You are on page 1of 10

CME

Current Status of Grafts and Implants in


Rhinoplasty: Part I. Autologous Grafts
Ali Sajjadian, M.D.
Roee Rubinstein, M.D.
Nima Naghshineh, M.D.,
M.Sc.
Pittsburgh, Pa.

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.)

hinoplasty outcomes can be improved significantly by the use of different maneuvers


and biomaterials. The two central issues of
inadequate structural integrity and volume can be
restored using a variety of grafts and implants.
Over the past 10 to 15 years, the paradigm has
shifted from overaggressive and reductive rhinoplasty to greater use of augmentation.1,2 Consequently, the use of grafts and implants has also
increased with this change. The choice of the implant and graft used during rhinoplasty remains
an area of continuous debate and controversy.
In a nose that has been operated on previously, excessive resection of the septum and upper
and lower lateral cartilages leads to loss of
support.3 Significant loss of the structural framework following rhinoplasty can result in skin and
soft-tissue shrinkage and volume deficiency. Inadequate dorsal height can be caused by injudicious
resection of the osteocartilaginous dorsum. In addition, loss of nasal tip projection, rotation, and
nasal length may be secondary to loss of adequate
tissue support and the dynamics of healing. Irregularities of the nasal tip and dorsal contour and
alar retraction are frequently caused by excessive
and asymmetric loss of nasal framework.4,5 Similarly, the function of the internal and/or external
From the Division of Plastic and Reconstructive Surgery,
University of Pittsburgh Medical Center.
Received for publication May 31, 2007; accepted March 24,
2008.
Copyright 2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181c82f12

40e

nasal valves can be compromised by overaggressive


resection of upper and/or lower lateral cartilages.
These complications and misadventures result in
difficult reconstructive challenges at the time of
secondary or tertiary rhinoplasty, often requiring
the carefully planned use of a variety of grafts and
implants to address specific functional and cosmetic issues. Grafts and implants can be used to
minimize the effects of overreduction, address
open roof deformities, camouflage contour irregularities, and correct airway compromise caused
by a collapsed cartilaginous vault and nasal valves.
There are various grafts and implants available
to the rhinoplastic surgeon that can be used to
restore the volume and structural integrity of the
nose. The available biomaterials can be divided
into two broad categories: autografts, which are
derived from the patient and include cartilage,
bone, fascia, and dermis; and homografts, which
are derived from tissues donated by members of
the same species and include irradiated cartilage
and acellular dermis. Alloplastic implants are synthetic implants (biocompatible polymers) with a
variety of applications in plastic surgery.
This review specifically addresses the use of
autologous grafts in rhinoplasty, without specific
recommendations. However, description of specific surgical techniques is beyond the scope of this
review. Autologous grafts have relatively high bio-

Disclosure: The authors have no financial interest


to declare in relation to the content of this article.

www.PRSJournal.com

Volume 125, Number 2 Grafts and Implants in Rhinoplasty


compatibility and low risk of infection and extrusion as compared with homografts and alloplastic
implants. Although autologous grafts remain the
preferred material for use in rhinoplasty, their
advantages should be counterbalanced with the
concerns of donor-site morbidity, graft availability,
and graft resorption.

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,

Fig. 1. Cartilaginous septum harvested and fashioned to form a


columellar strut, which is being sutured between the medial crura.

Table 1. Graft Sources and Their Use


Graft Use

Preferred Graft
Source

Onlay graft Septal cartilage

Strut graft

Septal cartilage

Other Options
Costal cartilage, auricular
cartilages, temporalis
fascia, calvarial bone
graft
Auricular cartilage, costal
cartilage, ethmoid
bone

Batten graft Auricular cartilage,


septal cartilage
Spreader
Septal cartilage
Resected dorsal cartilage,
graft
auricular cartilage,
vomer
Tip grafts
Septal cartilage,
Costal cartilage, lateral
auricular
crura (resected
cartilage
cephalic portion
of LLC)
Buttress
Septal cartilage
Costal cartilage
graft
with bone
such as ethmoid
or vomer
Alar graft
Septal cartilage,
Costal cartilage
auricular
cartilage
LLC, lower lateral cartilage.

