Ear cartilage grafts

What repeats

Five findings that hold across the literature.

It is the second source after the septum, and the first one in a revision

Septal cartilage is the preferred material and it runs out. A revision nose has usually had its septum harvested at the first operation, which is what puts the ear next in line. The published division of labour is that conchal cartilage suits tip and alar grafts because it is pliable and already curved, while rib supplies the stiff structural grafts.

Rests on: Duron and Aiach, cartilage donor sites · Becker et al., auricular cartilage in revision rhinoplasty · revision rhinoplasty.

The ear tolerates the harvest

A chart review of 372 conchal harvests found donor site problems in 9 patients, 2.4%: four keloids (1.1%) and five haematomas (1.3%). A separate series of 1,710 primary rhinoplasties using conchal cartilage with an absorbable plate reported an overall complication rate of 0.35%, six patients, and no delayed infections.

Rests on: Lan et al., donor site morbidities · Kim and Kim, 1,710 cases.

The shape of the ear is preserved, and it can be pushed further

Three-dimensional imaging of 15 ear donor sites compared conchal harvest alone against conchal plus triangular fossa cartilage through the same incision behind the ear. There were no significant differences in ear height, ear width or conchal cavity dimensions. A mild reduction in triangular fossa area was measured without visible deformity, and preserving the crus of the helix kept the curve of the antihelix.

Rests on: Huang et al., triangular fossa graft.

Its curve is the reason to use it and the reason to hide it

The concha comes with a bend in it. That bend is what supplies the spring in a butterfly graft laid across the middle of the nose, and it is why conchal columellar struts outperformed septal ones on rotation in a 173-patient series. The same curve makes conchal cartilage show through thin dorsal skin, which is why it is layered with fascia or diced when used on the bridge.

Rests on: Clark and Cook, the butterfly graft · Bucher et al., conchal against septal struts · Duron and Aiach · the butterfly graft.

The graft changes after it is moved

Specimens taken at revision surgery were compared with fresh ear cartilage from the same patients. The transplanted cartilage showed local fibrosis, a slight fall in elastic fibres and type II collagen, and lower glycosaminoglycan, DNA and total collagen content. Crushing lowers survival further: day 1 chondrocyte viability of auricular cartilage ran 70% intact and 45% severely crushed.

Rests on: Wu et al., biological changes · Buyuklu et al., crushed chondrocyte viability · crushed cartilage grafts.

By what the ear supplies

One incision behind the ear yields several different materials.

Conchal cartilage for tip support

The cymba and cavum of one ear were carved into a caudal septal extension graft, a cap graft and a diced columellar base in 81 patients. The columella-labial angle rose from 83.15 degrees to 96.50 degrees (p < 0.05) and the nostril to tip proportion from 0.83 to 1.17 (p < 0.01), across 12 to 36 months of follow-up. In 35 patients given a septal extension graft built from conchal cartilage, tip, nasolabial and nasofrontal angles all improved at 3 months (P < 0.001) with no significant change between 3 and 14 months.

Rests on: Chiang et al., unilateral auricular framework · Sun et al., auricular septal extension graft · the columellar strut.

Conchal cartilage shaped to keep the tip soft

An M-shaped conchal graft used as a septal extension graft in 36 patients was designed to avoid the stiff, immobile tip a rigid graft creates. Satisfaction was 91.7%, and no infection, gross absorption, graft exposure or implant migration was recorded.

Rests on: Wang et al., M-shaped auricular graft.

Cartilage and fascia together, for the bridge

Both come through the retroauricular incision. A sandwich of conchal cartilage pieces fixed to retroauricular fascia was used for dorsal augmentation in 19 patients, maximum graft thickness 4.5 mm, followed 12 to 35 months, with one undercorrection and two donor site problems. A cartilage-cored, fascia-sleeved graft used in 36 patients raised mean Rhinoplasty Outcome Evaluation scores from 20.94 +/- 8.67 to 79.56 +/- 10.65 over at least 18 months.

Rests on: Antohi et al., open sandwich graft · Amer et al., chondrofascial graft · Hodgkinson and Valente, posterior auricular fascia · diced cartilage grafts.

Skin and cartilage together, for lining

A composite graft carries the skin attached to the cartilage, which replaces missing lining rather than adding support. In 43 patients with a contracted nose after multiple operations, conchal composite grafts were used to rebuild the lining alongside rib septal extension grafts. Graft take above 80% was recorded in 12 patients (27.9%), 50% to 80% in 29 (67.4%) and 20% to 50% in 2 (4.6%). Two patients needed irrigation for infection.

