0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

A Modified Septal Extension Graft for the Asian Nasal Tip FREE

Jinde Lin, MD1; Xiaoping Chen, MD1; Xin Wang, MD1; Xia Gao, MD1; Xiangyu Zheng, MD1; Xin Chen, MD1; Yugang Yuan, MD1
[+] Author Affiliations
1Nanjing Friendship Plastic Surgery Hospital, Nanjing Medical University, Nanjing, China
JAMA Facial Plast Surg. 2013;15(5):362-368. doi:10.1001/jamafacial.2013.1285.
Text Size: A A A
Published online

Importance  Septal extension graft is an effective procedure in tip plasty because it can provide stable structural support for the nasal tip. However, in Asian patients septal cartilage is much weaker, thinner, and smaller than that of white people, causing the existing caudal septal cartilage and the septal extension graft to deviate to the opposite side of graft placement.

Objective  To introduce an effective and reliable modified septal extension graft in tip plasty.

Design, Setting, and Participants  Observational study of a total of 143 patients (84 undergoing primary rhinoplasty and 59 undergoing secondary rhinoplasty).

Intervention  A modified septal extension graft technique in combination with other procedures, including tip graft and implant augmentation.

Main Outcome and Measure  Subjective evaluation based on photographic analysis.

Results  This procedure was applied in 143 Asian patients, with substantial improvement seen in the nasal tip of all patients except for 3 (1 for the overprojected nasal tip and 2 for bending of existing caudal septum). Other complications included infection in 1 patient and implant deviation in 1 patient; the implant and grafts were removed 10 days after surgery in the patient with infection. The other patient underwent revision 3 months after surgery for the deviated implant.

Conclusions and Relevance  This technique is an effective method to provide long-term, stable nasal tip support. It helps to set the existing caudal septum and the septal extension grafts exactly at the anterior midline and decrease the deviation of the nasal tip.

Level of Evidence  4.

Figures in this Article

Controlling and reshaping the nasal tip are important parts of rhinoplasty procedures. Byrd et al1 first reported that the septal extension graft could control the projection, shape, and rotation of the nasal tip. There are 3 basic types of septal extension grafts: spreader, batten, and direct caudal. In addition, many modified techniques for septal extension graft are described in rhinoplasty, including unilateral or bilateral septal extension graft and symmetrical or asymmetrical septal extension graft.211 The grafts used for the septal extension procedure are septal cartilage,111 conchal cartilage,12 homologous costal cartilage,13 alloplastic materials,14,15 and bone.16

In Asian patients, the most common donor site for septal extension graft is the septum; however, septal cartilage is much weaker, thinner, and smaller in Asian people than in white people.2,16 Because of the limitation of useful septal cartilage, the most common septal extension graft is the unilateral graft and some types of bilateral grafts. In the unilateral septal extension graft, the graft is placed on one side of the L-shaped existing septal cartilage.17 This procedure is apt to cause the nasal tip to deviate to the extension graft placement side in patients with thick and strong septal cartilage because the septal extension graft is not placed at the anterior midline. On the contrary, in some patients with very thin and weak septal cartilage, the septal extension graft and existing caudal septal cartilage will deviate to the opposite side of the septal extension graft. Therefore, the nasal tip will deviate in the unilateral septal extension graft technique, and when the patients undergo concurrent implant augmentation, this technique may sometimes cause implant deviation. Bilateral spreader grafts may be the most stable septal extension grafts, but they need much more cartilage and can only be used in the few patients who have large septal cartilage. Bilateral direct caudal grafts or batten grafts are the less stable grafts, especially in patients with weak and thin septal cartilage. To solve these problems in tip plasty, we introduce an effective and reliable modified septal extension graft, which is different from all other techniques previously described.

Patients

A total of 143 patients underwent this modified septal extension graft (primary rhinoplasty in 84 patients and secondary rhinoplasty in 59 patients). The study included 135 women and 8 men. The patients ranged in age from 19 to 35 years (mean, 26.2 years). The follow-up period ranged from 6 to 36 months (mean, 26.4 months).

