COSMETIC

Rhinoplasty: Septal Saddle Nose Deformity and

Composite Reconstruction
Rollin K. Daniel, M.D.
Newport Beach, Calif.
Background: Saddle nose is one of the most challenging deformities in all of
rhinoplasty surgery. Recent advances in aesthetic reconstructive surgical tech-
niques warrant discussion of this subject.
Methods: A review of saddle nose cases revealed that an important subgroup
exists, which has been designated the septal saddle nose deformity. The patho-
physiology was weakening or loss of septal support, and not the classic dorsal
overresection. A prospective study of 25 consecutive cases was then completed,
with emphasis on analysis, classification, and treatment.
Results: Prior attempts at classification have emphasized cause. The author’s
study indicated that the majority of cases had multiple causes, with acute trauma
followed by a complete septorhinoplasty the most common, as opposed to
simple fracture reduction. In addition, 10 of 25 cases were true secondary saddle
nose deformities. Classification was divided into types I through V based on
presenting deformities and method of treatment. A new method of composite
reconstruction was devised that allows one to construct a deep structural foun-
dation layer that is then superimposed with an aesthetic layer.
Conclusions: Septal saddle nose is an important entity that must be recognized and
treated, especially when it is progressive. Composite reconstruction offers a unique
solution to saddle nose deformity, as it is a flexible method of restoring structural
support and aesthetic contour. (Plast. Reconstr. Surg. 119: 1029, 2007.)

S
addle nose deformity and its changing treat-
ment have been a critical part of the evolu-
tion of plastic surgery. As summarized in ex-
cellent review articles, the predominant cause has
progressed from disease to trauma to now surgery,
whereas the treatment has shifted from complex
flap reconstructions to restoration of septal
support.1–3 The present article details a classifica-
tion and treatment of saddle nose deformity within
the context of modern rhinoplasty surgery and
emphasizes a new entity, septal saddle nose defor-
mity. In addition, a new simplified concept of
composite reconstruction is presented in
which a deep foundation layer for septal sup-
port is restored first and then a more superfi-
cial aesthetic contour layer is added.
CLASSIFICATION AND TREATMENT
The first step in any classification system is to
define the entity. I have chosen to make the de-
Received for publication November 26, 2005; accepted
January 12, 2006.
Presented in part at the Annual Meeting of the Rhinoplasty
Society, in New Orleans, Louisiana, May of 2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000252503.30804.5e
fining characteristic compromise of septal support
caused by loss of integrity within the septum itself.
This strict interpretation excludes many pseudo-
saddle noses which are caused by overresection of
the dorsum during rhinoplasty surgery and can be
easily corrected by dorsal augmentation (Fig. 1,
above). Identification of cases caused by septal
compromise can be confirmed by the septal sup-
port test in which the patient presses on the tip of
the nose, which collapses the lobule against the
upper lip (Fig. 1, below). This simple test empha-
sizes the etiologic role of the septum and the need
for reconstructing septal support, especially in
cases where the saddling is progressive. Many sur-
geons have attempted to classify acquired saddle
nose deformities on the basis of cause: trauma,
surgery, disease, or drugs. As is discussed in the
following section, saddle noses often have multi-
ple causes and multiple prior operations. Despite
etiologic confusion, it is extremely important to
take a detailed history of the sequential events that
contributed to the current deformity (see case 3).
Ultimately, the most valuable classifications
are ones that integrate both clinical deformity and
treatment, with excellent ones provided by Tardy
et al.,4 Alsarraf and Murakami,5 and Vartanian and
Thomas.6 The present classification attempts to

www.PRSJournal.com 1029
 Plastic and Reconstructive Surgery • March 2007

Fig. 1. (Above) Photographs of a 53-year-old secondary rhinoplasty patient with a classic saddle nose deformity caused by an over-
resected dorsum, but with normal septal support and corrected surgically with a diced cartilage graft and no deep foundation layer.
(Below) Photographs of a 21-year-old patient with posttraumatic saddle nose deformity and deficient septal support that required a
deep foundation support. Compressing the tip indicates the level of septal support: positive support above, negative support below.

integrate the external appearance of the nose with Type 0 (Pseudosaddle)

compromise of septal support and selection of
surgical treatment (Figs. 2 and 3). However, these
cases are often complex, leading to a “mixed”
cause and treatment, thereby emphasizing
the need for designing the operation to fit the
specific deformity.
These patients present with depression of the
cartilaginous vault following a prior rhinoplasty.
They can occur as an absolute depression caused
by overresection of the cartilaginous vault, a rel-
ative depression of the cartilaginous dorsum

