Management of the keel nose and associated valve collapse

OBJECTIVES: To analyze the anatomical abnormality of the keel nose and correlate the findings with etiologic maneuvers of a routine rhinoplasty procedure; to identify the contributing factors and offer suggestions to avoid or decrease the severity of these surgical complications; and to present an effective revisional procedure to correct the functional and cosmetic consequences of this deformity. PATIENTS AND METHODS: A total of 47 patients (31 women and 16 men; age range, 18-71 years) with a keel-appearing nose presented for revision rhinoplasty. All had undergone at least 1 rhinoplasty procedure, and 39 had undergone 2 or more previous nasal procedures. All patients had bilateral lateral nasal wall collapse and an associated severely compromised internal nasal valve. All patients underwent reconstruction with a conchal cartilage overlay graft. RESULTS: All patients had a moderate to excellent cosmetic improvement; the subjective improvement in nasal airway was more dramatic. Since patients with a keel nose have an associated internal valve collapse, both abnormalities are addressed simultaneously with the conchal cartilage overlay repair, which results in minimal morbidity with no major complications. CONCLUSIONS: Conchal cartilage overlay repair uses a cartilage graft from the auricle with a recommended external rhinoplasty for placement. Appropriate sizing and fashioning precede the precise placement and suture fixation. This technique addresses both functional and cosmetic abnormalities.     

Experience harvesting costal cartilage under IV sedation

ImportanceWhile numerous techniques for costal cartilage harvesting have been described, one consistency in the published literature is that the procedure is performed under general anesthesia. This is the first report to offer IV sedation as a safe alternative to general inhalational anesthesia in cases involving costal cartilage harvesting.ObjectiveTo determine the feasibility and safety of costal cartilage harvest with IV sedation.DesignA retrospective chart review was performed of 116 rhinoplasty patients who underwent harvest of costal cartilage grafts under IV sedation from 2005 to 2019.SettingPrivate practice of senior author (AF) at Lasky Clinical Surgical Center.ParticipantsConsecutive patients who underwent cosmetic and/or functional rhinoplasty.Main outcome & measuresThe number of cases involving a pneumothorax, size of the pleural injury, radiographic findings, repair technique and treatment for pneumothorax were all recorded.ResultsThere were 7 cases involving a pleural tear (size range 3-8 mm) during costal cartilage harvest and each of these was repaired intra-operatively. All 7 patients remained clinically stable in recovery room on 2 L of oxygen. Although clinically stable, one patient had radiologic evidence of a pneumothorax of 50%, and thus she was transferred to a hospital for placement of a Heimlich tube with overnight observation.Conclusions and relevanceAlthough plenural tears can be attributed to surgical technique rather than the type of anesthesia, these cases do provide valuable insight to the fact that successful management of such complications can be accomplished without the need for general anesthesia.     

Stabilizing cartilage grafts in functional-aesthetic rhinoplasty

BACKGROUND: While traditionally most rhinoplastic operations were dominated by tissue resection, more and more surgeons emphasize the importance of restructuring and stabilizing the nose by cartilage grafts and suture techniques. This development in rhinosurgery is the result of long term experience showing that insufficient stabilization of nasal structures often leads to sequelae such as nasal valve collapse and tip ptosis, even decades after surgery. METHOD: Brief survey of five of the most important stabilizing cartilage grafts, i. e. spreader grafts, lateral crural grafts, alar batten grafts, the columellar strut graft, and the septal extension graft, with presentation of case reports. RESULT AND CONCLUSION: Cartilage grafts play a key role in the pursuit of obtaining functionally and aesthetically durable long term results in rhinoplasty.     

Alar batten grafting for management of the collapsed nasal valve

OBJECTIVE: The purpose of the study is to describe a commonly overlooked etiology of nasal airway obstruction. Collapse of the nasal valve can be corrected with precise placement of cartilage grafts. This study demonstrates the surgical technique, rarely described in the literature, of placing a contoured cartilage graft in the nasal valve region for the improvement of the nasal airway. STUDY DESIGN: Retrospective review of surgical results of the 21 patients who underwent alar batten grafting performed over a 3-year period at the Geisinger Medical Center (Danville, PA). METHODS: A retrospective review was conducted of 21 patients surgically treated with alar batten grafts for nasal valvular collapse between the 1997 and 1999. The surgical technique is described, and our results are analyzed including for both functional and aesthetic outcome. RESULTS: All patients treated with alar batten grafting at the nasal valve improved with regard to their airway obstruction. There were no complications, and there was only minor aesthetic fullness in six cases. CONCLUSIONS: Alar batten cartilage grafting is an easy, highly effective therapeutic measure in the treatment of nasal valve collapse. The surgical technique is demonstrated.     

