Facial Plastic Surgery & Aesthetic Medicine

Volume 25, Number 1, 2023

ª American Academy of Facial Plastic and Reconstructive Surgery, Inc.
DOI: 10.1089/fpsam.2022.0183

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SPECIAL COMMUNICATION Rhinoplasty

Auricular Composite Graft Survival in Rhinoplasty

Dean M. Toriumi, MD,1,2,* Richard Kao, MD,3 Taylor Vandenberg, BS,4
Robert Cristel, MD,5 and Alexander J. Caniglia, MD6
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Abstract
Auricular composite grafts can be used in rhinoplasty to correct defects of the internal nasal valve, ala, ves-
tibule, sill, and external nose. The objective of this study was to measure the auricular composite graft (ACG)
survival rate and patient-reported outcome with Nasal Obstruction Symptom Evaluation (NOSE) score
among patients undergoing rhinoplasty. A retrospective chart review was performed of all patients who
underwent rhinoplasty with ACGs from 2002 to 2019 by the senior author. Median patient age was 42
years (range 14–79) with 80.3% being female. In total, 234 rhinoplasty procedures were performed utilizing
367 auricular composite grafts. Secondary rhinoplasty (n = 160, 68.4%) was the most common. And 93.7% of
ACGs had full take. There were 23 partial or total graft failures, producing graft failure rate of 6.3%. Mean
preoperative NOSE score was 24.08, and mean postoperative NOSE score was 21.84, with a p-value of 0.63.
Auricular composite grafts can be used to repair a wide range of defects of the internal nasal valve, nasal
sill–ala junction, nasal vestibule, and external nose.

Introduction cases, failure to replace the deficient lining and external

The integrity of the internal lining of the nasal vestibule is
critical to the success of the rhinoplasty operation. The
lining of the nasal vestibule can become compromised
or damaged during rhinoplasty. Internal vestibular scar-
ring can obstruct the nasal airway, create deformity, and
may be the underlying cause of alar retraction. After rhi-
noplasty, scar contracture can occur that retracts the alar
margin creating deformity. Scarring of the internal nasal
valve can result in vestibular stenosis and nasal obstruc-
tion. Related injuries can contribute to the external nasal
deformity and may require management as well.
Correction of alar retraction, nasal vestibular stenosis,
and contracted nostrils frequently requires replacement
of the missing or damaged vestibular lining. In many
skin may be the primary cause of a failed rhinoplasty.
Any tension on the closure of the marginal incision can re-
sult in retraction of the alar margin and nostril asymmetry.
Auricular composite grafts (ACGs) are skin and carti-
lage grafts that are typically harvested from the cymba
concha of the ear. These grafts can be designed in many
different shapes and sizes to replace missing or damaged
vestibular lining or external skin deficiencies. Recon-
structing these vestibular deficiencies can be challenging.
If there is a deficiency of mucosa in the marginal incision,
replacement with a full thickness skin graft (FTSG) alone
may lead to significant contraction during the healing pro-
cess, whereas a graft of skin attached to cartilage will be
less likely to contract.

1
Toriumi Facial Plastics, Chicago, Illinois, USA.
2
Department of Otolaryngology-Head & Neck Surgery, Rush University Medical School, Chicago, Illinois, USA.
3
HKB Cosmetic Surgery, Charlotte, North Carolina, USA.
4
Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA.
5
Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of Illinois at Chicago, Chicago, Illinois, USA.
6
Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA.

*Address correspondence to: Dean M. Toriumi, MD, Toriumi Facial Plastics, 60 E Delaware Place Suite 1425, Chicago, IL 60611, USA, Email: deantoriumi@toriumimd.com

6
 COMPOSITE GRAFT SURVIVAL IN RHINOPLASTY 7

underlay technique involves overlapping the tissues at

KEY POINTS
Question: What is the role and survival rate of auricular com-
posite grafts in rhinoplasty?
Findings: There was a 93.7% survival rate of auricular com-
posite grafts and improvement in nasal symptoms among pa-
tients undergoing rhinoplasty in our study.
Meaning: Complicated nasal deformities of the nostril and in-
ternal valve can be improved in rhinoplasty with cartilage/skin
composite grafts from the ear.
the recipient site over a cartilage/perichondrial cuff to
promote more rapid revascularization of the composite
graft (Fig. 1). Most of the existing literature on related
techniques is in animal models and some studies recom-
mend alternative methods to increase graft survival.4–7
Many surgeons avoid using composite grafts due to
concern of graft failure. We believe there is limited exist-
ing literature on the survival rates of composite grafts in
rhinoplasty.1–3

