Aesthetic Plastic Surgery

, Volume 38, Issue 2, pp 275–281 | Cite as

Are Grafts Necessary in Rhinoplasty? Cartilage Flaps with Cartilage-Saving Rhinoplasty Concept

  • İsmail KüçükerEmail author
  • Selahattin Özmen
  • Basar Kaya
  • Betül Ak
  • Ahmet Demir
Original Article Aesthetic



Cartilage grafts are used routinely in rhinoplasty, but are they necessary? Can we support the normal anatomy by preserving and transposing the adjacent tissues? In this study we hypothesize that during rhinoplasty, cartilage flaps can give adequate support and may decrease the need for cartilage grafts.


Included in this study were 147 patients who underwent an open rhinoplasty technique under general anesthesia between January 2010 and May 2012. Mean operative time was 73 min (range = 44–120 min). After dissection and septoplasty (if needed), we performed dorsal bone and septal reductions. Following reduction, upper lateral cartilage superior segments were preserved and turned inward as cartilage flaps to replace the spreader grafts. Lower lateral cartilage cranial parts were not excised and were slid over the caudal part to replace the alar strut grafts. Cartilage from the caudal nasal septum was not excised; instead, lower lateral cartilages were cephaloposteriorly displaced with a tongue-in-groove technique to support the nasal tip.


Mean follow-up time was 19.6 months (6–30 months). All patients but 12 were satisfied or completely satisfied with the results. Among the 12 unsatisfied patients, four complained of a one-sided inverted-V deformity (secondary spreader grafts were added), three had supratip deformity (secondary additional dorsal septal excisions), two demanded extra tip definition (secondary tipoplasty), two were unhappy with the bone symmetry (secondary osteotomies), and one complained of hanging columella (secondary excision from the caudal septum).


Cartilage flaps have some advantages over cartilage grafts. First, graft harvest is not needed in the former; second, because flaps are a part of the normal anatomy, they provide a good tissue match, making fixation easier. However, the tongue-in-groove technique cannot be used in patients who do not need caudal excision, and cartilage flaps can be inadequate in some patients who may need additional grafts.

EBM Level IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors


Rhinoplasty Graft FLAP Spreader flap Septoplasty Cartilage flap Strut graft Tongue in groove 


Conflict of interest

The authors have no conflicts of interest to disclose.

Supplementary material

Supplementary material 1 (MP4 49429 kb)


