Comparison of the effects of columellar strut and septal extension grafts for tip support in rhinoplasty

Surgical Outcomes of Bilateral Technique of Septal Extension Graft in Septorhinoplasty: A Single-center Experience

Background

Several studies have explored the use of septal extension grafts (SEGs). However, there is a lack of research specifically addressing the bilateral application of this technique. The present retrospective study presented the surgical outcomes of the bilateral SEG at a single center in Saudi Arabia.

Methods

The present study was a retrospective cohort study that retrieved data from adult patients who underwent septorhinoplasty with the bilateral SEG technique between January 2015 and December 2022 at a single center in Saudi Arabia. The retrieved data included the Rhinoplasty Outcome Evaluation (ROE) scores and Nasal Obstruction Symptom Evaluation scores.

Results

The study included 58 patients with a mean age of 30.8 ± 7.4 years. The most frequent intraoperative findings were deviated nasal septum (62.1%), nasal hump (58.6%), and down rotation (62.1%). The ROE questionnaire results showed statistically significant improvements in all constituents (P < 0.0001) after surgery. The mean total ROE score improved from 9.3 ± 3.5 preoperatively to 18.7 ± 4.4 postoperatively (P < 0.001). Similarly, the mean total Nasal Obstruction Symptom Evaluation score improved from 6.6 ± 6.4 preoperatively to 2.1 ± 3.6 postoperatively (P < 0.001). None of the patients had dorsal or tip deviations. We observed tip stiffness in 8 (13.8%) patients.

Conclusions

Bilateral SEG in septorhinoplasty has demonstrated promising results in improving both functional and aesthetic outcomes. The results of this retrospective study showed high patient satisfaction rates and a low incidence of postoperative complications.

Aesthetic and Functional Outcomes of Combined Use of Extended Spreader Graft and Septal Extension Graft

Deviation of the cartilaginous midvault and caudal nasal septum can cause both aesthetic misalignment and functional impairment of the nasal valves. This study explores the technical considerations and outcomes of combining extended spreader graft and septal extension graft in septorhinoplasty to correct these deviations. A retrospective analysis of 24 patients who underwent primary septorhinoplasty between January 2022 and July 2023, performed by a single surgeon, was conducted with a mean follow-up of 11.28 months. Unilateral or bilateral extended spreader grafts and septal extension grafts were placed on the concave side of the deviation. Clinical charts, surgical records, standardized photographs, and acoustic rhinometry data were analyzed for objective and subjective outcomes. Among 24 patients (21 males, 3 females; mean age 35.2 ± 15.0 years), successful correction of C-shaped nasal deviation was achieved with no significant complications observed in the short-term follow-up (p < 0.0001). Functional improvements were observed in nasal volume and minimum cross-sectional area (p < 0.0001). Most patients reported high satisfaction with both functional and aesthetic outcomes. Compared to traditional septorhinoplasty techniques, this combined approach offers a structured method to address both cosmetic and functional concerns. These findings suggest that the combined use of extended spreader grafts and septal extension grafts offers a promising approach for addressing both cosmetic and functional concerns in septorhinoplasty.

Tip Surgery in Dorsal Preservation Rhinoplasty: The Effect of Modified Low Septal Strip Septoplasty on Tip Plasty

BACKGROUND

The aim in tip surgery is to provide rotation, derotation, projection and deprojection. In this study, we aimed to show the effects of modified low septal strip septoplasty, septal extension graft, TIG technique and additional maneuvers on tip shape in dorsal preservation rhinoplasty (DPR) and to discuss our clinical results.

PATIENTS AND METHODS

One hundred eighty-nine patients who underwent DPR with modified low septal strip septoplasty between November 2021 and August 2023 were included in the study. Demographic data, complications, revision surgeries and follow-up periods of the patients were analyzed retrospectively.

RESULTS

The mean age of the patients is 29.58±9.04 (17-65). The mean follow-up period was 14, 50±2,98 months. Complications were observed in 1.1% of the patients (n=2/189). Revision surgery was performed in all these patients. Residual hump in 2 were observed and dorsum rasping was performed under local anesthesia. No tip revision was performed on any patient.

CONCLUSIONS

A strong tip fixation is achieved with the modified low septal septoplasty technique described in this publication, and when combined with septal extension graft, tongue in groove technique and other suture techniques, an effective and permanent tip plasty can be performed in DPR.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Septal Extension Graft Versus Columellar Strut

Stabilizing the nasal base is important before working on the nasal tip lobule. This will help define the nasolabial angle, the alar columellar relationship and nasal tip projection and rotation. Columellar struts and septal extension grafts are techniques that balance the nasal base and create a stable structure to modify the nasal tip. The type of graft used, and its design will depend on the patient's needs, cartilage availability and surgical techniques used. An endonasal or open approach can be used. In this chapter, authors will share their experience using columellar struts and the different types of septal extension grafts.

