Atlas of Asian Rhinoplasty (Volume 2) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

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Operative Technique
To present the tip-defining points (TDPs), one or multiple layers of auricular or septal cartilage are laid on the dome of lower
lateral cartilage. Because of the intrinsic curvature, the ear cartilage graft allows for an easier time in creating the smooth
nasal tip and is therefore preferred over septal cartilage graft for the purpose of tip projection in Asian patients.
Completed tip onlay graft should not be readily observed through the nasal tip skin. In order to achieve this, the graft
margins should not have abrupt edges but have thin beveled edges, which is referred to as chamfering (Fig. 9.57). Slightly
crushing the edge of the cartilage graft will also prevent the graft from being seen externally (Fig. 9.58). Sometimes, the
whole body of graft is gently crushed or morselized to eliminate hardness (Fig. 9.59).
a
b
Fig. 9.57 (a) Cartilage graft
with beveled edge. (b) The
graft margin is tapered thin
using a blade
Fig. 9.58 Crushing of the graft margin with
morselizer to prevent implant visibility
through tip skin
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a
b
c
Fig. 9.59 A whole graft is treated with cartilage crusher to soften the cartilage
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Cartilage Crusher
The cartilage crusher is a device used to hide the graft irregularities and margin by creating a more uniform and supple car-
tilage graft. Once the cartilage is inserted into the device, the top of the crusher is hit with a mallet. Cartilage crushers come
in serrated and smooth types (Fig. 9.60).
a
b
Fig. 9.60 Cartilage crusher. (a) Smooth bed. (b) Serrated bed
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Cartilage Morselizer
The cartilage morselizer originates from septal morselizer. It neutralizes the tension in a cartilage graft and allows for recon-
touring of cartilage graft without impairment to the cartilage structure (Fig. 9.61). Depending on the application, the mor-
selizer can be used to soften the edge of a cartilage graft or to morselize the cartilage in whole.
Temporal fascia, mastoid fascia, or dermal allograft can be used to cover the cartilage graft and to reinforce the thin skin,
which can help to avoid graft visibility through a thin skin.
Visible type of grafts like onlay/shield grafts should be fixed to the underlying cartilaginous structure in a meticulous
manner using 4–6 stitches of 6-0 PDS suture. This is an important maneuver for avoiding a conspicuous graft margin show-
ing through the thin nasal tip skin (Fig. 9.62).
In patients with thick skin, as commonly observed among Asians, the graft does not always need to be fixed to the under-
lying lower lateral cartilage. Instead, the graft can be fixed to the overlying nasal tip soft tissue using pullout suture technique
via closed approach (Fig. 9.63).
The location of pullout suture is marked in the midline of nasal tip skin where the most amount of projection is desired.
A 6-0 nylon suture is passed from outside through the tip skin and withdrawn through an intranasal incision. It is then passed
through a prepared cartilage graft, returned into the nasal tip pocket, and out through the nasal tip skin. Using the pullout
suture, the graft is pulled into the nasal pocket. The suture string is lightly tied, after putting the paper pillow to avoid exerting
too much pressure on the tip skin.
This graft can project the nasal tip to a variable height, depending on the thickness of individual grafts and the number of
graft layers. For a successful onlay graft technique, it is important that the underlying medial crura of lower lateral cartilage
is strong enough to support the onlay graft (Fig. 9.64).
Thus, the use of this graft alone is not indicated in patients with very weak medial crura, which can easily be evaluated by
finger compression test (Fig. 9.65). It is also not indicated in patients with short columella.
Fig. 9.61 Cartilage morselizer
Fig. 9.62 Onlay graft is fixed meticulously to the underlying lower
lateral cartilage with 6-0 PDS, to minimize graft visibility through the
tip skin. Four to six stitches are needed
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a
b
Fig. 9.63 Fixation of cartilage onlay graft using pullout suture
a
b
Fig. 9.64 Cartilage onlay graft can twist or compress weak medial crura, and this can lead to loss of tip height
Fig. 9.65 Finger compression test. A nasal tip
with weak medial crura will collapse easily
with finger compression
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Shield Graft
Shield graft is very similar to onlay graft. The main difference is that the shield graft is shaped like a shield, and that the graft
is placed on the caudal part of dome. It is used for simultaneous projection of the tip height and augmentation of the infratip
lobule (Fig. 9.66).
a
b
c
Fig. 9.66 Shield graft. (a) Shield graft is used for both tip augmentation and infratip augmentation. (b, c) A shield graft fashioned from two layers
of conchal cartilage
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Operative Technique
Ear cartilage and septal cartilage are most frequently used for shield graft. A harvested graft is carved into the shield shape.