Auricular cartilage grafts and nasal surgery

OBJECTIVE: To illustrate the safety, effectiveness, and versatility of auricular cartilage grafts in nasal surgery. STUDY DESIGN: Retrospective chart review of the author's nasal surgery experience for an 8-year period. METHODS: Five hundred eight rhinoplasties were performed over an 8-year period. One hundred one of these cases used auricular cartilage grafts as donor material. RESULTS: Donor cartilage was used in a wide range of grafting techniques: tip grafts, dorsal onlays, spreader grafts, septal replacements, alar battens, composite grafts, etc. The average follow up was 12 months. The complication rate was low. Five patients experienced complications involving the auricular cartilage graft or its donor site. No patients experienced graft resorption or infection. Donor site morbidity was limited. No auricular infections or hematomas were observed. CONCLUSION: Septal cartilage is usually the first choice as donor material in nasal surgery; however, when indicated, auricular cartilage grafts can serve as a safe, effective, and versatile alternative. This conclusion is supported by their successful use in a wide variety of surgical techniques, with long-term follow-up. The author feels strongly that autografts should be favored over alloplastic material. Alloplastic grafts continue to present a risk of infection over the entire life of their use. When a rhinoplasty is performed skillfully with a cartilage autograft, time becomes an ally of the surgeon rather than an enemy.     

Central segment harvest of costal cartilage in rhinoplasty

Objectives/Hypothesis:

Our objective was to review our experience with a conservative central boat harvest of costal cartilage in patients undergoing rhinoplasty. It involves taking only the central portion of the rib for reconstruction. When cartilage harvest is performed in the above manner, donor site morbidity is minimized without limiting aesthetic results. The key seems to be preservation of intact costal cartilage on three sides, limiting harvest to the central portion only. This central portion is straight and much less prone to warping than the cartilage toward the periphery.

Study Design:

A retrospective review of a single surgeon's experience.

Methods:

All rhinoplasty operations performed by the senior author (Y.D. ) from January 2000 to August 2009 that required the harvest of rib cartilage were reviewed.

Results:

A total of 322 cases were identified in which rib cartilage was harvested via the described technique. In all cases sufficient cartilage volume was obtained for the intended purpose. Average operation time was 10 minutes. No drains were used, and only one patient developed seroma formation. Postoperative pain and scar were minimal. No major complications were noted, and on postoperative analysis there was no evidence of cartilage warping or displacement.

Conclusions:

When harvesting costal cartilage for rhinoplasty, the above technique allows for sufficient graft tissue while decreasing donor site morbidity and minimizing warping.     

Spreader graft in septo-rhinoplasty

Background The aim of study was to evaluate the effects of spreader graft in septorhinoplasty. Materials and Methods The study group comprised of 33 patients of various nasal deformities who underwent consecutive septorhinoplasty at Asan Medical Center, University of Ulsan, College of Medicine, Republic of Korea (South Korea). All the patients had undergone open rhinoplasty procedure. The submucous resection of septum was done, leaving 1 to 1.5 cm. of septal cartilage for dorsal and caudal support. The spreader graft was harvested from septal cartilage in 31 cases and costal cartilage in 2 cases. All the patients had undergone endonasal high to low to high osteotomy, paramedian osteotomy and percutaneous transverse osteotomy.The periosteum was not elevated in any case. The spreader graft was placed and secured with septal cartilage and upper lateral cartilage with suture material. Crushed small pieces of septal cartilage were used for dorsal augmentation. The tutuplast fascia lata was used to camouflage the dorsal irregularity. Conclusion All the cases had good aesthetically dorsal line, opening of internal nasal valve area and good septal support, which was weakened by the removal of deviated septum.     