Anatomy in Asian Noses

Nasal anatomy in Asian patients is different from that in white patients. The weaker alar cartilages render their tips structurally inadequate, and the nasal tip depends more on ligamentous and soft tissue support than alar cartilage.2 Actually, the septum is more important in Asian nasal tip support. A large thick septum can render adequate support to the nasal tip2; however, in Asian noses, the septum is weaker, thinner, and smaller; the dorsal and caudal borders of the septum are often retracted; the anterior septal angle is overobtuse; and the septum cannot provide sufficient support to the nasal tip.

Technique and Design

Our technique is designed based on the anatomy of the Asian nose, which has limited useful septal cartilage. Two factors must be considered for septal extension graft in the Asian nose. First, the septal cartilage and alar cartilages are smaller and weaker, the anterior septal angle is overobtuse, and the dorsal and caudal aspects of the septum and the anterior septal angle need to be extended. Second, the septal cartilage is weaker, thinner, and smaller; therefore, bilateral septal extension grafts should be recommended to render adequate support to the nasal tip. Unilateral or bilateral batten grafts or direct caudal grafts are less stable grafts and may not provide adequate and long-term stable strength for the nasal tip.

Our technique is an asymmetrical bilateral septal extension grafts. The big triangle graft is placed on one side of the L-shaped existing septum and extended beyond the dorsal and caudal aspects of the septum and the anterior septal angle, which renders main and adequate support to the nasal tip (Figure 1A).The small one is a stripped graft, which is approximately 4 to 5 mm in width and has the same length as the dorsal border of the triangle septal graft. It is designed like a conventional spreader graft but is shorter. It is placed on the other side of the L-shaped existing septum to compensate for the bulk of the triangle septal extension graft. It helps to consolidate the triangle septal extension graft and existing caudal septum (Figure 1B). Cephalic ends of both grafts are near the middle junction of the dorsal septum and upper lateral cartilages, where the vault is much narrower than that at the keystone area. Cephalic ends of both grafts must be fixed with the dorsal septum and upper lateral cartilages together to stabilize the grafts and existing caudal septal cartilage. Both grafts have almost the same dorsal lengths and borders. This procedure helps to set the existing caudal septal cartilage and septal extension grafts exactly at the anterior midline and avoid the existing septal cartilage and septal extension graft deviation (Figure 1C).

Place holder to copy figure label and caption
Figure 1.
Triangle Septal Extension and Stripped Grafts

A, The triangle septal extension graft was placed on one side of the L-shaped existing septum. B, The stripped graft was placed on the other side of the L-shaped existing septum. Both grafts have almost the same dorsal length and dorsal border. C, Cephalic ends of both grafts were near the middle junction of the dorsal septum and upper lateral cartilages. The cephalic ends of both grafts must be fixed with the dorsal septum and upper lateral cartilages together to stabilize both grafts and the L-shaped existing septal cartilage.

Graphic Jump Location
Implant

Used in 128 of 143 patients, the implant was silicone in 42 patients and expanded polytef (polytetrafluoroethylene) in 86 patients. The implant was shaped according to the patient’s specifications and intraoperative designing.

Anesthesia

All patients were underwent tracheal intubation anesthesia and local anesthesia. Local anesthesia consisted of lidocaine with epinephrine hydrochloride (1:100 000), 2%. Both infraorbital nerves were blocked using local anesthesia, and the mucoperichondrium of the septum was infiltrated.

Surgical Technique

Transcolumellar incision was preferred in all patients. Five minutes after local anesthesia, a transcolumellar incision across the narrowest portion of the columella was made, and the incision was connected to the marginal incisions. Then the columellar flap was created along the plane overlying the lower lateral cartilages. Once the columella flap was elevated, the medial and intermediate crura and the caudal aspect of the nasal septum were exposed. The dorsal pocket underlying the nasal dorsal fascia was made for the placement of the implant. In some patients with tight skin and short nose, the whole nasal skin was elevated to help the skin flap move caudally. Before dissecting the septum mucosa, local anesthetic agent was injected between the medial crura and both sides of the septum, making dissection easier.

