CME

Current Status of Grafts and Implants inRhinoplasty: 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 ableto: 1. Understand the challenges in restoring volume and structural integrity inrhinoplasty. 2. Identify the appropriate uses of various autografts in aesthetic andreconstructive rhinoplasty (septal cartilage, auricular cartilage, costal cartilage,calvarial and nasal bone, and olecranon process of the ulna). 3. Identify theadvantages and disadvantages of each of these autografts.Summary: This review specifically addresses the use of autologous grafts inrhinoplasty. Autologous materials remain the preferred graft material for use inrhinoplasty because of their high biocompatibility and low risk of infection andextrusion. However, these advantages should be counterbalanced with the con-cerns of donor-site morbidity, graft availability, and graft resorption. (Plast.Reconstr. Surg. 125: 40e, 2010.)

Rhinoplasty outcomes can be improved sig-nificantly by the use of different maneuversand biomaterials. The two central issues of

inadequate structural integrity and volume can berestored using a variety of grafts and implants.Over the past 10 to 15 years, the paradigm hasshifted from overaggressive and reductive rhino-plasty to greater use of augmentation.1,2 Conse-quently, the use of grafts and implants has alsoincreased with this change. The choice of the im-plant and graft used during rhinoplasty remainsan area of continuous debate and controversy.

In a nose that has been operated on previ-ously, excessive resection of the septum and upperand lower lateral cartilages leads to loss ofsupport.3 Significant loss of the structural frame-work following rhinoplasty can result in skin andsoft-tissue shrinkage and volume deficiency. Inad-equate dorsal height can be caused by injudiciousresection of the osteocartilaginous dorsum. In ad-dition, loss of nasal tip projection, rotation, andnasal length may be secondary to loss of adequatetissue support and the dynamics of healing. Irreg-ularities of the nasal tip and dorsal contour andalar retraction are frequently caused by excessiveand asymmetric loss of nasal framework.4,5 Simi-larly, the function of the internal and/or external

nasal valves can be compromised by overaggressiveresection of upper and/or lower lateral cartilages.These complications and misadventures result indifficult reconstructive challenges at the time ofsecondary or tertiary rhinoplasty, often requiringthe carefully planned use of a variety of grafts andimplants to address specific functional and cos-metic issues. Grafts and implants can be used tominimize the effects of overreduction, addressopen roof deformities, camouflage contour irreg-ularities, and correct airway compromise causedby a collapsed cartilaginous vault and nasal valves.

There are various grafts and implants availableto the rhinoplastic surgeon that can be used torestore the volume and structural integrity of thenose. The available biomaterials can be dividedinto two broad categories: autografts, which arederived from the patient and include cartilage,bone, fascia, and dermis; and homografts, whichare derived from tissues donated by members ofthe same species and include irradiated cartilageand acellular dermis. Alloplastic implants are syn-thetic implants (biocompatible polymers) with avariety of applications in plastic surgery.

This review specifically addresses the use ofautologous grafts in rhinoplasty, without specificrecommendations. However, description of spe-cific surgical techniques is beyond the scope of thisreview. Autologous grafts have relatively high bio-

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

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

www.PRSJournal.com40e

compatibility and low risk of infection and extru-sion as compared with homografts and alloplasticimplants. Although autologous grafts remain thepreferred material for use in rhinoplasty, theiradvantages should be counterbalanced with theconcerns of donor-site morbidity, graft availability,and graft resorption.

CHOICES OF AUTOGRAFTSeptal Cartilage

Septal cartilage is generally considered thebest material for correction of nasal deformities inrevision rhinoplasty patients (Table 1).3,6–25 Typi-cal uses for septal cartilage include dorsal grafts,struts, batten grafts, lateral crural grafts, lateral cru-ral strut grafts, spreader grafts, and tip grafts to in-crease projection, length, or definition to the nasaltip (Figs. 1 through 4).14,26,27 Septal cartilage can beeasily harvested during rhinoplasty regardless ofthe approach and without the need for additionalincisions. Septal cartilage is generally straight, pro-viding strong structural support, and has resiliencyproperties similar to those of the native nasal car-tilaginous framework.8 Furthermore, it offers easymanipulation.28 It can be contoured and carved tofit a precise pocket or sutured in an exact location.As with most autogenous cartilage grafts in thenose, clinically significant resorption and infec-tion are uncommon.8,29 In comparison with otherautografts, septal cartilage grafts exhibit fewer dis-advantages with regard to extrusion, resorption,

infection, or warping. Although the septal carti-lage graft resorption rate has been reported torange from 12 to 50 percent,12 this resorption ismost often clinically imperceptible secondary toreplacement by fibrous tissue.6,30,31 The long-termstability has also been shown in animal models,and this is thought to be secondary to the non-immunogenicity of this autograft and its incorpo-ration into surrounding tissues.30,32 Cartilage hasbeen shown to retain water and develop swelling

