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Caudal septal extension graft for correction of the retracted columella
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CAUDAL SEPTAL EXTENSION GRAFT FOR CORRECTION OF THE RETRACTED COLUMELLA DEAN M. TORIUMI, MD
Failure to correct a retracted columella deformity may prove to be the only flaw in an otherwise successful rhinoplasty. In some cases, the surgeon fails to make the proper preoperative diagnosis. More commonly the surgical technique used to repair the more severe retracted columella deformity provides inadequate correction. This article discusses a surgical technique that can be used in select cases to correct the retracted columella deformity.
DIAGNOSIS The relationship between the ala and columella is critical in determining the method used to correct the retracted columella deformity. Normally, there should be at least 2 to 4 mm of columellar show noted on lateral view of the nose (Fig 1). 1-3 The outline of the nostril usually takes on an oval shape with the alar rim forming the upper half and columellar rim at the junction of the external skin with the vestibular skin forming the lower half. 2 This oval configuration can be divided along its long axis (B) into an upper and lower half (Fig 1). Gunter described different categories of the alarcolumellar relationship based on the distance from the long axis of the nostril to the alar rim superiorly (AB) and to the columellar rim inferiorly (BC). 2 A normal alarcolumellar relationship exists when AB equals 1 to 2 mm and BC equals 1 to 2 mm (Fig 1). A retracted columella exists when AB equals 1 to 2 mm and BC is less than 1 mm (Fig 2). A hanging ala exists w h e n AB is less than 1 mm and B C i s 1 t o 2 mm. In some cases, there is a combination of a retracted columella and hanging ala. Proper diagnosis is critical because treatment of a hanging ala is different from treatment for a retracted columella.
ETIOLOGY The technique used to correct the hanging columella deformity depends on the severity and the etiology of the defect. The retracted columella deformity is frequently caused by a defect (deviation, fracture, etc) of the caudal From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology--Head and Neck Surgery, Umversity of Ilhnois College of Medicine, Chicago, IL. Address reprint requests to Dean M. Toriumi, MD, Dtvision of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Rm 242, M/C 648, 1855 W Taylor St, Chtcago, IL 60612 Copyright © 1995 by W.B Saunders Company 1043-1810/95/0604-0009505 00/0
margin of the nasal septum. Some patients possess a short septum that leaves them with a retracted columella. A retracted columella deformity can also result from previous overresection or loss of support of the caudal septurn from a previous operation. In most patients with a retracted columella secondary to a caudal septal deformity, correction of the septal deformity will help correct the alar-columellar dysharmony.
MANAGEMENT OF THE RETRACTED COLUMELLA DEFORMITY In cases that show only slight retraction of the columella (1 to 2 mm of columellar show), surgical management other than correction of a caudal septal deformity may not be necessary. In some cases, other surgical maneuvers may be necessary to correct the alar-columellar relationship. For example, conservative cephalic trim of the lateral crura (volume reduction) may result in slight postoperative retraction of the alar margin, creating a more favorable alar-columellar relationship. Alar retraction is a delayed p h e n o m e n o n and will not be apparent for many months after surgery. If minimal correction of the retracted columella is desired, a rectangular septal cartilage graft can be sutured between the medial crura and intermediate crura as a sutured-in-place columellar strut. 2'4 The sutured-inplace columellar strut may provide up to 2 m m of additional columellar show. Typically, these struts will measure 1(~ to 15 mm in length and 3 to 5 mm in width. Larger /(wide) columellar struts that protrude caudal to the caudal margin of the medial or intermediate crura may create a visible midline ridge. Wide struts that extend cephalic to the medial crura may override the caudal margin of the nasal septum and create tip asymmetry. Before applying a columellar strut, any caudal septal deviations must be corrected or the deviation may cause deformity of the columella. If the retraction of the columella is primarily posterior and i s noted as an acute nasolabial angle, cartilage plumping grafts or a premaxillary graft can be used. 4 Plumping grafts are usually 1- to 2-ram cube-shaped cartilage grafts that can be inserted into the inferior aspect of the columellar incision (external rhinoplasty approach) down to the feet of the medial crura and nasal spine (posterior septal angle). These grafts are more effective when they are applied in combination with a sutured-inplace columellar strut because the strut will prevent the grafts from lodging between the feet of the medial crura. Plumping grafts may also provide support for the lower third of the nose by forming a pedestal for the medial crura of the lower lateral cartilages.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 6, NO 4 (DEC), 1995: PP 311-318
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FIGURE 1. Normal alar-columellar relationship showing an oval-shaped nostril and 2 to 4 m m of columellar show. Note the line (B) that bisects the oval to delineate measurements AB and BC. AB is normally 1 to 2 m m and BC is normally 1 to 2 mm.
FIGURE 2. Retracted columella deformity. Note h o w distance BC is less than 1 mm.