The upper portion of the graft should have a width of 6–8 mm for the tip-defining point, with the lower portion of the graft
having less of width. Like the onlay graft, the margin of shield graft should be tapered thin to have a beveled edge, which
will make it less likely to show through a thin tip skin. The graft is sutured to the underlying cartilage at 4–6 points, to mini-
mize showing of the graft margin through the skin. Depending on the situation, the graft will require 1–3 layers. For optimal
tip projection in Asian patients, the upper margin of graft is usually placed 3–4 mm higher than the dome. With thick skin
and thin cartilage, the cephalic portion of shield graft is reinforced with additional cartilage graft (blocking graft), to prevent
bending of the shield graft in the cephalic direction and to fill the supratip dead space (Fig. 9.67).
When performed on weak and small lower lateral cartilage, a shield graft may appear stable during the operation. Upon
skin closure, however, the weak lateral crura may give under the weight of shield graft and yield to cephalic rotation of the
nasal tip. To avoid this problem, additional procedures are required, such as derotation graft or septal extension graft.
Effects of Shield Graft
1. Tip projection
2. Infratip lobule formation
3. Formation of tip-defining point
a
c
b
Fig. 9.67 A blocking graft to prevent cephalic bending of shield graft
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Extended Shield Graft
Extended shield graft allows for simultaneous formation of nasal tip definition and columella projection (Fig. 9.68).
This graft is a long shield-shaped graft placed in front of the dome and medial crura. Septal cartilage is the most ideal
source for this graft, but the auricular cartilage can also be used when necessary.
The graft margin should be tapered thin to a beveled edge. The margin should be sutured to the underlying cartilage to
minimize the showing of graft contour through the skin. When columella projection is insufficient, a single layer of cartilage
can be added to the columella area.
Fig. 9.68 Extended shield graft
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Columellar Strut Graft
Columellar strut graft is one of the structural grafts commonly used for tip projection. A harvested cartilage is carved into a
straight column and is fixated between the medial crura (Fig. 9.69).
Fig. 9.69 Columellar strut
graft
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Operative Technique
Cartilage Harvest
Among donor cartilages, the septal cartilage is the most commonly used for the straight shape needed. If the septal cartilage
is not available for harvest, the graft can be made from auricular cartilage or costal cartilage.
For simple harvest of septal cartilage, the dorsal approach is recommended. Compared to the intercrural approach, the
dorsal approach minimizes injury to tip-supporting connective tissue, such as intercrural soft tissue, membranous septum,
and footplate-caudal septal connection. Because of this, the use of dorsal approach minimizes the risk of tip drooping (refer
to Chap. 1).
For weak and/or thin septal cartilage, it is important to use the thickest portion of a harvested septal cartilage. The thicker
inferior portion of septal cartilage is usually a good location for this graft (Fig. 9.70). The graft should have a width of
3–4 mm and a length between 12 and 25 mm. The posterior end of the graft should be rounded to minimize clicking between
the graft and ANS (Fig. 9.71). For fixed type of strut graft, the posterior end of graft can be sutured to the ANS to avoid this
clicking.
When using the auricular cartilage as donor graft, two layers can be apposed to eliminate the curvature (Fig. 9.72).
Fig. 9.70 The inferior portion of the septal cartilage is the thickest and should be harvested for columellar strut graft in patients with thin
septal cartilage
Fig. 9.71 Columella strut graft using the septal cartilage. The posterior end of graft should be rounded to minimize clicking between the
graft and ANS
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348
a
b
c
d
Fig. 9.72 Conchal cartilage for columella strut graft. (a, b): The cartilage is scored along the long axis of concave side to allow for folding. (c, d)
The cartilage is folded lengthwise and straightened with several sutures
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Intercrural Dissection
The intercrural fibrous tissue between the medial crura is involved in supporting the tip and should be preserved. Therefore,
dissection into the intercrural space should be performed carefully to preserve this soft tissue as much as possible. Rather
than dissecting the space by cutting the soft tissue, dissecting scissors can be inserted into the soft tissue in a spreading
motion to create the space needed for the graft. Any necessary cutting should be limited to the absolutely necessary amount
(Fig. 9.73). This is important not only for tip-supporting purposes but also for minimizing tip drooping due to contracture of
postoperative scar tissue between medial crura. However, the intercrural tissue may need to be cut widely for correction of
short nose or retracted columella.
a
b
Fig. 9.73 Pocket formation for the columellar strut graft
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Placing the Graft
Columellar strut can be divided into fixed type (i.e., graft in contact with ANS) and floating type (i.e., no contact between
graft and ANS) (Fig. 9.74).
Floating strut preserves the soft-tissue cushion between the deep end of graft and the ANS. Because of the cushion effect,
the nasal tip maintains the natural “give” under pressure, and smiling will be accompanied by natural drooping of the nasal
tip. To avoid direct contact, the strut graft should be prepared to a length such that the lower end is about 3–4 mm above
the ANS.
For fixed-type strut, the lower end of strut graft will be in direct contact with ANS. However, it is difficult to ensure that
the graft sits end to end with the ANS. Therefore, posterior end of the graft should be located in front of the ANS, not on the
ANS. Close contact between the ANS and graft should be avoided by preserving the soft tissue between them (Fig. 9.75).
