Costal Cartilage Harvest Through a Small Incision in Asian Rhinoplasty After Breast Augmentation.

BACKGROUND: The costal cartilage is widely used in rhinoplasty. Although different surgical methods of costal cartilage harvest have been developed, few studies have reported the method of costal cartilage harvest for patients after breast augmentation. This study aims to provide our experience of costal cartilage harvest through a small incision approach. METHODS: A retrospective review was performed for patients undergoing esthetic rhinoplasty with costal cartilage after breast augmentation between May 2019 and May 2021. Postoperative pain was evaluated with the Visual Analog Scale, and the scars at the donor site were assessed 1 year postoperatively with the Modified Vancouver Scar Scale. RESULTS: A total of 23 female patients were included. The average follow-up time was 21.4 months. No complications of massive bleeding, pleural injury, or breast implant injury during the surgery, wound dehiscence, or wound infection in the harvested site were observed. No patients complained of changes in breast morphology or breast asymmetry after costal cartilage harvest. Results of Visual Analog Scale for donor-site pain indicated pain in donor-site peaked at 12 hours after surgery and gradually decreased. All patients were satisfied with the scarring of the donor sites after surgery. CONCLUSION: The better scar performance, low complication rates, and high satisfaction among patients suggest that this is a safe technique to harvest costal cartilage with a small incision in rhinoplasty for patients after breast augmentation.

Application of Auricular Cartilage Scaffold Combined With L-Shaped Prosthesis in Asian Rhinoplasty.

Rhinoplasty is a common surgical procedure in medical cosmetology. From patients with saddle nose deformity to beauty seekers with low and short noses, this surgery is mainly sought to improve the nose's appearance. To investigate the effect of modified auricular cartilage scaffold combined with L-shaped prosthesis in rhinoplasty. This retrospective study included 54 patients who underwent auricular cartilage augmentation rhinoplasty with L-shaped implants in our hospital from July 2018 to July 2021. The function of nasal ventilation and olfaction was inspected. As a result, the degree of nasal tip protrusion and the changes in the superior lip angle of columella were improved. The patients' satisfaction was measured a year after the surgery. Patients who underwent auricular cartilage augmentation rhinoplasty with L-shaped prosthesis were satisfied with the surgery outcomes. Using a protective auricular cartilage scaffold combined with an L-shaped implant for augmentation rhinoplasty reduced the shortage of the application and reinforced the stability of the auricular cartilage augmentation rhinoplasty. At >12 months follow-up, there were no serious adverse effects on nasal ventilation and olfactory function in any of the patients. The presented method made full use of auricular cartilage so that it reduced the harvest of the cartilage. Besides, it achieved the remarkable lift of the nose tip, thus simulating the appearance of costal cartilage rhinoplasty. Furthermore, the risk of implant exposure was efficiently reduced, making it worthy of clinical application.

Auricular Framework Construction Using Cadaveric Costal Cartilage in Type III Microtia: Preliminary Results.

PURPOSE: Non/minimally irradiated Cadaveric Costal Cartilage (NCCC) is commonly used for grafts in nasal reconstruction; however, no information exists on its use in total ear reconstruction for type III microtia. In this case series we describe preliminary results from the novel use of NCCC for auricular framework construction in 7 ear reconstructions. METHODS: Patients requiring total ear reconstruction from August 2020 to October 2021 were eligible and underwent ear reconstruction using NCCC from MTF Biologics (Edison, NJ). Patients were evaluated for surgical site infection, skin necrosis, cartilage exposure, warping, and resorption during regular follow up visits. RESULTS: Seven ears were reconstructed using NCCC across 5 patients with type III microtia. Patients ranged from 5 to 51 years old at the time of surgery. Follow up time ranged from 12 to 78 weeks (mean: 46 wk). No patients experienced surgical site infections or significant cartilage resorption. All procedures were done outpatient, total time under anesthesia was <90 minutes in 5/7 cases and postoperative narcotics for pain management were not needed in 5/7 cases. Complications included minor skin necrosis that was repaired via primary closure, construct exposure in the immediate postoperative period, which was successfully salvaged with a local flap, and explantation of one construct after reconstruction for a complicated revision surgery involving a previous temporoparietal fascial flap. CONCLUSION: NCCC serves as an immediately available alternative to alloplastic and autologous materials for construction of auricular frameworks during ear reconstruction. Longer follow up times and a larger sample size will further elucidate long-term efficacy.

