septal considerations in revision rhinoplasty · septal considerations in revision rhinoplasty...

Septal Considerations in RevisionRhinoplastyArmando Boccieri, MD*, Carlo Macro, MD

Assessment of the condition of the nasal septumis an indispensable preliminary stage in the surgicaltreatment of revision rhinoplasty. The septal struc-ture performs a key function in supporting the nasalpyramid, and its straightness constitutes an essen-tial prerequisite for the achievement of satisfactoryesthetic results. Irvin Goldman in the 1960s coinedthe renowned dictum, ‘‘As the septum goes, so goesthe nose.’’ This statement still retains validity andrelevance in light of the developments in nasalsurgery over the last few years. Examination of theoutcome of previous rhinoplasties often revealsoveraggressive resection of this anatomic structureand collapse of the nasal dorsum or, on the con-trary, insufficient correction of septal deviation.The result of such incorrect treatment is a varyingdegree of esthetic and functional impairment thatcan prove difficult to repair. The most recent recon-structive techniques adopted in surgical revision usegrafts to replace the missing structures, and the na-sal septum constitutes a primary source of materialto this end. This function as donor site depends onthe presence of the septum after the initial opera-tion and can be performed also in the patientwho has incomplete correction of the nasal septum.This article analyzes the following three funda-

mental aspects of the nasal septum in revision

rhinoplasty: (1) deficit of the septal structure tovarying degrees, (2) persistent deviation of the nasalseptum, and (3) supratip deformity caused by inap-propriate resection of the dorsal septum. Attentionis focused separately on the residual nasal septumas a source of material in revision operations forgrafts to reconstruct impaired anatomic structures.The article also describes and discusses some recentreconstructive techniques used to address problemsregarding the nasal septum during revisionrhinoplasty.

Pathologic anatomy of the nasal septum

The complete resolution of functional and estheticproblems during revision surgery can only be en-sured by a thorough understanding of certain ele-ments of anatomy and physiopathology. Theanatomic constituents of the nasal septum are thenasal spine of the frontal bone, the perpendicularplate of the ethmoid, a portion of the medial seg-ments of the nasal bones, the vomer and crest ofthe sphenoid, the nasal crest of the maxilla, the pre-maxilla and nasal spine, the quadrangular cartilage,the upper lateral cartilage, the membranous sep-tum, and the columella [1].

F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am - (2006) -–-

DepartmentofMaxillo-Facial Surgery, S. CamilloHospital, CirconvallazioneGianicolense, 87-00152, Rome, Italy* Corresponding author. Viale U. Tupini 133, Rome 00144, Italy.E-mail address: [email protected] (A. Boccieri).

- Pathologic anatomy of the nasal septum- Absence of the nasal septum- Persistent septal deviation- Supratip deformity owing to the dorsal

septum

- Use of septal cartilage for grafting- Discussion- Summary- References

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1064-7406/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2006.06.005facialplastic.theclinics.com

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The cartilaginous portion of the nasal septum sit-uated in front of an imaginary line running fromthe osteocartilaginous joint of the rhinion to theanterior nasal spine actually provides nasal support.Reconstruction of an L-shaped supporting septalstructure, regardless of the procedure used, must en-sure complete restoration of this important anterioranatomic region. The predominantly osseous por-tion of the nasal septum situated behind the sameimaginary line is far less involved in postsurgical es-thetic problems. Nevertheless, marked deviations ofthe ethmoid that are not surgically treated cansometimes prevent the correct positioning of nasalbones with respect to the septum after osteotomiesand can cause functional respiratory disorders. Insuch cases, revision will obviously involve the sub-mucous resection of the deviated area with no needfor structural repair.The anterior portion of the cartilaginous septum

performs its supporting function on the middle na-sal vault in conjunction with the upper lateral carti-lages and on the nasal tip through the attachmentsof the medial crural footplates to the caudal borderof the quadrangular cartilage and the domes. Ab-sence or severe deviation of the caudal septumcan cause loss of projection and ptosis of the tipas well as columellar retraction [2].The angle of the internal nasal valve formed by

the nasal septum and the upper lateral cartilages,which should physiologically have values between10 and 15 degrees, is impaired by the absence andby the severe deviation of the septum. In the firstcase, the structure collapses with extreme wideningof the angle, giving the anatomopathologic appear-ance referred to as ‘‘ballooning.’’ In the second case,there is a narrowing of the angle on the concave sideof the deviation with stenosis of the internal nasalvalve [3]. In both situations, the valvular impair-ments cause considerable difficulty in nasalrespiration.With respect to the relations between the cartilag-

inous septum and the upper lateral cartilages, thetwo structures are practically continuous, and re-cent anatomic studies have shown that the nasalseptum has a wide Y-shape in its dorsal most por-tion [4]. In a physiologic condition, this wideningof the dorsal septum functions with the two upperlateral cartilages as two spreader grafts [5] and en-sures normal respiratory flow at the level of the in-ternal nasal valve [6].Various factors are involved in the etiopathogen-

esis of persistent deviations of the nasal septum.Apart from cases of inadequate surgical treatment,failure is often caused by the presence of deformingforces extrinsic and intrinsic to the cartilaginousseptum that tend over time to cause the recurrenceof deviation [7]. The intrinsic forces are those

inherent in the structure of the cartilaginous sep-tum that retain the ‘‘memory’’ of their deviationand tend to return to the incorrect original positioneven after reshaping. From an ultrastructural view-point, this phenomenon appears to be due to inter-locked stresses inside the cartilage, which aregoverned, in turn, by the protein-polysaccharidecomplexes associated with the collagenic fibers[8,9]. The extrinsic deforming forces are exertedon the cartilaginous septum by the surroundingstructures connected to it, such as the nasal bones,upper lateral cartilages, vomer, ethmoid, and maxil-lary crest. If still deviated and not perfectly sepa-rated from the nasal septum during the operation,these anatomic structures can cause the deviationof the cartilaginous septum to reappear over time.The deforming forces external to the cartilaginousseptum also include the postoperative contractionof cicatricial fibrosis, which can lead to relapseand distortion.