The reason for this is to minimize the clicking sound that occurs between graft end and ANS and also to minimize columellar
deviation from the strut moving cephalically past the ANS on one side.
If clicking is a concern for fixed type of columellar strut graft, a strip of caudal septum can be resected (Fig. 9.76) or the
posterior end of graft can be fixed to the ANS.
Fig. 9.74 Types of
columellar strut graft. Left:
Floating type, right: fixed type
a
b
Fig. 9.75 Soft tissue between the caudal septum and pocket of the columella strut graft. The soft tissue between the anterior nasal spine and
pocket of the columella strut graft should be preserved. This is to minimize the risk of clicking that can occur if the graft and posterior end of ANS
come into contact and also to prevent cephalic movement of the graft onto either side of the ANS
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Fig. 9.76 Strip resection of caudal
septum
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Fixation of the Graft
For symmetric position of the medial crura, the columella strut graft needs to be temporarily fixed. A wide double hook is
used to retract both nostrils, and the domes are pulled upward. A 26-gauge needle is used to temporarily fixate the graft to
symmetrically positioned medial crura. The strut is then fixated using three 5-0 PDS sutures with round needle (Fig. 9.77).
An alternative to temporary fixation with the needle is to mark the medial crura and graft with gentian violet while retracting
the nostril apex. The suture knot should be made between a medial crura and the graft to limit exposure to the columella skin.
With the strut fixated, interdomal suture should be used to prevent the upper end of strut from moving beyond the
margin of the alar dome. If necessary, additional suture techniques can be performed, such as transdomal suture and lat-
eral crural steal.
For columella strut graft, two important factors are the straightness of graft itself and the symmetry in the medial crura.
In patients with asymmetric alar cartilages, the most important reference point for symmetric tip and nostril is not at the
dome but at the nostril apex. The operator must be looking at the nostril apex on both sides, during the process of fixating the
alar cartilages. The horizontal level of nostril apexes should be matched first, which is the beginning point of symmetric
nostril and tip formation. Sources of remaining asymmetry can include domal height, lateral crura length, and curvature,
which can be addressed using various suture techniques (Fig. 9.78). If suture techniques are performed first to create a sym-
metric dome, it is difficult to resolve the remaining asymmetry in the nostril apex.
a
b
c
d
Fig. 9.77 Fixation of columellar strut graft. (a) Graft is placed between the medial crura. (b–d) Fixation sutures are placed in the posterior and
midportion of graft and at the dome
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a
b
c
d
e
f
Fig. 9.78 Correction of asymmetric tip and nostril. (a) In this patient, tip and nostrils are asymmetric. (b) Medial and lateral crura of lower lateral
cartilages are twisted and asymmetric. (c) The horizontal level of nostril apexes is matched first using the columellar strut graft. (d, e) Domal asym-
metry is being corrected by right lateral crural shortening. (f) At 6 months, the symmetry of nasal tip and nostril is maintained well
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Effects of Columellar Strut Graft
1. Tip projection
2. Columella lengthening and elongation of the height of nostril apex
3. Widening of nasolabial angle
4. Caudal advancement of the subnasale
5. A strong foundation for tip onlay/shield graft and derotation graft
Columella strut graft projects the columella and subnasale and can be used to correct mild columella retraction. This is
especially the case when a wide strut is used (Fig. 9.79).
Combined with derotation graft, columella strut graft can project the tip and columella in caudal direction. The combina-
tion of these two grafts obviates the need for ANS augmentation or septal extension graft.
Fig. 9.79 Lower columella projection
using the columellar strut graft with wider
posterior end
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The Logic Behind the Columellar Strut Graft for Tip Projection in Asians
The mechanisms behind nasal tip projection differ slightly according to the type of columellar strut graft:
Floating-Type Columellar Strut Graft
1. The Asian nose with low tip and short columella has weak medial crura in the twisted shape. The floating strut graft can
straighten the twisted medial crura. This maneuver increases the height of medial crura by eliminating the height loss
from the twisting (Fig. 9.80).
2. Columellar strut graft can reinforce the weak medial crura, providing a strong foundation for suture technique and carti-
lage onlay/shield graft for the tip projection. Even a straight medial crura may become twisted by the compression force
from a suture technique (e.g., medialization of lateral crura) and cartilage onlay graft (Figs. 9.53a and 9.64). The compres-
sion of medial crura can be minimized or prevented by a floating strut graft.