Fig. 2. Bilateral asymmetric spreader grafts in situ harvested


and fashioned from septal cartilage. This patient had significant
deviation and asymmetry of the middle nasal vault, which was
corrected utilizing septoplasty, cartilage scoring, and direct mattress suturing of the septal cartilage as well as asymmetric placement of spreader grafts.

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

41e

Plastic and Reconstructive Surgery February 2010

Fig. 3. Bilateral spreader grafts in situ, stabilized with 25-gauge


needles before placement of horizontal mattress sutures.

pressure.33 However, provided that the surfaces


are not unilaterally scored or cut, septal cartilage
will not warp or curl, and it can be easily sculpted
or very lightly crushed to improve flexibility without risking cell loss.11 Known determinants of cartilage graft resorption include implantation in areas subjected to high tensile forces, exposure to
muscular activity, and crushing during preparation of the graft.34 A large study with over 2000
autologous septal cartilage grafts and 17 years of
experience demonstrated no incidence of rejection or loss caused by infection.9 Reported complications were infrequent, preventable, and attributable to surgical error rather than graft
properties. It was demonstrated that complications declined with increasing operator experi-

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.

42e

Volume 125, Number 2 Grafts and Implants in Rhinoplasty


ence in graft contouring, fashioning, and host
pocket preparation.9
To obtain a smoother appearance when augmenting or recontouring along the radix, dorsum,
tip, or lateral sidewall, septal cartilage has been
diced and placed within a blanket of oxidized
regenerated cellulose (Surgicel; Johnson & Johnson Medical, New Brunswick, N.J.).35,36 The oxidized regenerated cellulose (Surgicel) has not
been shown to cause cartilage proliferation, but
instead results in an increase in collagen formation,
leading to favorable contours. Alternatively, cephalic
trim grafts have been used to fill minor defects and
address irregularities of the nasal dorsum.37 It has
been suggested that diced cartilage wrapped in fascia is superior to Surgicel-wrapped diced cartilage
in addressing various deformities (Fig. 5).38 This
observation was supported by histologic evidence
that fascial wraps (particularly temporalis fascia)
allow for greater preservation of healthy
cartilage.39 In addition, tip definition or projection can be achieved through the addition of an
onlay or shield-shaped tip graft, followed by dorsal

augmentation over the cartilaginous vault with


diced cartilage or diced cartilage wrapped in
fascia.40 The reader is encouraged to pursue further information regarding tip grafting, as it is not
covered in detail in this review. Filing the grafts to
lower their profile has also been shown to improve
contour and decrease visibility.41 Moreover, greenstick-fracturing dorsal onlay grafts can produce a
softer, more natural appearance by correcting inverted-V or inverted-U configurations.7
Septal cartilage is most often used as a free
graft but may also be rotated on a mucoperichondrial pedicle for reconstruction of the nasal alae.42
Septal cartilage is readily obtained by the surgeon
by submucous resection12 or septoplasty and may
be harvested through whichever surgical approach (e.g., Killian, dorsal, hemitransfixion or
full transfixion, intranasal posterior approach)
the surgeon feels is most suitable to the particular
case. If an external rhinoplasty approach is undertaken, the septal cartilage may be harvested
from above, by separating the medial crura of the
lower lateral cartilages and the upper lateral car-

Fig. 5. (Above) Harvesting of temporalis fascia. (Below, left) Harvested


temporalis fascia. (Below, right) A temporalis fascia graft is used to wrap
small fragments of minced cartilage to form a pliable, soft graft for radix
augmentation.

