Aesth. Plast. Surg. 30:135140, 2006 DOI: 10.

1007/s00266-005-0154-5

Original Articles

Caudal Septal Advancement for Nasal Tip Projection and Support in Rhinoplasty

Cenk Sen, M.D., and Deniz Iscen, M.D.

Department of Plastic and Reconstructive Surgery, Kocaeli University Medical Faculty, 41380 Umuttepe, Kocaeli, Turkey

Abstract. Background: Management of nasal tip projection and support for positioning of the tip represent an important part of rhinoplasty operations that must be handled properly for a nal satisfying result. Manipulation of the nasal tip is complex and variable. Plastic surgeons use many techniques to achieve this goal. Methods: The authors propose that the caudal septal advancement technique be used to manipulate the positioning of the nasal tip, especially in cases of an underprojected tip and those requiring tip support. The authors prepare a rectangular septal cartilage, which after advancement carries the nasal tip to the desired position. Results: This technique is easy to use, and the results are dependable. All the patients who underwent surgery with this technique were satised with the result. Conclusion: The caudal septal advancement technique presents another good and reliable alternative for managing nasal tip projection and support. Key words: Nasal tip projectionSeptal advancement

Successful rhinoplasty depends on well-balanced nasal tip support and projection. Many dierent techniques for tip support and projection have been proposed, and some have been in routine use, although controversies or limitations exist in the literature concerning their late results. We performed the caudal septal advancement technique for patients requiring a mild to signicant increase in tip projection who needed tip projection support.

Patients and Surgical Technique We operated on 21 patients who needed an increase in or support for nasal tip projection between 2002 and 2004. Nine of the patients were preoperatively evaluated as having underprojected tips, and caudal septal advancement was planned to increase their tip projection. Four of these patients were secondary rhinoplasty cases for whom loss of tip projection was attributable to signicant septal resections that destroyed the L-shape frame of the septum. The remaining patients had normal tip projection preoperatively. However, they were intraoperatively evaluated as needing tip support, and the caudal septal advancement technique was used to provide this support. All the patients underwent surgery using an open technique and transcolumellar incision under general anesthesia (Fig. 1). With the caudal septal advancement technique, we rst determine where the nasal tip must be located. After completing all the steps of rhinoplasty, we prepare an angled rectangular cartilage graft extending down to the caudal edge of the septum that after advancement will carry the nasal tip to the desired position (Figs. 2 and 3). The grafts size, location, and angle of advancement depend on the individual requirements of the case, whether

Rhinoplasty is one of the most challenging operations in plastic surgery. Many techniques and maneuvers summarized in many volumes have been described as means to overcome the problems encountered during rhinoplasty operations. The most demanding part of the operation involves the tip of the nose, which, unless properly handled, could cause devastating sequels even if the remaining steps of the operation are managed perfectly.
Presented at the 10th Congress of European Society of Plastic Reconstructive and Aesthetic Surgery 2005, 30 August to 3 September 2005, Vienna, Austria Correspondence to Cenk Sen, M.D.; email: scenksen@ yahoo.com

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Fig. 1. The operations were performed using the open technique and transcolumellar incision with the patient under general anesthesia. Note that tip projection is not sufcient.

Fig. 4. The prepared septum is advanced and sutured to carry the tip to the desired position. Note that the graft is stable.

Fig. 2. Caudal septal advancement on the intact septum was planned.

Fig. 5. Relation of graft and alar cartilages.

Fig. 3. Schematic drawing of the septal cartilage planned for advancement.

elongation of the nose or an increase in tip projection or support. In preparation of the cartilage graft, care must be taken to design the advancement correctly and to incise the cartilage as precisely and as parallel as possible to prevent malalignments during xation of

the graft. If septum deviation exists, it is important to prepare the advancement in the straight segment of the septum to avoid possible deviations of the advanced graft after xation. The graft is advanced as required and xed again to the septum with six sutures. Two sutures in the middle are gure eight sutures, and four sutures at the corners are simple sutures that we call compression sutures, which tightly x the graft to the septum, rebuilding the L-shape frame of the septum and preventing instability and collapse (Figs. 4, 5, and 6). The lateral and anteroposterior stability of the graft at this stage is good because it rests on the intact septum. Next, the prepared alar cartilages are xed to this graft at two or three points in the desired projection and rotation. All layers are closed and approximated anatomically to rebuild the tensegrity of the nose. Skin is redraped, and the operation is nished (Figs. 7, 8, and 9).

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Fig. 7. Alar cartilages are xed to the advanced graft in the required position, and the skin is redraped over the repositioned cartilages.

Fig. 6. (a) Schematic drawing of the graft xed to the septum after advancement. The sutures at the corners depicted with A, a, C, and c are simple compression sutures, and the sutures in the middle depicted with B and b are gure eight sutures. (b) Diagram of the simple compression and gure eight sutures.

The patients were followed up for 6 to 24 months. We did not encounter any loss of projection in any patient, not even in the secondary cases with signicant septal resections, during the late postoperative period. Neither deviation nor septal complications were seen. Only one patient required a revision for a minimal dorsal irregularity. All the patients were satised with the tip projection (Figs. 10, 11, and 12). Discussion Controlling the position and shape of the nasal tip is the greatest challenge in rhinoplasty. The nasal tip is

Fig. 8. Preoperative appearance of the patient before and after caudal septal advancement.

a spring-loaded structure under tensile and compressive forces [5]. This fact must be fully understood for management of the nasal tip and recreation of its resilience, support, and function. The concept of tensegrity explains these compressive and tensile

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Fig. 9. Schematic drawing of the nasal architecture after caudal septal advancement.

