ORIGINAL ARTICLE

Perichondrium Graft: Harvesting and Indications

in Nasal Surgery
Armando Boccieri, MD, and Tito M. Marianetti, MD

more probable in cases where the skin is rather thin and the edges
Abstract: Irregularities in the nasal contour of patients who un- of the graft have not been rounded sufficiently. The close proximity
derwent multiple surgeries are frequently related also by skilled and contact of different grafts can also lead in time to the percep-
surgeons. The aim of this study was to describe the method of tion of unattractive ridges in the nasal profile. The use of the peri-
harvesting and the primary applications of erichondrium grafts in chondrium appropriately harvested from the auricular concha has
revision rhinoplasty to prevent postoperative irregularities. already been suggested more than once as an excellent way of
Conchal grafts were used in the reconstruction of structures covering grafts so as to conceal the irregularities beneath. Its pro-
missing as a result of rhinoplasty. The perichondrium was removed tective effect on the final result becomes evident a long time after,
from the cartilage during harvesting and fixed on the cartilagenous when the masking caused by the postoperative edema disappears
and the cartilaginous grafts are exposed to the pressure of scar
grafts to fill up empty spaces and make uniform the surface of the
contraction of the surrounding tissues.
grafts. These techniques were used on 62 patients. This article describes a method of preparing perichondrial
All of the patients treated showed aesthetic improvement with material harvested from the auricular concha and presents a codified
respect to the preoperative situation. Comparison with other cases in technique for grafting onto the nasal structures. Some guidelines
which the perichondrium graft was not used demonstrates its effec- are provided as regards the primary indications and the results of
tiveness in avoiding certain sequelae over time, especially as regards clinical experience. The advantages of the perichondrial graft in
the presence of unattractive sharp edges often visible beneath the comparison with other autogenous or alloplastic grafts are reviewed.
cutaneous covering after the use of structural grafts.
In conclusion, perichondrium grafting during secondary rhino-
plasty is an easily performed technique that involves a small increase PATIENTS AND METHODS
in operating time if combined with the harvesting of conchal mate- The study regards the use of perichondrium grafts on 62
rial. Its application over the surface of cartilage grafts constitutes a patients (45 women and 17 men) submitted to revision rhinoplasty
stable covering over time that protects the definitive result from between February 2002 and April 2006. Thirty of the patients had
irregularities caused by the disappearance of postoperative edema previously undergone more than 1 (2Y4) rhinoplasty. Although the
primary indication for surgical treatment was iatrogenic aesthetic
and scar retraction.
deformity, functional disorders were also present in approximately
Key Words: Revision rhinoplasty, perichondium graft, 30% of the cases. The latter were examined by means of basal rhino-
reconstructive rhinoplasty, autologous graft manometry followed by decongestion in accordance with the method
described by Constantian and Clardy.4 Preoperative aesthetic as-
(J Craniofac Surg 2010;21: 40Y44) sessment of the patients was based on photographs showing 6 views:
frontal, basal, left and right lateral, and three-quarter. The specific
nasal deformities present were catalogued as regarding the upper

I t is common practice in revision rhinoplasty to perform car-

tilaginous structural grafting using material taken from the nasal
septum or the auricular and costal cartilage, in order of preference.1
third (bony pyramid), middle third (cartilaginous pyramid), and lower
third (tip, ala, and columella), with at least 2 anatomic nasal sec-
tions simultaneously involved in 46 cases. They comprised a sad-
Septal cartilage is, however, often available in limited amounts as dle deformity, osteotomy irregularities, scar adhesions, asymmetries,
a result of previous operation, and material is therefore taken from a narrow nasal vault, a pollybeak deformity, and the continuing
the auricular concha.2 At the same time, although very safe in taking presence of deviation in the upper and middle third and overprojec-
root and infection, cartilage grafts can create problems of visibility tion or underprojection of the nasal tip, deviation, asymmetry, alar
beneath the cutaneous covering over time.3 This sequela, which can collapse, columellar retraction, and bossae to varying degrees in the
also manifest itself a long time after the operation, is unquestionably lower third. Perforation of the nasal septum was present in 3 cases.
More than 1 structural graft was indicated in all the cases. Because the
nasal septum was insufficient for this purpose, material was taken
From the Department of Maxillofacial Surgery, San Camillo Hospital, from one or both sides of the concha. Onlay grafts were used in
Rome, Italy. the upper third to correct various degrees of saddleback deformity.
Received May 20, 2009. Spreader grafts5 were used in the middle third to correct deficits of
Accepted for publication May 25, 2009.
the internal nasal valve and continuing deviation of the dorsum. Alar
Address correspondence and reprint requests to Tito M. Marianetti, MD,
San Camillo Hospital, V.le delle Province 55 int. 18, 00162 Rome,
batten grafts6 were used in the lower third to reconstruct the alar
Italy; E-mail: [email protected] cartilages and the external nasal valve. Underprojection of the nasal
Copyright * 2010 by Mutaz B. Habal, MD tip required the use of shield grafts7 or onlay grafts,8 often combined
ISSN: 1049-2275 with columellar struts.9 An open approach to the nasal pyramid with
DOI: 10.1097/SCS.0b013e3181c362df an inverted-V columellar incision was adopted in all cases.