43e

Plastic and Reconstructive Surgery February 2010


tilages, or by means of a standard septoplasty
approach, with a transfixion or hemitransfixion
incision.7 With an internal approach, the septal cartilage is exposed by elevation of a mucoperichondrial flap, which is facilitated by generous hydraulic
infiltration of local anesthetic within the subperichondrial plane.9 The quadrangular cartilage articulates with the upper lateral cartilages, bone, vomer,
and perpendicular plate of the ethmoid.43,44 The
quadrangular cartilage can be freed bluntly from the
maxillary crest inferiorly and disarticulated from the
bony septum posteriorly at its junctions with the
vomer and perpendicular plate of the ethmoid
bone. Alternatively, the anterior portion of the perpendicular plate of the ethmoid can be removed
attached to the quadrangular cartilage if separation
of the two is difficult inside the nose.7
The main disadvantage of using shaped autogenous grafts using septal cartilage is the limited
amount of cartilage that is available and that can be
harvested safely from the nasal septum. Generally, a
minimum of a 1-cm dorsal-caudal L-shaped strut
should remain to prevent collapse.4 Some surgeons have taken more conservative amounts of
cartilage, leaving dorsal and caudal septal struts of
15 mm,10,11 whereas others are more aggressive,
leaving only 8 mm for adequate support.7,42 The
septal cartilage thickens posteriorly, and this characteristic is useful when designing support struts
or tip grafts that are ideally fashioned from the
thickest portions of the cartilage (Figs. 6 and 7).42

Fig. 6. Intraoperative view of a shield tip graft and a cap graft


fashioned from harvested septum.

44e

Fig. 7. Intraoperative view of alar batten graft harvested from


concha in a tertiary rhinoplasty patient who did not have any
available septum to be harvested.

Furthermore, fashioning the graft in a patient


whose septum is severely deviated is sometimes
very difficult because of the existent memory and
angulation of the raw septal cartilage.7
Auricular/Conchal Cartilage
Conchal cartilage has proven indispensable as
an aid in secondary or reconstructive rhinoplasty,
when prior harvest, trauma, genetics, or infectious
processes have rendered the nasal framework deficient and the septal cartilage unavailable to the
surgeon.9,12,14 Conchal cartilage is considered the
graft of choice for most nonstructural applications
when septal cartilage is inadequate or unavailable
(Fig. 8).4,8,10 12,42,45 The cartilage is pliable yet resilient, and its natural contours allow for a variety
of cartilage shapes.12 Auricular cartilage is of the
elastic hyaline histologic type (type 4), exhibit-

Fig. 8. Intraoperative view of a double-layered cap graft.

Volume 125, Number 2 Grafts and Implants in Rhinoplasty


ing a fixed genetically sculpted configuration,
which renders it structurally most similar to the
lateral nasal cartilages and the external nasal
valve.30 Indeed, this natural convolution may be
disadvantageous in some instances as well.
By suturing layers of bruised auricular cartilage
into a multilaminar structure, restoration of significant nasal dorsal defects and irregularities, including the saddle-nose deformity, can be achieved.
Conchal cartilage is typically more brittle than
septal cartilage, making it more difficult to carve
precisely.9,42 However, it is characteristically less
rigid than septal cartilage and therefore is most
appropriately used as an onlay for contour improvement, particularly in the nasal tip region.10
As such, conchal cartilage is generally considered
inferior to septum or rib cartilage with respect to
structural support. Auricular cartilage has been
associated with occasional warping or even deformation associated with ongoing scar contracture.
However, experienced surgeons estimate that this
occurs in less than 5 percent of cases, usually requiring a minor revision procedure.
Grafts can be harvested easily under local anesthesia, and a significant portion of the concha
(including both the cymba conchae and the cavum conchae) can be removed without risking
donor-site deformity. Complete conchal cartilage
excision may cause slight medialization of the
pinna; thus, the more protrusive ear should be
used as the donor.10 However, leaving a segment
of the posterior conchal wall will avoid any medialization and should be the preferred method for
the less experienced surgeon. Patients with collagen vascular diseases and certain immunologic
diseases such as lupus, and those predisposed to
keloid formation, are poor candidates because of
the likelihood of postoperative deformity.10 Approximately 5 cm of cartilage, with perichondrium, can be relied on per ear.10 Removal of the
graft perichondrium, particularly when auricular
cartilage is to be used in dorsal augmentation, has
been recommended to minimize the chances of
warping.46 Others suggest that its preservation facilitates earlier fibrosis and graft stabilization in
the host bed.9,11 Free perichondrium has been
used as a camouflaging graft to soften the appearance of the nasal tip structures and can be used for
nasal tip and septal perforation repair.47 The conchal cartilage is thickest at the cymba concha, and
support grafts such as columellar struts should be
harvested from this portion.4 There is significant
variation in cartilage size and thickness among individuals, and thorough examination of potential
donor sites is crucial to preoperative planning.11