When harvesting the septal cartilage, bilateral mucoperichondrium of the septum was elevated to the junction between the upper lateral cartilages and septum. The upper lateral cartilages could be dissected from the dorsal margin of the nasal septum without damaging the mucosa.

Part of the septal cartilage was harvested, leaving an approximately 1.0-cm L-shaped caudal and dorsal cartilage to support the lower nose. If the septal cartilage collected was smaller, the auricular conchal cartilage was also harvested according to the method described by Han et al.18

After septal cartilage was collected, the medial and intermediate crura of the lower lateral cartilage were freed without damaging the mucosa. The collected septal cartilage was trimmed into 2 pieces of cartilage, both of which were used for the septal extension graft (Figure 2, A and B). Sometimes, if the septal cartilage harvested was big enough, it was trimmed into 3 pieces of cartilage; 2 pieces of cartilage were used for the septal extension graft and 1 for the tip graft (Figure 2, C and D). If the septal cartilage harvested was smaller, it was just used for the triangle septal extension graft. Therefore, the auricular conchal cartilage was harvested and cut into 2 pieces of cartilage: 1 for the stripped graft and 1 for the tip graft (Figure 2, E). The method to fix the stripped graft (from auricular cartilage) and the triangle graft was the same as that to fix the stripped graft (from septal cartilage) and the triangle graft.

Place holder to copy figure label and caption
Figure 2.
Septal Cartilage Graft

A and B, The septal cartilage was cut into 2 pieces of cartilage that were used for septal extension grafts. C and D, The septal cartilage was cut into 3 pieces of cartilage, and 2 pieces of cartilages were used for septal extension graft and 1 piece for the tip graft. The septal cartilage was smaller and was used as a triangle septal extension graft. E, Two pieces of conchal cartilage were harvested: 1 for stripped septal extension graft and 1 for the tip graft.

Graphic Jump Location

The stripped extension graft was 4 to 5 mm in width, which is the same length as the dorsal border of the triangle extension graft (Figure 1). To increase the graft’s stability, both septal extension grafts should be long enough to be fixed with the dorsal septum and upper lateral cartilage but should not go beyond the middle junction of the dorsal septum and upper lateral cartilage cephalically because then they would widen the midvault. The septal extension grafts extended caudally beyond the caudal margin of the L-shaped existing septum into the area between the medial and intermediate crura. It was preferable to leave the grafts slightly larger than expected. Then the grafts were trimmed after they had been sutured into the position. The first suture was to fix both the septal extension grafts with the dorsal septum. The second suture was to fix the triangle septal extension graft with the existing caudal septum. Before the second suture was performed, the angle between the dorsal border of the septum and the triangle septal extension graft was adjusted to obtain optimal nose length, optimal tip projection, and appropriate nasolabial angle. Once the triangle septal extension graft was in its final position, other sutures to fix the septal extension graft with the L-shaped existing septum were finished (Figure 3). The upper lateral cartilages should be fixed to the septum so that the septal extension grafts are sutured together. Special care was taken to secure the existing septum and both septal extension grafts at the aesthetic midline of the nose. If necessary, the graft’s position was modified to prevent deformity. Then the alar cartilages were controlled directly on the septal extension grafts (Figure 3). The columella flap was replaced to determine the tip shape, projection, rotation, and nasal shape. Then the implant was shaped and inserted into the dorsal pocket. Its distal end was fixed to the medial crura and the septal extension grafts. It was necessary to place a tip graft over the medial and intermediate crura to adjust the tip-lobular relationship and to increase its contact surface. After estimating the ideal projection of the tip and contour of the nose, the columellar skin flap was returned into position without tension. Finally, the skin incision was closed with 7-0 nylon sutures. Internal nasal splints and external nasal splints were applied. A drainage strip was maintained for 24 hours in all cases. Antibiotics were used for 3 to 5 days, and the suture was removed 7 days after surgery.

Place holder to copy figure label and caption
Figure 3.
Triangle and Stripped Septal Extension Grafts

A, Triangle septal extension graft. B, Stripped septal extension graft. C, Both septal extension grafts from the front view.

