Most Koreans have a relatively low nasal dorsum and nasal tip than do whites.1
The septal extension graft can provide more proper tip support for weak alar cartilage, which is common in Asian nasal tip, and is therefore used as the standard method for Asian nasal tip surgery.2 Placement of a septal extension graft requires a sufficiently wide and long piece of septal cartilage. However, there is often insufficient harvestable cartilage for septal extension graft due to previous surgeries such as maxillary anterior segmental osteotomy and 2-jaw surgery. In such cases, autologous costal cartilage or conchal cartilage or foreign material can be used for septal extension graft. But that involves additional morbidity and increased surgery time and some patients are unwilling to use costal cartilage or foreign material.
The use of autogenous bone in rhinoplasty was reported for the first time by Sheen in 1975.3 Since then, bone grafts had been used by many surgeons in the reconstruction of the nose and nasal tip. Some studies have used septal bone and they were aimed mostly at correction of caudal septal deviation.4,5
The purpose of this study was to evaluate the cosmetic outcomes and complications from a septal extension graft using septal bone in cartilage-depleted patients.
PATIENTS AND METHODS
Fifty patients underwent septorhinoplasty for cosmetic purposes. All patients complained of cosmetic problems. All patients were enrolled in this study between November 2009 and September 2012. All patients had undergone at least 1 previous surgery. Previous surgeries that patients underwent are as follows: 14 maxillary anterior segmental osteotomy and 36 2-jaw surgery (Table 1).
There were 7 male and 43 female patients, with a mean age of 26.8 years (range, 21–58 y). All operations were performed by one of us. The follow-up periods ranged from 6 to 30 months. Patients were asked to quantify their subjective satisfaction with the operation, which was classified as excellent, good, fair, no change, or poor at 6–12 months after rhinoplasty.
All rhinoplasties were performed under sedative anesthesia with additional infiltration of local anesthesia (mixture of 2% lidocaine hydrochloride with 1:100,000 of epinephrine). An external rhinoplasty approach was used to open the nose. The skin and soft tissue envelope was dissected and raised in the supraperichondrial plane to the rhinion. Subsequent subperiosteal elevation was performed over the nasal bone. All patients had undergone previous surgery including resection of caudal septal cartilage and anterior nasal spine partially, so bilateral mucoperichondrium of septum were adhered together; therefore, by using a Freer elevator and a D-knife, the extent of previous septal resection was evaluated via palpation and then septum was approached from anterior, with great care taken not to damage mucoperichondrium of septum with the aid of hydrodissection using lidocaine. Once the submucoperichondrial plane was established, the dissection was carried over the entire dorsal strut and transformed posteriorly into a submucoperiosteal plane. The vomer and perpendicular plate of the ethmoid bone with remnant septal cartilage were cut with septal scissor along the dorsal septal strut and maxillary crest and fractured using freer elevator, and then removed in 1 piece leaving a 10-mm L-shaped strut if it is possible. Great care was taken not to rock the bone during cutting to prevent possible damage to the cribriform plate. In our study, posterior caudal septum and anterior nasal spine were destructed due to previous skeletal surgery in all cases. Using septal bone, septal extension graft is fixed to 1 side of septum attaching to the premaxilla bone and then we performed swinging-door maneuvers to anchor the septal graft to the remnant nasal spine.
Using remnant septal cartilage, supportive batten graft was fixed to the opposite side of the septum. These bilateral asymmetric septal extension grafts were placed on each side of the L-strut and secured in the manner of through-and-through sutures (Figs. 1 and 2). The nasal skin is draped over the fixed extension graft, and the amount of projection created by the graft is checked. Several cautious shortenings and checking trials may be required. The domal parts of the medial crura and columella part are then fixed to the graft. When required, osteotomies and tip surgery using septal or conchal cartilage were performed before dorsal augmentation. For dorsal augmentation, a silicone implant or cartilage was used. Silastic sheets were applied to the septal mucosa bilaterally to attach soft tissue to the graft.
Assessment of Outcomes and Complications
Postoperative subjective satisfaction was evaluated by telephone or face-to-face meeting and was classified as excellent, good, fair, no change, or poor. Some patients were recalled for a late postoperative tomography examination and photographs at least 6 months after operation. Postoperative histories were reviewed to assess complications, including postoperative infection and postoperative deformity.
