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British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867

Comparison of different autografts for aural cartilage in

aesthetic rhinoplasty: is the tragal cartilage graft a viable
alternative?
Max J. Zinser a, , Mathias Siessegger b , Oliver Thamm c , Panangiotis Theodorou c ,
Mark Maegele d , Lutz Ritter a , Matthias Kreppel a , Martin H. Sailer e , Joachim E. Zller a ,
Robert A. Mischkowski a
a

Department of Oral and Craniomaxillofacial Surgery, University Cologne, Germany

Clinic for Facial Surgery, Cologne, Germany
c Department of Plastic Surgery, Clinic Cologne-Merheim, Germany
d Department of Trauma and Orthopaedics, Clinic Cologne-Merheim, Germany
e Department of Biomedicine, University of Basel, Switzerland
b

Accepted 1 April 2013

Available online 21 May 2013

Abstract
Auricular cartilage is an important source of grafts for various reconstructive procedures such as aesthetic rhinoplasty. The purpose of this
investigation was to compare tragal cartilage with auricular cartilage harvested from the concha and scapha, and describe its clinical viability,
indications, and morbidity in rhinoplasty. A total of 150 augmentation rhinoplasties with a total of 170 grafts were included. The donor sites
were tragus (n = 136), concha (n = 26), and scapha (n = 8). The time needed to harvest the grafts, the donor site morbidity, and the indications
for operation were recorded. The anthropometric changes to 4 auricular variables after the cartilage had been harvested were analysed and
compared with those on the opposite side in 48 patients using Students paired t-test. Intraobserver reliability was assessed using Pearsons
intraclass correlation. The mean (SD) harvesting time was 27 (8) min for the concha, 4.5 (1.4) min for the tragus, and 5.7 (1.6) min for the
scapha. The largest graft was taken from the concha (28 19 mm), followed by the tragus (20 12 mm), and the scapha (18 6 mm). The
grafts were placed at the following sites: tip grafts (n = 123), columella struts (n = 80), shield (n = 20), rim (n = 17), and dorsal onlay (n = 15).
Harvesting tragal cartilage is safe, simple, fast, and has a low morbidity, but it can affect the patients ability to wear earphones. Tragal cartilage
is a good alternative for nasal reconstruction if a graft of no longer than 20 mm is required.
2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Tragus; Scapha; Concha; Grafts; Rhinoplasty; Morbidity

Introduction

Hereby we disclose any commercial associations, current and within

the past 5 years, that might pose a potential, perceived or real conflict of
interest. These include grants, patent licensing arrangements, consultancies,
stock or other equity ownership, donations, advisory board memberships or
payments for conducting or publicising the study.
Corresponding author at: Eugen Langen Strasse 12, 50968 Kln,
Germany. Tel.: +49 171 8349256.
E-mail address: drmaxzinser@yahoo.de (M.J. Zinser).

Since the fundamental work of Ortiz-Monasterio et al.,1

Tardy et al.,2 Peck,3 and Sheen,4 autogenous cartilage has
been the graft material of choice in nasal surgery in terms
of safety, durability, and versatility. Most surgeons prefer
the septum as their first choice of donor site, followed
by the conchal cartilage.5,6 Only a few surgeons promote
the use of allografts as their first choice in augmentation
rhinoplasties.7,8 Cartilaginous grafts can be obtained from the

0266-4356/$ see front matter 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.bjoms.2013.04.001

864

M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867

Fig. 1. Distribution of donor sites and properties of auricular cartilage grafts.

nose, the septum, the rib, and the external auricle.2 The external ear provides a viable alternative in graft-depleted patients
when the septal cartilage had already been used, ideally for
secondary and tertiary rhinoplasties.913 Most surgeons still
prefer conchal grafts for augmentation-reconstruction rhinoplasties, but Grobbelaar et al.14 reported a morbidity of 2.2%,
mainly postoperative deformities of the ear, haematomas, and
hypertrophic scarring. The mean time needed to harvest the
conchal cartilage ranges between 25 and 30 min.2,11,13
Cochran and DeFatta9 and Kotzur and Gubitsch10 have
since introduced the tragal cartilage as a viable alternative in
graft-depleted patients. The purpose of the present comprehensive study was to compare tragal cartilage with conchal
and scaphal cartilage for augmentation rhinoplasty. We have
assessed the different clinical indications, viability, and feasibility including the time taken to harvest the graft, donor
site morbidity, and anthropometric changes of the ear for
each graft.