Graphic Jump Location

The length of septal cartilage harvested was 1.3 to 3.2 cm (mean, 1.92 cm). The width of septal cartilage harvested was 1.1 to 2.5 cm (mean, 1.65 cm). The dorsal length of cartilage used for the triangle septal extension graft was 1.3 to 2.5 cm (mean, 1.83 cm). The length of the stripped septal extension graft was 1.3 to 2.5 cm (mean, 1.83 cm). The width of the stripped septal extension graft was 0.4 to 0.6 cm (mean, 0.51 cm).

All triangle septal extension grafts were collected from septal cartilage. Of 143 patients, the stripped extension graft was harvested from septal cartilage in 59 patients or conchal cartilage in 84 patients. The tip graft was chosen from remnant septal cartilage in 17 patients and conchal cartilage in 126 patients.

Patients were followed up for 6 to 36 months (mean, 23 months). Results were evaluated mainly by subjective evaluation based on photographic analysis. The improvement on the nasal tip was successfully achieved in most patients, except for 3 (1 patient underwent secondary surgery for an overprojected nasal tip and 2 underwent revision for distortion of existing caudal septum). These complications occurred only in our early experiences. Other complications included infection in 1 patient and implant deviation in another patient. The implant and grafts were removed 10 days after surgery in the patient with infection. The other patient underwent revision 3 months after surgery for the deviated implant (Figure 4 and Figure 5).

Place holder to copy figure label and caption
Figure 4.
A 27-Year-Old Girl Who Underwent Rhinoplasty With Modified Septal Extension Graft, Implant Augmentation, and Tip Graft

A-D, Preoperative views. E-H, Postoperative views at 21 months.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.
A 25-Year-Old Girl Who Underwent Secondary Rhinoplasty, Including Replacement of Implant, Modified Septal Extension Graft, and Tip Graft

A-D, Preoperative views. E-H, Postoperative views at 12 months.

Graphic Jump Location

The septal extension graft is an effective procedure in nasal tip plasty because it can control the projection, shape, and rotation for the nasal tip. Byrd et al1 first described 3 basic forms of septal extension graft: spreader, battent, and direct caudal. Many modified techniques of septal extension graft have been described in rhinoplasty, including unilateral3,9 and bilateral grafts.2,15,19 The bilateral septal extension grafts may be symmetrical2,15,19 or asymmetrical.3 They all have advantages and disadvantages. Bilateral spreader grafts may be the most stable septal extension grafts, but bilateral spreader grafts need much more cartilage and can be only applied in a few noses in Asian people because of the limitation of useful septal cartilage.17 Batten grafts or direct caudal grafts are less stable and may not render adequate and long-term stable strength for nasal tip in patients with weak and thin septum and alar cartilages. Other techniques similar to septal extension graft, such as the caudal septal advancement technique, are also used in tip plasty, but these techniques break the septal integrity and influence its stability.20,21

The most common material used for septal extension graft is autologous septal cartilage. Conchal cartilage is often used as a tip graft; autologous costal cartilage has been used in patients with severe structural deformities.22 In some patients, the unilateral septal extension graft is sufficient to control the nasal tip. However, in more than half of these patients, this single graft needs to be strengthened.3 Unilateral septal extension graft cannot set the septal extension graft at the anterior midline; unilateral graft placement may cause the nasal tip to deviate to the graft placement side in patients with thick and strong septal cartilage. However, in patients with thin and weak septal cartilage, the unilateral septal extension graft can make the existing caudal septal cartilage and the septal extension graft deviate to the opposite side of the graft placement. Therefore, this single graft needs to be strengthened with bilateral grafts. The bilateral spreader graft may be the most stable graft and can strengthen the caudal septum and grafts, but the bilateral spreader grafts are just 5 cm wide, so they cannot successfully extend the caudal and dorsal aspects of the septum and the anterior septal angle at same time. The bilateral spreader grafts cannot be applied in all patients. Only 18.2% of patients had septal cartilages 25 mm long that could be used as bilateral spreader grafts.17 Furthermore, the conventional bilateral spreader grafts are often applied to improve the nasal valve, which may widen the midvault of the nose. Bilateral batten grafts and direct caudal grafts were only used in cases of limited cartilage. The grafts are affixed directly to the anterior septal angle or the caudal septum. These grafts are the potentially less stable type of the septal extension graft. They are more susceptible to cause deviation of the tip over time, especially in patients with weak and thin septal cartilage and alar cartilages.