Nasal Tip Flexibility and Stability: Comparison of Septal Extension Grafts and Columellar Strut Grafts in a Prospective Trial

BACKGROUND

The stability of nasal tip rotation and projection, and providing a flexible nasal tip, are important elements in rhinoplasty. Two common options to provide these requirements are the septal extension graft (SEG) and the columellar strut graft (CSG). This study aims to compare nasal tip stability and flexibility between the 2 graft options.

METHODS

A prospective randomized study was carried out in 60 patients operated on with either the CSG or the SEG. Tip rotation and projection stability were analyzed with photographic evaluation at the immediate postoperative period, the first month, and the first year. Nasal tip flexibility was evaluated with a newton meter at the preoperative period and postoperative first, third, and sixth months and the first year.

RESULTS

The CSG showed a significant loss of projection and rotation, whereas the SEG showed better preservation of projection and rotation. However, both options showed a greater loss of projection and rotation in the first month and then a slight decrease in the following months. Although the SEG had lesser flexibility compared with the CSG anteroposteriorly, there was no flexibility difference between them in the lateral direction in the long term.

CONCLUSIONS

The SEG provides better nasal tip stability compared with the CSG. The greatest downside of the SEG is decreased flexibility compared with the CSG. Surgeons should be aware of the loss of projection and rotation with both graft options and adjust their operation plan according to these points.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Boomerang Modification of the Septal Extension Graft: Graft Design and Functional Outcomes

Background: A "boomerang" graft is an end-to-end caudal septal extension graft (SEG) that conforms to the geometry of the anterior septal angle, and avoids septal overlap, unlike a side-to-side SEG. Objective: To compare breathing improvements in rhinoplasty patients receiving boomerang SEGs and patients receiving side-to-side SEGs. Methods: Retrospective cohort analysis of patients undergoing rhinoplasty with either end-to-end boomerang SEG or a side-to-side SEG. Functional outcomes were assessed through the Nasal Obstruction Symptom Evaluation (NOSE) survey. Results: The boomerang SEG cohort had a mean age of 34 years and were 68% female compared with 38 years and 67% female in the side-to-side SEG cohort (p > 0.05). The cohorts did not differ in the proportion of the lateral crural tensioning, spreader graft placement, or history of rhinoplasty. The boomerang cohort demonstrated a 67% reduction in NOSE scores compared with a 70% reduction among the side-to-side SEG cohort (p = 0.14). Men undergoing boomerang graft placement reported significantly less postoperative functional improvement than men undergoing placement of a side-to-side SEG (62% vs. 77%, p = 0.01). Conclusion: Use of a boomerang graft is not likely to negatively affect rhinoplasty functional outcomes when compared with a side-to-side SEG.

Internal suspension sutures in tip rhinoplasty

BACKGROUND

Achieving an aesthetically pleasant tip rotation is paramount in rhinoplasty, and these results should be long-lasting. However, even powerful structural techniques such as septal extension grafts can lose rotation over time, as most support depends on the attachment of the graft to the septal cartilage.

METHODS

We describe a simple suture technique to strengthen tip support in rhinoplasty, by suspending it to the cartilaginous dorsum, providing additional support to the tip against forces, such as gravity, scar contraction and muscle tension.

CONCLUSIONS

Combining traditional techniques with suspension sutures can improve intraoperative results and could enhance long-term tip stability.

Effect of septal extension graft on nasal tip support: A finite element analysis

BACKGROUND

Septal extension graft (SEG) is an effective method to control the projection, rotation, and shape of the nasal tip. However, the structural mechanics of SEG have not yet been adequately determined.

OBJECTIVES

The purpose of this study was to examine the effect of SEG parameters on nasal tip support using finite element analysis.

METHODS

A multicomponent nasal model was constructed from a computed tomographic scan. A control model without graft and a total of 15 models with different SEGs were created, regarding the direction, length, width, and piece of SEG. The nasal tip compression was simulated to analyze the von Mises stress, reaction force, and strain energy of the tip structure.

RESULTS

The SEG increased the max stress, reaction force, and strain energy of the nasal tip compared to the normal control. The SEG perpendicular to the nasal dorsum resulted in the highest maximum stress, reaction force, and strain energy for the same size of SEG. With the length increasing from 15 × 8 × 1 mm to 25 × 8 × 1 mm, the reaction force remained relatively stable, but the stress on the graft reduced significantly. Adding the width and pieces of the SEG increased the reaction force and strain energy of the tip.

CONCLUSION

The placement of SEG can strengthen the nasal tip support. The direction, length, width, and piece of SEG have an impact on the mechanics.

LEVEL OF EVIDENCE

Diagnostic, III.