Absence of the nasal septum

Unfortunately, the idea that an L-shaped structureat least 1.5 cm in width must always be preservedat the end of every septorhinoplasty operation isstill not known to and accepted by all surgeons.The function of this pillar is to support the nasalpyramid and maintain a physiologic relationshipbetween the nasal septum and the upper lateral car-tilages at the level of the internal nasal valve. Evenin cases in which the residual L-shaped structureis deviated, it must not be removed but rather re-shaped or replaced with no alteration of functions.It is probably the difficulty encountered in correct-ing deviations in this site that prompts some sur-geons to undertake its erroneous partial or totalremoval. In these circumstances, the mucoperi-chondrial covering can remain intact even thoughit no longer contains the cartilaginous structurenormally present. This point is important for surgi-cal purposes as a criterion to differentiate the typeof treatment to be employed. When the mucoperi-chondrium is also lacking and there is perforationof the nasal septum, it is necessary to employ differ-ent surgical techniques serving also to reconstructthe covering.In reconstruction of the cartilaginous septum, the

authors stress the need for preliminary assessmentof the impairment to the structure as a prerequisitein deciding which technique to use. When the def-icit is confined to the caudal most portion of the na-sal septum, it is possible to consider first thetechnique of caudal septal extension grafting [10],which consists of excising a straight inferoposteriorportion of the cartilaginous septum (if present) andusing it to replace the anterior pillar of the L-shaped

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structure (Fig. 1). This graft is posteriorly sutured tothe caudal border of the surviving nasal septumwith two 4.0 polydioxanone (PDS) mattress suturesand secured anteriorly between the medial crurawith two buried 5.0 Prolene sutures and a singletemporary 4.0 Monocryl mattress suture. Whena sufficiently large cartilaginous structure is notavailable posteriorly, any cartilaginous hump pres-ent can be excised and reshaped to reconstruct theabsent caudal septum [11]. The hump must obvi-ously be pared down and flattened to obtain a suit-able structure for the type of graft required. Whenneither of these sources for reconstruction of thenasal septum is available and the structural deficitof the septum is subtotal, the auricular conchacan be used for the graft [12]. It is essential whenharvesting conchal material to preserve the helixroot and the antihelix fold so as to leave no tracein the auricular pavilion. If the approach is per-formed from the posterior surface of the ear, it is ad-visable to insert four or five needles in the anteriorsurface of the ear so that the incisions can be madeposteriorly without damaging these important ana-tomic folds (Fig. 2A,B). The concha can be re-shaped and can provide a straight sturdy structuresimilar to that of the nasal septum to be replaced.To straighten the concha, it is first necessary to per-form a series of incisions in the concave side fol-lowed by two figure-eight sutures of 5.0 nylon. Toreinforce the structure, two spreader grafts takenfrom the outer and inferior border of the conchaare then sutured with 5.0 nylon to the two sidesof the concha with their concave sides to the inside(Fig. 3). The region of the concha where the twospreader grafts are attached will correspond to thedorsal pillar of the ‘‘neo-septum.’’ When the conchais particularly curved, it is sometimes possible touse a third graft taken from the central region ofthe concha and secured to what will then be thecaudal pillar of the neo-septum. The end result isa straight, sturdy, L-shaped supporting structure,

which will be inserted between the two flaps ofthe mucoperichondrium where the septal structureis missing.Regardless of the type of graft selected, it is essen-

tial to separate the two mucoperichondrial flapsprecisely so as to create a pocket (Fig. 4A). It isalso vital in such cases to use an open approach,and the authors systematically employ a transcruraland transdomal path of access. The detachmentmust be precise and avoid any laceration of the mu-cous membrane. Of crucial importance in thisphase are abundant infiltration with vasoconstric-tor, strong outward traction of the two flaps, andthe use of a sharpened scalpel from front to backand from top to bottom. Insertion of the surgeon’sindex finger into the right nasal cavity and frequentinterior checking of the nasal cavities can prove use-ful to proceed confidently during the detachmentand to ensure immediate awareness of any lacera-tion of the mucous membrane. After insertion be-tween the two flaps of mucous membrane, thegraft must be secured with permanent sutures tothe posterior septal residues (if present), the upperlateral cartilages, and the medial crura by means ofa tongue-in-groove technique (Fig. 4B) [13]. Thistechnique makes it possible to obtain a correct na-solabial angle and adequate tip projection (Fig. 5).

