a novel technique for short nose correction

Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 27, Number 1, January 2016

A Novel Technique for ShortNose Correction: Hybrid SeptalExtension Graft

Jong Seol Woo, MD,� Nguyen Phan Tu Dung, MD PhD,y

and Man Koon Suh, MD�

Background: There are many techniques for correcting short nose deformities and the septal extension graft is the most commonly

performed technique among Asians. In many Asian patients septal cartilage, however, is too small and insufficient to perform an effective septal extension graft. Therefore, we designed a novel technique, named hybrid septal extension graft to overcome this pitfall in Asian tip plasty.Methods: From February 2010 to March 2013, 41 patients with primary (N ¼ 30) or secondary (N ¼ 11) short nose deformity underwent a hybrid septal extension graft. The hybrid septal extension graft is a modified septal extension graft which uses the small septal cartilage along with irradiated homologous costal cartilage. Irradiated homologous costal cartilage was carved into a shape of a thin batten and securely fixed bilaterally to the caudal septum. Harvested septal cartilage was located between the 2 irra-diated homologous costal cartilage batten grafts and fixed with sutures. Then, the alar cartilage was fixed at the end of the septal cartilage graft. The nasal lengths, nasal tip projections, and naso-labial angles were measured pre- and postoperatively.Results: The hybrid septal extension graft showed enough nose lengthening and a decreased nostril show, even in cases with a very small septal cartilage.Conclusions: The authors present a novel technique for correction of short nose deformity in Asians. The hybrid septal extension graft provides good results with minimal complications and overall patient satisfaction was very high.

Key Words: Asians, hybrid septal extension graft, short nose

C orrection of short nose deformity consists of several important steps, such as release of alar cartilage from the upper lateral

cartilage, wide undermining and release of dorsal skin flap, andfixation of lengthened alar cartilage. For the fixation of length-ened alar cartilage, septal extension graft is one of the most secureand most commonly performed techniques. Harvested septalcartilage should be more than 25 mm in length, although thismay vary according to the needs of the patient. Most Asianpatients have very small and insufficient septal cartilage whichmakes it difficult to be used as an effective septal extension graft.For this reason, autogenous rib cartilage or irradiated homologouscostal cartilage (IHCC) may be used as an alternative. Thesealternatives, however, have disadvantages. An autogenous ribcartilage may evoke the patient’s worries about a scar on the chestwall and they are often hesitant to go under general anesthesia.Moreover, an autogenous rib cartilage or IHCC may lead to a veryrigid nasal tip.1,2

The hybrid septal extension graft is a modified technique ofseptal extension graft that can use even a very small septal cartilagefor septal extension by using IHCC or conchal cartilage simul-taneously to supplement the small septal cartilage. In this study, wedescribe a novel technique of the hybrid septal extension graft forcorrecting short nose deformities in Asian patients.

From the �JW Plastic Surgery Center, Seoul, South Korea; and yJW PlasticSurgery Vietnam Clinic, Ho Chi Minh City, Vietnam.

Received June 16, 2015.Accepted for publication August 16, 2015.Address correspondence and reprint requests to Man Koon Suh, MD, JW

Plastic surgery Center, Samsin Building, 836 Nonhyeon-ro, Gangnam-gu, Seoul 135-893, South Korea; E-mail: [email protected] The authors report no conflicts of interest.Copyright # 2015 by Mutaz B. Habal, MDISSN: 1049-2275

Copyright © 2015 Mutaz B. Habal, MD. Unautho

e44DOI: 10.1097/SCS.0000000000002307

MATERIALS AND METHODS

PatientsFrom February 2010 to March 2013, 41 patients, both women

(N ¼ 38) and men (N ¼ 3), with a different degree of short nose underwent a hybrid septal extension graft. All 41 patients required septal extension graft for short nose correction. Because their septal cartilages were too small to be used as a septal extension graft, we performed a hybrid septal extension graft using autogenous septal cartilage combined with IHCC in 39 patients and a conchal cartilage in 2 patients. The patients were divided into 30 primary cases and 11 secondary cases. Combined operations consisted of dorsal augmentation with silicone implant (N ¼ 35), Gore-tex (N ¼ 2), and dermofat (N ¼ 3). Corrective rhinoplasty was performed in 2 patients with deviated nose.