  1. 1.
    Sheen JH (1984) Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73:230–239PubMedCrossRefGoogle Scholar
  2. 2.
    Gunter JP, Friedman RM (1997) Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg 99(4):943–955PubMedCrossRefGoogle Scholar
  3. 3.
    Rohrich RJ, Raniere J Jr, Ha RY (2002) The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg 109(7):2495–2508PubMedCrossRefGoogle Scholar
  4. 4.
    Cervelli V, Spallone D, Bottini JD, Silvi E, Gentile P, Curcio B, Pascali M (2009) Alar batten cartilage graft: treatment of internal and external nasal valve collapse. Aesthet Plast Surg 33(4):625–634CrossRefGoogle Scholar
  5. 5.
    Gruber RP, Zhang AY, Mohebali K (2010) Preventing alar retraction by preservation of the lateral crus. Plast Reconstr Surg 126(2):581–588PubMedCrossRefGoogle Scholar
  6. 6.
    Gruber RP, Kryger G, Chang D (2008) The intercartilaginous graft for actual and potential alar retraction. Plast Reconstr Surg 121(5):288e–296ePubMedCrossRefGoogle Scholar
  7. 7.
    Rohrich RJ, Kurkjian TJ, Hoxworth RE, Stephan PJ, Mojallal A (2012) The effect of the columellar strut graft on nasal tip position in primary rhinoplasty. Plast Reconstr Surg 130(4):926–932PubMedCrossRefGoogle Scholar
  8. 8.
    Reiffel AJ, Cross KJ, Spinelli HM (2011) Nasal spreader grafts: a comparison of Medpor to autologous tissue reconstruction. Ann Plast Surg 66(1):24–28PubMedCrossRefGoogle Scholar
  9. 9.
    Oneal RM, Berkowitz RL (1988) Upper lateral cartilage spreader flaps in rhinoplasty. Aesthet Surg J 18:370–371CrossRefGoogle Scholar
  10. 10.
    Gruber RP, Melkun ET, Woodward JF, Perkins SW (2011) Dorsal reduction and spreader flaps. Aesthet Surg J 31(4):456–464PubMedCrossRefGoogle Scholar
  11. 11.
    Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K (2008) Upper lateral cartilage fold-in flap: a combined spreader and/or splay graft effect without cartilage grafts. Ann Plast Surg 61(5):527–532PubMedCrossRefGoogle Scholar
  12. 12.
    Ozmen S, Eryilmaz T, Sencan A, Cukurluoglu O, Uygur S, Ayhan S, Atabay K (2009) Sliding alar cartilage (SAC) flap: a new technique for nasal tip surgery. Ann Plast Surg 63(5):480–485PubMedCrossRefGoogle Scholar
  13. 13.
    Williams EF (2012) Alar-columellar disharmony using the tongue-in-groove maneuver in primary endonasal rhinoplasty. Arch Facial Plast Surg 14(4):283–288PubMedCrossRefGoogle Scholar
  14. 14.
    Tezel E, Numanoğlu A (2007) Septocolumellar suture in closed rhinoplasty. Ann Plast Surg 59(3):268–272PubMedCrossRefGoogle Scholar
  15. 15.
    Çakir B, Doğan T, Öreroğlu AR, Daniel RK (2013) Rhinoplasty: surface aesthetics and surgical techniques. Aesthet Surg J 33(3):363–375PubMedCrossRefGoogle Scholar
  16. 16.
    de Pochat VD, Alonso N, Mendes RR, Cunha MS, Menezes JV (2012) Nasal patency after open rhinoplasty with spreader grafts. J Plast Reconstr Aesthet Surg 65(6):732–738PubMedCrossRefGoogle Scholar
  17. 17.
    Kucuker I, Ozmen S (2013) Extended Spreader graft placement before lateral nasal osteotomy. Aesthetic Plast Surg 37(4):684–691PubMedCrossRefGoogle Scholar
  18. 18.
    Seyhan A (1997) Method for middle vault reconstruction in primary rhinoplasty: upper lateral cartilage bending. Plast Reconstr Surg 100:1941–1943PubMedCrossRefGoogle Scholar
  19. 19.
    Rohrich RJ, Muzaffar AR, Janis JE (2004) Component dorsal hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg 114:1298–1308PubMedCrossRefGoogle Scholar
  20. 20.
    Fischer H, Gubisch W (2006) Nasal valves—importance and surgical procedures. Facial Plast Surg 22(4):266–280 [review]PubMedCrossRefGoogle Scholar
  21. 21.
    Constantinides MS, Adamson PA, Cole P (1996) The long-term effects of open cosmetic septorhinoplasty on nasal air flow. Arch Otolaryngol Head Neck Surg 122:41–45PubMedCrossRefGoogle Scholar
  22. 22.
    Guyuron B (2001) Alar rim deformities. Plast Reconstr Surg 107:856–863PubMedCrossRefGoogle Scholar
  23. 23.
    Toriumi DM, Checcone MA (2009) New concepts in nasal tip contouring. Facial Plast Surg Clin North Am 17:55–90PubMedCrossRefGoogle Scholar
  24. 24.
    Dobratz EJ, Tran V, Hilger PA (2010) Comparison of techniques used to support the nasal tip and their long-term effects on tip position. Arch Facial Plast Surg 12(3):172–179PubMedCrossRefGoogle Scholar
  25. 25.
    Kridel RW, Scott BA, Foda HM (1999) The tongue-in-groove technique in septorhinoplasty: a 10-year experience. Arch Facial Plast Surg 1(4):246–258PubMedCrossRefGoogle Scholar
  26. 26.
    Daniel RK (2009) Tip refinement grafts: the designer tip. Aesthet Surg J 29(6):528–537PubMedCrossRefGoogle Scholar
  27. 27.
    Gruber RP, Chang E, Buchanan E (2010) Suture techniques in rhinoplasty. Clin Plast Surg 37(2):231–243PubMedCrossRefGoogle Scholar
  28. 28.
    Dosanjh AS, Hsu C, Gruber RP (2010) The hemitransdomal suture for narrowing the nasal tip. Ann Plast Surg 64(6):708–712PubMedCrossRefGoogle Scholar
  29. 29.
    Daniel RK (2011) Rhinoplasty: open tip suture techniques: a 25-year experience. Facial Plast Surg 27(2):213–224PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013

Authors and Affiliations

  • İsmail Küçüker
    • 5
    Email author
  • Selahattin Özmen
    • 2
  • Basar Kaya
    • 3
  • Betül Ak
    • 4
  • Ahmet Demir
    • 1
  1. 1.Plastic Surgery Department, Faculty of MedicineOndokuz Mayıs UniversitySamsunTurkey
  2. 2.Plastic Surgery Department, Faculty of MedicineGazi UniversityAnkaraTurkey
  3. 3.Plastic Surgery Department, Faculty of MedicineUfuk UniversityAnkaraTurkey
  4. 4.Plastic Surgery DepartmentErzurum Regional Research and Training HospitalErzurumTurkey
  5. 5.Plastic Reconstructive and Aesthetic Surgery Department, Faculty of MedicineOndokuz Mayis UniversitySamsunTurkey

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