forces that act on the nasal tip to dene the tip position. Transxing incisions with resection of the caudal septum, intercartilaginous incisions with cephalic trim of the lower lateral cartilages, alar base resection, and dorsal resection are accepted as standard maneuvers used to rene and reposition the nasal tip [3]. However, all these maneuvers also may contribute to the loss of tip support and projection. Actually, tip projection after rhinoplasty is an illusion created by reduction of the dorsum of the nose. Therefore, it is important to balance the dorsum and tip during the operation. The study of Adams et al. [1] showed a signicant loss of projection with the open approach, as compared with the closed approach. The researchers attributed this dierence to the ligamentous disruption and skin undermining that occurred with the open approach. Droopy nasal tip, a deformity involving an inferiorly rotated nasal tip, is cosmetically unattractive and interferes with the normal nasal air ow. Foda [6] stated that 72% of 500 rhinoplasty patients had variable degrees of droopy nasal tip. The droopy tip is caused by two factors. One factor is related to alar cartilages with long lateral crura, vertically oriented lateral crura, or short, weak medial crura. The other factor is inferior displacement of normal alar cartilage by the eect of extrinsic compressive forces, as explained by the tensegrity concept. These forces are exerted by long upper lateral cartilages, high anterior septal angles, and an overdeveloped caudal septum. They also can result from pulling forces as in the case of thick heavy nasal skin, overactive depressor septi muscles, or the eect of gravity in cases with compromised nasal tip support as a result of aging or previous operations [6]. Many techniques have been proposed for correction of an underprojected tip, but the aim of any corrective technique must be to reposition the alar cartilages to attain a more cephalic orientation.

To increase nasal tip projection and rotation in rhinoplasty, especially in cases with droopy tip, septal extension grafts, columellar struts, alar and septal surgical interventions, and many other techniques have been proposed and are in routine use [24,7,9]. All these techniques have their advantages and disadvantages. The transdomal suture is the most common maneuver used to increase tip projection. But the gain does not exceed 1 to 2 mm. Onlay tip grafts also are used for tip projection, but not for more than 3 mm. A columellar strut is another means used to gain more tip projection [7]. From their study, Byrd et al. [3] stated that tip projection is not predictably controlled unless the columellar strut is xed. Therefore, columellar struts are not as reliable as they are thought to be, unless xed. Another method for tip projection is direct septal suturing, which is especially indicated for the long nose requiring cephalic rotation and shortening. For severely collapsed noses in which the septum is completely resected, costal grafts also can be used reliably for tip projection even in complicated cases [10]. Septal extension grafts are thought to be more reliable than columellar struts [3]. Although the caudal septal advancement technique is based on a principle similar to that of septal extension grafts (xing of the tip complex to a stable cartilage graft), it has many advantages over septal extension grafts. Byrd, after 6 years of experience with the three different septal extension graft techniques, stated that some important problems should be considered when this technique is used, namely, widening of the supratip and midvault and an abnormal columellarlobular relationship [8]. With the caudal septal advancement technique, signicantly less cartilage is required for the graft. Cartilage is just an advancement of the septum, with the same properties on the same plane. The graft rests on the septum itself and is more steady than suture xations to the sides the septum, as with septal extension grafts. Although caudal septal advancement is thought to destroy the L-shape frame of the septum, septal integrity is rebuilt again, especially with compression sutures. Moreover, in the nal form, the L shape is reconstructed. Compressive suture xations, sticking of the two side mucopericondrial aps to each other on the donor site of the graft, and mucoperichondrial support on the graft prevent the late-term collapse of the advanced graft and therefore the projection. We have not observed loss of projection or collapse even in secondary rhinoplasty patients with signicant resections of the L-shape frame of the septum from previous operations, and have successfully provided durable tip projection. This technique does not cause any complications related to the L-shape frame of the septum, but successfully corrects deformities secondary to resections of the septal L-shape frame by using the remaining septum for advancement.

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Fig. 10. This patient, who complained of an underprojected tip, underwent surgery using caudal septal advancement, and a very minimal hump was resected.

Fig. 11. This patient with loss of tip support and respiratory problems who had undergone a previous septal surgery with signicant resection of the L-shape frame of the septum had surgery using the caudal septal advancement technique to increase the tip projection. Note that the remaining septum was sufcient to support the tip.

With caudal septal advancement, grafts prepared from septum can be designed geometrically according to the requirements of individual cases. This, in addition to improvement of tip projection and

support, can be helpful for short noses if the angle of advancement is more caudal. The angle of advancement determines the extent of elongation or projection. More caudal advancement helps in the

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Fig. 12. The caudal septal advancement technique was used successfully for this secondary rhinoplasty patient with minimal hump resection.

elongation of short noses, and more anterior advancement helps in increasing the projection of the tip. It also can be used for support or elongation of the columella if a wider graft is advanced more caudally toward the columella. The technique maintains septal integrity, and only the required amount of septum is used for advancement. In the case of columellar struts or septal extension grafts, the surgeon must obtain more graft than the required projection because the graft is positioned on the nasal spine or xed to the sides of the septum, respectively. Caudal advancement of septal cartilage does not eventually cause a deviation or tilt because it is advanced only on the septal plane. The main disadvantage of the technique is that it is dicult to prepare the graft in a severely deviated septum. In such cases, it also is dicult to harvest straight cartilage for columellar struts or extension grafts. Caudal septal advancement is an easy technique to learn and execute, and the results are dependable. It does not interfere with the tensegrity of the nose because all layers are closed and approximated anatomically to rebuild the septal integrity. No major complications have been observed with this technique. Although more clinical experience is needed, it seems that the technique stands on a rather physiologic basis. For selected patients, we believe caudal septal advancement presents another good and reliable alternative for managing tip projection and support.

References
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