CME

Frequently Used Grafts in Rhinoplasty:

Nomenclature and Analysis
Jack P. Gunter, M.D.
Alan Landecker, M.D.
C. Spencer Cochran, M.D.
Dallas, Texas
Downloaded from https://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3mH5nK33R3QjNeko75EsYcNk/7vuYGk4QYnqFxM2Fr+o= on 08/25/2019
Learning Objectives: After studying this article, the participant should be able
to: 1. Accurately name the most frequently used grafts in primary and secondary
rhinoplasty. 2. Describe the precise anatomical position of each graft. 3. Discuss
the clinical indications of each graft.
Summary: In this article, the authors present the grafting techniques most

commonly used to sculpt the nasal framework in primary and secondary rhi-
noplasty. The grafts are described in terms of their nomenclature, anatomical
location, and clinical indications, presenting a simple and easy-to-reference
guide for both beginners and expert surgeons. (Plast. Reconstr. Surg. 118: 14e,
2006.)

I
n the last few decades, numerous grafting
techniques have been developed to sculpt the
nasal framework in primary and secondary
rhinoplasty. These techniques have originated
from the basic principle that maintenance of the
major supporting structures of the nose is fun-
damental for aesthetic and functional purposes.
Failure to maintain or furnish needed support
results in suboptimal results with deformities
that are challenging to correct.
Discussion of these grafting techniques at
meetings and in the plastic surgery literature has
greatly improved our results in modern rhino-
plasty. However, surgeons have been confused
by the significant variability related to the no-
menclature, anatomic position, and clinical in-
dications for each graft. In this article, the most
commonly utilized grafts in modern rhinoplasty
are analyzed according to the aforementioned
factors to provide a simple and easy-to-reference
rhinoplasty grafting guide for surgeons at all
levels. For the detailed surgical techniques for
these grafts, the reader is referred to the related
articles in the references.
Finally, it should be realized that this is a
generalized description of the grafts. Some-
From the Departments of Plastic Surgery and Otolaryngolo-
gy–Head and Neck Surgery, The University of Texas South-
western Medical Center at Dallas.
Received for publication August 27, 2005; accepted October
12, 2005.
Presented at the 22nd Annual Dallas Rhinoplasty Sympo-
sium, in Dallas, Texas, March 4 through 6, 2005.
Copyright ©2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000221222.15451.fc
times the shape, position, and usage may vary
depending on the situation and the desires of
the surgeon. However, we hope that this gen-
eralized information will improve the under-
standing and teaching of this fascinating oper-
ation.
METHODS
The most commonly utilized grafts in modern
rhinoplasty are divided by alphabetical order ac-
cording to their intended location on the nose
(Table 1). With the help of the Gunter rhinoplasty
diagrams (Canfield Clinical Systems), each graft is
didactically presented and analyzed in terms of its
nomenclature, anatomical location, and clinical
indications. The project was evaluated by numer-
ous expert surgeons (see Acknowledgments) be-
fore its completion to include their experience,
preferred nomenclature, and technical modifica-
tions.
Gunter Diagram System
The Gunter rhinoplasty diagrams were in-
troduced in 1989 to graphically document the
intraoperative maneuvers in rhinoplasty.1 They
serve as valuable tools for postoperative evalu-
ation of the patient as well as effective teaching
instruments for other surgeons learning the
technical steps performed in rhinoplasty. An
individualized Gunter diagram is included to
depict the anatomical position of each graft de-
scribed herein. The following is the color key for
interpreting the diagrams:

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Volume 118, Number 1 • Rhinoplasty Nomenclature and Analysis
Table 1. Overview of Rhinoplasty Grafts by Region
Dorsum Tip
Dorsal onlay graft Anchor graft
Dorsal sidewall onlay graft Cap graft
(lateral nasal wall graft) Columellar strut (floating/fixed-
Radix graft floating)
Spreader grafts Columellar strut (fixed)
Septal extension grafts Extended columellar strut-tip graft
(extended shield graft)
Onlay tip graft
Shield graft (Sheen or infralobular
graft)
Subdomal graft
Umbrella graft
Green ⫽ Autologous grafts
Black ⫽ Sutures and outline of anatomic struc-
tures
Red ⫽ Incisions and excisions
Orange ⫽ Previous incisions or excisions
Blue ⫽ Implants
Pink ⫽ Homografts (i.e., irradiated cartilage, der-
mal homograft, and so on)
GRAFTS OF THE NASAL DORSUM
Dorsal Onlay Graft
A dorsal onlay graft is a longitudinal graft used
to augment the nasal dorsum (Fig. 1).2 While the
graft is best used to span the entire length of the
dorsum from the radix to the septal angle to avoid
visible “step-off” deformities, it occasionally can be
used for shorter distances to correct localized de-
pressions, asymmetries, or irregularities. Septal
cartilage is the preferred source for minimal to
moderate augmentation, but costal cartilage usu-
ally is required for large augmentations. Internal
stabilization of the costal cartilage grafts is recom-
mended to avoid warping.3 Auricular cartilage is
used occasionally but has the disadvantage of be-
ing difficult to shape so that it has a smooth sur-
face. To avoid displacement, dorsal onlay grafts
should be fixed to the underlying framework us-
ing sutures and/or a percutaneous Kirschner wire.
Dorsal Sidewall Onlay Graft (Lateral Nasal Wall
Graft)
Dorsal sidewall onlay grafts are placed along
the lateral side of the nose and are different shapes
and sizes depending on the indications (Fig. 2).4
They are used to combat localized lateral depres-
sions or asymmetries of the body of the nose and
especially to camouflage collapse of the upper
lateral cartilages. The graft may be crushed to aid
Alar Region Base
Alar batten graft Alar base graft
Alar contour graft (alar rim Columellar plumping
graft) grafts(s)
Alar spreader graft (lateral Premaxillary graft
crural spanning graft)
Composite alar rim graft
Lateral crural onlay graft
Lateral crural strut graft
Lateral crural turnover
graft
in camouflaging sidewall irregularities. If it is
placed over bone, the graft is more likely to be
palpable or visible, because the bony base is un-
yielding.
Radix Graft
A radix graft is a single or layered dorsal graft
placed in a tight pocket created over the radix
(Fig. 3).5 If the pocket is larger than the graft,
percutaneous sutures or Kirschner wires are used
to fix the graft in place. Radix grafts are used to
augment an inadequate nasofrontal angle or to
redefine the radix breakpoint further cephalad,
which causes an apparent lengthening of the nose.
The graft’s shape and thickness will depend on the
amount of augmentation desired. The edges
should be crushed or carefully beveled to avoid
visibility.
Spreader Grafts
Spreader grafts are usually paired, longitu-
dinal grafts placed between the dorsal septum
and the upper lateral cartilages in a submuco-
perichondrial pocket (Fig. 4). Spreader grafts
are used to restore or maintain the internal
nasal valve, straighten a deviated dorsal septum,
improve the dorsal aesthetic lines, and recon-
struct an open roof deformity.6 Septal cartilage
is the preferred source of the grafts, whose
length and shape may vary depending on the
indication. The grafts may extend above the
level of the dorsal septum to slightly augment
the dorsum (pistol grafts) or caudally beyond
the septal angle to lengthen the nose or to in-
crease tip projection (see Septal Extension
Grafts). The grafts should be suture-fixated to
the septum before reapproximation of the up-
per lateral cartilages to the septum-spreader
graft complex.
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 Plastic and Reconstructive Surgery • July 2006

Fig. 1. Dorsal onlay graft.

Fig. 2. Dorsal sidewall onlay graft (lateral nasal wall graft).

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Volume 118, Number 1 • Rhinoplasty Nomenclature and Analysis

Fig. 3. Radix graft.

Fig. 4. Spreader grafts.

