10.1.1 Septal Cartilage (First Choice)

Cartilage from the nasal septum has good stability and elasticity. The Rubin cartilage morselizer can be used to squeeze cartilage with careful, controlled pressure to alter its bending properties without damaging the cartilage tissue. The cartilage remains pressure-stable and changes its bending properties without fraying when worked by gentle pressure ( Fig. 10.1 ). Generally speaking, the properties of the cartilage should be altered as little as possible. The cartilage can be harvested through a hemitransfixion incision or a posterior endoscopic endonasal approach.

10.1.2 Alar Cartilage

Pieces of alar cartilage, usually from the upper lateral crura, can be used for augmentation of the nasal dorsum or tip. Because of their thinness, they are excellent grafts for superficial contouring.

10.1.3 Conchal Cartilage (Second Choice)

As Tardy observed, “the external ear exists as a marvelous storehouse of skeletal spare parts for the nose.” ² Conchal cartilage is dimensionally stable, resilient, and provides good mechanical support for applications in the nose. It can be harvested quickly and easily ( Fig. 10.2 ).

One advantage of conchal cartilage is its varieties of convexities and concavities, which can be matched as needed to specific recipient sites in the nose. ⁴ Conchal cartilage can be used for the replacement of septal cartilage, upper lateral cartilage, and alar cartilage. It can be used in the form of a shield graft, tip graft, alar button graft, or columellar strut ( Fig. 10.3 ). It is often recommended that connective tissue be left on the cartilage when the graft is harvested, as that will be helpful for reconstructing larger defects in the nasal dorsum. Conchal cartilage is easy to carve with a scalpel. It is extremely difficult to compress, however, as the slightest pressure will cause it to fray. The implanted graft should heal without difficulty and is highly resistant to resorption.

10.1.4 Tragal Cartilage

Tragal cartilage is harvested through an incision made with a No. 15 blade just behind the anterior border and directed toward the ear canal. It can be harvested along with two small perichondrial flaps, which can be dissected quickly and easily. The cartilage is thin but very strong. The perichondrium undergoes less postoperative swelling than fascia.

10.1.5 Costal Cartilage

Costal cartilage is used in cases that require a stable reconstruction due to extensive loss of structural support. It is harvested from the sixth or seventh rib through a 4- to 5-mm skin incision, which in women is placed in the inframammary crease ( Fig. 10.4 ). The perichondrium is incised, and the costal cartilage is harvested within a perichondrial sleeve. Rib cartilage should be “balanced,” meaning that only the central portions of the cartilage should be used for grafting. One disadvantage of costal cartilage is its unnatural consistency in the nasal dorsum, for example. It makes the nose stiff, and even a perfectly healed graft may create a foreign-body sensation.