In addition, small skin grafts can be difficult to handle,

as they have a propensity to fold over on themselves.
Thus, placement of an ACG can be technically simpler
and less likely to bury a skin edge, which could lead to
infection. In the case of contracted scars at areas of con-
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cavity, such as the internal valve or externally at the site

of a previous base reduction, an FTSG alone may con-
tract significantly or lead to significant deposit of scar tis-
sue while healing. Without placement of a ACG, it is
likely to see a recurrence of the scarring with an FTSG
alone. These are areas where the cartilage is needed to
change the contour and skin is needed to repair the defi-
ciency of lining.
We have developed a method of using ACGs that max-
imizes survival by leveraging the vascular affinity of
perichondrium within the composite grafts to enhance
vascular ingrowth into the grafts.1–3 The perichondrial

Fig. 2. Patient with category V defect

Fig. 1. Composite graft perichondrial underlay
technique. With larger composite grafts
(>6 mm), a strip of skin can be excised around
the periphery of the graft, leaving the
underlying perichondrium on the cartilage to
underlay the tissues at the recipient site. This
perichondrium has a high vascular affinity and
will promote more rapid vascularization of the
composite graft. (Reprinted with permission
from Toriumi3).
involving a deficit of the left alar lobule
requiring replacement of missing tissue. (A) A
large composite graft is employed creating an
area of underlay with perichondrium on the
cartilage. The green broken line marks where
the skin of the graft ends. Note the
perichondrium left on the cartilage that will
underlay the skin at the recipient site.
(B) Composite graft sutured into position along
the lateral alar lobule. The yellow broken line
marks where the de-epithelialized segment of
the graft is underlapped. (C) Preoperative defect
showing missing area of left alar lobule.
(D) Three-year postoperative view showing
reconstitution of the left alar lobule.
 8 TORIUMI ET AL.

The objective of this study is to look at composite graft Table 1. Patient demographics and composite graft specifics
survival and patient-reported outcomes measured by pre- Variable n (%)
operative and postoperative Nasal Obstruction Symptom
Evaluation (NOSE) scores. Gender
Males 46 (19.7%)
Females 188 (80.3%)
Surgical Technique Age, median years (range) 42 (14–79)
ACGs were typically harvested from the cymba concha of Race/ethnicity (self-reported)
African American 3 (1.3%)
the ear. Local anesthetic is injected under the harvest site Asian 39 (16.7%)
(deep to the cartilage) and not directly into the composite Caucasian 164 (70.1%)
grafts. The grafts are harvested meticulously, taking care Hispanic 9 (3.8%)
Middle Eastern 6 (2.6%)
not to grasp the skin of the graft to avoid shearing the skin Other 13 (5.6%)
from the underlying cartilage and perichondrium. Once har- No. of procedures 234
vested, the composite grafts should be sutured into the recip- Primary 32 (13.7%)
Secondary 160 (68.4%)
ient site as soon as possible to minimize extracorporeal Revision 42 (17.9%)
ischemic time. Careful suturing with 5–0 chromic suture (in- Total composite grafts 367
tranasal grafting) is very important taking care to avoid Marginal incision—category I 225 (61.3%)
burying a skin edge and to maximize graft contact with Internal nasal valve—category II 36 (9.8%)
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Alar nostril ring/external nasal valve—category III 52 (14.1%)