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FIGURE 3. Dissection of the upper lateral cartilages from the dorsal (anterior) margin of the nasal septum to provide additional exposure of the nasal septum. To perform this maneuver, bilateral mucoperichondrial flaps are elevated and a Freer elevator is directed up to the junction between the upper lateral cartilages and septum via a hemitransfixion incision. This maneuver will allow the upper lateral cartilages to be freed from the nasal septum without disrupting the mtranasal mucosa. Special care is taken to avoid damaging the intact L-shaped nasal septal strut. 312
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normal tip recoil. If this technique is planned, such changes in tip character should be explained to the patient preoperatively• To perform this technique the following criteria should be met: (1) Relatively straight and firm septal cartilage can be collected from the septum; (2) The deformity cannot be corrected by less invasive methods (columellar strut, plumping grafts, etc); (3) There is sufficient vestibular skin available between the existing caudal septum and columella to allow caudal advancement; and (4) The existing nasal septum is not severely deviated and provides adequate support for the lower third of the nose. This technique should not be used if the patient has a septal perforation or inadequate septal support. If there is a lack of vestibular skin, a composite graft from the ear may be n e e d e d to replace both lining and support, lz'r3 However, whenever a composite graft is used there is the possibility of graft failure•
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FIGURE 4. After freeing the upper lateral cartilages from the septum and dissecting the medial and intermediate crura and vestibular skin apart from each other, the caudal margin of the nasal septum is exposed• This exposure will allow direct suture fixation of the caudal septal extension graft. Arrow shows caudal margin of nasal septum.
CAUDAL SEPTAL EXTENSION GRAFTING In cases with less than 1 m m of columellar show and a deficiency in the caudal septum, simple application of a columellar strut or plumping grafts will usually not correct the deformity. In these cases, caudal repositioning of the columella can be performed with a caudal septal extension graft, which is an extension off the existing septum and sutured between the medial crura. 5'6 This technique is similar to previously described techniques that use a cartilage graft extension off the existing septum. 7-11 Long-term follow-up of these patients does not show any evidence of resorption of the cartilage graft. 9'11 Caudal septal extension grafting involves harvesting a segment of relatively straight septal cartilage from the posteroinferior septum. This cartilage graft is then sutured to the existing caudal septum as an extension to the septum. The extension graft is sutured between the medial and intermediate crura to also act as a sutured-inplace columellar strut. The technique allows the surgeon to precisely position the columella and provide excellent tip support. A disadvantage of this technique is that the patient will have a rigid (stiff) nasal tip without TORIUMI
Via a hemitransfixion incision, bilateral mucoperichondrial flaps are elevated up to the junction between the upper lateral cartilages and septum. The region of the posteroinferior septum is dissected to identify cartilage that can be used as the caudal septal extension graft. If no straight septal cartilage is available, a caudal septal extension graft cannot be used. The cartilage should be collected leaving an intact L-shaped strut of cartilage extending from the osseocartilaginous junction to the posterior septal angle (nasal spine). If large rents in the septal flaps are created, caudal septal extension grafting should not be performed• The external rhinoplasty approach is executed to gain access to the lower lateral cartilages and middle nasal vault. Once the flap is elevated, the medial and intermediate crura and vestibular skin are dissected apart to expose the caudal aspect of the nasal septum. Before dissecting the vestibular mucosa, local anesthetic agent should be injected between the flaps to hydrodissect and thicken the flaps and make dissection easier. If additional exposure of the septum is required, the upper lateral cartilages can be dissected from the dorsal (anterior) margin of the nasal septum (Fig 3). This maneuver can be performed via a hemitransfixion incision leaving all of the intranasal mucosal flaps intact. At this point, the surgeon should have excellent exposure of the septal cartilage (Fig 4). The cartilage graft is cut to a size that will allow it to overlap the caudal margin of the existing septal cartilage, yet extend between the medial crura. The length and shape of the extension graft is critical because this will determine the position of the columella in relation to the ala. It is preferable to leave the graft slightly larger than expected and trim the graft after it is sutured into position. Positioning of the graft must be determined with the external rhinoplasty skin flap down because cephalic retraction of the flap will distort the position of the tip cartilages and not provide an accurate assessment of the alar-columellar relationship. The cartilage graft is sutured to the caudal margin of the existing septal cartilage in an orientation that will set the caudal aspect of the extension graft in the midline. In many cases there is a slight deviation of the existing caudal septum. By using the curvature of the caudal septum and cartilage graft, the caudal margin of the ex313
Unilateral spreader graft
Caudal septal extension graft FIGURE 5. Caudal septal extension graft sutured to the caudal margin of the existing caudal septum with two 4-0 PDS mattress sutures. Note how the curvature of the cartilage is used to ensure that the caudal margin of the extension graft lies in the midline. A unilateral spreader graft can be used to account for the bulk of the extension graft on the ipsilateral side of the septum. The broken line pattern shows the point at which the accompanying cross-section is taken through the nose. tension graft can be set precisely in the midline. The caudal extension graft should overlap the caudal septum by at least 4 m m to allow firm integration and fixation of the graft (Fig 5). Two 4-0 PDS mattress sutures (Polydioxanone, Ethicon, Somerville, NJ) can be tied as slip knots to allow the suture to cinch down and provide good fixation of the graft. In some cases a unilateral spreader graft may be needed to account for the bulk of the caudal extension graft on the ipsilateral side of the septum (Fig 5). If the bulk of the caudal extension graft is not balanced by the spreader graft, there may be noticeable fullness on the ipsilateral side of the middle nasal vault. The nasal airway should be examined to be sure the overlapping site of the cartilage graft is not creating nasal obstruction. If the caudal extension graft is properly positioned and is of appropriate thickness, there should be no evidence of the graft on intranasal exam. If the caudal margin of the nasal septum is severely deviated, the deviated segment can be excised and replaced by a septal replacement graft. 5'6 In these patients, a large stiff segment of relatively straight septal cartilage is needed. After the deformed septal cartilage is excised, the graft should be sutured to remnant septal cartilage firmly fixed to the osseocartilaginous junction and nasal spine region. 5 This is a much more complex operation than correction of the retracted columella because a segment of the L-shaped septal strut is resected and then reconstructed. Application of a caudal extension graft to correct the retracted columella simply involves extending a septal cartilage graft off the existing caudal segment of an intact L-shaped septal strut.
