An Alternative Fixation Technique for Onlay Cartilage Grafts in the Nasal Dorsum: A Surgical Innovation

An Alternative Fixation Technique for Onlay Cartilage Grafts in the Nasal Dorsum: A Surgical Innovation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report An Alternative Fixation Technique for Onlay Cartilage Grafts in the Nasal Dorsum: A Surgical Innovation Frederico Keim, Alexandre Palaro Braga This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8288356/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Onlay cartilage grafts are widely used to correct dorsal contour irregularities and enhance nasal projection. However, conventional fixation techniques often present limitations, such as graft instability, displacement, and warping. We present an alternative fixation technique designed to offer reliable stabilization of dorsal onlay grafts. The method involves creating a linear groove in the bony dorsum and a corresponding notch in the graft, which is then secured using a small cartilage peg–a 'peg‑and‑groove' anchoring mechanism. This design provides primary mechanical stability against graft displacement and warping, addressing a key limitation of conventional techniques. Developed for patients requiring significant dorsal augmentation, its preliminary application has demonstrated reliable graft position and smooth dorsal contours at 6‑month follow‑up. Requiring moderate surgical experience, this technique offers a simple and reproducible solution for secure dorsal augmentation. Figures Figure 1 Introduction Achieving dorsal harmony and symmetry is a key objective in rhinoplasty. Irregularities or depressions along the nasal dorsum whether congenital, post- traumatic, or secondary to prior surgery can disrupt facial aesthetics and lead to patient dissatisfaction. Recent series indicate that dorsal contour irregularities are among the most common causes of revision rhinoplasty, accounting for up to 40% of secondary procedures [1,2]. Even minor asymmetries can attract disproportionate attention, emphasizing the importance of precision and long-term stability in dorsal augmentation. Onlay cartilage grafts remain one of the most versatile tools in the rhinoplasty surgeon’s armamentarium. They effectively restore dorsal height, correct depressions, and support tip projection. However, securing these grafts, particularly in patients with a very low bony dorsum presents challenges. Fixation can be technically difficult, especially in anatomies commonly observed in east Asian populations, where minimal bone surface limits suturing options. Use of costal cartilage further introduces the risk of warping [3.4]. Traditional fixation methods like tight subperiosteal pockets, sutures to septal or bony structures, or fibrin glue all have inherent drawbacks. Pockets may cause graft deformation; sutures prolong operative time and may be difficult to apply; adhesives increase cost and may not be widely available [5,6]. In this article, we introduce a novel fixation method developed through iterative clinical practice, providing secure stabilization of onlay grafts with minimal dissection and technical complexity. It is particularly beneficial in patients with flat or under- projected nasal dorsum. Surgical Technique Surgical Challenge In patients with a low nasal dorsum, dorsal augmentation with onlay cartilage grafts is often necessary. However, conventional fixation techniques frequently result in asymmetry or displacement, particularly when the bony dorsum is narrow or flat. These challenges are especially common in Asian rhinoplasty and revision procedures. Limitations of Existing Techniques and Rationale for a New Approach Traditional methods are limited by the difficulty of anchoring grafts securely in patients with minimal bony support. This often leads to displacement, asymmetry, or visibility of the graft. Our alternative technique addresses these limitations by creating a bony groove and a corresponding notch in the graft, allowing a cartilage peg to securely anchor the graft in position. This minimizes dissection and technical complexity while improving stability and contour predictability. Development of the Technique This innovation arose from repeated intraoperative challenges where conventional fixation methods failed to ensure durable results. The technique evolved as a response to these limitations, aiming to offer a simple yet effective solution for dorsal graft stabilization. Step-by-Step Surgical Technique Exposure : The nasal dorsum is exposed via an open or closed rhinoplasty approach, providing clear visualization of the bony framework. Cartilage Harvest : Costal cartilage is harvested and prepared for dorsal augmentation. Groove Preparation : A linear groove is created along the bony midline of the nasal dorsum using a 1.2 mm cylindrical bur. Alternative instruments, such as piezoelectric devices or an osteotomy saw (Magicsaw), may also be used. Graft Preparation: The cartilage graft is pre-shaped to the desired