Table 1. Graft Sources and Their Use

Graft UsePreferred Graft

Source Other Options

Onlay graft Septal cartilage Costal cartilage, auricularcartilages, temporalisfascia, calvarial bonegraft

Strut graft Septal cartilage Auricular cartilage, costalcartilage, ethmoidbone

Batten graft Auricular cartilage,septal cartilage

Spreadergraft

Septal cartilage Resected dorsal cartilage,auricular cartilage,vomer

Tip grafts Septal cartilage,auricularcartilage

Costal cartilage, lateralcrura (resectedcephalic portionof LLC)

Buttressgraft

Septal cartilagewith bonesuch as ethmoidor vomer

Costal cartilage

Alar graft Septal cartilage,auricularcartilage

Costal cartilage

LLC, lower lateral cartilage.

Fig. 1. Cartilaginous septum harvested and fashioned to form acolumellar strut, which is being sutured between the medial crura.

Fig. 2. Bilateral asymmetric spreader grafts in situ harvestedand fashioned from septal cartilage. This patient had significantdeviation and asymmetry of the middle nasal vault, which wascorrected utilizing septoplasty, cartilage scoring, and direct mat-tress suturing of the septal cartilage as well as asymmetric place-ment of spreader grafts.

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pressure.33 However, provided that the surfacesare not unilaterally scored or cut, septal cartilagewill not warp or curl, and it can be easily sculptedor very lightly crushed to improve flexibility with-out risking cell loss.11 Known determinants of car-tilage graft resorption include implantation in ar-eas subjected to high tensile forces, exposure tomuscular activity, and crushing during prepara-tion of the graft.34 A large study with over 2000autologous septal cartilage grafts and 17 years ofexperience demonstrated no incidence of rejec-tion or loss caused by infection.9 Reported com-plications were infrequent, preventable, and at-tributable to surgical error rather than graftproperties. It was demonstrated that complica-tions declined with increasing operator experi-

Fig. 4. (Left) Preoperative and (right) 9-month postoperative views of a patient who underwent primaryrhinoplasty in which bilateral spreader, collumellar strut, shield, cap, and alar rim grafts were used.

Fig. 3. Bilateral spreader grafts in situ, stabilized with 25-gaugeneedles before placement of horizontal mattress sutures.

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ence in graft contouring, fashioning, and hostpocket preparation.9

To obtain a smoother appearance when aug-menting or recontouring along the radix, dorsum,tip, or lateral sidewall, septal cartilage has beendiced and placed within a blanket of oxidizedregenerated cellulose (Surgicel; Johnson & John-son Medical, New Brunswick, N.J.).35,36 The oxi-dized regenerated cellulose (Surgicel) has notbeen shown to cause cartilage proliferation, butinstead results in an increase in collagen formation,leading to favorable contours. Alternatively, cephalictrim grafts have been used to fill minor defects andaddress irregularities of the nasal dorsum.37 It hasbeen suggested that diced cartilage wrapped in fas-cia is superior to Surgicel-wrapped diced cartilagein addressing various deformities (Fig. 5).38 Thisobservation was supported by histologic evidencethat fascial wraps (particularly temporalis fascia)allow for greater preservation of healthycartilage.39 In addition, tip definition or projec-tion can be achieved through the addition of anonlay or shield-shaped tip graft, followed by dorsal

augmentation over the cartilaginous vault withdiced cartilage or diced cartilage wrapped infascia.40 The reader is encouraged to pursue fur-ther information regarding tip grafting, as it is notcovered in detail in this review. Filing the grafts tolower their profile has also been shown to improvecontour and decrease visibility.41 Moreover, green-stick-fracturing dorsal onlay grafts can produce asofter, more natural appearance by correcting in-verted-V or inverted-U configurations.7