Rests on: Kim and Choi, auricular composite graft with rib · rib cartilage grafts.

Skin and cartilage together, for a cleft nostril

Nineteen patients had unilateral cleft lip nasal deformity repaired with an auricular cartilage-skin graft chosen to prevent the rim retraction that follows a lining shortage. Satisfaction on each index was above 90%, nostril height and columellar length increased (P < 0.01) and no significant rim retraction was measured at 1 to 2 years.

Rests on: Zhao et al., auricular cartilage-skin graft · alar retraction.

What to ask about an ear cartilage graft

Questions the evidence supports asking.

Where is the incision and what will the ear look like

The usual route is behind the ear, which hides the scar in the crease. Measured on 3D imaging, ear height, width and conchal dimensions do not change. Ask which side, whether both ears are needed, and to see the donor ear in photographs.

Rests on: Huang et al. · Lan et al..

What can go wrong at the ear

Haematoma and keloid, at 1.3% and 1.1% in the largest series. A pressure dressing is placed to prevent the haematoma, and one report describes a full-thickness hole in the concha after a bolster was left on for two months. Ask when the dressing comes off.

Rests on: Lan et al. · Mundra et al., iatrogenic conchal defect · what recovery looks like.

Is there enough cartilage

One concha is a limited supply. The published answers when it is short are to take the triangular fossa through the same incision, to harvest both ears, or to move to rib.

Rests on: Huang et al. · Chiang et al. · costal cartilage harvest.

Will the graft show on the bridge

Conchal cartilage is curved and irregular, which is why it is combined with fascia or diced when used on the dorsum. Ask what will cover it and how thick your skin is over the bridge.

Rests on: Duron and Aiach · Antohi et al. · Amer et al..

Will the tip feel hard

A rigid extension graft makes a stiff tip. The M-shaped conchal design was published for that reason. Ask what the tip will feel like at a year, and press on the surgeon's before and after cases if they are available in person.

Rests on: Wang et al. · the pinched tip.

The terms, defined

The words used about this graft.

• Conchal cartilage: cartilage from the concha, the bowl of the outer ear. [28316288]
• Cymba concha and cavum concha: the upper and lower halves of that bowl, often carved into separate grafts. [37487259]
• Triangular fossa: the hollow above the concha, a second source through the same incision. [41335126]
• Composite graft: skin and cartilage taken as one piece, used to replace missing lining. [38739901]
• Retroauricular fascia: the sheet of tissue behind the ear, harvested through the same incision as the cartilage. [28341947]
• Perichondrium: the layer covering cartilage, which carries its blood supply. [36168124]
• Septal extension graft: cartilage fixed to the septum and carried to the tip, here built from ear cartilage. [36411690]
• Keloid: a raised overgrown scar, reported in 1.1% of conchal harvests. [28316288]
• Haematoma: a collection of blood under the skin at the donor site, reported in 1.3%. [28316288]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and document before operating, whatever the graft material.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries two chapters on ear cartilage in the nose. They are written for surgeons and go further into technique than a patient page should.

• Auricular Cartilage in Revision Rhinoplasty
• The Butterfly graft, conchal cartilage laid across the middle vault.

The reference summary

Cartilage Graft in StatPearls covers the donor sites, the handling of the graft and the complication list in full text at no charge. Rhinoplasty in StatPearls gives the anatomy and the operation around it.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Two registered studies measure the graft material itself rather than the operation.

• Study of the Biomechanical and Histological Properties of Septal, Auricular, and Costal Cartilage in the Context of Optimizing Total Nasal Reconstruction, not yet recruiting, 33 participants.
• The Impact of Rhinoplasty Approach and Used Autologous Cartilage Grafts on the Nasal Skin-soft Tissue Envelope Metabolism, status unknown, 100 participants.

What is not settled

• Donor site data come from single-centre chart reviews. The 2.4% figure counts what was recorded in notes, not what patients reported. [28316288]
• No trial compares ear cartilage with rib cartilage for the same graft in the same nose. The division between them is stated by convention. [25213491]
• Long-term shape of conchal grafts in the nose is not measured. Published follow-up runs 12 to 36 months. [37487259] [36411690]
• The tissue changes measured in transplanted ear cartilage, fibrosis and lower collagen and glycosaminoglycan content, have not been linked to any clinical outcome. [36168124]
• How much cartilage one concha yields is not reported as a number in any of these series, so planning between one ear, two ears and rib rests on the surgeon's estimate at the time. [41335126]