Septal Considerations in Revision Rhinoplasty

ARTICLE IN PRESS
1
FACIAL PLASTIC
SURGERY CLINICS
OF NORTH AMERICA
Facial Plast Surg Clin N Am - (2006) -–-
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Septal Considerations in Revision
Rhinoplasty
Armando Boccieri,
-
MD*,
Carlo Macro,
Pathologic anatomy of the nasal septum
Absence of the nasal septum
Persistent septal deviation
Supratip deformity owing to the dorsal
septum
Assessment of the condition of the nasal septum
is an indispensable preliminary stage in the surgical
treatment of revision rhinoplasty. The septal structure performs a key function in supporting the nasal
pyramid, and its straightness constitutes an essential prerequisite for the achievement of satisfactory
esthetic results. Irvin Goldman in the 1960s coined
the renowned dictum, ‘‘As the septum goes, so goes
the nose.’’ This statement still retains validity and
relevance in light of the developments in nasal
surgery over the last few years. Examination of the
outcome of previous rhinoplasties often reveals
overaggressive resection of this anatomic structure
and collapse of the nasal dorsum or, on the contrary, insufficient correction of septal deviation.
The result of such incorrect treatment is a varying
degree of esthetic and functional impairment that
can prove difficult to repair. The most recent reconstructive techniques adopted in surgical revision use
grafts to replace the missing structures, and the nasal septum constitutes a primary source of material
to this end. This function as donor site depends on
the presence of the septum after the initial operation and can be performed also in the patient
who has incomplete correction of the nasal septum.
This article analyzes the following three fundamental aspects of the nasal septum in revision
-
MD
Use of septal cartilage for grafting
Discussion
Summary
References
rhinoplasty: (1) deficit of the septal structure to
varying degrees, (2) persistent deviation of the nasal
septum, and (3) supratip deformity caused by inappropriate resection of the dorsal septum. Attention
is focused separately on the residual nasal septum
as a source of material in revision operations for
grafts to reconstruct impaired anatomic structures.
The article also describes and discusses some recent
reconstructive techniques used to address problems
regarding the nasal septum during revision
rhinoplasty.
Pathologic anatomy of the nasal septum
The complete resolution of functional and esthetic
problems during revision surgery can only be ensured by a thorough understanding of certain elements of anatomy and physiopathology. The
anatomic constituents of the nasal septum are the
nasal spine of the frontal bone, the perpendicular
plate of the ethmoid, a portion of the medial segments of the nasal bones, the vomer and crest of
the sphenoid, the nasal crest of the maxilla, the premaxilla and nasal spine, the quadrangular cartilage,
the upper lateral cartilage, the membranous septum, and the columella [1].
Department of Maxillo-Facial Surgery, S. Camillo Hospital, Circonvallazione Gianicolense, 87-00152, Rome, Italy
* Corresponding author. Viale U. Tupini 133, Rome 00144, Italy.
E-mail address: armando.boccieri@libero.it (A. Boccieri).
1064-7406/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
fsc0256 15 September 2006 8:11 pm
doi:10.1016/j.fsc.2006.06.005
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Boccieri & Macro
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The cartilaginous portion of the nasal septum situated in front of an imaginary line running from
the osteocartilaginous joint of the rhinion to the
anterior nasal spine actually provides nasal support.
Reconstruction of an L-shaped supporting septal
structure, regardless of the procedure used, must ensure complete restoration of this important anterior
anatomic region. The predominantly osseous portion of the nasal septum situated behind the same
imaginary line is far less involved in postsurgical esthetic problems. Nevertheless, marked deviations of
the ethmoid that are not surgically treated can
sometimes prevent the correct positioning of nasal
bones with respect to the septum after osteotomies
and can cause functional respiratory disorders. In
such cases, revision will obviously involve the submucous resection of the deviated area with no need
for structural repair.
The anterior portion of the cartilaginous septum
performs its supporting function on the middle nasal vault in conjunction with the upper lateral cartilages and on the nasal tip through the attachments
of the medial crural footplates to the caudal border
of the quadrangular cartilage and the domes. Absence or severe deviation of the caudal septum
can cause loss of projection and ptosis of the tip
as 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 between
10 and 15 degrees, is impaired by the absence and
by the severe deviation of the septum. In the first
case, the structure collapses with extreme widening
of the angle, giving the anatomopathologic appearance referred to as ‘‘ballooning.’’ In the second case,
there is a narrowing of the angle on the concave side
of the deviation with stenosis of the internal nasal
valve [3]. In both situations, the valvular impairments cause considerable difficulty in nasal
respiration.
With respect to the relations between the cartilaginous septum and the upper lateral cartilages, the
two structures are practically continuous, and recent anatomic studies have shown that the nasal
septum has a wide Y-shape in its dorsal most portion [4]. In a physiologic condition, this widening
of the dorsal septum functions with the two upper
lateral cartilages as two spreader grafts [5] and ensures normal respiratory flow at the level of the internal nasal valve [6].