Materials and methods

This retrospective study comprised 150 augmentation rhinoplasties done between February 2001 and April 2011
(Table 1); 140 were done for aesthetic reasons, and 100 were
primary, 35 secondary, and 5 tertiary. Ten patients had had a
cleft lip repair and required reconstruction of the cleft nose.
Only patients who had auricular cartilage grafts (tragus,
concha, or scapha) were included (Fig. 1, Table 1). Patients in
whom septal cartilage was used were excluded. A total of 170
cartilage grafts (136 tragal (80%), 26 conchal (15%), and 8
scaphal grafts (5%)) were harvested (Fig. 1). All operations
were done by 3 experienced surgeons. In 10 patients, tragal cartilage was harvested from both sides. There were102
women (68%), mean (SD) age 25 (5) years, and 48 men
(32%), mean (SD) age 26 (5) years.
The grafts were used to: reconstruct the cartilaginous
structure of cleft noses, cover bony and cartilaginous
defects, smooth out irregularities, stabilise (as batten grafts),

Fig. 2. Technique for harvesting tragal cartilage. The incision line must be
marked at the posterior border of the edge of the tragus.

contour (as shield grafts), refine the nasal tip, avoid open
roof syndrome, and prevent formation of scars between the
skin and the bone, particularly if the skin was thin. All subjects signed consent forms according to the Declaration of
Helsinki preoperatively.
Assessment of donor site morbidity and anthropometric
analysis
Donor site morbidity and harvesting time of each graft were
recorded for each patient. This included documentation of
early complaints, including haematoma and perioperative
pain that resolved within 3 weeks, and irreversible complaints including scarring, sensory disturbances, and pain at
the donor sites.
In 48 patients the anthropometric changes after cartilage had been harvested were compared with those from the
opposite unaffected ear according to the protocol described
by Weerda.15 The width, length of the auricles, the protrusion angle of the mastoidauricular plane, and the distance
between the tragus and the lateral canthus, were measured and compared with those of the unaffected side. The
anthropometric measurements were made at least 6 months
postoperatively when the swelling had completely resolved.
Grafting techniques
The scaphal and conchal cartilage grafts were harvested
according to the technique described by Nolst Trenit.16
The minimally invasive approach to the harvesting of tragal cartilage is shown in Fig. 2.10 From an incision in the
tragal rim at the inner border, we dissect subperichondrally
to the anterior and posterior of the tragal cartilage. Hydrodissection with local anaesthetic solution containing adrenaline
facilitates the preparation. The facial nerve is located about
1012 mm anterior to the lower end of the cartilage. Nearly
the whole tragus can be removed, leaving only a small rim
2 mm wide at the site of the incision for structural support.

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865

Table 1
Morbidity of donor and recipient sites of external cartilage of the ear (n = 170). Data are number (%) of patients.
Variable

Tragus (n = 136)

Concha (n = 26)

Scapha (n = 8)

Total (n = 170)

Rhinoplasty
Primary
Secondary
Tertiary
Cleft nose
Recipient site
Tip/onlay graft
Dorsum onlay graft
Rim/batten graft
Columella strut
Shield graft
Donor site morbidity
Early (reversible)
Haematoma
Perioperative pain
Late (not reversible)
Scarring
Pain on pressure
Hypoaesthesia
Clicking sensation
Unable to wear earplugs
Harvesting time (min)
Dressing
Properties of cartilage
Size (mm)
Shape
Quality

126
89
30
6
1

26
9
6
2
9

150
100
5
5
10

100
4
9
60
10

17
11
6
20
10

8
8
8

2 (1)
1
1
5 (4)
1
1
1

2
5

5
4
1
6
4
1
1

27
45

7(4)
5
2
10 (7)
5
2
2
1

20 20
Thin, straight
Firm

28 19
Convex
Stiff

18 6
Straight
Flexible

The wound can be closed with a transtragal mattress suture

to prevent a haematoma. No additional dressing is needed.
Statistical analysis
All data were analysed with the help of the Statistical Package for the Social Sciences (version 17.0, SPSS
Inc., Chicago). The distribution was assessed by the
KolmogorovSmirnov test and found to be normal. All
soft tissue variables of the external ear were normally
distributed, allowing the use of Students paired t-test
to assess the significance of the difference between the
anthropometric variables after the graft had been harvested compared with those on the unaffected side. To
assess interobserver reliability, two different surgeons made
the anthropometric measurements. Reliability was quantified using Pearsons intraclass correlation coefficient.
Probabilities of less than 0.05 were accepted as significant.