METHODS

Photometric EvaluationWe used proportional indices that were described by previous

report of Kim et al3 to evaluate the postoperative outcomes. Pre- and postoperative lateral views were obtained from each patient and the glabella, sellion, subnasale, pronasale, and pogonion were identified. The proportional indices, such as nasal bridge length index and nasal tip projection index, were measured (Fig. 1). Also the columella-labial angle was measured. All indices were obtained before and after surgery (Table 1). We used the paired t-test to compare differences in these values before and after surgery. The statistical analyses were performed by SPSS (version 19.0, IBM, Armonk, NY).

Modified Septal Extension Grafting (HybridSeptal Extension Graft)

All patients were operated under local anesthesia with intrave-nous sedation using propofol and midazolam.

Open rhinoplasty technique was performed as follows; an inverted V-shape transcolumella incision or incision along the previous open rhinoplasty incision scar was made and was extended upward along the anterior margin of the medial crus, caudal margin of alar dome area and then laterally extended along the caudal margin of the lateral crus. In primary cases, dissection was done above the supraperichondrial plane and the alar cartilage was fully

FIGURE 1. The points and measured indices. Glabella, the most prominentpoint in the midline between the brows; sellion, the deepest point of thenasofrontal angle at the intersection of forehead slope and nasal slope;pronasale, the most prominent point on the nasal tip; subnasale, the pointbeneath the nose where the columella merges with the upper lip in the

rized reproduction of this article is prohibited.

# 2015 Mutaz B. Habal, MDmidsagittal plane; and pogonion, the most anterior point on the chin.

The Journal of Craniofacial Surgery � Volume 27, Number 1, January 2016 Brief Clinical Studies

Len

op

33

58

77

69

05

38

16

37

74

63

92

86

54

77

47

06

75

77

56

23

63

28

26

76

36

52

48

33

TABLE 1. Patient Information

Case Age (year) Sex Follow-up (Month) Pre

1 21 F 16 33.

2 37 F 12 31.

3 35 F 14 30.

4 23 F 36 31.

5 27 F 12 32.

6 41 F 24 31.

7 31 F 15 33.

8 33 F 12 31.

9 20 F 12 31.

10 29 M 14 32.

11 53 F 13 30.

12 34 F 12 31.

13 27 F 16 31.

14 19 F 12 31.

15 35 M 13 32.

16 26 F 23 33.

17 36 F 15 32.

18 42 F 12 31.

19 23 F 36 30.

20 37 F 12 31.

21 33 F 18 31.

22 58 F 13 31.

23 28 F 12 31.

24 35 F 13 30.

25 30 F 20 32.

26 24 F 16 31.

27 43 F 12 31.

28 38 F 24 32.

skin envelope. After elevating the scar tissue and the skin envelope,we separated the skin envelope from the underlying scar tissue orcapsule, allowing the skin to lengthen and cover the extended alarcartilage. The septal cartilage was harvested leaving 10 to 12 mm ofL-strut, depending on the strength of the septum.

The carved IHCC, approximately 1.0 mm in thickness and 10 to15 mm in length, was grafted on both sides of the caudal septum

29

86

16

05

72

58

89

32

07

95

61

27 37.79 8.07 11.16 105.5 93.5

19 38.32 7.94 11.24 106 95

exposed. Subperiosteal dissection over the nasal bone was donewhen a dorsal augmentation was planned. Wide subperiosteal andsupraperichondrial dissection was performed to release andlengthen the skin envelope. Transverse nasalis muscle was releasedbilaterally at the pyriform aperture to further lengthen the skinenvelope. Then, the lower lateral cartilage was released for itscaudal repositioning. First, the scroll area between the upper and

29 45 F 14 31.