Septal cartilage is most often used as a freegraft but may also be rotated on a mucoperichon-drial pedicle for reconstruction of the nasal alae.42

Septal cartilage is readily obtained by the surgeonby submucous resection12 or septoplasty and maybe harvested through whichever surgical ap-proach (e.g., Killian, dorsal, hemitransfixion orfull transfixion, intranasal posterior approach)the surgeon feels is most suitable to the particularcase. If an external rhinoplasty approach is un-dertaken, the septal cartilage may be harvestedfrom above, by separating the medial crura of thelower lateral cartilages and the upper lateral car-

Fig. 5. (Above) Harvesting of temporalis fascia. (Below, left) Harvestedtemporalis fascia. (Below, right) A temporalis fascia graft is used to wrapsmall fragments of minced cartilage to form a pliable, soft graft for radixaugmentation.

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tilages, or by means of a standard septoplastyapproach, with a transfixion or hemitransfixionincision.7 With an internal approach, the septal car-tilage is exposed by elevation of a mucoperichon-drial flap, which is facilitated by generous hydraulicinfiltration of local anesthetic within the subperi-chondrial plane.9 The quadrangular cartilage artic-ulates with the upper lateral cartilages, bone, vomer,and perpendicular plate of the ethmoid.43,44 Thequadrangular cartilage can be freed bluntly from themaxillary crest inferiorly and disarticulated from thebony septum posteriorly at its junctions with thevomer and perpendicular plate of the ethmoidbone. Alternatively, the anterior portion of the per-pendicular plate of the ethmoid can be removedattached to the quadrangular cartilage if separationof the two is difficult inside the nose.7

The main disadvantage of using shaped autog-enous grafts using septal cartilage is the limitedamount of cartilage that is available and that can beharvested safely from the nasal septum. Generally, aminimum of a 1-cm dorsal-caudal L-shaped strutshould remain to prevent collapse.4 Some sur-geons have taken more conservative amounts ofcartilage, leaving dorsal and caudal septal struts of15 mm,10,11 whereas others are more aggressive,leaving only 8 mm for adequate support.7,42 Theseptal cartilage thickens posteriorly, and this char-acteristic is useful when designing support strutsor tip grafts that are ideally fashioned from thethickest portions of the cartilage (Figs. 6 and 7).42

Furthermore, fashioning the graft in a patientwhose septum is severely deviated is sometimesvery difficult because of the existent memory andangulation of the raw septal cartilage.7

Auricular/Conchal CartilageConchal cartilage has proven indispensable as

an aid in secondary or reconstructive rhinoplasty,when prior harvest, trauma, genetics, or infectiousprocesses have rendered the nasal framework de-ficient and the septal cartilage unavailable to thesurgeon.9,12,14 Conchal cartilage is considered thegraft of choice for most nonstructural applicationswhen septal cartilage is inadequate or unavailable(Fig. 8).4,8,10–12,42,45 The cartilage is pliable yet re-silient, and its natural contours allow for a varietyof cartilage shapes.12 Auricular cartilage is of the“elastic hyaline” histologic type (type 4), exhibit-

Fig. 6. Intraoperative view of a shield tip graft and a cap graftfashioned from harvested septum.

Fig. 7. Intraoperative view of alar batten graft harvested fromconcha in a tertiary rhinoplasty patient who did not have anyavailable septum to be harvested.

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

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ing a fixed “genetically sculpted” configuration,which renders it structurally most similar to thelateral nasal cartilages and the external nasalvalve.30 Indeed, this natural convolution may bedisadvantageous in some instances as well.

By suturing layers of bruised auricular cartilageinto a multilaminar structure, restoration of signif-icant nasal dorsal defects and irregularities, includ-ing the saddle-nose deformity, can be achieved.Conchal cartilage is typically more brittle thanseptal cartilage, making it more difficult to carveprecisely.9,42 However, it is characteristically lessrigid than septal cartilage and therefore is mostappropriately used as an onlay for contour im-provement, particularly in the nasal tip region.10

As such, conchal cartilage is generally consideredinferior to septum or rib cartilage with respect tostructural support. Auricular cartilage has beenassociated with occasional warping or even defor-mation associated with ongoing scar contracture.However, experienced surgeons estimate that thisoccurs in less than 5 percent of cases, usually re-quiring a minor revision procedure.