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-

45e

Plastic and Reconstructive Surgery February 2010


scribed placement of a longitudinally threaded
Kirschner wire within dorsal onlay grafts or columellar struts. In vitro data and a corroborating clinical application in 28 patients showed no warping
over 13.5 months.49 In addition, the costal cartilage
can be laminated together in opposite directions
and secured with suturing or with a very small
amount of cyanoacrylate to prevent warping.58
Costal cartilage autografts also have the disadvantage of significant donor-site morbidity,11 including iatrogenic pneumothorax, chest wall deformities
caused by unpredictable scarring, persistent postoperative pain, longer anesthesia times, and incisional
dehiscence or infection.52,54,59 In a study with 14 patients receiving 40 grafts from 20 autogenous ribs
harvested during septorhinoplasty, there was one
pleural tear and one donor wound dehiscence,
with the author suggesting that complications associated with harvesting costal cartilage are both surgeon and technique dependent.51 To further minimize donor-site morbidity, several authors have
described short incisions (2 to 3.5 cm in the nonobese patient) facilitated by the use of differential
retraction9,51 or even endoscopic techniques for
graft harvest.60 Use of a method where costal cartilages are harvested en bloc with the perichondrium
left completely intact at the donor site, with remaining costal cartilage cut into small blocks to fill the
dead space formed in the perichondrial pocket, has
been reported, with no chest wall deformities and
decreased intraoperative complications.61
It should be noted that costal cartilage should be
used with caution in the older patient, as progressive
calcification renders it less likely to warp but more
difficult to sculpt in many cases.9,12,42 Perichondrium should be excluded meticulously from
grafts because of its chondrogenic potential,62
which may distort the graft and jeopardize cosmesis. Importantly, careful dissection and preparation of the vascular pocket to limit tension and
movement of the inset graft is thought to prevent
warping and resorption.12
Bone Grafts: Calvarial and Olecranon Process
The forces of scarring in the healing nose with
severe deformity tend to overwhelm any type of
reconstruction that is not rigid or semirigid. Thus,
a reconstructive strategy should aim to provide
stabilization of the tip and dorsum until contraction has abated.63 Bone grafting is a good option
because it provides good stability, is available in
abundance for any nasal application, and produces reliable aesthetic results. However, whereas
cartilage is indifferent to functional stress for its