40 The Journal of Craniofacial Surgery & Volume 21, Number 1, January 2010

Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 21, Number 1, January 2010 Perichondrium Graft

TECHNIQUE
The harvesting of conchal cartilage is carried out by means
of a retroauricular approach so as to leave no visible scar. Infiltra-
tion of xylocaine with adrenaline (1:100,000) is carried out on both
sides of the concha followed by a vertical median-posterior incision.
The tissues above the concha are detached so as to avoid exposing
the cartilage completely and leave the perichondrium attached to its
posterior surface. Particular care must be taken in this phase to avoid
lesions of the perichondrial covering. To this end, it proves advisable
to subject the cutaneous strip to firm posterior traction and use
the scalpel for detachment purposes.
The outline of the graft is then traced by inserting 4 or 5
straight needles into the anterior surface, taking care to leave the fold FIGURE 2. Left, Auricular concha. Right, Perichondrium with
of the antihelix and the root of the helix intact.10 This makes it a suture of 6.0 nylon on its outer surface.
possible to cut the cartilage of the concha with no risk of impairing
the morphology of the auricular pavilion. At this point, the anterior
surface of the graft is subjected to subperichondrial detachment, anatomic structures beneath it as soon as the watery component is
freed completely, and removed. The cutaneous incision is sutured dispersed. To this end, it can be useful to apply light pressure from
with 5.0 nylon. If this is carried out by another surgeon, preparation the outside, combined in any case with careful taping of the nasal
of the perichondrium graft can proceed at the same time. ridge at the end of the operation. The graft can also be used in a very
Detachment of the perichondrium from the cartilage of the similar way to deal with scar adhesions between the skin and
auricular concha constitutes an essential stage in this technique. The the supporting structures beneath. In such situations, the 2 layers
concha must be held firmly in a horizontal position with its posterior are separated and the graft is inserted between them to provide
surface on top. This can be done either by securing it to a support thickness, permit sliding, and prevent relapse.
with needles or by having an assistant hold it firmly in 2 cartilage Perichondrial tissue can be used in connection with the nasal
forceps. As the perichondrium is very strongly attached to the car- tip to attenuate the unevenness between the shield or Peck grafts
tilaginous surface, its detachment must be carefully executed with and the surrounding cartilages or other grafts and thus make the
sharply pointed scissors, proceeding edgewise from one end to the edges smoother (Figs. 3AYC). The depression between the tip and
other (Fig. 1). The use of an elevator has proved risky because the supratip, commonly known as the supratip break, can also prove
the tissue is easily torn. Before completing the detachment, it is excessive during the operation and be attenuated through suitable
advisable to suture the outer side of the perichondrium with 1 stitch positioning of the perichondrium graft in that area. In other cases,
of 6.0 nylon so that it can be correctly positioned during the graft reconstruction of the tip involves suturing portions of the medial to
onto the nasal structures (Fig. 2). The strip of perichondrium should lateral crura or conchal grafts and inevitably leads to the formation
then be placed on gauze and kept moist through frequent irrigation of ridges between the cartilages. Here too, the perichondrium graft
with a saline solution. can serve to restore apparent external continuity to all the structures
The use of this graft is essentially indicated for the nasal (Fig. 4). In all of these cases, the graft must first be secured to the
dorsum and tip. It proves useful in the case of a saddle nose defor- surrounding structures with fine sutures of 6.0 nylon and then cut
mity in eliminating the gaps that inevitably form between the car- and reshaped according to requirements with finely pointed scissors.
tilaginous onlay graft and the surrounding structures. Insertion of In the case of perforation of the nasal septum, after using a
the graft can be facilitated by further moistening and its positioning suitable technique to detach the mucosa and suture the perforation,11
by a combination of external palpation and internal adjustment by a perichondrium graft can be placed between the 2 flaps so as to
means of forceps. It is not necessary to secure the graft in these provide a further barrier against relapse. If the mucosa is insufficient
cases because the rough surface of the perichondrium adheres to the for complete closure of the perforation, a small portion of the graft
can be left uncovered on 1 of the 2 sides. Great importance attaches
in any case to securing it in the right position with a number of long-
term absorbable mattress sutures.