30 22 F 12 30.

31 19 F 12 33.

32 23 F 12 32.

33 34 F 18 31.

34 32 F 14 30.

35 58 F 12 31.

36 30 F 34 31.

37 29 F 21 31.

38 27 M 12 30.

39 40 F 15 31.

40 25 F 12 31.

41 33 F 14 32.

M, male; F, Female; Preop, preoperative; Postop, postoperative.


# 2015 Mutaz B. Habal, MD

lower lateral cartilage was released by a Metzenbaum scissors. Thisrelease was done so that the thin whitish vestibular mucosa alonewas left between the upper and lower lateral cartilages. Also, adisconnection of the accessory ligament was done if the lengtheningof the lower lateral cartilage was not sufficient with the scroll areadissection alone. In addition, dissection of membranous septum wassometimes necessary for a more caudal release of the lower lateralcartilage. In secondary rhinoplasty, the release of lower lateralcartilage was not different from that of primary case, even thoughthe abundant scar tissue usually makes it more difficult and timeconsuming. Dual plane dissection was carried out to lengthen the

gth Index Projection Index Nasolabial Angle

Postop Preop Postop Preop Postop

36.84 7.89 10.53 113 97

38.71 8.77 11.29 104.5 94

37.29 8.46 11.02 109 89.5

35.93 8.39 10.93 105 93.9

37.32 7.52 11.23 106.5 92

36.85 7.9 10.61 108.5 96.5

38.03 8.95 11.34 106 92.5

37.42 8.42 10.38 103.5 94

38.03 8.51 11.27 108 90.5

37.82 8.06 10.78 106 94.5

36.37 8.47 11.23 110.5 92.5

36.31 8.12 11.03 107 97.5

36.88 8.64 11.45 109 97

37.13 8.83 11.26 107.5 99.5

36.95 8.19 10.66 111 96.5

38.34 8.05 10.13 106.5 98

37.29 7.62 10.51 109.5 96.5

36.01 8.71 11.2 107 93

36.42 8.54 11.16 107.5 91.5

36.97 8.69 11.05 108.5 94

37.31 8.26 10.48 109.5 93.5

38.04 8.17 10.77 105 96.5

36.75 7.83 11.12 109 96.5

59.92 8.42 11.37 105.5 97.5

37.18 8.29 10.93 107 94.5

36.82 8.34 11.28 107.5 95

38.62 8.65 10.97 110.5 96.5

37.48 8.61 11.33 106.5 94.5

38.31 8.9 11.15 108.5 96

37.25 8.34 11.2 106.5 93.5

37.03 8.79 11.16 104.5 93

38.03 8.41 10.74 105.5 96

38.36 8.53 11.04 109.5 95.5

37.71 7.71 10.85 106 96.5

38.67 8.29 11.36 107.5 97.5

36.78 8.74 11.52 111.5 96

38.42 8.58 11.29 106.5 93.5

37.47 8.45 10.86 107 96.5

36.28 8.27 11.29 104 91.5


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(batten type) (Fig. 2A). Ear cartilage could be used as an alternativeto IHCC. 5–0 PDS anchoring sutures were used in 3 to 4 locationsto fixate the grafts firmly. The harvested small septal cartilage waslocated between the 2 IHCC batten grafts and rigidly fixated using5–0 PDS (Fig. 2B). The tip tripod was then caudally pulled forfixation with 5–0 PDS sutures between the bilateral alar domes andthe anterior edges of the septal cartilage graft (Fig. 3A). If theharvested septal cartilage was exceptionally small (less than 10 mmlength), it was pulled more caudally between the IHCC grafts,without touching the caudal septum (Fig. 3B). Tip onlay graft orshield graft was performed for further tip projection, if necessary.

Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 27, Number 1, January 2016

FIGURE 3. The hybrid septal extension graft. A, The harvested septal cartilage islocated between the 2 irradiated homologous costal cartilage batten grafts. B, Ifthe harvested septal cartilage is exceptionally small, septal cartilage can be fixedwith irradiated homologous costal cartilage without touching the caudal septum.