1030
Volume 119, Number 3 • Septal Saddle Nose Deformity
Fig. 2. Pathophysiology of septal saddle nose deformity. Type I
(above) indicates a loss of septal support and columellar retrac-
tion. Type II (second row) shows additional loss of tip projection
and rounding out of the nostrils. Type III (third row) cases show a
marked flattening of the tip and shortening of the nose, with sig-
nificant basilar deformity. Type IV (below) shows involvement of
the bony vault and further loss of lobular support.
caused by a prominence of the bony vault, or a
combination. However, the cause is not linked to
septal surgery, but rather dorsal modification.
Septal support is excellent and there is a neg-
ative septal support test.
Type I (Minor: Cosmetic Concealment)
These cases have excessive supratip depression
and columellar retraction but normal septal sup-
port. The true etiologic factor is a weakening of
septal support, but it is not progressive. Cosmetic
Fig. 3. Surgical correction of septal saddle nose deformity.
(Above) Cosmetic concealment using diced cartilage for the dor-
sum and a crural strut for the columellar labial angle. (Second row)
Cartilage vault grafts attached to a columellar strut restore the
ideal profile line with use of alar rim grafts. (Third row) Composite
reconstruction. Foundation layer of pistol spreader grafts and a
true septal strut to provide deep support. Aesthetic layer of col-
umellar strut with alar advancement and a diced-cartilage graft
wrapped in fascia to restore the dorsum. (Below) A classic rib graft
and strut to provide structural support to the entire nose.
concealment is possible, provided that the septal
compromise is static. The simplest method of cor-
recting supratip depression is with diced cartilage
grafts.7,8 These grafts are inserted into the recipient
site by means of an intercartilaginous incision; no
overgrafting is required. Concealment of columellar
contraction can be achieved with filler grafts or wrap-
around grafts inserted through a transfixion inci-
sion. True structural correction of columellar retrac-
tion can be achieved with a columellar strut inserted
from either a closed or an open approach.
Type II (Moderate: Cartilage Vault Restoration)
The dominant factor is compromise of septal
support, which leads directly to cartilaginous vault
1031
 Plastic and Reconstructive Surgery • March 2007
collapse, columellar retraction, and loss of tip sup-
port. The easiest method of correction is a com-
bination of extended vault grafts and a true col-
umellar strut. If possible, the cartilage is harvested
from the remaining septum, with rib cartilage as
an alternative. The first step is making extended
vault grafts (20 to 25 ⫻ 3 mm). In addition, a true
columellar strut is cut that is quite long and wide
(25 ⫻ 8 mm) as opposed to a crural strut (20 ⫻
3 mm). The columellar strut is designed to both
push down the columellar labial angle and pro-
vide support for the entire lobule.9. The columel-
lar strut is inserted between the alar cartilages,
with its maximum width at the columellar labial
angle, and then fixed with no. 25 needles. The
extended vault grafts are placed on either side
of the dorsal septum and fixed cephalically with
a no. 25 needle. The caudal end of the vault
grafts are angulated upward on the columellar
strut until the desired dorsal profile line is ob-
tained (Fig. 4). Once the surgeon is satisfied
with the dorsal line, the grafts are sutured to-
gether with 4-0 and 5-0 polydioxanone sutures.
Every effort is made to achieve a narrow colu-
mella and defined tip by advancing the alar
cartilages caudal to the columellar strut and
then over the strut’s most projecting point.
Type III (Major: Composite Reconstruction)
In major cases, there is a total absence of septal
support for the cartilaginous vault, columella, na-