Grafts can be harvested easily under local an-esthesia, and a significant portion of the concha(including both the cymba conchae and the ca-vum conchae) can be removed without riskingdonor-site deformity. Complete conchal cartilageexcision may cause slight medialization of thepinna; thus, the more protrusive ear should beused as the donor.10 However, leaving a segmentof the posterior conchal wall will avoid any medi-alization and should be the preferred method forthe less experienced surgeon. Patients with colla-gen vascular diseases and certain immunologicdiseases such as lupus, and those predisposed tokeloid formation, are poor candidates because ofthe likelihood of postoperative deformity.10 Ap-proximately 5 cm of cartilage, with perichon-drium, can be relied on per ear.10 Removal of thegraft perichondrium, particularly when auricularcartilage is to be used in dorsal augmentation, hasbeen recommended to minimize the chances ofwarping.46 Others suggest that its preservation fa-cilitates earlier fibrosis and graft stabilization inthe host bed.9,11 Free perichondrium has beenused as a camouflaging graft to soften the appear-ance of the nasal tip structures and can be used fornasal tip and septal perforation repair.47 The con-chal cartilage is thickest at the cymba concha, andsupport grafts such as columellar struts should beharvested from this portion.4 There is significantvariation in cartilage size and thickness among in-dividuals, and thorough examination of potentialdonor sites is crucial to preoperative planning.11

Costal CartilageAlthough autogenous septal cartilage is gen-

erally preferred for use in the primary correctionof mild deficiencies in the projection of the nasaltip and dorsum, often there is an insufficient sup-ply for more severe deformities or the supply isunavailable in cases of graft-depleted revision rhi-noplasty. In such cases where alternatives to septaland conchal cartilage grafts are needed, autoge-nous rib cartilage may be the graft material ofchoice.48–51

Costal cartilage is available in abundance, un-dergoes minimal postoperative resorption whennot morselized or crushed excessively,9 and isrelatively easy to carve.49 Grafts can be harvestedsimultaneously during rhinoplasty exposure bya second surgeon, minimizing operative time.51

Costal cartilage can be refrigerated, carved me-ticulously at the surgeon’s leisure, and trans-planted within several days with good long-termviability.12 Both abundant and versatile, costalcartilage can supply the plastic surgeon withample cartilage for essentially any structural de-ficiency of the nose.12,26,49,51

Costal cartilage is often overlooked whengrafting materials are sought because of its per-ceived disadvantages, the foremost of which is un-predictable warping, which could jeopardize theaesthetic result in a dorsal graft and necessitaterevision.12,52,53 Gibson’s principles of balancedcross-sectional carving along the long axis of thecartilage have been used conscientiously by sur-geons who wish to prevent warping.54 Typically,this involves symmetrical removal from both sidesand using only the central part of the cartilage forreconstruction or augmentation, particularly ofmidline nasal structures.9,11,48,51 Previous strategiesincluded allowing the graft to warp to completionin water or an abdominal pocket for 3 monthsbefore use in recontouring.55 More recent in vitrostudies have shown full distortion of cartilagegrafts within 15 to 30 minutes of carving,49,56,57 butthe clinical setting is less predictable, with casereports of noticeable warping of grafts up to 9months postoperatively.54 Gibsonian balancedcarving with 15 minutes allowed for maximalwarping has also been advocated.51 In his seriesof 40 costal cartilage grafts for nasal reconstruc-tion in 14 patients followed for an average of 12months, there were no instances of postopera-tive graft warping.

Internal rigid stabilization of the cartilagegraft with alloplastic support has been anotherstrategy to prevent warping. Gunter et al. de-

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scribed placement of a longitudinally threadedKirschner wire within dorsal onlay grafts or colu-mellar struts. In vitro data and a corroborating clin-ical application in 28 patients showed no warpingover 13.5 months.49 In addition, the costal cartilagecan be laminated together in opposite directionsand secured with suturing or with a very smallamount of cyanoacrylate to prevent warping.58

