Surgical procedure
In all patients, an entire cymba-cavum concha complex was harvested from the external ear using an anterolateral approach through an incision several millimeters inside the contour line along the posterior conchal wall and inferior crus. Lidocaine hydrochloride (1%) with epinephrine (1:100,000) was injected for vasoconstriction at the harvest site. Several dissections were used to elevate the soft tissue away from the cymba-cavum conchal cartilage complex. All layers including cartilage, perichondrium, and soft tissue were preserved on the graft. Both halves of the harvested conchal cartilage were folded back-to-back with perichondrial surfaces positioned face-to-face without any cutting or incision. Three or four horizontal mattress sutures were then placed on the graft to fix the folded layers and reinforce bearing capacity. The ends of the folded transplant were intentionally left. Finally, the large bean-shaped original cavum concha was divided into an elliptical main piece and several smaller polygonal pieces. The elliptical main piece produced a strong and stable caudal end graft, that resists cephalic-rotatory tendency. The latter pieces were stacked to form a pagoda-shaped transplant that filled the anterior space of the nasal tip (Fig. 1). The columellar strut graft was placed in the intercrural space, where spreader grafts were anchored to one or both sides of the anterior part of the strut graft. Grafts were fixed to the dorsal septum to locate the anterior end of the columellar strut graft precisely and to prevent cephalic rotation of the dome caused by the columellar strut graft (Fig. 2). The folded portion of the graft was directed caudal to strengthen the strut force and maintained the entire skeleton to prevent cephalic rotation.