In Asian rhinoplasty, nasal tip projection and lengthening are often required because of the low nasal tip position and short nose. These procedures also require a solid septal support. Procedures to increase septal support include septal extension grafting (SEG) and columellar strut grafting [1]. Anterior septal reconstruction (ASR) is also beneficial in patients with caudal septal deviation. It obliterates the severe caudal septal deviation with a horizontal incision preserving the dorsal septal strut and then reconstructs the new L-strut with a caudal strut from a flat portion of the removed nasal septum [2]. It can be extended as one piece after reconstruction with suturing to the dorsal septum. Therefore, it has better stability compared to SEG and columella strut grafting.

The autologous cartilage is the best septal support material. Artificial graft materials, such as high-density porous polyethylene sheets, are used for SEG in Asian rhinoplasty; however, they have higher rates of infection and extrusion [3]. In addition, in many Asians, the nasal septal cartilage is not sufficiently large or robust to be used for SEG. Particularly, when spreader and tip grafts are required, the septal cartilage is unsuitable. ASR has the advantage of saving the cartilage because it can be a single extended piece with a relatively small overlapping area compared to SEG. However, it is also insufficiently combined with other cartilage-consuming procedures, such as spreader, shield, and cap grafting.

Here, we introduce a practical tip-supporting technique using a septal cartilage-bone complex for Asians with a small septal cartilage and severe caudal septal deviation.

With the external rhinoplasty approach, make an inverted V-shaped columellar and marginal incision. Elevate the nasal flap and separate the upper and lower lateral cartilages to expose the nasal septum. Make a horizontal incision on the septal cartilage preserving a 1.0- to 1.5-cm wide dorsal strut using a D-knife or No. #15 blade. Extend the incision on the septal bone downward using Becker septum scissors. This bone cut can cause unwilling cribriform plate damage, and caution should be exercised accordingly. Separate the inferior border of the septal cartilage from the maxillary crest using the Cottle or Freer elevator. Extend this inferior separation line to the inferior septal bone. Preserve the septal cartilage-bone junction to harvest it as a single piece. Carefully make a vertical fracture line on the relatively thin portion of the ethmoid perpendicular plate and vomer using the Joseph periosteal elevator (Fig. 1).

Figure 1. Harvested septal cartilage-bone complex.

Carve the harvested septal cartilage-bone complex using no. #15 blades and scissors to obtain the ASR graft. Design the ASR graft to reconstruct the neo-L strut with a 1.5-cm width. The bony part of the ASR graft goes down, while the cartilage part goes up. Trim the inferior border of the bony ASR graft carefully using scissors to match the maxillary crest. Design the anterosuperior angle of the cartilaginous ASR graft to be extended sufficiently for the nasal tip projection and lengthening (Fig. 2A). When the ASR graft is curved, bat the polycaprolactone sheet to flatten the graft (Fig. 2B).

Figure 2. (A) Fashioned septal cartilage-bone complex. (B) Battened septal cartilage-bone complex with a polycaprolactone sheet.

Use a titanium miniplate to reconstruct the L-strut with the ASR graft. First, attach the miniplate to the premaxilla using two 3-mm screws (Fig. 3A). Next, suture the ASR graft to the miniplate, with the posteroinferior border sutured to the hole made in the maxillary crest to stabilize the ASR graft. Finally, reconstruct the straight, stable, and extended neo-L strut after suturing the overlapped dorsal septal cartilage and ASR graft (Fig. 3B). The rest of the cartilage can be utilized for spreader, shield, or cap grafting or dorsal augmentation. After 6 months, when the postoperative septum is sufficiently stable, remove the titanium miniplate under local anesthesia.

Figure 3. Intraoperative view of anterior septal reconstruction. (A) The miniplate is attached to the premaxilla. (B) The septal cartilage-bone complex has been overlapped and sutured to the dorsal septal cartilage.

The nasal septal cartilage is the best graft material in rhinoplasty. It has the strength for nasal tip support and low risks of resorption and warping. It can be harvested in the same operation field without additional incisions. Its disadvantage is the small size and inadequacy for nasal tip projection and lengthening in Asians. In a Korean nasal septal cartilage anatomical study, the average height and length were 29.9±4.7 and 33.1±5.3 mm, respectively [4]. In a similar study involving Chinese cadavers, the average height and length were 20.41±3.0 and 20.83±4.7 mm, respectively [5]. In a study involving Thai cadavers, the mean height and length were 30.96±5.90 and 26.13±6.90 mm, respectively [6]. The mean height and length of Caucasian septal cartilages were reported to be 33.50 and 37.90 mm, respectively [7]. Therefore, saving and maximally using the nasal septal cartilage is essential in Asian rhinoplasty. The cartilage-bone complex can reduce the use of the septal cartilage as the use of the septal bone increases.

Bone is a good grafting material because of its rigidity and stability. However, it may be resorbed at low-stress sites over time [8]. Therefore, the septal bone is seldom used as a nasal tip graft or dorsal augmentation material. However, it can be used as a buttress graft in ASR. Furthermore, less resorption is expected because it is in contact with the maxilla. Lee et al. [9] used the nasal cartilage-bone complex in SEG and showed that it was useful in lengthening a short nose with sufficient structural support and without recurrence.

Patients with severe nasal septal deviation have a curved septal cartilage. Battening with a rigid material, such as the ethmoid bone or septal cartilage, can help flatten the curved septal cartilage. A polycaprolactone sheet can also be useful as a batten graft, and its utilization can save the septal cartilage and bone. Using the titanium miniplate as a buttress can enhance the ASR graft stability and surgical outcomes [10].

Using the nasal septal cartilage-bone complex for ASR is applicable when nasal tip projection or lengthening is required for patients with a small nasal septal cartilage and severe caudal septal deviation, which are relatively common in Asians requiring rhinoplasty. In addition, this procedure is highly recommended when other cartilage graft procedures are required, such as spreader, shield, and cap grafting.

The authors have nothing to disclose.