An Optimizing Surgical Procedures for Correcting Severe Constricted Ears: Helix Costal Cartilage Scaffold Combined With V-Y Advanced Flap.

PURPOSE: A constricted ear is a deformity that is distinguished by curling of the upper portion of the ear, which includes the helix, scapha, and antihelix. The treatment for severely constricted ears seems to be quite invasive. To reduce invasiveness and fully utilize the folded cartilage, the authors used a helix costal cartilage scaffold combined with a single V-Y advanced flap in the correction of Tanzer type IIB constricted ear deformity to investigate the clinical effect. MATERIALS AND METHODS: From 2020 to 2021, autologous costal cartilage helix stent combined with local V-Y advanced flap was applied to correct the constricted ear malformation in 18 patients admitted to the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences. RESULTS: All patients were followed for a duration of 6 to 12 months (average 7 months). Reconstructed auricles were cosmetically satisfying, with a natural-looking helix and enlarged cavum conchae cavity, as well as auricle sizes that were close to normal and near symmetry between both ears. CONCLUSIONS: With satisfactory clinical results, our technique can be used to repair types IIB cup ear deformities. It has a broad range of practical applications.

Application of a Modified Costal Cartilaginous Framework in Correction of Severe Saddle Nose Deformity.

BACKGROUND: Insufficient support of the nasal septum due to congenital or secondary deficiency leads to severe saddle nose deformity, which presents an unpleasant appearance. OBJECTIVES: The purpose of this study is to present our approach to constructing a costal cartilaginous framework with autologous costal cartilage for correction of severe saddle nose deformities. METHODS: A retrospective analysis was conducted of patients who underwent correction of severe saddle nose deformity (type 2 to type 4) by a senior surgeon from January 2018 to January 2022. Preoperative and postoperative measurements were conducted to evaluate the surgical outcomes. RESULTS: A total of 41 patients ages 15 to 50 years completed the study. The average follow-up time was 20.6 months. No short-term complications were observed. Revisional operations were performed on 3 patients. All patients were satisfied with the aesthetic results. Analysis of objective measurements showed that the nasofrontal angle, columellar-labial angle, and tip projection improved significantly in type 2 cases, the nasofrontal angle and tip projection improved significantly in type 3 cases, and tip projection improved significantly in type 4 cases. CONCLUSIONS: Application of this modified costal cartilaginous framework, which consists of a fairly stable foundation layer and an aesthetic contour layer of block costal cartilage, has achieved satisfactory results over the long term.

A Two-Stage Training Program for Auricular Framework Fabrication Practicing Using Three-Dimensional Printing Silicone Ribs and Porcine Costal Cartilage.

BACKGROUND: The manufacture of cartilage framework is a key element in the success of total ear reconstruction. Appropriate training can improve cartilage curving and fabricating skills, which is especially helpful for the novice clinicians. Based on threedimensional printing silicone model and porcine rib cartilage, the authors have designed a 2-stage training program to improve skills and cosmetic cognition for ear reconstruction. METHODS: The training program includes 2 successive stages. In the first stage, trainees completed observation of framework fabrication, design and sculpturing practice on silicone rib models. Porcine costal cartilages are used for fabrication in the second stage. After that, the framework was put in a latex glove connected with a suction to simulate the skin cover procedure in operation. RESULTS: At the end of the training program, all trainees could fabricate an ear-shaped cartilage framework successfully. Their cosmetic cognitions of the ear have also improved. CONCLUSIONS: Based on three-dimensional printing silicone model and porcine rib cartilage, the authors have designed a 2-stage training program to improve trainee's carving techniques and cosmetic cognition for ear reconstruction. The authors believe that this training program is helpful in training, practicing and teaching activities of framework fabrication in total ear reconstruction.

Revision Operation of the Unsatisfactory Microtia Reconstruction With Autologous Costal Cartilage.

