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Learning Objectives: After reading this article, the participant should be able
to: 1. Understand the challenges in restoring volume and structural integrity in
rhinoplasty. 2. Identify the appropriate uses of various autografts in aesthetic and
reconstructive rhinoplasty (septal cartilage, auricular cartilage, costal cartilage,
calvarial and nasal bone, and olecranon process of the ulna). 3. Identify the
advantages and disadvantages of each of these autografts.
Summary: This review specifically addresses the use of autologous grafts in
rhinoplasty. Autologous materials remain the preferred graft material for use in
rhinoplasty because of their high biocompatibility and low risk of infection and
extrusion. However, these advantages should be counterbalanced with the concerns of donor-site morbidity, graft availability, and graft resorption. (Plast.
Reconstr. Surg. 125: 40e, 2010.)
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CHOICES OF AUTOGRAFT
Septal Cartilage
Septal cartilage is generally considered the
best material for correction of nasal deformities in
revision rhinoplasty patients (Table 1).3,6 25 Typical uses for septal cartilage include dorsal grafts,
struts, batten grafts, lateral crural grafts, lateral crural strut grafts, spreader grafts, and tip grafts to increase projection, length, or definition to the nasal
tip (Figs. 1 through 4).14,26,27 Septal cartilage can be
easily harvested during rhinoplasty regardless of
the approach and without the need for additional
incisions. Septal cartilage is generally straight, providing strong structural support, and has resiliency
properties similar to those of the native nasal cartilaginous framework.8 Furthermore, it offers easy
manipulation.28 It can be contoured and carved to
fit a precise pocket or sutured in an exact location.
As with most autogenous cartilage grafts in the
nose, clinically significant resorption and infection are uncommon.8,29 In comparison with other
autografts, septal cartilage grafts exhibit fewer disadvantages with regard to extrusion, resorption,
Preferred Graft
Source
Strut graft
Septal cartilage
Other Options
Costal cartilage, auricular
cartilages, temporalis
fascia, calvarial bone
graft
Auricular cartilage, costal
cartilage, ethmoid
bone
infection, or warping. Although the septal cartilage graft resorption rate has been reported to
range from 12 to 50 percent,12 this resorption is
most often clinically imperceptible secondary to
replacement by fibrous tissue.6,30,31 The long-term
stability has also been shown in animal models,
and this is thought to be secondary to the nonimmunogenicity of this autograft and its incorporation into surrounding tissues.30,32 Cartilage has
been shown to retain water and develop swelling
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Fig. 4. (Left) Preoperative and (right) 9-month postoperative views of a patient who underwent primary
rhinoplasty in which bilateral spreader, collumellar strut, shield, cap, and alar rim grafts were used.
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Costal Cartilage
Although autogenous septal cartilage is generally preferred for use in the primary correction
of mild deficiencies in the projection of the nasal
tip and dorsum, often there is an insufficient supply for more severe deformities or the supply is
unavailable in cases of graft-depleted revision rhinoplasty. In such cases where alternatives to septal
and conchal cartilage grafts are needed, autogenous rib cartilage may be the graft material of
choice.48 51
Costal cartilage is available in abundance, undergoes minimal postoperative resorption when
not morselized or crushed excessively,9 and is
relatively easy to carve.49 Grafts can be harvested
simultaneously during rhinoplasty exposure by
a second surgeon, minimizing operative time.51
Costal cartilage can be refrigerated, carved meticulously at the surgeons leisure, and transplanted within several days with good long-term
viability.12 Both abundant and versatile, costal
cartilage can supply the plastic surgeon with
ample cartilage for essentially any structural deficiency of the nose.12,26,49,51
Costal cartilage is often overlooked when
grafting materials are sought because of its perceived disadvantages, the foremost of which is unpredictable warping, which could jeopardize the
aesthetic result in a dorsal graft and necessitate
revision.12,52,53 Gibsons principles of balanced
cross-sectional carving along the long axis of the
cartilage have been used conscientiously by surgeons who wish to prevent warping.54 Typically,
this involves symmetrical removal from both sides
and using only the central part of the cartilage for
reconstruction or augmentation, particularly of
midline nasal structures.9,11,48,51 Previous strategies
included allowing the graft to warp to completion
in water or an abdominal pocket for 3 months
before use in recontouring.55 More recent in vitro
studies have shown full distortion of cartilage
grafts within 15 to 30 minutes of carving,49,56,57 but
the clinical setting is less predictable, with case
reports of noticeable warping of grafts up to 9
months postoperatively.54 Gibsonian balanced
carving with 15 minutes allowed for maximal
warping has also been advocated.51 In his series
of 40 costal cartilage grafts for nasal reconstruction in 14 patients followed for an average of 12
months, there were no instances of postoperative graft warping.
Internal rigid stabilization of the cartilage
graft with alloplastic support has been another
strategy to prevent warping. Gunter et al. de-
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CONCLUSIONS
Each of the available autografts that can be
used by the rhinoplastic surgeon has advantages
and disadvantages. The most common complication associated with cartilage grafts is malposition.
Other complications include resorption, extrusion, and warping.25,86 Septal cartilage, generally
considered the best material for correction of nasal deformities, has the advantage of relative ease
of harvest. It has properties similar to those of
native nasal cartilaginous framework and provides
very good structural support. However, the surgeon is generally limited by the amount of material that can be harvested before structural instability of nose results. Auricular cartilage has been
shown to be pliable and resilient, with a broad
range of available shapes that can be harvested.
This has made it an excellent choice for external
nasal valve reconstruction while offering low donor-site morbidity. Just as the shape of the graft
may be an advantage, its potential convolution
may be a disadvantage, as it tends to be more
brittle and offers less rigidity and support than
septal cartilage. When the surgeon is limited by
the amount of septal or auricular cartilage that can
be harvested, costal cartilage offers the advantage
of an abundant source of support material. It has
been shown to have long-term viability, with minimal resorption after implantation. However, it
has also been associated with significant donor-site
morbidity and shown to be susceptible to late
warping if specific measures are not taken to prevent it. Bone grafts such as those from the calvaria,
nose, or olecranon process of the ulna provide
excellent structural support, are available in abundance, and offer reliable aesthetic results. Although resorption rates have been shown to be
better in calvarial and olecranon process grafts as
compared with iliac crest grafts, the unnatural feel
and possible risk of complications associated with
harvesting (less so in olecranon process grafts)
presents drawbacks to their use.
Clinical judgment remains the most important
determinant in selecting the appropriate type,
size, and shape of graft used to correct nasal deformities in revision rhinoplasty. Each material
offers advantages that may be necessary based on
the clinical scenario and nature of the revision,
augmentation, or reconstruction. Similarly, each
graft type may have disadvantages that preclude its
Descriptor
Bone graft, any donor area; minor or small
Bone graft, any donor area; major or large
Cartilage graft; costochondral
Cartilage graft; nasal septum
Graft, bone; nasal, maxillary or malar areas
(includes obtaining graft)
Graft; rib cartilage, autogenous, to face, chin,
nose or ear (includes obtaining graft)
Graft; ear cartilage, autogenous, to nose or ear
(includes obtaining graft)
use in different cases. It is important for the rhinoplastic surgeon to be aware of such advantages
and disadvantages and the appropriate techniques
needed to overcome some of the limitations of the
grafting method so that the optimal aesthetic and
reconstructive result is achieved. Table 2 lists CPT
codes commonly used for grafting procedures in
rhinoplasty.
Ali Sajjadian, M.D.
496 Old Newport Boulevard
Newport Beach, Calif. 92663
sajjadiana@yahoo.com
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