Various factors are involved in the etiopathogenesis of persistent deviations of the nasal septum.
Apart from cases of inadequate surgical treatment,
failure is often caused by the presence of deforming
forces extrinsic and intrinsic to the cartilaginous
septum that tend over time to cause the recurrence
of deviation [7]. The intrinsic forces are those
inherent in the structure of the cartilaginous septum that retain the ‘‘memory’’ of their deviation
and tend to return to the incorrect original position
even after reshaping. From an ultrastructural viewpoint, this phenomenon appears to be due to interlocked stresses inside the cartilage, which are
governed, in turn, by the protein-polysaccharide
complexes associated with the collagenic fibers
[8,9]. The extrinsic deforming forces are exerted
on the cartilaginous septum by the surrounding
structures connected to it, such as the nasal bones,
upper lateral cartilages, vomer, ethmoid, and maxillary crest. If still deviated and not perfectly separated from the nasal septum during the operation,
these anatomic structures can cause the deviation
of the cartilaginous septum to reappear over time.
The deforming forces external to the cartilaginous
septum also include the postoperative contraction
of cicatricial fibrosis, which can lead to relapse
and distortion.
Absence of the nasal septum
Unfortunately, the idea that an L-shaped structure
at least 1.5 cm in width must always be preserved
at the end of every septorhinoplasty operation is
still not known to and accepted by all surgeons.
The function of this pillar is to support the nasal
pyramid and maintain a physiologic relationship
between the nasal septum and the upper lateral cartilages at the level of the internal nasal valve. Even
in cases in which the residual L-shaped structure
is deviated, it must not be removed but rather reshaped or replaced with no alteration of functions.
It is probably the difficulty encountered in correcting deviations in this site that prompts some surgeons to undertake its erroneous partial or total
removal. In these circumstances, the mucoperichondrial covering can remain intact even though
it no longer contains the cartilaginous structure
normally present. This point is important for surgical purposes as a criterion to differentiate the type
of treatment to be employed. When the mucoperichondrium is also lacking and there is perforation
of the nasal septum, it is necessary to employ different surgical techniques serving also to reconstruct
the covering.
In reconstruction of the cartilaginous septum, the
authors stress the need for preliminary assessment
of the impairment to the structure as a prerequisite
in deciding which technique to use. When the deficit is confined to the caudal most portion of the nasal septum, it is possible to consider first the
technique of caudal septal extension grafting [10],
which consists of excising a straight inferoposterior
portion of the cartilaginous septum (if present) and
using it to replace the anterior pillar of the L-shaped
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ARTICLE IN PRESS
Septal Considerations in Revision Rhinoplasty
structure (Fig. 1). This graft is posteriorly sutured to
the caudal border of the surviving nasal septum
with two 4.0 polydioxanone (PDS) mattress sutures
and secured anteriorly between the medial crura
with two buried 5.0 Prolene sutures and a single
temporary 4.0 Monocryl mattress suture. When
a sufficiently large cartilaginous structure is not
available posteriorly, any cartilaginous hump present can be excised and reshaped to reconstruct the
absent caudal septum [11]. The hump must obviously be pared down and flattened to obtain a suitable structure for the type of graft required. When
neither of these sources for reconstruction of the
nasal septum is available and the structural deficit
of the septum is subtotal, the auricular concha
can be used for the graft [12]. It is essential when
harvesting conchal material to preserve the helix
root and the antihelix fold so as to leave no trace
in the auricular pavilion. If the approach is performed from the posterior surface of the ear, it is advisable to insert four or five needles in the anterior
surface of the ear so that the incisions can be made
posteriorly without damaging these important anatomic folds (Fig. 2A,B). The concha can be reshaped and can provide a straight sturdy structure
similar to that of the nasal septum to be replaced.
To straighten the concha, it is first necessary to perform a series of incisions in the concave side followed by two figure-eight sutures of 5.0 nylon. To
reinforce the structure, two spreader grafts taken
from the outer and inferior border of the concha
are then sutured with 5.0 nylon to the two sides
of the concha with their concave sides to the inside
(Fig. 3). The region of the concha where the two
spreader grafts are attached will correspond to the
dorsal pillar of the ‘‘neo-septum.’’ When the concha
is particularly curved, it is sometimes possible to
use a third graft taken from the central region of
the concha and secured to what will then be the
caudal pillar of the neo-septum. The end result is
a straight, sturdy, L-shaped supporting structure,
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Fig. 1. Caudal extension graft technique. A segment
of straight septal cartilage is harvested from the posteroinferior septum and then sutured to the existing
caudal septum.
which will be inserted between the two flaps of
the mucoperichondrium where the septal structure
is missing.
