CME

Frequently Used Grafts in Rhinoplasty:

Nomenclature and Analysis
Jack P. Gunter, M.D.
Learning Objectives: After studying this article, the participant should be able
Alan Landecker, M.D. to: 1. Accurately name the most frequently used grafts in primary and secondary
C. Spencer Cochran, M.D. rhinoplasty. 2. Describe the precise anatomical position of each graft. 3. Discuss
Dallas, Texas the clinical indications of each graft.
Summary: In this article, the authors present the grafting techniques most
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commonly used to sculpt the nasal framework in primary and secondary rhi-
noplasty. The grafts are described in terms of their nomenclature, anatomical
location, and clinical indications, presenting a simple and easy-to-reference
guide for both beginners and expert surgeons. (Plast. Reconstr. Surg. 118: 14e,
2006.)

I
n the last few decades, numerous grafting times the shape, position, and usage may vary
techniques have been developed to sculpt the depending on the situation and the desires of
nasal framework in primary and secondary the surgeon. However, we hope that this gen-
rhinoplasty. These techniques have originated eralized information will improve the under-
from the basic principle that maintenance of the standing and teaching of this fascinating oper-
major supporting structures of the nose is fun- ation.
damental for aesthetic and functional purposes.
Failure to maintain or furnish needed support
results in suboptimal results with deformities
that are challenging to correct. METHODS
Discussion of these grafting techniques at The most commonly utilized grafts in modern
meetings and in the plastic surgery literature has rhinoplasty are divided by alphabetical order ac-
greatly improved our results in modern rhino- cording to their intended location on the nose
plasty. However, surgeons have been confused (Table 1). With the help of the Gunter rhinoplasty
by the significant variability related to the no- diagrams (Canfield Clinical Systems), each graft is
menclature, anatomic position, and clinical in- didactically presented and analyzed in terms of its
dications for each graft. In this article, the most nomenclature, anatomical location, and clinical
commonly utilized grafts in modern rhinoplasty indications. The project was evaluated by numer-
are analyzed according to the aforementioned ous expert surgeons (see Acknowledgments) be-
factors to provide a simple and easy-to-reference fore its completion to include their experience,
rhinoplasty grafting guide for surgeons at all preferred nomenclature, and technical modifica-
levels. For the detailed surgical techniques for tions.
these grafts, the reader is referred to the related
articles in the references. Gunter Diagram System
Finally, it should be realized that this is a
generalized description of the grafts. Some- The Gunter rhinoplasty diagrams were in-
troduced in 1989 to graphically document the
From the Departments of Plastic Surgery and Otolaryngolo- intraoperative maneuvers in rhinoplasty.1 They
gy–Head and Neck Surgery, The University of Texas South- serve as valuable tools for postoperative evalu-
western Medical Center at Dallas. ation of the patient as well as effective teaching
Received for publication August 27, 2005; accepted October instruments for other surgeons learning the
12, 2005. technical steps performed in rhinoplasty. An
Presented at the 22nd Annual Dallas Rhinoplasty Sympo- individualized Gunter diagram is included to
sium, in Dallas, Texas, March 4 through 6, 2005. depict the anatomical position of each graft de-
Copyright ©2006 by the American Society of Plastic Surgeons scribed herein. The following is the color key for
DOI: 10.1097/01.prs.0000221222.15451.fc interpreting the diagrams:

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Volume 118, Number 1 • Rhinoplasty Nomenclature and Analysis

Table 1. Overview of Rhinoplasty Grafts by Region

Dorsum Tip Alar Region Base
Dorsal onlay graft Anchor graft Alar batten graft Alar base graft
Dorsal sidewall onlay graft Cap graft Alar contour graft (alar rim Columellar plumping
(lateral nasal wall graft) Columellar strut (floating/fixed- graft) grafts(s)
Radix graft floating) Alar spreader graft (lateral Premaxillary graft
Spreader grafts Columellar strut (fixed) crural spanning graft)
Septal extension grafts Extended columellar strut-tip graft Composite alar rim graft
(extended shield graft) Lateral crural onlay graft
Onlay tip graft Lateral crural strut graft
Shield graft (Sheen or infralobular Lateral crural turnover
graft) graft
Subdomal graft
Umbrella graft

