In an adult undergoing primary or secondary rhinoplasty or tip reconstruction, how should conchal ear cartilage be placed and sutured on the nasal tip, and to which portion of the lower lateral cartilage should it be attached?

Placement and Suturing of Ear Cartilage on the Nasal Tip

Conchal ear cartilage should be placed as onlay grafts over the domal and infratip region of the lower lateral cartilages, or as batten-type grafts sutured to the deep surface of the lateral crura, with the specific attachment site determined by whether you need projection enhancement (medial/domal crura) or lateral support (lateral crura). 1

Anatomic Attachment Sites on Lower Lateral Cartilage

For Tip Projection and Definition

• Domal and infratip region: Onlay or shield-type cartilage grafts are positioned over the dome area where the medial and lateral crura meet 1
• Medial crura: Batten-type onlay grafts can be placed along the caudal aspect of the medial crura for augmentation and symmetry 1
• The position and shape of these grafts must be determined by the patient's specific anatomical abnormality, with asymmetric grafting sometimes necessary to create symmetry 1

For Lateral Support and Alar Contour

• Lateral crura (deep surface): Subalar batten grafts are sutured to the undersurface of the lateral alar cartilage, extending onto the piriform aperture 1
• These lateral crural strut grafts are particularly useful for lateral alar crus repositioning, reinforcement after previous overresection, and reshaping of concave or convex alar cartilages 1

Surgical Technique Considerations

Graft Preparation

• Countercurve placement technique: When using conchal cartilage as a columella strut with lateral extension, place the graft in countercurve orientation to take advantage of the structural memory intrinsic to mature cartilage 2
• This springlike property enhances tip projection and supports the lower lateral cartilage 2
• Proper preparation is critical to minimize warping or resorption, though this risk is minimal with correct technique 3

Key Technical Steps

• Adequate mobilization of the nasal cartilage is essential before graft placement 2
• Careful pocket dissection must be performed to accommodate the graft 2
• Suture fixation: Grafts should be fixed with sutures during open rhinoplasty to minimize displacement problems 4
• When reconstructing entire alar cartilages, anatomically designed replacements can be fashioned to replace missing medial, middle, or lateral crus and fixed to residual medial crura and/or a columellar strut 4

Material Selection Priority

Pure autologous ear cartilage is strongly recommended over composite materials for all nasal tip work, as it has lower infection rates, better long-term stability, no risk of implant-related complications, and maintains structural integrity indefinitely without biodegradation 3

Advantages of Conchal Cartilage

• Essentially no risk of foreign body rejection in primary rhinoplasty 3
• Allows precise sculpting and contouring for desired aesthetic outcomes specific to tip work 3
• Integrates naturally with surrounding tissues through vascular ingrowth 3
• Provides predictable long-term results without material degradation affecting nasal projection 3

Common Pitfalls and Caveats

• Inadequate graft fixation: Problems with graft visibility, unnatural appearance, or malposition can occur if grafts are not properly secured with sutures 4
• Insufficient pocket dissection: Improper pocket preparation can lead to graft displacement or irregular contours, particularly visible in patients with thin skin 5
• Ignoring cartilage memory: Failure to account for the natural curve of conchal cartilage can result in unpredictable graft behavior; use countercurve placement strategically 2
• Limited cartilage quantity: In revision cases where septal cartilage may have been previously harvested, available ear cartilage may be limited, requiring careful planning 3

Surgical Approach Framework

• Septal correction must precede any tip work, as the position of the nasal tip is largely determined by septal position 1
• A columellar strut is typically placed between the medial crura for support and realignment before adding tip grafts 1
• The external rhinoplasty approach provides superior access for precise graft placement and suture fixation 4