Persistent septal deviation

In the results of septorhinoplasty, a basic distinc-tion should be drawn between deviations of the na-sal septum that affect the dorsal or caudal pillar ofthe structure and those affecting the internal basaland medioseptal region. An evident esthetic defectarises in the first two cases, whereas the third in-volves only a functional respiratory defect of vary-ing severity. The presence of these problems stemsessentially from two causes: (1) incomplete treat-ment on the part of the surgeon or (2) the use of in-appropriate surgical techniques to neutralize thetendency of the cartilaginous deviation to returnto its original incorrect position over time. Humpexcision can sometimes accentuate deviation ofthe nasal dorsum because the nasal septum, previ-ously concealed beneath the hump, is clearly ex-posed and can present a more marked deviationthan the removed upper portion.The correction of septal deviation constitutes the

first stage during revision because other associatedcorrections could be affected by the persistence ofthe defect if performed first. For example, correctionof the nasal tip or a graft on the dorsum could, ifperformed in an earlier phase, leave major asymme-tries at the end of the operation.In patients in whom internal deviations of the

nasal septum do not involve the L-shaped structure,

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Fig. 1. Caudal extension graft technique. A segmentof straight septal cartilage is harvested from the post-eroinferior septum and then sutured to the existingcaudal septum.

Septal Considerations in Revision Rhinoplasty 3

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the preferred treatment involves vertical shaves andstaggered incisions or the resection of particularlycrooked portions [14–16]. Septal or maxillary spurson the floor of the nasal cavities require submucousexcision above all when they are in the vicinity ofthe internal nasal valve, in which position theyare functionally significant. There is no good reasonto insist on the removal of very posterior spurs,given their negligible functional effect on respira-tory airflow. Posterior deviations of the perpendicu-lar plate of the ethmoid can be repositioned easilyon the median line by means of fracture witha Goldman displacer. The anterior nasal spine, ifleft crooked in the previous operation, can also befractured and secured to the periosteum in the mid-dle with slow absorption sutures.In the patient who has deviation of the caudal

septum with projection of the septal border into

one of the nasal cavities, excellent results can be ob-tained through use of the ‘‘swinging door’’ tech-nique [17]. This technique involves excision ofa thin vertical strip of cartilage at the point of great-est angle of the nasal septum, inferior detachmentfrom the maxillary crest, and rotation toward thecenter of the freed caudal septum like a door swing-ing on its hinges. The base of the caudal septum isthen secured with slow absorption stitches to thecolumella and the anterior nasal spine to ensurethat the correct position is maintained over time.Although a closed approach with hemitransfix-

ion incision can prove sufficient for all of the tech-niques outlined previously, an open approach isindicated if the persistence of the deviation affectsthe dorsal portion of the nasal septum. This ap-proach is justified by the need for a more completeand three-dimensional view of the deviation and bythe greater ease of suturing grafts in the more poste-rior regions, which are otherwise inaccessible [18].The technique used in revision rhinoplasty to

correct deviation of the dorsal septum must be cho-sen in relation to the severity of the defect and thetype of graft available. For slight C-shaped defor-mities of the middle third, it is possible to opt forselective tangential shaving of the convex side ofthe dorsal border of the septum with the insertionof a unilateral planoconvex spreader graft betweenthe concave side of the dorsal septum and the upperlateral cartilage [2]. The use of one or two spreadergrafts is indicated for moderately severe residual de-formities of the dorsal septum [19–21]. In patientsin whom the cartilaginous septum is still present af-ter the previous operation, a unilateral spreadergraft harvested from the septum and sutured to theconcave side of the deviation can prove sufficient(Fig. 6A,B). Before the graft is secured, several verti-cal incisions are generally made on the concave sideto open the cartilaginous spring. When the residualcartilaginous septum is not sufficient to providema-terial, two spreader grafts can be harvested from theauricular concha and secured to either side of theseptum with their concave sides on the inside.

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Fig. 2. (A) Cartilage incision along the outline marked by needles. (B) Resection of the cartilage graft leaving thehelix root and the antihelix fold intact.

Fig. 3. (Above left) Incision of curved conchal carti-lage. (Above right) Figure-eight suture. (Below left)Harvesting of spreader grafts. (Below right) Place-ment of spreader grafts. (From Boccieri A. Subtotalreconstruction of the nasal septum using a conchalreshaped graft. Ann Plast Surg 2004;119; withpermission).

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The crossbar graft technique is indicated for se-vere persistent deviations of the dorsal septum[22]. This technique combines septoplasty bymeans of staggered incisions with the insertion ofa spreader graft in the dorsal septum. The graftmust be positioned on the concave side of the devi-ation or, in the patient who has linear deviation ofthe dorsal septum, on the side where there is a gapbetween the septum and the upper lateral cartilages.The incisions are made on the dorsal and caudalpillars of the L-shaped structure, normally, threeon each side, two on the outside, and one on the in-side in the areas of greatest deviation. At the end,the crossbar graft is embedded between the two in-cisions in the dorsal and caudal pillars and suturedfront and back with two mattress stitches of 5.0Vicryl (Fig. 7). In revision cases, the crossbar canalso be harvested from the cartilaginous nasal sep-tum, if this was not radically excised during theprevious operation, provided that the L-shapedstructure is left intact. If harvesting the crossbarfrom the cartilaginous septum would impair the in-tegrity of the L-shaped structure, a strip of the per-pendicular plate of the ethmoid can be used forthe same end (Fig. 8).In patients in whom the deviation of the dorsal

septum is accompanied by an inverted V deformityof the nasal pyramid owing to excessive excision ofthe upper lateral cartilages, it is advisable to use twospreader grafts taken from the auricular concha,which are effective in the correction of both defor-mations. The two spreader grafts are secured tothe dorsal septum with their natural concavityturned to the inside, and their thickness is adjustedto the concavity and convexity of the dorsal septumto make it straight (Fig. 9).

