Grafts and implants — Where to get the material and what each one does
The hierarchy of donor sites and what each cartilage can do, how a graft is prepared so it does not warp, the catalogue by function, diced cartilage and fascia, and the slippery ground of alloplastic materials.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Septal cartilage is always the first choice: strong, flexible, thin, of varying thickness by zone, and it adds strength without adding bulk.
- Each cartilage does one thing well and another badly: conchal cartilage has curvature and suits domes and dorsum, but yields no long, straight, strong pieces; costal cartilage does, but it warps.
- The skin dictates graft form: in thick skin the edges barely show; in thin skin any ridge shows through, and there the answer is crushed or diced cartilage, never a sharp edge.
- Two placement rules that avoid most problems: the pocket is tailored to the graft, and the graft is always fixed, with resorbable suture or temporary transcutaneous stitches.
- Autologous tissue is always the best implant material. Alloplasts have specific, limited indications, and permanent injectables have none at all in the nose.
Why autologous cartilage still rules
Autologous cartilage combines properties no substitute has fully matched: flexibility and firmness in the right proportion to shape the nose, absence of unwanted reaction in the local soft tissues, straightforward harvest with minimal morbidity and, above all, persistence of shape and size over years, with resorption very uncommon. That last characteristic is what separates it from almost everything else and what justifies accepting donor-site morbidity rather than turning to an inert material. In rhinoplasty it is used to provide structural support, volume, coverage or shape according to its consistency, and much of the craft lies in not confusing those four functions: a graft meant to support must be rigid and anchored; one meant to add volume must be soft and transmit no edges.
The donor sites, in order
| Source | What it gives | What it does not give |
|---|---|---|
| Septal | Straight, strong, thin pieces. Thickness varies by zone, allowing selection: the part joining the maxillary crest is thickest and yields the best spreaders | Quantity. The L-strut rule sharply limits what is available, and in secondary cases or after previous septoplasty there is usually nothing left |
| Conchal | Natural curvature, very useful to reconstruct the domal area and the dorsum. Retroauricular approach with the scar in the sulcus | Long, straight or strong pieces: it is more fragile, softer and thicker than septal. For the columella it must be doubled or rolled, with the added bulk that entails |
| Costal | Quantity and strength. The cartilaginous portion of the 8th or 9th rib is used; the cartilaginous tips of the 10th and 11th are particularly suited to columellar struts | Convenience. Greater morbidity, pain and scarring, a tendency to warp, and in older patients a degree of ossification that hampers carving |
| Alar remnants | In broad tips with large alar excess, the resected cephalic portion is autologous cartilage already curved and at hand: it serves as an interdomal graft, crossed and overlapped, sutured to domes and intermediate crura | Structure. It is a shaping resource, not a supporting one |
| Bone: perpendicular plate and hump | When no septal cartilage remains, a fragment of the perpendicular plate of the ethmoid serves for a columellar strut or to correct alar collapse. The resected bony hump can be used for mild chin or maxillary hypoplasia | Flexibility. Bone forgives no carving errors and does not conform |
Why cartilage warps, and how to avoid it
Cartilage holds internal forces in equilibrium: when it is cut, the surface retaining more perichondrium and more fibres contracts and the piece curves. This is the phenomenon Gibson and Davis described in the middle of the last century, and it still explains 90 % of costal grafts that twist. From it come the practical rules. Carving in balanced fashion, respecting the symmetry of the piece about the cartilage axis, is the first and most important. Waiting 20-30 minutes before placing it lets the warp show itself on the table rather than in the nose. In long straight pieces, a Kirschner wire inside neutralises the tendency to curve. And if the cartilage is angulated and must be thinned, resection is done on the concave surface, not the convex one: it is the fibres of that surface that hold the angulation, and removing them is what straightens it.
Preparing the graft before placing it
- CarvingShape, size and curvature must fit the defect, not the other way round. A cartilage slicer helps achieve uniform thickness — of the order of 1.5 mm for spreaders
- EdgesBevelling or thinning the edges is what stops them showing under the skin. In thin skin bevelling is not enough: crush it
- CurvatureScoring incisions on the surface to straighten, or to create a controlled curve. They are made on the side to be lengthened
- PocketWhenever possible, limited and tailored to the graft dimensions. A wide pocket means a graft that will move
- FixationInternal with 5/0 or 6/0 resorbable suture, or external with 4/0 monofilament transcutaneous stitches left untied and removed at 2-3 days
The catalogue, by what each one does
| Graft | Function | Practical detail |
|---|---|---|
| Spreader | Opens the internal valve and closes the open roof | About 25 × 2.5 mm, 1.5 mm thick, from the thickest part of the septum. The stiffer one on the deviated side |
| Columellar strut | Unifies the tip complex and shapes and stiffens the columella | Of the order of 30 × 3 mm. Fixed only to the medial crura: on its own it controls neither projection nor rotation |
| Caudal septal extension | Controls projection and rotation with real support | Sutured in continuity with the septum and reinforced with two mini-spreaders in the columellar zone. It can be carved over a plastic template to get the shape right |
| Alar batten | Corrects external valve collapse and alar retraction with excessive nostril show | 10 × 2 mm from septum or concha, in a subcutaneous pocket. In moderate retraction it is sutured only to skin; in severe depression, to the alar cephalically and to skin caudally. If too long it deforms the tip: trim the cephalic end |
| Alar contour graft | Prevents and corrects alar rim retraction and the pinched look | A thin strip in a pocket just below the rim, not anchored to the alar cartilage. It is a cheap preventive graft: placed before the problem appears |
| Tip definition grafts (shield and derivatives) | They add definition and light reflex to the tip | Placed at the end, before closure. In thin skin, use crushed cartilage or cover it with perichondrium. And the golden rule: if in doubt about the effect, remove it |
Rib harvest, step by step
- An inframammary incision, hiding the scar in the fold. About 4-5 cm of cartilage are needed.