Evaluation of the Results of Septum Extension Batten Graft in Patients Referred for Septorhinoplasty

Introduction  Correction of caudal septal deviations has always been a challenging subject in septorhinoplasty. The septum batten extension graft (SBEG) is a new graft that has potential properties in rhinoplasty. However, few reports have evaluated the surgical outcomes of this technique. Objective  The purpose of this study was to evaluate the effectiveness of SBEG in correcting caudal septal deviation. Methods  This cross-sectional study was conducted on patients with caudal septal deviation undergoing septorhinoplasty using SBEG at 2 different hospitals in 2019. We then retrospectively reviewed medical records and photographs of 50 patients at the preoperative period, as well as at 1-month, and 12-month postoperatively. Gross changes in nasolabial angle, columellar show, nasal tip projection, and dorsal nasal deviation were evaluated by a photographic analysis method, and nasal obstruction was assessed by patient satisfaction with breathing. Results  There was a significant difference between the mean nasolabial angle and columellar show at 1 and 12-months postoperatively, compared with the previous values ( p  < 0.0001). The nasolabial angles were in a favorable position with an increase of 12 to 15 degrees compared with the preoperative state. The columellar show also improved by an average of 1.2 mm and was in good condition. The postoperative dorsal nasal deviation was significantly reduced, and projection was significantly increased (3.521 ± 0.087 mm vs. 0.719 ± 0.028; p  < 0.0001; p  < 0.001). Moreover, this method had a significant favorable effect on nasal obstruction ( p  = 0.049). Conclusion  Our results showed that septorhinoplasty using SBEG is useful for correcting caudal septal deviation, with favorable surgical outcomes, and it has responded well to all five aforementioned criteria.

Current Surgical Outcomes of Nasal Tip Grafts in Rhinoplasty: A Systematic Review

BACKGROUND

Refinement of the nasal tip plays an important role in rhinoplasty surgery outcomes and may be considered the most technically challenging aspect of the procedure. Numerous techniques have been described for nasal tip augmentation utilizing grafts. The aim of this study was to systematically review the existing literature on nasal tip grafts and appraise it critically.

METHODS

A PubMed search was performed to identify journal articles related to nasal tip grafts from the past decade. A total of 44 studies met inclusion criteria. The Newcastle-Ottawa Quality Assessment Scale and Jadad scale were used to appraise 38 observational studies and six randomized trials, respectively, to determine the quality of the studies.

RESULTS

Critical assessment revealed that the studies were highly variable in focus and encompassed autologous, homologous, and alloplastic grafts. The quality of the data included an average Newcastle-Ottawa Quality Assessment Scale score of 6.5 (out of 9) and Jadad score of 2.5 (out of 5). A majority of studies (86.4%) included objective outcomes using anthropometric measurements and a portion of studies (27.3%) also included patient-reported outcomes.

CONCLUSIONS

The results of this systematic review suggest that more than one type of nasal tip graft may result in satisfactory outcomes. This review provides an expansive collection of studies on nasal tip grafts, which can serve as an invaluable tool for the plastic surgeon engaging in rhinoplasty.

Hinge Strut: A New Septal Strut for Nasal Tip Projection, Definition, and Stability in Latino Noses

Background

Obtaining ideal support to maintain the nasal tip has been investigated in several rhinoplasty studies. We aimed to describe a support technique, namely the use of a "hinge strut" (HS) for the nasal tip in Latino noses and to evaluate nasolabial angles at 6-months follow-up.

Methods

In total, 46 Latino patients who had undergone rhinoplasty using the HS technique between June 2021 and June 2022 were recruited in Lima, Peru. All patients had nasolabial angle measurements taken preoperatively and at 1, 3, and 6 months postoperatively in active and passive positions to evaluate angle changes during this 6-month period.

Results

We evaluated 38 women and six men aged 18-45 years (mean age, 25.74 years). In the passive position, the mean nasolabial angles were 91.5 degrees preoperatively and 106, 104, and 103 degrees at 1, 3, and 6 months, respectively, postoperatively. In the active position, the mean nasolabial angles were 85.5 degrees preoperatively and 102.6, 99.1, and 98.1 degrees at 1, 3, and 6 months, respectively, postoperatively (P < 0.0001, using Friedman chi-square test).

Conclusions

The HS technique is safe and reproducible, with nasal tip maintenance and an adequate angle elevation trend observed at 6-months follow-up. Further studies and longer observation times are necessary to determine longer-term outcomes.

Surgical Pearls: Combined Septal Extension-Columellar Strut Graft for Rhinoplasty

Importance: The nasal tip projection, rotation, and support are essential components to address during rhinoplasty surgery. Objective: To describe a novel combined septal extension-columellar strut autologous cartilage graft for use in rhinoplasty to control tip projection, shape, and rotation while restoring strength to the nasal tip. Design: Surgical pearls-description of a novel surgical technique. Setting: An academic practice. Participants: Patients who underwent the operation.

