Changing Role of Septal Extension versus Columellar Grafts in Modern Rhinoplasty

Overview

Controlling how far the tip projects and how far it rotates is central to modern rhinoplasty. Two graft types dominate: a strut placed between the nostrils, and a graft attached to the septum. This review compares their effectiveness and proposes a classification and decision algorithm.

Sections of note

• Tip projection is described as the product of several factors: length and strength of the lower lateral cartilages, the suspensory ligament, fibrous connections to the upper lateral cartilages, and the anterior septal angle.
• Columellar struts have shown moderate efficacy in maintaining tip projection and unifying the tip complex.
• Their effect on increasing tip projection has been shown to be very limited.
• Septal extension grafts effectively control projection, rotation and shape by securing the tip to the septum.
• Varieties of septal extension graft exist to support the medial crura and control tip shape, all depending on a stable caudal septum.
• The type of graft used depends on the characteristics of the underlying tip structures.
• The authors provide an updated classification of tip grafts and an algorithmic approach for choosing between them.

What it means for a patient

• A strut between the nostrils mainly holds position rather than pushing the tip forward.
• To actually increase projection, the tip is anchored to the septum instead.
• That anchoring requires the front edge of the septum to be strong and straight, which it may not be after previous surgery.
• This is a review with no measured outcomes, so it does not report rates of tip position loss over time.

Why this paper matters

Tip support choice determines whether a result holds its shape over years, and the two options are not interchangeable. Stating plainly that struts do not increase projection corrects a common assumption. No comparative outcome data accompanies the recommendation.

Terms

• Columellar strut: A cartilage piece placed between the nostrils to support the tip.
• Septal extension graft: A cartilage piece attached to the septum and projecting forward to set tip position.
• Tip projection: How far the tip stands out from the face.
• Medial crura: The inner arms of the tip cartilages, running down into the columella.
• Caudal septum: The front lower edge of the septum, behind the columella.