The LaryngoscopeVC 2009 The American Laryngological,Rhinological and Otological Society, Inc.

How I Do It

Reconstruction of Significant Saddle NoseDeformity Using Autogenous CostalCartilage Graft With Incorporated MirrorImage Spreader Grafts

Aftab Ahmed, MB, ChB, FRCS (ORL-HNS); Pedram Imani, MBBS, FRACS; Hade D. Vuyk, MD

Key Words: Saddle nose, rhinoplasty, costalcartilage.

Laryngoscope, 120:491–494, 2010

INTRODUCTIONThe classical term ‘‘saddle nose’’ is used to describe

a number of nasal deformities of the lower two thirdsof the nose resulting from loss of septal height and tipsupport. These deformities include underprojected carti-laginous dorsum, underprojected and over-rotated nasaltip, retracted columella, acute nasolabial angle, broadnasal tip, wide alar base, and an infratip:columella ratioof 1:1. Congenital causes are rare, but previous septo-plasty or rhinoplasty, facial trauma, and septal abscessaccount for most saddle nose problems.1 Cocaine abuseand granulomatous disorders may result in the sametype of deformities.1–3 From a practical point of viewsaddle nose deformities can be classified as minimal,moderate, and major.4 Minimal saddle nose deformitiescan be camouflaged using cartilage filler grafts. The ma-jority of moderate deformities with reasonable septalsupport can be successfully treated with dorsal onlaygrafts in combination with a columellar strut and tipgraft shaped from the remaining septal and/or conchalcartilage. However, major saddle nose deformities, often

devoid of septal cartilage, require significant structuralrestoration to resupport the lower two thirds of the nose.Conchal cartilage lacks both the strength and volume, incontrast to rib costal cartilage, which fulfils theserequirements. Autogenous rib costal cartilage doesrarely get infected or extrude.5 Moreover, resorption isless as compared to homologous irradiated rib cartilagegrafts.6,7 However, warping of the costal cartilage,whether autogenous or homologous in origin, is anestablished major problem that can lead to obvious post-operative deformities of the nose. We report a techniquethat may overcome the potential of warping when ribgrafts are used to reconstruct the lower two thirds of thenose (major and moderate saddle nose deformity).

SURGICAL TECHNIQUEThe nasal cartilages and bones are skeletonized via

a standard external rhinoplasty approach with particu-lar attention to preserving the remaining septal mucosa.Only if insufficient septal cartilage remains, a graft istaken from the sixth rib with an incision length of 4 to 5cm. The entire circumference of the cartilaginous ribmay be dissected out from its perichondrial envelope.Alternatively, a strip of cartilage may be left inferiorly tomaintain the continuity of the rib. The costal graftshould have a length of at least 4 cm. The midportion ofthe costal cartilage is shaped as a neoseptum by carvingthe cartilage equally on each side. These outer slices willwarp away from the central component by the nature ofreleased interlocked stresses. Both outer aspects of thecostal cartilage, which were shaved off as longitudinalstrips, can now be sculptured symmetrically to form twospreader grafts.

The caudal end of the septal part of the reconstruc-tion is secured onto the anterior nasal spine (ANS) bydrilling two small burr holes tangentially through theANS and one burr hole in the caudal protruding edge. A

From the Department of Otolaryngology, Facial Plastic andReconstructive Surgery, Tergooi Hospitals, Blaricum (H.D.V., P.I.), TheNetherlands; and Doncaster Royal Infirmary, Doncaster, United Kingdom(A.A.).

Editor’s Note: This Manuscript was accepted for publicationAugust 27, 2009.

Send correspondence to Hade D. Vuyk, Department of Otolaryn-gology, Facial Plastic and Reconstructive Surgery, Tergooi Hospitals,1261 AN Blaricum, The Netherlands.E-mail: hvuyk@tergooiziekenhuizen.nl

DOI: 10.1002/lary.20736

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stable fixation of the neoseptum is created by suturingthe neoseptum to the ANS using 3/0 Vicryl, which ispassed through the burr holes. The inferior part of theneoseptum that will come to rest on the ANS, and themaxillary crest can be beveled so that the free caudalborder will be positioned in between the medial crura at120�. The more ventral part of the graft is used formedial crural support. In all cases, the septal graftextends caudally to be able to reproject the tip by fixingthe medial crura to the septal graft in a tongue-in-groove fashion.