123
15
17
80
20

choice for secondary and tertiary rhinoplasties when the septal cartilage had already been used.
Donor site morbidity
The early and late morbidity are shown in Table 1. One patient
whose scar retracted and who had an adhesion between the
posterior auricle and the mastoid skin required revision.
There was less early morbidity after harvest of tragal
grafts (Fig. 3, Table 1). Following tragal harvest, the scars
were nearly invisible (Fig. 3) and were of better quality

Results
The types of graft and their distribution are shown in Table 1.
It was possible to use the tragal cartilage in 136 cases (80%).
It was necessary to use conchal cartilage in 26 patients (15%)
who required extensive reconstruction of the cartilage frame
(such as a cleft nose). Grafts from the ears were our first

Fig. 3. Technique for harvesting tragal cartilage. An anterior flap must be

prepared and a strip of cartilage 1.52 mm wide preserved at the posterior
tragal border to ensure structural support.

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M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867

Anthropometric analysis
Four soft tissue variables were chosen to evaluate the anthropometric changes to the ears after the cartilage had been
harvested, and these did not differ significantly. Although
there was a mean difference in length of the conchal grafts,
harvesting of scaphal or tragal cartilage had no effect
(p < 0.45). The difference in width amounted to 2.3 mm
(p < 0.52). The mean difference in distance between the tragus and the lateral canthus was 1.3 mm (p < 0.341) and the
mean variation in the protrusion angle was 2.1 (p < 0.61).
The inter-observer reliability (0.814).
Fig. 4. Technique for harvesting tragal cartilage: almost the entire cartilage
can be harvested.

than the chonchal grafts (Fig. 4). The tragal cartilage also
showed superior results as far as late morbidity was concerned
(Table 1 and Fig. 5).
Harvesting time and properties of the grafts
A further focus of this study was the time taken to harvest the
graft, including the size and shape of the monolayer cartilage
(Fig. 1 and Table 1), and tragal grafts took less time, and did
not require dressing. Fig. 1 illustrates the properties of each
cartilage graft.

Fig. 5. Appearance of the almost invisible scar after harvest of the tragal
graft.

Discussion
Numerous materials have been described for grafting in
functional as well as in aesthetic rhinoplasty. Niechajev8
most recently published excellent long-term results using
high-density polyethylene implants, which have a morbidity
similar to procedures that involve autologous grafts. However, the first choice for most authors is still septal cartilage.17
Unfortunately, enough of this is not always available, particularly in secondary rhinoplasty revisions. Auricular cartilage
from different sites around the ear is the second choice.18 The
problem with conchal cartilage grafts is their irregular structure, their curvature, and the fact that the cartilage is elastic
and cannot be crushed. Some authors also combine auricular
cartilage grafts with bone grafts or cartilage from the ribs.19
The conchal cartilage is a beneficial source of cartilage when
multiple, bigger pieces of cartilage are needed, for instance in
rhinoplasties for cleft lip or nasal reconstructions after trauma
and resection of tumours.
Murrell12 reported changes in the aesthetics of the auricular framework including distortion of the auricle, changes in
the cephaloauricular angle that result in asymmetry between
the two ears, or visible scarring after harvest of the cartilage. However, our results showed that none of the external
aural grafts (tragus, scapha, or concha) showed significant
morphological differences between the operated side and the
unaffected side. Independently of the surgical intervention, it
is reasonable to assume that there is normal variation between
the ears.20
Murrell12 further stated that changes in the auricular
framework can be avoided by preserving a central strut of
cartilage between the cymba and cavum concha. In addition, the harvesting of conchal cartilage also requires the
placement of a cumbersome and often uncomfortable postoperative dressing, or bolster, to prevent a haematoma from
forming.
Tragal cartilage avoids many of these complications and
has other essential advantages, the biggest of which is that
it is both thin and straight. Harvesting from the tragus is
easier and faster than harvesting from the concha. There is no
need for special postoperative dressings, there is less risk of
haematoma, and a straight graft can be obtained that is firmer