a
b
Fig. 9.80 The function of floating-type columellar strut
graft. (a) A common cause of low nasal tip in Asian patients
is weak and twisted medial crura. (b) The nasal tip height can
be increased by more than 3–4 mm, using floating strut graft
to straighten a twisted medial crura
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356
Fig. 9.81 Long fixed type of columellar strut graft
a
b
c
Fig. 9.82 A short, fixed type of columellar strut graft is used to prevent
the medial crura/footplates from being compressed down by the carti-
lage onlay graft. (a) A short columellar strut graft is prepared from two
layers of auricular cartilage. (b) The graft is fixed to the ANS, with the
anterior end of graft reaching the middle portion of medial crura. This
graft prevents compression of medial crura. The anterior half of medial
crura is strong without any twisting; there is no need for support from
strut graft. (c) The graft is fixed to medial crura
Fixed-Type Columellar Strut Graft
1. In the long fixed type, the strut graft should be longer than the height of alar dome. After insertion of the graft into intercrural
space, the medial crura and alar dome can be pulled upward and fixed over the anterior end of the graft. Then, the whole lower
lateral cartilage can be suspended over the graft tip, which results in a robust tip projection (Fig. 9.81). This is a direct suspension
of lower lateral cartilage for tip projection (see Chap. 10 for more detailed explanation of tip-projection techniques).
2. Thick nasal tip skin is not uncommon among Asians. Cartilage onlay graft or medialization of lateral crura may not ade-
quately project the nasal tip, because the thick skin does not stretch well, and the medial crura and footplates compress
down easily (Fig. 9.53b). Shorter fixed-type columellar strut graft can prevent this loss of projection (Fig. 9.82), by resisting
the compression force of the nasal tip skin above. If the medial crura are not weak, the strut graft does not need to reach the
alar dome and can be made short to span the distance between the midportion of medial crura and the footplates.
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In summary, floating-type strut graft is appropriate for straightening twisted medial crura, and fixed type is useful for
preventing compression of medial crura. The fixed strut graft is especially important for low nasal tip with thick skin and
short columella.
Columellar strut graft can be performed alone or in conjunction with other cartilage graft techniques. In Asian patients,
additional cartilage graft techniques are frequently used because of the small lower lateral cartilages (e.g., cartilage shield
graft or onlay graft) (Fig. 9.83).
Fig. 9.83 Columellar strut
graft and cartilage onlay graft
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358
a
b
c
d
e
f
Fig. 9.84 Use of spanning suture of lateral crura to counteract cephalic rotation of the tip from columellar strut graft. (a, b) Prior to columellar
strut graft. (c, d) The strut graft rotates the nasal tip in cephalic direction. (e, f) The spanning suture in the lateral crura rotates the tip caudally
Cephalic Rotation of the Tip by Columellar Strut Graft
Projection of nasal tip using a columellar strut graft is associated with cephalic rotation of the tip. This cephalic rotation from
columellar strut graft can be useful for correction of long drooping tip. However, this is undesirable in patients with mildly
short nose or mild alar retraction because the cephalic rotation can further shorten the dorsal length and make the nostril even
more visible.
Methods to prevent or correct cephalic rotation include, in the order of increasing effectiveness, spanning suture of lateral
crura, derotation suture, and derotation graft (Fig. 9.84). Caudal mobilization using suture techniques has been described
earlier in this chapter. To rotate the dome caudally using suture techniques, the lateral crura should be of adequate strength.
Otherwise, the tension from suture may result in buckling of the lateral crura. If the lateral crura do buckle, lateral crural
onlay graft should be used to bolster the lateral crura, or a derotation graft should be used.
Columellar strut graft can be modified to prevent cephalic rotation of the dome. The modified grafts include L-shaped
columellar strut graft and rein-shaped columellar strut graft. Both of these modifications are fixed type of strut grafts, and
prevent cephalic rotation by the free placement of the dome onto the anterior end of the graft.
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Indication and Purpose of the Columellar Strut Graft
1. The best indication for this graft is tip projection for nose with short columella and retracted subnasale with acute naso-
labial angle.
2. To correct the asymmetry in medial and middle crura.
3. To elongate a short columella.
4. To reinforce and stabilize the weak medial crura, which serves to provide a strong foundation for suture technique and
cartilage onlay/shield graft.
5. To resist the tip drooping from the depressor septi nasi muscle (smiling tip).
L-Shaped Columellar Strut Graft
This graft is a modification of fixed strut graft (Fig. 9.85).
Harvested septal cartilage is prepared into L-shape. The horizontal portion of strut is fixed to the caudal septum with 5-0
PDS sutures (Fig. 9.86). The vertical portion of strut is then placed between the lower lateral cartilages. The lower lateral
cartilages are advanced as much as needed (caudally, cephalically, or anteriorly). The domal segment and medial crura are
sutured at several points along the vertical portion of strut.
The advantage of this technique is that it allows a wide degree of freedom in placing the anterior end of the graft, which
prevents cephalic rotation of the dome. This wide degree of freedom makes the strut graft useful in tip projection as well as
correction of both short and long noses (Figs. 9.87 and 9.88). Moreover, the L-shaped columellar strut is secured to the base
of columella, which can be used to correct retracted columellar base.