46e

survival, bone grafts implanted in low-stress sites


may resorb over time, with concomitant reversal of
the augmentation effect.64,65 For example, ethmoid has been abandoned as a tip graft because
of its lack of long-term survival. However, its utility
as a buttress graft supporting primary grafts has
become evident.25 Other disadvantages of bone
grafting include the possibility of an unnatural
feel and the potential for significant donor-site
pain and other harvest-related morbidity.26,66,67
Various bone graft donor sites have been used
reliably in nasal reconstruction and dorsal augmentation, including iliac crest, calvaria, mastoid bone,
ulna, rib, and nasal hump implants.68 74 Regardless
of the source of the bone graft used in nasal reconstruction, time-honored principles of bone graft survival are felt to apply in the nose, including the notion
that increased graft-to-recipient bone contact improves
graft volume conservation,75 and that rigid fixation of
the graft is associated with decreased resorption and
improved longevity of the aesthetic result.76
Split calvarial bone has emerged as a preferred
graft in recent nasal reconstruction literature because of its superior strength, lower resorption
rate, and low donor-site morbidity.11,70,77,78 Calvarial bone has been shown to have a lower resorption
rate than iliac crests (13.5 percent versus 0 percent
with 5-year follow-up).65 The need for intact periosteum to retain volume is uncertain in this
situation.79 Because of its strength, calvarial bone
can be thinned to 1 mm and arranged in a hinged,
interlocking fashion with an L-configuration for
support of both dorsal contour (dorsal graft) and
tip projection (columellar graft).63,78 The olecranon process has a uniquely thick cortex (2 to 5
mm), which is thought to also resist resorption (0
percent resorption with 3-year follow-up).70
Harvesting of calvarial bone is well tolerated by
patients, with minimal or no postoperative discomfort compared with the significant morbidity classically associated with iliac crest resections, which
typically lasts 2 or 3 weeks postoperatively.63,80,81 However, the risk of central nervous system injury and
hematoma formation, though rare, exists.79,82 Supporters of use of the olecranon process note that
its harvest is easy and without the threat of central
nervous system injury.82 85 Calvarial grafts are harvested over the nondominant side of the brain in
the temporoparietal area. A contouring burr is
used to cut around the graft to the level of the
diploe, which is then removed carefully to expose
the inner table. The outer table surrounding the
graft is contoured with a burr, rendering the donor-site defect mild, wide, and inconspicuous.
Bone dust can be placed into the donor defect and

Volume 125, Number 2 Grafts and Implants in Rhinoplasty


covered with oxidized regenerated cellulose (Surgicel) to further conceal the depression, which
becomes less palpable 6 to 12 months following
surgery.79

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

Table 2. CPT Codes Commonly Used for Grafting


Procedures in Rhinoplasty
CPT Code
20900
20902
20910
20912
21210
21230
21235

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)

This information prepared by Dr. Raymond Janevicius is intended to


provide coding guidance.

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

REFERENCES
1. Constantian MB. Functional effects of alar cartilage malposition. Ann Plast Surg. 1993;30:487499.
2. Tardy M. Dynamics of rhinoplasty. In: Tardy ME Jr, ed.
Rhinoplasty: The Art and the Science. Philadelphia: Saunders;
1997:188276.
3. Sheen JH. Spreader graft: A method of reconstructing the
roof of the middle nasal vault following rhinoplasty. Plast
Reconstr Surg. 1984;73:230239.
4. Kridel RW. Grafts and implants in revision rhinoplasty. Facial
Plast Surg Clin North Am. 1995;3:473486.
5. Costantino PD, Friedman CD, Lane A. Synthetic biomaterials
in facial plastic and reconstructive surgery. Facial Plast Surg.
1993;9:115.
6. Cardenas-Camarena L, Guerrero MT. Use of cartilaginous
autografts in nasal surgery: 8 years of experience. Plast Reconstr Surg. 1999;103:10031014.
7. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: Dorsal
onlay grafting using shaped autogenous septal cartilage. Plast
Reconstr Surg. 1990;86:3945.
8. Ortiz-Monasterio F, Olmedo A, Oscoy LO. The use of cartilage grafts in primary aesthetic rhinoplasty. Plast Reconstr
Surg. 1981;67:597605.
9. Tardy ME Jr, Denneny J III, Fritsch MH. The versatile
cartilage autograft in reconstruction of the nose and face.
Laryngoscope 1985;95:523533.
10. Toriumi DM. Autogenous grafts are worth the extra time.
Arch Otolaryngol Head Neck Surg. 2000;126:562564.
11. Vuyk HD, Adamson PA. Biomaterials in rhinoplasty. Clin
Otolaryngol Allied Sci. 1998;23:209217.
12. Brent B. The versatile cartilage autograft: Current trends in
clinical transplantation. Clin Plast Surg. 1979;6:163180.