BACKGROUND: Revision operation of the unsatisfactory microtia reconstruction is 1 of the most difficult revision operations in plastic surgery. This study discussed the cases about revision operation of the unsatisfactory or failed ear reconstruction using autologous costal cartilage and residual. METHODS: A prospectively maintained database of all consecutive patients who underwent secondary total ear reconstruction from 2013 to 2020 was reviewed. Demographic data and outcomes were assessed. RESULTS: Thirty-six patients with microtia met the inclusion criteria. The age of the patients who underwent secondary reconstruction ranged 6 to 56 years. The follow-up duration was from 1 to 8 years. Primary reconstruction using costal cartilage was performed in 34 cases, and Medpor (porous high-density polyethylene) were used in 2 cases. All 36 cases were treated with costal cartilage as the revision. One-stage revision was performed in 27 cases, including scaffold covered by superficial temporal fascia flap in 9 cases, retroauricular fascia flap in 12 cases and superficial temporal plus retroauricular fascia flap in 5 cases. Nine cases were renovated with expanders by stages, of which 8 cases were covered by retroauricular fascia and 1 case was covered by expanded skin flap. Complications occurred in 2 cases, and 1 patient was not satisfied with the partial scaffold repair. CONCLUSIONS: The effect of revision operation of ear reconstruction with costal cartilage is satisfactory, and different methods of ear reconstruction are indicated in different operation conditions, and the revision surgery requires adequate preoperative evaluation.Level of Evidence: Level IV, therapeutic study.

Augmentation Rhinoplasty in Cleft Lip Nasal Deformity Using Alloplastic Material and Autologous Cartilage.

Secondary cleft rhinoplasty typically requires large amounts of cartilage grafts for augmentation. The purpose of this study was to present our short-term experience with alloplastic implants in cleft rhinoplasty. This was a retrospective cohort study of cleft lip and palate patients treated with secondary rhinoplasty at Hanoi Medical University Hospital and Ruby Hospital between 2017 and 2020. All rhinoplasty procedures consisted of lower lateral cartilage repositioning, a dorsal augmentation with silicone implant, columellar strut implant or graft, and onlay tip grafts. Cartilage was obtained from the septum and concha, and no cartilage was harvested from the rib. The study outcomes included the Rhinoplasty Outcome Evaluation (ROE) survey, a modified Mortier scoring scale, 8 intranasal measures of symmetry, and 4 nasofacial measures of tip projection and nasal length. Changes in patient satisfaction and nasal esthetics were compared before and after surgery. A total of 38 patients were included in the final study sample, of whom 65.79% had unilateral clefts. The overall complication rate was 7.89%, and there were 2 cases of infection and 1 case of dorsal implant displacement. Following rhinoplasty, ROE satisfaction scores significantly increased (+39.36, P <0.01) and Mortier severity scores decreased (-3.06, P <0.01). Nostril symmetry nearly normalized in width, height, and inclination. Mean columellar deviation decreased from 8.82 to 2.08 degrees, and nasal projection increased as assessed on multiple analyses. Patients with bilateral clefts had similar improvements in ROE and Mortier scores. In our experience, synthetic implants simplified the correction of cleft nasal deformity and eliminated the need for costal cartilage. We found that our protocol produced acceptable and stable short-term clinical results without increasing the complication rate above what has been reported with autologous grafts.

Chondrotomy and sternotomy combined with the Nuss procedure for severe asymmetric pectus excavatum: how to do it.

The correction of severe asymmetric pectus excavatum is still challenging, especially for adults with a rigid thorax. For the repair of asymmetric cases, we introduce our surgical techniques added to the Nuss procedure. Chondrotomy of the depressed and deformed costal cartilage to elevate the depressed side was performed in a 42-year-old female patient. The depressed chest wall was directly elevated using pectus bars. Her sternal rotation angle improved from 27° to 15° after bar removal. In a 26-year-old male patient, oblique sternotomy and chondrotomy were performed. The sternal rotation angle improved from 26° to 9° postoperatively. These techniques were effective for correcting severe asymmetric pectus excavatum in adults.

The Harvest of a Lateral Segment of Costal Cartilage for Treating Nasal Deformities.

