A Novel Technique for Precise Placement and Secure Fixation of Onlay Grafts in Rhinoplasty: Our 4-Year Experience

Abstract

Sir: Cartilage grafting has been widely used to improve aesthetic and functional rhinoplasty outcomes. Autologous onlay grafts, in particular, can be used to camouflage contour irregularities, address open roof deformities, and minimize the effects of overaggressive and reductive rhinoplasty.1 Numerous grafting techniques have been reported.2–5 We present a novel technique for precise placement and secure fixation of onlay autologous grafts that can be applied in open or closed rhinoplasty, and review our 4-year results. Onlay graft placement is performed after all necessary nasal sculpturing has been completed. The existing or created defect is outlined with a marker on the nasal skin. The graft is molded to the desired shape, and its edges are beveled to ensure a smooth transition between the graft and the native nasal cartilages and bones. Once graft fashioning is completed, it is accurately placed over the marked skin and fixed temporarily with two 27-gauge needles, which pierce the graft close to its cephalic and caudal edges. Then, the graft is removed together with the needles, and a pull-out double arm 5-0 Prolene suture is passed through the graft. The needles of the suture are stuck into the tip of the 27-gauge needles (Fig. 1). Thus, removing the 27-gauge needles, the suture threads pass exactly from the points at which the 27-gauge needles had pierced the graft. Before insetting the graft, the marked nasal skin is squeezed until a drop of blood appears at the point of each needle entrance. These points serve as skin markings for precise graft placement. The suture needles, with the use of a needle holder, are inserted through the rhinoplasty incisions between the nasal skeleton and the skin and delivered on the nasal skin through the corresponding markings to ensure proper orientation of the graft (Fig. 2). The graft is inset precisely into the desired position with traction on the suture threads, which are secured on the skin using sterile strips only. Finally, typical taping and casting is applied, and the suture is left in place until cast removal at 8 days postoperatively.Fig. 1.: (Left) Temporary fixation of the graft on the nasal skin with the use of 27-gauge needles. (Right) The suture needle is shown stuck into the tip of the 27-gauge needle.Fig. 2.: (Left) Drops of blood, which are the marking points of entrance of the 27-gauge needles. (Right) The suture needle is shown passing exactly from the proximal marking point.Twenty-nine patients underwent onlay grafting with the use of the aforementioned technique. No postoperative complications were noted; follow-up, ranging from 3 months to 4 years, revealed no cases of graft migration or step-off deformities; and a pleasing functional and aesthetic outcome was achieved in all cases. The technique described is simple and reliable, ensures both precise graft placement and secure fixation, and precludes any injury to the osteocartilaginous skeleton. The use of sterile strips, instead of tying the suture, prevents the suture from cutting into the skin, allows the skin room to expand during the phase of tissue edema, obviates the need for a bolster dressing, and permits the application of the typical taping and casting to the nose. Consequently, the graft is kept in close contact with both the skin and the osteocartilaginous skeleton, the dead space between the graft and surrounding tissues is eliminated, fluid accumulation and tissue edema are diminished, and minimal or no scarring is induced. Efstathios G. Lykoudis, M.D., Ph.D. Konstantinos Seretis, M.D., M.Sc. George E. Papanikolaou, M.D. Department of Plastic Surgery Ioannina University School of Medicine Ioannina, Greece DISCLOSURE The authors have no financial interests to disclose.