47e

Plastic and Reconstructive Surgery February 2010


13. Adamson PA. Grafts in rhinoplasty: Autogenous grafts are
superior to alloplastic. Arch Otolaryngol Head Neck Surg. 2000;
126:561562.
14. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft:
Correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002;109:24952505; discussion
25062508.
15. Arslan E, Majka C, Beden V. Combined use of triple cartilage
grafts in secondary rhinoplasty. J Plast Reconstr Aesthet Surg.
2007;60:171179.
16. Ballert JA, Park SS. Functional rhinoplasty: Treatment of the
dysfunctional nasal sidewall. Facial Plast Surg. 2006;22:4954.
17. Cardenas-Camarena L, Gomez RB, Guerrero MT, Solis M,
Guerrerosantos J. Cartilaginous behavior in nasal surgery: A
comparative observational study. Ann Plast Surg. 1998;40:3438.
18. Cochran CS, Ducic Y, DeFatta RJ. Restorative rhinoplasty in
the aging patient. Laryngoscope 2007;117:803807.
19. Guyuron B, Ghavami A, Wishnek SM. Components of the
short nostril. Plast Reconstr Surg. 2005;116:15171524.
20. Murrell GL. Auricular cartilage grafts and nasal surgery.
Laryngoscope 2004;114:20922102.
21. Naficy S, Baker SR. Lengthening the short nose. Arch Otolaryngol Head Neck Surg. 1998;124:809813.
22. Otley CC. Alar batten cartilage grafting. Dermatol Surg. 2000;
26:969972.
23. Pastorek NJ, Bustillo A, Murphy MR, Becker DG. The extended columellar strut-tip graft. Arch Facial Plast Surg. 2005;
7:176184.
24. Pontius AT, Williams EF III. Endonasal placement of
spreader grafts in rhinoplasty. Ear Nose Throat J. 2005;84:
135136.
25. Sheen JH. Tip graft: A 20-year retrospective. Plast Reconstr
Surg. 1993;91:4863.
26. Lovice DB, Mingrone MD, Toriumi DM. Grafts and implants
in rhinoplasty and nasal reconstruction. Otolaryngol Clin North
Am. 1999;32:113141.
27. Rohrich RJ, Hollier LH. Use of spreader grafts in the external
approach to rhinoplasty. Clin Plast Surg. 1996;23:255262.
28. Bateman N, Jones NS. Retrospective review of augmentation
rhinoplasties using autologous cartilage grafts. J Otolaryngol
Otol. 2000;114:514518.
29. Staffel G, Shockley W. Nasal implants. Otolaryngol Clin North
Am. 1995;28:295308.
30. Donald PJ. Cartilage grafting in facial reconstruction with
special consideration of irradiated grafts. Laryngoscope 1986;
96:786807.
31. Holmes RE, Hagler HK. Porous hydroxyapatite as a bone graft
substitute in cranial reconstruction: A histometric study. Plast
Reconstr Surg. 1988;81:662671.
32. Bujia J, Wilmes E, Hammer C, Kastenbauer E. Class II antigenicity of human cartilage: Relevance to the use of homologous cartilage graft for reconstructive surgery. Ann Plast
Surg. 1991;26:541543.
33. Fry H. Cartilage and cartilage grafts: The basic properties of
the tissue and the components responsible for them. Plast
Reconstr Surg. 1967;40:526539.
34. Bujia J. Determination of the viability of crushed cartilage
grafts: Clinical implications for wound healing in nasal surgery. Ann Plast Surg. 1994;32:261265.
35. Erol OO. The Turkish delight: A pliable graft for rhinoplasty.
Plast Reconstr Surg. 2000;105:22292241; discussion 22422243.
36. Rohrich RJ, Muzaffar AR. The Turkish delight: A pliable graft
for rhinoplasty. Plast Reconstr Surg. 2000;105:22422243.
37. Gruber RP, Pardun J, Wall S. Grafting the nasal dorsum with
tandem ear cartilage. Plast Reconstr Surg. 2003;112:11101122;
discussion 11231124.