However, this is a unilateral graft and can lead to caudal septal deviation and/or graft deviation in patients with weak
caudal septum. This can subsequently result in columella deviation and nostril asymmetry (Fig. 9.89). To avoid this, a small
batten graft is required to bolster the contralateral side of the caudal septum (Fig. 9.90).
Fig. 9.85 L-shaped columellar strut graft
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360
a
b
c
d
e
Fig. 9.86 Procedures of L-shaped columellar strut graft. (a) Harvested septal cartilage is carved into L-shape. (b–d) The horizontal portion of the
strut is fixed to the caudal septum with 5-0 PDS sutures. (e) The lower lateral cartilages are advanced anteriorly and fixed to the graft
9 Nasal Tip Plasty: Suture Techniques and Cartilage Grafts

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a
b
c
d
e
f
Fig. 9.87 L-shaped columellar strut graft
for tip projection without rotation of the
dome. (a–c) Preoperative views. (d–f)
Postoperative views (dorsal augmentation
with silicone implant, tip plasty with
L-shaped columellar strut graft, and
cartilage onlay graft on the tip)
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362
a
b
c
d
f
Fig. 9.88 L-shaped columellar strut graft
for cephalic rotation of the tip (long-nose
correction). (a–c) Preoperative
photographs. (d–f) Postoperative
photographs (osteotomy, dorsal
augmentation with silicone implant, tip
plasty with cephalic trimming of lateral
crura, caudal septal shortening, L-shaped
columellar strut graft, and alar base
reduction)
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a
b
c
Fig. 9.90 Additional batten graft for prevention of L-shaped columellar strut deviation. (a) L-shaped columellar strut graft was placed on the right
caudal septum. (b, c) A small batten graft was applied to the left caudal septum
a
b
Fig. 9.89 Columellar deviation and nostril asymmetry from the L-shaped columellar strut graft. (a) Preoperative photograph. (b) Columella
deviation and nostril asymmetry after L-shaped columellar strut graft. This was caused by caudal septal deviation
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364
Fig. 9.91 Rein-shaped
columellar strut graft
Rein-Shaped Columellar Strut Graft
The rein-shaped columellar strut graft is also a modification of fixed strut graft (Fig. 9.91).
First, a standard fixed-type columellar strut graft is placed in the intercrural space. Mini-spreader grafts are attached to
both sides of the anterior part of the strut graft at a right angle (Fig. 9.92). The mini-spreader grafts are fixed to the dorsal
septum to locate the anterior end of the columellar strut graft at the exact position the operator wants it to be and to prevent
the cephalic rotation of the dome by columellar strut graft. Occasionally, the flag-shaped strut can be performed using a
unilateral mini-spreader graft (Fig. 9.93).
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a
b
c
d
e
Fig. 9.92 Procedure for rein-shaped columellar strut graft. (a–c) The bilateral mini-spreader grafts are fixed to the dorsal septum and to the ante-
rior portion of columellar strut graft. (d, e) The lower lateral cartilages are sutured to the columellar strut graft. There is no cephalic rotation of the
dome
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366
a
b
c
d
e
f
Fig. 9.93 Unilateral mini-spreader type of graft can be performed as a single block. (a) The mini-spreader graft and columellar strut graft are
carved as a single block. (b–d) The graft is placed between the medial crura. The mini-spreader portion is fixed to the right side of dorsal septum.
(e, f) The medial crura and dome are fixated to the strut graft
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Spreader Graft
The spreader graft is placed between the dorsal septum and the medial margin of the upper lateral cartilage. The graft is usu-
ally bilateral but can occasionally be placed unilaterally to address asymmetry in the deviated dorsal septal cartilage
(Fig. 9.94).
Fig. 9.94 Spreader graft
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368
Operative Techniques
Spreader graft requires a rectangular segment of cartilage. The graft can be harvested from septal cartilage, auricular carti-
lage, and costal cartilage, among which the septal cartilage is the most preferred.
The two edges of graft should be made smooth, as to avoid palpable step-off of the dorsal surface. After detaching the
upper lateral cartilage from the dorsal septum, the prepared graft(s) is placed between the two cartilages. Each spreader graft
is fixed to the septal cartilage using 5-0 PDS suture. Upon graft fixation, the upper lateral cartilages are brought back into
position and repaired to the septal cartilage- spreader graft (Fig. 9.95).
b
c
e
d
a
Fig. 9.95 Operative details for unilateral spreader graft. (a) Upper lateral cartilages are detached from the dorsal septum. (b) To avoid palpable
graft edge, both ends of the graft are trimmed. (c) The spreader graft is placed between right upper lateral cartilage and dorsal septum. (d) Graft is
fixed to the dorsal septum using 5-0 PDS suture. (e) Upper lateral cartilages are brought back into position and repaired
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In most situations, a single layer of cartilage is used as spreader graft. However, the spreader graft can be made two or
more layers on both sides of septal cartilage, or the spreader graft may only require a unilateral, single-layer cartilage graft
for correction of deviated septal cartilage.