Open structure rhinoplasty

Open structure rhinoplasty (OSR) uses the open or external approach via a mid-columellar and bilateral marginal incision. In combination with grafting procedures, such as columellar struts, dorsal grafts and tip grafts, rhinoplasty has developed from a merely reductive procedure to a more graduated approach to the nose. Emphasis is now placed on repositioning, augmentation and restructuring the nassal anatomy to create as natural and fuctional a nose as possible. This retrospective study analyses our experience with 130 rhinoplasties over a 3-year-period. The study reveals OSR to be a safe and reliable technique which produces predictable results.     

The effect on snoring of structural nasal valve dilatation with a butterfly graft

OBJECTIVE: To evaluate the effect on snoring of structural nasal valve dilatation with butterfly spreader grafts in patients with nasal valve insufficiency. DESIGN: Retrospective medical chart review and telephone follow-up; mean +/- SD follow-up time, 20.7 +/- 11.34 months (range, 3-48 months). SETTINGS: Tertiary care referral center. SUBJECTS: A total of 37 snoring patients with nasal valve insufficiency who underwent nasal valve dilatation with a butterfly spreader graft. INTERVENTIONS: The conchal cartilage butterfly graft technique was performed during rhinoplasty through either an external or endonasal approach. MAIN OUTCOME MEASURE: To establish through a retrospective review that butterfly graft conchal cartilage nasal reconstruction is effective in reducing snoring. RESULTS: After surgery, 30 patients (81%) had significant improvement in breathing, 5 (14%) had slight improvement, and 2 (5%) had no benefit in breathing. Snoring stopped completely in 11 (30%) of the patients after surgery. The improvement in snoring was significant in 13 patients (35%) and slight in 3 (8%). Twenty-six patients (70%) reported tiredness and grogginess on awakening before the surgery. Surgery significantly improved patients' tiredness and grogginess on awakening in 15 cases (58%), slightly improved them in 5 (19%), and did not change the patients' tiredness and grogginess in 6 cases (23%). CONCLUSION: The conchal cartilage butterfly graft yields successful results not only in breathing but also in snoring symptoms in patients with nasal valve insufficiency.     

Vascularized radial forearm free tissue transfer for lining in nasal reconstruction

OBJECTIVES/HYPOTHESIS: Total and near-total nasal reconstruction requires the surgeon to replace external nasal cover, skeletal support, and internal nasal lining. The successful result must re-create the form and function of the original nose. In large defects, traditional sources of internal lining may be unavailable. The study describes the recreation of nasal lining in three patients with extensive nasal defects with vascularized radial forearm tissue. STUDY DESIGN: Retrospective review of three patients who underwent nasal reconstruction with radial forearm for internal lining, costal cartilage grafts for skeletal support, and paramedian forehead flap for cover. METHODS: The charts of three patients who underwent total nasal reconstruction with radial forearm tissue transfer for lining were retrospectively reviewed. The technique was evaluated. The authors present a method for internal lining reconstruction in extensive nasal defects. They discuss the advantages and disadvantages of this method. RESULTS: Three patients underwent successful total nasal reconstruction with radial forearm tissue transfer for lining, costal cartilage for skeletal support, and paramedian forehead flap. None of the patients had adequate septal mucosa or nasal subunit skin to support mucosal rotation grafts or epithelial turn-in flaps. All patients have completed reconstruction and have satisfactory nasal form and function. Loss of the lining flap or graft loss did not occur. CONCLUSION: Vascularized radial forearm tissue supplies ample quantities of skin to recreate nasal lining. The tissue provides excellent support of graft material, and it prevents contracture of the covering flap. Because of its bulk and donor site morbidity, free forearm tissue transfer should not be considered for reconstruction of smaller defects when another lining flap will suffice.     