Supratip deformity owing to the dorsalseptum

Supratip deformity is frequently involved in revi-sion rhinoplasty. It takes the form of convexity inthe region of Converse’s weak triangle, whichcauses the lower third of the nose to assume the par-ticular ‘‘polly beak’’ shape. This sequela can arise af-ter rhinoplasties performed by inexperiencedsurgeons and unexpectedly after rhinoplasties per-formed by expert surgeons, in which case impon-derables connected with the characteristics of thepatient and aspects of scar-tissue formation areprobably involved [23]. Insufficient removal ofthe dorsal cartilaginous septum and overresectionof the nasal dorsum with the formation of scar tis-sue are securely identified as two etiopathogeneticcauses connected with the nasal septum in the gen-esis of polly beak deformity [24]. In the secondcase, the deformity is caused by an excess of scar tis-sue produced to eliminate the void left in the supra-tip region by overzealous resection of the caudalnasal dorsum [25]. In addition to these causes,two other elements are often present that work toaccentuate the deformity, namely, underprojectionof the tip and insufficient resection of the cephalicportion of the lower lateral cartilages.Simple palpation of the supratip can reveal the

consistency of the region and supply diagnostic in-dications of the type of polly beak deformity pre-sented by the patient before surgery. When thecause is an overprojected caudal dorsum, the defor-mity can easily be corrected by removal of the sur-plus cartilage (Fig. 10). If the supratip fullness isinstead caused by swelling and scar tissue and is di-agnosed within 3 months after the operation, the

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Fig. 4. (A) Separation of thetwomucoperichondrialflaps.A suitable pocket hasbeen obtained for the graft.(B) Suturing of the conchalgraft in place of the missingseptum.

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Fig. 5. Case 1. Man aged 19 years subjected to two previous septoplasties. Loss of the supporting septal structurecaused droopiness of the nasal tip, an acute nasolabial angle, and respiratory difficulty. Subtotal reconstructionof the nasal septum was performed using a reshaped conchal graft. (A) Finger pressure revealing the absence ofthe cartilaginous septum. (B,D,F,H) Preoperative views. (C,E,G,I) Postoperative views 1 year after surgery.

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area can be subjected to injection with triamcino-lone and compression taping [24]. The triamcino-lone injection must be performed carefully to thecorrect subdermal depth, avoiding injection intothe dermis, and can be repeated up to three timesat intervals of 3 to 4 weeks. If pharmacologic treat-ment fails to provide the desired results, revisionsurgery must be performed after an interval of atleast 1 year. This period of time is necessary to en-sure that the cicatricial contraction is completelyfinished and the condition to be corrected is defin-itive. The surgical treatment in such cases involvescomplete removal of scar tissue from the area ofthe supratip and exposure of the dorsal cartilagi-nous septum beneath. The height of the latter is of-ten insufficient, and a graft of septal or auricularcartilage can be used to fill the void in the area ofthe supratip.Regardless of whether the deformity of the dorsal

septum is due to the excess or absence of material, itis important to ascertain whether there is any ac-companying decrease in tip projection, in whichcase cartilaginous grafts of the shield [26] or Pecktype [27] are indicated. In such cases, reshaping of

the tip must precede reshaping of the dorsum be-cause the latter depends on the projection of thetip. It is important to create a break point at thelevel of the supratip at the end of the revision.A slight unevenness between the domes and theplane of the dorsal septum ensures a more than sat-isfactory esthetic result. It is advisable to leave a gapbetween the two cartilaginous structures of approx-imately 6 to 7mm, or even asmuch as 10mm in thepatient who has particularly thick skin [24,28].Careful postoperative observation of the patient,prolonged taping of the supratip, and injectionwith triamcinolone if required are part of the cor-rect treatment to avoid this deformity in surgicalrevision.

Use of septal cartilage for grafting

When present, the nasal septum constitutes the pri-mary source of material for structural grafts in revi-sion rhinoplasties. The quality of the cartilage isoptimal for durability and definition beneath thelayer of soft tissues and the skin.

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Fig. 6. (A) Persistent septal deviation with concave side on the left. (B) Placement of unilateral spreader graft onthe concave side.

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Fig. 5. (continued).

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Fig 5, continued. Basal view prior to (H) and post (I) revision surgery.

Harvesting can be performed bymeans of a hemi-transfixion incision or through a transcrural openapproach if planned for other corrections. After de-taching the mucoperichondrium on one side, a ver-tical cartilaginous incision is performed posteriorand parallel to the caudal border of the septum ata distance of approximately 1 to 1.5 cm. The inci-sion stops approximately 1 to 1.5 cm from the dor-sal edge of the septum. This incision serves todeglove the contralateral mucoperichondrium aswell as the perpendicular plate of the ethmoid onboth sides. The cartilaginous septum is then de-tached inferiorly from the maxillary crest, and anincision is made in it superiorly parallel to the dor-sal edge so as to leave the graft connected only pos-teriorly to the perpendicular plate of the ethmoid.At this point, it is preferable, if necessary, to fracturethe perpendicular plate of the ethmoid inferiorlywith a Goldman displacer to extract the graft of car-tilaginous septum together with a small portion ofethmoidal bone (Fig. 11). The cartilaginous septumis harvested together with this portion of ethmoidbecause of the difficulty of separating them insidethe nasal cavities without risking a fracture of thecartilage anterior to their joint, reducing the lengthof the graft [29]. The excision should be performedwith as little trauma as possible, because even smalllacerations or fractures of the septum can impairthe shape of the grafts to be obtained and their