In patients with thin dorsal skin, spreader graft can lead to visible or palpable contour irregularity in the mid-vault area.
This can occur due to rough edges from incomplete trimming of graft ends, or it can occur if the graft placement is not pre-
cise (elevated or sunken graft edge). Therefore, accurate carving and placement are both important for spreader graft. For
extremely thin dorsal skin, temporalis fascia graft can be used as a soft-tissue blanket over the spreader graft to minimize
unwanted contour irregularities.
Indications of the Spreader Graft
Indications of the spreader graft are as follows:
1. To create a more defined dorsal aesthetic line
2. To correct the deviation of dorsal septum or upper lateral cartilage
3. To prevent the medial shift of upper lateral cartilages, or mid-vault collapse (inverted-V deformity), after hump reduction
and osteotomy
4. To correct a preexisting internal valve insufficiency
5. To derotate the nasal tip (extended spreader type of septal extension graft)
Septal Extension Graft
The septal extension graft, first introduced by Byrd et al., is a very useful technique for nasal lengthening, tip projection, and
rotation. Fixed to the caudal or dorsal septum, the extension can lead to a very strong structural graft. Because of this struc-
tural robustness, it has been considered to be a very powerful and reliable technique for maintaining tip projection and elon-
gation in Asian patients with weak and small lower lateral cartilages.
In Asian countries, main use for septal extension graft is short-nose correction, followed by tip projection and columella
projection.
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Types of Septal Extension Graft
There are three types of septal extension grafts, as introduced by Byrd (Fig. 9.96):
1. Extended spreader type
2. Batten type
3. Direct extension type
Extended spreader type places the graft between the dorsal septum and upper lateral cartilage (Fig. 9.97). This can be
either a unilateral or a bilateral graft. A unilateral graft is placed on the concave side of the dorsal septum, which is useful for
addressing both dorsal deviation and short nose (Fig. 9.98). To coincide the caudal end of the graft with the dome of lower
lateral cartilage, the graft should be made into a hockey stick shape (Fig. 9.99).
a
b
c
Fig. 9.96 Three types of septal extension graft. (a) Extended spreader type, (b) batten type, (c) direct extension type
Fig. 9.97 Extended spreader type of septal
extension graft (unilateral graft)
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a
b
c
Fig. 9.98 Extended spreader type of septal extension graft (unilateral graft). (a, b) In this patient, the upper lateral cartilages are deviated, with
drooping tip. (c) A unilateral extended spreader type of septal extension graft is placed on left side of the dorsal septum. (d, e) The graft has cor-
rected upper lateral cartilage deviation while projecting and lengthening the nasal tip
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d
e
Fig. 9.98 (continued)
a
b
Fig. 9.99 Hockey stick-shaped graft (extended spreader type of septal extension graft). (a) This hockey stick-shaped graft was prepared from a
harvested septal cartilage. (b) The graft is placed between dorsal septum and right upper lateral cartilage
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Batten type is relatively easier to carve and fix. Because of the stable graft construct, the batten type is the most commonly
used type of septal extension graft. The graft is fixated to the caudal septum or to the caudal septum-septal angle- dorsal
septum (Fig. 9.100), and is useful for tip lengthening and columella projection.
Depending on the placement of the caudal end, the graft can either lengthen the nose or lengthen and project the nose. It
is also possible to project the nose without lengthening, as well as improving columella projection (Fig. 9.101). This ability
to freely determine the location of caudal end makes the batten type of septal extension graft extremely useful.
In direct extension type, the graft is fixed directly to the caudal septal border by a horizontal figure-of-eight suture. This
type is not believed to allow a sustained tip projection and is used only for limited amount of graft cartilage.
Fig. 9.100 Batten type of septal extension graft
a
b
c
Fig. 9.101 Various
applications of
batten type of septal
extension graft.
(a) Tip lengthening.
(b) Tip projection.
(c) Tip projection
and lengthening
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Operative Technique
Harvest of Cartilage
The most common donor site for septal extension graft is the septum. Upon bilateral mucoperichondrial flap elevation, an
adequate amount of septal cartilage is harvested, leaving at least 10–12 mm of dorsal and caudal L-strut to support mid- vault.
Septal cartilage harvest is discussed in detail in Chap. 4.
If septal cartilage is not available for harvest, the extension graft can be performed with autogenous costal cartilage or
homologous costal cartilage (see Chap. 12).
Carving of the Graft
When a harvested septal cartilage is large enough, the cartilage can be divided to be used as two separate grafts: septal exten-
sion graft and tip onlay/shield graft. If a harvested cartilage is not sufficiently large, the cartilage should be reserved for use
as septal extension graft.
The shape and orientation of the graft should vary according to operative goals and patient wishes (Fig. 9.101). For an
acute nasolabial angle requiring columella projection, the inferior portion of graft should cross the membranous septum and
therefore needs to be longer. This longer inferior portion of the graft will project the deficient inferior columella and stabilize
the base of the nasal tip. However, this can result in a rigid nasal tip (Fig. 9.102).