Septal Advancement Flap: Preserving, Restructuring, and Reshaping the Nasal Tip Contour with a Novel Flap

Tip support and the tip's exact final position-rotation and projection-remain a main concern among rhinoplasty surgeons. The available options can be classified into two groups: septal extension graft (variations including tongue-in-groove) and columellar strut (with all its variations). There is still the possibility of nasal tip ligament(s) preservation-namely the interdomal ligament, when anchoraged cephalically to the anterior septal angle preserving the tip support. Including this panoply of solutions, the author has identified some challenges with insufficient outcome. Based on engineering concepts, a novel septal flap was developed to facilitate a preferred tip position and shape. The septal advancement flap (SAF) is a rotational-advancement flap of the superior and caudal aspects of the cartilaginous septum that enables the surgeon to create stable and accurate tip shape and position. This flap was designed following the spare roof technique B sequence, although it can be completed along with any technique of structure or preservation rhinoplasty.

Septal Extension Graft in Increasing Nasal Tip Projection

To study the use of septal extension graft for increasing nasal tip projection in cases of an under-projected nasal tip and to evaluate post-operative aesthetic and functional outcomes associated with it. 28 patients of underprojected tip underwent rhinoplasty with use of Direct caudal type of Septal extension graft with a minimum follow up of 12 months, operated between January 2018 to January 2020. ROE questionnaire and photographic evaluation were used for the assessment of post-operative functional and aesthetic outcomes. Significant improvement was seen in both aesthetic and functional outcomes with a mean ROE questionnaire score of 30.5 pre-operatively to 79.5 post-operatively. Pre-operative and post-operative photographic evaluation showed significant improvement in aesthetic outcome. None of the patients reported any postoperative complication. Septal extension graft can be used in patients with nasal tip deformity, Binder's syndrome, caudal septal dislocation, drooping tip,/ retracted columella and short nose with good post-operative aesthetic and functional outcomes and hence is an important technique for grafting. Owing to its rigid fixation with nasal septum, anterior nasal spine and lower alar cartilage, long term results for the control of nasal tip projection and rotation are remarkable.

Columellar strut grafts versus septal extension grafts during rhinoplasty for airway function, patient satisfaction and tip support

IMPORTANCE

Different techniques exist to provide tip support in rhinoplasty. There is little evidence to provide a consensus on the most effective choice.

OBJECTIVE

Evaluating columellar strut graft (CSG) and septal extension grafts (SEG) for their influence on airway function, patient satisfaction and tip support.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective cohort study was undertaken on 165 adult patients who underwent open rhinoplasty with either a CSG or SEG, from February 2012 to August 2019 in a single tertiary facial-plastic practice in Sydney, Australia. Operations were for both cosmetic and functional indications, and both primary and revision cases were assessed. Airway testing and patient-reported outcomes (PROMs) were performed preoperatively and at least 6 months following the procedure. Photographic tip analysis was taken from approximately 4 and 12-month postoperative photographs.

MAIN OUTCOMES AND MEASURES

Nasal peak inspiratory flow (NPIF) and total nasal airway resistance (NAR) were the primary airway functional outcomes. The primary PROMs analysed were a visual analogue scale (VAS) for nasal obstruction and 13-point Likert scale for global cosmesis, the Nose Outcome Symptom Evaluation (NOSE), and the nasal obstruction score. Tip support was determined by the nasolabial angle (NLA) and Simon's ratio as assessed by Rhinobase developed by Apaydin et al. on lateral Frankfort plane photographs. Data normalised as an improvement over preoperative baseline, accounting for individual variability.

RESULTS

A total of 165 patients was assessed (35.2 ± 12.9 yrs, 72% female), 100 (61%) of which received SEG. There were similar nasal airway assessments between CSG and SEG groups, with ΔNPIF (20.0 ± 42.1 L/min v 19.9 ± 44.9 L/min, p = 0.983) and Δ "obstructed" NAR (-1.13 ± 1.90 v -1.02 ± 4.33 Pa/cm3/s, p = 0.849). Amongst PROMs, a greater cosmetic outcome was seen in the SEG group (7.20 ± 2.97 v 5.69 ± 3.45, p < 0.01) with all other assessments similar between CSG and SEG techniques. Photographic analysis of tip projection showed reduced NLA distortion in the SEG.

CONCLUSION AND RELEVANCE

While greater patient-perceived cosmesis was seen in patients with a SEG, there were similar airflow and patient-reported nasal function between groups. Photographic analysis of tip projection showed SEG patients additionally benefited from less NLA distortion and greater tip maintenance.

Effect of Septal Extension Graft on Creating and Maintaining Tip Rotation in Tongue-in-Groove Technique: A Case Control Study

OBJECTIVE

The outcome of rhinoplasty was evaluated in patients undergoing tongue-in-groove technique (TIG) with and without septal extension grafts (SEG) placement for stabilization of nasal tip rotation.

SUBJECTS AND METHODS

Three hundred and sixty-seven patients who underwent rhinoplasty using TIG from 2016 to 2020 were included in this study. SEG was used if the caudal segment of the septum was not suitable for TIG. All patients were photographed pre- and postoperatively. Columellar Facial angle (CFA) and Nasolabial angle (NLA) were measured preoperatively at three intervals including up to six months after the operation (early or T1), up to one year after T1 (midterm or T2), and up to two years after T2 (late or T3).