RESULTS
All of the patients underwent revision rhinoplasty using a
perichondrium graft. Improvement of the preoperative nasal defor-
mity was obtained in all the cases. Follow-up ranged from 30 to
60 months (median, 42 mo). There were no instances of infec-
tion, movement, or substantial absorption of the grafts. Satisfactory
results were achieved in all the cases as regards reconstruction and
aesthetic appearance together with an improvement in nasal func-
tionality wherever an obstructive syndrome was present. Positive
aesthetic judgements were expressed not only by the operating team
but also by the surgeons involved in the control tests, the family
physicians, and the patients themselves. Only 1 patient, affected
by saddle nose deformity, required further revision surgery, not
because of the perichondrium graft but to raise the height of the
profile. The correction was achieved by supplementing the grafts
FIGURE 1. Removal of the perichondrium from the present with another onlay graft of cartilage from the contralateral
cartilage of the auricular concha. concha.

* 2010 Mutaz B. Habal, MD 41

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Boccieri and Marianetti The Journal of Craniofacial Surgery & Volume 21, Number 1, January 2010

FIGURE 3. A, Reconstruction of the nasal tip with lateral crural and shield grafts (Sheen type) harvested from the cartilage of
the auricular concha. B, Graft of the perichondrium stretched over and secured to cartilaginous grafts to make the contours
smooth and disguise tip grafts. C, Lateral view of the same graft.

In the cases involving an obstructive syndrome, the com-

parison of preoperative and postoperative rhinomanometric data
showed a decrease in nasal resistance and an improvement in nasal
functionality. As regards the 3 operations for perforation of the sep-
tum, a complete closure was obtained in 2 cases (diameter, 2 and
3 cm) and an almost complete closure was obtained in the other
(diameter, 3 cm).
Attention should be drawn to the presence in 3 cases of sub-
stantial swelling of the tip for more than 3 months. These patients
also returned to the mean range of values after 3 injections of tri-
amcinolone administered at intervals of approximately 3 weeks.
The postoperative photographs of 2 patients subjected to
multiple cartilaginous grafts of the tip with a covering perichondrial
graft show a soft nasal contour with no underlying irregularities
(Figs. 5 and 6).

DISCUSSION
Even experienced surgeons have complained of the appear-
FIGURE 4. Schematic illustration of the perichondrium ance of irregularities in the nasal dorsum and the tip after revision
graft positioning and fixation. Presence of numerous grafts rhinoplasty. The use of multiple grafts with sharp edges and the
inevitably leads to sharp ridges and irregularities in the presence of thin skin and scar tissue are risk factors for this problem.
cartilaginous contour that can be eliminated by means of It has therefore been suggested that various materials should be used
the perichondrium graft. in high-risk cases so as to prevent this unwelcome sequela. Those
most frequently used and reported in the literature are crushed car-
tilage,3 temporal fascia,12 acellular dermis,13 and perichondrium.

FIGURE 5. Patient submitted to 2 previous rhinoplasties with absence of both lateral crura, underprojection of the nasal tip,
and scar adhesion between the skin and the nasal bone on the right. Reconstruction was performed by means of 2 lateral
crural grafts and 1 shield graft of the auricular concha with a covering graft of the perichondrium. Another graft of the
perichondrium was positioned between the skin and the bone in the right lateral wall. A, C, and E, Preoperative views.
B, D, and F, Postoperative views.