sal tip, and external valves. Flattening of the nose
is obvious in all views. Whenever possible, a com-
posite reconstruction is performed. The funda-
mental concept is to reestablish support for the
nose first and then to achieve the desired aesthetic
contour. This two-part approach allows greater
finesse and less reliance on the vagaries of rib
reconstruction. A deep foundation layer is recon-
structed using spreader grafts and a septal strut.
An overlying aesthetic contour layer is provided by
diced cartilage in fascia for the dorsum and a
columellar strut with alar advancement and/or tip
graft for the tip. In most cases, autogenous rib
cartilage is required, as the quantity of required
cartilage exceeds septal material and the rigidity
of cartilage required precludes conchal cartilage.
The rib grafts are harvested at the beginning of the
case to minimize infection and to permit prelim-
inary carving. Depending on the operative team,
rib harvesting and exposure of the nose can be
performed concurrently, thereby reducing oper-
ative time. The foundation layer consists of long
spreader grafts (35 ⫻ 3 mm) whose contour fol-
1032
lows the rib curvature and facilitates placement
under the bony vault cephalically. Gunter refers to
these as “pistol” grafts.10 The septal strut is de-
signed to replace the vertical component of the
L-shape dorsocaudal septum. It can be fixed to the
nasal spine directly or through a gingival incision.
The aesthetic layer consists of a dorsal diced car-
tilage wrapped in fascia graft and a supported
aesthetic tip. A columellar strut is placed between
the alar cartilages and then the alae are advanced
upward with multiple sutures. The desired tip is
achieved with sutures if possible If additional tip
definition or projection is required, either onlay
or shield shape tip grafts can be added. Once the
ideal tip is achieved, dorsal augmentation over
the cartilaginous vault can be achieved with fas-
cia, diced cartilage, or diced cartilage wrapped
in fascia grafts. The dorsum is augmented until
the desired profile is achieved. Collapse of the
vestibular and nostril valves requires insertion of
alar rim support grafts.11 These grafts are made
from shaved curled rib segments measuring 20 ⫻ 3
to 6 mm but are very thin (1 mm) and contoured
to maximize aesthetic nostril contour while pro-
viding the requisite support. Essentially, they are
variations of Sheen’s alar grafts. They are sutured
along the alar rim rather than being inserted
through an alotomy incision in the alar base.12
Type IV (Severe: Structural Reconstruction)
These cases represent the endstage of septal
collapse. They are compounded by bony vault dis-
ruption and severe contracture of the nasal lining
often associated with major septal perforations.
Septal collapse has occurred resulting in cartilage
vault depression and columellar shortening. The
nasal tip has lost its projection and the nostrils are
broad. There is no support to the vestibular and
nostril valves, resulting in dramatic compromise of
the external airway. The nasal lobule is often ro-
tated upward. The nose is short in absolute terms,
which is further emphasized by an acute nasolabial
angle. Depression of the bony vault is a major
factor that may limit support for the reconstruc-
tion. The greater the bony vault destruction and
the severity of the lining contracture, the greater
the need for a structural dorsal graft. As shorten-
ing and upward rotation of the nose becomes the
overriding deformity, the greater the need for a
cantilevered dorsal graft integrated with a colu-
mellar strut to provide a new framework for the
nose.13 Release of the nasal lining sleeve and clo-
sure of the skin envelope are often major chal-
lenges in these cases.3 Ultimately, rib reconstruc-
Volume 119, Number 3 • Septal Saddle Nose Deformity

