
step-o at the anterior end of the gra’s cephalic margin.
Lateral Crural Strut Gra
A lateral crural strut gra is placed in an undermined pocket between the undersurface of the lateral crus and the vestibular skin and stabilized by suturing
to the crus. It is used to correct alar retraction; alar rim collapse; and concave,
convex, or malpositioned lateral crura. e lateral end of the gra is usually positioned supercial to the piriform aperture rim to prevent medial displacement
of the gra.
Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 191
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e undermined lateral pocket should be inferior to the alar groove to prevent
visibility of the end of the gra.
e more inferiorly the pocket is placed, the lower the alar rim will be displaced.
Septal cartilage is the preferred source for graing material, but costal cartilage
may be required in gra-depleted patients.
Lateral Crural Turnover Flap
A lateral crural turnover ap is created from the cephalic portion of the lateral
crus aer the vestibular skin has been undermined from its undersurface. A
partial-thickness incision is made on the undersurface of the lateral crus along
its length so that the crus is halved longitudinally. is allows the gra to be
turned supercial to the caudal segment so that it breaks but does not separate.
e original cephalic margin of the crus is sutured to the caudal margin. Lateral
crural turnover aps are used to increase the strength of the lateral crura or to
straighten convex or concave lateral crura. e thicker and stronger the lateral
crus, the more eective the ap.
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GRAFTS OF THE ALAR BASE
Alar Base Gra
An alar base gra is placed along the lateral piriform aperture to augment a recessed lip–alar base junction. Carved cartilage gras have been used but are difcult to shape and stabilize. Although some surgeons still use these gras, others
prefer hydroxyapatite granules or other alloplastic implants.
Columellar Plumping Gras
Columellar plumping gras usually consist of diced or morselized cartilage and
are placed in the space between the medial crural footplates and the nasal spine.
eir purpose is to augment an inadequate columellar-labial angle or to correct
minor posterior columellar contour deformities.
Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 193
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Premaxillary Gra
A premaxillary gra is typically placed along the caudal border of the piriform
aperture. It is used to correct premaxillary recession. ese gras are dicult
to carve and stabilize, and many surgeons prefer to use alloplastic material.
KEY POINTS
■
Maintenance of the major supporting structures of the nose is fundamental
for aesthetic and functional purposes.
■
Failure to maintain or furnish needed support results in suboptimal results,
with deformities that are challenging to correct.
■
e shapes, position, and usage of gras vary depending on the situation and
the desires of the surgeon.
■
Septal cartilage is the preferred source for minimal to moderate augmentation with a dorsal onlay gra, but costal cartilage usually is required for large
augmentations.
■
e shape and thickness of a radix gra will depend on the amount of augmentation desired.
■
Spreader grafts are used to restore or maintain the internal nasal valve,
straighten a deviated dorsal septum, improve the dorsal aesthetic lines, and
reconstruct an open roof deformity.
■
Anchor gras may be used to improve tip support and/or projection and collapse or deformation of the lateral crura.
■
An onlay tip gra acts as the transverse component of an umbrella gra.
■
A shield gra is used to increase tip projection, dene the tip, and improve
contour of the infratip lobule.
■
Alar contour gras are used to correct or prevent alar retraction or collapse.
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■
An alar spreader gra improves both external and internal valve dysfunction
by correcting crural collapse.
■
e edge of a lateral crural onlay gra must be carefully beveled to prevent a
step-off at the anterior end of the gra’s cephalic margin.
■
e undermined lateral pocket should be inferior to the alar groove to prevent
visibility of the end of the gra.
ACKNOWLEDGMENTS
We thank William P. Adams, Jr., MD, Steve H. Byrd, MD, Mark B. Constantian, MD, Ronald P. Gruber,
MD, Bahman Guyuron, MD, Robert M. Oneal, MD, Norman J. Pastorek, MD, Stephen W. Perkins,
MD, Rod J. Rohrich, MD, Samuel Stal, MD, Eugene M. Tardy, MD, and Dean M. Toriumi, MD, for the
valuable suggestions that improved the content of this chapter.
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