42 * 2010 Mutaz B. Habal, MD

Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 21, Number 1, January 2010 Perichondrium Graft

FIGURE 6. Patient subjected to 2 previous rhinoplasties with persistent deviation of the dorsal septum and underprojection
and asymmetry of the nasal tip. Revision was performed by means of 2 spreader grafts, a right lateral crural graft, and an
umbrella graft of the Peck type, all harvested from the auricular concha. A perichondrium graft was secured on top of the
cartilaginous grafts of the nasal tip. A, C, and E, Preoperative views. B, D, and F, Postoperative views.

Whichever material is used, it must be positioned between the skin involves suturing cartilaginous structures together, the use of the
and the osteocartilaginous nasal supporting structures so as to cover perichondrium to cover the edges in contact creates anatomic con-
and disguise any underlying sharp edges and asymmetries with its tinuity and provides protection against subsequent modification. In
thickness. It can also perform associated functions of filling up small this connection, it can be suggested that the structures covered by
structural gaps and retouching for the purposes of reconstruction. the perichondrium are also strengthened by it and better able to resist
Although easy to shape, crushed cartilage possesses limited the forces of scar contraction working to displace them.
flexibility, tends to fragment, and can only be obtained from the sep- The only negative aspect registered with this technique is
tum, which is often insufficient or absent in cases of repeated surgical the greater extent of swelling in the postoperative period, which in
intervention. The temporal fascia proves very suitable for wrapping any case, disappears in a few months and should thus cause no
the structures below, but its use entails further harvesting and leaves concern. It is, however, advisable to warn patients of this fact before
another surgical scar, albeit one that is not visible. An acellular dermis the operation and explain that it is a small price to pay for a better
is soft and natural despite being an allogeneic material but is also definitive result.
expensive and absorbable to a not-always-predictable degree. The
perichondrium can easily be harvested from the concha with no need CONCLUSIONS
of additional surgical approaches, and the use of auricular cartilage The technique combining a perichondrium graft with a graft
is, in any case, very frequent in secondary rhinoplasties. Its thinness of auricular concha is easy to perform and involves no additional
and malleability make it particularly suitable for covering every part harvesting sites or scars. The operating time added for removing and
of the cartilaginous grafts, and it is easy to fold into various layers preparing the material can be minimal if this takes place while
if greater thickness is required in filling certain areas. another surgeon performs the retroauricular cutaneous suture.
Numerous experimental studies have been carried out on The technique is particularly useful in revision rhinoplasties
rabbits to ascertain the potential of the perichondrium in cartilag- involving a number of cartilaginous grafts that can become visible
inous cellular regeneration.14Y16 Some more recent studies seem to over time in the presence of thin skin and lead to irregularity of the
have demonstrated the development of new cartilage subsequent to nasal contour. It is also indicated in cases that involve the suturing
vascularized perichondrial grafts.17 The perichondrium has been of sections of cartilaginous structures, which can be displaced
used solely for reconstructive purposes in nasal surgery, and there in time through scar contraction and show sharp ridges beneath the
are descriptions of operations to repair defects of the lower third with cutaneous covering. A further possibility is insertion of the peri-
perichondrial cutaneous grafts or to close perforations of the nasal chondrium graft between the 2 mucosal flaps in operations to repair
septum with perichondrial grafts adhering to the tragal cartilage.18,19 perforations of the nasal septum.
Although examination of the literature reveals no specific papers In all these cases, the perichondrium graft is easy to shape
on the use of the perichondrium graft in rhinoplasty or descriptions in accordance with requirements and secure to the surrounding
of case studies, various references to its usage are made in a number structures with sutures. Clinical experience has shown no adverse
of articles. There is a description of the use of this type of graft in effects of infection, absorption, or rejection of the graft. The only
the correction of bossae to smooth out the cartilaginous contour if negative aspect is swelling to a greater extent than usual, which
the sharp edges of the cartilage remain apparent.20 Attention has can be particularly marked at the tip but disappears slowly over time
recently been drawn to its effectiveness in revision rhinoplasties to in any case.
prevent the graft’s showing after long-term follow-up and to ensure The perichondrium graft has proved useful in optimizing the
a smooth contour in cases involving a combination of shield and long-term results of revision rhinoplasty by preventing impairment
lateral crural grafts.21,22 and blemishes of the nasal contour.
From a histological point of view, it has been recently dem-
onstrated that the grafted perichondrium does not cause encapsu- REFERENCES
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44 * 2010 Mutaz B. Habal, MD

Copyright @ 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.