Nasal reconstruction and revision rhinoplasty surgery have been fraught with multiple complications. Synthetic, bone, and cartilage grafts have been used in many ways. Synthetic grafts have helped with correction of nasal dorsal abnormalities and the lower third of the nose. It is the region of the lower third that is fraught with exposure to complications to these types of implants. Bone grafting, is effective in the upper third of the nose, but in the lower third, lack of pliability leads to unnatural appearances. Cartilage continues to be the mainstay for lower third reconstructive work and revision rhinoplasty. We reviewed our rhinoplasty nasal reconstructive work in an attempt to determine the best cartilage grafts for lower third reconstruction.

We reviewed our data over the past 5 years looking at ear cartilage uses for nasal reconstruction. Pre and post-operative photos were evaluated (frontal and side views represented the standards used), as well as surgical techniques used in harvesting cartilage from the ear. The scapha (triangular fossa) was used frequently for nasal tip reconstruction and composite grafting of the soft triangle region. This portion of cartilage can be removed from either an anterior or posterior approach if the cartilage is to be used for tip grafting, and incision lines are easily hidden. An anterior approach is used for a composite graft. The incision line is placed along the antihelix. The incision can be placed such to take an ellipse of skin, half of which typically can be removed from the region hidden by the crus of the helix. The natural curvature of the antihelix crura tracking into the scapha, is removed using anterior elevation of the skin and beveling the edges of the cartilage with a 15 blade technique. Cartilage can be removed from a posterior approach by making a high incision over the back side of the scapha. Placing a 27g needle from the anterior surface of the ear through and through the posterior surface, the cartilage scaphal resection can be marked. Cartilage grafts taken from the conchal bowl were predominantly taken from a posterior incision line approach. A 27g needle through and through technique allowed for marking of the cartilage to be harvested. Care was taken to preserve the crus of the helix as it forms a cartilaginous bar into the conchal bowl. Septal cartilage grafts were harvested in the standard fashion used for septoplasty with mucoperichondrial elevation.

The scaphal graft is an ideal nasal tip graft and nearly perfect composite graft for the soft triangle reconstructive region. There have been concerns about contour irregularity, but the cosmetic and structural strength of the ear remains relatively unchanged. Structural posts necessary for support of the ear, specifically the antihelix, crus of the helix, and antitragal cartilages, remain supportive after harvesting these grafts. The scaphal cartilage has the appropriate contour for use as a tip graft since it softens the tip, and allows for good tip projection without the need for stacking cartilage. The composite graft has a strong curve at the antihelical fold, and a gentle curve as the scapha tracks into the superior position. This allows the cartilage to be used to hold the contracting soft triangle tissue in position. Grafts used from the ear and nasal septum have not been as ideal largely due to contour and shape mismatching. There are no significant complications in the use of scaphal cartilage grafts.

In conclusion, ear cartilage grafts are ideal for lower one-third nasal reconstruction in cancer resection patients and revision rhinoplasty patients. In both types of patients, septal cartilage access and availability is often limited. The scapha graft is a versatile graft in the head and neck region. It is easily harvested under local anesthesia and the post-operative ear position and contour are relatively unchanged.
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