the recipient site tissues. Externally applied grafts may be
sutured with 7–0 nylon and 6–0 absorbing sutures.
For composite grafts larger than 8 to 10 mm, a cuff of the
skin is carefully dissected around the periphery of the com-
posite graft to create a ‘‘shelf’’ of cartilage with attached
perichondrium that can ‘‘underlap’’ the tissues at the recip-
ient site to enhance vascular ingrowth into the graft (Fig. 2).
With smaller composite grafts (<6 mm in width), the under-
lap technique is not necessary and end-to-end suturing is
adequate.
A FTSG is harvested from behind the ear to close the
donor site defect on the anterior aspect of the ear. A cotton
bolster is placed and left in position for 2 weeks. When-
ever possible, splinting with plastic or silastic sheets is
important to immobilize the composite grafts and prevent
shearing at the graft–host interface.
For larger grafts, nanofat injections around the grafts
and postoperative hyperbaric oxygen (HBO) treatments
may improve composite graft survival.3
Nasal vestibule—category IV 41 (11.2%)
External nasal defects—category V 13 (3.5%)
riod to identify all rhinoplasty patients who underwent
placement of composite grafts. This extra step was per-
formed to ensure the number of rhinoplasties was accu-
rate and that the data did not rely solely on billing data.
After all rhinoplasty patients undergoing rhinoplasty
with composite grafting were identified, a thorough review
of the medical record was performed. Site of composite
graft placement, graft failure, fat injection utilization, and
Nasal Obstruction Symptom Evaluation (NOSE) scale
scores were obtained.
The site of composite graft placement was sorted into one
of five distinct locations: category I—marginal incision
Table 2. Graft failure
n (%)

Materials and Methods Graft failure—total (procedures)

No failure (0%) 211 (90.2)
A retrospective study was designed in patients undergoing Partial failure (<50%) 19 (8.1)
primary, secondary, or revision rhinoplasty in which a Near complete failure (>50%) 3 (1.3)
Complete failure (100%) 1 (0.4)
composite graft was used between 2002 and 2019. All pro-
Graft failure—primary (procedures)
cedures were performed by the senior author (D.M.T.). No failure (0%) 30 (93.8)
Secondary rhinoplasty was defined as a surgery performed Partial failure (<50%) 2 (6.3)
on a patient who underwent a rhinoplasty by another sur- Graft failure—secondary (procedures)
No failure (0%) 145 (90.6)
geon. Revision rhinoplasty was defined as a rhinoplasty Partial failure (<50%) 12 (7.5)
performed after a rhinoplasty is performed by the senior Near complete failure (>50%) 2 (1.3)
author. All data collection and research and analysis Complete failure (100%) 1 (0.63)
were performed in accordance to the World Medical Asso- Graft failure—revision (procedures)
No failure (0%) 36 (85.7)
ciation Declaration of Helsinki and in compliance with the Partial failure (<50%) 5 (11.9)
Health Insurance Portability and Accountability Act.8,9 Near complete failure (>50%) 1 (2.4)
Billing data were collected on the senior author’s Graft failure—any percentage of failure (failure rate per site category)
Marginal incision 15 (6.7)
(D.M.T.) patients undergoing rhinoplasty from 2002 to Internal nasal valve 1 (2.7)
2019. These data included ICD-9/10 codes to isolate Ala/nostril rim 3 (4.8)
the number of rhinoplasties performed. In addition, all Nasal vestibule 4 (9.3)
External nasal contour 0 (0)
operative reports were reviewed during the same time pe-
 COMPOSITE GRAFT SURVIVAL IN RHINOPLASTY 9

closure, category II—internal nasal valve, category III—ala– fully placed into the nose without any sign of graft failure.
nostril rim, category IV—nasal vestibule, and category V— There was only one complete graft failure in a patient who
external nasal skin. Graft failure was categorized as no fail- suffered an infection immediately postoperatively.
ure, partial failure (<50% graft loss), near complete failure Only 87 (37.2%) patients had both preoperative and
(>50% loss), or complete failure (100% graft loss). Compo- postoperative NOSE scores available. Mean preoperative
site graft failure was assessed by direct examination of the
composite graft at the site of graft placement.
The NOSE scores were collected for each patient fol-
lowing the NOSE scoring instrument.10 Preoperative and
postoperative NOSE scores were collected. Postoperative
NOSE scores were collected at each postoperative visit.
The preoperative NOSE score was compared to furthest
out postoperative NOSE score to assess for change in
nasal obstruction symptoms.
All statistical analyses were performed using Micro-
soft Excel (Redmond, WA) and GraphPad (San Diego,
CA). Preoperative and furthest out postoperative NOSE
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scores were analyzed. Statistical analysis was performed

using two-tailed unpaired t-tests to assess differences
among NOSE scores. A two-tailed p-value <0.05 was con-
sidered significant for all results.