Fig. 4. Operativetechniques.(Above)Cartilagevaultgraftsadvancedonacolumellarstruttorestoreidealdorsalprofileline.Case
1. (Second row) Pistol spreader grafts and columellar strut of costal cartilage fixed together by a step-off method. (Third row)
Fixation of the septal strut to the anterior nasal spine followed by packing of diced cartilage into the peripyriform area. Case 2.
(Below) Removal of prior grafts including dorsum, columellar strut, and tip graft. Grafts to be inserted included diced
cartilage and fascia, pistol spreader grafts, columellar strut, and a full concha composite graft subdivided into four grafts.

1033
 Plastic and Reconstructive Surgery • March 2007
tion becomes the only option, and it serves as both
structural framework and aesthetic contour. In
general, the author prefers an osseocartilaginous
dorsal graft from the ninth rib, as there is minimal
risk of warping and no need for internal Kirschner
wire stabilization. The dorsal graft is inserted into
a smooth recipient bed and fixed with percutane-
ous Kirschner wires proximally, which will be re-
moved at 7 days, and sutured distally. The con-
toured structure strut is inserted between the
crura down to the premaxilla. A gingival incision
is made and the anterior nasal spine exposed. A
drill hole is made in the nasal spine, the legs of the
septal strut are split vertically, the septal strut strad-
dles the nasal spine, and they are then sutured
together with 4-0 polydioxanone.1,13 The strut is
designed to rise above the dorsal graft, thereby
bringing the tip above the dorsal line. The rela-
tionship of the strut to the dorsal graft varies,
depending on the severity of the shortening and
envelope contracture. Although appositional flex-
ibility is desired, a rigid tongue-in-groove fixation
is often required. Advancement of the alar carti-
lages over the strut is attempted, but partial ad-
vancement is often the limitation, and an isolated
tip graft is sutured to the strut. Total support of
alar rims and vestibule is a requisite, and major
batten grafts are inserted (20 ⫻ 6 to 10 mm, 2- to
3-mm thickness).
Type V (Catastrophic: Nasal Reconstruction)
The majority of these cases have progressed
from reconstructive aesthetic rhinoplasty to aes-
thetic reconstruction of the nose and its adjacent
tissues. Many will require forehead flaps for either
lining or skin coverage. Equally significant, the
bony deformity extends further into the facial skel-
eton, warranting some type of degloving approach
and extensive bone grafting and/or plating.
These cases are best referred to surgeons who have
a high degree of special expertise.14,15
CLINICAL SERIES
After a review of saddle nose cases, the au-
thor identified the subgroup of septal saddle
nose cases and initiated a prospective study of 25
consecutive cases over a 2-year period for a 5 per-
cent (25 of 492) incidence. All classic saddle nose
cases caused by overresected dorsum (type 0) were
excluded. This distinction is critical. If one were to
use “dorsal depression” as the criterion for a sad-
dle nose and then apply the septal compression
test, approximately 75 percent of these patients
would have intact septal support and many would
1034
never have had prior septal surgery. In contrast, 25
percent of saddle nose cases would have inade-
quate septal support as diagnosed by the septal
compression test, and major reconstruction of the
septum would be necessary. There were no cases
resulting from severe nasofacial trauma or cancer
resection (type V). The data indicate an age range
of 18 to 67 years, with 14 women and 11 men. The
primary etiologic factors were trauma (n ⫽ 11), sur-
gery (n ⫽ 9), drugs (n ⫽ 4), and infection (n ⫽ 1).
Of special interest was the further subdivision into
single (n ⫽ 10) and multiple (n ⫽ 15) causes. The
most common combination was an initial nasal
trauma followed by extensive surgical treatment.
The initial trauma produced a saddle deformity in
only three of 15 cases, whereas the subsequent
surgical intervention was to blame for the onset of
saddling in 12 of 15 of these multiple cause cases.
This is explained in part by the fact that the initial
surgery was not a simple closed or open nasal
fracture reduction but rather a complete septo-
rhinoplasty designed to correct the traumatic de-
formity and to improve the aesthetic appearance
of the nose. Of special interest, 10 patients had
true secondary saddle nose deformities with failed
prior surgical attempts at correction. Within this
group, three patients had had total absorption of
their cadaver cartilage grafts and two had had
extrusion of their alloplastic implants. This con-
firms again the futility of using alloplasts or ho-
mografts in high-risk cases. Another critical factor
was the incidence [eight of 25 (32 percent)] of
septal perforation, with equal distribution be-
tween cocaine and prior surgery. Cocaine defor-
mities are extraordinarily complex because of the
widespread destruction that can progress beyond
the septum and nasal lining with extension into
the cartilaginous vault, paranasal sinuses, palate,
and even overlying skin. The importance of a de-
tailed history and physical examination cannot be
overemphasized. Although one can be mesmer-
ized by the external deformity, a detailed internal
examination and operative plan for functional fac-
tors is of equal importance. Persistence of septal
deviation is often present, as are septal perfora-
tions. Internal valve collapse is a common finding,
as is vestibular collapse with compromise of the
external valve. Careful assessment of the nasal lin-
ing is critical, and a decision must be made as to
its mobility. Using the prior classification, our se-
ries can be subdivided into the following types:
type I (n ⫽ 7), type II (n ⫽ 7), type III (n ⫽ 8), and
type IV (n ⫽ 3). It should be noted that because