RESULTS

Two hundred and nine patients (56.94%) underwent TIG and the rest of them (43.06%) received SEG plus TIG (SEG+TIG). The TIG group had a mean CFA of 95.9±7.56 degrees preoperatively, 106.5±6.77 degrees at T1, 105.4±6.48 degrees at T2, and 104.8 ±7.52 at T3. The SEG+TIG had a mean CFA of 98.9±7.65 degrees preoperatively, 108.8±6.58 degrees at T1, 107.7±6.86 degrees at T2, and 106.2 ±15.6 at T3. Comparison of T1, T2, and T3 showed that the CFA changes were less than 1%, indicating a nonsignificant difference. The same results were obtained for NLA as well.

CONCLUSION

Adding of SEG to TIG may be an effective technique to create and maintain a stable rotation comparing to TIG independently.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nasal Tip Support and Management of the Tip Tripod Complex

Controlling the nasal tip to achieve excellent structural and cosmetic outcomes is challenging in rhinoplasty surgery. A strong foundation and understanding of the nasal tripod complex and the various methods for restoring tip support mechanisms when disrupted either from surgery or other means is critical. The columellar strut graft, septal extension graft, and tongue-in-groove suture technique are well-described methods to control and support the nasal tip. There are advantages and disadvantages to each method, but one should be comfortable with the nuances of each to master nasal tip surgery.

Functional Outcomes of Septal Extension Grafting in Aesthetic Rhinoplasty: A Cohort Analysis

Background: Septal extension grafts (SEGs) are used widely in rhinoplasty as a means of controlling tip position. Grafts positioned in a side-to-side configuration may cause nasal airway obstruction. Methods: Retrospective cohort analysis of patients undergoing cosmetic rhinoplasty. Patients undergoing SEG placement were grouped according to completion of the Nasal Obstruction Symptom Evaluation (NOSE) or Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). The latter has a cosmetic (C) and functional (O) domain. Each group was matched to a cohort that did not undergo SEG placement using criteria: preoperative NOSE or SCHNOS-O score, age, and gender. Patient demographics and outcomes, including NOSE, SCHNOS, and visual analog scale (VAS) scores, were compared between SEG and no-SEG groups using univariate and multivariate analyses. If patients underwent placement of an SEG and complained of obstruction, the laterality of the graft in relation to the complaint was examined. Results: SEGs were placed in 79 patients, of whom 77 completed the NOSE survey and 37 completed the SCHNOS-O both pre- and postoperatively. These patients were matched to patients without SEGs. For both the SCHNOS and NOSE-matched cohorts, functional outcomes (NOSE, SCHNOS-O, and VAS-F) did not significantly differ between SEG and no-SEG groups. These findings were also observed when patients were stratified by cosmetic surgery alone versus combined functional and cosmetic surgery. On multivariate linear regression analysis, when accounting for intraoperative techniques, there was no difference in postoperative NOSE or SCHNOS-O outcomes between the SEG and no-SEG cohorts. Side of postoperative nasal obstruction did not correlate with side of SEG placement. Conclusion: SEGs, when used in a unilateral side-to-side configuration, yield excellent aesthetic results without compromising functional outcomes.

Updated Dynamics of Rhinoplasty: A Review of the Literature and Comprehensive List of the Findings

BACKGROUND

The cardinal reason accounting for the complexity of rhinoplasty is that each maneuver during this operation has both intended and unintended effects. The purpose of this report is to review the literature and update the dynamics of rhinoplasty.

METHODS

PubMed searches were conducted for "rhinoplasty dynamics" as well for keywords associated with each specific rhinoplasty maneuver. Titles were evaluated for relevance, and duplicates were consolidated with years of publication 1991 to 2019. Article types include case series (retrospective and prospective), cohort studies, and review articles.

RESULTS

Beginning with the radix, its reduction apparently elongates the nose and widens the intercanthal space, while radix augmentation creates the opposite illusions. In a similar manner, dorsal hump reduction widens both the nose and intercanthal space. Nasal tip dynamics focus on the aftermath of changes to tip projection, width, and rotational position. Resection of the upper lateral cartilages can cephalically rotate the tip and reduce tip width. Manipulation of the footplates of the medial crura primarily influences the columella but can also affect tip projection. Placement of a columellar strut firmly establishes tip position. Placement of alar rim grafts advances the ala caudally, widens the nostrils, and elongates the short nostril. Alar base reduction can create the illusion of increased tip projection. Augmentation and reduction in the anterior nasal spine influence tip projection, upper lip length, and the nasolabial angle.

