Aesthetic Surgery Journal

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Alternative Technique for Tip Support in Secondary Rhinoplasty

Alberto Echeverry, Jenny Carvajal and Elsy Medina
Aesthetic Surgery Journal 2006 26: 662
DOI: 10.1016/j.asj.2006.10.007
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Alternative Technique for Tip

Support in Secondary Rhinoplasty
COLOMBIA

Alberto Echeverry, MD; Jenny Carvajal, MD; and Elsy Medina, MD

The authors are from Medellin, Colombia. Dr. Echeverry and Dr. Carvajal are in private practice. Dr. Medina is Professor, Department of Radiology,
Universidad de Antioquia.

Background: Re-establishing nasal tip projection is one of the main objectives in secondary rhinoplasty. The columellar strut
is used as a basic element for support and the septal cartilage graft as the rst choice for reconstruction. Nevertheless, the septal cartilage is often missing in this category of patient because of previous surgery, obliging the surgeon to seek a safe, effective, and versatile alternative.
Objective: We describe a simple procedure to increase the strength of an autologous ear graft cartilage to be used as a columellar strut in patients having secondary rhinoplasty.
Methods: We removed a 3.5 1.5-cm auricular concha graft through a postauricular approach, leaving the perichondrium on
the posterior surface and trimming it on the helical crus. Later, we made a cylinder-shaped structure to be used as a columellar
strut graft in patients in whom the septum was absent. We used the open rhinoplasty technique, applying the basic principles
of secondary rhinoplasty, in all of the patients.
Results: Between February 2002 and June 2006, we used this technique in 13 patients ranging in age from 19 to 52 years who
required revision rhinoplasty. The clinical follow-up period ranged from 4 to 48 months. Five of the patients experienced
minor complications; nevertheless, all were satised with the postoperative results.
Conclusion: The auricular cartilage struts constructed using this method were strong enough to enhance tip support and projection, with satisfactory results assessed by both the patients and our team. (Aesthetic Surg J 2006;26:662668.)

evision rhinoplasty is a challenge for the surgeon,

with respect to both repair techniques and choice
of implant material to be used for augmentation
grafting1-6 The nasal tip is the area of the greatest postrhinoplasty dissatisfaction.7 Because most rhinoplasty
techniques destabilize major and minor tip-supporting
mechanisms, they create a condition of inherent weakness that sometimes results in an underprojected ptotic
nasal tip often associated with nasal valve collapse.
Consequently, re-establishing nasal tip projection is one
of the main objectives in secondary rhinoplasty.5,7-13
There are a number of grafting materials available,
each of which has its own advantages and drawbacks.1,7,14-20 In revision rhinoplasty, it is advisable to
replace missing or scarred structures with similar tissue;
if the cartilage is deficient, this structure should be
replaced with like tissue as well. It is recommended that
autogenous tissue be used whenever available for this
procedure for the following reasons: lack of immunogenicity; minimal inflammatory response; low rates of
resorption, infection, and extrusion; easy manipulation,

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carving and shaping; exibility; long-lasting results with

respect to shape and size; and finally, unlike bone or
alloplastic material, autogenous cartilage may be positioned in areas where there is little soft tissue coverage.1,2,4,13,15-18,21-24
Nasal procedures that involve structural autologous cartilage grafting include columellar strut, tip graft, alar
replacement, sidewall replacement, spreader grafts, and
caudal and dorsal septal grafts. All of these ensure adequate nasal tip support for the patient and are ideal for
correction of the underprojected ptotic tip.7,16 Since nasal
projection is principally supported by the columella, the
main reason for using the columellar strut as an integral
structural graft is to increase tip support, strength, stability,
and symmetry lost as a result of previous rhinoplasty.5,7,8,25
Autogenous septal cartilage (hyaline cartilage) is generally recognized as the ideal material for columellar struts.27,13,16,19,20,23,24,26-28 Often, patients requiring secondary
rhinoplasty have undergone septoplasty that involved sacrice of almost all of the septal cartilage. The surgeon is
then faced with the dilemma of which material to use for

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structural grafting.1-3,16,26,29 When septal cartilage is not