of recent success with the composite reconstruc-
tion technique, the number of structural recon-
Volume 119, Number 3 • Septal Saddle Nose Deformity
structions has decreased markedly from 10 years
ago. At a mean follow-up of 16 months, there have
been no cases of infection, extrusion, or absorp-
tion of any grafts, and no revision surgery, al-
though one is planned. Because of the fascial
wrap, the diced cartilage is not palpable under
thin skin.7 In cases of vascularly compromised,
thin, scarred skin, a more superficial layer of fascia
alone would be added on top of the diced cartilage
wrapped in fascia graft for further padding. On
the basis of experience with more routine second-
ary cases, any visible edges are easily removed sec-
ondarily under local anesthesia with a pituitary
rongeur. There has been no evidence of absorp-
tion in over 150 consecutive cases followed for
up to 3 years.11 Because of the simplicity of treat-
ing type I cases and prior publications dealing
with type IV cases,1,9,13 emphasis is placed on type
II and type III cases.
CASE REPORTS
Case 1: Cartilage Vault Restoration
A 21-year-old student presented with a history of nasal
trauma followed by gradual saddling of her nose over a 6-month
period (Figs. 5 and 6). There was no septal support on palpation
(Fig. 1). The patient’s respiratory function was compromised by
numerous intranasal polyps and inferior turbinate hypertro-
phy. Surgical correction of this type II saddle deformity con-
sisted of the following:
1. To gain access to the nasal cavity, it was necessary to
resect first the intranasal polyps.
2. The septum was exposed through a unilateral transfixion
incision, and multiple fracture lines were found within
the body of the septum.
3. An open approach was performed and the dorsum ex-
posed.
4. The upper lateral cartilages were split off from the dorsal
septum.
5. Harvest of the septal cartilage was performed leaving a
10-mm L-shaped strut.
6. Vault spreader grafts and a columellar strut (25 ⫻ 7 mm)
were inserted. The vault spreader grafts were advanced
upward 5 mm on the strut and sutured into place.
7. The alar cartilages were then advanced on the strut, and
a suture tip procedure was performed consisting of strut,
domal creation, and interdomal sutures.
8. Transverse and low-to-low osteotomies were performed.
9. All incisions were closed. Doyle splints and external cast
were applied.
Note that there was no dorsal reduction whatsoever, only
elevation of the cartilage vault grafts to restore the ideal dorsal
profile line, whereas the 7-mm-wide columellar strut pushed
down the columellar labial angle.
Case 2: Structural Support
A 43-year-old woman presented with a history of substance
abuse in her twenties resulting in a collapsed nose and a 4-cm
septal perforation (Figs. 7 and 8). The need for structural
support in this type III septal saddle nose was the indication for
a rib graft. Note that asymmetrical nostrils are quite common
in substance abuse cases, as is the soft-tissue contracture in the
peripyriform area, thus requiring major augmentation.
1. Harvest of portions of the eighth and ninth ribs.
2. Initial carving of a 4-cm columellar strut from the ninth
rib plus cartilage vault and alar rim grafts from the
eighth rib. The remaining cartilage was diced.
3. Open approach with dorsal exposure followed by split-
ting off of upper lateral cartilages from the septum.
4. Gingival incision. Exposure and placement of a drill
hole in the anterior nasal spine.
5. Insertion of the columellar strut, splitting its base for
straddling the anterior nasal spine, and then suture
fixation with 4-0 polydioxanone.
6. Insertion of cartilage vault grafts, elevation, and fixation
onto the columellar strut.
7. Mobilization of the alar cartilages and suture over the
strut.
8. Closure of all the nasal incision followed by insertion of
major alar rim grafts.
9. A 12 ⫻ 4-mm composite graft inserted into the con-
tracted left nostril.
10. Augmentation of the peripyriform and subnasal areas
using 5 cc of diced cartilage.
Case 3: Composite Reconstruction (Primary)
A 47-year-old man presented with a significant saddle nose
deformity 13 months after facial trauma. The initial history was
severe facial trauma requiring reduction of a Le Fort I fracture
at 1 week followed by gradual saddling of the nose over a 3- to
4-month period (Figs. 9 and 10). Further questioning revealed
that the patient had had a major aspirin-induced epistaxis on
the third postoperative day requiring extensive nasal packing
for 10 days. Internal examination revealed a large septal per-
foration and no evidence of caudal septal support. The nasal
lining was contracted, which made a structural reconstruction
the initial choice. However, careful examination indicated that
lengthening of the nose was possible with a composite recon-
struction, and the following operation was performed for this
type IV saddle nose deformity:
1. Harvesting of cartilaginous portions of the eighth and
ninth ribs, plus deep temporal fascia.
2. An open approach with elevation of the soft-tissue enve-
lope. Septal exploration.
3. Insertion of a septal strut with a V-overlap and suture
fixation to the anterior nasal spine by means of a gingival
incision.
4. Insertion of pistol-shaped spreader grafts beneath the
bony vault cephalically and fixation to the septal strut
caudally.
5. Tip creation with a major columellar strut to push down
the columellar labial angle followed by upward advance-
ment of the alar cartilages and a concealer tip graft.
6. Unilateral left low-to-low osteotomy.
7. Dorsal creation with a 1-cc syringe of diced cartilage
wrapped in fascia.
8. Closure with incorporation of major alar rim support
grafts.
DISCUSSION
The saddle nose deformity has always been an
enormous challenge for rhinoplasty surgeons. In
1035
 Plastic and Reconstructive Surgery • March 2007