BACKGROUND: Although costal cartilage has many uses and is a reliable source of cartilage for rhinoplasty procedures, donor-site complications may arise with conventional harvesting techniques. The present report reports a novel technique of harvesting costal cartilage using a specially designed scalpel and studies the use of the harvested cartilage in the reconstruction of secondary nasal deformities in patients with cleft lips. METHODS: Ten patients (7 females and 3 males) with nasal deformities secondary to cleft lip underwent rhinoplasty using this new technique at the Department of Oral and Maxillofacial Surgery, Second Hospital of Hebei Medical University, China, between May 2011 and December 2013. Clinical outcomes were evaluated with a follow-up period of 6 to 30 months. RESULTS: The new technique successfully corrected primary nasal deformities, including flat nasal tip, short columella, flaring alae, and asymmetrical nostrils. Surgeons and patients assessed the outcome to be either good or satisfactory. Patients experienced transient discomfort at the wound site but there were no major complications (such as wound infection, dehiscence, exposure, graft extrusion, and pulmonary involvement). CONCLUSIONS: The novel technique can harvest a lateral segment of costal cartilage for use in the reconstruction of nasal deformities secondary to cleft lip in a one-stage procedure, with minimal donor-site morbidity.

Application of Three-Dimensional Imaging in Asian Rhinoplasty with Costal Cartilage.

BACKGROUND: 3D computer-simulated technology is becoming popular in China. Rhinoplasty with costal cartilage is a good option for Asians. However, the application of 3D imaging in Asian rhinoplasty with costal cartilage has not been systematically assessed. OBJECTIVE: To analyze the effect of 3D imaging in Asian rhinoplasty with costal cartilage. METHODS: In this study, 44 patients were included and randomly divided into 3D and non-3D imaging groups. We performed a prospective survey on the aesthetic scores for preoperative, simulated, and postoperative images and calculated the relative nasal index scores of patients in both groups. Additionally, surveys on satisfactions with surgical outcomes and doctor-patient communication in both groups were conducted. RESULTS: The actual postoperative result was well consistent with the preoperative simulation result. The 3D computer simulation did not impact the satisfaction with surgical outcomes but increased that with doctor-patient communication. The 3D computer-simulated technology was an effective tool for doctor-patient communication and surgery planning in Asian rhinoplasty with costal cartilage. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Application of Diced Autologous Rib Cartilage for Paranasal Augmentation in Cleft Nose.

OBJECTIVE: This study aimed to investigate the clinical effect of diced cartilage on correcting nasal alar base depression in Asian cleft rhinoplasty. METHODS: A retrospective study was conducted on 25 patients with nasal deformity, who underwent the second cleft rhinoplasty between January 2018 and January 2020. Autologous costal cartilage was harvested in all the patients to reconstruct the contour of the nose, while the remaining cartilage from the surgery was cut into 1.0×1.0 mm pieces and filled into the nasal alar base. The preoperative and postoperative effects of visual images were compared and analyzed using Adobe Photoshop CS6 software. The patients were followed up for 8-18 months (mean 12 months) to investigate the satisfaction and complication rate. RESULTS: The nasal alar base depression was corrected, and the profile of malformed noses was significantly improved in 25 patients after the surgery. The postoperative effect was satisfactory, and no obvious graft shift or other complications were observed in the follow-up. CONCLUSIONS: The application of diced cartilage to correct nasal alar base depression after cleft lip surgery is a feasible method. Its advantages include mainly the crafty use of the remaining cartilage and the presentation of a more natural appearance than mass cartilage. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Correction of Severe Short Nose Using a Costal Cartilage Extension Framework.

BACKGROUND: Various techniques for the aesthetic correction of short noses have been described, but the selection of the adequate graft material remains controversial. Previous reports have mainly focused on the application of septal cartilage or alloplastic materials for short nose elongation, but the lengthening effect is often unsatisfactory for severe short noses. We propose costal cartilage as an alternative treatment for short noses, describe the technique, and discuss outcomes, patient selection, and complications based on our 15-year experience. METHODS: From February 2004 to December 2018, 611 patients with varying degrees of short noses were included in this retrospective study. All patients underwent nose elongation surgery using a costal cartilage graft. Nasal length before and after surgery was measured based on a 3-dimensional simulation technology. Outcomes and complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey. RESULTS: Nasal elongation using costal cartilage was successfully achieved, with a mean increase in nasal length of 4.06 ±0.79 mm. Patients were followed up for a period of 8.5 months on average, ranging from 6 months to 8 years. Follow-up examinations demonstrated stable results. The overall complication rate was 3.8%. Complications included infection, implant extrusion, migration, deviation, visibility, prominence, and reddening of the nasal skin. Most patients (95.2%) rated their outcome as improved and much improved. CONCLUSION: Nasal elongation using costal cartilage grafting is an effective therapeutic approach for patients with severe short noses. Reliable outcomes and the use of autologous tissue along with minimal donor site morbidity contribute to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

Prevention of Autologous Costal Cartilage Graft Warping in Secondary Rhinoplasty.