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Septal Extension Grafts
Septal extension grafts are used to control the
projection, support, shape, and rotation of the tip
and are dependent on the presence of a stable cau-
dal septum (Fig. 5).7 They also help to create a su-
pratip break. The grafts are divided into three types.
Type I grafts function as paired dorsal spreader
grafts that extend beyond the anterior septal angle
into the interdomal space. Type II grafts are paired
batten grafts that extend diagonally across the cau-
dal-dorsal junction of the septal L-strut into the tip-
lobule complex. A type III graft functions as a direct
extension graft affixed to the anterior septal angle.
Although septal cartilage is the preferred source of
the grafts, both auricular cartilage and rib cartilage
can be used.
GRAFTS OF THE NASAL TIP
Anchor Graft
The anchor graft is an anchor-shaped graft
whose shaft is sutured to the caudal margin of the
medial crura (Fig. 6). The transverse components
(wings) may replace the lateral crura or lie over
their remnants and are sutured to them. Anchor
grafts may be used to improve tip support and/or
projection and collapse or deformation of the lat-
eral crura.8 The graft is harvested from the auric-
ular concha and is then designed according to the
patient’s needs. Symmetrical carving of the wings
may be difficult due to the asymmetries of the
conchal bowl.
Fig. 5. Septal extension grafts.
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Plastic and Reconstructive Surgery • July 2006
Cap Graft
A cap graft is a small graft placed in the space
between the tip-defining points and the middle
crura (Fig. 7). The graft is used to refine, soften,
and fill in clefts of the nasal tip in patients with thin
skin, to minimally enhance tip projection and oc-
casionally refine the infratip lobule area.9 The pre-
ferred source of cartilage is from remnants ob-
tained from the cephalic trim of the lower lateral
cartilages, but septal, auricular, or rib cartilage
may also be utilized.
Columellar Strut (Floating/Fixed Floating)
A floating columellar strut is a graft placed in
a tight pocket dissected between the medial crura
through a small incision caudal to the feet of the
medial crura (endonasal approach) (Fig. 8).10 The
fixed-floating columellar strut (open approach) is
sutured to the medial crura for stabilization. A 2-
to 3-mm pad of soft tissue is usually maintained
between the graft and the nasal spine to keep the
graft from moving back and forth over the spine
with lip movements.11 The columellar strut helps
in maintaining tip support and increasing tip pro-
jection and aids in shaping the columellar-lobular
angle. Septal cartilage is preferred, but costal car-
tilage is used when a stronger strut and more
enhanced projection are desired. Auricular carti-
lage may be used, but a double layer should be
used if strength is needed.
Volume 118, Number 1 • Rhinoplasty Nomenclature and Analysis
Fig. 6. Anchor graft.
Fig. 7. Cap graft.
Columellar Strut (Fixed)
Columellar struts may be fixed to the nasal
spine or premaxilla to give more stable support to
the nasal tip (Fig. 9). A fixed columellar strut is the
most effective way of increasing tip projection with
a strut and can also aid in lengthening the nose.3
When using rib cartilage, more stabilization and
control are obtained by using a 0.035-inch
threaded Kirschner wire inserted longitudinally in
the strut (a Kirschner wire cannot be placed in
septal cartilage because it is too thin). The Kirsch-
ner wire should be inserted up to three-quarters of
the length of the strut, with 10 mm left exposed at
the base. This is then placed in a 12-mm drill hole
just lateral to the maxillary midline, parallel and
inferior to the nasal floor. When fixed with a
Kirschner wire, the medial crura can be advanced
and sutured to the strut to control projection, and
rotation can be controlled by the angle made in
the Kirschner wire at the base of the strut.
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Fig. 8. Columellar strut (floating/fixed floating).
Fig. 9. Columellar strut (fixed).
Extended Columellar Strut-Tip Graft (Extended
Shield Graft)
The extended columellar strut-tip graft is an
elongated, shield-shaped graft that lies caudal to
or between the medial crura and extends anteri-
orly to project beyond the domes and posteriorly
toward the medial crural footplates (Fig. 10).12
The graft is used to provide tip support, projec-
tion, definition, and fullness caudal to the medial
crura to aid in shaping the columella. It is stabi-
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Plastic and Reconstructive Surgery • July 2006
lized in a tight pocket in the precrural space (en-
donasal approach) or by placing it caudal to or
between the medial crura and suturing it in place
to the crura (open approach). The anterior end of
the graft is rounded and shaved extremely thin to
prevent visibility. The further the tip of the graft
extends above the tip-defining points, the more it
will tend to bend backward. If the bending is more
than desired, a small rectangular block of cartilage
may be sutured to the domes behind the graft.
Volume 118, Number 1 • Rhinoplasty Nomenclature and Analysis
Fig. 10. Extended columellar strut-tip graft (extended shield graft).
Fig. 11. Onlay tip graft.
This results in increased stability and a barrier
against bending upward with loss of tip projection
and increased infratip lobular show.
Onlay Tip Graft
An onlay tip graft is a single or multilayered
graft placed horizontally over the alar domes (Fig.
11).13 It is placed in a tight pocket if the endonasal
approach is used or sutured for stabilization in the
open approach. The onlay tip graft is used to
minimally increase tip projection but mainly to
camouflage tip irregularities. The edges of the
graft must be beveled or crushed to avoid post-
operative visibility. This graft acts as the transverse
component of the umbrella graft.
Shield Graft (Sheen or Infralobular Graft)
This shield-shaped graft is placed adjacent to
the caudal edges of the anterior middle crura,
extending into the tip (Fig. 12).14 The shield graft
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is used to increase tip projection, define the tip,
and improve contour of the infratip-lobule. Ad-
ditional tip projection can be achieved by moving
the graft more anteriorly above the tip. If used with
the endonasal approach, it is stabilized by placing
it in a tightly undermined pocket. If the open
approach is used, it is sutured to the caudal mar-
gins of the cartilages.15 To avoid excessive cepha-
lad tilting of the graft, a small “block” graft can be
sutured to the alar domes to increase the stability.
Fig. 12. Shield graft (Sheen or infralobular graft).
Fig. 13. Subdomal graft.
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Plastic and Reconstructive Surgery • July 2006
The graft edges should be beveled or lightly mor-
selized to make them softer and less visible.
Subdomal Graft
A subdomal graft is a bar-shaped graft placed in a
pocket under the domes (Fig. 13).16 The subdomal
graft corrects dome asymmetry by controlling the hor-
izontal and vertical orientation of the domes. It may
also be used to correct the pinched nasal tip deformity.
Septal cartilage is the preferred graft material.
Volume 118, Number 1 • Rhinoplasty Nomenclature and Analysis
Umbrella Graft
The umbrella graft is composed of a vertical
columellar strut combined with a horizontal on-
lay graft (Fig. 14).17 This graft is used in patients
with both inadequate tip projection and inade-
quate support. The edges of the graft’s trans-
verse component should be beveled or mor-
selized to avoid postoperative visibility. It is
usually stabilized by placing the transverse com-
ponent in a small tight pocket (endonasal ap-
proach) or by suturing it to the domes of the
lateral crura (open approach).
GRAFTS OF THE ALAR REGION
Alar Batten Grafts
Alar batten grafts are nonanatomic grafts placed
in a pocket extending from the piriform aperture to
a paramedian position in the alar sidewall at the site
of maximal lateral nasal wall collapse during inspi-
ration (Fig. 15).18,19 The alar batten graft can be
extended caudal to the area of the lateral crus to
correct external valve dysfunction caused by loss of
support from overresected lateral crura. Alterna-
tively, the graft can be placed cephalad to the lateral
crus for internal valve collapse.
Alar Contour Grafts (Alar Rim Grafts)
Alar contour grafts are used to correct or prevent
alar retraction or collapse (Fig. 16).20 These grafts
are placed in a subcutaneous pocket immediately
above and parallel to the alar rim and must span the
length of the alar deformity. The more severe the
Fig. 14. Umbrella graft.
problem, the longer and wider the graft will need to
be. They are not as effective as lateral crural strut
grafts in patients with significant alar scarring, loss of
vestibular skin, or absent lower lateral cartilages.
Alar Spreader Graft (Lateral Crural Spanning
Graft)
An alar spreader graft is a single bar graft that
bridges the intercrural space, with the ends of the
grafts placed in an undermined pocket between
the lateral crura and vestibular skin (Fig. 17).21
The graft is sutured to the lateral crura for stabi-
lization. It is used to correct or prevent the
pinched nasal tip deformity by controlling the
distance between and providing support to the
lateral crura. This graft improves both external
and internal valve dysfunction by correcting the
collapse of the crura. The shape (triangular or
bar-shaped) and size of the graft will vary depend-
ing on the severity of the deformity.
Composite Alar Rim Graft
A composite alar rim graft is a composite skin–
conchal cartilage graft harvested from the concha
cymba or concha cavum and placed along the
intranasal alar rim (Fig. 18).22,23 It is used to cor-
rect moderate to severe alar retraction or notch-
ing not amenable to other techniques, to correct
asymmetries in alar rim height, and to combat
nostril or vestibular stenosis. The skin of the graft
should be sutured to the edges of the defect in the
vestibule. Percutaneous sutures are often used to
23e