size and volume. Its edges are beveled to prevent visibility through the skin. A transfixing cut mirroring the groove made in the bone is created in the graft using the same bur or cautery. Fixation : A small cartilage peg is inserted through the graft’s transfixing cut and into the bony groove. This peg serves as a bridge between the graft and bone, locking the graft in place. Excess cartilage from the peg is trimmed to avoid skin marking. Final sutures are placed to secure the graft to the cartilaginous dorsum. While vertical (craniocaudal) adjustment remains possible before fixation, lateral movement is restricted by the groove. Evaluation : Dorsal contour and symmetry are assessed from multiple angles intraoperatively. A video demonstrating this step-by-step procedure is available as Supplemental Video 1. Technical Considerations Edge sculpting is essential to avoid skin irregularities or visibility, especially in thin-shinned patients. Stable fixation reduces the risk of graft migration during the healing phase. Meticulous hemostasis and preservation of vascular integrity enhance graft integration. Indications This technique is indicated for both primary and revision rhinoplasty cases requiring dorsal augmentation. It is particularly useful in: Patients with congenital or post-traumatic dorsal deficiencies. Individuals with low or flat nasal dorsum, including those of East Asian descent. Secondary rhinoplasty cases with compromised nasal support. Case Illustration A 35-year-old Caucasian woman presented for secondary rhinoplasty. She had undergone a primary procedure in 2012, followed by nonsurgical dorsal augmentation with hyaluronic acid filler. Her primary concern was dorsal underprojection resulting from excessive resection during the initial surgery, producing a low nasal profile. She also reported insufficient projection and support of the nasal tip. Physical examination confirmed an excessively low and irregular bony dorsum in addition to a poorly defined, inadequately supported nasal tip. The patient sought dorsal augmentation and overall refinement while preserving a natural appearance. The dorsal-groove anchoring technique was performed using costal cartilage harvested from the sixth rib. An open rhinoplasty approach was used. A linear midline groove was created along the bony dorsum with a 1.2-mm cylindrical drill. The cartilage graft was precisely sculpted with beveled edges, and a corresponding through-cut was fashioned to accommodate the cartilage peg. The graft was secured using the peg-and-groove mechanism. Intraoperative evaluation demonstrated excellent stability and a smooth dorsal contour. Total operative time was reduced compared with traditional suture-fixation techniques routinely employed by the senior surgeon in comparable cases. Postoperative Course Recovery was uneventful. At the 3-month follow-up, the nasal dorsum showed a smooth, symmetric, and natural contour without evidence of graft displacement, asymmetry, or visibility. The patient reported high satisfaction with the aesthetic result. Pre and postoperative images are shown in Fig. 1 . Surgeon Experience Requirement This technique can be safely performed by surgeons with moderate experience in rhinoplasty, offering a balance between simplicity and effectiveness. Discussion Dorsal onlay cartilage grafts are critical tools in achieving structural and aesthetic improvements in rhinoplasty. However, their success hinges on secure and stable fixation. Displacement not only compromises outcomes but may necessitate revision surgery, increasing cost and patient dissatisfaction [3,5]. The technique presented here offers a novel solution, particularly for anatomies where traditional fixation methods are less effective. As demonstrated in our case illustration, the peg-and-groove mechanism provided immediate intraoperative stability, effectively preventing lateral displacement of the graft. Compared to suture-based fixation, it is faster and less technically demanding, a practical advantage observed during the procedure where the graft was secured efficiently without the need for complex suturing in a narrow surgical field. Compared to pocket-dependent methods, it minimizes the risk of graft deformation. Unlike fibrin glue, it does not rely on costly or inconsistent materials [6]. While initial results are promising, limitations must be acknowledged. In patients with thin skin, even well-sculpted grafts may remain partially visible. Although not encountered in our case, meticulous edge beveling remains paramount to mitigate this risk. Additionally, further long-term studies are necessary to evaluate graft integration and stability over time. A supplemental 1 video (S1) is provided to enhance reproducibility and illustrate intraoperative handling in detail. Conclusion This alternative fixation technique for dorsal onlay cartilage grafts represents a meaningful innovation in rhinoplasty. By providing a secure, reproducible, and technically simple method for graft stabilization, it addresses a long-standing challenge in both primary and revision procedures. The successful application and stable outcome in our illustrative case confirm the practical viability and initial efficacy of this approach. With proper patient selection and moderate surgical experience, the technique offers consistent aesthetic results and may become a valuable addition to the modern rhinoplasty toolkit. Declarations Declaration of Conflicting Interests The authors declare no conflicts of interest related to this work. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Patient Consent Written informed consent was obtained from the patient for the publication of this case and the accompanying images/videos. References Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP (2014) Dallas Rhinoplasty: Nasal Surgery by the Masters. 3 rd ed. St. Louis: Quality Medical Publishing. . Taş S (2020) Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty. Aesthet Surg J 40(3):263–275. DOI: 10.1093/asj/sjz063 Fisher M, Alba B, Ahmad J, Manzor M, Stocum M, Rohrich RJ, et al (2022) Current practices in dorsal augmentation rhinoplasty. Plast Reconstr Surg 149(5):1088–1102. DOI: 10.1097/PRS.0000000000009057 Lee HJ, Bukhari S, Jang YJ (2021) Dorsal augmentation using crushed autologous costal cartilage in rhinoplasty. Laryngoscope 131(7):E2181–E2187. DOI: 10.1002/lary.29398 Toriumi DM (2005) Structural approach in rhinoplasty. Facial Plast Surg Clin North Am 13(1):93–113. DOI: 10.1016/j.fsc.2004.07.004 Wong BJF (2018) Grafting techniques in primary and revision rhinoplasty. Facial Plast Surg Clin North Am 26(2):129–138. DOI: 10.1016/j.fsc.2017.12.006 Additional Declarations No competing interests reported. Supplementary Files SupplementaryVideo1.mp4 S1. Supplemental Material (mp4) Video 1 – Step-by-Step Surgical Demonstration · Part 1 (0:00–4:30): Exposure of the dorsum and identification of irregularities. · Part 2 (4:31–9:00): Cartilage harvesting and edge beveling. · Part 3 (9:01–13:30): Subperiosteal dissection and hemostasis. · Part 4 (13:31–18:00): Placement and alignment of the onlay graft. · Part 5 (18:01–21:22): Graft fixation and final contour evaluation. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8288356","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":558966558,"identity":"55011b23-5ec2-4ff0-aa91-29489872a4cf","order_by":0,"name":"Frederico Keim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYBAC+wMMDBJgxMPAcICh4p8cSPTAAzxaDBhQtJw5YAzWkkBYCwNYCwNj24HEBhAHrxbpwwdvfNxjIc/Pc/jgoRtsd9Lnhx1+CLTFTk63AYdf+NKSLWc8kzCc2duWcDiH51nuxttpBkAtycZmB3DYwsNjJs1zQCLB4DyPweEcCebcjbMTQFoOJG7DqYX/m/QfsBb+D4dzDJjTDWenfyCghYdNmgGk5WwPw+GchMMJ8tI5hGxhM7bsOQD0S88xoMMOpBlukM4pOJBggM8vzA9v/DhQBwyx5Mefc//ZyMvPTt/84UOFnRwuLVgMAas0IFY5CMg3kKJ6FIyCUTAKRgIAALJiY4vJJGT9AAAAAElFTkSuQmCC","orcid":"","institution":"FK Clínica Médica","correspondingAuthor":true,"prefix":"","firstName":"Frederico","middleName":"","lastName":"Keim","suffix":""},{"id":558966560,"identity":"c56c30a5-83e5-4126-91da-95aa6e36e52d","order_by":1,"name":"Alexandre Palaro Braga","email":"","orcid":"","institution":"FK Clínica Médica","correspondingAuthor":false,"prefix":"","firstName":"Alexandre","middleName":"Palaro","lastName":"Braga","suffix":""}],"badges":[],"createdAt":"2025-12-05 13:38:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8288356/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8288356/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98262204,"identity":"42e63c96-0e5a-43a4-b9a5-5c50ad32ea30","added_by":"auto","created_at":"2025-12-15 21:18:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":906648,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative (a, c, e) and 6-month postoperative (b, d, f) views demonstrating improved dorsal projection and a harmonious nasal profile following the dorsal-groove–anchored onlay graft technique.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8288356/v1/ba2fde666d2461c524ed888b.png"},{"id":98776906,"identity":"b34cf436-1c31-4433-b0ef-c01f8985f851","added_by":"auto","created_at":"2025-12-22 12:24:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1727809,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8288356/v1/cb308dc9-aa34-4b3d-b39d-3e96f8184179.pdf"},{"id":98262205,"identity":"d759449e-a04f-46c9-a8e0-71bf3d0aca3a","added_by":"auto","created_at":"2025-12-15 21:18:12","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":6442072,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eS1. Supplemental Material (mp4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVideo 1 – Step-by-Step Surgical Demonstration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePart 1 (0:00–4:30):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExposure of the dorsum and identification of irregularities.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePart 2 (4:31–9:00):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCartilage harvesting and edge beveling.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePart 3 (9:01–13:30):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubperiosteal dissection and hemostasis.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePart 4 (13:31–18:00):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlacement and alignment of the onlay graft.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePart 5 (18:01–21:22):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGraft fixation and final contour evaluation.\u003c/p\u003e","description":"","filename":"SupplementaryVideo1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8288356/v1/82f6d772cbdc45db8982abfb.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"An Alternative Fixation Technique for Onlay Cartilage Grafts in the Nasal Dorsum: A Surgical Innovation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAchieving dorsal harmony and symmetry is a key objective in rhinoplasty. Irregularities or depressions along the nasal dorsum whether congenital, post- traumatic, or secondary to prior surgery can disrupt facial aesthetics and lead to patient dissatisfaction.\u003c/p\u003e\n\u003cp\u003eRecent series indicate that dorsal contour irregularities are among the most common causes of revision rhinoplasty, accounting for up to 40% of secondary procedures [1,2].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eEven minor asymmetries can attract disproportionate attention, emphasizing the importance of precision and long-term stability in dorsal augmentation.\u003c/p\u003e\n\u003cp\u003eOnlay cartilage grafts remain one of the most versatile tools in the rhinoplasty surgeon\u0026rsquo;s armamentarium. They effectively restore dorsal height, correct depressions, and support tip projection. However, securing these grafts, particularly in patients with a very low bony dorsum presents challenges. Fixation can be technically difficult, especially in anatomies commonly observed in east Asian populations, where minimal bone surface limits suturing options. Use of costal cartilage further introduces the risk of warping [3.4].\u003c/p\u003e\n\u003cp\u003eTraditional fixation methods like tight subperiosteal pockets, sutures to septal or bony structures, or fibrin glue all have inherent drawbacks. Pockets may cause graft deformation; sutures prolong operative time and may be difficult to apply; adhesives increase cost and may not be widely available [5,6].\u003c/p\u003e\n\u003cp\u003eIn this article, we introduce a novel fixation method developed through iterative clinical practice, providing secure stabilization of onlay grafts with minimal dissection and technical complexity. It is particularly beneficial in patients with flat or under- projected nasal dorsum.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Challenge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn patients with a low nasal dorsum, dorsal augmentation with onlay cartilage grafts is often necessary. However, conventional fixation techniques frequently result in asymmetry or displacement, particularly when the bony dorsum is narrow or flat. These challenges are especially common in Asian rhinoplasty and revision procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations of Existing Techniques and Rationale for a New Approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraditional methods are limited by the difficulty of anchoring grafts securely in patients with minimal bony support. This often leads to displacement, asymmetry, or visibility of the graft. Our alternative technique addresses these limitations by creating a bony groove and a corresponding notch in the graft, allowing a cartilage peg to securely anchor the graft in position. This minimizes dissection and technical complexity while improving stability and contour predictability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDevelopment of the Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis innovation arose from repeated intraoperative challenges where conventional fixation methods failed to ensure durable results. The technique evolved as a response to these limitations, aiming to offer a simple yet effective solution for dorsal graft stabilization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep-by-Step Surgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eExposure\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe nasal dorsum is exposed via an open or closed rhinoplasty approach, providing clear visualization of the bony framework.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCartilage Harvest\u003c/strong\u003e: Costal cartilage is harvested and prepared for dorsal augmentation.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGroove Preparation\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eA linear groove is created along the bony midline of the nasal dorsum using a 1.2 mm cylindrical bur. Alternative instruments, such as piezoelectric devices or an osteotomy saw (Magicsaw), may also be used.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGraft Preparation:\u0026nbsp;\u003c/strong\u003eThe cartilage graft is pre-shaped to the desired size and volume. Its edges are beveled to prevent visibility through the skin. A transfixing cut mirroring the groove made in the bone is created in the graft using the same bur or cautery.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFixation\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eA small cartilage peg is inserted through the graft\u0026rsquo;s transfixing cut and into the bony groove. This peg serves as a bridge between the graft and bone, locking the graft in place. Excess cartilage from the peg is trimmed to avoid skin marking. Final sutures are placed to secure the graft to the cartilaginous dorsum. While vertical (craniocaudal) adjustment remains possible before fixation, lateral movement is restricted by the groove.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEvaluation\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDorsal contour and symmetry are assessed from multiple angles intraoperatively.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eA video demonstrating this step-by-step procedure is available as Supplemental Video 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTechnical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEdge sculpting\u003c/strong\u003e is essential to avoid skin irregularities or visibility, especially in thin-shinned patients.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStable fixation\u0026nbsp;\u003c/strong\u003ereduces the risk of graft migration during the healing phase.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMeticulous hemostasis\u003c/strong\u003e and preservation of vascular integrity enhance graft integration.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eIndications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis technique is indicated for both primary and revision rhinoplasty cases requiring dorsal augmentation. It is particularly useful in:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePatients with congenital or post-traumatic dorsal deficiencies.\u003c/li\u003e\n \u003cli\u003eIndividuals with low or flat nasal dorsum, including those of East Asian descent.\u003c/li\u003e\n \u003cli\u003eSecondary rhinoplasty cases with compromised nasal support.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Case Illustration","content":"\u003cp\u003eA 35-year-old Caucasian woman presented for secondary rhinoplasty. She had undergone a primary procedure in 2012, followed by nonsurgical dorsal augmentation with hyaluronic acid filler. Her primary concern was dorsal underprojection resulting from excessive resection during the initial surgery, producing a low nasal profile. She also reported insufficient projection and support of the nasal tip. Physical examination confirmed an excessively low and irregular bony dorsum in addition to a poorly defined, inadequately supported nasal tip. The patient sought dorsal augmentation and overall refinement while preserving a natural appearance.\u003c/p\u003e\n\u003cp\u003eThe dorsal-groove anchoring technique was performed using costal cartilage harvested from the sixth rib. An open rhinoplasty approach was used. A linear midline groove was created along the bony dorsum with a 1.2-mm cylindrical drill. The cartilage graft was precisely sculpted with beveled edges, and a corresponding through-cut was fashioned to accommodate the cartilage peg.\u003c/p\u003e\n\u003cp\u003eThe graft was secured using the peg-and-groove mechanism. Intraoperative evaluation demonstrated excellent stability and a smooth dorsal contour. Total operative time was reduced compared with traditional suture-fixation techniques routinely employed by the senior surgeon in comparable cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Course\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecovery was uneventful. At the 3-month follow-up, the nasal dorsum showed a smooth, symmetric, and natural contour without evidence of graft displacement, asymmetry, or visibility. The patient reported high satisfaction with the aesthetic result. Pre and postoperative images are shown in \u003cstrong\u003eFig. 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgeon Experience Requirement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis technique can be safely performed by surgeons with moderate experience in\u003c/p\u003e\n\u003cp\u003erhinoplasty, offering a balance between simplicity and effectiveness.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDorsal onlay cartilage grafts are critical tools in achieving structural and aesthetic improvements in rhinoplasty. However, their success hinges on secure and stable fixation. Displacement not only compromises outcomes but may necessitate revision surgery, increasing cost and patient dissatisfaction [3,5].