Discussion: Septum-Based Nasal Tip Plasty

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In the article entitled “Septum-Based Nasal Tip Plasty: A Comparative Study between Septal Extension Graft and Double-Layered Conchal Cartilage Extension Graft,”1 the authors compare use of harvested septal cartilage and auricular cartilage as a caudal septal extension graft. It should be pointed out that this study was performed on Asian patients, who have much thinner and weaker septal cartilage, which does not work well for stabilizing the nasal base. In addition, most Asian patients require an increase in nasal tip projection while preserving nasal length. As the tip is projected, the thicker nasal tip skin pushes back on the projected cartilages, potentially introducing tension on the closure of the columellar incision. This creates a compressive force on the cartilage structure that can deform, resulting in overrotation of the nasal tip. For this reason, most Asian patients require stronger cartilage support to stabilize the nasal base than Caucasian patients do.
The authors describe their use of a double-layered auricular cartilage extension graft to stabilize the nasal base in Asian patients. They selectively use the auricular cartilage in patients who have thinner, weaker septal cartilage. Most Caucasian patients have much thicker and stronger septal cartilage that works well as a septal extension graft. I routinely use septal cartilage for the caudal septal extension graft and find this cartilage has sufficient strength to support the nasal tip. On the contrary, most of the Asian patients that I augment have much thinner, weaker septal cartilage that will not support the nasal tip position. In most Asian patients I treat, I choose costal cartilage for the caudal septal extension graft or I use the thin septal cartilage but reinforce it with thin segments of ethmoid bone or slivers of costal cartilage. Another option is to use bilateral spreader grafts that extend caudal to the septum and support the caudal septal extension graft, thereby providing the added strength needed to stabilize nasal tip position. I find this approach to be much better than the use of auricular cartilage, as it is less bulky and stronger than the auricular cartilage. In addition, auricular cartilage is not flat and must be manipulated or trimmed to avoid irregularity or deviation. In their article, the authors use a double-layered auricular cartilage extension graft. I would be concerned that two layers of auricular cartilage could create some excess width to the columella, even though the authors did not see this problem in their patients.
The authors analyzed changes in nasal tip projection from an early time point (+/− 2 weeks) versus a later time point (+/− 7 months postoperatively) and found a change of 61 percent for the septal cartilage extension grafts and 74 percent for the double-layered auricular cartilage extension grafts. This was then recorded as a relapse ratio of 39 percent for the septal cartilage extension graft and 26 percent for the double-layered auricular cartilage extension graft, showing slightly less relapse with the double-layered auricular cartilage grafts. In both cases, the relapse ratio was very high, indicating that both the septal cartilage and the double-layered auricular cartilage showed statistically significant losses in nasal tip projection over time. This indicates that both the septal cartilage and the double-layered auricular cartilage lacked sufficient strength to stabilize nasal tip position in their patient population.
My colleagues and I looked at a series of 95 patients who underwent placement of a septal cartilage caudal septal extension graft stabilized to the caudal septum with a 0.25-mm polydioxanone plate (Ethicon, Somerville, N.J.).
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