314
Once the extension graft is fixed to the nasal septum, the caudal margin of the graft is sutured between the medial crura with two buried 5-0 Prolene sutures and a single temporary 4-0 Monacryl mattress suture (Fig 6). The temporary suture (4-0 Monacryl) goes through vestibular skin and acts to support the reconstruction for several weeks as the suture resorbs. Long-term support is provided by permanent 5-0 Prolene sutures that go through medial and intermediate crura and extension graft. The Prolene sutures are buried and the knots are between the extension graft and internal surface of the medial and intermediate crura (Fig 6). Once the medial crura are sutured to the caudal extension graft, the alarcolumellar relationship should be corrected with approximately 3 to 4 m m of columellar show. The domes should be 5 to 8 m m above the dorsum and graft to ensure a favorable tip/supratip relationship (Fig 7). If necessary, graft position should be modified to prevent deformity (hanging columella, overprojection, overrotation, blunting of nasolabial angle, etc). Special care should be taken to set appropriate columellar position (alar-columellar relationship), tip projection, and nasal length. If there is primarily a deficiency in the region of the nasolabial angle, the graft can be left slightly longer along its inferior border. If deficiency is near the anterior septal angle and nasal length must be preserved or increased, the caudal septal extension graft can be left longer along the superior (dorsal) border. Because the caudal extension graft is setting position of the tip structures, proper positioning is critical to avoid creating deformity. Intraoperative nasal measurements should be CAUDAL SEPTAL EXTENSION GRAFT
FIGURE 6. Caudal septal extension graft is sutured between the medial and intermediate crura with two buried 5-0 Prolene sutures. The Prolene sutures (broken line pattern) traverse the internal surface of the medial and intermediate crura, tying the knot between the cartilages. A single temporary 4-0 Monacryl mattress suture goes through the medial crura and extension graft (temporary suture external to vestibular mucosa). Note how the extension graft does not extend caudal to the medial or intermediate crura. Positioning of the graft is critical to avoid deformity. taken with the columellar incision partially closed to verify proper aesthetic parameters. The method of nasal analysis described by Byrd :4 can be used to insure proper positioning of the nasal tip. The surgeon should limit increases in tip projection to allow sufficient soft tissue for closure of the columellar incision without tension. The surgeon must be careful to avoid excessive projection or rotation of the lower third of the nose. There is very little room for error with the caudal extension graft because it firmly fixes the columella into position. Therefore, only modest changes in tip position should be made, with the focus on correcting the retracted columella deformity. Once the caudal extension graft is in its final position, the upper lateral cartilages should be resutured to the septum to prevent infero-medial collapse. The domes should project above the caudal extension graft and middle nasal vault to prevent polybeak formation (Fig 7). Tip projection can be increased with a transdomal suture that passes through both domes. :s This suture will secure the dome position over the caudal extension graft. The caudal septal extension graft should not extend beyond the caudal margin of the medial or intermediate crura, otherwise a vertical midline ridge may be noted postoperatively (Fig 8). It is advisable to place a thin camouflaging shield-shaped tip graft over the medial and intermediate crura to cover the caudal margin of the caudal extension graft (Fig 9). This cartilage graft does not have to project above the existing domes be-
TORIUMI
cause it is not being used to increase tip projection. If increased tip projection is desired, the tip graft can project 2 to 3 mm above the existing domes. Tip grafts should be avoided in patients with thin skin because the leading edge of the grafts may become visible over time. :6 Once the caudal septal extension graft is sutured into position, the mucosal flaps should be approximated with a running 5-0 plain catgut mucosal quilting suture. Then the flaps can be compressed by placing bilateral intranasal splints (Reuter bivalve splint, Xomed-Treace, Jacksonville, FL) on both sides of the septum for 5 to 7 days. An intranasal pack (Merosol sponge pack, Merosol Corp., Mystic, CT) should be inserted and can be removed the morning after surgery. Oral antibiotics should be administered for 10 days after surgery.