48e

38. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty


surgery. Plast Reconstr Surg. 2004;113:21562171.
39. Brenner KA, McConnell MP, Evans GR, Calvert JW. Survival
of diced cartilage grafts: An experimental study. Plast Reconstr
Surg. 2006;117:105115.
40. Daniel RK. Rhinoplasty: Septal saddle nose deformity and composite reconstruction. Plast Reconstr Surg. 2007;119:10291043.
41. McKinney P. An aesthetic dorsum: The CATS graft. Cartilaginous autogenous thin septal. Clin Plast Surg. 1996;23:
233244.
42. Allcroft RA, Friedman CD, Quatela VC. Cartilage grafts for
head and neck augmentation and reconstruction: Autografts
and homografts. Otolaryngol Clin North Am. 1994;27:6980.
43. Beeson WH. The nasal septum. Otolaryngol Clin North Am.
1987;20:743767.
44. Mowlavi A, Masouem S, Kalkanis J, Guyuron B. Septal cartilage defined: Implications for nasal dynamics and rhinoplasty. Plast Reconstr Surg. 2006;117:21712174.
45. Collawn SS, Fix RJ, Moore JR, Vasconez LO. Nasal cartilage
grafts: More than a decade of experience. Plast Reconstr Surg.
1997;100:15471552.
46. Parker P. Grafts in rhinoplasty: Alloplastic vs. autogenous.
Arch Otolaryngol Head Neck Surg. 2000;126:558561.
47. Brent B, Ott R. Perichondro-cutaneous graft. Plast Reconstr
Surg. 1978;62:114.
48. Daniel RK. Rhinoplasty and rib grafts: Evolving a flexible
operative technique. Plast Reconstr Surg. 1994;94:597609;
discussion 610611.
49. Gunter JP, Clark CP, Friedman RM. Internal stabilization of
autogenous rib cartilage grafts in rhinoplasty: A barrier to
cartilage warping. Plast Reconstr Surg. 1997;100:161169.
50. Gunter JP, Rohrich RJ. External approach for secondary
rhinoplasty. Plast Reconstr Surg. 1987;80:161174.
51. Sherris DA, Kern EB. The versatile autogenous rib graft in
septorhinoplasty. Am J Rhinol. 1998;12:221227.
52. Agaoglu G, Erol OO. In situ split costal cartilage graft harvesting through a small incision using a gouge. Plast Reconstr
Surg. 2000;106:932935; discussion 936937.
53. Maas CS, Monhian N, Shah SB. Implants in rhinoplasty.
Facial Plast Surg. 1997;13:279290.
54. Gibson T, Davis WB. The distortion of autogenous cartilage
grafts: Its cause and prevention. Br J Plast Surg. 1958;10:257274.
55. Mowlem R. Bone (iliac) and cartilage transplants to ear and
nose: Their use and behaviour. Br J Plast Surg. 1941;29:182.
56. Adams WP Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JB
Jr. The rate of warping in irradiated and nonirradiated homograft rib cartilage: A controlled comparison and clinical
implications. Plast Reconstr Surg. 1999;103:265270.
57. Harris S, Pan Y, Peterson R, Stal S, Spira M. Cartilage warping: An experimental model. Plast Reconstr Surg. 1993;92:
912915.
58. Sajjadian A, Gordon C. Cartilage lamination in reconstructive rhinoplasty. (Manuscript in preparation).
59. Ohara K, Nakamura K, Ohta E. Chest wall deformities and
thoracic scoliosis after costal cartilage graft harvesting. Plast
Reconstr Surg. 1997;99:10301036.
60. Kobayashi S, Yoza S, Takada H, Nagase T, Ohmori K. Endoscope-assisted rib cartilage harvesting. Ann Plast Surg.
1995;35:571575.
61. Kawanabe Y, Nagata S. A new method of costal cartilage harvest
for total auricular reconstruction: Part I. Avoidance and prevention of intraoperative and postoperative complications and
problems. Plast Reconstr Surg. 2006;117:20112018.
62. Skoog T, Johansson SH. New articular cartilage from transplanted perichondrium (in Swedish). Lakartidningen 1975;
72:17891792.