CONCLUSIONS

As rhinoplasty techniques continue to evolve, surgeons undertaking this operation must continue to reassess the dynamics of various maneuvers.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Changing Role of Septal Extension versus Columellar Grafts in Modern Rhinoplasty

Effective control of nasal tip projection and rotation is a key component in modern rhinoplasty. Tip projection is a product of several anatomical factors: length and strength of lower lateral cartilages, the suspensory ligament, fibrous connections to the upper lateral cartilages, and the anterior septal angle. Several cartilage grafts have been described for effectively altering nasal tip projection and rotation. Columellar struts and septal extension grafts are both commonly used in modern rhinoplasty to affect projection and rotation of the nasal tip. Although columellar strut grafts have shown moderate efficacy in maintaining tip projection and unifying the tip complex, their effect on increasing tip projection has been shown to be very limited. In comparison, septal extension grafts have been shown to effectively control tip projection, rotation, and shape by securing the nasal tip to the septum. Varieties of septal extension grafts have been described to support the medial crura and control tip shape, all of which depend on the presence of a stable caudal septum. The type of graft used is dependent on the specific characteristics of the underlying tip structures. The authors' aim is to provide an updated classification of cartilage grafts for altering nasal tip projection and rotation, and an algorithmic approach for their implementation. Although both columellar struts and septal extension grafts offer the modern rhinoplasty surgeon a way to alter tip projection and rotation, they do vary in efficacy. Understanding which graft to use and in what setting is key in successfully controlling projection, rotation, and shape of the nasal tip.

Reporting Outcomes and Outcome Measures in Open Rhinoplasty: A Systematic Review

BACKGROUND

Comparative studies have shown little statistical difference in outcomes following rhinoplasty, demonstrating near equivalent results across all surgical techniques. Cross-study comparisons of these trials are difficult because variation in outcome reporting prevents statistical pooling and analysis.

OBJECTIVES

The authors sought to identify all outcomes and outcome measures used to evaluate postoperative results in rhinoplasty.

METHODS

An extensive computerized database search of MEDLINE and EMBASE was performed; all trials involving n ≥ 20 patients, aged 18 years and older undergoing a primary, open rhinoplasty procedure, were included for review.

RESULTS

Of the 3235 citations initially screened, 72 studies met the stated inclusion criteria. A total of 53 unique outcomes and 55 postoperative outcome measures were identified. Outcomes were divided into 6 unique domains: objective signs, subjective symptom severity, physical function related to activities of daily living, patient satisfaction, surgeon satisfaction, and quality of life. The identified outcome measures consisted of 5 nasal-specific, author-reported instruments; 5 nasal specific, patient-reported instruments; 5 patient-reported, generic instruments; and 40 author-generated instruments. Of the outcome measures identified, the Rhinoplasty Outcomes Evaluation, Sino-Nasal Outcome Test-22, and FACE-Q were the only instruments to demonstrate adequate validity, reliability, and responsiveness to change in patients who underwent a rhinoplasty procedure.

CONCLUSIONS

There is heterogeneity in the outcomes and outcome measures employed to assess postsurgical outcomes following rhinoplasty. A standardized core outcome set is urgently needed to make it possible for future investigators to compare results of various techniques in rhinoplasty surgery.

LEVEL OF EVIDENCE: 2

Biomechanical analysis of a modified suture technique for septal extension grafts: Transloop suture

BACKGROUND

A successful rhinoplasty procedure requires a well-defined and properly projected nasal tip; however, surgical control of the nasal tip is difficult. The aim of this investigation was to assess the efficacy and safety of a modified suture technique, which can be used to fix the caudal septal extension graft during primary rhinoplasty of the Asian population and revision septorhinoplasties of the Caucasian population, and to compare it with those of other commonly used techniques.

METHODS

After peeling of perichondrium of scapular cartilages, cartilage pieces of 3 × 1 cm in size and 2 mm in thickness were divided into two from the midline. These pieces were repaired end-to-end using three different repair techniques: two simple interrupted in Group A (n = 40), vertical figure-of-eight in Group B (n = 40) and modified vertical figure-of-eight (transloop) in Group C (n = 40). All repaired cartilage specimens were subjected to a biomechanical analysis, in which four different forces were applied: tension, lateral bending, shearing and buckling.

RESULTS

According to the tensile test, Group C had statistically significantly higher strength than Group A at 2 mm range. The lateral bending test similarly revealed that Group C had statistically significantly higher strength at 1.5 mm and 2 mm range than Group A. However, there was no statistically significant difference between the three groups in the assessment of shearing and buckling forces.

CONCLUSION

The modified transloop suture technique provides a more stable repair, and we consider that it can be used as an alternative suture repair method.

Caudal Septal Extension Graft Sutured with Absorbable Material and Not Fixed to the Nasal Spine Region Compared with the Conventional Fixation Method: A Retrospective Study

BACKGROUND

The caudal septal extension graft (CSEG) is a predictable method for positioning the tip and columella during rhinoplasty, and it is commonly performed using permanent sutures and in some cases fixating the graft to the nasal spine region (NSR) (conventional method). Whether this predictability is preserved when using absorbable sutures has yet to be determined.

