Nasal Elongation with Septal Half Extension Graft: Modification of Conventional Septal Extension Graft Using Minimal Septal Cartilage

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.

Effect of Modified Septal Extension Grafts on the Nasal Tip in Rhinoplasty

Background:

One of the faced difficulties of nasal tip surgery is progressive loss of nasal tip projection and rotation postoperatively. Nasal base stabilization by septal extension grafts has shown to improve this loss over time. The aim of this study was to demonstrate that a modified septal extension graft can provide the required tip rotation/derotation by changing the angle of the graft’s insertion. In addition, it maintains nasal tip projection without creating a rigid tip. Other than that it avoids the requirement of a large amount of cartilage.

Materials/Methods:

This study involves a retrospective review of 37 patients who underwent open rhinoplasty for primary or secondary cases over a period of 12 months. The average age of the patients was 28 years (range = 20–43 years), and all patients were of Middle Eastern origin. Subjective evaluation based on photographic analysis was used pre and postoperatively.

Results:

All cases included in this study maintained their operative results of tip rotation. Two cases showed a minimal decrease in tip projection documented upon review 6–12 months postoperatively. No patient needed secondary revision surgery due to changes in tip projection or rotation. The objective pre and postoperative findings were satisfying for the patients and surgeons.

Conclusions:

The modified septal extension graft is an effective tool for rotation of the nasal tip as well as derotation of an over rotated tip. It is also capable of maintaining nasal tip projection.

The Caudal Septum Pivot Technique for Short Nose Correction

The short nose represents one of the greatest challenges in rhinoplasty. It is characterized by a reduced distance from the nasal radix to the tip-defining points, often associated with inadequate tip projection. Several techniques have been described for correction of short nose with the common objective of replacing and rebuilding the osteocartilaginous framework. One of the most effective method to correct the short nose is the septal extension graft. The authors describe the caudal septum pivot (CSP) technique, a simple method to elongate short noses by using a graft inserted in the dorsal septum after its division using as pivot the caudal portion, without detaching it from its natural anchorage to the anterior nasal spine. A retrospective analysis was performed reviewing the clinical charts and the operative records of 315 patients who underwent revision rhinoplasty from January 2015 to June 2019; among this group, 34 were considered eligible for the study. The patients (8 men, 26 women; mean age: 25.4 years; age range: 22-53 years) were divided into two groups: in 12 patients (Group 1) the CSP technique was performed, while Group 2 was composed of 22 patients who received a more classic treatment with a septal extension graft. To evaluate the outcomes, nasal length, tip projection, and tip rotation were measured pre- and 1 year postoperatively on digital photographs of each patient. Nasal anthropometric measurements revealed, at 12-month visit follow-up, an improvement in nasal length, tip projection, and nasolabial angle was achieved in all the patients. The comparison of the pre- and postoperative values showed a statistically significant reduction in the nasolabial angle (p < 0.05) and an increase in the tip projection (p < 0.05) and in the nasal lengthening (p < 0.05) in both groups. In authors' experience, the CSP technique could be considered a safe, reliable, and effective alternative technique in selected patients.

Correction of Severe Short Nose Using a Costal Cartilage Extension Framework

BACKGROUND

Various techniques for the aesthetic correction of short noses have been described, but the selection of the adequate graft material remains controversial. Previous reports have mainly focused on the application of septal cartilage or alloplastic materials for short nose elongation, but the lengthening effect is often unsatisfactory for severe short noses. We propose costal cartilage as an alternative treatment for short noses, describe the technique, and discuss outcomes, patient selection, and complications based on our 15-year experience.

METHODS

From February 2004 to December 2018, 611 patients with varying degrees of short noses were included in this retrospective study. All patients underwent nose elongation surgery using a costal cartilage graft. Nasal length before and after surgery was measured based on a 3-dimensional simulation technology. Outcomes and complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey.

RESULTS

Nasal elongation using costal cartilage was successfully achieved, with a mean increase in nasal length of 4.06 ±0.79 mm. Patients were followed up for a period of 8.5 months on average, ranging from 6 months to 8 years. Follow-up examinations demonstrated stable results. The overall complication rate was 3.8%. Complications included infection, implant extrusion, migration, deviation, visibility, prominence, and reddening of the nasal skin. Most patients (95.2%) rated their outcome as improved and much improved.

CONCLUSION

Nasal elongation using costal cartilage grafting is an effective therapeutic approach for patients with severe short noses. Reliable outcomes and the use of autologous tissue along with minimal donor site morbidity contribute to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

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.