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Original Investigation |

Identifying Septal Support Reconstructions for Saddle Nose Deformity The Cakmak Algorithm

Ozcan Cakmak, MD1; Ismet Emrah Emre, MD2; Fazil Emre Ozkurt, MD3
[+] Author Affiliations
1Facial Plastic Surgeon, FACEISTANBUL Private Clinic, Istanbul, Turkey
2Department of Otolaryngology, Acibadem University Faculty of Medicine, Istanbul, Turkey
3Department of Otolaryngology, Dicle University Faculty of Medicine, Diyarbakir, Turkey
JAMA Facial Plast Surg. 2015;17(6):433-439. doi:10.1001/jamafacial.2015.1081.
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Importance  The saddle nose deformity is one of the most challenging problems in nasal surgery with a less predictable and reproducible result than other nasal procedures. The main feature of this deformity is loss of septal support with both functional and aesthetic implications. Most reports on saddle nose have focused on aesthetic improvement and neglected the reestablishment of septal support to improve airway.

Objectives  To explain how the Cakmak algorithm, an algorithm that describes various fixation techniques and grafts in different types of saddle nose deformities, aids in identifying saddle nose reconstructions that restore supportive nasal framework and provide the aesthetic improvements typically associated with procedures to correct saddle nose deformities.

Design, Setting, and Participants  This algorithm presents septal support reconstruction of patients with saddle nose deformity based on the experience of the senior author in 206 patients with saddle nose deformity. Preoperative examination, intraoperative assessment, reconstruction techniques, graft materials, and patient evaluation of aesthetic success were documented, and 4 different types of saddle nose deformities were defined.

Main Outcomes and Measures  The Cakmak algorithm classifies varying degrees of saddle nose deformity from type 0 to type 4 and helps identify the most appropriate surgical procedure to restore the supportive nasal framework and aesthetic dorsum.

Results  Among the 206 patients, 110 women and 96 men, mean (range) age was 39.7 years (15-68 years), and mean (range) of follow-up was 32 months (6-148 months). All but 12 patients had a history of previous nasal surgeries. Application of the Cakmak algorithm resulted in 36 patients categorized with type 0 saddle nose deformities; 79, type 1; 50, type 2; 20, type 3a; 7, type 3b; and 14, type 4. Postoperative photographs showed improvement of deformities, and patient surveys revealed aesthetic improvement in 201 patients and improvement in nasal breathing in 195 patients. Three patients developed postoperative infection and 21 patients underwent revision septal surgery.

Conclusions and Relevance  The goal of saddle nose reconstruction should be not only to restore an aesthetic dorsum but also to restore the supportive nasal framework. The surgeon should provide more projected and strengthened septal support before augmentation of saddle nose deformity to improve breathing and achieve a stable long-term result. The Cakmak algorithm is a mechanism that helps surgeons identify the most effective way to maximize septal support and aesthetic appeal.

Level of Evidence  4.

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Figure 1.
Cakmak Algorithm
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Figure 2.
Reconstruction Techniques Identified by the Cakmak Algorithm for the Type of Saddle Nose Deformity

Schematic drawings representing reconstruction techniques for the type of saddle nose deformity based on the Cakmak algorithm. A, Wide columellar strut for type 1 deformity. B, L-strut septal replacement graft affixed to septal remnant for type 2 deformity. C, L-strut septal replacement graft affixed to notch created between nasal bones for type 3a deformity, and L-strut septal replacement graft affixed to notch created on nondeviated side of nasal bones for type 3b deformity. D, Cantilever graft sitting on radix and wide columellar strut.

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Figure 3.
Intraoperative View of a Patient With Type 2 Saddle Nose Deformity

Photograph of a patient with a type 2 saddle nose deformity having an L-strut costal cartilage septal replacement graft placed by holding the septal cartilage remnant. Inset shows L-strut costal cartilage septal replacement graft.

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Figure 4.
Intraoperative View of a Patient With Type 3 Saddle Nose Deformity

Photograph of a patient with a type 3 saddle nose deformity having an L-strut costal cartilage septal replacement graft placed into a notch created between nasal bones. Inset shows L-strut costal cartilage septal replacement graft prepared as 2 separate pieces.

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Figure 5.
Preoperative and 4-Year Postoperative Photographs of a Patient With Type 3 Saddle Nose Deformity
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