Costal cartilage autografts also have the disad-vantage of significant donor-site morbidity,11 includ-ing iatrogenic pneumothorax, chest wall deformitiescaused by unpredictable scarring, persistent postop-erative pain, longer anesthesia times, and incisionaldehiscence or infection.52,54,59 In a study with 14 pa-tients receiving 40 grafts from 20 autogenous ribsharvested during septorhinoplasty, there was onepleural tear and one donor wound dehiscence,with the author suggesting that complications as-sociated with harvesting costal cartilage are both sur-geon and technique dependent.51 To further min-imize donor-site morbidity, several authors havedescribed short incisions (2 to 3.5 cm in the nono-bese patient) facilitated by the use of differentialretraction9,51 or even endoscopic techniques forgraft harvest.60 Use of a method where costal carti-lages are harvested en bloc with the perichondriumleft completely intact at the donor site, with remain-ing costal cartilage cut into small blocks to fill thedead space formed in the perichondrial pocket, hasbeen reported, with no chest wall deformities anddecreased intraoperative complications.61

It should be noted that costal cartilage should beused with caution in the older patient, as progressivecalcification renders it less likely to warp but moredifficult to sculpt in many cases.9,12,42 Perichon-drium should be excluded meticulously fromgrafts because of its chondrogenic potential,62

which may distort the graft and jeopardize cos-mesis. Importantly, careful dissection and prepa-ration of the vascular pocket to limit tension andmovement of the inset graft is thought to preventwarping and resorption.12

Bone Grafts: Calvarial and Olecranon ProcessThe forces of scarring in the healing nose with

severe deformity tend to overwhelm any type ofreconstruction that is not rigid or semirigid. Thus,a reconstructive strategy should aim to providestabilization of the tip and dorsum until contrac-tion has abated.63 Bone grafting is a good optionbecause it provides good stability, is available inabundance for any nasal application, and pro-duces reliable aesthetic results. However, whereascartilage is indifferent to functional stress for its

survival, bone grafts implanted in low-stress sitesmay resorb over time, with concomitant reversal ofthe augmentation effect.64,65 For example, eth-moid has been abandoned as a tip graft becauseof its lack of long-term survival. However, its utilityas a buttress graft supporting primary grafts hasbecome evident.25 Other disadvantages of bonegrafting include the possibility of an unnaturalfeel and the potential for significant donor-sitepain and other harvest-related morbidity.26,66,67

Various bone graft donor sites have been usedreliably in nasal reconstruction and dorsal augmen-tation, including iliac crest, calvaria, mastoid bone,ulna, rib, and nasal hump implants.68–74 Regardlessof the source of the bone graft used in nasal recon-struction, time-honored principles of bone graft sur-vival are felt to apply in the nose, including the notionthat increasedgraft-to-recipientbonecontact improvesgraft volume conservation,75 and that rigid fixation ofthe graft is associated with decreased resorption andimproved longevity of the aesthetic result.76

Split calvarial bone has emerged as a preferredgraft in recent nasal reconstruction literature be-cause of its superior strength, lower resorptionrate, and low donor-site morbidity.11,70,77,78 Calvar-ial bone has been shown to have a lower resorptionrate than iliac crests (13.5 percent versus 0 percentwith 5-year follow-up).65 The need for intact peri-osteum to retain volume is uncertain in thissituation.79 Because of its strength, calvarial bonecan be thinned to 1 mm and arranged in a hinged,interlocking fashion with an L-configuration forsupport of both dorsal contour (dorsal graft) andtip projection (columellar graft).63,78 The olecra-non process has a uniquely thick cortex (2 to 5mm), which is thought to also resist resorption (0percent resorption with 3-year follow-up).70

Harvesting of calvarial bone is well tolerated bypatients, with minimal or no postoperative discom-fort compared with the significant morbidity classi-cally associated with iliac crest resections, whichtypically lasts 2 or 3 weeks postoperatively.63,80,81 How-ever, the risk of central nervous system injury andhematoma formation, though rare, exists.79,82 Sup-porters of use of the olecranon process note thatits harvest is easy and without the threat of centralnervous system injury.82–85 Calvarial grafts are har-vested over the nondominant side of the brain inthe temporoparietal area. A contouring burr isused to cut around the graft to the level of thediploe, which is then removed carefully to exposethe inner table. The outer table surrounding thegraft is contoured with a burr, rendering the do-nor-site defect mild, wide, and inconspicuous.Bone dust can be placed into the donor defect and