Fig. 15. Alar batten graft.
Fig. 16. Alar contour graft (alar rim graft).
stabilize the graft. If the donor site cannot be
closed primarily, it is closed with a full-thickness
postauricular skin graft.
Lateral Crural Onlay Grafts
The lateral crural onlay graft is placed over
the existing lateral crus as an onlay graft (Fig.
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Plastic and Reconstructive Surgery • July 2006
19).24 It is used to correct alar contour irregu-
larities caused by a deformed, intact lateral crus.
These grafts are used to strengthen and shape
the ala and may improve external valve dysfunc-
tion. However, graft placement superficial to the
lateral crus may be visible as a “step-off” at the
anterior end and cephalic margin of the graft.
Volume 118, Number 1 • Rhinoplasty Nomenclature and Analysis
Fig. 17. Alar spreader graft (lateral crural spanning graft).
Fig. 18. Composite alar rim graft.
The edges of the graft must be carefully beveled
if this is to be avoided.
Lateral Crural Strut Graft
The lateral crural strut graft is a graft placed
in an undermined pocket between the undersur-
face of the lateral crus and the vestibular skin and
stabilized by suturing it to the crus (Fig. 20).25 It
is used to correct alar retraction, alar rim collapse,
and concave, convex, or malpositioned lateral
crura. The lateral end of the graft is usually placed
superficial to the piriform aperture rim to avoid
medial displacement of the graft. The under-
mined lateral pocket should be inferior to the alar
groove to avoid visibility of the end of the graft.
25e