FINAL C O M M E N T S Correction of the retracted columella deformity may be difficult because of an underlying deficiency in nasal septal support. In most cases, relatively simple techniques such as a sutured-in-place columellar strut or plumping grafts will help correct the deformity. Caudal septal extension grafting should only be used in cases in which there is marked retraction of the columella (Fig 10). Application of a caudal septal extension graft attempts to correct the underlying septal deficiency and create a more
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FIGURE 7. Final position of the caudal extension graft overlapping the existing caudal margin of the nasal septum. Note the two 4-0 PDS sutures used to fix the graft to the caudal margin of the nasal septum. The medial crura are fixed to the caudal margin of the extension graft to set the new position of the lower lateral cartilages and columella. Note how the domes project above the caudal extension graft and middle nasal vault to ensure a favorable tlp/supratip relationship.
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FIGURE 8. Intraoperative photograph showing position of caudal extension graft sutured between medial and intermediate crura. Note how the caudal extension graft does not extend caudal to the medial and intermediate crura. Arrow shows caudal extension graft. A white arrowhead shows existing caudal margin of nasal septum.
FIGURE 9. A thin camouflaging shield shaped tip graft is sutured to the caudal margin of the medial and intermediate crura. This graft will help camouflage the caudal margin of the caudal septal extension graft. Special care should be taken to round off the edges of the graft to avoid a visible tip graft.
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FIGURE 10. Patient with a retracted columella due to a short caudal septem. The caudal s e p t u m was over-reduced in a previous rhinoplasty. The patient u n d e r w e n t secondary rhinoplasty and application of a caudal extension graft to correct the retracted columella. A dorsal onlay graft a n d shield s h a p e d tip graft were also applied. Left side of page are preoperative views. Right-hand side are 2-years postoperative.
f a v o r a b l e a l a r - c o l u m e l l a r r e l a t i o n s h i p . C a u d a l s e p t a l ext e n s i o n g r a f t i n g s h o u l d b e l i m i t e d to c a s e s t h a t fit t h e preoperative criteria and cannot be corrected using other less invasive methods. The surgeon should be aware that dramatic changes in tip position can be made using t h i s t e c h n i q u e a n d s p e c i a l c a r e m u s t b e t a k e n to a v o i d creating deformity. This procedure should only be performed by surgeons familiar with complex nasal septal s u r g e r y a n d t h o s e w h o h a v e a g o o d u n d e r s t a n d i n g of aesthetic nasal proportions.
REFERENCES 1. Powell N, Humphries B' Proportions of the Aesthet:c Face New York, Thleme-Stratton, 1984 2. Gunter JP, Rohrich RJ' The importance of the alar-columellar relationship m rhmoplasty. Course compendmm: Rhinoplasty 1988, Key Blscayne, FL, December 1988 3. Adamson PA, Tropper GJ, McGraw BL: The hanging columella J Otolaryngol 19:319-323, 1990 4. Johnson CM, Toriumi DM: Open Structure Rhlnoplasty. Philadelphia, PA, Saunders, 1990 5. Tonuml DM: Subtotal reconstruction of the nasal septum. Laryngoscope 104:906-913, 1994
318
6. Tonum~ DM, R~es WR: Innovatwe surg:cal management of the crooked nose. Faoal Plast Chn North Am 1:63-78, 1993 7. Peer L. An operation to repa:r lateral displacement of the lower border of the septal cart:lage. Arch Otolaryngol 25:475-477, 1937 8. Galloway T' Plastic repa:r of the deflected nasal septum Arch Laryngol 44.141-149, 1946 9. Brlant TDR, M:ddleton WG' The management of severe nasal septal deformities. J Otolaryngol 14:120-124, 1985 10. Tebbetts JB: Shaping and pos:tlonmg the nasal t~p without structural disruption' A new, systemat:c approach. Plast Reconstr Surg 94:61-77, 1994 11. Walker PJ, Crysdale WS, Farkas WG: External septorhmoplasty m children Arch Otolaryngol Head Neck Surg 119.984-989, 1993 12. Dmgman RO, Walter C. Use of compos:te ear grafts in correction of the short nose. Plast Reconstr Surg 93'117, 1969 13. Kamer FM. Lengthening the short nose Ann Plast Surg 4:281-285, 1980 14. Byrd HS, Hobar PC: Rhmoplasty: A practical gu:de for surgical planning Plast Reconstr Surg 91:642-654, 1993 15. Tardy ME, Cheng E Transdomal suture rehnement of the nasal tip Facial Plast Surg 4.317, 1987 16. Torlum: DM, Johnson CM' Open structure rhmoplasty. Featured techmcal pomts and long-term follow-up Facial Plast Chn North Am 1'1-22, 1993
CAUDAL SEPTAL EXTENSION GRAFT
CAUDAL SEPTAL EXTENSION GRAFT FOR CORRECTION OF THE RETRACTED COLUMELLA DEAN M. TORIUMI, MD
Failure to correct a retracted columella deformity may prove to be the only flaw in an otherwise successful rhinoplasty. In some cases, the surgeon fails to make the proper preoperative diagnosis. More commonly the surgical technique used to repair the more severe retracted columella deformity provides inadequate correction. This article discusses a surgical technique that can be used in select cases to correct the retracted columella deformity.