BACKGROUND: Autogenous costal cartilage grafts (ACCG) are frequently used in secondary rhinoplasty; however, these grafts tend to warp. The objective of this study is to systematically evaluate current interventions to prevent warping of ACCGs and to assess long-term outcomes with their use. METHODS: A systematic review was undertaken using a computerized search. Eligible articles assessed adult patients undergoing secondary rhinoplasty with ACCGs. Interventions to reduce warping were examined. Publication descriptors were extracted, heterogeneity was examined, and methodological quality of articles was assessed. RESULTS: Eighteen studies were included. Most studies were published after 2010 (83.3%), assessed a single intervention (83.3%), and were of levels of evidence III and IV. Mean patient age was 30 (range 5-95 years) and studies included a mean of 64 cases (range 9-357). Nine of the 15 non-comparative studies were considered of high methodological quality, while all 3 comparative studies were considered high quality. Secondary rhinoplasties which did not describe a method to address warping showed increased rates of warping compared to counter balancing techniques, chimeric grafts, titanium microplating, Kirschner wire and suture usage, irradiation, and various carving techniques. Rates of warping remained low with no major complications with the use of a variety of approaches. CONCLUSIONS: ACCG warping during secondary rhinoplasty can be alleviated with a variety of techniques with no clear difference in outcomes between approaches. Plastic surgeons may consider adopting one of the various techniques described in order to reduce warping, maximize aesthetic outcomes and patient satisfaction.

A Simple Combination Approach for Costal Cartilage Augmentation Rhinoplasty.

Autologous costal cartilage graft is optimal for augmentation rhinoplasty but with complications including markedly visible graft margins and dorsal contour irregularities. Therefore, the authors introduced the diced costal cartilage graft to smoothen the margins of bilateral spreader graft for nasal dorsum augmentation. A total of 6 patients were recruited for this augmentation rhinoplasty. The pre- and postoperative photographs were taken for improvement evaluation. During a mean follow-up of 15 months, none of the patients developed major complications that may require removal or revision of the costal cartilage grafts. Five patients (80%) were very satisfied with the aesthetic outcome. This simple algorithm facilitates the substantial augmentation and removes the visibility of dorsal graft in the costal cartilage rhinoplasty for the East Asian population.

Method of Reducing Thoracic Deformity in Auricular Reconstruction.

Autologous costal cartilage graft is an important material in orthopedic surgery. However, postoperative deformity of costal cartilage in donors is also a matter of concern. In our clinical experience, the preservation of the intercostal perichondrium, the replantation of part of the costal cartilage, and wearing an elastic chest strap for half a year are all ways to avoid thoracic deformity. Methods by which to avoid thoracic deformity is still the focus of our efforts.

Thermal Chondroplasty Technique for Costal Cartilage Harvesting and Contouring.

Although costal cartilage autograft has versatile usage, harvesting the graft is an invasive procedure with potential risks for complications. Therefore, it is important to make every effort to minimize these risks. Moreover, sculpting costal cartilage to the desired shape is challenging and time-consuming because of the natural rigidity. This study aimed to evaluate cases of costal cartilage harvest in terms of the most important donor site complications and to present a novel, practical and inexpensive technique to overcome the challenges in costal cartilage harvesting and contouring. A retrospective review of patient records was made of 103 patients who underwent costal cartilage harvest by the senior author. Costal cartilage harvest was applied using either the thermal chondroplasty technique or the conventional technique on patients undergoing revision rhinoplasty surgery. The number of complications and operation times were compared between the 2 techniques.A cohort of 47 patients (30 males, 17 females; mean age 34.5 years [range, 28-48 years]) underwent costal cartilage harvest using the thermal chondroplasty technique and a cohort of 56 patients (31 males, 25 females; mean age 36 years [range, 28-52 years]) underwent costal cartilage harvest with the conventional technique. The mean operation time for the costal cartilage harvest decreased by 7.5 minutes and the total operation time decreased by 17 minutes with the use of the thermal chondroplasty technique compared to the conventional technique (P < 0.05). Complications of 2 pneumothorax and 1 hematoma developed in the conventional technique group, and no complications were seen in the thermal chondroplasty group. The results of this study suggest that the thermal chondroplasty technique is safer and time-saving compared to the conventional technique.