Fig. 5. A patient with posttraumatic type II septal saddle nose deformity corrected with
vault spreader grafts and a columellar strut using septal cartilage. The operative tech-
nique is shown in Figure 4.

the modern era, major contributions have come
from Sheen and Sheen,12 Meyer,3 Tardy et al.,4 and
Gunter et al.10 The author acknowledges their in-
fluence on his work and makes no claims of orig-
inality. It should be noted that all of these sur-
geons have condemned the use of alloplastic grafts
and cadaver cartilage in saddle nose deformity.
Although numerous areas of discussion are pos-
sible, pathophysiology and surgical techniques
seem most worthy. One important observation is
that there are very few “pure” saddle nose defor-
mities, either etiologically or surgically. There-

1036
Volume 119, Number 3 • Septal Saddle Nose Deformity
Fig. 6. Same patient as shown in Figure 5.
fore, one must be prepared to use a component
approach to each defect and design an individu-
alized operative solution for each case.
Cosmetic Concealment
These are the simplest of the saddle nose
deformities, as they do not require restoration
of septal support. In most cases, there is an
obvious depression in the supratip area that
needs filling and slight retraction of the colu-
mellar base. The pathophysiology is usually a
static “septal sagging” that follows a prior iso-
lated septoplasty or nasal trauma. Tip projection
and rotation are normal, and no progression of
the deformity is likely. The classic methods of
diced cartilage grafts or fascia or both remain
simple and effective options. More complex
methods of rotating cephalic lateral crura or
solid cartilage grafts have a higher risk and are
not as flexible a solution.
Cartilage Vault Restoration
With loss of septal support, the reconstruction
becomes more demanding, requiring both septal
and tip correction. The simplest method of re-
construction is insertion of cartilaginous vault
spreader grafts and a true columellar strut. The
vault spreader grafts are relatively long (25 mm)
and more rigid than standard spreader grafts. A
columellar strut differs from a crural strut in that
it is longer (25 mm) and has a wider tapered width
(6 to 8 mm) designed to push down the columellar
labial angle. The columellar strut is inserted be-
tween the crura and fixed with a single strut suture
1037
 Plastic and Reconstructive Surgery • March 2007

Fig. 7. A 43-year-old woman with long-standing type III nasal collapse including a 4-cm
septal perforation. This was corrected with rib grafts divided into vault spreader grafts,
columellar strut, and diced cartilage for peripyriform augmentation. The operative tech-
nique is shown in Figure 4.

of 5-0 polydioxanone, usually at the level of the
columellar breakpoint. One should avoid too long
a graft, as it may rock across the anterior nasal
spine. In cases where the septal support is mark-
edly deficient, one can fix the columellar strut to
the anterior nasal spine using 4-0 polydioxanone.
The vault spreader grafts are fixed cephalically
with percutaneous no. 25 needles in extramucosal
pockets on either side of the septum. Caudally, the
grafts straddle the columellar strut. They are then
brought upward on the columellar strut until the
ideal dorsal profile line is obtained. This is an
important distinction between a columellar break-
point fixation used in nasal lengthening versus

1038
Volume 119, Number 3 • Septal Saddle Nose Deformity
Fig. 8. Same patient as shown in Figure 7.
this more upwardly angulated fixation that is de-
signed to reestablish the ideal dorsal profile line.
In contrast to a normal nose where the anterior
septal angle is 8 to 10 mm from the columella, the
vault spreader grafts are now crossing this area and
providing support to the supratip depression. It
should be noted that this fixation point will usually
be halfway between the columellar breakpoint
and the tip point. A step-off type of fixation, keep-
ing one vault graft long and the other shortened
to abut the columellar strut, is used to decrease
width in the septal angle area. The alar cartilages
are then advanced up and over the top of the strut
to achieve the ideal tip projection. Essentially, one
is achieving correction of the dorsal profile line
and restoring nasal support, which in turn pre-
cludes any future saddling.
Structural Reconstruction
Although pure rib graft reconstructions are re-
served for the most complex cases with marked
shortening and contraction, it is appropriate to dis-
cuss them at this point. These cases reflect the history
of reconstructive and aesthetic surgery of the nose.
Two important decisions must be made: what should
be the shape and composition of the graft? Canti-
levered grafts fixed cephalically were often necessary
in true nasal reconstruction following cancer
resection.2 In contrast, dorsal onlay grafts were used
to correct overresection in secondary rhinoplasties.3
Currently, rib graft, either osseocartilaginous or car-
tilaginous, is the material of choice. I prefer the
osseocartilaginous graft, as there is very little risk of
warping, in contrast to pure cartilaginous grafts. To-
riumi and Ries16 feel that careful carving minimizes
1039
 Plastic and Reconstructive Surgery • March 2007

Fig. 9. A patient with total type IV nasal collapse following trauma including a 3-cm
septal perforation. Composite reconstruction achieved with a foundation layer of pistol
spreader grafts and a septal strut. Aesthetic contouring was performed with a columellar
strut, tip graft, and diced cartilage wrapped in fascia graft to the dorsum.

