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Page 6 of 10 Rajbhandari et al. Plast Aesthet Res 2019;6:8 I http://dx.doi.org/10.20517/2347-9264.2018.86

Figure 9. Intraoperative picture showing graft placement for dorsal augmentation

A B

Figure 10. A: Medial portion of harvested rib cartilage carved into a dorsal onlay graft and the remaining lateral portion; B: the lateral
portion of the harvested rib is split into three pieces which are used as caudal septal extension graft and splint grafts

of the harvested rib, for better fixation of the onlay graft over the underlying nasal framework. If the patient
requires or wishes for a higher dorsum, we can assemble an additional rib cartilage underneath the onlay
graft, carved to mingle with the underlying nasal framework and raise the overlying harvested rib for dorsal
augmentation. Carving is done carefully to taper the margins of the rib so as not to make the graft too
obvious or visible postoperatively. The caudal end of the rib graft is narrowed which harmonizes with the
nasal bridge. While carving, we make sure that the end result is not a very narrow looking nose, nor is it
too broad. We always keep in mind that a graft that is too narrow might not be in tone with the rest of the
Asian facial features. We seldom use diced cartilage for dorsal augmentation as its absorption rate is very
unpredictable and the nasal skin surface may appear irregular.

Splint grafts are carved either from the remaining septum or the harvested rib. The lateral or shorter part of
the L-shaped harvested rib, is split into three identical grafts. The grafts are sliced in a longitudinal direction.
The central part of the sliced rib is generally used as a caudal septal extension graft (CSEG) to minimize
warping. The CSEG is carved into an approximately 2 mm thick graft. The length and height of the rib graft
to be carved into a CSEG can be manipulated according to the requirements of the patient. The peripheral
sliced grafts are further carved into spreader grafts or splint grafts [Figure 10]. The splint grafts are shaped as
a trapezoid - the key point is that they need to support the septal cartilage along with the CSEG and form a
strong platform. The remaining cartilage from the medial rib, after carving out the required amount needed