Regardless of the type of graft selected, it is essential to separate the two mucoperichondrial flaps
precisely so as to create a pocket (Fig. 4A). It is
also vital in such cases to use an open approach,
and the authors systematically employ a transcrural
and transdomal path of access. The detachment
must be precise and avoid any laceration of the mucous membrane. Of crucial importance in this
phase are abundant infiltration with vasoconstrictor, strong outward traction of the two flaps, and
the use of a sharpened scalpel from front to back
and from top to bottom. Insertion of the surgeon’s
index finger into the right nasal cavity and frequent
interior checking of the nasal cavities can prove useful to proceed confidently during the detachment
and to ensure immediate awareness of any laceration of the mucous membrane. After insertion between the two flaps of mucous membrane, the
graft must be secured with permanent sutures to
the posterior septal residues (if present), the upper
lateral cartilages, and the medial crura by means of
a tongue-in-groove technique (Fig. 4B) [13]. This
technique makes it possible to obtain a correct nasolabial angle and adequate tip projection (Fig. 5).
Persistent septal deviation
In the results of septorhinoplasty, a basic distinction should be drawn between deviations of the nasal septum that affect the dorsal or caudal pillar of
the structure and those affecting the internal basal
and medioseptal region. An evident esthetic defect
arises in the first two cases, whereas the third involves only a functional respiratory defect of varying severity. The presence of these problems stems
essentially from two causes: (1) incomplete treatment on the part of the surgeon or (2) the use of inappropriate surgical techniques to neutralize the
tendency of the cartilaginous deviation to return
to its original incorrect position over time. Hump
excision can sometimes accentuate deviation of
the nasal dorsum because the nasal septum, previously concealed beneath the hump, is clearly exposed and can present a more marked deviation
than the removed upper portion.
The correction of septal deviation constitutes the
first stage during revision because other associated
corrections could be affected by the persistence of
the defect if performed first. For example, correction
of the nasal tip or a graft on the dorsum could, if
performed in an earlier phase, leave major asymmetries 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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Boccieri & Macro
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Fig. 2. (A) Cartilage incision along the outline marked by needles. (B) Resection of the cartilage graft leaving the
helix root and the antihelix fold intact.
the preferred treatment involves vertical shaves and
staggered incisions or the resection of particularly
crooked portions [14–16]. Septal or maxillary spurs
on the floor of the nasal cavities require submucous
excision above all when they are in the vicinity of
the internal nasal valve, in which position they
are functionally significant. There is no good reason
to insist on the removal of very posterior spurs,
given their negligible functional effect on respiratory airflow. Posterior deviations of the perpendicular plate of the ethmoid can be repositioned easily
on the median line by means of fracture with
a Goldman displacer. The anterior nasal spine, if
left crooked in the previous operation, can also be
fractured and secured to the periosteum in the middle with slow absorption sutures.
In the patient who has deviation of the caudal
septum with projection of the septal border into
Fig. 3. (Above left) Incision of curved conchal cartilage. (Above right) Figure-eight suture. (Below left)
Harvesting of spreader grafts. (Below right) Placement of spreader grafts. (From Boccieri A. Subtotal
reconstruction of the nasal septum using a conchal
reshaped graft. Ann Plast Surg 2004;119; with
permission).
one of the nasal cavities, excellent results can be obtained through use of the ‘‘swinging door’’ technique [17]. This technique involves excision of
a thin vertical strip of cartilage at the point of greatest angle of the nasal septum, inferior detachment
from the maxillary crest, and rotation toward the
center of the freed caudal septum like a door swinging on its hinges. The base of the caudal septum is
then secured with slow absorption stitches to the
columella and the anterior nasal spine to ensure
that the correct position is maintained over time.
Although a closed approach with hemitransfixion incision can prove sufficient for all of the techniques outlined previously, an open approach is
indicated if the persistence of the deviation affects
the dorsal portion of the nasal septum. This approach is justified by the need for a more complete
and three-dimensional view of the deviation and by
the greater ease of suturing grafts in the more posterior regions, which are otherwise inaccessible [18].
The technique used in revision rhinoplasty to
correct deviation of the dorsal septum must be chosen in relation to the severity of the defect and the
type of graft available. For slight C-shaped deformities of the middle third, it is possible to opt for
selective tangential shaving of the convex side of
the dorsal border of the septum with the insertion
of a unilateral planoconvex spreader graft between
the concave side of the dorsal septum and the upper
lateral cartilage [2]. The use of one or two spreader
grafts is indicated for moderately severe residual deformities of the dorsal septum [19–21]. In patients
in whom the cartilaginous septum is still present after the previous operation, a unilateral spreader
graft harvested from the septum and sutured to the
concave side of the deviation can prove sufficient
(Fig. 6A,B). Before the graft is secured, several vertical incisions are generally made on the concave side
to open the cartilaginous spring. When the residual
cartilaginous septum is not sufficient to provide material, two spreader grafts can be harvested from the
auricular concha and secured to either side of the
septum with their concave sides on the inside.