warping, whereas Gunter et al. use internal Kirsch-
ner wires to avoid warping.10 Maintaining the desired
length requires a rigid framework, which in most
cases implies a dorsal graft abutting or fixed to a rigid
columellar strut. The dorsal graft restores mul-
tiple aspects of the nose—structural support,
dorsal augmentation, and aesthetic contour.
Equally, the columellar strut will directly affect
tip projection, nasal length, and alar base sup-
port. Often, the alar cartilage remnants are min-
imal, and skin closure is under great tension,
which increases the role of the columellar strut

1040
Volume 119, Number 3 • Septal Saddle Nose Deformity
Fig. 10. Same patient as shown in Figure 9.
in defining tip projection above the dorsal line.
Therefore, any deviations or imperfections of
these grafts are magnified, both functionally
and aesthetically. It is for this reason that a com-
posite reconstruction separating structural sup-
port and aesthetic contour has been developed.
Composite Reconstruction
As the septum collapses, functional and aes-
thetic problems multiply. Three areas must be
discussed: structural support, aesthetic contour,
and alar base support. As reviewed in the prior
section, the majority of saddle noses have been
corrected using a dorsal graft that is cantilevered
cephalically on the bony vault with either apposi-
tion or support caudally from a columellar strut.
These grafts provide both structure and aesthetic
contour for the nose. In contrast, composite re-
construction splits these two objectives into a deep
foundation layer that provides a rigid structural
framework and a more superficial aesthetic con-
tour layer. Essentially, one has a “nonvisible” foun-
dation layer and a “visible” aesthetic layer. Con-
ceptually, the deep foundation layer is designed to
replicate the normal preexisting L-shaped septal
dorsocaudal strut. It consists of paired pistol
spreader grafts and a true septal strut. Essentially,
it is similar to a “total septoplasty” in which the
L-shaped dorsocaudal strut is replaced.16,17 This is
a true replica of the septum and not an extended
type of graft designed to influence the columella
or provide support for the alar cartilages. As de-
veloped by Gunter et al.,10 the pistol spreader
1041
 Plastic and Reconstructive Surgery • March 2007
grafts follow the natural curve of the costal rib
segment and are designed to fit under the ce-
phalic bony vault. Their thickness is varied to allow
for restoration of midvault width and their length
replicates that of the normal dorsal septum. The
septal strut is not a columellar strut but rather a
true replacement of the caudal portion of the
septal dorsocaudal strut (i.e., the vertical portion
of the L-shaped strut). It is designed to rest on the
anterior nasal spine. The septal strut is split ver-
tically for 5 mm, straddles the anterior nasal spine,
and is then sutured to a drill hole in the anterior
nasal spine using a 4-0 polydioxanone suture. It is
rigidly fixed to the pistol spreader grafts superi-
orly. The pistol spreader grafts are sutured to the
upper lateral cartilages and septal remnants at two
points using a 4-0 polydioxanone suture in a five-
layer sandwich configuration. The septal strut is
sandwiched in a step-off fashion between the pistol
spreader grafts and rigidly fixed with 4-0 polydiox-
anone sutures. Initially, the strut was placed in-
between the two spreader grafts, but this produced
an extremely wide area that could potentially
block the nasal airway. Therefore, the spreader
grafts have been narrowed significantly, approach-
ing 2 mm in width, and a step-off configuration is
used. Essentially, one graft is left long to fix to the
strut and the other graft is shortened and serves as
a backstop for the strip. This modification has
resulted in a 50 percent narrowing of the junction
over the initial tongue-in-groove type of fixation.
Obviously, these grafts correct internal valve col-
lapse and improve nasal function.
Once a rigid foundation has been established,
the visible aesthetic contour can be created. A
rigid columellar strut is shaped. Its height will
provide support for the alar cartilages, thereby
restoring tip projection above the dorsal line. The
width of the strut at its base is designed to correct
the retracted columellar labial angle. Advance-
ment of the alar cartilages is performed with per-
cutaneous needles, with the goal being to derotate
and reproject the tip. In traumatic and 50 percent
of secondary cases, the alar remnants are sufficient
to restore an attractive tip. If necessary, one can
