Tip surgery using conchal cartilage
Chuan-Hsiang Kao, M.D.
Department of Otolaryngology-Head and Neck Surgery,
Cosmetic and Laser Center,
Tri-Service General Hospital,
National Defense Medical Center, Taipei, Taiwan, R.O.C.
The characteristics of nasal tips in Asia include the short columella, a bulbous appearance,
alar flare, ovoid shaped nostrils, and weaker tip support. These are attributable to
underdeveloped medical crus of the alar cartilage. To achieve the optimal cosmetic result of
the Asian rhinoplasty, it is not sufficient to only increase the nasal dorsal high, but also to
refine the shape of nasal tip. However, it has been a challenging operation for nasal tip
rhinoplasty. Inadequate nasal tip projection and nasal length are the most common problems
of primary and secondary rhinoplasty. Successful nasal tip rhinoplasty depends on
well-balanced nasal tip support and projection. Many different techniques for tip support and
projection have been proposed, and some have been in routine use, although controversies or
limitations exist in the literature concerning their late results.
We introduced the caudal extension graft (CEG) as trapezoidal shape to predictably
control nasal tip projection and shape. The trapezoidal caudal extension cartilage graft was
harvested either from septal cartilage or costal cartilage. The CEG was fixed to the caudal
septum and positioned in midline, between the bilateral medial crura of the lower lateral
cartilages. It can provide a stable platform for tip complex suturing and also maintenance of
tip projection. We routinely performed the trapezoidal caudal extension cartilage graft
technique for patients requiring a mild to significant increase in tip projection and support.
The graft’s size, location, and angle of advancement depend on the individual
requirements of the patient, whether elongation of the nose or an increase in tip
projection or support. To prevent a possible bulbous tip deformity after strut
application, the two medial crura were sutured with CEG. The trapezoidal caudal
extension cartilage graft supports the nasal tip pyramid very well, and helps to reestablish a
new nasal tip. This graft is particularly useful in the patients characterized by a shot nose or a
saddle deformity in Asian patients.
Due to the elasticity of the ear conchal cartilage being similar to the tip cartilage, we
prefer to harvest the ear cartilage for the most tip grafting. When harvesting the ear cartilage,
a retro-auricular incision is recommended, rather than the anterior incision, because the scar
will be behind the ear and almost invisible after surgery. Subperichondrial dissection is done
at the anterior side and supraperichondrial dissection at the posterior side. The wound is
closed in running or interrupted sutures with a conchal packing fixed with two
through-and–through mattress sutures. The cymba and cavum conchae are harvested for
various tip grafts. We need to pay attention to meticulously carve the conchal cartilage to
prevent the postoperative graft visibility and asymmetry. No major complications have been
observed with tip grafting using conchal cartilage.