Fig. 19. Lateral crural onlay graft.
Fig. 20. Lateral crural strut graft.
The more inferiorly the pocket is placed, the lower
the alar rim will be displaced. Septal cartilage is the
preferred source of grafting material, but costal
cartilage may be required in the graft-depleted
patient.
Lateral Crural Turnover Graft
The turndown cephalic lateral crural graft is
created from the cephalic portion of the lateral
crus after the vestibular skin is undermined from
its undersurface (Fig. 21).26 The lateral crus is
incised partial thickness on the undersurface
along its length so that the crus is halved longi-
tudinally. This allows the graft to be turned su-
perficial to the caudal segment, so that it breaks
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Plastic and Reconstructive Surgery • July 2006
but does not separate. The original cephalic mar-
gin of the crus is sutured to the caudal margin.
Turndown cephalic lateral crural grafts are used to
increase the strength of the lateral crura or to
straighten convex or concave lateral crura. The
thicker and stronger the lateral crus, the more
effective it is.
GRAFTS OF THE ALAR BASE
Alar Base Graft
An alar base graft is a graft placed along the
lateral piriform aperture to augment a recessed
lip-alar base junction (Fig. 22). Carved cartilage
grafts have been used but are difficult to shape and
stabilize. While some surgeons still use these
Volume 118, Number 1 • Rhinoplasty Nomenclature and Analysis
Fig. 21. Lateral crural turnover graft.
Fig. 22. Alar base graft.
grafts, hydroxyapatite granules or other alloplastic
implants are preferred by others.27
Columellar Plumping Graft(s)
Columellar plumping grafts are usually com-
posed of diced or morselized cartilage that is
placed in the space between the medial crura foot-
plates and the nasal spine (Fig. 23). Their purpose
is to augment an inadequate columellar-labial an-
gle or to correct minor posterior columellar con-
tour deformities.
Premaxillary Graft
A premaxillary graft is a graft that is typically
placed along the caudal border of the piriform
aperture (Fig. 24).28 The premaxillary graft is used
to correct premaxillary recession. Again, these
27e

Fig. 23. Columellar plumping graft(s).
Fig. 24. Premaxillary graft.
grafts are difficult to carve and stabilize, and many
surgeons use alloplastic material for these grafts.
Jack P. Gunter, M.D.
Suite 170
8144 Walnut Hill Lane
Dallas, Texas 75231
drgunter@drjackgunter.com
ACKNOWLEDGMENTS
The authors thank William P. Adams, Jr., M.D., H.
Steve Byrd, M.D., Mark B. Constantian, M.D., Ronald
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Plastic and Reconstructive Surgery • July 2006
P. Gruber, M.D., Bahman Guyuron, M.D., Robert M.
Oneal, M.D., Norman J. Pastorek, M.D., Stephen W.
Perkins, M.D., Rod J. Rohrich, M.D., Samuel Stal,
M.D., Eugene M. Tardy, M.D., and Dean M. Toriumi,
M.D., for the valuable suggestions that improved the
content of this project.
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