The projection of the tip of the nose is an important element in rhinoplasty. This becomes of almost primary importance in noses that have inadequate tip projection due to congenital development such as in Asian and African-American noses. Numerous techniques have been used to increase tip projection based on the nasal tripod concept with the central septal support as its foundation. This has led to numerous concepts to create increased tip projections from which the most effective approach is to use it as a support platform to push out the tip from behind it. It is believed that due to the inherent strength of the caudal septum, maintaining as much of its structure as possible is important.
In the January 2018 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Septum-Based Nasal Tip Plasty: A Comparative Study between Septal Extension Graft and Double-Layered Conchal Cartilage Extension Graft’ In this paper the authors compared two methods of increasing tip projection through extension grafting, a septal extension graft (10mm long grafts) or double-layered ear cartilage interposition grafts, in the amounts of tip projection obtained and its ability to control its rotation. Twenty-seven (27) patients (14 with septal extensions grafts and 13 with ear cartilage grafts) over a two year period were studied. Nasal tip projection and nasolabial angles were measured before, 2 weeks after surgery as well as 7 months after surgery.
Nasal tip projection increased 60% in septal extension grafts and 75% by ear cartilage extension grafting. Longer term followup showed that relapse rates were nearly 40% and 25% respectively. The nasolabial angles increased after surgery by about 3 degrees for both groups which was maintained over time. Over 10% of the total patients required revision surgery for aesthetic reasons. Almost 15% of the total patients developed an infection.
This paper documents that septal extension grafts are effective at increasing and maintaining tip projection. Whether it is harvested from the septum or the ear, both types of extension grafts offered similar structural enhancement, stability and complication rates.
If one wants to maintain complete septal integrity and place a septal extension graft, options also include a rib graft as well as ear cartilage grafts. Ear cartilage grafts in my experience always seem weak and not very stiff. Thus a sliver of rib cartilage is much better. Adding an ear cartilage graft to a PDS plate us another option that could be effective in this rhinoplasty technique.
Dr. Barry Eppley
Indianapolis, Indiana