Dorsal augmentation was done using silicone implants or Gore-TexR with 2.0 to 4.0 mm thickness. Silicone wrapped by deeptemporal fascia or dermofat graft harvested from buttock was usedin patients who presented with thin skin.

RESULTSThe range of nasal lengthening in 41 patients was between 3 to10 mm (mean, 5.6 mm). There were no perioperative complications,such as infection, resorption, warping or asymmetric tip or colu-mella. All patients were followed up for an average of 15 months(range 12 months to 3 years). No major complications associatedwith the implants, such as exposure or migration of the implants,necrosis of the overlying tissues, or infection caused by the implantswere noted during the follow-up period. Three cases needed minorrevision because of inadequate lengthening and tip projection. Two

FIGURE 4. Cases of rhinoplasty with hybrid septal extension graft. Case 1a,preoperative and 1b, 18-month postoperative (left). Case 2a, preoperative and2b, 12-month postoperative (center). Case 3a, preoperative and 3b, 30-monthpostoperative (right).

DISCUSSIONIn this study, the hybrid septal extension graft for short nose patientsshowed enough nasal lengthening and tip projection, even inpatients with a very small septal cartilage. Autogenous cartilages,such as septal and conchal cartilages are optimal as graft materialsfor nasal tip projection and derotation.4–7 In short nose corrections,the septal cartilage is most commonly used for the septal extensiongraft.8,9 Septal cartilage is used most commonly as donors becauseit can directly extend and strongly support the alar cartilage and itcan be harvested easily in the same operative filed.10

Septal extension graft is an effective procedure for tip projectionand lengthening during rhinoplasty. Septal extension graft was firstreported by Byrd et al11 which was classified according to thestability of the caudal septum and the amount of septal cartilage.Subsequently, a few modified techniques were reported such astongue-and-groove technique by Guyuron et al12 and extensiveharvest technique by Kim et al.3 In these techniques, however, largeamount of septal cartilage is needed.

In Asians, however, the adequate septal cartilage harvesting isnot always possible because of insufficient quantity, deviation,weakness, and severe ossification.13 A septal extension graft forshort nose correction needs a septal cartilage of more than 20 mm inlength. The mean septal cartilage which could be harvested was12.1 mm� 18.0 mm if the remained L-strut was of 10 mm width in aKorean cadaver study by Kim et al.3 The harvested septal cartilagehowever, is usually too small to be used as an effective septalextension graft. Moreover, in these patients, more septal cartilageshould be preserved as an L-strut for the stability of the nasalframework.9 In these cases, ear cartilage or rarely rib cartilage canbe used for the septal extension graft. Even though ear cartilage canbe used for septal extension, its predictability is somewhat low

FIGURE 2. Thecarvedirradiatedhomologouscostalcartilage(A)andtheirradiatedhomologous costal cartilage located in both sides of the caudal septum (B).

patients complained of high tip projection whereas 1 patientcomplained of low tip projection. Trimming of septal cartilageand cephalic rotation of alar cartilage were performed to correct thehigh projected tip. An onlay graft using the conchal cartilage wasperformed to correct low tip projection.

There were statistically significant differences between the pre-and postoperative values in nose length and nose tip projection. Also,the nasolabial anglewassignificantly reduced(Table 2). Mostpatientswere satisfied with their nasal contour and tip projection (Fig. 4).