DIAGNOSIS The relationship between the ala and columella is critical in determining the method used to correct the retracted columella deformity. Normally, there should be at least 2 to 4 mm of columellar show noted on lateral view of the nose (Fig 1). 1-3 The outline of the nostril usually takes on an oval shape with the alar rim forming the upper half and columellar rim at the junction of the external skin with the vestibular skin forming the lower half. 2 This oval configuration can be divided along its long axis (B) into an upper and lower half (Fig 1). Gunter described different categories of the alarcolumellar relationship based on the distance from the long axis of the nostril to the alar rim superiorly (AB) and to the columellar rim inferiorly (BC). 2 A normal alarcolumellar relationship exists when AB equals 1 to 2 mm and BC equals 1 to 2 mm (Fig 1). A retracted columella exists when AB equals 1 to 2 mm and BC is less than 1 mm (Fig 2). A hanging ala exists w h e n AB is less than 1 mm and B C i s 1 t o 2 mm. In some cases, there is a combination of a retracted columella and hanging ala. Proper diagnosis is critical because treatment of a hanging ala is different from treatment for a retracted columella.
ETIOLOGY The technique used to correct the hanging columella deformity depends on the severity and the etiology of the defect. The retracted columella deformity is frequently caused by a defect (deviation, fracture, etc) of the caudal From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology--Head and Neck Surgery, Umversity of Ilhnois College of Medicine, Chicago, IL. Address reprint requests to Dean M. Toriumi, MD, Dtvision of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Rm 242, M/C 648, 1855 W Taylor St, Chtcago, IL 60612 Copyright © 1995 by W.B Saunders Company 1043-1810/95/0604-0009505 00/0
margin of the nasal septum. Some patients possess a short septum that leaves them with a retracted columella. A retracted columella deformity can also result from previous overresection or loss of support of the caudal septurn from a previous operation. In most patients with a retracted columella secondary to a caudal septal deformity, correction of the septal deformity will help correct the alar-columellar dysharmony.
MANAGEMENT OF THE RETRACTED COLUMELLA DEFORMITY In cases that show only slight retraction of the columella (1 to 2 mm of columellar show), surgical management other than correction of a caudal septal deformity may not be necessary. In some cases, other surgical maneuvers may be necessary to correct the alar-columellar relationship. For example, conservative cephalic trim of the lateral crura (volume reduction) may result in slight postoperative retraction of the alar margin, creating a more favorable alar-columellar relationship. Alar retraction is a delayed p h e n o m e n o n and will not be apparent for many months after surgery. If minimal correction of the retracted columella is desired, a rectangular septal cartilage graft can be sutured between the medial crura and intermediate crura as a sutured-in-place columellar strut. 2'4 The sutured-inplace columellar strut may provide up to 2 m m of additional columellar show. Typically, these struts will measure 1(~ to 15 mm in length and 3 to 5 mm in width. Larger /(wide) columellar struts that protrude caudal to the caudal margin of the medial or intermediate crura may create a visible midline ridge. Wide struts that extend cephalic to the medial crura may override the caudal margin of the nasal septum and create tip asymmetry. Before applying a columellar strut, any caudal septal deviations must be corrected or the deviation may cause deformity of the columella. If the retraction of the columella is primarily posterior and i s noted as an acute nasolabial angle, cartilage plumping grafts or a premaxillary graft can be used. 4 Plumping grafts are usually 1- to 2-ram cube-shaped cartilage grafts that can be inserted into the inferior aspect of the columellar incision (external rhinoplasty approach) down to the feet of the medial crura and nasal spine (posterior septal angle). These grafts are more effective when they are applied in combination with a sutured-inplace columellar strut because the strut will prevent the grafts from lodging between the feet of the medial crura. Plumping grafts may also provide support for the lower third of the nose by forming a pedestal for the medial crura of the lower lateral cartilages.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 6, NO 4 (DEC), 1995: PP 311-318
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FIGURE 1. Normal alar-columellar relationship showing an oval-shaped nostril and 2 to 4 m m of columellar show. Note the line (B) that bisects the oval to delineate measurements AB and BC. AB is normally 1 to 2 m m and BC is normally 1 to 2 mm.