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ARTICLE IN PRESS
Septal Considerations in Revision Rhinoplasty
Fig. 4. (A) Separation of the
two mucoperichondrial flaps.
A suitable pocket has
been obtained for the graft.
(B) Suturing of the conchal
graft in place of the missing
septum.
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The crossbar graft technique is indicated for severe persistent deviations of the dorsal septum
[22]. This technique combines septoplasty by
means of staggered incisions with the insertion of
a spreader graft in the dorsal septum. The graft
must be positioned on the concave side of the deviation or, in the patient who has linear deviation of
the dorsal septum, on the side where there is a gap
between the septum and the upper lateral cartilages.
The incisions are made on the dorsal and caudal
pillars of the L-shaped structure, normally, three
on each side, two on the outside, and one on the inside in the areas of greatest deviation. At the end,
the crossbar graft is embedded between the two incisions in the dorsal and caudal pillars and sutured
front and back with two mattress stitches of 5.0
Vicryl (Fig. 7). In revision cases, the crossbar can
also be harvested from the cartilaginous nasal septum, if this was not radically excised during the
previous operation, provided that the L-shaped
structure is left intact. If harvesting the crossbar
from the cartilaginous septum would impair the integrity of the L-shaped structure, a strip of the perpendicular plate of the ethmoid can be used for
the same end (Fig. 8).
In patients in whom the deviation of the dorsal
septum is accompanied by an inverted V deformity
of the nasal pyramid owing to excessive excision of
the upper lateral cartilages, it is advisable to use two
spreader grafts taken from the auricular concha,
which are effective in the correction of both deformations. The two spreader grafts are secured to
the dorsal septum with their natural concavity
turned to the inside, and their thickness is adjusted
to the concavity and convexity of the dorsal septum
to make it straight (Fig. 9).
Supratip deformity owing to the dorsal
septum
Supratip deformity is frequently involved in revision rhinoplasty. It takes the form of convexity in
the region of Converse’s weak triangle, which
causes the lower third of the nose to assume the particular ‘‘polly beak’’ shape. This sequela can arise after rhinoplasties performed by inexperienced
surgeons and unexpectedly after rhinoplasties performed by expert surgeons, in which case imponderables connected with the characteristics of the
patient and aspects of scar-tissue formation are
probably involved [23]. Insufficient removal of
the dorsal cartilaginous septum and overresection
of the nasal dorsum with the formation of scar tissue are securely identified as two etiopathogenetic
causes connected with the nasal septum in the genesis of polly beak deformity [24]. In the second
case, the deformity is caused by an excess of scar tissue produced to eliminate the void left in the supratip region by overzealous resection of the caudal
nasal dorsum [25]. In addition to these causes,
two other elements are often present that work to
accentuate the deformity, namely, underprojection
of the tip and insufficient resection of the cephalic
portion of the lower lateral cartilages.
Simple palpation of the supratip can reveal the
consistency of the region and supply diagnostic indications of the type of polly beak deformity presented by the patient before surgery. When the
cause is an overprojected caudal dorsum, the deformity can easily be corrected by removal of the surplus cartilage (Fig. 10). If the supratip fullness is
instead caused by swelling and scar tissue and is diagnosed within 3 months after the operation, the
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Fig. 5. Case 1. Man aged 19 years subjected to two previous septoplasties. Loss of the supporting septal structure
caused droopiness of the nasal tip, an acute nasolabial angle, and respiratory difficulty. Subtotal reconstruction
of the nasal septum was performed using a reshaped conchal graft. (A) Finger pressure revealing the absence of
the cartilaginous septum. (B,D,F,H) Preoperative views. (C,E,G,I) Postoperative views 1 year after surgery.
fsc0256 15 September 2006 8:11 pm
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Septal Considerations in Revision Rhinoplasty
Fig. 5. (continued).
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Fig 5, continued. Basal view
prior to (H) and post (I)
revision surgery.
area can be subjected to injection with triamcinolone and compression taping [24]. The triamcinolone injection must be performed carefully to the
correct subdermal depth, avoiding injection into
the dermis, and can be repeated up to three times
at intervals of 3 to 4 weeks. If pharmacologic treatment fails to provide the desired results, revision
surgery must be performed after an interval of at
least 1 year. This period of time is necessary to ensure that the cicatricial contraction is completely
finished and the condition to be corrected is definitive. The surgical treatment in such cases involves
complete removal of scar tissue from the area of
the supratip and exposure of the dorsal cartilaginous septum beneath. The height of the latter is often insufficient, and a graft of septal or auricular
cartilage can be used to fill the void in the area of
the supratip.
