Key points
- A septal extension graft is described as a way of adjusting how far the nasal tip projects, its shape, and its rotation by attaching cartilage to the septum, the wall that divides the inside of the nose [1].
- One review noted that when tip sutures alone are not enough, cartilage grafts can offer a variety of ways to change the nasal tip [2].
- The septal extension graft has been described as the most commonly performed method for correcting a short nose, but other grafting methods that lengthen the nasal tip have also been presented [3].
- In rhinoplasty for Asian patients, as this graft and synthetic implants came into wide use, surgery-related (iatrogenic) complications such as a shortened nose and damage to the remaining septum have been pointed out [1].
- Most of the evidence reviewed consists of reviews that summarize expert experience, so the method should be decided after an in-person examination of the structure of your nose.
What supports the nasal tip?
The nasal tip is the most prominent part of the nose [2]. Its outward shape is described as being determined by the curvature and contour of the lower lateral cartilages and by how these cartilages fit together with the surrounding tissue [2]. Running down the middle of the inside of the nose is the nasal septum, which divides the left and right nostrils, and its front, cartilage portion acts as a pillar that supports the structure of the tip.
Surgery to change the nasal tip can be broadly divided into methods that shape the cartilage with sutures and grafting methods that add cartilage. One review noted that when tip sutures alone are not enough, cartilage grafts are a versatile and effective way to change the nasal tip [2]. The same review listed commonly used tip grafts, including a strut graft that supports the columella, the strip of tissue between the nostrils (columellar strut graft), a shield-shaped graft (shield graft), and a graft that extends the end of the septum (caudal septal extension graft) [2].
What is a septal extension graft?
In a septal extension graft, a piece of cartilage is fixed to the end of the septum to extend it forward or downward, and the tip cartilages are then secured to it to set their position. A review of rhinoplasty in Asian patients explained that this graft can adjust the projection, shape, and rotation of the nasal tip [1].
The same review presented a method for Asian patients with relatively small noses that extends the L-shaped support structure of the septum (septal L-strut extension graft), describing it as able to reinforce the lower two-thirds of the nose forward and downward [1]. The indications described for this method were first surgeries in which the bony part of the bridge is fine but the cartilage part is relatively underdeveloped, and revision surgeries for noses that have become shorter because of synthetic implants [1].
Besides septal cartilage from inside the nose, cartilage from the ear or ribs is sometimes used for the graft. A review of patients of African descent presented open rhinoplasty that combines a rib cartilage (costal cartilage) graft with a septal extension graft as its standard approach [6].
When is it considered?
A low or short nasal tip, or wanting to change the direction the tip points, are common reasons people seek a consultation. A review of East Asian rhinoplasty described the septal extension graft as the most commonly performed method for correcting a short nose [3].
It is also used in revision surgery. A nose that becomes too short after previous nose surgery has been linked to weakening or loss of the cartilage that supports the tip, along with contraction of the skin and scarring [4]. A treatment approach has also been presented for a deformity in which the rims of the nostrils are pulled upward after a technique that trims the upper part of the tip cartilages (cephalic trim), and it includes a step that firmly secures the central structure of the tip with a septal extension graft [5].
How it differs from other ways of lengthening the tip
A septal extension graft is not the only way to lengthen the nasal tip. A review of East Asian rhinoplasty presented the derotation graft as allowing sufficient lengthening while keeping the tip soft and mobile [3]. The columellar strut graft, which places a piece of cartilage upright inside the columella, is also listed as a type of tip graft [2].
None of the research summaries reviewed for this article included a study that directly compared these methods and showed one to be better. A realistic approach, then, is to decide with your surgeon what matters most to you: the firmness of the tip, how it moves, or how much its length changes.
Complications and precautions
A review of rhinoplasty in Asian patients pointed out that as septal extension grafts and synthetic bridge implants came into wide use, surgery-related (iatrogenic) complications arose, such as deformities in which the nose actually becomes shorter and damage to the remaining septum [1]. When a nose has become shorter after previous surgery, a lack of cartilage support and contraction of the skin can both play a part [4]. For this reason, revision surgery involves more factors to consider than a first operation.
A review of patients of African descent stressed that the amount of cartilage removed should be kept to a minimum [6]. In addition, as with any surgery, there are general risks such as bleeding, infection, and asymmetry, and how quickly swelling goes down and how the final shape settles also vary from person to person.
What to check during your consultation
It has been noted that the success of surgery depends on accurately assessing the anatomy and balancing it with the patient's aesthetic expectations [6]. It is a good idea to describe the shape you want in specific terms and to confirm directly with a specialist what is possible given the condition of your cartilage and skin.
- Which you want to change: the height, length, or direction of the nasal tip
- Where the graft cartilage will come from, and the condition of that area
- Whether you have had nose surgery before, and what implants were used
- How the feel and movement of the nasal tip may change
- What your options are if the result differs from what you expected
Frequently asked questions
- Will a septal extension graft make my nasal tip feel stiff?
- The research summaries reviewed for this article did not include results that measured how firm the tip becomes. However, one review cited keeping the tip soft and mobile as an advantage of a different method, the derotation graft [3]. If you are concerned about how your tip will feel, ask your surgeon before surgery what changes to expect.
- Can a nose that became shorter after previous surgery be lengthened again?
- A nose that has become shorter after previous surgery has been linked to weakened cartilage support, contraction of the skin, and scarring [4]. A method that applies a septal L-strut extension graft to noses shortened by synthetic implants has been described [1]. The condition of the skin and scar tissue differs from person to person, so what is possible has to be judged through an examination.
- Where does the graft cartilage come from?
- Septal cartilage from inside the nose is often considered first, and if there is not enough, cartilage from the ear or ribs is sometimes used. A review of patients of African descent described rib cartilage grafts as part of its standard approach [6]. Which site is used depends on the condition of your nose and how much cartilage is needed.
References
- Hwang NH, Dhong ES. Septal Extension Graft in Asian Rhinoplasty. Facial Plast Surg Clin North Am. 2018.PubMed 30005789DOI
- Cingi C, Bayar Muluk N, Winkler A, et al. Nasal Tip Grafts. J Craniofac Surg. 2018.PubMed 30234713DOI
- Suh MK. Cosmetic Augmentation Rhinoplasty for East Asians. Facial Plast Surg Clin North Am. 2021.PubMed 34579840DOI
- Peng GL, Azizzadeh B. Correction of the Overly Shortened Nose. Oral Maxillofac Surg Clin North Am. 2021.PubMed 33246544DOI
- Kao WTK, Davis RE. Postsurgical Alar Retraction: Etiology and Treatment. Facial Plast Surg Clin North Am. 2019.PubMed 31587768DOI
- Patrocinio LG, Patrocinio TG, Patrocinio JA. Approach for Rhinoplasty in African Descendants. Facial Plast Surg Clin North Am. 2021.PubMed 34579839DOI
This article is an English translation of general health information that DOY JUN Plastic Surgery compiled in Korean from the summaries (abstracts) of papers in international academic journals. Treatment methods and results vary depending on each person's condition, so please consult a specialist for an accurate diagnosis and treatment plan.