TABLE 2. The Results of the Photometric Evaluation of Indices

Preop (N¼ 41) Postop (N¼ 41) P

31.70� 0.7 37.90� 3.6 <0.001

8.40� 0.4 11.00� 0.3 <0.001

Length index

Projection index

Nasolabial angle index 107.40� 2.1 94.9� 2.2 <0.001

Preop, preoperative; Postop, postoperative.


e46

because of its size and curvature. Rib cartilage on the contrary, isabundant, durable, and stronger than septal cartilage. Rib cartilage,however, is not widely used as it is a more invasive procedurerequiring general anesthesia and warping is one of the majordisadvantages of autogenous rib cartilage grafts.2

We applied a new technique to overcome a very small septalcartilage as a troublesome obstacle in Asian short nose correction. It iscalled hybrid septal extension graft and requires only 10 to 15 mmlength of septal cartilage. With this technique it is possible to achievesufficient tip projection and extension. We named this new techniqueas hybrid septal extension graft (hybrid SEG), as it uses 2 differentkinds of cartilage for the modified type of septal extension graft.Hybrid SEG uses the IHCC or conchal cartilage as a bilateral battengraft fixed to caudal septum and it provides more extension to caudalseptum and provides basis for septal extension grafts. Harvested smallseptal cartilage is fixed between the bilateral IHCC (or conchalcartilage), even a small septal cartilage can act as a strong septalextension graft based on the lengthened caudal septum.



The Journal of Craniofacial Surgery � Volume 27, Number 1, January 2016 Brief Clinical Studies

This hybrid SEG has several advantages: the nasal tip is softerand mobile than in cases using autogenous rib cartilage or IHCCalone. Compared to the conventional septal extension the graftdeviation is much less, since septal cartilage is centrally locatedbetween the 2 IHCC or ear cartilage in hybrid SEG. The grafted tipreceives pressure from the alar cartilage in a very parallel directioncompared with the unilaterally fixed graft. Therefore, a chance ofnasal tip deviation is extremely low for these 2 reasons. Comparedto IHCC use alone, a deformity or relapse because of this techniquewould be much smaller in case the IHCC would be unexpectedlyresorbed, because hybrid SEG uses a smaller amount of IHCC thanthe septal extension graft using IHCC only. If the resorption rate isthe same, a deformity would be smaller in case of using less volumeof IHCC than in case of using a larger volume. Recently, there aremany reports about the IHCC graft for rhinoplasty. Irradiatedhomologous costal cartilage is easy to manipulate and has lowdonor site morbidity compared to autogenous rib cartilage. Andmultiple grafts are possible because of its abundant quantity.Therefore, the IHCC graft is increasingly used as graft materialespecially in patients with short nose deformities with limited donorbecause of previous operation. The use of IHCC grafts, however, isstill controversial in terms of resorption, warping, and infections.10

Some papers show that the absorption rate is not significantly differentfrom autogenous cases,14–16 but other reports insist that 100% of theIHCC graft were completely absorbed.17 Suh et al1 reported minimal2-year follow-up cases where the use of IHCC solemnly showed nosign of resorption and its original shape was maintained. Theyrecommended to select the dense area of the IHCC and to do a tightfixation of the grafts. Warping may occur immediately or delayedafter cartilage graft. In short nose patients, delayed warping of

REFERENCES1. Suh MK, Ahn ES, Kim HR, et al. A 2-year follow-up of irradiated

homologous costal cartilage used as a septal extension graft for thecorrection of contracted nose in Asians. Ann Plast Surg 2013;71:45–49

2. Kim SK, Kim HS. Secondary Asian rhinoplasty: lengthening the shortnose. Aesthet Surg J 2013;33:353–362

3. Kim JS, Han KH, Choi TH, et al. Correction of the nasal tip and columellain Koreans by a complete septal extension graft using an extensiveharvesting technique. J Plast Reconstr Aesthet Surg 2007;60:163–170

4. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St Louis, MO:Quality Medical Publishing; 1998

5. Marin VP, Landecker A, Gunter JP. Harvesting rib cartilage grafts forsecondary rhinoplasty. Plast Reconstr Surg 2008;121:1442–1448

6. Jang YJ, Yu MS. Rhinoplasty for the Asian nose. Facial Plast Surg2010;26:93–101

7. Gunter JP, Rohrich RJ. Lengthening the aesthetically short nose. Plast

cartilage graft may be more common because of skin tension. Toavoid immediate and delayed warping, we waited at least for 1 hourafter cutting the cartilage before insertion to check for immediatewarping of cartilage. To minimize delayed warping, we graftedcartilage bilaterally and folded the cartilage onto the same surface.