Regardless of whether the deformity of the dorsal
septum is due to the excess or absence of material, it
is important to ascertain whether there is any accompanying decrease in tip projection, in which
case cartilaginous grafts of the shield [26] or Peck
type [27] are indicated. In such cases, reshaping of
the tip must precede reshaping of the dorsum because the latter depends on the projection of the
tip. It is important to create a break point at the
level of the supratip at the end of the revision.
A slight unevenness between the domes and the
plane of the dorsal septum ensures a more than satisfactory esthetic result. It is advisable to leave a gap
between the two cartilaginous structures of approximately 6 to 7 mm, or even as much as 10 mm in the
patient who has particularly thick skin [24,28].
Careful postoperative observation of the patient,
prolonged taping of the supratip, and injection
with triamcinolone if required are part of the correct treatment to avoid this deformity in surgical
revision.
Use of septal cartilage for grafting
When present, the nasal septum constitutes the primary source of material for structural grafts in revision rhinoplasties. The quality of the cartilage is
optimal for durability and definition beneath the
layer 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 on
the concave side.
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Fig. 8. Septal crossbar graft harvested from ethmoidal
bone is sutured on the concave side of the septal
deviation.
Fig. 7. (Above left) Preoperative curvature of the septum. (Above right) Pattern of staggered incisions.
(Below left) Septal crossbar graft fitted between
two septal vertical intracartilaginous incisions (closed
approach). (Below right) Additional posterior suture
(open approach). (From Boccieri A, Pascali M. Septal
crossbar graft for the correction of the crooked
nose. Plast Reconstr Surg 2003;111:631; with
permission).
Harvesting can be performed by means of a hemitransfixion incision or through a transcrural open
approach if planned for other corrections. After detaching the mucoperichondrium on one side, a vertical cartilaginous incision is performed posterior
and parallel to the caudal border of the septum at
a distance of approximately 1 to 1.5 cm. The incision stops approximately 1 to 1.5 cm from the dorsal edge of the septum. This incision serves to
deglove the contralateral mucoperichondrium as
well as the perpendicular plate of the ethmoid on
both sides. The cartilaginous septum is then detached inferiorly from the maxillary crest, and an
incision is made in it superiorly parallel to the dorsal edge so as to leave the graft connected only posteriorly to the perpendicular plate of the ethmoid.
At this point, it is preferable, if necessary, to fracture
the perpendicular plate of the ethmoid inferiorly
with a Goldman displacer to extract the graft of cartilaginous septum together with a small portion of
ethmoidal bone (Fig. 11). The cartilaginous septum
is harvested together with this portion of ethmoid
because of the difficulty of separating them inside
the nasal cavities without risking a fracture of the
cartilage anterior to their joint, reducing the length
of the graft [29]. The excision should be performed
with as little trauma as possible, because even small
lacerations or fractures of the septum can impair
the shape of the grafts to be obtained and their
strength as structural supports. The newly harvested
piece of cartilage is vaguely rectangular in shape and
can be used to carve all of the grafts required for the
revision. If only one or two grafts are required, the
excision can be confined to a limited portion of
the cartilaginous septum to avoid uselessly weakening the structural support of the nasal pyramid. In
the patient who has undergone previous submucous resection of the septum, the excision will necessarily be limited to a small quantity of cartilage
to avoid any damage to the residual supporting
L-shaped structure. Numerous types of grafts can
be obtained from the nasal septum for surgical revision, including grafts serving to reconstruct all three
thirds of the nasal pyramid.
Correction of a saddle nose deformity is frequently needed in connection with the upper and
middle thirds of the nose. In these patients, the graft
must be cut in an oval shape and carefully tapered
to the sides with the edges beveled so as to avoid
any perception of ‘‘steps’’ beneath the skin. A useful
procedure for curving the graft is to perform an incision part of the way through the thickness along
the midline together with another two lateral and
parallel incisions, if necessary. By exerting pressure
with the fingers along the lines of incision, it is possible to cause a greenstick fracture and to obtain an
inverted V-frame graft or U-frame graft adapting
well to the nasal dorsum [29].
A narrow middle third of the nose with collapse
of the middle nasal vault and an inverted V deformity can be the result of particularly aggressive
and excessively reductive rhinoplasty. Revision rhinoplasty requires the use of spreader grafts in
such cases [5]. These rectangular grafts are inserted
and secured between the dorsal septum and the upper lateral cartilages and are useful in functional
and esthetic terms, first, by restoring a physiologic
angle of 10 to 15 degrees at the level of the internal
nasal valve and, second, by bringing the middle
third of the nose into the right balance with the
upper and lower thirds. Spreader grafts can be
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Septal Considerations in Revision Rhinoplasty
Fig. 9. Case 2. Patient aged 28 years subjected to three previous septorhinoplasties. The patient presented with
persistent deviation of the dorsal septum with an inverted V deformity, nasal obstruction, a malpositioned septal graft on the nasal dorsum, and an overprojected tip. Revision rhinoplasty was performed using two conchal
spreader grafts, removal of the previous graft, and dome truncation. (A) Collapse of the middle nasal vault is
evident during forced inspiration. (B,D,F,H) Preoperative views. (C,E,G,I) Postoperative views 1 year after surgery.