- Skin and subcutaneous tissue are crossed to the rectus abdominis fascia, which is worth keeping: it is excellent coverage material for the dorsum.
- The muscle fibres are split vertically, following their anatomy, not divided transversely.
- Cartilage dissection is subperiosteal, and the periosteum can also be collected. Incise both ends of the segment and elevate in that plane.
- Layered closure. It is worth checking for pneumothorax before closing, filling the field with saline and asking for a sustained inspiration.
Diced, crushed and wrapped cartilage
When what is needed is volume rather than structure, cartilage can be diced into fragments under 1 mm and used as a mouldable filler. It is the solution for the irregular dorsum, the low radix and middle-third depressions, and it avoids the classic problem of the block graft: the visible edge. Loose dice tend to scatter, so they are wrapped: the original wrapping was alloplastic, but it was soon replaced by deep temporal or rectus abdominis fascia, which is autologous, provokes no reaction and lets the whole be shaped as a cylinder placed and adjusted with the fingers. In the same vein is the chondroplatelet graft, which uses the remaining cartilage fragments mixed with platelet-rich plasma so that the clot holds them together: it is especially useful in secondary cases with little material available. And for very thin skin the most elegant resource remains perichondrium — from the septum itself, though harvesting it is not easy, or from conchal or costal cartilage — laid as a protective layer over the worked structures.
Soft tissues: fascia, fat and composite grafts
- Fascia and aponeurosis — from SMAS, temporalis or fascia lata — resorb minimally and serve for pyramidal sequelae, above all in skin adhesions with deteriorated skin quality. Their drawback is cicatricial retraction, which can produce irregularities.
- The composite chondrocutaneous graft from the anterior conchal surface provides stiffness and coverage at once: it is the answer to severe alar retraction and to part of nasal reconstruction. The donor site can be closed with a retroauricular skin graft.
- Fat — as a block, dermofat or lipograft — adds volume where soft tissue is lacking, especially with depressed scars and damaged skin. The technical key is to distribute it in multiple fine tunnels at different levels, avoiding deposits over 2-3 mm, which necrose centrally.
- Platelet-rich plasma plays three distinct roles here: a protective clot over the dorsal structures in very thin skin, an adhesive for crushed grafts, and a fibrolytic agent injected intradermally in secondary cases with retracted skin.
Implants: where the line is
The reasonable position is clear: autologous tissue is always considered first, and alloplast is indicated only when no autologous material is available or when harvesting it would be more invasive without improving the result. On that condition there are legitimate indications: to correct bony structures such as maxilla or chin, solid silicone prostheses or expanded polytetrafluoroethylene sheets are frequently used, both permanent and easy to remove; in maxillary hypoplasia, which limits the rhinoplasty result because it leaves the tip with low foundations, a triangular sheet under the alae, introduced through the transfixion incision or the labial frenulum, solves the problem with little trauma. For small soft-tissue defects and irregularities, resorbable fillers — hyaluronic acid, hydroxyapatite — have a place, and sometimes their real purpose is not to fill but to stretch the cicatricial fibrosis tethering skin to bone and creating the optical effect of a deviated nose. Where there is no reasonable debate is over permanent or non-resorbable injectables: displacement, infection, foreign-body reaction, fibrosis, granulomas with breakdown of the skin envelope. They have no indication in the nose.
Where do I get the cartilage from
Is septal cartilage available after respecting the L-strut?
Is structural support needed, or shape and volume?
References
- 1.Arquero P. Injertos. rinoplastia.eu.
- 2.Arquero P. Implantes. rinoplastia.eu.
- 3.Gibson T, Davis WB. The distortion of autogenous cartilage grafts: its cause and prevention. Br J Plast Surg. 1957;10:257-274.
- 4.Daniel RK. Diced cartilage grafts in rhinoplasty surgery: current techniques and applications. Plast Reconstr Surg. 2008;122(6):1883-1891.
- 5.Erol ÖO. The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr Surg. 2000;105(6):2229-2241.
- 6.Toriumi DM, Josen J, Weinberger M, Tardy ME. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123(8):802-808.
- 7.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(7):2495-2505.
- 8.Kridel RWH, Ashoori F, Liu ES, Hart CG. Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose. Arch Facial Plast Surg. 2009;11(6):378-394.
- 9.Byrd HS, Andochick S, Copit S, Walton KG. Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg. 1997;100(4):999-1010.
- 10.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer; 2018.
Related specialty: Rhinoplasty