\u003c/p\u003e\n\u003cp\u003eThe technique presented here offers a novel solution, particularly for anatomies where traditional fixation methods are less effective. As demonstrated in our case illustration, the peg-and-groove mechanism provided immediate intraoperative stability, effectively preventing lateral displacement of the graft. Compared to suture-based fixation, it is faster and less technically demanding, a practical advantage observed during the procedure where the graft was secured efficiently without the need for complex suturing in a narrow surgical field.\u0026nbsp;Compared to pocket-dependent methods, it minimizes the risk of graft deformation. Unlike fibrin glue, it does not rely on costly or inconsistent materials [6].\u003c/p\u003e\n\u003cp\u003eWhile initial results are promising, limitations must be acknowledged. In patients with thin skin, even well-sculpted grafts may remain partially visible. Although not encountered in our case, meticulous edge beveling remains paramount to mitigate this risk.\u0026nbsp;Additionally, further long-term studies are necessary to evaluate graft integration and stability over time.\u003c/p\u003e\n\u003cp\u003eA supplemental 1 video (S1) is provided to enhance reproducibility and illustrate intraoperative handling in detail.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis alternative fixation technique for dorsal onlay cartilage grafts represents a meaningful innovation in rhinoplasty. By providing a secure, reproducible, and technically simple method for graft stabilization, it addresses a long-standing challenge in both primary and revision procedures. The successful application and stable outcome in our illustrative case confirm the practical viability and initial efficacy of this approach. With proper patient selection and moderate surgical experience, the technique offers consistent aesthetic results and may become a valuable addition to the modern rhinoplasty toolkit.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case and the accompanying images/videos.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eRohrich RJ, Adams WP Jr, Ahmad J, Gunter JP (2014) Dallas Rhinoplasty: Nasal Surgery by the Masters. 3\u003csup\u003erd\u003c/sup\u003e ed. St. Louis: Quality Medical Publishing.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eTaş S (2020) Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty. Aesthet Surg J 40(3):263\u0026ndash;275. DOI: 10.1093/asj/sjz063\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFisher M, Alba B, Ahmad J, Manzor M, Stocum M, Rohrich RJ, et al (2022) Current practices in dorsal augmentation rhinoplasty. Plast Reconstr Surg 149(5):1088\u0026ndash;1102. DOI: 10.1097/PRS.0000000000009057\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLee HJ, Bukhari S, Jang YJ (2021) Dorsal augmentation using crushed autologous costal cartilage in rhinoplasty. Laryngoscope 131(7):E2181\u0026ndash;E2187. DOI: 10.1002/lary.29398\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eToriumi DM (2005) Structural approach in rhinoplasty. Facial Plast Surg Clin North Am 13(1):93\u0026ndash;113. DOI: 10.1016/j.fsc.2004.07.004\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWong BJF (2018) Grafting techniques in primary and revision rhinoplasty. Facial Plast Surg Clin North Am 26(2):129\u0026ndash;138. DOI: 10.1016/j.fsc.2017.12.006 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8288356/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8288356/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Onlay cartilage grafts are widely used to correct dorsal contour irregularities and enhance nasal projection. However, conventional fixation techniques often present limitations, such as graft instability, displacement, and warping. We present an alternative fixation technique designed to offer reliable stabilization of dorsal onlay grafts. The method involves creating a linear groove in the bony dorsum and a corresponding notch in the graft, which is then secured using a small cartilage peg–a 'peg‑and‑groove' anchoring mechanism. This design provides primary mechanical stability against graft displacement and warping, addressing a key limitation of conventional techniques. Developed for patients requiring significant dorsal augmentation, its preliminary application has demonstrated reliable graft position and smooth dorsal contours at 6‑month follow‑up. Requiring moderate surgical experience, this technique offers a simple and reproducible solution for secure dorsal augmentation.","manuscriptTitle":"An Alternative Fixation Technique for Onlay Cartilage Grafts in the Nasal Dorsum: A Surgical Innovation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 21:18:07","doi":"10.21203/rs.3.rs-8288356/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9c5087dc-4651-4694-9b04-b66f35354abd","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-20T14:08:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-15 21:18:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8288356","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8288356","identity":"rs-8288356","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}