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Saddle nose deformity

A saddle nose is a bridge that has lost height in the middle, so the profile dips between the radix and the tip the way a saddle dips between its pommel and cantle. It happens when the septum that holds the nose up stops holding it up, after surgery, after trauma, after infection or inflammatory disease. Correcting it means rebuilding the support rather than filling the dip.

What repeats

Four findings that hold across the series.

The cause is usually the septum, and usually surgery or trauma

Most saddle noses are secondary to surgery or trauma; congenital causes exist and are rare. The common mechanism is loss of the septal L-strut, the dorsal and caudal margins that keep the nose standing, whether from over-resection at a previous operation, a septal haematoma that destroyed cartilage, or a disease that eroded it.

Rests on: Ferreira et al., the reverse spare roof technique · Cochran and Gunter, secondary rhinoplasty with rib · and the anatomy of the nose.

It sits at the top of the over-resection list

The review of what goes wrong in reductive rhinoplasty names saddle nose alongside the deep radix, the inverted-V, the polly-beak, alar retraction, the pinched tip, bossae and external valve collapse as the standing sequelae of taking too much. Its stated remedy is the same as the others': avoidance first, grafting second.

Rests on: Moritz et al., when reductive rhinoplasty goes wrong.

Correction is graded, and the grade decides the graft

A 60-patient single-surgeon series proposes an algorithm that starts with classifying the deformity by severity and cause before choosing anything. Mild loss can be camouflaged; a collapsed L-strut has to be replaced. Septal cartilage is ideal and usually insufficient in anything but the mildest case, which is why conchal and costal cartilage carry this operation.

Rests on: Battista et al., 60 patients and an algorithm · Ferreira et al. · and rib cartilage grafts.

The skin envelope is the limit, not the cartilage

A nose that has been saddled for years has a contracted soft-tissue envelope, and pushing a graft into it fails. Two answers appear in the literature: expand the skin first with a tissue expander along the dorsum in a two-stage reconstruction, or expand it with hyaluronic acid filler preoperatively. Both exist because the envelope, not the graft, is what limits how much height can be restored.

Rests on: Ostby et al., tissue expander in four patients · Battista et al., filler for preoperative skin expansion.

By cause

Where the lost support went, and what that changes.

After septal surgery

The commonest surgical cause: too much dorsal or caudal septum taken, leaving less than the 10 to 15 mm L-strut the nose needs to stand. The correction rebuilds the strut, usually from rib.

Rests on: Cochran and Gunter · and the septum and the airway.

After trauma

A fracture or a septal haematoma that was not drained. Timing is its own question: in 41 patients with nasal bone fractures, those operated within fourteen days and those operated later were compared on blinded photographic assessment, and the later group received spreader and shield grafts more often.

Rests on: Liao et al., early against late after fracture.

After inflammatory disease

Vasculitis, sarcoidosis, granulomatosis and cocaine use destroy septal cartilage from within. These are the noses with the worst envelopes, and the ones the tissue-expander papers are written about. The disease has to be quiet before the nose is rebuilt.

Rests on: Ostby et al..

The preservation exception

Dorsal preservation lowers an intact roof rather than removing it, and one published variant, the reverse spare roof, applies the same thinking to a saddle: reconstruct using the patient's own roof rather than replacing it with a graft. It is a technique note, not a comparative series.

Rests on: Ferreira et al. · and preservation rhinoplasty.

What to ask about a saddle nose

Questions the evidence supports asking.

What is left of my septum?

The answer decides everything downstream: whether the operation is a camouflage or a reconstruction, and whether the cartilage comes from the septum, the ear or the rib. Surgeons surveyed on what matters in the examination rank the septum among the regions they most want to assess for this deformity.

Rests on: Longino et al., what experienced surgeons examine.

Will my skin stretch far enough?

A contracted envelope caps the height that can be restored in one stage. If the nose has been flat for years, ask whether the plan is one operation or two, and whether skin expansion comes first.

Rests on: Ostby et al. · Battista et al..

Where is the cartilage coming from?

Septum if there is any, ear for camouflage and rim support, rib for structure. Rib carries a chest scar and about a 3% warping rate; that trade is the reason the question is asked at consultation rather than in theatre.

Rests on: rib cartilage grafts · and Cochran and Gunter.

Is the underlying disease controlled?

For a saddle from vasculitis, sarcoidosis or cocaine, the operation follows disease control. Nobody in this literature rebuilds an actively inflamed nose.

Rests on: Ostby et al..

The terms, defined

The words used about this deformity.

  • Saddle nose deformity: loss of dorsal height in the middle third from failure of septal support, giving a scooped profile. [35357956]
  • L-strut: the 10 to 15 mm dorsal and caudal septal margins that keep the nose standing; the structure whose failure produces a saddle. [20206752]
  • Dorsal onlay graft: cartilage laid on the bridge to restore height; the camouflage answer for a mild saddle.
  • L-strut reconstruction: replacing the failed support itself, usually with rib. [20206752]
  • Reverse spare roof: a preservation technique that reconstructs the saddle using the nose's own osseocartilaginous roof. [35357956]
  • Tissue expansion: stretching a contracted envelope before reconstruction, with an expander or with filler. [30566988, 42324394]
  • Septal haematoma: blood between septal cartilage and its perichondrium; untreated it kills the cartilage and is a classic route to a saddle in a child.

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and record before operating, including the airway a collapsed dorsum takes with it.

Rests on: the clinical practice guideline · the plain language summary.

What is not settled

  • Every correction series on file is one surgeon's consecutive patients. There is no comparison of camouflage against reconstruction at matched severity. [42324394, 35357956]
  • The classifications are proposals. No grading scale for saddle nose has been used across centres. [42324394]
  • Skin expansion rests on four patients for the expander and a preoperative filler protocol from a single algorithm paper. [30566988, 42324394]
  • Timing after trauma is compared in 41 patients, retrospectively, with the groups differing in what was grafted, which is the thing the outcome would depend on. [38151040]
  • Long-term height retention is barely reported: most follow-up in these series is under two years, in an operation whose failure mode is gradual loss of the height it restored.

Written by rhinoplasty.cc from the sources linked above, 2026-09-09.

Who publishes on revision and secondary rhinoplasty

Ranked surgeons with papers under this topic in the archive, most first.

Rod J. Rohrich (8) · Dean M. Toriumi (7) · Samuel Lin (5) · Richard E. Davis (4) · Sam P. Most (4) · Michael Lee (3) · Paul Nassif (2) · Angela Sturm (1) · Anil Shah (1) · Anita Patel (1)

The literature: Revision and secondary rhinoplasty, 181 papers. Video: Revision and secondary, 322 videos. Every technique.