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Fig. 9. (continued).
Fig 9. (continued). Base view prior
to (H) and post (I) revision surgery.
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harvested from the middle portion of the cartilaginous septum and from the posteroinferior region
and are generally cut and pared down to about 1
to 4 mm in thickness, 3 to 6 mm in height, and 8
to 25 mm in length [30].
The problem most often encountered in the
lower third of the nose after septorhinoplasty is
an underprojected ptotic nasal tip. Such anomalies
can present immediately after the operation or years
later owing to the force of gravity and the cicatricial
contraction of the cutaneous covering. A columellar
strut, shield graft, or onlay tip graft are the procedures indicated for correction. These grafts can be
obtained from any part of the septum but preferably are harvested from the cartilaginous portion adjacent to the ethmoidal bone where the septum is
thicker and tougher and better suited to the required function of structural support. The columellar strut is rectangular in shape and is inserted and
sutured in place between the two medial crura from
the nasal spine to the domes [31]. This graft proves
particularly useful to improve the projection and
support of the nasal tip and to straighten and reinforce the columella. A further increase in the projection and definition of the nasal tip can be obtained
by means of a shield graft. This versatile graft is
roughly trapezoidal in shape and is sutured with
6.0 nylon to the front of the medial crura in their
upper portion to protrude approximately 1 to
2 mm over the domes. The shield graft also gives
symmetry to the tip, masks irregularities of the
domes, and determines the supratip break. Another
graft serving to increase projection is the tip onlay
graft described by Peck, which can also be positioned in layers on the domes by means of the umbrella technique.
Alar batten grafts are also obtained from the nasal
septum and are frequently used in revision
rhinoplasties [32]. These rectangular curvilinear
grafts measure about 10 to 15 mm in length and
4 to 8 mm in width. They are used in cases of excessive resection of the lateral or upper lateral cartilages with weakening and retraction of the lateral
nasal wall, situations that often cause respiratory
problems with collapse of the nasal valve during inspiration. Alar batten grafts are lodged in a precisely
formed pocket extending from the lateral third of
the lateral crura to the piriform aperture. The convex side of the graft is placed on the outside so as
to lateralize the collapsed portion of the lateral nasal wall. Another type of graft used in revision rhinoplasty and obtained primarily from the septum
is the lateral crural strut graft [33], consisting of
a strip of cartilage about 3 to 4 mm in width and
15 to 25 mm in length. This graft is secured to the
deep surface of the lateral crura with two or three sutures of 5.0 Vicryl. This procedure can be used in
secondary rhinoplasty to correct alar rim retraction
and alar rim collapse owing to excessive resection of
the lateral crura. The cartilage of the septum is the
only one that can be used in crushed form as a filling
graft in the closing phases of revision to finish off
and optimize the contours of the nasal pyramid.
Discussion
A septal anomaly is frequently found subsequent to
septorhinoplasty and can stem from a pathology already present before the operation or an iatrogenic
pathology. The abnormalities of the nasal septum
presented by patients often differ greatly, and it is
difficult to find any features common to them all.
In their pathogenesis, there is always the common
fact of failure in the initial operation to find the
right proportion between how much should be removed and how much should be left of this
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Septal Considerations in Revision Rhinoplasty
Fig. 10. Case 3. Woman aged 31 years subjected to one previous septorhinoplasty presenting with a supratip deformity caused by an overprojecting caudal dorsum as well as persistent septal deviation and an alar collapse on
the right side. Correction was obtained through resection of residual excessive caudal dorsum and placement of
a septal spreader graft and alar graft on the right side. (A,C,E,G) Preoperative views. (B,D,F,H) Postoperative
views 1 year after surgery.
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Fig. 11. Septal graft of cartilage with ethmoidal bone
harvested during revision rhinoplasty.
important anatomic structure. Added to this in all
cases is the difficulty of re-establishing a balance between the nasal septum and the surrounding structures, whose position is influenced by the septum,
which, in turn, is influenced by certain close anatomic connections.
When the nasal septum is missing, examination
of the latest literature shows that most authors agree
on the need to reconstruct an L-shaped structure
similar to the original one. Onlay grafts, which disguise the esthetic deformity but are functionally
inefficient, are thought to be useless. Despite agreement on this common reconstructive aim, opinions
are divided on the type of graft to use, with experts
variously advocating rib, alloplastic materials, and
the auricular concha [34–37]. Obtaining grafts
from 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 tends
to warp over time. Alloplastic grafts do not possess
the particular elasticity of the tissues they are to replace and are subject to infection and extrusion. If
performed by means of a retroauricular approach,
leaving the root of the helix and the fold of the antihelix intact, the harvesting of grafts from the auricular concha leaves no visible signs. As autologous
cartilage, it also provides the best guarantees of resistance to infection and a low degree of resorption
as well as being easy to shape. Nevertheless, the auricular cartilage presents histologic characteristics
differing from those of the structure to be replaced,
being elastic and not hyaline, unlike the nasal septum. From a macroscopic viewpoint, the concha is
curved rather then straight like the septum and not
sturdy enough to serve as a supporting structure.