Commercially supplied IHCC does not have an intrinsic uniformdensity; some area is dense while the other area is crumbly. Thecrumbly area is a degenerative area and has no visible lacunae orchondrocyte, even though the chondrocyte itself inside the IHCC isnot a living cell. During hybrid SEG, we selected only the densearea of the IHCC and rigid fixation sutures were done in more than 3points between the bilateral grafts and the septal cartilage graft. Weused a minimal size of IHCC as bilateral batten grafts that acted as a‘‘bridge’’ to locate the septal cartilage in a stable and proper positionfor the septal extension graft. It may cause less deformity of thenasal tip even if there is any unexpected resorption of IHCC,because IHCC is less contributable to septal extension in hybridSEG than in SEG using IHCC alone. The use of ear cartilage insteadof IHCC may cause much less worries about resorption.

There are many methods to measure the outcome after rhino-plasty.18–20 It is hard to convince all patients to regularly visit thehospital and to measure indices directly even though it is the best wayto estimate the outcome of surgery. Therefore, we took clinicalpictures of the lateral views of the patients before and after rhinoplastyand measured the change of tip projection and nasal length on the basis



of 2 points; glabella and pogonion (Fig. 1). In the photometricevaluation, the projection of nasal tip and nasal length were signifi-cantly increased and the columellar-labial angle was also significantlydecreased in patients who underwent hybrid SEG.

CONCLUSIONSSmall septal cartilage is the most common obstacle a surgeon mustovercome during short nose corrections in Asian patients. With ournovel technique, surgeons may effectively lengthen the nose even inpatients with small septal cartilage.

Reconstr Surg 1989;83:793–8008. Lin J, Chen X, Wang X, et al. A modified septal extension graft for the

Asian nasal tip. J Am Med Assoc Facial Plast Surg 2013;15:362–3689. Paik MH, Chu LS. Correction of short nose deformity using a septal

extension graft combined with a derotation graft. Arch Plast Surg2014;41:12–18

10. Cochran CS, Gunter JP. Secondary rhinoplasty and the use ofautogenous rib cartilage grafts. Clin Plast Surg 2010;37:371–382

11. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: amethod of controlling tip projection shape. Plast Reconstr Surg1997;100:999–1010

12. Guyuron B, Varghai A. Lengthening the nose with a tongue-and-groovetechnique. Plast Reconstr Surg 2003;111:1533–1539

13. Jeong JY. Obtaining maximal stability with a septal extension techniquein East Asian rhinoplasty. Arch Plast Surg 2014;41:19–28

14. Lefkovits G. Irradiated homologous costal cartilage for augmentationrhinoplasty. Ann Plast Surg 1990;25:317–327

15. Demirkan F, Arslan E, Unal S, et al. Irradiated homologous costalcartilage: versatile grafting material for rhinoplasty. Aesthetic Plast Surg2003;27:213–220

16. Kridel RW, Ashoori F, Liu ES, et al. Long-term use and follow-up ofirradiated homologous costal cartilage grafts in the nose. Arch FacialPlast Surg 2009;11:378–394

17. Welling DB, Maves MD, Schuller DE, et al. Irradiated homologouscartilage grafts. Long-term results. Arch Otolaryngol Head Neck Surg1988;114:291–295

18. Dhong ES, Kim YJ, Suh MK. L-shaped columellar strut in East Asiannasal tip plasty. Arch Plast Surg 2013;40:616–620

19. Park JH, Mangoba DC, Mun SJ, et al. Lengthening the short nose inAsians: key maneuvers and surgical results. JAMA Facial Plast Surg2013;15:439–447

20. Huang J, Liu Y. A modified technique of septal extension using a septalcartilage graft for short-nose rhinoplasty in Asians. Aesthetic Plast Surg2012;36:1028–1038


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a novel technique for short nose correction

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