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.
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© 2013 American Society of Plastic Surgeons
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