add a tip graft using excised cartilaginous rem-
nants or rib cartilage. A severe acute columellar
labial angle may require placement of small car-
tilage chips in front of the columellar strut. With
establishment of the tip, it is now possible to re-
store the appropriate dorsal height using a diced
cartilage graft wrapped in fascia.7 Rib cartilage is
diced into 0.5-mm pieces and placed in a tuber-
culin syringe, where it is compacted. The hub is
1042
cut off with a no. 10 blade. The syringe is wrapped
in deep temporal fascia that is sutured with 4-0
plain catgut. The syringe is then placed in the
dorsal pocket and injected until the desired dorsal
contour is achieved. The syringe is removed and
the fascial sleeve is sutured shut. The transcolu-
mellar incision is closed with 6-0 nylon.
Attention is then directed to restoring nos-
tril rim and vestibular support. Very thin (1- to
2-mm) grafts of rib cartilage measuring 12 to 18
mm are inserted along the alar rim. The width
of the grafts will vary depending on whether it
is only the nostril rims that are collapsed (2 to
3 mm wide) or whether the entire vestibular area
is collapsed (6 to 8 mm wide). The grafts are
sutured into the closure of the rim incision us-
ing 4-0 plain catgut. These grafts are much far-
ther caudal than a classic alar batten graft. They
are placed right along the nostril rim from soft-
tissue triangle down into the alar base and thus
are in a nonanatomical location for cartilage
tissue. However, they provide critical structural
support for the external valve. Parapyriform
augmentation with 3 to 5 cc of diced cartilage is
an important part of the surgical technique.
CONCLUSIONS
During the past 2 years, we have come to
prefer composite reconstruction, as it is an ex-
tremely flexible technique associated with very
little downside risk. Obviously, warping and mal-
alignment are not an issue, as the major struc-
tural grafts are placed in a nonvisible location.
The aesthetic contour layer is composed of a
routine columellar strut with alar advancement
and a simple diced cartilage and fascia dorsal
graft. Essentially, this is becoming a relatively
standardized reconstructive aesthetic rhino-
plasty procedure, with a high degree of aesthetic
and functional success.
Rollin K. Daniel, M.D.
1441 Avocado Avenue, Suite 308
Newport Beach, Calf. 92660
rkdaniel@aol.com
DISCLOSURE
The author receives a small stipend from Snowden
Pencer for the design of surgical instruments that is used
for educational purposes.
REFERENCES
1. Daniel, R. K. Rhinoplasty: An Atlas of Surgical Techniques. New
York: Springer, 2002.
2. Converse, J. M. Corrective and reconstructive surgery of the
nose. In J. M. Converse (Ed.), Reconstructive Plastic Surgery.
Philadelphia: Saunders, 1977.
Volume 119, Number 3 • Septal Saddle Nose Deformity
3. Meyer, R. Secondary Rhinoplasty, 2nd Ed. Berlin: Springer,
2002.
4. Tardy, M. E., Schwartz, M. S., and Parras, G. Saddle nose
deformity: Autogenous graft repair. Facial Plast. Surg. 6: 121,
1989.
5. Alsarraf, P., and Murakami, C. S. The saddle nose deformity.
Facial Plast. Clin. 7: 303, 1999.
6. Vartanian, A. J., and Thomas, J. R. Emedicine from WebMD.
Available at: www.emedicine.com/ent/topic121.htm. Accessed
March 3, 2005.
7. Daniel, R. K., and Calvert, J. C. Diced cartilage in rhinoplasty
surgery. Plast. Reconstr. Surg. 113: 2156, 2004.
8. Tardy, M. E. Rhinoplasty: The Art and Science. Philadelphia:
Saunders, 1997.
9. Daniel, R. K. Aesthetic Plastic Surgery: Rhinoplasty. Boston: Lit-
tle, Brown, 1993.
10. Gunter, J. P., Rohrich, R. J., and Adams, W. P. Special
emphasis on dorsal augmentation: Autologous rib carti-
lage. In Dallas Rhinoplasty. St. Louis: Quality Medical Pub-
lishing, 2002. Pp. 513–527.
11. Daniel, R. K. Diced cartilage grafts in rhinoplasty. Aesthetic
Plast. Surg. 6: 209, 2006.
12. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty. St. Louis:
Mosby, 1987.
13. Daniel, R. K. Rhinoplasty and rib grafts: Evolving a flex-
ible operative technique. Plast. Reconstr. Surg. 94: 597, 1994.
14. Graper, C., Milne, M. M., and Stevens, M. R. The traumatic
saddle nose deformity: Etiology and treatment (Discussion).
J. Craniomaxillofac. Trauma 2: 37, 1996.
15. Byrd, H. S., Hobar, C. P., and Shewmake, K. Augmentation
of the craniofacial skeleton with porous hydroxyapatite gran-
ules. Plast. Reconstr. Surg. 91: 15, 1993.
16. Jugo, S. B. Surgical Atlas of External Rhinoplasty. Edinburgh:
Churchill Livingstone, 1995.
17. Toriumi, D. M., and Ries, W. R. Innovative surgical man-
agement of the crooked nose. Facial Plast. Clin. 1: 63, 1993.
1043