METHODS

We performed a retrospective assessment of 1146 patients who underwent rhinoplasty performed by the same surgeon using the CSEG method from 2008 through 2017 in an academic setting. We utilized a computer-based patient record system for automatic data collection comparing outcomes of two groups: a group of patients who were operated on using the conventional fixation method (2008-2011) (group 1) with a second group in which absorbable sutures were used without fixation to the NSR (2011-2017) (group 2). The average follow-up period was 33.2 months. Patients operated on using a combination of methods and patients with less than 6 months of follow-up were excluded. All cases had the same septum-to-extension graft suturing technique with either permanent or absorbable suture material. This technique was side-to-side fixation with simple interrupted stitches.

RESULTS

Outcomes were measured in terms of reoperation rates and complication rates grouped in 10 categories. There were no statistical differences in complication or reoperation rates between group 1 and group 2 except for suture extrusion and/or foreign body reaction (3.9% and 0.2%, respectively, P < 0.0001). Tip deprojection was of rare and similar occurrence in both groups (0.9% and 0.8%, respectively, P 0.88).

CONCLUSION

Suturing CSEG with absorbable material and not fixing it to the NSR is a reliable variation in the conventional technique.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of Tongue-in-Groove and Columellar Strut on Rotation and Projection in Droopy Nasal Tip: Contribution of a Cap Graft

Underrotation of the nasal tip with narrow nasolabial angle is a common nasal deformity that leads to a long nose appearance, named drooping nose. In these patients, there are various techniques described to correct droopy tip and to achieve a desirable nasal tip rotation such as lateral crural steal, lateral crural overlay, tongue-ingroove, columellar strut graft, tip rotation sutures, cephalic trimming, and others. In this study, the effects of tongue-in-groove (TIG) and columellar strut graft (CS) and the contribution of cap graft on nasal tip rotation and projection were evaluated. Twenty-eight consecutive patients who underwent open approach rhinoplasty by the same senior author (ULD) between January 2015 and December 2016 with the diagnosis of septonasal deformity and droopy nasal tip were included. In 9 of these patients nasal tip was constructed with strut graft, in 6 patients with both strut and cap grafts, in 6 patients with TIG technique and in 7 patients with both TIG and cap graft. Standardized right lateral images were taken preoperatively and 6 months postoperatively to use for further assessments. The nasal tip rotation was evaluated by measuring nasolabial angle (NLA) and the nasal projection (NP) was evaluated by using the Goode method. Finally, the postoperative values of NLA and NP at the 6th month were compared with preoperative recorded values in between groups. Each group showed increase at nasal projection; however, significance was present only in CS graft and TIG groups (P=0.011 and P=0.027 relatively). Each 4 groups showed significant increase in nasal tip rotation. In addition, the comparison of percent changes between preoperative and postoperative NP and NLA revealed no difference (P=0.56 and P=0.431 relatively). In conclusion, the authors argued that TIG and CS graft techniques are both reliable methods to correct droopy nasal tip and using additional cap graft over dome area when required is safe and useful.

Caudal Septal Support Versus Strut Graft in Achieving the Desired Lateral Profile in Rhinoplasty

Nasal tip support is critical to achieve a lasting result in rhinoplasty. In this article, the authors compared the effects of strut grafts (SG) and caudal septum-based nasal tip supporting techniques (CSB-T) in terms of reaching the desired tip projection.Included in this study were 40 patients (24 women and 16 men) who underwent primary open rhinoplasty via transcolumellar incision between January and June 2012. To achieve a good nasal projection, SG and CSB-T were used for 15 and 25 of these patients, respectively.Certain anatomic landmarks were identified on preoperative, simulative, and 1-year follow-up photos. With these landmarks, certain angular and proportional values were calculated.In the SG, the authors found no statistically significant difference in between simulative goals and postoperative results regarding bending angle. Postoperative nasolabial angle (NLA), tip angle, subnasal-tip/subnasal-radix (SnT/SnR) ratios were significantly lower than the simulation values; radix angle and supratip index values were significantly higher.In the CSB-T group, the authors found no statistically significant difference in between preoperative values and postoperative results regarding NLA, tip angle, bending angle, (SnT/SnR) ratio values. Postoperative supratip index and radix angle measurements were found to be significantly higher than the simulation values.With these findings, the authors concluded that CSB-T support is superior than the SG for supporting the nasal tip in noses that also need shortening in caudal length. In noses that do not need caudal shortening, nasal tip projection can again be supported by the caudal septum by just forming a bridge between lower lateral cartilage and quadrangular septum using a wider SG that mimics septal extension grafts.

The Effect of the Short and Floating Columellar Strut Graft and Septocolumellar Suture on Nasal Tip Projection and Rotation in Primary Open Approach Rhinoplasty

OBJECTIVE

The maintenance of desired tip projection and rotation is an important goal in rhinoplasty. In this study, the effects of the columellar strut graft and septocolumellar sutures were evaluated in a follow-up period of 1 year.

PATIENTS AND METHODS

In half of 44 patients, nasal tip was constructed with basic tip maneuvers and two septocolumellar sutures (Group-1, Suture Group), whereas in the remaining 22 patients, a columellar strut graft was added for tip support (Group-2, Suture + Graft Group). Standardized right profile images were taken preoperatively, 1 month postoperatively and 1 year postoperatively. Nasal tip projection was evaluated using Goode's method. For the evaluation of tip rotation, the nasolabial angle was measured. The results were statistically compared, and a p value lower than 0.05 was considered as significant.