The technique described for reshaping the conchal
graft by means of incisions, figure-eight sutures,
and the use of spreader grafts harvested from the
concha and attached to the concha itself succeeds
in rectifying these negative aspects of the auricular
cartilage [12]. Although retaining elasticity, the
neo-septum obtained from the auricular concha is
ultimately very similar to the nasal septum to be
reconstructed in terms of toughness and straightness. Moreover, the presence of spreader grafts on
the dorsal side of the graft can prove useful in reconstructing the middle nasal vault in patients in
whom the upper lateral cartilages were subjected
to abundant excision during the previous operation. In patients in whom the upper lateral cartilages are normally present, the spreader grafts
should instead be secured in a lower position
with respect to the dorsal edge of the neo-septum
so as to have no esthetic effect.
The use of spreader grafts has constituted a great
step forward in the correction of persistent deviations of the nasal septum after septorhinoplastic
surgery; however, in these cases, the therapeutic
strategy requires a gradual and sequential approach
in 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 indispensable
prerequisite for selection of the most suitable procedure to solve the problem. In the patient who has
deflection of the nasal septum in the inner portion
of the nasal cavities with no involvement of the peripheral structure and the presence of respiratory
problems alone, it will be necessary to remove the
deviated part (above all if it is osseous) or to perform a septoplasty. This situation is not common
in dealing with the results of septorhinoplasty, because it would mean that the functional pathology
had been completely ignored during the previous
operation. The persistence of deviation owing to
the use of techniques incapable of countering the
postoperative deforming forces responsible for relapse is instead more frequently encountered. As
noted previously, an anatomic memory of the deviation tends to make the cartilaginous septum return
to the original incorrect position. In this connection, many techniques using morselizations, incisions, and sections fail to ensure satisfactory end
results even though the septal pillar is left intact
to perform its function of structural support.
Although effective, the treatment adopted is sometimes performed incompletely. During performance
of the ‘‘swinging door’’ technique, for example, the
surgeon may make a vertical incision but fail to
excise a strip or to secure adequately the detached
segment anteriorly to the nasal spine. Conversely,
overaggressive resection of the nasal septum often
causes collapse of the nasal dorsum with the presence of notches and hollows to varying degrees.
To prevent such problems, the septoplasty techniques regarded to be safest are those making use
of staggered incisions, which interrupt the cartilaginous spring without destroying the continuity
within the structure.
In all cases of persistence of septal deviation, it is
indispensable during revision to neutralize all of
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Septal Considerations in Revision Rhinoplasty
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the deforming forces that support the cartilaginous
memory [7]. The cartilaginous septum can be detached from the extrinsic deforming forces of the
surrounding structures by means of osteotomies,
extramucous separation from the upper lateral cartilages, and the severing of attachments with the vomer, maxillary crest, and ethmoid. The septum is
then freed from the effect of the intrinsic deforming
forces within the cartilage by means of incisions to
open the cartilaginous spring and straighten the
septum. In most cases of deviation of the dorsal
portion of the septum, it is advisable to combine
these procedures with the use of spreader grafts,
which ensures a stable result over time, counters
the cartilaginous memory, and reinforces the septal
structure. The placement of a spreader graft on the
concave side of the septal deviation generally provides an excellent solution in all cases of medium
severity. The crossbar graft technique is most appropriate in more serious cases of crooked noses,
whereas the thickness of a single spreader graft
could prove insufficient to correct the deformity
[22]. In surgical revision, this type of graft can be
obtained 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 the
greatest possible degree the deforming forces extrinsic and intrinsic to the septum that tend to cause relapse over time. The crossbar graft also exerts lateral
pressure on the upper lateral cartilage on the concave side, restoring a correct angle of the internal
nasal valve and harmonizing the esthetic lines
from eyebrow to tip on both sides.
An alternative to the use of one spreader graft
obtained from the septum is two spreader grafts
obtained from the auricular concha. Although
not as tough as septal cartilage, grafts of auricular
cartilage can serve to guide and reinforce the structure when placed on both sides of the dorsal septum. These bilateral spreader grafts are indicated
in revisions involving not only the correction of
septal deviation but also reconstruction of the
middle nasal vault owing to the presence of an inverted V deformity.
