Emerging Trends in Advanced Rhinoplasty: Evolving Roles of Two Cartilage Grafts
Controlling the projection and rotation of the nasal tip is an important part of modern rhinoplasty. Several factors contribute to tip projection: length and strength of lower lateral cartilages, the suspensory ligament, fibrous connections to the upper lateral cartilages, and the anterior septal angle.
Surgeons use different cartilage grafts to effectively change the projection and rotation of the nasal tip. Two commonly used grafts are columellar struts and septal extension grafts.
Columellar struts help maintain tip projection and bring the tip together, but they have limited effectiveness in increasing tip projection.
On the other hand, septal extension grafts effectively control tip projection, rotation, and shape by securing the nasal tip to the septum. Different types 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. In this blog, we provide an updated classification of cartilage grafts for changing nasal tip projection and rotation, along with a systematic approach for their use. While 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. It is crucial for surgeons to understand which graft to use in specific situations to successfully control the projection, rotation, and shape of the nasal tip.
Methods 1: Columellar Struts
The role of the columellar strut in altering nasal tip projection has been a topic of discussion in rhinoplasty literature. While fixed columellar struts are no longer favored in aesthetic rhinoplasty, floating columellar struts are still commonly used. However, studies have shown that the effect of floating columellar struts on increasing tip projection is minimal. Instead, columellar struts are considered effective in unifying the nasal tip and maintaining its position when 3 distinct structural characteristics are present:
Weak medial or middle crura
Asymmetric lower lateral cartilages
Short medial crura
The degree of nasal tip projection and the structural integrity of the lower lateral cartilages determine how the columellar strut should be used. Different types of struts have been described, and their design and placement depend on a careful analysis of these variables. For instance, if there is adequate nasal tip projection with weak or asymmetric cartilages, a shorter strut may be used to strengthen and unify the tip, rather than a longer floating strut that is more suitable for cases lacking tip projection.
While columellar struts can be beneficial for certain patients, they also have significant drawbacks. Placing a structure between the medial crura can unintentionally widen the columella. Depending on the type of strut used, there have been reports of it clicking against the anterior nasal spine. Additionally, there is always a risk of warping with any cartilage graft, which can lead to a loss of tip projection and symmetry. Finally, although columellar struts have been found unreliable in increasing tip projection, it is the lack of control over nasal tip rotation that is their single most important limitation.
See below the figure illustrating a Columellar strut graft. (From Rohrich, et al, 2020)
Methods 2: Septal Extension Graft
Septal extension grafts have emerged as a more reliable method for controlling nasal tip projection, shape, and rotation, especially in patients with weak lower lateral cartilages. Unlike columellar struts, septal extension grafts provide better control over the nasal tip in cases where the midvault is weak, the tip is droopy, and the alae are drawn up. These grafts redefine the skeletal relationship between the nasal tip and dorsum, offering predictable control over tip projection and rotation.
Various types of septal extension grafts have been described to support the medial crura and control tip shape, relying on a stable caudal septum. The shape and points of fixation of these grafts differ, but they have similar points of fixation within the tip-lobule complex. The specific points of septal fixation depend on the midvault status, septal stability, and available cartilage, while the extension of the graft beyond the dorsal septum is determined by the thickness of the overlying skin.
For effective results, septal extension grafts should extend beyond the anterior septal angle into the interdomal space. The most inferior part of the graft is placed on the cephalic border of the medial crus at the columellar-lobular angle. The crucial point of fixation is below the divergence of the middle crura, where the medial crura's cephalic borders meet. This fixation point determines the desired columellar-lobular angle. Interdomal fixation can be used to control interdomal distance and projection. If a supratip break is desired, the graft's fixation to the lower lateral cartilage should create a noticeable difference between the domes and nasal dorsum.
It is important to note that while septal extension grafts are an excellent tool for suitable patients, they are not suitable for noses with bulky lower lateral cartilages and normal or excessive tip projection.
Varieties of Septal Extension Grafts
1. Paired Extended Spreader Grafts
Paired extender spreader grafts are a useful technique for modifying both nasal tip projection and rotation when dealing with midvault collapse or narrowing. These grafts are placed at the junction of the upper lateral cartilage and septum, aligned parallel to the nasal dorsum. This placement helps increase the angle of the internal nasal valve. To avoid excessive widening of the dorsal area, any excess horizontal cartilage is recessed slightly below the dorsum's plane (1 to 2 mm). To enhance tip projection, the distal segments of the graft should extend vertically beyond the level of the dorsum. Finally, suturing the tip-lobule complex to the graft helps achieve the desired tip projection or rotation.
2. Septal Batten Grafts
Bilateral septal batten grafts offer a solution for changing both nasal tip rotation and projection. These grafts require less cartilage compared to extended spreader grafts, but they do not address issues related to the internal valve or midvault. Strong caudal septum is necessary for paired septal batten grafts. They are placed below the junction of the upper lateral cartilages with the septum at a 45-degree angle from the anterior septal angle and extend diagonally across the caudal and dorsal L-strut of the septum. Proper suture anchorage is crucial for graft stability and to prevent rotation.
In addition to bilateral grafts, unilateral septal batten grafts can also be used to control tip projection and rotation. These require less cartilage and their intrinsic curvature can correct asymmetries associated with unilateral designs. Unilateral septal batten grafts are particularly useful when tip deviation is caused by issues with the anterior septum.
3. Direct Caudal Septal Extension Grafts
The concept of caudal extension grafts was introduced to address cases of caudal septal deficiency. These grafts are useful in reducing tip rotation and modifying the relationship between the ala and columella in noses with a shortened appearance or columellar retraction. Typically, the grafts are directly fixed to the anterior nasal angle, which can make them unstable. To overcome this, various techniques can be employed. Suture fixation in at least three points is crucial for stability, and using a sufficient amount of cartilage allows for better overlap between the graft and the caudal septum. Additionally, extended spreader grafts can be utilized to help stabilize the caudal extension graft.
See below the figure illustrating a Paired extended spreader graft, Bilateral septal batten graft, Unilateral septal batten graft and Direct caudal septal extension graft, in chronological order. (From Rohrich, et al, 2020)
Controlling the position, rotation, and shape of the nasal tip is crucial in modern rhinoplasty.
Columellar struts, which were previously used to increase tip projection, are now recognized as effective for unifying the nasal tip and maintaining its position. They are suitable for noses with weak medial or middle crura, asymmetric lower lateral cartilages, or short medial crura.
In contrast, septal extension grafts offer a more reliable method for controlling tip projection, shape, and rotation. These grafts redefine the relationship between the nasal tip and dorsum and come in different types with variations in shape and points of fixation to the septum.
Both columellar struts and septal extension grafts provide options for altering tip projection and rotation, although each has its limitations and can potentially increase tip rigidity. Understanding the appropriate graft to use in specific cases is essential for successfully achieving the desired projection, rotation, and shape of the nasal tip.
Changing Role of Septal Extension versus Columellar Grafts in Modern Rhinoplasty (2020)
Open rhinoplasty using a columellar strut: effects of the graft on nasal tip projection and rotation (2020)
Septal Extension Graft in Asian Rhinoplasty (2018)
The extended columellar strut-tip graft (2005)
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