M.J. Zinser et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 863867

than one taken from the concha. However, haematomas can

be prevented simply and effectively when harvesting tragal
cartilage by insertion of a single transtragal mattress suture,
which can be removed 48 h postoperatively.
Tragal cartilage has many different applications in rhinoplasty surgery. Because of its shape it is ideal for the slight
augmentation of the nasal dorsum, to smooth irregularities,
and to hide an open roof. It can also be used for alar contour
(rim) grafts, for which the cartilage is cut into 3 15 mm
pieces and then placed in an undermined pocket to help correct minor alar retraction or to strengthen the alar side wall.
For patients with collapsed nasal valves, tragal cartilage is
suitable for use as alar batten grafts. It is particularly wellsuited for grafts of the nasal tip such as shield grafts, onlay
tip grafts, and columella struts, because it is pliable and not
particularly thick. Its uniform, smooth contour makes it an
excellent source of onlay grafts for minimal amounts of dorsal augmentation, or for camouflaging localised depressions
or irregularities of contour in the osseocartilagenous framework. However, Cochran and DeFatta9 reported that the tragal
cartilage is less suitable for structural grafting such as columellar struts, lateral crural strut grafts, and dorsal spreader
grafts because it is not sufficiently strong or thick. This is
not the case according to our experience; we routinely used
tragal grafts as columellar or lateral crural strut grafts, and
we have not found any limitations. In patients with particularly thin skin it can also be used to camouflage scars and
prevent their formation between the skin and the bony nasal
skeleton.
A drawback of tragal cartilage is its limited supply. However, the piece of tragal cartilage that can usually be harvested
typically measures 20 12 mm and is usually of sufficient
quality for the applications described. These results have
caused us to change our clinical conception, and we currently use predominantly tragal grafts, although it must be
borne in mind that Pothier and Charaklias21 found that tragal
harvesting significantly affects the patients ability to wear
earphones. This can be an important issue (for example, if
they work in security or the police) and should be discussed
with the patients.
The scaphal cartilage also gave low morbidity. However,
we have almost completely abandoned its use because of the
limited amount that can be harvested and the rather thin and
flat quality of the cartilage. It may best be used for small

867

corrective measures, and cannot be recommended for cases

in which substantial structural change is needed.

References
1. Ortiz-Monasterio F, Olmedo A, Oscoy LO. The use of cartilage grafts in
primary aesthetic rhinoplasty. Plast Reconstr Surg 1981;67:597605.
2. Tardy Jr ME, Denneny III J, Fritsch MH. The versatile cartilage autograft
in reconstruction of the nose and face. Laryngoscope 1985;95:52333.
3. Peck GC. Secondary rhinoplasty. Clin Plast Surg 1988;15:2941.
4. Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr Surg
1993;91:4863.
5. Guerrerosantos J. Nose and paranasal augmentation: autogenous, fascia
and cartilage. Clin Plast Surg 1991;18:6586.
6. Rodriguez-Camps S. Augmentative rhinoplasty with an auricular gibbus.
Aesthetic Plast Surg 1998;22:196205.
7. Niechajev I. Porous polyethylene implants for nasal reconstruction: clinical and histologic studies. Aesthetic Plast Surg 1999;23:395402.
8. Niechajev I. Facial reconstruction by porous high-density polyethylene
(Medpore): long-term results. Aesthetic Plast Surg 2012;36:91727.
9. Cochran CS, DeFatta RJ. Tragal cartilage grafts in rhinoplasty: a viable
alternative in the graft-depleted patient. Otolaryngol Head Neck Surg
2008;138:1669.
10. Kotzur A, Gubisch W. Tragal cartilage grafts in aesthetic rhinoplasty.
Aesthetic Plast Surg 2003;27:2328.
11. Lee M, Callahan S, Cochran CS. Auricular cartilage: harvest technique
and versality in rhinoplasty. Am J Otolaryngol 2011;32:54752.
12. Murrell GL. Tragal cartilage grafts in rhinoplasty. Otolaryngol Head Neck
Surg 2008;139:1767.
13. Orticochea M. A new method for total reconstruction of the nose: the
ears as a donor area. Clin Plast Surg 1981;8:481505.
14. Grobbelaar AO, Matti BA, Nicolle FV. Donor site morbidity post conchal
cartilage grafting. Aesthetic Plast Surg 1997;21:902.
15. Weerda H. Basic principles. In: Weerda H, editor. Surgery of the ear.
Stuttgart: Thieme; 2004. p. 110 [in German].
16. Nolst Trenit GJ. Grafts in nasal surgery. In: Nolst Trenit GJ, editor.
Rhinoplasty. Amsterdam: Klugerer Publications; 1998. p. 4966.
17. Neu BR. Combined conchal cartilageethmoid bone grafts in nasal
surgery. Plast Reconstr Surg 2000;106:1715.
18. Jovanovic S, Berghaus A. Autogenous auricular concha cartilage transplant in corrective rhinoplasty. Practical hints and critical remarks.
Rhinology 1991;29:2739.
19. Lee Y, Kim J, Lee E. Lengthening of the postoperative short nose: combined use of a gull-wing concha composite graft and a rib costochondral
dorsal onlay graft. Plast Reconstr Surg 2000;105:2190201.
20. Mischkowski RA, Domingos-Hadamitzky C, Siessegger M, et al.
Donor-site morbidity of ear cartilage autografts. Plast Reconstr Surg
2008;121:7987.
21. Pothier DD, Charaklias N. Tragal cartilage harvesting and in the ear
earphones: a pilot study. J Laryngol Otol 2006;120:13.