FIGURE 2. Retracted columella deformity. Note h o w distance BC is less than 1 mm.
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FIGURE 3. Dissection of the upper lateral cartilages from the dorsal (anterior) margin of the nasal septum to provide additional exposure of the nasal septum. To perform this maneuver, bilateral mucoperichondrial flaps are elevated and a Freer elevator is directed up to the junction between the upper lateral cartilages and septum via a hemitransfixion incision. This maneuver will allow the upper lateral cartilages to be freed from the nasal septum without disrupting the mtranasal mucosa. Special care is taken to avoid damaging the intact L-shaped nasal septal strut. 312
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normal tip recoil. If this technique is planned, such changes in tip character should be explained to the patient preoperatively• To perform this technique the following criteria should be met: (1) Relatively straight and firm septal cartilage can be collected from the septum; (2) The deformity cannot be corrected by less invasive methods (columellar strut, plumping grafts, etc); (3) There is sufficient vestibular skin available between the existing caudal septum and columella to allow caudal advancement; and (4) The existing nasal septum is not severely deviated and provides adequate support for the lower third of the nose. This technique should not be used if the patient has a septal perforation or inadequate septal support. If there is a lack of vestibular skin, a composite graft from the ear may be n e e d e d to replace both lining and support, lz'r3 However, whenever a composite graft is used there is the possibility of graft failure•
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FIGURE 4. After freeing the upper lateral cartilages from the septum and dissecting the medial and intermediate crura and vestibular skin apart from each other, the caudal margin of the nasal septum is exposed• This exposure will allow direct suture fixation of the caudal septal extension graft. Arrow shows caudal margin of nasal septum.
CAUDAL SEPTAL EXTENSION GRAFTING In cases with less than 1 m m of columellar show and a deficiency in the caudal septum, simple application of a columellar strut or plumping grafts will usually not correct the deformity. In these cases, caudal repositioning of the columella can be performed with a caudal septal extension graft, which is an extension off the existing septum and sutured between the medial crura. 5'6 This technique is similar to previously described techniques that use a cartilage graft extension off the existing septum. 7-11 Long-term follow-up of these patients does not show any evidence of resorption of the cartilage graft. 9'11 Caudal septal extension grafting involves harvesting a segment of relatively straight septal cartilage from the posteroinferior septum. This cartilage graft is then sutured to the existing caudal septum as an extension to the septum. The extension graft is sutured between the medial and intermediate crura to also act as a sutured-inplace columellar strut. The technique allows the surgeon to precisely position the columella and provide excellent tip support. A disadvantage of this technique is that the patient will have a rigid (stiff) nasal tip without TORIUMI
Via a hemitransfixion incision, bilateral mucoperichondrial flaps are elevated up to the junction between the upper lateral cartilages and septum. The region of the posteroinferior septum is dissected to identify cartilage that can be used as the caudal septal extension graft. If no straight septal cartilage is available, a caudal septal extension graft cannot be used. The cartilage should be collected leaving an intact L-shaped strut of cartilage extending from the osseocartilaginous junction to the posterior septal angle (nasal spine). If large rents in the septal flaps are created, caudal septal extension grafting should not be performed• The external rhinoplasty approach is executed to gain access to the lower lateral cartilages and middle nasal vault. Once the flap is elevated, the medial and intermediate crura and vestibular skin are dissected apart to expose the caudal aspect of the nasal septum. Before dissecting the vestibular mucosa, local anesthetic agent should be injected between the flaps to hydrodissect and thicken the flaps and make dissection easier. If additional exposure of the septum is required, the upper lateral cartilages can be dissected from the dorsal (anterior) margin of the nasal septum (Fig 3). This maneuver can be performed via a hemitransfixion incision leaving all of the intranasal mucosal flaps intact. At this point, the surgeon should have excellent exposure of the septal cartilage (Fig 4). The cartilage graft is cut to a size that will allow it to overlap the caudal margin of the existing septal cartilage, yet extend between the medial crura. The length and shape of the extension graft is critical because this will determine the position of the columella in relation to the ala. It is preferable to leave the graft slightly larger than expected and trim the graft after it is sutured into position. Positioning of the graft must be determined with the external rhinoplasty skin flap down because cephalic retraction of the flap will distort the position of the tip cartilages and not provide an accurate assessment of the alar-columellar relationship. The cartilage graft is sutured to the caudal margin of the existing septal cartilage in an orientation that will set the caudal aspect of the extension graft in the midline. In many cases there is a slight deviation of the existing caudal septum. By using the curvature of the caudal septum and cartilage graft, the caudal margin of the ex313
Unilateral spreader graft