strength as structural supports. The newly harvestedpiece of cartilage is vaguely rectangular in shape andcan be used to carve all of the grafts required for therevision. If only one or two grafts are required, theexcision can be confined to a limited portion ofthe cartilaginous septum to avoid uselessly weaken-ing the structural support of the nasal pyramid. Inthe patient who has undergone previous submu-cous resection of the septum, the excision will nec-essarily be limited to a small quantity of cartilageto avoid any damage to the residual supportingL-shaped structure. Numerous types of grafts canbe obtained from the nasal septum for surgical revi-sion, including grafts serving to reconstruct all threethirds of the nasal pyramid.Correction of a saddle nose deformity is fre-

quently needed in connection with the upper andmiddle thirds of the nose. In these patients, the graftmust be cut in an oval shape and carefully taperedto the sides with the edges beveled so as to avoidany perception of ‘‘steps’’ beneath the skin. A usefulprocedure for curving the graft is to perform an in-cision part of the way through the thickness alongthe midline together with another two lateral andparallel incisions, if necessary. By exerting pressurewith the fingers along the lines of incision, it is pos-sible to cause a greenstick fracture and to obtain aninverted V-frame graft or U-frame graft adaptingwell to the nasal dorsum [29].A narrow middle third of the nose with collapse

of the middle nasal vault and an inverted V defor-mity can be the result of particularly aggressiveand excessively reductive rhinoplasty. Revision rhi-noplasty requires the use of spreader grafts insuch cases [5]. These rectangular grafts are insertedand secured between the dorsal septum and the up-per lateral cartilages and are useful in functionaland esthetic terms, first, by restoring a physiologicangle of 10 to 15 degrees at the level of the internalnasal valve and, second, by bringing the middlethird of the nose into the right balance with theupper and lower thirds. Spreader grafts can be

Fig. 7. (Above left) Preoperative curvature of the sep-tum. (Above right) Pattern of staggered incisions.(Below left) Septal crossbar graft fitted betweentwo septal vertical intracartilaginous incisions (closedapproach). (Below right) Additional posterior suture(open approach). (From Boccieri A, Pascali M. Septalcrossbar graft for the correction of the crookednose. Plast Reconstr Surg 2003;111:631; withpermission).

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Fig. 8. Septal crossbar graft harvested from ethmoidalbone is sutured on the concave side of the septaldeviation.

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Fig. 9. Case 2. Patient aged 28 years subjected to three previous septorhinoplasties. The patient presented withpersistent deviation of the dorsal septum with an inverted V deformity, nasal obstruction, a malpositioned sep-tal graft on the nasal dorsum, and an overprojected tip. Revision rhinoplasty was performed using two conchalspreader grafts, removal of the previous graft, and dome truncation. (A) Collapse of the middle nasal vault isevident during forced inspiration. (B,D,F,H) Preoperative views. (C,E,G,I) Postoperative views 1 year after surgery.

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harvested from the middle portion of the cartilagi-nous septum and from the posteroinferior regionand are generally cut and pared down to about 1to 4 mm in thickness, 3 to 6 mm in height, and 8to 25 mm in length [30].The problem most often encountered in the

lower third of the nose after septorhinoplasty isan underprojected ptotic nasal tip. Such anomaliescan present immediately after the operation or yearslater owing to the force of gravity and the cicatricialcontraction of the cutaneous covering. A columellarstrut, shield graft, or onlay tip graft are the proce-dures indicated for correction. These grafts can beobtained from any part of the septum but prefera-bly are harvested from the cartilaginous portion ad-jacent to the ethmoidal bone where the septum isthicker and tougher and better suited to the re-quired function of structural support. The columel-lar strut is rectangular in shape and is inserted andsutured in place between the twomedial crura fromthe nasal spine to the domes [31]. This graft provesparticularly useful to improve the projection andsupport of the nasal tip and to straighten and rein-force the columella. A further increase in the projec-tion and definition of the nasal tip can be obtainedby means of a shield graft. This versatile graft isroughly trapezoidal in shape and is sutured with6.0 nylon to the front of the medial crura in theirupper portion to protrude approximately 1 to2 mm over the domes. The shield graft also givessymmetry to the tip, masks irregularities of thedomes, and determines the supratip break. Anothergraft serving to increase projection is the tip onlaygraft described by Peck, which can also be posi-tioned in layers on the domes by means of the um-brella technique.Alar batten grafts are also obtained from the nasal

septum and are frequently used in revision

rhinoplasties [32]. These rectangular curvilineargrafts measure about 10 to 15 mm in length and4 to 8 mm in width. They are used in cases of exces-sive resection of the lateral or upper lateral carti-lages with weakening and retraction of the lateralnasal wall, situations that often cause respiratoryproblems with collapse of the nasal valve during in-spiration. Alar batten grafts are lodged in a preciselyformed pocket extending from the lateral third ofthe lateral crura to the piriform aperture. The con-vex side of the graft is placed on the outside so asto lateralize the collapsed portion of the lateral na-sal wall. Another type of graft used in revision rhi-noplasty and obtained primarily from the septumis the lateral crural strut graft [33], consisting ofa strip of cartilage about 3 to 4 mm in width and15 to 25 mm in length. This graft is secured to thedeep surface of the lateral crura with two or three su-tures of 5.0 Vicryl. This procedure can be used insecondary rhinoplasty to correct alar rim retractionand alar rim collapse owing to excessive resection ofthe lateral crura. The cartilage of the septum is theonly one that can be used in crushed form as a fillinggraft in the closing phases of revision to finish offand optimize the contours of the nasal pyramid.

Discussion

A septal anomaly is frequently found subsequent toseptorhinoplasty and can stem from a pathology al-ready present before the operation or an iatrogenicpathology. The abnormalities of the nasal septumpresented by patients often differ greatly, and it isdifficult to find any features common to them all.In their pathogenesis, there is always the commonfact of failure in the initial operation to find theright proportion between how much should be re-moved and how much should be left of this

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Fig. 9. (continued).

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Fig 9. (continued). Base view prior to (H) and post (I) revision surgery.

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Fig. 10. Case 3. Woman aged 31 years subjected to one previous septorhinoplasty presenting with a supratip de-formity caused by an overprojecting caudal dorsum as well as persistent septal deviation and an alar collapse onthe right side. Correction was obtained through resection of residual excessive caudal dorsum and placement ofa septal spreader graft and alar graft on the right side. (A,C,E,G) Preoperative views. (B,D,F,H) Postoperativeviews 1 year after surgery.


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important anatomic structure. Added to this in allcases is the difficulty of re-establishing a balance be-tween the nasal septum and the surrounding struc-tures, whose position is influenced by the septum,which, in turn, is influenced by certain close ana-tomic connections.When the nasal septum is missing, examination

of the latest literature shows that most authors agreeon the need to reconstruct an L-shaped structuresimilar to the original one. Onlay grafts, which dis-guise the esthetic deformity but are functionallyinefficient, are thought to be useless. Despite agree-ment on this common reconstructive aim, opinionsare divided on the type of graft to use, with expertsvariously advocating rib, alloplastic materials, andthe auricular concha [34–37]. Obtaining graftsfrom the rib leaves an unavoidable visible scar,and there is a risk of morbidity of the donor site.Moreover, the graft is not easy to reshape and tendsto warp over time. Alloplastic grafts do not possessthe particular elasticity of the tissues they are to re-place and are subject to infection and extrusion. Ifperformed by means of a retroauricular approach,leaving the root of the helix and the fold of the anti-helix intact, the harvesting of grafts from the auric-ular concha leaves no visible signs. As autologouscartilage, it also provides the best guarantees of re-sistance to infection and a low degree of resorptionas well as being easy to shape. Nevertheless, the au-ricular cartilage presents histologic characteristicsdiffering from those of the structure to be replaced,being elastic and not hyaline, unlike the nasal sep-tum. From a macroscopic viewpoint, the concha iscurved rather then straight like the septum and notsturdy enough to serve as a supporting structure.The technique described for reshaping the conchalgraft by means of incisions, figure-eight sutures,and the use of spreader grafts harvested from theconcha and attached to the concha itself succeedsin rectifying these negative aspects of the auricularcartilage [12]. Although retaining elasticity, theneo-septum obtained from the auricular concha isultimately very similar to the nasal septum to be

reconstructed in terms of toughness and straight-ness. Moreover, the presence of spreader grafts onthe dorsal side of the graft can prove useful in re-constructing the middle nasal vault in patients inwhom the upper lateral cartilages were subjectedto abundant excision during the previous opera-tion. In patients in whom the upper lateral carti-lages are normally present, the spreader graftsshould instead be secured in a lower positionwith respect to the dorsal edge of the neo-septumso as to have no esthetic effect.The use of spreader grafts has constituted a great

step forward in the correction of persistent devia-tions of the nasal septum after septorhinoplasticsurgery; however, in these cases, the therapeuticstrategy requires a gradual and sequential approachin which the use of these grafts may not be needed.Careful analysis of the cause of the septal deviation,its location, and its extent is an indispensableprerequisite for selection of the most suitable proce-dure to solve the problem. In the patient who hasdeflection of the nasal septum in the inner portionof the nasal cavities with no involvement of the pe-ripheral structure and the presence of respiratoryproblems alone, it will be necessary to remove thedeviated part (above all if it is osseous) or to per-form a septoplasty. This situation is not commonin dealing with the results of septorhinoplasty, be-cause it would mean that the functional pathologyhad been completely ignored during the previousoperation. The persistence of deviation owing tothe use of techniques incapable of countering thepostoperative deforming forces responsible for re-lapse is instead more frequently encountered. Asnoted previously, an anatomic memory of the devi-ation tends to make the cartilaginous septum returnto the original incorrect position. In this connec-tion, many techniques using morselizations, inci-sions, and sections fail to ensure satisfactory endresults even though the septal pillar is left intactto perform its function of structural support.Although effective, the treatment adopted is some-times performed incompletely. During performanceof the ‘‘swinging door’’ technique, for example, thesurgeon may make a vertical incision but fail toexcise a strip or to secure adequately the detachedsegment anteriorly to the nasal spine. Conversely,overaggressive resection of the nasal septum oftencauses collapse of the nasal dorsum with the pres-ence of notches and hollows to varying degrees.To prevent such problems, the septoplasty tech-niques regarded to be safest are those making useof staggered incisions, which interrupt the cartilagi-nous spring without destroying the continuitywithin the structure.In all cases of persistence of septal deviation, it is

indispensable during revision to neutralize all of

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Fig. 11. Septal graft of cartilage with ethmoidal boneharvested during revision rhinoplasty.