RESULTS

Between the postoperative first month to first year, the loss of tip projection was 3.8% in Group-1 and 3.5% in Group-2 which was statistically insignificant (p value 0.942). The loss of tip rotation was found as 4.6° (4.1%) in Group-1 and 4.6° (4.0%) in Group-2 which was also statistically insignificant (p value 0.979).

CONCLUSIONS

Considering the results of the study, in most of the primary cases, two septocolumellar sutures in conjunction with basic tip maneuvers are sufficient for positioning and stabilizing of the nasal tip, and a short and floating columellar strut graft does not have any affect in maintenance of the desired nasal tip rotation and projection.

LEVEL OF EVIDENCE III

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The Multi-Lock System for Rhinoplasty

BACKGROUND

Among the greatest challenges in rhinoplasty are setting the nasal tip contour and projection, and avoiding excessive upward rotation of the nose. Many suture and graft fixation techniques have attempted to achieve this result but may still produce results lacking in refinement. This study aims to describe in detail a new approach to stabilize the nasal tip for a durable and more predictable result.

METHODS

Twenty-eight surgeries were performed by the author, following a standardized technique which included: a modified distal onlay dorsal graft, a modified columella strut, and bilateral caudal septal sliver grafts. Follow-ups were conducted with all patients for at least 365 days. Twelve patients had follow-ups ranging from 456 to 619 days.

RESULTS

At the nasal tip there was no loss of projection or rotation. One patient had a traumatic nasal fracture and left the study. Two patients had unilateral alar retraction not related to the technique described. One patient with thin nasal skin was submitted to a surgical revision to thin the caudal septal extension grafts and improve the nasal airflow.

CONCLUSIONS

The Multi-Lock System for rhinoplasty is a good option to assure nasal length as well as projection and rotation of the tip. Also, it seemed to decrease the dead space of the supra-tip area which avoided pollybeak deformity.

LEVEL OF EVIDENCE V

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Open rhinoplasty: influence of incisions, alar resection, and columellar strut on final appearance of the tip

BACKGROUND

The aim of this study is to analyze scientifically the results of a rhinoplasty is a difficult task because of the multiplicity of surgical procedures and the subjective nature of the nose's beauty. Nevertheless, we wanted to evaluate open rhinoplasty by relying on objective and subjective criteria.

METHODS

From 2004 to 2011, a total of 155 patients underwent open septorhinoplasty at our hospital. After excluding patients lost to follow-up and those who underwent orthognathic surgery, 55 patients were included in the study. The evaluation was based on the clinical record, the standardized photographs, and the consultation of control. We studied in particular the nasolabial angle (NLA), the Goode ratio (projection/length of nose), and patient satisfaction using the rhinoplasty outcome evaluation form.

RESULTS

The columella-transalar incision tended to close the NLA (p = 0.001) and lowered the Goode ratio (p = 0.01), in contrast to the Réthi incision. The resection of the alar cartilages logically induced closure of the NLA (p = 0.02) and a decrease of nose projection (p = 0.001), whereas the use of a columellar strut induced a projection increase (p = 0.01).

CONCLUSION

Despite the existence of unavoidable measures bias, we confirmed a number of assumptions that had never been demonstrated statistically. Furthermore, we found that the incision used could affect the final result of a rhinoplasty.

LEVEL OF EVIDENCE IV

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Caudal extension graft versus columellar strut with plumping graft for acute nasolabial angle correction in rhinoplasty surgery

Nasal tip support is an important factor to be considered in rhinoplasty surgery. There are several techniques for improving tip support. Caudal extension graft (CEG) and columellar strut with plumping graft (CSPG) are two methods in rhinoplasty surgery. The final goal of this experimental study is to find the most effective method for tip correction among patients with tip ptosis. In this study, we compare two different methods which are used for the tip correction among patients who suffer from acute nasolabial angle (NLA) and columellar retraction. We performed a randomized clinical trial to compare correction ratio of NLA and columellar show obtained via CEG and CSPG methods. Standardized photographs were taken before the surgery and 12 months after the surgery to compare results between two groups. The mean post-operation NLA was 112.55° in CEG and 104.17° in CSPG (p value < 0.001). Correction ratio of NLA was 22.26° in CEG and 13.77° in CSPG (p value < 0.001). The difference in the mean and the correction ratio of NLA were statistically significant in two groups. The mean post-operation columellar show was 3.75 mm in CEG and 3.44 mm in CSPG (p value < 0.083). The correction ratio of columellar show was 1.76 mm in CEG and 1.20 mm in CSPG (p value < 0.007). The difference in the correction ratio of the two groups was statistically significant. Our study reveals that both techniques properly improve NLA and columellar show, however, CEG is a more stable method in patients with tip ptosis.