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Page 8 of 16 Won et al. Plast Aesthet Res 2019;6:6 I http://dx.doi.org/10.20517/2347-9264.2018.82

Figure 9. Warping of the costal cartilage

A B

C D

Figure 10. A dorsal onlay graft carved from a rib cartilage. A straight portion of the harvested rib cartilage is selected (A); the peripheral
portion is excised leaving a central portion for additional carving (B); the final graft has a canoe-like shape from the frontal view and a
slightly convexity in the dorsal side when seen from the lateral view (C); insertion of the dorsal graft (D)

of migration [Figure 11]. When wide dissection of the dorsal skin is necessary, fixation of the carved rib
cartilage needs additional procedures. A K-wire fixation for two weeks or transcutaneous suture fixation of
the graft to the nasal bony pyramid helps to stabilize the graft [Figure 12].

Dorsal augmentation with layered costal cartilage
Alternatively, the costal cartilage can be cut in layers or long strips which can be stacked to be used as the
dorsal graft. Usually strips of 1.0-1.5 cm by 3-4 cm with 1mm thickness are used. Obtaining strips with
consistent thickness is not easy. Using a dermatome blade is helpful to achieve this goal [Figure 13]. The
number of strips to stack depends on the desired dorsal height and are sutured with 5-0 PDS or nylon.
More often than not, the strips bend or warp. By stacking the warped strips in a way that can counteract
the forces of one another can succeed in obtaining a straight dorsal graft. Special care is taken to bevel all
the edges. Fascia or perichondrium is used to cover and camouflage the graft.