Management of severe bilateral nasal wall collapse

OBJECTIVE: The aim of this study was to examine and analyze the pathology contributing to severe bilateral nasal wall collapse seen in certain revision rhinoplasty patients and identify those surgical maneuvers in the previous nasal surgery, which may have contributed to this complication; suggest alternatives or modifying steps in nasal surgery to prevent lateral wall collapse; analyze consecutive revision rhinoplasties and identify those patients who have complete bilateral nasal collapse at the internal nasal valve; and analyze the results achieved after surgical reconstruction of complete bilateral nasal collapse. PATIENTS: We identified 49 patients, who presented from 1990 to 2000 for revision surgery, who had bilateral collapse of the upper lateral cartilage. All patients had at least one previous rhinoplasty and all but 14 patients had undergone two or more procedures. The patients were reconstructed with a conchal cartilage graft placed through an external rhinoplasty approach. RESULTS: All patients complained of nasal obstruction with forced nasal inspiration. The collapse was visualized on inspiration and when prevented with intranasal positioning of a bayonet, all patients experienced an immediate improvement in nasal breathing. Postoperatively, all patients experienced this same improvement in their nasal airway. Collapse was not identified in any of the patients after surgery. Two patients underwent revision because of cosmetic asymmetries. CONCLUSION: We strongly recommend a cartilage overlay to reconstitute the rigid midline continuity of the upper lateral cartilages. Unfortunately, with any significant hump removal, this structural interruption is, to varying degrees, inevitable in most rhinoplasty techniques. The upper lateral cartilages can be sutured to circumvent some of the inferior drift, but this will not reconstitute the rigid lateral cantilever effect of the intact cartilage.     

The 'butterfly' graft in functional secondary rhinoplasty

OBJECTIVE: To describe a surgical technique (the conchal cartilage "butterfly" graft) which, when used in properly selected patients, has been found to be a dependable method for alleviation of postrhinoplasty internal nasal valve dysfunction. STUDY DESIGN: Retrospective chart review. METHODS: Analysis of consecutive patients with weakness and/or collapse of the upper lateral cartilages following rhinoplasty. Seventy-two patients (37 women and 35 men, age range 17-76 y) had severe nasal obstruction and were found to have indications for this procedure. All patients had undergone at least one rhinoplastic procedure. All patients were followed for a minimum of 2 years after surgery. RESULTS: All 72 patients experienced significant subjective improvement in relative nasal obstruction. Two patients (3%) reported less than total resolution of their difficulty breathing through their nose; the remaining 70 patients (97%) reported complete resolution of their nasal airway problems. No patients reported their postoperative nasal obstruction as the same or worse than their preoperative baseline. Sixty-two patients (86%) reported improvement in the appearance of their nose, 8 patients (11%) felt that their appearance was unchanged, and 2 patients (3%) felt that the appearance of their nose was made worse by the procedure. CONCLUSIONS: Patients presenting with nasal obstruction after rhinoplasty are frequently found to have collapse and/or weakening of their upper lateral cartilages with resulting nasal valve dysfunction. The conchal cartilage "butterfly" graft is a technique which, when properly performed during revision rhinoplasty, yields predictable functional and cosmetic results with minimal morbidity.     

乳突腔充填术在开放式鼓室成形术中的应用

目的 :探讨乳突腔充填术在开放式鼓室成形术中对恢复生理性外耳道功能的作用。方法 :对行开放式鼓室成形术的 85例 85耳胆脂瘤型中耳炎 ,以乳突皮质骨、同种异体软骨和 U形肌骨膜瓣同期行乳突腔充填。听骨链重建情况 :因骨导域值增高或行阶段性手术未作听骨链重建 10耳 ,鼓室成形术改良 型 40耳 ,改良 型35耳。结果 :总听觉改善率 76 % ,其中改良 型为 80 % ,改良 型为 71.4%。术后干耳率为 97.6 % ,平均干耳时间(19.86± 5 .31) d。术后随访半年以上 ,具有圆滑外耳道以及良好自净作用的占 89.4%。未见胆脂瘤复发病例。结论 :对没有条件行完壁式鼓室成形术的胆脂瘤型中耳炎 ,行乳突充填可以有效地克服开放式鼓室成形术破坏生理外耳道结构的不足 ,保存外耳道皮肤的自净作用 ,提高患者术后的生活质量。     

Saddle nose surgery: long term aesthetic outcomes of support grafts

Saddle nose surgery requires support grafts to improve the aesthestic of the nose such as the functional ventilation. Many kind of graft are available: Calvarial bone graft, iliac crest, septal cartilage, conchal cartilage, nasal hump, bony inferior turbinate. OBJECTIVES: To define the surgical strategy and long term aesthetic outcomes of rhinoplasty with support graft for saddle nose correction. MATERIAL AND METHOD: Retrospective study during the period 1985-2005: 160 patients underwent rhinoplasty with support graft for saddle nose correction. Patients were divided into 3 groups depending on the deformation (group I: Minor saddle nose; group II: Intermediate saddle nose; group III: Major saddle nose). Long term results were analysed at least 5 years after surgery, in 70 patients. RESULTS: An intranasal approach was performed in 92 cases, while an open approach was performed in 68 cases. A bony support graft was used in 85% of patients of group II and 94% of patients of group III. These grafts allowed a more rigid correction of the saddle nose than cartilage. For groups II and III patients, cartilage support grafts were not used because of the lack of quantity to correct the saddle nose. CONCLUSION: Calvarial bone support graft has a great role in saddle nose surgery. The postoperative aesthetic outcomes are interesting and its absorption is low.     

鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正治疗外伤性歪鼻畸形的临床分析

目的对鼻内镜下自体软骨（鼻中隔软骨、耳软骨和肋软骨）鼻整形同期行鼻中隔偏曲矫正治疗外伤性歪鼻畸形的临床分析。方法收集2017~2018年20 例陈旧外伤性歪鼻畸形患者的临床资料,所有患者均行全麻下鼻小柱倒“V”型切口暴露松解并切除偏曲的鼻中隔软骨及骨质,针对不同患者设计使用不同软骨（鼻中隔软骨、耳软骨和肋软骨）矫正鼻中隔骨性或软骨性支架,对鼻尖、鼻背及外鼻重新塑形。结果随访3~12个月,行鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正术的患者鼻外形及通气均有明显改善,手术效果更好,无鼻腔粘连、鼻中隔血肿及穿孔。结论鼻内镜下自体软骨鼻整形同期鼻中隔偏曲矫正治疗外伤性歪鼻畸形同期解决了鼻部畸形和鼻通气功能,实现了美容和功能的统一,同时减少了手术治疗的次数和费用,可行性高。     

自体软骨在外伤性歪鼻合并鼻通气障碍患者鼻整形术中的应用探讨

目的探讨自体软骨在外伤性歪鼻合并鼻通气功障碍患者鼻整形术中的使用方法和效果。方法回顾性分析2017年1月至2019年4月,在陆军军医大学大坪医院耳鼻咽喉头颈外科收治的30例鼻外伤患者的病例资料,其中男21例,女9例,年龄21~50岁,平均34.9岁,病程6 d至14年。全部患者均伴有不同程度的歪鼻畸形及鼻通气障碍,分为轻、中、重三类,其中轻度8例,中度11例,重度11例,均同期行开放性鼻整形术及鼻中隔偏曲矫正术。对于轻、中度歪鼻畸形及鼻通气障碍,采用耳软骨修饰鼻尖及加强鼻中隔软骨支撑、修饰鼻背凹陷畸形。对于重度歪鼻畸形及鼻通气障碍,将肋软骨雕刻成"Y"字型整体支架或者片状肋软骨构成2+1或4+1支架,将肋软骨支架与鼻中隔软骨尾端贯穿缝合固定,重塑加固鼻中隔支撑架及鼻小柱,避免鼻背塌陷。术前、术后测量鼻外观偏离值,并分别进行鼻外观视觉评分量表(VAS)、鼻腔通气VAS评分。采用Stata 15统计软件对术前与术后的测量数据行配对资料的t检验,VAS评分行卡方检验。结果30例患者中,3例术后出现鼻中隔血肿,经清理后正常恢复。术后随访2个月至2年,所有患者均无鼻中隔穿孔、鼻梁塌陷等并发症发生。术后治愈率为60.0%(18/30),所有患者术后歪鼻程度下降Ⅰ级,有效率为100%(30/30)。患者术后测量鼻外观偏离值低于术前,差异有统计学意义[(2.40±1.58)mm比(6.85±2.43)mm,t=8.42,P<0.001]。术后鼻外观VAS评分高于术前,差异有统计学意义[(6.60±1.16)分比(1.93±1.31)分,t=-14.59,P<0.001]。患者术后鼻腔通气VAS评分高于术前,差异有统计学意义[(6.53±1.04)分比(1.97±1.07)分,t=-16.78,P<0.001]。结论自体软骨在外伤性歪鼻合并鼻通气功障碍患者鼻整形术中使用疗效好,同期行开放性鼻整形术及鼻中隔偏曲矫正手术,可缩短治疗时间,及时改善患者鼻外观及鼻通气功能。     