Results
In our study, 234 rhinoplasty procedures were found uti-
lizing ACGs. More female subjects (n = 188, 80.3%)
were identified than male subjects (n = 46, 19.7%).
Median patient age at surgery was 42 years (range 14–
79). Secondary rhinoplasties (n = 160, 68.4%) were the
most common procedure utilizing composite grafts. Mul-
tiple composite grafts were frequently used in secondary
rhinoplasty procedures. Of the 234 distinct procedures,
there were a total of 367 composite grafts utilized. Patient
demographics and composite graft specifics are displayed
in Table 1. There was a total of 23 grafts with at least par-
tial failures out of 234 procedures, for a failure rate of
9.8% per procedure (Table 2).
There were 211 (90.2%) procedures where the compos-
ite graft was successfully integrated to the nose without
any amount of graft failure. Given 367 total composite
grafts and 23 graft failures (any amount of failure from
0% to 100%), overall composite graft failure rate was
6.3%. There were 344 (93.7%) composite grafts success-

‰
Fig. 3. Patient with a category I defect at the
marginal incision closure noted during secondary
rhinoplasty to correct alar retraction. (A) Composite
graft fashioned to fit the deficiency in the marginal
incision closure (yellow arrow). (B) Composite graft
sutured into position (yellow arrow). (C) Preoperative
frontal view (left). Three-year postoperative frontal view
(right). (D) Preoperative lateral view (left). Postoperative
lateral view (right). (E) Preoperative base view (left).
Postoperative base view (right).
 10 TORIUMI ET AL.

NOSE score was 24.08 and the mean postoperative and over-resection of the alar base when performing in-
NOSE score was 21.84, with a p-value of 0.63. Mean ternal alar base reductions. The deformity after over-
postoperative days of latest postoperative NOSE score resection of the alar base is difficult to correct unless tis-
used was 247.3 days. sue is recruited into the defect to re-establish a normal
curvature of the lateral nostril sill as it transitions to the
Discussion
Of all the composite grafts performed in this study, 93.7%
had full take and only 1 ACG of 367 (0.27%) ACGs had
complete failure. This is the largest known reporting of
composite graft survival rate in rhinoplasty patients, and
comparison of survival rates with those of other studies is
challenging due to multiple factors. However, such high
composite graft survival rates demonstrated in this study
suggest that with proper technique, auricular composite
grafts can be successful in correcting a multitude of nasal
defects.
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We have classified deformities requiring auricular

composite grafts for correction into five groups. Category
I defects are primarily limited to the vestibular skin along
the marginal incision closure and frequently result in alar
retraction or notching. Such defects are typically treated
with lateral crural strut grafts with repositioning (with
or without lateral crural replacement grafts) and compos-
ite grafts to fill any vestibular lining deficit (Fig. 311–14
and Supplementary Video S1).
Category II deformities primarily involve the nasal
valve and or superior nasal vestibule in the form of a con-
tracted scar. In most cases, this occurs after circumferen-
tial scarring of an extended intercartilaginous incision or
possibly after infection. In these cases, we use the hinged
composite graft to reline the valve area and enlarge the
airway (Fig. 4). In the hinged graft, an incision is made
through the cartilage portion of the graft but not the peri-
chondrium. This allows the graft to hinge and fit into the
apex of the nasal vestibule to maximize the size of the air-
way (Supplementary Video S2).
Category III deformities are primarily confined to the
alar nostril ring/external nasal valve and the junction be-
tween the nostril sill and alar lobule. These deformities
are primarily due to scarring of the alar base, alar lobule,

‰
Fig. 4. Patient with category II defect of the nasal
vestibule. Repair required release of the right vestibular
scar and placement of a hinged composite graft.
(A) Preoperative base view showing right nasal
vestibular stenosis (yellow arrow). (B) Hinged composite
graft with incision through cartilage and not underlying
perichondrium. (C) Preoperative frontal view (left). Four-
and one-half-year postoperative frontal view (right).
(D) Preoperative lateral view (left). Postoperative lateral
view (right). (E) Preoperative base view (left).
Postoperative base view (right).
 COMPOSITE GRAFT SURVIVAL IN RHINOPLASTY 11

fat injections or other revision surgery may be necessary

to achieve the best outcomes. In some cases, composite
grafts employing the posterior auricular skin can be
used if thicker skin coverage is needed. These grafts
are not as reliable as the composite grafts employing
the anterior auricular skin.