Fifty patients underwent rhinoplasty using septal bone and cartilage graft only.
Medial or lateral osteotomies were performed in 32 patients. Dorsal augmentation with a silicone implant was performed in 48 patients. Tip grafting techniques such as onlay or shield grafting were performed in 48 patients (Table 2).
Forty-three patients (86%) answered the questionnaire after the operation. Postoperative subjective satisfaction was excellent in 28 cases (65%) (Figs. 3–5), good in 9 cases (21%), fair in 4 cases (9%), no change in 1 case (2%), and poor in 1 case (1%) (Table 3). Twenty-four patients, who answered the first questionnaire, answered the second questionnaire at 12–24 months after operation. Postoperative subjective satisfaction at 12–24 months was excellent in 15 cases, good in 5 cases, and fair in 3 cases. By comparing the first and second questionnaire, 1 patient changed from excellent to good on the questionnaire answer and the others kept answering the same. Some patients were recalled for a late postoperative tomography examination and photographs at least 6 months after operation. So we were able to perform the late postoperative tomography examination at least 6 months after operation in 16 patients. In Figure 6, we can see a major absorption of bone graft at 9 months postoperatively; this patient answered the questionnaire as no change. Figure 7 shows 26-month postoperative tomographic image, and it looks like the whole graft is still there due to its size in the caudal and posterior position of the graft. There was 1 infection case from unknown cause, which was related to answers as poor in questionnaire.
The impending exposure of a silicone implant was noted in 1 of 50 patients (2%) during follow-up, which was excluded in this study.
Septal extension grafts have proved to be a more proper method of controlling tip projection than columella struts. Byrd et al6 showed the analysis of preoperative and postoperative measurements of patients with columella struts; it was obvious that tip projection was not predictably controlled unless the columella strut was fixed to the caudal septum or abutted the maxilla and was attached to the medial crus. In our study, all patients had undergone rhinoplasty in the manner of septal extension graft. Using of septal extension graft needs enough septal cartilage. However, in many cases of primary rhinoplasty, which was related to previous facial skeletal surgery affecting construction of septal cartilage, it is difficult to get enough septal cartilage. In such cases, we can use autologous costal cartilage, or conchal cartilage, or foreign material. But that involves additional morbidity and increased surgery time. Some patients are reluctant to use costal cartilage or foreign material. In addition, some patients do not tell us the medical history exactly, so meet with a difficulty using other cartilages for graft during surgery. Septal bone is thin and relatively strong, allowing construction of a stable caudal septum–strut complex. This technique seems to be consistent and reproducible with low donor-site morbidity and avoids use of foreign materials for rhinoplasty.7
The use of septal bone graft was described in the correction of caudal septal deviation4,7 and external deviation,5 those targeted mostly the correction of deviation. In our present study, we showed the availability of using septal bone for septal extension graft in nasal tip surgery, especially in cartilage-depleted patients.
Some authors used other nasal bone or foreign material for septal extension graft.
Emsen8 used removed nasal hump as spreader graft in the correction of crooked nose. Resected hump is not enough for septal extension graft, requiring more labor to design than septal bone.
Han et al9 used porous high-density polyethylene sheets for complete septal extension grafts in Asian rhinoplasty. In Asian patients, a high level of resisting force is applied to a septal extension graft,2 these conditions have been associated with higher rates of implant infection, perforation, extrusion, and necessitating removal.9
Applying septal extension graft, a stable caudal septum is essential to the success of the technique,6 but all the septa were off the anterior nasal spine in our study, so using septal bone graft, authors performed swinging-door maneuvers to anchor the caudal septum to the nasal spine in all the cases. The site of fixation of the graft to the septum varies according to the shape of the midvault and amount of available septal bone and cartilage. One septal bone graft is sutured to the posterior caudal septum, projecting superoanteriorly above the dorsum of the nose. Another septal batten graft is sutured to the dorsal caudal septum diagonally to meet the other side graft in the middle line. This technique provides a strong construct for tip surgery.