Green ⫽ Autologous grafts in camouflaging sidewall irregularities. If it is

Black ⫽ Sutures and outline of anatomic struc- placed over bone, the graft is more likely to be
tures palpable or visible, because the bony base is un-
Red ⫽ Incisions and excisions yielding.
Orange ⫽ Previous incisions or excisions
Blue ⫽ Implants
Pink ⫽ Homografts (i.e., irradiated cartilage, der- Radix Graft
mal homograft, and so on) A radix graft is a single or layered dorsal graft
placed in a tight pocket created over the radix
(Fig. 3).5 If the pocket is larger than the graft,
GRAFTS OF THE NASAL DORSUM percutaneous sutures or Kirschner wires are used
Dorsal Onlay Graft to fix the graft in place. Radix grafts are used to
augment an inadequate nasofrontal angle or to
A dorsal onlay graft is a longitudinal graft used redefine the radix breakpoint further cephalad,
to augment the nasal dorsum (Fig. 1).2 While the which causes an apparent lengthening of the nose.
graft is best used to span the entire length of the The graft’s shape and thickness will depend on the
dorsum from the radix to the septal angle to avoid amount of augmentation desired. The edges
visible “step-off” deformities, it occasionally can be should be crushed or carefully beveled to avoid
used for shorter distances to correct localized de- visibility.
pressions, asymmetries, or irregularities. Septal
cartilage is the preferred source for minimal to
moderate augmentation, but costal cartilage usu- Spreader Grafts
ally is required for large augmentations. Internal Spreader grafts are usually paired, longitu-
stabilization of the costal cartilage grafts is recom- dinal grafts placed between the dorsal septum
mended to avoid warping.3 Auricular cartilage is and the upper lateral cartilages in a submuco-
used occasionally but has the disadvantage of be- perichondrial pocket (Fig. 4). Spreader grafts
ing difficult to shape so that it has a smooth sur- are used to restore or maintain the internal
face. To avoid displacement, dorsal onlay grafts nasal valve, straighten a deviated dorsal septum,
should be fixed to the underlying framework us- improve the dorsal aesthetic lines, and recon-
ing sutures and/or a percutaneous Kirschner wire. struct an open roof deformity.6 Septal cartilage
is the preferred source of the grafts, whose
length and shape may vary depending on the
Dorsal Sidewall Onlay Graft (Lateral Nasal Wall indication. The grafts may extend above the
Graft) level of the dorsal septum to slightly augment
Dorsal sidewall onlay grafts are placed along the dorsum (pistol grafts) or caudally beyond
the lateral side of the nose and are different shapes the septal angle to lengthen the nose or to in-
and sizes depending on the indications (Fig. 2).4 crease tip projection (see Septal Extension
They are used to combat localized lateral depres- Grafts). The grafts should be suture-fixated to
sions or asymmetries of the body of the nose and the septum before reapproximation of the up-
especially to camouflage collapse of the upper per lateral cartilages to the septum-spreader
lateral cartilages. The graft may be crushed to aid graft complex.

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Fig. 1. Dorsal onlay graft.

Fig. 2. Dorsal sidewall onlay graft (lateral nasal wall graft).

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Fig. 3. Radix graft.

Fig. 4. Spreader grafts.

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Septal Extension Grafts Cap Graft