Morbidity in Patients With Separation of Cartilaginous Framework: Temporoparietal Fascia Flap and Treatment With Dermal Regeneration Template.

BACKGROUND: The full creation of an ear requires 2 reconstruction stages. In the second stage of reconstruction, the cartilaginous framework placed at first stage is separated from the head creating an auriculocephalic sulcus. Then a piece of rib cartilage is placed in the sulcus to maintain this separation and is covered with tissue that allows the integration of a full-thickness skin graft. METHODS: A descriptive study based on the pre and postoperative medical records and photographic archives of patients diagnosed with microtia who underwent separation of the cartilaginous framework from February 2010 to July 2015 in the Plastic and Reconstructive Surgery Department at Hospital General Dr. Manuel Gea González. RESULTS: Fifty-four patients met the selection criteria. The temporoparietal fascial flap was performed on 85% (n = 46), and 8 cases with random occipito-temporal fascial flap in association to a dermal regeneration template. The average time at the operating room was 177 minutes in patients with temporoparietal fascial flap versus 84.5 minutes in dermal regeneration template. The complication rate was 25.9% (n = 14), being similar rate with both techniques. CONCLUSIONS: Coverage with dermal regeneration template and random occipito-temporal fascia flap as an alternative use instead of temporoparietal fascial flaps, offers good postoperative results, lower operating times, and similar rate of complications, with the advantage of producing no visible scars and reserve the temporoparietal fascial flap for possible exposure of the cartilaginous framework.

Costal Cartilage and Costal Perichondrium Sandwich Graft in Septal Perforation Repair.

BACKGROUND: Repair of the septal perforation is a challenging procedure and there are many different surgical techniques. In this study, the authors present a novel method which the authors use costal cartilage and costal perichondrium sandwich graft as an interposition graft with bilateral opposing mucoperichondrial flaps. PATIENTS AND METHODS: Fourteen patients (5 females, 9 males) underwent septal perforation repair. All surgeries were performed through an open approach septoplasty technique. The edges of the perforation were incised to excise the mucosa with a thickness of 2 mm. Bilateral mucoperichondrial flaps were raised. Then costal cartilage and costal perichondrium were harvested from the rib. The cartilage was divided into a smaller piece which is 2 mm thick and 1 cm wider than perforation size. The prepared cartilage was wrapped with perichondrium to obtain a sandwich graft. This sandwich graft was placed between the mucoperichondrial flaps, corresponding to the perforation. RESULTS: After 9 months of follow-up, 11 (78%) of the 14 perforations were completely closed. Failure of the repair was observed in 3 patients; 2 of the perforations were medium size and one perforation was large size. No complications occurred. CONCLUSION: Using costal cartilage and costal perichondrium sandwich graft is a novel and useful technique especially in large septal perforations. Considering that septum surgery has an important role in the etiology of septum perforation, this method provides a good graft source for both perforation closure and simultaneous rhinoplasty surgery.

Anais Cerci Forceps: A Novel Instrument for Shaping the Nasal Dome Before Transdomal Suture Placement.

One of the most important components of an attractive nasal tip is the cephalocaudally conical form of the dome at the sagittal plane. With respect to this fact, the author tried to design a new forceps which holds the dome in a convex shape on a transverse plane and cephalocaudally conical in shape on the sagittal plane. Before grasping the dome in the desired position with Anais Cerci forceps, some degree of lateral steal is suggested and can be performed to increase the tip rotation and projection. With the help of its specific shape and template forming function, this novel instrument may also help to prevent the excess strain of transdomal suture which is crucially important to prevent the formation of pinching. This newly designed forceps can also help to provide the opportunity of the required acute angle between two domes. Slight oblique grasping of the dome reciprocally provides nice acute angle between 2 domes. Additionally, this forceps may also help to provide formation of symmetrically and reciprocally designed dome curvatures. In several secondary rhinoplasty cases with highly destroyed lower lateral cartilages, septal, auricular or costal cartilages are used for alar reconstruction. Mimicking the lower lateral cartilage anatomy from a straight cartilage graft piece is not an easy way of restoration. In such cases, Anais Cerci forceps may facilitate reshaping of the dome from an amorphous cartilage graft.