Several factors should be concerned when planning to use the bony septum for septal extension graft. Bony septum as septal extension graft may be resorbed faster and much more than septal cartilage.10–12 However, in 1952, Peer13 had proved that an autogenous vomer or ethmoid bone graft would survive in soft tissues without contact to living bone. Dupont et al14 showed that the autogenous vomer bone graft survives and provides a good permanent postoperative correction of the nasal deviation. Dini et al4 had proved that septal bone grafts for straightening deviated nose were evident in all cases through late tomography with good results. When performing revision surgery, authors confirmed that the grafted septal bone is resorbed sparsely, so projection seems to be maintained over time despite resorption.
Bone is more difficult to shape than cartilage and can be easily fractured while being shaped.5 Authors were able to obtain properly shaped graft with the aid of electrical burr.
Fixation of bone grafts to the L-strut is also difficult; authors drilled several holes to allow a precise and secured fixation of the graft. These holes allow rapid ingrowth of vascularized tissue. Ingrowth of tissue within and around graft can stabilize nasal tip in their proper position.
In the learning curve of this technique, it is difficult to put septal extension grafts in the proper position, so it is essential to remove and reposition the graft until adequate location is found.
In this study, we used bilateral asymmetrical septal extension graft, which provides a stronger construct for nasal tip than bilateral symmetric grafts or intercrural strut.
Forty-five of fifty cases undergone dorsal augmentation using silicone, and no complications related with the bone/cartilage graft and silicone were reported.
Applying septal bone for septal extension graft, deviated septum and nose were corrected with success at the same time. Dini et al4 described that septal bone grafting provides increased strength against the forces of scar contracture and prevents recurrence attributable to cartilage memory.
We have noted very few complications using septal bone and generally have been able to satisfy our patients. As a result, we believe that the use of septal bone may serve as a useful maneuver in cartilage-depleted patients.
The use of septal bone as a septal extension graft for nasal tip surgery increases surgeon’s repertoire of techniques. Septal bone grafting is not meant to be used for all rhinoplasties.
This technique is a safe and reliable method for nasal tip surgery and especially beneficial in cartilage-depleted patients.
Patients provided written consent for the use of their images.
1. Wang JH, Jang YJ, Park SK, et al. Measurement of aesthetic proportions in the profile view of Koreans. Ann Plast Surg. 2009;62:109–113
2. Kang JG, Ryu J. Nasal tip surgery using a modified septal extension graft by means of extended marginal incision. Plast Reconstr Surg. 2009;123:343–352
3. Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal cartilage graft. A preliminary report. Plast Reconstr Surg. 1975;56:35–40
4. Dini GM, Iurk LK, Ferreira MC, et al. Grafts for straightening deviated noses. Plast Reconstr Surg. 2011;128:529e–537e
5. Jang YJ, Kim JM, Yeo NK, et al. Use of nasal septal bone to straighten deviated septal cartilage in correction of deviated nose. Ann Otol Rhinol Laryngol. 2009;118:488–494
6. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg. 1997;100:999–1010
7. Metzinger SE, Boyce RG, Rigby PL, et al. Ethmoid bone sandwich grafting for caudal septal defects. Arch Otolaryngol Head Neck Surg. 1994;120:1121–1125
8. Emsen IM. A different approach to the reconstruction of the stubborn crooked nose with a different spreader graft: nasal bone grafts harvested from the removed nasal hump. Aesthetic Plast Surg. 2008;32:266–273
9. Han K, Jeong JW, Kim JH, et al. Complete septal extension grafts using porous high-density polyethylene sheets for the westernization of the Asian nose. Plast Reconstr Surg. 2012;130:106e–115e
10. Gewalli F, Berlanga F, Monasterio FO, et al. Nasomaxillary reconstruction in Binder syndrome: bone versus cartilage grafts. A long-term intercenter comparison between Sweden and Mexico. J Craniofac Surg. 2008;19:1225–1236
11. Wheeler ES, Kawamoto HK, Zarem HA. Bone grafts for nasal reconstruction. Plast Reconstr Surg. 1982;69:9–18
12. Bateman N, Jones NS. Retrospective review of augmentation rhinoplasties using autologous cartilage grafts. J Laryngol Otol. 2000;114:514–518
13. Peer LA. Fate of autogenous human bone grafts. Br J Plast Surg. 1951;3:233–243
14. Dupont C, Cloutier GE, Prevost Y. Autogenous vomer bone graft for permanent correction of the cartilaginous septal deviations. Plast Reconstr Surg. 1966;38:243–247