Under these circumstances, we applied a new technique that can give the existing caudal septum and septal extension grafts considerable stability and does not need a large amount of septal cartilage. This technique is different from all other techniques previously described in publications. The technique consists of a combined triangle septal extension graft and a stripped septal extension graft. The triangle septal extension graft can extend beyond the dorsal and caudal septum and the anterior septal angle. It goes into the area between the medial crura and intermediate crura to consolidate the alar cartilages and control the tip. The triangle septal extension graft provides main support to the alar cartilages and nasal tip. The stripped septal extension graft is used to compensate for the bulk of the triangle septal extension graft placement and consolidate the triangle septal extension graft and existing caudal septum. The cephalic ends of the 2 grafts are fixed with the dorsal septum and upper lateral cartilage together, which can greatly increase the existing stability of the caudal septum and grafts. Both grafts have almost the same dorsal length and coincident dorsal border. They help to set the existing caudal septum and extension grafts exactly at the anterior midline. In addition, this procedure needs less cartilage. It can be applied in almost every patient who needs a septal extension graft. The placement of 2 grafts can effectively increase the stability for the nasal tip. Moreover, it can ensure the dorsal implant is in the correct position and avoid implant deviation.

Widening the supratip or midvault area after implantation of a bilateral extension graft has been considered, especially in patients with short nasal bones.3 In our study patients, the midvault and supratip areas are not widened too much. First, the original midvault area at the middle junction of the septum and upper lateral cartilages is much narrower than that of the keystone area. The length of the septal extension grafts is shorter than that of the spreader graft. Furthermore, the placement of both septal extension grafts in our procedure is different from the placement of the conventional spreader graft. Cephalic ends of both extension grafts in our technique do not go cephalically beyond the middle junction of the dorsal septum and upper lateral cartilages, where the midvault is much narrower. The conventional spreader graft is placed near the keystone area, which would widen the midvault. Second, the harvested cartilage is relatively thin. Its thickness is approximately 1 mm in Asian patients.23 The conchal cartilage is also approximately 1 mm, although the postoperative midvault at this site is composed of 5-layered cartilages, including 2-layered septal extension cartilages, 2-layered upper lateral cartilages, and 1-layered dorsal septum; their total thickness is approximately 6 mm. The supratip area is not widened. After 2 septal extension grafts are placed, the new dorsal septum near the supratip area consists of 2 layered cartilages; its thickness is only approximately 2 to 3 mm. Furthermore, sometimes, if the septal cartilage used for the septal extension graft is somewhat thick, then the septal cartilage can be thinned to decrease the postoperative thickness of the midvault and supratip areas. Third, in Asian patients, who commonly have saddle nose, even if the middle vault is somewhat widened, the implant placement can camouflaged this defect.

In conclusion, this technique is an effective method to provide long-term, stable support of the nasal tip. It helps to set the existing caudal septum and septal extension grafts exactly at the aesthetic midline and decreases the deviation of the nasal tip. This technique can be used in Asian patients.

Accepted for Publication: February 22, 2013.

Corresponding Author: Jinde Lin, MD, Nanjing Friendship Plastic Surgery Hospital, Nanjing Medical University, 146 Hanzhong Rd, Nanjing, China (hzljd@sohu.com).

Published Online: July 25, 2013. doi:10.1001/jamafacial.2013.1285.

Author Contributions:Study concept and design: Lin, Xiaoping Chen.

Acquisition of data: Lin, Gao, Zheng, Xin Chen, Yuan.

Analysis and interpretation of data: Lin, Wang.

Drafting of the manuscript: Lin, Xiaoping Chen, Gao, Zheng, Xin Chen, Yuan.

