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Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 195
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18. Peck GC, Peck GC Jr, Adams WP Jr. Long-term follow-up of the onlay tip gra and umbrella gra.
In Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St
Louis: Quality Medical Publishing, .
19. Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal
cartilage gra. A preliminary report. Plast Reconstr Surg :-, .
20. Johnson CM Jr, Toriumi DM, eds. Open Structure Rhinoplasty. Philadelphia: WB Saunders, .
21. Guyuron B, Poggi JT, Michelow BJ. e subdomal gra. Plast Reconstr Surg :-; discus
sion -, .
22. Peck GC Jr, Michelson L, Segal J, et al. An -year experience with the umbrella gra in rhinoplasty.
Plast Reconstr Surg :-; discussion -, .
23. Tardy ME, Garner ET. Inspiratory nasal obstruction secondary to alar and nasal valve collapse:
technique for repair using autogenous cartilage. Operative Tech Otolaryngol Head Neck Surg :, .
24. Toriumi DM, Josen J, Weinberger M, et al. Use of alar batten gras for correction of nasal valve
collapse. Arch Otolaryngol Head Neck Surg :-, .
25. Rohrich RJ, Raniere J Jr, Ha RY. e alar contour gra: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg :-; discussion -, .
26. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader gras. Plast Reconstr
Surg :-, .
27. Constantian MB. Indications and use of composite gras in consecutive secondary and tertiary
rhinoplasty patients: introduction of the axial orientation. Plast Reconstr Surg :-, .
28. Perkins SW, Tardy ME. External columellar incisional approach to revision of the lower third of
the nose. Facial Plast Surg Clin North Am :-, .
29. DeRosa J, Watson D, Toriumi DM. Structural graing in secondary rhinoplasty. In Gunter JP,
Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, ed . St Louis:
Quality Medical Publishing, .
30. Gunter JP, Friedman RM. Lateral crural strut gra: technique and clinical applications in rhinoplasty. Plast Reconstr Surg :-; discussion -, .
31. McCollough EG, Fedok FG. e lateral crural turnover gra: correction of the concave lateral crus.
Laryngoscope :-, .
32. Pessa JE, Peterson ML, ompson JW, et al. Pyriform augmentation as an ancillary procedure in
facial rejuvenation surgery. Plast Reconstr Surg :-, .
33. Sheen JH. Adjunctive techniques: maxillary augmentation. In Sheen JH, Sheen AP, eds. Aesthetic
Rhinoplasty, ed . St Louis: CV Mosby, .
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12
Harvesting Autologous Gras
for Primary Rhinoplasty
Rod J. Rohrich Stefan O.P. Hofer Jamil Ahmad
O
ver the past few decades, the trend in rhinoplasty has shied away from ablative techniques involving reduction or division of the osteocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and
augmentation of decient areas to correct contour deformities and restore structural support. Consequently, there is a growing need for donor sites that provide
sucient and consistent amounts of cartilage to produce adequate gras. Autologous cartilage is preferred, because it is usually accessible with relatively minimal
morbidity, integrates well into the recipient site, and has a signicantly lower rate
of complications when compared to alloplastic materials.
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Autologous cartilage is preferred, because it is usually accessible with relatively
minimal morbidity, integrates well into the recipient site, and has a signicantly
lower rate of complications when compared with alloplastic materials.
Cartilage gras for primary rhinoplasty are generally harvested from the nasal
septum. Ear cartilage is less frequently used. In the vast majority of patients, these
donor sites provide enough cartilage for adequate sculpting of the nasal framework. In cases that demand a signicant amount of cartilage, it may be necessary
to harvest rib cartilage. More recently, temporal fascia gras have also found utility as an autologous gra material in rhinoplasty.
197
Part Two Basic Surgical Concepts198
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is chapter will focus on our preferred techniques for harvesting these cartilages and temporal fascia. When designing these procedures, special emphasis
has been placed on decreasing donor site morbidity and its functional and aesthetic implications.
SEPTAL CARTILAGE
Septal cartilage is our primary choice for almost all gras used in primary and
secondary rhinoplasty for several reasons. First, it is already within the operative eld, and therefore no additional incisions are necessary for harvesting the
cartilage. Second, if the harvest is performed on a deviated segment of septum,
the patient’s airway may be improved postoperatively.
Septal cartilage is the primary choice for almost all gras used in primary rhinoplasty because it is already within the operative eld and no additional incisions
are necessary for harvesting the cartilage.