available, other autogenous cartilage grafts (conchal or
costal) are considered to be the most desirable materials
because they provide structural support.26-28,30
Auricular cartilage (elastic cartilage) can be used in
rhinoplasty because it is almost always available and
because it can be harvested easily with little risk of an
ear deformity.16,31 However, its use is limited because it
lacks sufcient strength, due to its elasticity. This is the
reason that it has sometimes been associated with warping or deformation with ongoing scar contracture in the
nose.2,5,7,21,22,26,28,31,32
Rib cartilage (hyaline cartilage), another choice that
has been demonstrated to provide a large amount of
structural cartilage for sculpting a collumellar strut, provides both strength and resistance to resorption. Some
drawbacks of using this material are increased pain and
transient atelectasis, hematoma, chest scar, damage of
the intracostal nerves and vessels, a possibility of pneumothorax, a tendency to warp, and lengthy operative
time.2,7,13,16,17,19,20-22,24,28,33
The elastic ear cartilage is soft and, thus, not an ideal
substitute for the structured hyaline cartilage of the septum for the columellar strut. Several possibilities have
been proposed to try to strengthen the conchal cartilage
so that it could be used as a columellar strut, including
the following: doubling the thickness by folding it over or
combining 2 pieces of cartilage; joining the cartilage with
a thin strip of perpendicular plate of ethmoid, making a
cartilage-bone combination graft26; using a 2-layered conchal cartilage graft and placing the concave sides together
to create a single pea-pod shaped graft34; applying a mattress suture nylon to the convex side of the conchal cartilage graft to straighten an abnormally curved columellar
strut graft35; and using a conchal cartilage as a butteryshaped graft.36 However, even when layered, the strut
taken from the ear is not as strong for nasal tip support
as a septal cartilage graft of the same size.26
We have applied the principles of materials resistance
engineering to overcome the inherent weakness of auricular cartilage. In materials resistance engineering, the
strength or stiffness of a material to support weight is
known as the elastic modus, and can be thought of as the
load that is required to displace or distort a homogeneous, geometrical sample.35 The intrinsic capacity of a
structural element depends on both its geometry and the
mechanical resistance and elastic modus of its material.
Let us consider the ear cartilage as a laminal structure
of thin thickness. When the lamina is positioned parallel
to the vertical axis and weight is placed on its superior

Alternative Technique for Tip Support in Secondary

Rhinoplasty

edge, the structure bends and curves (Figure 1, A and B).

This is demonstrated through the theory of columns and
by the theory of plaques and membranes. It occurs
because the strength necessary to bend the material is
much less than that which is necessary to compress (atten) the element in respect to the vertical axis. However
a curved surface has a greater weight capacity (Figure 1,
C and D). We applied this theory to form a structural
graft using ear cartilage to be used as a columellar strut
in patients requiring revision rhinoplasty.

Surgical Technique
It is important to consider the method by which cartilage grafts are harvested, carved, and placed to carry out
a successful procedure. All cartilage grafts must be collected as atraumatically as possible because small lacerations in the cartilage can alter their tensile strength and
ability to support the nose.7 Except for the lobule, the
auricle is supported by a thin elastic brocartilage that is
0.5 to 1 mm thick, and varies among individuals, determining its stiffness and exibility.1,21,31
We examined the patients ears to see if one was more
prominent than the other and, thus, a more preferred site
for harvest, while also keeping in mind the patients preferred side for sleeping. All procedures were performed
with the patient under general anesthesia using a postauricular approach. Local anesthetic (1% lidocaine with
1:100,000 epinephrine) was injected on the anterior surface of the ear into the subperichondrial plane and on the
posterior surface into the subcutaneous plane to enable
hydrodissection and to separate the skin that covers the
concha cavum and cymba from the underlying cartilage.37
Having prepared the postauricular area, a vertical incision measuring approximately 3.5 cm was made in the skin
overlying the prominence of the concha. The skin-soft tissue envelope was removed and the cymba concha and
cavum concha were exposed, leaving the perichondrium
intact, and therefore contributing to the 3-dimensional
strength of the cartilage. The anterior skin and soft tissue
were elevated in the subperichondrial plane, and the cartilage was resected, taking care to preserve an adequate
amount of cartilage along the antihelical fold (Figure 2).
(An approximately 5-mm vertical wall of the cavum concha
was left intact to avoid attening of the ear).8 After hemostasis was achieved, the incision was closed with Monocryl
4-0 (Ethicon, Johnson & Johnson, Somerville, NJ) using an
intradermal running suture, making 1 or 2 stitches in the
anterior dermis to close the dead space. A bolster dressing
of cotton dental roll or other suitable material was placed
into the concha to decrease the risk of hematoma.

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Figure 2. The anterior skin and soft tissue were elevated in the subperichondrial plane and the cartilage was resected, taking care to preserve
an adequate amount of cartilage along the antihelical fold.

Figure 1. A, B, The weight put on the superior edge of a lamina bends

and curves the structure. C, D, The curved surface has much more
strength to support the weight.

On average, an ear cartilage graft of 3.5 1.5 cm

was obtained from the auricular concha to create a columellar strut. It was sometimes necessary to trim the
helical crus, located between the cymba and cavum, to
obtain even thickness throughout the graft (Figure 3).
The cartilage graft was rolled to form a cylinder-shaped
structure and then sutured with 5-0 nylon to be used as a
strut graft and placed caudally to the septal cartilage
(Figure 4). It was our theory that rolling the conchal cartilage strengthened the cartilage, and at the same time,

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Figure 3. An ear cartilage graft of 3.5 1.5 cm was obtained from the
auricular concha to create a columellar strut.

allowed the strut graft to retain some exibility and provide more support to the tip.
Open rhinoplasty was performed in all patients using
standard techniques. Stairstep columellar and bilateral
marginal incisions were made. The strut was placed in a

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Figure 4. A, The cartilage graft was rolled to form a cylinder-shaped structure and then sutured with 5-0 nylon to be used as a strut graft and
B, placed caudally in the septal cartilage.