Critical revision of the manuscript for important intellectual content: Lin.

Statistical analysis: Lin, Wang, Gao, Zheng, Xin Chen, Yuan.

Administrative, technical, and material support: Xiaoping Chen.

Conflict of Interest Disclosures: None reported.

Byrd  HS, Andochick  S, Copit  S, Walton  KG.  Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg. 1997;100(4):999-1010.
PubMed
Kang  JG, Ryu  J.  Nasal tip surgery using a modified septal extension graft by means of extended marginal incision. Plast Reconstr Surg. 2009;123(1):343-352.
PubMed   |  Link to Article
Seyhan  A, Ozden  S, Ozaslan  U, Sir  E.  A simplified use of septal extension graft to control nasal tip location. Aesthetic Plast Surg. 2007;31(5):506-513.
PubMed   |  Link to Article
Han  K, Jin  HS, Choi  TH, Kim  JH, Son  D.  A biomechanical comparison of vertical figure-of-eight locking suture for septal extension grafts. J Plast Reconstr Aesthet Surg. 2010;63(2):265-269.
PubMed   |  Link to Article
Hubbard  TJ.  Exploiting the septum for maximal tip control. Ann Plast Surg. 2000;44(2):173-180.
PubMed   |  Link to Article
Byrd  HS, Salomon  J, Flood  J.  Correction of the crooked nose. Plast Reconstr Surg. 1998;102(6):2148-2157.
PubMed   |  Link to Article
Jang  YJ, Yu  MS.  Rhinoplasty for the Asian nose. Facial Plast Surg. 2010;26(2):93-101.
PubMed   |  Link to Article
Pham  AM, Tollefson  TT.  Correction of caudal septal deviation: use of a caudal septal extension graft. Ear Nose Throat J. 2007;86(3):142-144.
Kim  JS, Han  KH, Choi  TH,  et al.  Correction of the nasal tip and columella in Koreans by a complete septal extension graft using an extensive harvesting technique. J Plast Reconstr Aesthet Surg. 2007;60(2):163-170.
PubMed   |  Link to Article
Ha  RY, Byrd  HS.  Septal extension grafts revisited: 6-year experience in controlling nasal tip projection and shape. Plast Reconstr Surg. 2003;112(7):1929-1935.
PubMed   |  Link to Article
Ponsky  DC, Harvey  DJ, Khan  SW, Guyuron  B.  Nose elongation: a review and description of the septal extension tongue-and-groove technique. Aesthet Surg J. 2010;30(3):335-346.
PubMed   |  Link to Article
Koch  CA, Friedman  O.  Modified back-to-back autogenous conchal cartilage graft for caudal septal reconstruction: the medial crural extension graft. Arch Facial Plast Surg. 2011;13(1):20-25.
PubMed   |  Link to Article
Song  HM, Lee  BJ, Jang  YJ.  Processed costal cartilage homograft in rhinoplasty: the Asan Medical Center experience. Arch Otolaryngol Head Neck Surg. 2008;134(5):485-489.
PubMed   |  Link to Article
Gürlek  A, Fariz  A, Celik  M, Ersöz-Oztürk  A, Arslan  A.  Straightening the crooked middle third of the nose: use of high-density porous polyethylene spreader grafts. Arch Facial Plast Surg. 2005;7(6):420-421.
PubMed   |  Link to Article
Alyssa  JR, Kevin  JC, Henry  MS.  Nasal spreader grafts: a comparison of Medpor to autologous tissue reconstruction. Ann Plast Surg. 2011;66(1):24-28.
PubMed   |  Link to Article
Emsen  IM.  A different approach to the reconstruction of the stubborn crooked nose with a different spreader graft: nasal bone grafts harvested from the removed nasal hump [retracted in Aesthetic Plast Surg. 2009;33(4):674]. Aesthetic Plast Surg. 2008;32(2):266-273.
PubMed   |  Link to Article
Kim  JS, Khan  NA, Song  HM, Jang  YJ.  Intraoperative measurements of harvestable septal cartilage in rhinoplasty. Ann Plast Surg. 2010;65(6):519-523.
PubMed   |  Link to Article
Han  K, Kim  J, Son  D, Park  B.  How to harvest the maximal amount of conchal cartilage grafts. J Plast Reconstr Aesthet Surg. 2008;61(12):1465-1471.
PubMed   |  Link to Article
Palacín  JM, Bravo  FG, Zeky  R, Schwarze  H.  Controlling nasal length with extended spreader grafts: a reliable technique in primary rhinoplasty. Aesthetic Plast Surg. 2007;31(6):645-650.
PubMed   |  Link to Article
Sen  C, Iscen  D.  Caudal septal advancement for nasal tip projection and support in rhinoplasty. Aesthetic Plast Surg. 2006;30(2):135-140.
PubMed   |  Link to Article
Chang  YL.  Correction of difficult short nose by modified caudal septal advancement in Asian patients. Aesthet Surg J. 2010;30(2):166-175.
PubMed   |  Link to Article
Millard  DR, Mejia  FA.  Reconstruction of the nose damaged by cocaine. Plast Reconstr Surg. 2001;107(2):419-424.
PubMed   |  Link to Article
Haiting  XU, Sheng  YAN, Sufan  WU,  et al.  Anatomical measurement of nasal septal cartilage in Chinese. Chin J Aesthet Plast Surg.2009;20(5):267-270.