Fig. 9.102 Batten type of septal extension
graft for the columellar projection. The
inferior portion is designed to be longer for
columellar projection
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Fixation of the Graft to the Septum (Batten Type)
The septal cartilages are much smaller in Asians than in Caucasians. Because of this, septal extension graft is most com-
monly performed as a unilateral graft in Asian patients.
The graft is placed on the caudal dorsal septum, anterior septal angle, and sometimes distal dorsal septum (Fig. 9.103). It
is better for the cephalic portion of graft not to extend beyond the middle part of dorsal septum to avoid mid-vault widening.
If the dorsal septum is weak and is likely to deviate, the graft can be placed further cephalically to reinforce the dorsal
septum.
The graft extends beyond the caudal margin of septum, and occupies the space between the medial crura for tip projection.
For tip lengthening, the graft should extend beyond the medial and middle crura for tip lengthening.
Once the graft is in the desired location and orientation, the first key suture is placed using a 5-0 PDS between the graft
and dorsal septum. The second suture is applied between the graft and caudal septum. These two sutures are called pivot-
locking suture, as demonstrated by Oh et al. In addition to the conventional sutures, a figure-of-eight suture is performed on
the cephalic and caudal margin at the intersection between the graft and L-strut (Fig. 9.104). This limits the up-and-down
movement of the graft and improves vertical stability.
After the key sutures, additional (2-4) sutures are placed in other areas of the graft. After firm fixation to the septum, the
graft is trimmed to an adequate height and length to match the desired height and length of the nose.
For correction of retraced columella, the graft should be extended beyond the anterior nasal spine (ANS) and cross
the membranous septum (Fig. 9.102). The caudal end of graft must be vertical in the midline, to avoid deviation of the
nasal tip and columellar deviation.
a
b
Fig. 9.103 Fixation of the batten type of septal extension graft
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Fig. 9.104 Pivot-locking suture of the septal
extension graft. The pivot-locking suture fixes
the septal extension graft to the cephalic and
caudal margin of L-strut of the septum, using
a figure-of-eight suture
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Release of the Lower Lateral Cartilages
To obtain satisfactory tip elongation and projection, the lower lateral cartilages should be sufficiently released from the sur-
rounding structure, to remove the resistance to projection and lengthening.
The lower lateral cartilages should be released from three neighboring structures, which are the upper lateral cartilage,
lateral crus attachment to the pyriform aperture, and membranous septum (Fig. 9.105).
1. Release from the upper lateral cartilage (scroll area)
The area between the lower and upper lateral cartilages is referred to as scroll area. The dissection of scroll area is the
most important component for tip projection and elongation using septal extension graft. Leaving the vestibular mucosa
intact, the fibrous connecting tissue should be adequately released between the two cartilages (Fig. 9.106).
2. Release from the hinge complex
If scroll area release by itself is insufficient, division of accessory ligament in the hinge complex may be helpful in further
caudal or anterior movement of the lower lateral cartilages (Fig. 9.107).
3. Release from the membranous septum
At times, the membranous septum needs to be released for short-nose correction (Fig. 9.108). It is, however, not necessary
for simple projection or cephalic rotation of the nasal tip. Excessive dissection in the membranous septum can induce scar
contracture, which can pull the nasal tip caudally, with resultant tip drooping. For this reason, membranous septum should
not be released for relatively simple tip projection.
Resection of depressor nasi septi muscle will be helpful for preventing tip drooping in patients with smiling tip. However,
one must remember that the dissection between medial crura and footplates will create more scar tissue, which can cause tip
drooping. Thus, the author recommends the muscle resection or repositioning be accessed through an intraoral incision.
Fig. 9.105 Three regions are fibrous connections to the
lower lateral cartilage that are released for septal extension
graft: scroll area, hinge complex, and membranous septum
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378
a
b
c
Fig. 9.106 Release of scroll area
a
b
Fig. 9.107 Detachment of distal lateral crura or accessory ligament in the hinge complex
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a
b
Fig. 9.108 Release of membranous septum. Release of fibrous tissue from the membranous septum can sometimes be helpful for additional
caudal mobilization of lower lateral cartilage for tip lengthening
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380
a
b
c
d
e
f
Fig. 9.109 Fixation of the lower lateral cartilage to septal extension graft. (a, b): A unilateral septal extension graft is fixed to the caudal septum
and septal angle. (c) The lower lateral cartilage is fixated to the caudal end of graft. (d, e) Interdomal suture was placed
Fixation of the Lower Lateral Cartilages to the Graft
Once the graft is in position, the released upper lateral cartilages are now fixed to the graft with 5-0 PDS suture (Fig. 9.109).
Dome of the lower lateral cartilage is placed at the most caudal and anterior end of the graft. The location of first suture
can vary across operators. The author begins with the medial crura and proceeds to the dome. The dome area is sutured first,
if the medial crura do not need to be sutured.