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covered with oxidized regenerated cellulose (Sur-gicel) to further conceal the depression, whichbecomes less palpable 6 to 12 months followingsurgery.79

CONCLUSIONSEach of the available autografts that can be

used by the rhinoplastic surgeon has advantagesand disadvantages. The most common complica-tion associated with cartilage grafts is malposition.Other complications include resorption, extru-sion, and warping.25,86 Septal cartilage, generallyconsidered the best material for correction of na-sal deformities, has the advantage of relative easeof harvest. It has properties similar to those ofnative nasal cartilaginous framework and providesvery good structural support. However, the sur-geon is generally limited by the amount of mate-rial that can be harvested before structural insta-bility of nose results. Auricular cartilage has beenshown to be pliable and resilient, with a broadrange of available shapes that can be harvested.This has made it an excellent choice for externalnasal valve reconstruction while offering low do-nor-site morbidity. Just as the shape of the graftmay be an advantage, its potential convolutionmay be a disadvantage, as it tends to be morebrittle and offers less rigidity and support thanseptal cartilage. When the surgeon is limited bythe amount of septal or auricular cartilage that canbe harvested, costal cartilage offers the advantageof an abundant source of support material. It hasbeen shown to have long-term viability, with min-imal resorption after implantation. However, ithas also been associated with significant donor-sitemorbidity and shown to be susceptible to latewarping if specific measures are not taken to pre-vent it. Bone grafts such as those from the calvaria,nose, or olecranon process of the ulna provideexcellent structural support, are available in abun-dance, and offer reliable aesthetic results. Al-though resorption rates have been shown to bebetter in calvarial and olecranon process grafts ascompared with iliac crest grafts, the unnatural feeland possible risk of complications associated withharvesting (less so in olecranon process grafts)presents drawbacks to their use.

Clinical judgment remains the most importantdeterminant in selecting the appropriate type,size, and shape of graft used to correct nasal de-formities in revision rhinoplasty. Each materialoffers advantages that may be necessary based onthe clinical scenario and nature of the revision,augmentation, or reconstruction. Similarly, eachgraft type may have disadvantages that preclude its

use in different cases. It is important for the rhi-noplastic surgeon to be aware of such advantagesand disadvantages and the appropriate techniquesneeded to overcome some of the limitations of thegrafting method so that the optimal aesthetic andreconstructive result is achieved. Table 2 lists CPTcodes commonly used for grafting procedures inrhinoplasty.

Ali Sajjadian, M.D.496 Old Newport BoulevardNewport Beach, Calif. 92663

sajjadiana@yahoo.com

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3. Sheen JH. Spreader graft: A method of reconstructing theroof of the middle nasal vault following rhinoplasty. PlastReconstr Surg. 1984;73:230–239.

4. Kridel RW. Grafts and implants in revision rhinoplasty. FacialPlast Surg Clin North Am. 1995;3:473–486.

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6. Cardenas-Camarena L, Guerrero MT. Use of cartilaginousautografts in nasal surgery: 8 years of experience. Plast Re-constr Surg. 1999;103:1003–1014.

7. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: Dorsalonlay grafting using shaped autogenous septal cartilage. PlastReconstr Surg. 1990;86:39–45.

8. Ortiz-Monasterio F, Olmedo A, Oscoy LO. The use of car-tilage grafts in primary aesthetic rhinoplasty. Plast ReconstrSurg. 1981;67:597–605.

9. Tardy ME Jr, Denneny J III, Fritsch MH. The versatilecartilage autograft in reconstruction of the nose and face.Laryngoscope 1985;95:523–533.

10. Toriumi DM. Autogenous grafts are worth the extra time.Arch Otolaryngol Head Neck Surg. 2000;126:562–564.

11. Vuyk HD, Adamson PA. Biomaterials in rhinoplasty. ClinOtolaryngol Allied Sci. 1998;23:209–217.

12. Brent B. The versatile cartilage autograft: Current trends inclinical transplantation. Clin Plast Surg. 1979;6:163–180.