Figures

Place holder to copy figure label and caption
Figure 1.
Triangle Septal Extension and Stripped Grafts

A, The triangle septal extension graft was placed on one side of the L-shaped existing septum. B, The stripped graft was placed on the other side of the L-shaped existing septum. Both grafts have almost the same dorsal length and dorsal border. C, Cephalic ends of both grafts were near the middle junction of the dorsal septum and upper lateral cartilages. The cephalic ends of both grafts must be fixed with the dorsal septum and upper lateral cartilages together to stabilize both grafts and the L-shaped existing septal cartilage.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Septal Cartilage Graft

A and B, The septal cartilage was cut into 2 pieces of cartilage that were used for septal extension grafts. C and D, The septal cartilage was cut into 3 pieces of cartilage, and 2 pieces of cartilages were used for septal extension graft and 1 piece for the tip graft. The septal cartilage was smaller and was used as a triangle septal extension graft. E, Two pieces of conchal cartilage were harvested: 1 for stripped septal extension graft and 1 for the tip graft.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Triangle and Stripped Septal Extension Grafts

A, Triangle septal extension graft. B, Stripped septal extension graft. C, Both septal extension grafts from the front view.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.
A 27-Year-Old Girl Who Underwent Rhinoplasty With Modified Septal Extension Graft, Implant Augmentation, and Tip Graft

A-D, Preoperative views. E-H, Postoperative views at 21 months.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.
A 25-Year-Old Girl Who Underwent Secondary Rhinoplasty, Including Replacement of Implant, Modified Septal Extension Graft, and Tip Graft

A-D, Preoperative views. E-H, Postoperative views at 12 months.