Septal extension grafts are used to control the A cap graft is a small graft placed in the space
projection, support, shape, and rotation of the tip between the tip-defining points and the middle
and are dependent on the presence of a stable cau- crura (Fig. 7). The graft is used to refine, soften,
dal septum (Fig. 5).7 They also help to create a su- and fill in clefts of the nasal tip in patients with thin
pratip break. The grafts are divided into three types. skin, to minimally enhance tip projection and oc-
Type I grafts function as paired dorsal spreader casionally refine the infratip lobule area.9 The pre-
grafts that extend beyond the anterior septal angle ferred source of cartilage is from remnants ob-
into the interdomal space. Type II grafts are paired tained from the cephalic trim of the lower lateral
batten grafts that extend diagonally across the cau- cartilages, but septal, auricular, or rib cartilage
dal-dorsal junction of the septal L-strut into the tip- may also be utilized.
lobule complex. A type III graft functions as a direct
extension graft affixed to the anterior septal angle.
Although septal cartilage is the preferred source of Columellar Strut (Floating/Fixed Floating)
the grafts, both auricular cartilage and rib cartilage A floating columellar strut is a graft placed in
can be used.
a tight pocket dissected between the medial crura
through a small incision caudal to the feet of the
GRAFTS OF THE NASAL TIP medial crura (endonasal approach) (Fig. 8).10 The
Anchor Graft fixed-floating columellar strut (open approach) is
The anchor graft is an anchor-shaped graft sutured to the medial crura for stabilization. A 2-
whose shaft is sutured to the caudal margin of the to 3-mm pad of soft tissue is usually maintained
medial crura (Fig. 6). The transverse components between the graft and the nasal spine to keep the
(wings) may replace the lateral crura or lie over graft from moving back and forth over the spine
their remnants and are sutured to them. Anchor with lip movements.11 The columellar strut helps
grafts may be used to improve tip support and/or in maintaining tip support and increasing tip pro-
projection and collapse or deformation of the lat- jection and aids in shaping the columellar-lobular
eral crura.8 The graft is harvested from the auric- angle. Septal cartilage is preferred, but costal car-
ular concha and is then designed according to the tilage is used when a stronger strut and more
patient’s needs. Symmetrical carving of the wings enhanced projection are desired. Auricular carti-
may be difficult due to the asymmetries of the lage may be used, but a double layer should be
conchal bowl. used if strength is needed.

Fig. 5. Septal extension grafts.

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Fig. 6. Anchor graft.

Fig. 7. Cap graft.

Columellar Strut (Fixed) septal cartilage because it is too thin). The Kirsch-
Columellar struts may be fixed to the nasal ner wire should be inserted up to three-quarters of
spine or premaxilla to give more stable support to the length of the strut, with 10 mm left exposed at
the nasal tip (Fig. 9). A fixed columellar strut is the the base. This is then placed in a 12-mm drill hole
most effective way of increasing tip projection with just lateral to the maxillary midline, parallel and
a strut and can also aid in lengthening the nose.3 inferior to the nasal floor. When fixed with a
When using rib cartilage, more stabilization and Kirschner wire, the medial crura can be advanced
control are obtained by using a 0.035-inch and sutured to the strut to control projection, and
threaded Kirschner wire inserted longitudinally in rotation can be controlled by the angle made in
the strut (a Kirschner wire cannot be placed in the Kirschner wire at the base of the strut.

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Fig. 8. Columellar strut (floating/fixed floating).

Fig. 9. Columellar strut (fixed).

Extended Columellar Strut-Tip Graft (Extended lized in a tight pocket in the precrural space (en-
Shield Graft) donasal approach) or by placing it caudal to or
The extended columellar strut-tip graft is an between the medial crura and suturing it in place
elongated, shield-shaped graft that lies caudal to to the crura (open approach). The anterior end of
or between the medial crura and extends anteri- the graft is rounded and shaved extremely thin to
orly to project beyond the domes and posteriorly prevent visibility. The further the tip of the graft
toward the medial crural footplates (Fig. 10).12 extends above the tip-defining points, the more it
The graft is used to provide tip support, projec- will tend to bend backward. If the bending is more
tion, definition, and fullness caudal to the medial than desired, a small rectangular block of cartilage
crura to aid in shaping the columella. It is stabi- may be sutured to the domes behind the graft.

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Fig. 10. Extended columellar strut-tip graft (extended shield graft).

Fig. 11. Onlay tip graft.

This results in increased stability and a barrier minimally increase tip projection but mainly to
against bending upward with loss of tip projection camouflage tip irregularities. The edges of the
and increased infratip lobular show. graft must be beveled or crushed to avoid post-
operative visibility. This graft acts as the transverse
Onlay Tip Graft component of the umbrella graft.
An onlay tip graft is a single or multilayered
graft placed horizontally over the alar domes (Fig. Shield Graft (Sheen or Infralobular Graft)
11).13 It is placed in a tight pocket if the endonasal This shield-shaped graft is placed adjacent to
approach is used or sutured for stabilization in the the caudal edges of the anterior middle crura,
open approach. The onlay tip graft is used to extending into the tip (Fig. 12).14 The shield graft

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is used to increase tip projection, define the tip, The graft edges should be beveled or lightly mor-
and improve contour of the infratip-lobule. Ad- selized to make them softer and less visible.
ditional tip projection can be achieved by moving
the graft more anteriorly above the tip. If used with Subdomal Graft
the endonasal approach, it is stabilized by placing A subdomal graft is a bar-shaped graft placed in a
it in a tightly undermined pocket. If the open pocket under the domes (Fig. 13).16 The subdomal
approach is used, it is sutured to the caudal mar- graft corrects dome asymmetry by controlling the hor-
gins of the cartilages.15 To avoid excessive cepha- izontal and vertical orientation of the domes. It may
lad tilting of the graft, a small “block” graft can be also be used to correct the pinched nasal tip deformity.
sutured to the alar domes to increase the stability. Septal cartilage is the preferred graft material.

Fig. 12. Shield graft (Sheen or infralobular graft).

Fig. 13. Subdomal graft.

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Umbrella Graft problem, the longer and wider the graft will need to
The umbrella graft is composed of a vertical be. They are not as effective as lateral crural strut
columellar strut combined with a horizontal on- grafts in patients with significant alar scarring, loss of
lay graft (Fig. 14).17 This graft is used in patients vestibular skin, or absent lower lateral cartilages.
with both inadequate tip projection and inade-
quate support. The edges of the graft’s trans- Alar Spreader Graft (Lateral Crural Spanning
verse component should be beveled or mor- Graft)
selized to avoid postoperative visibility. It is An alar spreader graft is a single bar graft that
usually stabilized by placing the transverse com- bridges the intercrural space, with the ends of the
ponent in a small tight pocket (endonasal ap- grafts placed in an undermined pocket between
proach) or by suturing it to the domes of the the lateral crura and vestibular skin (Fig. 17).21
lateral crura (open approach). The graft is sutured to the lateral crura for stabi-
lization. It is used to correct or prevent the
GRAFTS OF THE ALAR REGION pinched nasal tip deformity by controlling the
Alar Batten Grafts distance between and providing support to the
Alar batten grafts are nonanatomic grafts placed lateral crura. This graft improves both external
in a pocket extending from the piriform aperture to and internal valve dysfunction by correcting the
a paramedian position in the alar sidewall at the site collapse of the crura. The shape (triangular or
of maximal lateral nasal wall collapse during inspi- bar-shaped) and size of the graft will vary depend-
ration (Fig. 15).18,19 The alar batten graft can be ing on the severity of the deformity.
extended caudal to the area of the lateral crus to
correct external valve dysfunction caused by loss of Composite Alar Rim Graft
support from overresected lateral crura. Alterna- A composite alar rim graft is a composite skin–
tively, the graft can be placed cephalad to the lateral conchal cartilage graft harvested from the concha
crus for internal valve collapse. cymba or concha cavum and placed along the
intranasal alar rim (Fig. 18).22,23 It is used to cor-
Alar Contour Grafts (Alar Rim Grafts) rect moderate to severe alar retraction or notch-
Alar contour grafts are used to correct or prevent ing not amenable to other techniques, to correct
alar retraction or collapse (Fig. 16).20 These grafts asymmetries in alar rim height, and to combat
are placed in a subcutaneous pocket immediately nostril or vestibular stenosis. The skin of the graft
above and parallel to the alar rim and must span the should be sutured to the edges of the defect in the
length of the alar deformity. The more severe the vestibule. Percutaneous sutures are often used to

Fig. 14. Umbrella graft.

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Fig. 15. Alar batten graft.

Fig. 16. Alar contour graft (alar rim graft).

stabilize the graft. If the donor site cannot be 19).24 It is used to correct alar contour irregu-
closed primarily, it is closed with a full-thickness larities caused by a deformed, intact lateral crus.
postauricular skin graft. These grafts are used to strengthen and shape
the ala and may improve external valve dysfunc-
Lateral Crural Onlay Grafts tion. However, graft placement superficial to the
The lateral crural onlay graft is placed over lateral crus may be visible as a “step-off” at the
the existing lateral crus as an onlay graft (Fig. anterior end and cephalic margin of the graft.

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Fig. 17. Alar spreader graft (lateral crural spanning graft).

Fig. 18. Composite alar rim graft.

The edges of the graft must be carefully beveled stabilized by suturing it to the crus (Fig. 20).25 It
if this is to be avoided. is used to correct alar retraction, alar rim collapse,
and concave, convex, or malpositioned lateral
crura. The lateral end of the graft is usually placed
Lateral Crural Strut Graft superficial to the piriform aperture rim to avoid
The lateral crural strut graft is a graft placed medial displacement of the graft. The under-
in an undermined pocket between the undersur- mined lateral pocket should be inferior to the alar
face of the lateral crus and the vestibular skin and groove to avoid visibility of the end of the graft.

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Fig. 19. Lateral crural onlay graft.

Fig. 20. Lateral crural strut graft.

The more inferiorly the pocket is placed, the lower but does not separate. The original cephalic mar-
the alar rim will be displaced. Septal cartilage is the gin of the crus is sutured to the caudal margin.
preferred source of grafting material, but costal Turndown cephalic lateral crural grafts are used to
cartilage may be required in the graft-depleted increase the strength of the lateral crura or to
patient. straighten convex or concave lateral crura. The
thicker and stronger the lateral crus, the more
effective it is.
Lateral Crural Turnover Graft
The turndown cephalic lateral crural graft is
GRAFTS OF THE ALAR BASE
created from the cephalic portion of the lateral
crus after the vestibular skin is undermined from Alar Base Graft
its undersurface (Fig. 21).26 The lateral crus is An alar base graft is a graft placed along the
incised partial thickness on the undersurface lateral piriform aperture to augment a recessed
along its length so that the crus is halved longi- lip-alar base junction (Fig. 22). Carved cartilage
tudinally. This allows the graft to be turned su- grafts have been used but are difficult to shape and
perficial to the caudal segment, so that it breaks stabilize. While some surgeons still use these

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Fig. 21. Lateral crural turnover graft.

Fig. 22. Alar base graft.

grafts, hydroxyapatite granules or other alloplastic gle or to correct minor posterior columellar con-
implants are preferred by others.27 tour deformities.

Columellar Plumping Graft(s)

Columellar plumping grafts are usually com- Premaxillary Graft
posed of diced or morselized cartilage that is A premaxillary graft is a graft that is typically
placed in the space between the medial crura foot- placed along the caudal border of the piriform
plates and the nasal spine (Fig. 23). Their purpose aperture (Fig. 24).28 The premaxillary graft is used
is to augment an inadequate columellar-labial an- to correct premaxillary recession. Again, these

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Fig. 23. Columellar plumping graft(s).

Fig. 24. Premaxillary graft.

grafts are difficult to carve and stabilize, and many P. Gruber, M.D., Bahman Guyuron, M.D., Robert M.
surgeons use alloplastic material for these grafts. Oneal, M.D., Norman J. Pastorek, M.D., Stephen W.
Perkins, M.D., Rod J. Rohrich, M.D., Samuel Stal,
Jack P. Gunter, M.D.
Suite 170
M.D., Eugene M. Tardy, M.D., and Dean M. Toriumi,
8144 Walnut Hill Lane M.D., for the valuable suggestions that improved the
Dallas, Texas 75231 content of this project.
drgunter@drjackgunter.com

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ACKNOWLEDGMENTS
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The authors thank William P. Adams, Jr., M.D., H. in rhinoplasty: The missing link for evaluating rhinoplasty
Steve Byrd, M.D., Mark B. Constantian, M.D., Ronald results. Plast. Reconstr. Surg. 84: 204, 1989.