Table 2. CPT Codes Commonly Used for GraftingProcedures in Rhinoplasty

CPT Code Descriptor

20900 Bone graft, any donor area; minor or small20902 Bone graft, any donor area; major or large20910 Cartilage graft; costochondral20912 Cartilage graft; nasal septum21210 Graft, bone; nasal, maxillary or malar areas

(includes obtaining graft)21230 Graft; rib cartilage, autogenous, to face, chin,

nose or ear (includes obtaining graft)21235 Graft; ear cartilage, autogenous, to nose or ear

(includes obtaining graft)This information prepared by Dr. Raymond Janevicius is intended toprovide coding guidance.

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13. Adamson PA. Grafts in rhinoplasty: Autogenous grafts aresuperior to alloplastic. Arch Otolaryngol Head Neck Surg. 2000;126:561–562.

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15. Arslan E, Majka C, Beden V. Combined use of triple cartilagegrafts in secondary rhinoplasty. J Plast Reconstr Aesthet Surg.2007;60:171–179.

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30. Donald PJ. Cartilage grafting in facial reconstruction withspecial consideration of irradiated grafts. Laryngoscope 1986;96:786–807.

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32. Bujia J, Wilmes E, Hammer C, Kastenbauer E. Class II anti-genicity of human cartilage: Relevance to the use of homol-ogous cartilage graft for reconstructive surgery. Ann PlastSurg. 1991;26:541–543.

33. Fry H. Cartilage and cartilage grafts: The basic properties ofthe tissue and the components responsible for them. PlastReconstr Surg. 1967;40:526–539.

34. Bujia J. Determination of the viability of crushed cartilagegrafts: Clinical implications for wound healing in nasal sur-gery. Ann Plast Surg. 1994;32:261–265.

35. Erol OO. The Turkish delight: A pliable graft for rhinoplasty.Plast Reconstr Surg. 2000;105:2229–2241; discussion 2242–2243.

36. Rohrich RJ, Muzaffar AR. The Turkish delight: A pliable graftfor rhinoplasty. Plast Reconstr Surg. 2000;105:2242–2243.

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38. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplastysurgery. Plast Reconstr Surg. 2004;113:2156–2171.

39. Brenner KA, McConnell MP, Evans GR, Calvert JW. Survivalof diced cartilage grafts: An experimental study. Plast ReconstrSurg. 2006;117:105–115.

40. Daniel RK. Rhinoplasty: Septal saddle nose deformity and com-posite reconstruction. Plast Reconstr Surg. 2007;119:1029–1043.

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44. Mowlavi A, Masouem S, Kalkanis J, Guyuron B. Septal car-tilage defined: Implications for nasal dynamics and rhino-plasty. Plast Reconstr Surg. 2006;117:2171–2174.

45. Collawn SS, Fix RJ, Moore JR, Vasconez LO. Nasal cartilagegrafts: More than a decade of experience. Plast Reconstr Surg.1997;100:1547–1552.

46. Parker P. Grafts in rhinoplasty: Alloplastic vs. autogenous.Arch Otolaryngol Head Neck Surg. 2000;126:558–561.

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48. Daniel RK. Rhinoplasty and rib grafts: Evolving a flexibleoperative technique. Plast Reconstr Surg. 1994;94:597–609;discussion 610–611.

49. Gunter JP, Clark CP, Friedman RM. Internal stabilization ofautogenous rib cartilage grafts in rhinoplasty: A barrier tocartilage warping. Plast Reconstr Surg. 1997;100:161–169.

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51. Sherris DA, Kern EB. The versatile autogenous rib graft inseptorhinoplasty. Am J Rhinol. 1998;12:221–227.

52. Agaoglu G, Erol OO. In situ split costal cartilage graft har-vesting through a small incision using a gouge. Plast ReconstrSurg. 2000;106:932–935; discussion 936–937.

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56. Adams WP Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JBJr. The rate of warping in irradiated and nonirradiated ho-mograft rib cartilage: A controlled comparison and clinicalimplications. Plast Reconstr Surg. 1999;103:265–270.

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58. Sajjadian A, Gordon C. Cartilage lamination in reconstruc-tive rhinoplasty. (Manuscript in preparation).

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63. Leach J. Interlocking calvarial bone grafts: A solution for theshort, depressed nose. Laryngoscope 2000;110:955–960.

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65. Thomassin JM, Paris J, Richard-Vitton T. Management andaesthetic results of support grafts in saddle nose surgery.Aesthetic Plast Surg. 2001;25:332–337.

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