The graft end is tucked under the dome with an interdomal suture, using 5-0 Prolene nonabsorbable suture. At times, the
use of absorbable sutures can lead to cephalic mobilization of the lower lateral cartilage with suture resorption, which can
lead to the graft protrusion beyond the dome (Fig. 9.110).
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381
a
b
c
Fig. 9.110 A patient with visible graft end through the tip skin after septal extension graft. (a) The graft protrusion can be just deep to the tip skin.
(b, c) The lower lateral cartilages are pulled cephalically, and the end of septal extension graft is exposed between the domes
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382
Small Septal Cartilage for the Septal Extension Graft
A minimal length of 1.5 cm is required for a cartilage to be used as a septal extension graft. If the harvested graft is smaller
than this dimension, the following strategies are available.
First, an additional batten graft can be placed on the side contralateral to the septal extension graft to stabilize graft’s
instability coming from its narrow contact surface with caudal septum. This additional graft can be prepared from not only
septal cartilage but also from auricular cartilage or irradiated homologous costal cartilage (IHCC) (Fig. 9.111).
Second, the middle and medial crura can be fixed to wrap around the caudal end of the graft, as opposed to direct fixation
of lower lateral cartilage to caudal end of the graft. This method can yield as much extension as the vertical width of domal
segment (Fig. 9.112).
Third, a small graft can be combined with an auricular cartilage or an IHCC, as a hybrid septal extension graft. This hybrid
graft is described in Chap. 12.
Fourth, the septal extension graft can be performed using a costal cartilage graft. The use of costal cartilage for septal
extension graft is described in Chap. 12.
Fig. 9.111 Small batten graft
(auricular cartilage) to stabilize the
septal extension graft
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383
a
b
c
Fig. 9.112 Wraparound fixation technique. The lower lateral cartilages are not directly fixated to the caudal end of the graft. Instead, the medial
crura and domes wrap around the graft end and are fixated using intercrural suture and interdomal suture. These sutures should be placed such that
the cephalic margins of the domes and medial crura are placed more caudally than the caudal end of graft. In other words, the suture does not
directly fixate the caudal end of the graft
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384
Potential Problems to Avoid During Septal Extension Graft
First, caudal septum should be in the midline. Otherwise, the graft can warp and cause deviation of the nasal tip and colu-
mella. Because of this, any preexisting deviation in the caudal septum should be straightened out prior to placing the septal
extension graft.
Caudal septal deviations present in a wide spectrum of shapes. Correction of caudal septal deviations is described in Chap. 15.
Second, dorsal and caudal L-strut of the septum should be strong enough to support the extension graft. A weak L-strut
may not withstand the torque that is applied by a unilateral septal extension graft, and this will result in a crooked L-strut and
graft deviation. This can subsequently lead to deviation of nasal tip and columella and nostril asymmetry (Fig. 9.113). The
a
b
c
Fig. 9.113 Cause of the columella deviation after septal extension graft. (a) A unilateral septal extension graft. (b) A weak L-strut will gradually
warp from the unilateral graft, which will lead to secondary deviation of the graft. (c) Intraoperative photograph of a deviated septum and graft
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385
deformation of L-strut can be an intraoperative observation but can also be a postoperative manifestation of the weak under-
lying structure (Fig. 9.114). Therefore, the operator must evaluate the graft by pushing the caudal end of the graft in the
cephalic direction to see if the L-strut gives under pressure. A weak L-strut will need to be bolstered by a small batten graft
at the caudal and/or dorsal septum (Fig. 9.115).
Third, a common complaint after septal extension graft is the centralization of nasal lobule and ala. The septal exten-
sion graft tends to pull the dome and medial crura in the central and caudal direction. While the tip and columella are
advanced caudally, the alar does not advance as much. Thus, the lengthened nasal tip makes the ala appear retracted,
which worsens with smiling (Fig. 9.116). Prevention of this problem requires a wide soft-tissue dissection and avoidance
of lateral crural spanning suture. If relative alar retraction occurs with septal extension graft, then an alar rim graft or alar
spreader graft should be performed to caudally reposition the ala to match the central portion of nasal lobule. For short-
nose correction, the witched nose deformity can be avoided by using the derotation graft to elongate the nose, without
septal extension graft.
a
b
c
Fig. 9.114 Columellar deviation and nostril asymmetry after septal extension graft. This patient underwent dorsal augmentation (silicone implant)
and septal extension graft for tip projection. At 3 months after operation, there has been a gradual development of columella deviation and nostril
asymmetry
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386
Fig. 9.115 A small spreader
graft is applied on the side
opposite from the septal
extension graft, to support and
strengthen the weak dorsal
septum
a
b
Fig. 9.116 Witch-nose appearance when smiling after septal extension graft for tip projection
9 Nasal Tip Plasty: Suture Techniques and Cartilage Grafts