Figure 5. A, B, The strut was placed in a pocket between the medial crura from the nasal spine to the tip and was xated with a 6-0 nylon suture.

pocket between the medial crura from the nasal spine to

the tip, and it was xated with a 6-0 nylon suture (Figure
5). Any tip asymmetry was corrected with interdomal
and/or transdomal sutures, minimizing the need for tip
grafts. The domes were then pulled superiorly and medially into the strut, increasing nasal tip projection. The
length of the strut did not project into the skin-soft tissue, thus avoiding any external deformity

Results
Between February 2002 and June 2006, we performed
our technique on 13 patients, 6 men and 7 women, who
required revision rhinoplasty. Their ages ranged between
19 and 52 years. Twelve of the cases were secondary cos-

Alternative Technique for Tip Support in Secondary

Rhinoplasty

metic rhinoplasties and 1 was tertiary. The methods used

to assess the viability of the columellar strut were clinical
and computed tomographic follow-up during a period
ranging between 4 and 48 months (Figure 6).
The placement of the columellar strut as described corrected columellar retraction, improved the nasolabial angle,
and increased tip projection. Five of the patients experienced minor complications, including 2 cases of hematoma
at the donor site, 1 case of infection in the soft tissue of the
nasal tip, and 2 cases of slight lateral deviation of the columella. No patients complained of ear deformity, but 2
patients presented with insignicant rippling at the donor
site. It is important to note that no cases of graft resorption
or extrusion were observed in any of the cases during clini-

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Figure 6. Postoperative coronal computed tomography 6 months after

placement of a columellar strut for tip support in secondary rhinoplasty.
The tubular cartilage graft is visible as a round density under the caudal
septum (white arrow).

cal follow-up. All patients had inconspicuous scars as a

result of the ear and nose incisions. We noted that there
was minimal widening at the columellar base in almost all
cases; nevertheless, all patients were satised with the postoperative results (Figures 7 and 8).

Discussion
Columellar struts were popularized by Peck. 34,38
Placement of a columellar strut provides an approximately 40% increase in nasal tip support in the vector along
the columella,9 rendering it capable of withstanding the
compressive forces of the inherent weight of the skin-soft
tissue and the inevitability of scar contracture.9,39
Septal cartilage is usually the first choice as donor
material in nasal surgery. In situations where septum is
lacking because of a calcified septum, prior trauma,
surgery, disease, or other reasons, the patients own septum may not supply a sufcient amount of donor cartilage. Auricular cartilage grafts have become a versatile
alternative for treating such cases and have been used in
nasal surgery for more than 100 years with a low incidence of complications. 4,17,18 Contraindications for
auricular cartilage grafting include systemic diseases that
might impair wound healing or the quality/quantity of

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Figure 7. A, C, E, G, Preoperative views of a 29-year old man with an

underprojected nasal tip after 2 previous surgeries. B, D, F, H,
Postoperative views 3 years after tertiary rhinoplasty using an open
rhinoplasty technique, cephalic resection of alar cartilages, and transdomal suture through the strut of ear cartilage.

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the donor cartilage, collagen vascular disease, rheumatic

disease, lupus, polychondritis, sarcoid, Wegeners granulomatosis, predilection for keloid formation, and prior
extensive auricular cartilage graft harvesting.4
Some studies have suggested an improved resistance to
resorption of conchal cartilage grafts with perichondrium.
Histopathology analysis strongly suggests that the presence
of perichondrium enhances both survival and healing of free
cartilage grafts. Moreover, when the perichondrium is left
intact on the posterior surface of the graft during harvesting,
dissection is easier and the risk of cartilage damage is lower.
It is important to recognize that although cartilage
has chondrocytes and intercellular substances as its main
tissues, these elements differ considerably and their functions within the body are quite different. Some, like the
costal and septal cartilage, serve basically to give support, whereas others such as the auricular cartilage serve
mainly to provide contour.3,28,40
The elastic auricular concha cartilage has many chondrocytes and little intercellular substance, and is basically
made up of irregularly distributed elastic bers. The septal, costal, and alar hyaline cartilages have a considerable
amount of intercellular substance, primarily formed by
regularly distributed collagen bers whose main function
is to give tensile strength for tissue, whereas elastic bers
easily yield to tension but recover their original shape
once the tension is released.20,28,40

Conclusion

Auricular cartilage grafts are a safe, effective, and

versatile option for use as a donor material in secondary rhinoplasty. In our practice, we have obtained
satisfactory results with minimal complications by
using these grafts.

References
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Postoperative views 13 months after open rhinoplasty and placement of
ear cartilage columellar strut with mattress suture to straighten the dorsal septum and transdomal suture through the strut.

Alternative Technique for Tip Support in Secondary

Rhinoplasty

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Reprint requests: Jenny Carvajal, MD, Calle 6 sur #43-A-214, Medellin,

Colombia.
Copyright 2006 by The American Society for Aesthetic Plastic Surgery,
Inc.
1090-820X/$32.00
doi:10.1016/j.asj.2006.10.007

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