Supratip deformity is another of the most frequent causes prompting revision rhinoplasty. This
unesthetic convexity, located immediately above
the nasal tip, was long attributed exclusively to
the presence of an excess of dorsal septum in that
area. Sheen stated in 1979 that many supratip deformities were, in fact, not due to this cause but to
overresection of the caudal dorsum [25]. In such
cases, overzealous resection creates a void that stimulates the formation of scar tissue to fill it up. An excess of this tissue creates the polly beak deformity.
Given that very different forms of treatment are
possible, correct diagnostic analysis is essential in
addressing this problem. Toward this end, study
of the case history can provide useful information
about previous instances of scar tissue formation,
and palpation of the supratip region can ascertain
the consistency of the convexity present. In the patient who has an underresected caudal dorsum, the
correct treatment cannot be other than appropriate
and carefully calibrated excision of the septum in
the region of the supratip. Conversely, in the patient
who has an overresected caudal dorsum and excessive scar tissue, the surgical treatment must seek not
only to remove the fibrous excess but also to avoid
recreating the void that actually caused the deformity in the first place. If satisfactory results are to
be obtained, crucial steps are the placement of cartilaginous grafts in the area of the supratip, a compressive nasal splint, and careful prolonged
postoperative taping. It has also been suggested
that a Vicryl suture can be used in this area between
the subcutis and the cartilage of the dorsal septum
to eliminate the void [24].
The creation of an esthetically valid supratip
break is often difficult to achieve owing to the different factors involved in its definition. The calculation of a difference in height of 6 to 10 mm between
the dorsal septum and the domes is a rough guide
that must be adapted in relation to other parameters such as the thickness of the skin and projection
of the tip [24,28]. The same holds true for the angle
formed between the perpendicular through the
domes and the cephalic border of the lower lateral
cartilages, which should ideally range between 45
and 30 degrees according to whether the skin is
thin or thick [28]. All of these numerical calculations assume that the intraoperative projection of
the nasal tip will remain the same in the later postoperative result; however, the mechanisms of tip
support are often affected by the surgical maneuvers
performed during revision, such as access incisions
severing the membranous septum or the attachments between septum and domes. It is nearly always necessary in these cases to use a columellar
strut to ensure that tip projection is controlled
and stable over time. In treatment of the polly
beak deformity, a further and highly variable factor
can sometimes thwart even the efforts of the most
expert surgeon, namely, postoperative cicatrization.
Some patients tend to present with hypertrophic
cicatrization even in the absence of any triggering
element. This tendency, which can sometimes be revealed by other hypertrophic or keloid scars, must
be detected through careful postoperative observation and treated with injections of triamcinolone
in 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 fashion. A depression in the area of the supratip may
correspond to an esthetic ideal of female but not
male beauty, and some patients may prefer an almost completely straight profile, which also appears to be in line with contemporary fashion.
The cartilaginous septum is the central element
involved in planning a revision operation not
only as the location of impairments to be corrected
but also as a possible source of material for reconstructive grafts. When present, the cartilage of the
nasal septum has long been recognized as preferable to other types of cartilage and to alloplastic
grafts [38]. It is easy to harvest and carve, structurally suitable for supporting functions, thick and
useful for filling depressions, easy to flatten, and
displays little tendency to warp. Because it is elastic
and not hyaline, unlike the septum, the cartilage of
the auricular concha is less sturdy and less capable
for providing support. Its curved shape makes it
generally suitable for reconstruction of the nasal
wing. Rib cartilage is of the hyaline type, like the
septum, but harvesting leaves a visible scar, and
the donor site presents a certain degree of morbidity. It is also more difficult to shape, fragile, and subject to warping over time [39]. Grafts obtained from
the cartilaginous septum are effective in the reconstruction of all sections of the nasal pyramid and
can be adapted to meet all of the specific requirements presented by each individual case. Unlike
most alloplastic grafts, these grafts combine toughness with sufficient elasticity to allow the ‘‘mobile
part’’ of the nose to preserve its physiologic flexibility. Like the other cartilaginous grafts, they are
largely impervious to infection and resorption, the
latter being in most cases minimal and short-lived
with a tendency to decrease considerably after the
initial postoperative period [40].
A common objective exists no matter which reconstructive technique is employed, namely, the
restoration of a straight, sturdy, and elastic L-shaped
septal structure. Correction of the nasal septum
constitutes the first indispensable phase of reconstruction during revision when there are also other
nasal structures to be reconstructed. The symmetry
and support of the nasal pyramid in all of its components will depend on the precision with which
this important internal pillar is restored. Nasal respiratory function will also hinge upon this structure being restored as closely as possible to its
physiologic state.
Summary
The correction of impairments of the nasal septum
is a crucial surgical stage in revision rhinoplasty.
The pathologic elements observed most frequently
in clinical practice include structural deficits of the
caudal septum, the persistence of septal deviation,
and deformity of the supratip area. This article is intended as a guide to the gradual analytical correction of the different anomalies of the nasal
septum, with the septum being the primary source
of material for the most common types of reconstructive grafts.
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