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2. Gunter, J. P., and Rohrich, R. J. Augmentation rhinoplasty: 15. Johnson, C. M., Jr., and Toriumi, D. M. Open Structure Rhi-
Dorsal onlay grafting using shaped autogenous septal carti- noplasty. Philadelphia: Saunders, 1990.
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3. Gunter, J. P., Clark, C. P., and Friedman, R. M. Internal graft. Plast. Reconstr. Surg. 113: 1037, 2004.
stabilization of autogenous rib cartilage grafts in rhino- 17. Peck, G. C., Jr., Michelson, L., Segal, J., and Peck, G. C. An
plasty: A barrier to cartilage warping. Plast. Reconstr. Surg. 18 year experience with the umbrella graft in rhinoplasty.
100: 161, 1997. Plast. Reconstr. Surg. 102: 2158, 1998.
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metrical nose. Plast. Reconstr. Surg. 83: 801, 1989. secondary to alar and nasal valve collapse: Technique for
5. Becker, D. G., and Pastorek, N. J. The radix graft in cosmetic repair using autogenous cartilage. Oper. Tech. Otolaryngol.
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roof of the middle nasal vault following rhinoplasty. Plast. Use of alar batten grafts for correction of nasal valve collapse.
Reconstr. Surg. 73: 230, 1984. Arch. Otolaryngol. Head Neck Surg. 123: 802, 1997.
7. Byrd, H. S., Burt, J. D., Andochick, S., Copit, S., and Walton, 20. Rohrich, R. J., Raniere, J., Jr., and Ha, R. Y. The alar contour
K. G. Septal extension grafts: A method for controlling tip graft: Correction and prevention of alar rim deformities in
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tip with alar spreader grafts. Plast. Reconstr. Surg. 90: 821, 1992.
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22. Constantian, M. B. Indications and use of composite grafts
columellar collapse. Plast. Reconstr. Surg. 82: 160, 1988.
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9. Rohrich, R. J., Adams, W. P., Jr., and Deuber, M. A. Gradu-
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Gunter, R. J. Rohrich, and W. P. Adams, Jr., Dallas Rhinoplasty:
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Medical Publishing, 2002. P. 354. Facial Plast. Surg. Clin. North Am. 1: 79, 1993.
10. Anderson, J. R. A new approach to rhinoplasty: A five-year 24. Watson, D., and Toriumi, D. M. Structural grafting in
reappraisal. Arch. Otolaryngol. 93: 284, 1971. secondary rhinoplasty. In J. P. Gunter, R. J. Rohrich, and
11. Gunter, J. P. Personal approaches: Gunter’s approach. In J. P. W. P. Adams, Jr., Dallas Rhinoplasty: Nasal Surgery by the
Gunter, R. J. Rohrich, and W. P. Adams, Jr., Dallas Rhinoplasty: Masters, 1st Ed. St. Louis, Mo.: Quality Medical Publishing,
Nasal Surgery by the Masters, 1st Ed. St. Louis, Mo.: Quality 2002. P. 705.
Medical Publishing, 2002. P. 1049. 25. Gunter, J. P., and Friedman, R. M. Lateral crural strut graft:
12. Pastorek, N. J., Bustillo, A., Murphy, M. R., and Becker, D. G. Technique and clinical applications in rhinoplasty. Plast.
The extended columellar strut-tip graft. Arch. Facial Plast. Reconstr. Surg. 99: 943, 1997.
Surg. 7: 176, 2005. 26. McCollough, E. G., and Fedok, F. G. The lateral crural turn-
13. Peck, G. C, Peck, G. C., Jr., and Adams, W. P., Jr. Long-term over graft: Correction of the concave lateral crus. Laryngo-
follow-up of the onlay tip graft and umbrella graft. In J. P. scope 103: 463, 1993.
Gunter, R. J. Rohrich, and W. P. Adams, Jr., Dallas Rhinoplasty: 27. Pessa, J. E., Peterson, M. L., Thompson, J. W, Cochran, C. S,
Nasal Surgery by the Masters, 1st Ed. St. Louis, Mo.: Quality and Garza, J. R. Pyriform augmentation as an ancillary pro-
Medical Publishing, 2002. P. 292. cedure in facial rejuvenation surgery. Plast. Reconstr. Surg.
14. Sheen, J. H. Achieving more nasal tip projection by the use 103: 683, 1999.
of a small autogenous vomer or septal cartilage graft: A 28. Sheen, J. H. Adjunctive techniques: Maxillary augmentation.
preliminary report. Plast. Reconstr. Surg. 56: 35, 1975. In Aesthetic Rhinoplasty. St. Louis, Mo.: Mosby, 1978. P. 194.

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