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the deforming forces that support the cartilaginousmemory [7]. The cartilaginous septum can be de-tached from the extrinsic deforming forces of thesurrounding structures by means of osteotomies,extramucous separation from the upper lateral car-tilages, and the severing of attachments with the vo-mer, maxillary crest, and ethmoid. The septum isthen freed from the effect of the intrinsic deformingforces within the cartilage by means of incisions toopen the cartilaginous spring and straighten theseptum. In most cases of deviation of the dorsalportion of the septum, it is advisable to combinethese procedures with the use of spreader grafts,which ensures a stable result over time, countersthe cartilaginous memory, and reinforces the septalstructure. The placement of a spreader graft on theconcave side of the septal deviation generally pro-vides an excellent solution in all cases of mediumseverity. The crossbar graft technique is most appro-priate in more serious cases of crooked noses,whereas the thickness of a single spreader graftcould prove insufficient to correct the deformity[22]. In surgical revision, this type of graft can beobtained from the septal cartilage, if still present,or the ethmoidal bone.The final effect is to straighten the dorsal septum,

reinforce the L-shaped structure, and counter to thegreatest possible degree the deforming forces extrin-sic and intrinsic to the septum that tend to cause re-lapse over time. The crossbar graft also exerts lateralpressure on the upper lateral cartilage on the con-cave side, restoring a correct angle of the internalnasal valve and harmonizing the esthetic linesfrom eyebrow to tip on both sides.An alternative to the use of one spreader graft

obtained from the septum is two spreader graftsobtained from the auricular concha. Althoughnot as tough as septal cartilage, grafts of auricularcartilage can serve to guide and reinforce the struc-ture when placed on both sides of the dorsal sep-tum. These bilateral spreader grafts are indicatedin revisions involving not only the correction ofseptal deviation but also reconstruction of themiddle nasal vault owing to the presence of an in-verted V deformity.Supratip deformity is another of the most fre-

quent causes prompting revision rhinoplasty. Thisunesthetic convexity, located immediately abovethe nasal tip, was long attributed exclusively tothe presence of an excess of dorsal septum in thatarea. Sheen stated in 1979 that many supratip de-formities were, in fact, not due to this cause but tooverresection of the caudal dorsum [25]. In suchcases, overzealous resection creates a void that stim-ulates the formation of scar tissue to fill it up. An ex-cess of this tissue creates the polly beak deformity.Given that very different forms of treatment are

possible, correct diagnostic analysis is essential inaddressing this problem. Toward this end, studyof the case history can provide useful informationabout previous instances of scar tissue formation,and palpation of the supratip region can ascertainthe consistency of the convexity present. In the pa-tient who has an underresected caudal dorsum, thecorrect treatment cannot be other than appropriateand carefully calibrated excision of the septum inthe region of the supratip. Conversely, in the patientwho has an overresected caudal dorsum and exces-sive scar tissue, the surgical treatment must seek notonly to remove the fibrous excess but also to avoidrecreating the void that actually caused the defor-mity in the first place. If satisfactory results are tobe obtained, crucial steps are the placement of car-tilaginous grafts in the area of the supratip, a com-pressive nasal splint, and careful prolongedpostoperative taping. It has also been suggestedthat a Vicryl suture can be used in this area betweenthe subcutis and the cartilage of the dorsal septumto eliminate the void [24].The creation of an esthetically valid supratip

break is often difficult to achieve owing to the dif-ferent factors involved in its definition. The calcula-tion of a difference in height of 6 to 10mm betweenthe dorsal septum and the domes is a rough guidethat must be adapted in relation to other parame-ters such as the thickness of the skin and projectionof the tip [24,28]. The same holds true for the angleformed between the perpendicular through thedomes and the cephalic border of the lower lateralcartilages, which should ideally range between 45and 30 degrees according to whether the skin isthin or thick [28]. All of these numerical calcula-tions assume that the intraoperative projection ofthe nasal tip will remain the same in the later post-operative result; however, the mechanisms of tipsupport are often affected by the surgical maneuversperformed during revision, such as access incisionssevering the membranous septum or the attach-ments between septum and domes. It is nearly al-ways necessary in these cases to use a columellarstrut to ensure that tip projection is controlledand stable over time. In treatment of the pollybeak deformity, a further and highly variable factorcan sometimes thwart even the efforts of the mostexpert surgeon, namely, postoperative cicatrization.Some patients tend to present with hypertrophiccicatrization even in the absence of any triggeringelement. This tendency, which can sometimes be re-vealed by other hypertrophic or keloid scars, mustbe detected through careful postoperative observa-tion and treated with injections of triamcinolonein the supratip area.Other variables involved in the definition of the

supratip break include the sex and taste of the


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patient, the taste of the surgeon, and current fash-ion. A depression in the area of the supratip maycorrespond to an esthetic ideal of female but notmale beauty, and some patients may prefer an al-most completely straight profile, which also ap-pears to be in line with contemporary fashion.The cartilaginous septum is the central element

involved in planning a revision operation notonly as the location of impairments to be correctedbut also as a possible source of material for recon-structive grafts. When present, the cartilage of thenasal septum has long been recognized as prefera-ble to other types of cartilage and to alloplasticgrafts [38]. It is easy to harvest and carve, structur-ally suitable for supporting functions, thick anduseful for filling depressions, easy to flatten, anddisplays little tendency to warp. Because it is elasticand not hyaline, unlike the septum, the cartilage ofthe auricular concha is less sturdy and less capablefor providing support. Its curved shape makes itgenerally suitable for reconstruction of the nasalwing. Rib cartilage is of the hyaline type, like theseptum, but harvesting leaves a visible scar, andthe donor site presents a certain degree of morbid-ity. It is also more difficult to shape, fragile, and sub-ject to warping over time [39]. Grafts obtained fromthe cartilaginous septum are effective in the recon-struction of all sections of the nasal pyramid andcan be adapted to meet all of the specific require-ments presented by each individual case. Unlikemost alloplastic grafts, these grafts combine tough-ness with sufficient elasticity to allow the ‘‘mobilepart’’ of the nose to preserve its physiologic flexibil-ity. Like the other cartilaginous grafts, they arelargely impervious to infection and resorption, thelatter being in most cases minimal and short-livedwith a tendency to decrease considerably after theinitial postoperative period [40].A common objective exists no matter which re-

constructive technique is employed, namely, therestoration of a straight, sturdy, and elastic L-shapedseptal structure. Correction of the nasal septumconstitutes the first indispensable phase of recon-struction during revision when there are also othernasal structures to be reconstructed. The symmetryand support of the nasal pyramid in all of its com-ponents will depend on the precision with whichthis important internal pillar is restored. Nasal re-spiratory function will also hinge upon this struc-ture being restored as closely as possible to itsphysiologic state.