Caudal septal extension graft FIGURE 5. Caudal septal extension graft sutured to the caudal margin of the existing caudal septum with two 4-0 PDS mattress sutures. Note how the curvature of the cartilage is used to ensure that the caudal margin of the extension graft lies in the midline. A unilateral spreader graft can be used to account for the bulk of the extension graft on the ipsilateral side of the septum. The broken line pattern shows the point at which the accompanying cross-section is taken through the nose. tension graft can be set precisely in the midline. The caudal extension graft should overlap the caudal septum by at least 4 m m to allow firm integration and fixation of the graft (Fig 5). Two 4-0 PDS mattress sutures (Polydioxanone, Ethicon, Somerville, NJ) can be tied as slip knots to allow the suture to cinch down and provide good fixation of the graft. In some cases a unilateral spreader graft may be needed to account for the bulk of the caudal extension graft on the ipsilateral side of the septum (Fig 5). If the bulk of the caudal extension graft is not balanced by the spreader graft, there may be noticeable fullness on the ipsilateral side of the middle nasal vault. The nasal airway should be examined to be sure the overlapping site of the cartilage graft is not creating nasal obstruction. If the caudal extension graft is properly positioned and is of appropriate thickness, there should be no evidence of the graft on intranasal exam. If the caudal margin of the nasal septum is severely deviated, the deviated segment can be excised and replaced by a septal replacement graft. 5'6 In these patients, a large stiff segment of relatively straight septal cartilage is needed. After the deformed septal cartilage is excised, the graft should be sutured to remnant septal cartilage firmly fixed to the osseocartilaginous junction and nasal spine region. 5 This is a much more complex operation than correction of the retracted columella because a segment of the L-shaped septal strut is resected and then reconstructed. Application of a caudal extension graft to correct the retracted columella simply involves extending a septal cartilage graft off the existing caudal segment of an intact L-shaped septal strut.
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Once the extension graft is fixed to the nasal septum, the caudal margin of the graft is sutured between the medial crura with two buried 5-0 Prolene sutures and a single temporary 4-0 Monacryl mattress suture (Fig 6). The temporary suture (4-0 Monacryl) goes through vestibular skin and acts to support the reconstruction for several weeks as the suture resorbs. Long-term support is provided by permanent 5-0 Prolene sutures that go through medial and intermediate crura and extension graft. The Prolene sutures are buried and the knots are between the extension graft and internal surface of the medial and intermediate crura (Fig 6). Once the medial crura are sutured to the caudal extension graft, the alarcolumellar relationship should be corrected with approximately 3 to 4 m m of columellar show. The domes should be 5 to 8 m m above the dorsum and graft to ensure a favorable tip/supratip relationship (Fig 7). If necessary, graft position should be modified to prevent deformity (hanging columella, overprojection, overrotation, blunting of nasolabial angle, etc). Special care should be taken to set appropriate columellar position (alar-columellar relationship), tip projection, and nasal length. If there is primarily a deficiency in the region of the nasolabial angle, the graft can be left slightly longer along its inferior border. If deficiency is near the anterior septal angle and nasal length must be preserved or increased, the caudal septal extension graft can be left longer along the superior (dorsal) border. Because the caudal extension graft is setting position of the tip structures, proper positioning is critical to avoid creating deformity. Intraoperative nasal measurements should be CAUDAL SEPTAL EXTENSION GRAFT
FIGURE 6. Caudal septal extension graft is sutured between the medial and intermediate crura with two buried 5-0 Prolene sutures. The Prolene sutures (broken line pattern) traverse the internal surface of the medial and intermediate crura, tying the knot between the cartilages. A single temporary 4-0 Monacryl mattress suture goes through the medial crura and extension graft (temporary suture external to vestibular mucosa). Note how the extension graft does not extend caudal to the medial or intermediate crura. Positioning of the graft is critical to avoid deformity. taken with the columellar incision partially closed to verify proper aesthetic parameters. The method of nasal analysis described by Byrd :4 can be used to insure proper positioning of the nasal tip. The surgeon should limit increases in tip projection to allow sufficient soft tissue for closure of the columellar incision without tension. The surgeon must be careful to avoid excessive projection or rotation of the lower third of the nose. There is very little room for error with the caudal extension graft because it firmly fixes the columella into position. Therefore, only modest changes in tip position should be made, with the focus on correcting the retracted columella deformity. Once the caudal extension graft is in its final position, the upper lateral cartilages should be resutured to the septum to prevent infero-medial collapse. The domes should project above the caudal extension graft and middle nasal vault to prevent polybeak formation (Fig 7). Tip projection can be increased with a transdomal suture that passes through both domes. :s This suture will secure the dome position over the caudal extension graft. The caudal septal extension graft should not extend beyond the caudal margin of the medial or intermediate crura, otherwise a vertical midline ridge may be noted postoperatively (Fig 8). It is advisable to place a thin camouflaging shield-shaped tip graft over the medial and intermediate crura to cover the caudal margin of the caudal extension graft (Fig 9). This cartilage graft does not have to project above the existing domes be-
TORIUMI
cause it is not being used to increase tip projection. If increased tip projection is desired, the tip graft can project 2 to 3 mm above the existing domes. Tip grafts should be avoided in patients with thin skin because the leading edge of the grafts may become visible over time. :6 Once the caudal septal extension graft is sutured into position, the mucosal flaps should be approximated with a running 5-0 plain catgut mucosal quilting suture. Then the flaps can be compressed by placing bilateral intranasal splints (Reuter bivalve splint, Xomed-Treace, Jacksonville, FL) on both sides of the septum for 5 to 7 days. An intranasal pack (Merosol sponge pack, Merosol Corp., Mystic, CT) should be inserted and can be removed the morning after surgery. Oral antibiotics should be administered for 10 days after surgery.