Graphic Jump Location

Tables

References

Byrd  HS, Andochick  S, Copit  S, Walton  KG.  Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg. 1997;100(4):999-1010.
PubMed
Kang  JG, Ryu  J.  Nasal tip surgery using a modified septal extension graft by means of extended marginal incision. Plast Reconstr Surg. 2009;123(1):343-352.
PubMed   |  Link to Article
Seyhan  A, Ozden  S, Ozaslan  U, Sir  E.  A simplified use of septal extension graft to control nasal tip location. Aesthetic Plast Surg. 2007;31(5):506-513.
PubMed   |  Link to Article
Han  K, Jin  HS, Choi  TH, Kim  JH, Son  D.  A biomechanical comparison of vertical figure-of-eight locking suture for septal extension grafts. J Plast Reconstr Aesthet Surg. 2010;63(2):265-269.
PubMed   |  Link to Article
Hubbard  TJ.  Exploiting the septum for maximal tip control. Ann Plast Surg. 2000;44(2):173-180.
PubMed   |  Link to Article
Byrd  HS, Salomon  J, Flood  J.  Correction of the crooked nose. Plast Reconstr Surg. 1998;102(6):2148-2157.
PubMed   |  Link to Article
Jang  YJ, Yu  MS.  Rhinoplasty for the Asian nose. Facial Plast Surg. 2010;26(2):93-101.
PubMed   |  Link to Article
Pham  AM, Tollefson  TT.  Correction of caudal septal deviation: use of a caudal septal extension graft. Ear Nose Throat J. 2007;86(3):142-144.
Kim  JS, Han  KH, Choi  TH,  et al.  Correction of the nasal tip and columella in Koreans by a complete septal extension graft using an extensive harvesting technique. J Plast Reconstr Aesthet Surg. 2007;60(2):163-170.
PubMed   |  Link to Article
Ha  RY, Byrd  HS.  Septal extension grafts revisited: 6-year experience in controlling nasal tip projection and shape. Plast Reconstr Surg. 2003;112(7):1929-1935.
PubMed   |  Link to Article
Ponsky  DC, Harvey  DJ, Khan  SW, Guyuron  B.  Nose elongation: a review and description of the septal extension tongue-and-groove technique. Aesthet Surg J. 2010;30(3):335-346.
PubMed   |  Link to Article
Koch  CA, Friedman  O.  Modified back-to-back autogenous conchal cartilage graft for caudal septal reconstruction: the medial crural extension graft. Arch Facial Plast Surg. 2011;13(1):20-25.
PubMed   |  Link to Article
Song  HM, Lee  BJ, Jang  YJ.  Processed costal cartilage homograft in rhinoplasty: the Asan Medical Center experience. Arch Otolaryngol Head Neck Surg. 2008;134(5):485-489.
PubMed   |  Link to Article
Gürlek  A, Fariz  A, Celik  M, Ersöz-Oztürk  A, Arslan  A.  Straightening the crooked middle third of the nose: use of high-density porous polyethylene spreader grafts. Arch Facial Plast Surg. 2005;7(6):420-421.
PubMed   |  Link to Article
Alyssa  JR, Kevin  JC, Henry  MS.  Nasal spreader grafts: a comparison of Medpor to autologous tissue reconstruction. Ann Plast Surg. 2011;66(1):24-28.
PubMed   |  Link to Article
Emsen  IM.  A different approach to the reconstruction of the stubborn crooked nose with a different spreader graft: nasal bone grafts harvested from the removed nasal hump [retracted in Aesthetic Plast Surg. 2009;33(4):674]. Aesthetic Plast Surg. 2008;32(2):266-273.
PubMed   |  Link to Article
Kim  JS, Khan  NA, Song  HM, Jang  YJ.  Intraoperative measurements of harvestable septal cartilage in rhinoplasty. Ann Plast Surg. 2010;65(6):519-523.
PubMed   |  Link to Article
Han  K, Kim  J, Son  D, Park  B.  How to harvest the maximal amount of conchal cartilage grafts. J Plast Reconstr Aesthet Surg. 2008;61(12):1465-1471.
PubMed   |  Link to Article
Palacín  JM, Bravo  FG, Zeky  R, Schwarze  H.  Controlling nasal length with extended spreader grafts: a reliable technique in primary rhinoplasty. Aesthetic Plast Surg. 2007;31(6):645-650.
PubMed   |  Link to Article
Sen  C, Iscen  D.  Caudal septal advancement for nasal tip projection and support in rhinoplasty. Aesthetic Plast Surg. 2006;30(2):135-140.
PubMed   |  Link to Article
Chang  YL.  Correction of difficult short nose by modified caudal septal advancement in Asian patients. Aesthet Surg J. 2010;30(2):166-175.
PubMed   |  Link to Article
Millard  DR, Mejia  FA.  Reconstruction of the nose damaged by cocaine. Plast Reconstr Surg. 2001;107(2):419-424.
PubMed   |  Link to Article
Haiting  XU, Sheng  YAN, Sufan  WU,  et al.  Anatomical measurement of nasal septal cartilage in Chinese. Chin J Aesthet Plast Surg.2009;20(5):267-270.

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections