The tip onlay graft

What repeats

Five findings that hold across the literature.

The idea is old and the shapes have multiplied

Onlay cartilage grafts at the tip were first reported in 1895. The shield graft, a vertical graft standing in front of the tip rather than lying on top of it, was reported in 43 patients lacking tip projection. The current catalogue of tip grafts also runs to the floating graft, the columellar strut, the caudal septal extension graft, the alar batten onlay and the lateral crural strut graft.

Rests on: Kamer and Churukian, shield graft · Cingi et al., nasal tip grafts · Adham, disk cartilage graft technique.

What it adds is small, and it stays

Twenty-eight patients with onlay septal cartilage tip grafts were photographed at 6 months and 18 months. Comparison of the two showed no visible difference in tip projection, and measurement gave a mean reduction of 0.06 mm, 0.19%. In a separate 82-patient series using processed fascia lata rather than cartilage, tip projection rose from 0.56 +/- 0.09 to 0.60 +/- 0.08 (P < .05) while the nasolabial angle did not change significantly (P = .08).

Rests on: Persichetti et al., 18-month permanence · Jang and Kim, processed fascia lata onlay.

The complication is the graft becoming visible

Visible graft contour and infection are named as not uncommon after tip grafting. The related deformity, a hard knob at the tip called a bossa, appeared in 37 of 875 patients (4.2%) in a single-practice series. On multivariate analysis, younger age, thin skin and a wide gap between the domes were independently associated with bossae, independent of the type of tip surgery performed.

Rests on: Jang and Kim, tip grafting for the Asian nose · Gillman et al., nasal tip bossae · the pinched tip.

It is a finishing step, placed after the tip is built

Current practice puts the septal extension graft first for structural support, projection and rotation, and uses tip-onlay or shield grafting afterwards for refinement. A conjoint shield and onlay graft used as the last element in 41 rib-based cases raised tip projection from 22.93 +/- 1.32 to 26.63 +/- 1.35 mm and nasal length from 39.62 +/- 1.64 to 43.16 +/- 1.47 mm, with a Goode ratio of 0.58 +/- 0.038 before and 0.62 +/- 0.031 after.

Rests on: Yoo and Jang, augmentation rhinoplasty · Wu et al., conjoint shield and onlay · the columellar strut.

A shield graft needs something behind it

A shield graft placed alone bends and its edge shows. The published rule is to add a supporting graft at the upper border and further grafts below so the assembly projects forward and downward on the profile, and that shield grafts require sufficient support to prevent bending.

Rests on: Jang and Yu, rhinoplasty for the Asian nose · Jang and Kim.

By what the graft is asked to do

One flat piece of cartilage answers several separate complaints.

The tip is too low

Adding projection is the original indication. In a 358-case review, 84 patients had a trapezoidal caudal extension graft as their only tip procedure and 62 were followed 24 months. Surgeons rated the result good or very good in 57 (91.9%) and 56 patients (90.3%) were satisfied or very satisfied. Two patients needed revision, one for insufficient augmentation and one for migration of the onlay graft.

Rests on: Liu et al., trapezoidal caudal extension graft · Apaydin, projection and deprojection.

The skin is thick and the tip has no definition

Thick skin hides the shape underneath. The published answer is a graft with enough height to read through it, built as a shield, a multilayer onlay, usually two layers, or both, from conchal or costal cartilage.

Rests on: Jang and Kim · Jang and Yi, the Asian nose · ear cartilage grafts.

The structural grafts underneath have edges

A layer laid over the assembled tip hides the joins. The conjoint shield and onlay pair was described for exactly that, wrapping the top of the dome and the lower border of the tip graft and adding width so the tip does not narrow to a point over time.

Rests on: Wu et al. · crushed cartilage grafts.

There is a step between the bridge and the new tip

Raising the tip creates a hollow above it. A relay graft filling the gap between the upper dorsum and the tip graft was used in 15 patients to avoid reducing the bridge, with no crooked dorsal profile or visible graft. A transition ramp graft placed for the same purpose was used in 56 patients, assessed at 12 months with no graft-related complications.

Rests on: Wu et al., the relay graft · Guray and Tezel, transition ramp graft · the polly beak.

The tip is a cleft tip, or a revision tip

Two-layer conchal onlay grafting was used to set tip height in 62 adults with secondary unilateral cleft nasal deformity, with 34 analysed on photographs: tip projection increased, alar base width index decreased and alar and columellar symmetry improved significantly. In revision noses a shield-shaped septal extension graft carved from rib was used in 18 patients, median follow-up 12 months, with no significant complications.

Rests on: Cho et al., secondary cleft correction · Balikci et al., shield-like septal extension graft · revision rhinoplasty.

What to ask about a tip onlay graft

Questions the evidence supports asking.

Will it show

That is the main risk, and thin skin is the main predictor. Ask what will cover the graft, whether the edges are bevelled or crushed, and to see one-year photographs of thin-skinned patients.

Rests on: Gillman et al. · Jang and Kim.

Will it still be there

Onlay septal cartilage grafts measured 0.19% loss of projection between 6 and 18 months. Ask what the surgeon has measured in their own patients, and at what interval.

Rests on: Persichetti et al. · what recovery looks like.

Onlay, shield, or septal extension graft

They do different jobs. The extension graft holds the tip in position, the shield stands in front of it, the onlay lies on top and refines it. Ask which of the three, or which combination, and what each is contributing.

Rests on: Yoo and Jang · Cingi et al. · Kamer and Churukian.

What is it made of

Septal, conchal and costal cartilage are all used. Processed donor fascia lata was tried as an alternative in 82 patients and rated excellent in only 6 (7%), fair in 51 (62%) and poor in 25 (31%), with the authors concluding it was not satisfactory for this job.

Rests on: Jang and Kim, fascia lata onlay · costal cartilage harvest.

What happens if it moves

Migration of an onlay graft was one of two revisions in a 62-patient followed series. Ask whether the graft is sutured in place or set in a pocket, and what the plan is if it shifts.

Rests on: Liu et al. · revision rhinoplasty.

The terms, defined

The words used about this graft.

• Tip onlay graft: cartilage laid horizontally over the domes of the tip cartilages, in one or more layers. [23547534]
• Shield graft: cartilage standing vertically in front of the tip, named for its outline. [6477281]
• Multilayer tip graft: two or more stacked onlay layers, the usual number being two. [30005790]
• Dome: the highest point of each lower lateral cartilage, where the tip is defined. [40195133]
• Bossa: a visible knob at the tip from a cartilage edge showing through the skin, reported in 4.2% of one 875-patient series. [10937083]
• Septal extension graft: cartilage fixed to the septum that sets tip position, placed before any onlay. [41962580]
• Goode ratio: a photographic measure of tip projection against nasal length. [40195133]
• Relay graft: a graft filling the gap between the upper bridge and a raised tip. [38402818]
• Global aesthetic improvement scale: a rater score of overall change, recorded at 1.12 +/- 0.40 in the conjoint graft series. [40195133]

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, whichever tip graft is chosen.

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 a chapter on this graft and two on the tip it sits over. They are written for surgeons and go further into technique than a patient page should.

• Tip onlay graft: the Peck graft revisited
• Nasal Tip Contour and Support Management
• Supporting the Nasal Tip

The reference summary

Rhinoplasty Tip-Shaping Surgery in StatPearls sets out the tip anatomy, the suture and graft techniques and the complications in full text at no charge. Cartilage Graft in StatPearls covers the material the graft is cut from.

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 test the structural grafts placed under an onlay.

• Unilateral Septal Extension Graft and Bilateral Septal Extension Graft in Droopy Tip and Its Effect on Tip Deviation, not yet recruiting, 34 participants.
• Lateral Crural Steal With Columellar Strut Graft in Primary Open Rhinoplasty, recruiting, 22 participants.

What is not settled

• Series are small, retrospective and single-surgeon. The permanence study has 28 patients and the conjoint graft study 41. [23547534] [40195133]
• Photographic measurement of projection cannot separate the onlay graft from everything else done at the same operation. [21493229]
• Bossa risk is tied to thin skin, young age and a wide dome gap, and was independent of the type of tip surgery, so no graft design has been shown to avoid it. [10937083]
• Follow-up ends at 12 to 24 months in every series here. What a stacked graft looks like at ten years is not reported. [26829689] [41845076]
• Patient-reported comparisons between graft types exist but do not control for the rest of the operation. In a 510-patient review, shield, tongue-in-groove and tip-onlay groups scored better than several others, and the authors state the changes cannot be attributed to graft choice alone. [41849710]