FINAL C O M M E N T S Correction of the retracted columella deformity may be difficult because of an underlying deficiency in nasal septal support. In most cases, relatively simple techniques such as a sutured-in-place columellar strut or plumping grafts will help correct the deformity. Caudal septal extension grafting should only be used in cases in which there is marked retraction of the columella (Fig 10). Application of a caudal septal extension graft attempts to correct the underlying septal deficiency and create a more
315
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FIGURE 8. Intraoperative photograph showing position of caudal extension graft sutured between medial and intermediate crura. Note how the caudal extension graft does not extend caudal to the medial and intermediate crura. Arrow shows caudal extension graft. A white arrowhead shows existing caudal margin of nasal septum.
FIGURE 9. A thin camouflaging shield shaped tip graft is sutured to the caudal margin of the medial and intermediate crura. This graft will help camouflage the caudal margin of the caudal septal extension graft. Special care should be taken to round off the edges of the graft to avoid a visible tip graft.
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FIGURE 10. Patient with a retracted columella due to a short caudal septem. The caudal s e p t u m was over-reduced in a previous rhinoplasty. The patient u n d e r w e n t secondary rhinoplasty and application of a caudal extension graft to correct the retracted columella. A dorsal onlay graft a n d shield s h a p e d tip graft were also applied. Left side of page are preoperative views. Right-hand side are 2-years postoperative.
f a v o r a b l e a l a r - c o l u m e l l a r r e l a t i o n s h i p . C a u d a l s e p t a l ext e n s i o n g r a f t i n g s h o u l d b e l i m i t e d to c a s e s t h a t fit t h e preoperative criteria and cannot be corrected using other less invasive methods. The surgeon should be aware that dramatic changes in tip position can be made using t h i s t e c h n i q u e a n d s p e c i a l c a r e m u s t b e t a k e n to a v o i d creating deformity. This procedure should only be performed by surgeons familiar with complex nasal septal s u r g e r y a n d t h o s e w h o h a v e a g o o d u n d e r s t a n d i n g of aesthetic nasal proportions.
REFERENCES 1. Powell N, Humphries B' Proportions of the Aesthet:c Face New York, Thleme-Stratton, 1984 2. Gunter JP, Rohrich RJ' The importance of the alar-columellar relationship m rhmoplasty. Course compendmm: Rhinoplasty 1988, Key Blscayne, FL, December 1988 3. Adamson PA, Tropper GJ, McGraw BL: The hanging columella J Otolaryngol 19:319-323, 1990 4. Johnson CM, Toriumi DM: Open Structure Rhlnoplasty. Philadelphia, PA, Saunders, 1990 5. Tonuml DM: Subtotal reconstruction of the nasal septum. Laryngoscope 104:906-913, 1994
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6. Tonum~ DM, R~es WR: Innovatwe surg:cal management of the crooked nose. Faoal Plast Chn North Am 1:63-78, 1993 7. Peer L. An operation to repa:r lateral displacement of the lower border of the septal cart:lage. Arch Otolaryngol 25:475-477, 1937 8. Galloway T' Plastic repa:r of the deflected nasal septum Arch Laryngol 44.141-149, 1946 9. Brlant TDR, M:ddleton WG' The management of severe nasal septal deformities. J Otolaryngol 14:120-124, 1985 10. Tebbetts JB: Shaping and pos:tlonmg the nasal t~p without structural disruption' A new, systemat:c approach. Plast Reconstr Surg 94:61-77, 1994 11. Walker PJ, Crysdale WS, Farkas WG: External septorhmoplasty m children Arch Otolaryngol Head Neck Surg 119.984-989, 1993 12. Dmgman RO, Walter C. Use of compos:te ear grafts in correction of the short nose. Plast Reconstr Surg 93'117, 1969 13. Kamer FM. Lengthening the short nose Ann Plast Surg 4:281-285, 1980 14. Byrd HS, Hobar PC: Rhmoplasty: A practical gu:de for surgical planning Plast Reconstr Surg 91:642-654, 1993 15. Tardy ME, Cheng E Transdomal suture rehnement of the nasal tip Facial Plast Surg 4.317, 1987 16. Torlum: DM, Johnson CM' Open structure rhmoplasty. Featured techmcal pomts and long-term follow-up Facial Plast Chn North Am 1'1-22, 1993
CAUDAL SEPTAL EXTENSION GRAFT