Fig. 5. Composite technique with island of

skin and peripheral de-epithelialized segment of
the graft that underlays the recipient site to
enhance survival and spring open the lobule as
it meets the sill. Note how the skin is removed
leaving the perichondrium on the underlying
cartilage. The perichondrium enhances vascular
ingrowth into the graft. (Reprinted with
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permission from Toriumi3).

internal margin of the alar lobule. Constantian described

the use of a specially fashioned composite graft to repair
over-resection of the alar base.15 A uniquely fashioned
composite graft can be used to re-establish normal alar
flare and open the airway (Figs. 5 and 6).
Category IV deformities involve near complete stenosis
of the nasal vestibule and are typically due to infection,
trauma, or extended vestibular incisions. Reconstruction re-
quires complete release of the scarred area followed by relin-
ing using a large composite graft (Fig. 7 and Supplementary
Video S3). These cases may require nasal splinting for sev-
eral weeks postoperatively to avoid late scar contracture.
Category V defects involve the external nasal contour
including the columella, lateral wall, and alae. These de-
fects require use of custom-designed composite grafts
that can be large, requiring employment of the perichon-
drial underlay technique to enhance graft survival
(Fig. 8). Use of composite grafts for external nasal de-
fects may leave a contour deficiency due to the lack of
subcutaneous tissue in the composite graft. Secondary

‰
Fig. 6. Patient with category III defect involving over
reduction of alar base after internal alar base reduction.
(A) Composite graft with skin island (marked in blue)
and lateral extensions with perichondrium on the
cartilage to underlay the recipient site pockets.
(B) Composite graft being sutured into pockets.
(C) Composite graft sutured into position.
(D) Preoperative frontal view (left). One-year
postoperative frontal view (right). (E) Preoperative
lateral view (left). Postoperative lateral view (right).
(F) Preoperative base view (left). Postoperative base
view (right).
 12 TORIUMI ET AL.

In our estimation, auricular composite grafts tend to be more than 6 mm in width. In the case of a circular com-
underused and deemed unnecessary. Failure to repair de- posite graft, the distance from the center to the periphery
fects of the nasal vestibule and external nose can be the will be the radius of the circle, which could be 4 to 6 mm
primary reason for suboptimal outcomes in rhinoplasty. with larger grafts. In these cases, circular or other shaped
Our use of composite grafts has increased dramatically grafts that are not fusiform can be challenged in the cen-
in recent years due to multiple factors. The most common ter of the graft with blood supply arriving to the center
reason is for replacement of inadequate nasal vestibular more slowly.
skin at the closure of the marginal incision. Many of
the primary rhinoplasties that required composite grafts
were short noses in ethnic patients who required length-
ening and hence additional internal lining. There should
be little if any tension on the marginal incision closure.
Once a suture is placed in the marginal incision, if any re-
traction or deformation of the alar margin is noted, then
there is likely a need for a composite graft.
In this study, we had excellent composite graft survival
with only one complete loss of the graft in a patient who
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suffered a postoperative infection. Composite grafts do

not do well in the presence of infection. The author
uses active postoperative care including antibiotic irriga-
tions and antibiotic soaks to help minimize infection
risk.13 Despite the placement of some very large compos-
ite grafts, survival was relatively high.
There are several technical factors that contribute to
higher survival rates for composite grafts. Careful han-
dling of the composite grafts is very important by avoid-
ing pulling the skin component of the graft away from the
cartilage component. If the grafts are mishandled, the
skin can shear away from the remainder of the graft.
Composite graft harvest should be performed immedi-
ately before placement as extracorporeal ischemic time
should be kept to a minimum. We try to harvest the grafts
and then immediately place them into the nose. If grafts
are harvested and not used immediately, they can be
left in the ear donor site until used.
Composite graft revascularization is directly related to
the distance from the periphery of the graft where the
blood supply comes in, to the center of the graft. Most
composite grafts are fusiform in shape to fill smaller de-
fects at the marginal incision closure. In this case, the dis-
tance from the center of the graft to the periphery of the
graft is likely <3 mm as most composite grafts are no

‰
Fig. 7. Patient with category IV defect involving
severe nasal vestibular stenosis of right nostril.
(A) Preoperative base view showing near complete
stenosis of right nasal vestibule. (B) Large composite
graft incorporating entire conchal bowl to reline right
nasal vestibule. (C) Preoperative frontal view (left). One-
year postoperative frontal view (right). (D) Preoperative
lateral view (left). Postoperative lateral view (right).
(E) Preoperative base view (left). Postoperative base
view (right).
 COMPOSITE GRAFT SURVIVAL IN RHINOPLASTY 13

With larger composite grafts (larger than 6 mm), it is ad-

visable to perform modifications that aid in more rapid re-
vascularization. The perichondrium provides a high affinity
surface for the ingrowth of microvasculature that can then
permeate the entire composite graft. We use a perichondrial
underlay technique around the periphery of the graft to en-
hance vascular ingrowth into the graft. In this technique, a
strip of skin (leaving the underlying perichondrium) is re-
moved around the periphery of the composite graft to cre-
ate segments of the graft that can be tucked under the skin
or mucosa at the recipient site (Figs. 1 and 2).
The tissues that are overlaid on the rim of cartilage
with native perichondrium allow rapid vascular ingrowth
into the graft and allow blood supply to rapidly develop
under the cutaneous portion of the graft. The larger the
composite graft the larger the area of overlapping peri-
chondrium. Grafts <6 mm are likely to survive under
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most circumstances as long as the recipient site has

good vascularity, and the graft is sutured properly.
With composite grafts >1 cm, the perichondrial overlap
should be at least 4 mm. We recommend overlapping
the perichondrium for *20% of the size of grafts >1 cm.
An additional maneuver with larger grafts is to make
holes in the cartilage portion of the graft to allow vascular
ingrowth through the cartilage to reach the skin. A small
punch can be used to make the holes in the cartilage layer
of the graft. It is the cutaneous portion of the graft that is
most likely to suffer vascular compromise and these ma-
neuvers can help to prevent graft failure.
We also splint most composite graft with a thin plastic
splint Reuter Bivalve septal splints (Medtronic Xomed,
St. Paul, MN), which is sutured in place (one splint

‰
Fig. 8. This patient underwent multiple reconstructive
surgeries to correct deformity after removal of a large
Med Por implant. Owing to damage to the skin from
the implant and to allow adequate projection, a
composite graft was used to increase columellar length.
The perichondrial underlay technique was used.
(A) Med Por implant was removed in the first surgery
and reconstructed with costal cartilage. (B) In a
subsequent procedure, a composite graft was used to
further lengthen the columella. Yellow broken line
demarcates the edges of the skin island. (C) Composite
graft placed into pocket inferiorly and superiorly.
(D) Composite graft sutured into position using
transcutaneous guide sutures with small cotton bolsters.
(E) Preoperative frontal view showing deviated Med Por
implant (left). Nine-year postoperative frontal view
(right). (F) Preoperative lateral view (left). Postoperative
lateral view (right). (G) Preoperative base view (left).
Postoperative base view. Yellow arrows outline the
margins of the healed composite graft (right).
 14
internal and one external) and left for at least 1 week
(Supplementary Video S4). These splints sandwich the
lateral wall and alar margin to protect the grafts from
trauma, movement, and shearing forces that can disrupt
the graft–host interface. The splint creates a ‘‘healing
chamber’’ for the grafts and minimizes micromovement
that could result in shearing of the connection of the
graft to its blood supply (graft–host interface). In some
larger grafts, we will leave the splints in place for 3
weeks to allow adequate stabilization of the graft.
With larger composite grafts, we will also have the pa-
tients undergo HBO treatments to enhance revasculariza-
tion.16–18 The HBO treatments involve 1-h dives at 100%
oxygen with 2.2 to 2.6 atm pressure to help maximize
graft survival. We typically have patients do at least
seven dives on consecutive days. We believe the HBO
is very important in patients who have larger composite
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grafts measuring >6 mm in size.
An additional maneuver to enhance ACG survival is to
inject nanofat into the periphery of the graft or into the
tissues surrounding the graft. Nanofat is a 600-lm sized
fat particle that is purified from harvested autologous
fat. The nanofat brings adipose-derived stem cells into
the area around the graft that can enhance graft survival.
Care should be taken to avoid injecting the nanofat be-
tween the skin and cartilage component of the graft.
It should be noted that accurately measuring composite
graft viability can be challenging. There is inherently an
element of subjectivity. Composite grafts can have areas
of ecchymosis or congestion that can result in superficial
epidermolysis but ultimately heal well. The authors did
their best to try to accurately measure and present true
composite graft failure rates. Another limitation is that
much of the early NOSE data was unable to be located
and only 37.2% of patients had sufficient data to log
their accompanying NOSE scores.
This significantly limits evaluation of functional results.
The improvement in NOSE scores is not as one may expect.
This may be due to several factors including potential partial
blockage of the airway due to the thickness of the composite
grafts. The strategy in many of these complex cases is to get
the lining and structure into place and then potentially per-
form a minor revision procedure at a later date to thin out
the bulk of the composite graft to maximize the airway.
In recent years, the senior author has noted improved
functional outcomes by trimming the thickness of the
cartilage segment of the composite graft or using a
perichondrial–cutaneous graft.19 The perichondrial–cuta-
neous graft is skin and perichondrium with most of the
cartilage excised leaving a thinner lower profile graft.
Survival rates appear to be similar to when the cartilage
is left on the grafts. The key is the presence of the peri-
chondrium with its high affinity for vascular ingrowth.
Availability of composite grafts for internal lining as
well as other defects is critical to successful secondary
TORIUMI ET AL.
rhinoplasty surgery. For this reason, the author leaves
the ears untouched and uses primarily autologous costal
cartilage for structural grafting in rhinoplasty. When the
ears have been previously harvested, availability of com-
posite skin/cartilage grafts from the ear is sparse, making
adequate repair of the nose difficult if not impossible. It is
the unique combination of thinner skin and its underlying
perichondrium and cartilage that makes the ACG an in-
credibly valuable graft in complex rhinoplasty. The min-
imal subcutaneous tissue layer with skin adjacent to the
perichondrium is critical to the success and utility of
the grafts.
In our practice, the use of microfat/nanofat injections
to the nose is common as they contain adipose-derived
stem cells that provide stromal support and assist growth
of adipose tissue and generate neovascularization. A fu-
ture avenue of research will be determining how postop-
erative HBO as well as microfat and nanofat injections
around composite grafts affect composite graft survival
rates and functional outcomes. Improved survival rates
using both of these modalities have given us the confi-
dence to extend the use of larger composite grafts for
an increased number of indications.
Conclusions
Auricular composite grafts are a critical component of the
reconstruction of nasal vestibular and cutaneous defects
seen in rhinoplasty. In this study, we have shown that
strategic use and meticulous execution can provide excel-
lent graft survival rates and lasting aesthetic and func-
tional outcomes.
Authors’ Contributions
All authors had full access to all the data in the study and
take responsibility for the integrity of the data and the ac-
curacy of the data analysis. Study concept and design
were carried out by D.M.T. Acquisition, analysis, or in-
terpretation of data was undertaken by all authors. Draft-
ing of the article was by all authors. Critical revision of
the article for important intellectual content was done
by all authors. Statistical analysis was done by all au-
thors. Administrative, technical, or material support
was done by D.M.T. Study supervision was carried out
by D.M.T.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
Supplementary Material
Supplementary Video SV1
Supplementary Video SV2
Supplementary Video SV3
Supplementary Video SV4
 COMPOSITE GRAFT SURVIVAL IN RHINOPLASTY
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