Volume 125, Number 2 Grafts and Implants in Rhinoplasty


63. Leach J. Interlocking calvarial bone grafts: A solution for the
short, depressed nose. Laryngoscope 2000;110:955960.
64. Citardi MJ, Friedman CD. Nonvascularized autogenous bone
grafts for craniofacial skeletal augmentation and replacement. Otolaryngol Clin North Am. 1994;27:891910.
65. Thomassin JM, Paris J, Richard-Vitton T. Management and
aesthetic results of support grafts in saddle nose surgery.
Aesthetic Plast Surg. 2001;25:332337.
66. Neu BR. Segmental bone and cartilage reconstruction of major
nasal dorsal defects. Plast Reconstr Surg. 2000;106:160170.
67. Tessier P. Aesthetic aspects of bone grafting to the face. Clin
Plast Surg. 1981;8:279301.
68. David DJ, Moore MH. Cantilever nasal bone grafting with
miniscrew fixation. Plast Reconstr Surg. 1989;83:728732.
69. Gurlek A, Askar I, Bilen BT, Aydogen H, Fariz A, Alaybeyoglu
N. The use of lower turbinate bone grafts in the treatment of
saddle nose deformities. Aesthetic Plast Surg. 2002;26:407412.
70. Hodgkinson DJ. The olecranon bone graft for nasal augmentation. Aesthetic Plast Surg. 1992;16:129132.
71. Jackson IT, Choi HY, Clay R, et al. Long-term follow-up of
cranial bone graft in dorsal nasal augmentation. Plast Reconstr
Surg. 1998;102:18691873.
72. Sarukawa S, Sugawara Y, Harii K. Cephalometric long-term
follow-up of nasal augmentation using iliac bone graft. J Craniomaxillofac Surg. 2004;32:233235.
73. Smith JD, Abramson M. Membranous vs endochondrial bone
autografts. Arch Otolaryngol. 1974;99:203205.
74. Zins JE, Whitaker LA. Membranous versus endochondral
bone: Implications for craniofacial reconstruction. Plast Reconstr Surg. 1983;72:778785.

75. Whitaker LA. Biological boundaries: A concept in facial skeletal restructuring. Clin Plast Surg. 1989;16:110.
76. Phillips JH, Rahn BA. Fixation effects on membranous and
endochondral onlay bone-graft resorption. Plast Reconstr
Surg. 1988;82:872877.
77. Tessier P. Autogenous bone grafts taken from the calvarium
for facial and cranial applications. Clin Plast Surg. 1982;9:
531538.
78. Romo T III, Jablonski RD. Nasal reconstruction using split
calvarial grafts. Otolaryngol Head Neck Surg. 1992;107:622630.
79. Parsa FD. Nasal augmentation with split calvarial grafts in
Orientals. Plast Reconstr Surg. 1991;87:245253.
80. Atkins J. Saddle nose deformity. J R Soc Med. 1979;72:846
848.
81. Dyer WK II, Beaty MM, Prabhat A. Architectural deficiencies
of the nose: Treatment of the saddle nose and short nose
deformities. Otolaryngol Clin North Am. 1999;32:89112.
82. Jackson IT, Helden G, Marx R. Skull bone grafts in maxillofacial and craniofacial surgery. J Oral Maxillofac Surg. 1986;
44:949955.
83. Powell NB, Riley RW. Cranial bone grafting in facial aesthetic
and reconstructive contouring. Arch Otolaryngol Head Neck
Surg. 1987;113:713719.
84. Wilkinson HA. Autogeneic skull bone grafts. Neurosurgery
1987;21:760.
85. Young VL, Schuster RH, Harris LW. Intracerebral hematoma
complicating split calvarial bone-graft harvesting. Plast Reconstr Surg. 1990;86:763765.
86. Endo T, Nakayama Y, Ito Y. Augmentation rhinoplasty:
Observations on 1200 cases. Plast Reconstr Surg. 1991;87:
5459.

49e

You might also like