Operative Technique
e cartilaginous septum is quadrangular in shape and bounded by three bones:
the perpendicular plate of the ethmoid, the vomer, and the nasal crest of the
maxilla. erefore releasing the required cartilage from these structures is necessary for adequate harvesting of the septum. During closed rhinoplasty, access
for septal harvest can be obtained through a hemitransxion incision or a Killian
incision. A full transxion incision should be avoided, because to mm of tip
projection can be lost, particularly when the dissection is carried down over the
anterior nasal spine. Alternatively, the open approach can provide extensive exposure of the septum, facilitating septal harvest.
Aer separating the suspensory ligament between the medial crura,
the anterior septal angle is identied. A scalpel is used to score the
perichondrium about mm posterior to the anterior septal angle un
til the underlying cartilage is exposed.
Initially a Cottle elevator is used to elevate the mucoperichondrial
ap in a posterior and superior direction. is submucoperichon
drial plane is identied by the distinct gray-blue appearance of the
cartilage, the gritty feel of it, and the relative lack of resistance. Once
in the submucoperichondrial plane, dissection proceeds quite easily.
If there is resistance, this is usually because the plane of dissection is
slightly supercial, and the perichondrium should be scored again so
the ap can be elevated in the correct plane. Elevation of the muco
perichondrial ap in a supercial plane will lead to a greater chance
of mucosal perforations.
Chapter Harvesting Autologous Gras for Primary Rhinoplasty 199
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In our practice, the open approach is preferred because of the improved visualization it aords and the ease of harvesting large quantities of septal cartilage.
If reduction of the dorsum is indicated, this should be done before septal harvest to ensure that an adequate L-strut is preserved. If the septal harvest is performed before dorsal reduction, any further excision of cartilage will decrease
the width of the L-strut to less than what is required, weakening the remaining
support and increasing the potential for deformities from lack of support, such
as a saddlenose deformity.
If reduction of the dorsum is indicated, this should be done before septal harvest
to ensure that an adequate L-strut is preserved.
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e submucoperichondrial plane is identied by the distinct gray-blue appearance of the cartilage, the gritty feel of it, and the relative lack of resistance.
Bilateral submucoperichondrial tunnels are dissected deep to the upper lateral
cartilages and a scalpel is used to separate the upper lateral cartilages from the
dorsal septum. Release of the upper lateral cartilages from the dorsal septum
allows direct visualization of the entire dissection. e submucoperichondrial
dissection should be continued bilaterally to release the entire quadrangular cartilage. At the junction of the cartilaginous septum with the bony septum, dissection becomes more dicult because of crossed perichondrial and periosteal
bers, and care should be taken not to perforate the mucoperichondrial aps.
Small unilateral mucosal perforations typically do not require repair. If large perforations or bilateral opposing perforations occur, they should be repaired using
- chromic gut absorbable sutures. Repair of large or posterior perforations can
be technically challenging because of the tight working space. In some cases, it
may be necessary to place an interposition gra of cartilage, fascia, or allogras
such as acellular dermal matrix to prevent bilateral opposing perforations to heal
together, developing a septal perforation. In these cases, septal splints should be
le in place for to weeks to allow reepithelialization of the interposition gra.
Small unilateral mucosal perforations typically do not require repair. If large
perforations or bilateral opposing perforations occur, they should be repaired.
e dissection is continued inferiorly and posteriorly over the posterior vomer.
e junction of the perichondrium with the periosteum overlying this region is
allel to the anterior edge of the septum, from the junction of the
dorsal L-strut with the perpendicular plate of the ethmoid to
the junction of the caudal L-strut with the maxillary crest. e
tilage. e dorsal and caudal L-strut should be at least mm,
quired to ensure long-term support. e L-strut should remain
attached to the perpendicular plate at the keystone area and the
sition points between the perpendicular plate of the ethmoid
and the dorsal L-strut as well as between the dorsal and caudal
Chapter Harvesting Autologous Gras for Primary Rhinoplasty 201
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particularly dicult to dissect and should be performed with great care. It may
be helpful to dissect two separate tunnels, one subperichondrial and one subperiosteal, and to divide the junction sharply to avoid tears in this region.