Summary

The correction of impairments of the nasal septumis a crucial surgical stage in revision rhinoplasty.The pathologic elements observed most frequently

in clinical practice include structural deficits of thecaudal septum, the persistence of septal deviation,and deformity of the supratip area. This article is in-tended as a guide to the gradual analytical correc-tion of the different anomalies of the nasalseptum, with the septum being the primary sourceof material for the most common types of recon-structive grafts.

References

[1] Tardy ME. Rhinoplasty: the art and the science.In: Surgical Anatomy, Vol. I. Napoli: EdiSES Srl;1999. p. 87–99.

[2] Toriumi DM, Ries WR. Innovative surgical man-agement of the crooked nose. Facial Plast ClinN Am 1993;1:63–78.

[3] WustrowTPU, Kastenbauer E. Surgery of the inter-nal nasal valve. Facial Plast Surg 1995;11:213–27.

[4] Teller DC. Anatomy of a rhinoplasty: emphasison the middle third of the nose. Facial PlastSurg 1997;13:241–52.

[5] Sheen JH. Spreader graft: a method of recon-structing the roof of the middle nasal vault fol-lowing rhinoplasty. Plast Reconstr Surg 1984;73:230–7.

[6] Boccieri A, Macro C. The use of spreader grafts inprimary rhinoplasty. Ann Plast Surg 2005;55(2):127–31.

[7] Byrd HS. The crooked nose: an algorithm for re-pair. In: Proceedings of the 17th Annual DallasRhinoplasty Symposium. 2000. p. 239–42.

[8] TardyME. Rhinoplasty: the art and the science. In:Nasal reconstruction with autologous cartilagi-nous grafts. Napoli: EdiSES Srl; 1999. p. 661.

[9] Fry HJ. Nasal skeletal trauma and the interlockedstresses of the nasal septal cartilage. Br J PlastSurg 1967;20:146–58.

[10] Toriumi DM. Subtotal reconstruction of the na-sal septum: a preliminary report. Laryngoscope1994;104:906–13.

[11] Mocella S. Septal perforations’ closure and recon-structive septorhinoplasty with hump and bioim-plant material. Presented at the AnnualConference of the EAFPS. Florence, Italy, Septem-ber 2005.

[12] Boccieri A. Subtotal reconstruction of the nasalseptum using a conchal reshaped graft. Ann PlastSurg 2004;53(2):118–25.

[13] Kridel RWH, Scott BA, Foda HMT. The tongue ingroove technique in septorhinoplasty: a ten yearexperience. Arch Facial Plast Surg 1999;1:246–56.

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[16] Lawson W, Reind AJ. Correcting functional prob-lems. Facial Plast Surg Clin North Am 1994;2:501–20.

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[21] Pontius AT, Leach JL. New techniques for man-agement of the crooked nose. Arch Facial PlastSurg 2004;6(4):263–6.

[22] Boccieri A, Pascali M. Septal crossbar graft for thecorrection of the crooked nose. Plast ReconstrSurg 2003;111:629–38.

[23] Meyer R. Secondary and functional rhinoplasty:the difficult nose. In: Residual deformity of thecartilaginous framework. Orlando (FL): Grune &Stratton; 1998. p. 130–8.

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[25] Sheen JH. A new look at supratip deformity. AnnPlast Surg 1979;3:498–504.

[26] Sheen JH. Achieving more nasal tip projectionby the use of a small autogenous vomer or septalcartilage graft. Plast Reconstr Surg 1975;56:35–40.

[27] Peck GC. The onlay graft for nasal tip projection.Plast Reconstr Surg 1983;71:27–37.

[28] Byrd HS. The supratip break. In: Proceedings ofthe 17th Annual Dallas Rhinoplasty Sympo-sium. 2000. p. 261.

[29] Gunter JP, Rohrich RJ. Augmentation rhino-plasty: dorsal onlay grafting using shaped autog-enous septal cartilage. Plast Reconstr Surg 1990;86:39–45.

[30] Toriumi DM. Management of the middle nasalvault in rhinoplasty. Operative Tech Plast Re-constr Surg 1995;2:16–30.

[31] Foman S, Goldman IB, Neivert H, et al. Manage-ment of deformities of the lower cartilaginousvault. Arch Otolaryngol 1951;54:467–72.

[32] Toriumi DM, Josen J, Weinberger M, et al. Use ofalar batten graft for correction of nasal collapse.Arch Otolaryngol Head Neck Surg 1997;123:802–8.

[33] Gunter JP, Friedman RM. Lateral crural strutgraft: technique and applications in rhinoplasty.Plast Reconstr Surg 1997;99:943–52.

[34] Kridel RWH, Konior RJ. Irradiated cartilage graftsin the nose: a preliminary report. Arch Otolar-yngol Head Neck Surg 1993;119:24–31.

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