Laryngotracheal reconstruction for subglottic stenosis in children

The experience with laryngotracheal reconstruction in 20 children in Chicago is reviewed. Nine of the 20 children (45%) operated upon had congenital subglottic stenosis. Ten (50%) had acquired stenosis. One child was classified as having combined types. All patients underwent laryngotracheal reconstruction with autogenous costal cartilage grafts. Eight patients had both anterior and posterior costal cartilage grafts with stent insertion. One had a posterior costal cartilage graft only. Sixteen of the 20 children (80%) have been decannulated. Midtracheal or lower tracheal disease concomitant with laryngotracheal stenosis is an indication that endoscopic management of severe subglottic stenosis is likely to fail. Early laryngotracheal reconstruction is indicated for patients with a high likelihood of failure of endoscopic management and for those with severe cricoid cartilage deformities. Our results support the use of laryngotracheal reconstruction as an alternative to conservative (endoscopic) management of severe subglottic stenosis in carefully selected patients.     

Irradiated costal cartilage graft in experimental laryngotracheal reconstruction

Autogenous costal cartilage graft has been employed successfully to correct subglottic stenosis. In an effort to reduce the morbidity and operative time, the use of irradiated homologous costal cartilage was investigated. Irradiated homologous grafting was performed to the subglottic region of 37 young New Zealand rabbits. The rabbits were sacrificed at 2.5- and 4-month intervals, and the grafts histologically examined. Fifty percent of the grafts were epithelialized and 50% revealed at least partial resorption. The percentage of grafts which resorbed were unrelated to the length of implantation. Because of the higher rate of resorption of the irradiated cartilage over autogenous fresh cartilage, the latter is still the preferred material.     

Functional and aesthetic results after augmentation rhinoplasty

IntroductionAugmentation rhinoplasty could be defined as the method whose goal is to increase the dimensions of the nasal pyramid, both the dorsum and the tip. For a long time, surgeons have used different kinds of materials that have often been the object of discussion.The aim of this study is to report our experience with augmentation septorhinoplasty, emphasising the type and nature of the grafts employed and the ensuing complications.Material and methodThis is a retrospective study describing the medical history of 188 patients who underwent septorhinoplasty surgery in our Department over a period of 12 years, from January 1998 to April 2009. Of these patients, 42 underwent augmentation septorhinoplasty, which is the object of our study.ResultsIn 66% of the cases (28/42), quadrangular autologous cartilage was the “onlay” graft most widely employed; we used a single graft in 22 (85.7%) cases and a double one in the other 6 (21%).In 14 patients, it was necessary to use grafts of synthetic material: in all the cases Gore-Tex® was chosen, in 12 (28.5%) patients as the only graft material and in 2 (4.7%) used together with septal cartilage.ConclusionsNasal dorsum reconstruction requires the knowledge of different methods and surgical procedures, as well as the use of different types of grafts according to the needs of each patient. The ideal graft, which exists only as a concept, would be the one combining biocompatibility, a low complication rate and results that remained stable for a long time.At present, autologous cartilage, and more precisely septal cartilage, is still the first option for augmentation rhinoplasty. If septal cartilage is not available, we always turn to conchal cartilage grafts, from one or both sides depending on the amount of cartilage required.     

Auricular cartilage: harvest technique and versatility in rhinoplasty

Objectives/Hypothesis

This study aims to present an improved technique for auricular cartilage harvest that maximizes graft volume while preserving auricular cosmesis. Also discussed is the versatility of auricular cartilage utilization in rhinoplasty.

Study Design

A retrospective review of a single surgeon's experience.

Methods

All auricular cartilage harvest and rhinoplasty operations performed by the senior author (CSC) from December 2006 through December 2009 cartilage were reviewed.

Results

Twenty-two cases were identified in which the described technique was used to harvest auricular cartilage for the purpose of functional or aesthetic rhinoplasty. There was sufficient tissue harvested in all operations, and no patients required costal cartilage harvest. Pain at the donor site after surgery was minimal and well controlled with oral medication. There were no donor-site complications and no cases of wound infection.

Conclusions

The proposed technique allows for optimal auricular cartilage harvest. By applying this method, the ear retains the preoperative appearance while the surgeon is able to obtain the largest graft possible. Auricular cartilage is a versatile source of grafting material in primary and secondary rhinoplasty.