In cases of septal deviation, the mucoperichondrium on the convex side of the
deviation is typically attenuated and more fragile making dissection more dicult; mucosal perforations occur more readily on this side. On the concave side
of the deviation, dissection is generally more straightforward, and the surgeon
should be especially careful to avoid any mucosal perforations on this side.
In cases of septal deviation, the mucoperichondrium on the convex side of the
deviation is typically attenuated and more fragile making dissection more difcult; mucosal perforations occur more readily on this side.
When the septal cartilage is harvested, an incision is made par
width of the L-strut is determined by the strength of the car
but in many instances a width of mm or more may be re
nasal spine−maxillary crest area. In addition, curving the tran
L-strut can help to strengthen the construct.
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In many instances, the width of the dorsal and caudal L-strut should be 15mm
or more to ensure long-term support. Curving the transition points between the
perpendicular plate of the ethmoid and the dorsal L-strut and between the dorsal and caudal L-strut can help add strength.
e septal cartilage is then disarticulated from its posterior osteocartilaginous
junctions with the perpendicular plate of the ethmoid, vomer and maxillary crest
using a Cottle elevator. e septal cartilage can then be removed with ease.
If there is deviation of the bony septum or septal spurs, the septum can be microfractured and returned to the midline. Microfracture of the septum should
be performed in a careful and controlled manner to avoid uncontrolled fractures
into the superior nasal septum and cribriform plate. is is particularly important
in posttraumatic cases where there may have been a prior septal fracture. Bony
spurs of the septum can be removed using Takahashi forceps. Septal cartilage or
bone should be removed with ease; if there is any resistance, residual so tissue
attachments should be completely released.
Microfracture of the septum should be performed in a careful and controlled
manner to avoid uncontrolled fractures into the superior nasal septum and cribriform plate. is is particularly important in posttraumatic cases where there
may have been a prior septal fracture.
During these maneuvers, it is important to avoid pressure on the L-strut so that
damage to the L-strut does not occur.
It is important to keep a record of the amount of cartilage harvested from the
septum, and any excess material should be banked posterior to the L-strut for
use during possible subsequent procedures.
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At the end of the operation, Doyle septal splints (Micromedics Inc., St. Paul, MN)
are placed. It is oen necessary to trim the superior edge of the splints so they can
be inserted and removed easily. e splints are lubricated with antistaphylococcal
antibiotic ointment and secured with a single through-and-through - nylon
horizontal mattress suture tied loosely to avoid strangulation of the septum as the
tissues swell in the postoperative period. e goals are to avoid hematomas between the mucoperichondrial aps, to support and stabilize the septal structures
in the midline, to protect the mucosa, and to prevent the formation of synechiae
by opposition of adjacent mucosal surfaces. Typically, the splints are removed
aer to days. Nasal packing is not routinely performed.
EAR CARTILAGE
Ear
Septal
cartilage
Ear cartilage can provide a surprisingly large volume of gra material. Given its
accidity and the convolutions inherent in its structure, ear cartilage is ideal for
reconstructing the lower lateral cartilages. It is most frequently used in secondary rhinoplasty, when the septum has previously been harvested but has limited
utility when structural support is mandatory. However, harvest of ear cartilage
may be required during primary rhinoplasty to reinforce the lower lateral cartilages or to extend support into the lateral nasal ala, which is not supported by
cartilage
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cartilage but merely contains brofatty tissue. In harvesting ear cartilage, the entire conchal bowl can be harvested without resulting in any contour deformity
of the ear as long as the antihelix is not disturbed. Despite this, it is possible to
harvest a signicant length of cartilage.
Ear cartilage may be harvested through anterior or posterior approaches. e
scar resulting from its harvest is very well concealed, even when placed anteriorly
within the conchal bowl. An anterior approach provides clear visualization of
the exact area of cartilage to be harvested, making this a very precise procedure.
Given its accidity and the convolutions inherent in its structure, ear cartilage
is ideal for reconstructing the lower lateral cartilages.
Operative Technique for the Anterior Approach
e anterior approach can be used when either a small or a large piece of cartilage
is required. e anterior approach provides excellent exposure and is especially
useful when a very large piece of cartilage is required.
e anterior approach provides excellent exposure and is especially useful when
a very large piece of cartilage is required.
e incision is placed approximately mm inside of the conchal bowl both to
camouage the scar within the concha and preserve the antihelix to prevent
contour deformities of the ear. Before the incision is made, the concha is inltrated from the anterior and posterior sides with to ml of % lidocaine with
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