The longitudinal costal cartilage strips are placedin a mirror image fashion in between the septum andthe separated upper lateral cartilages and suture-fixatedto the costal cartilage neoseptum using 4/0 polidioxa-none (PDS) mattress sutures. Using these warped costalcartilage strips in a mirror image fashion neutralizestheir warping tendencies. The superior ends of thespreader grafts are attached on both sides of a remain-ing dorsal septal strut near to the keystone area. Thespreader grafts are fixed in a position so that they pro-ject above the free edges of the collapsed alar cartilagesaiming to give more height to the middle third of thenose. Caudally, the two spreader grafts slightly overlapthe reconstructed neoseptum (Fig. 1). Thus, a strong

laminated longitudinal midline structure results, provid-ing strong midline support for the entire lower twothirds of the nose.

Subsequently, the dorsal aspect of the compositeneoseptum þ spreader grafts is aligned with a 27-g nee-dle and secured with 4/0 PDS sutures to the upperlateral cartilages. The septal mucosa is secured to theneoseptum with 4/0 Vicryl Rapide (Ethicon, Somerville,NJ) mattress sutures. Any minor dorsal deformities arecamouflaged with shaped and bruised cartilage grafts orsoft tissue grafts, such as perichondrium or temporalisfascia. Further tip refinement is done as required at thisstage. The incisions are closed and the neoseptum issupported with light nasal packs and an external nasal

Fig. 1. (A) Composite structure of neoseptum and two mirrorimage spreader grafts. The exact size of the graft will be shapedwhen secured inside the nasal mucosal envelope and fixed to theremaining structures. The high spreader grafts will project abovethe upper lateral cartilages to correct the under projected middlethird. (B) The warped spreader grafts are secured to the neosep-tum in a mirror image fashion. [Color figure can be viewed in theonline issue, which is available at www.interscience.wiley.com.]

Fig. 2. Preoperative (A, B, and C) and 18-months postoperativeviews (D, E, and F) of patient with significant collapse of the lowertwo thirds of the nose with inadequate remaining septal cartilage.The under projection of the lower two thirds of the nose was cor-rected with autogenous costal cartilage graft with incorporatedmirror image spreader grafts. Bruised extremely thin rib wasplaced in the nasofrontal angle and K areas. Supratip contourenhanced with perichondrial grafts taken from the concomitantlyharvested conchal cartilage. [Color figure can be viewed in theonline issue, which is available at www.interscience.wiley.com.]

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splint is applied. Figure 2 demonstrates the surgical out-come of this technique.

DISCUSSIONDepression of the lower two thirds of the nose is

predominantly due to the loss of septal height and sup-port.1,2 Septal integrity is essentially dependent on astrong L-shaped dorsal and caudal cartilage strut withadequate attachments to the nasal bones and maxilla.Tip position is largely dependent on adequate support.Reconstruction of a major saddle nose deformity requiresstructural replacement—a common indication for ribgrafting. This involves reconstruction of dorsal and cau-dal support structure with two articulated pieces of rib8

or a single unit costal cartilage graft.9 Alternatively, therib graft can be used to create a stable midline septum.10

The main problem with rib costal cartilage used for dor-sal augmentation is its tendency for warping.11–13

Hence, to address this problem principally, alternativeosseocartilaginous grafts in various configurations havebeen described.14–17 Our technique involves reconstruct-ing a stable midline extended septal structure that alsoprovides support to the cartilaginous vault andaddresses the problem of cartilage warping.

Although the complete pathogenesis of warping isnot fully understood, inhibition of protein polysaccharidecomplexes appears to lead to reduction of interlockingstresses leading to warping.12 The technique of balancedcross-sectional carving of rib costal cartilage to minimizewarping is well established.11 However, a curved rib can-not be modified into a straight dorsal or columellar graftwithout violating the principles set forth by Gibson andDavis.11 Allowing time for the initial warping to occurfollowing harvesting of the cartilage before carving isanother routine practice, as studies have shown that90% of warping occurs within 60 minutes of harvest-ing13,18; however, warping may continue over a 4-weekperiod.18

Internal stabilization of rib cartilage with Kirschnerwires to prevent warping has been described, but pre-vention of warping is not always guaranteed.19 The useof dorsal cartilage in a laminated fashion has beenreported recently.20 This seems a good idea, but thelaminated graft still needs asymmetric shaping toexactly conform to the dorsum.

In the technique that we describe, the neoseptum isreconstructed using the central part of the graft (to min-imize warping effect) and has a stable fixation point tothe ANS. The dorsum is reinforced with the mirrorimage costal cartilage spreader grafts. The momentthese strips are shaved off from the central portion ofthe costal graft, the released interlocked stresses causethese strips to bend. The natural warping appearance isprevented by applying them in a mirror image fashion.The extended septal plate and spreader grafts interdigi-tate to produce a strong midline structure to whichfurther rhinoplasty techniques can be applied. Thesespreader grafts also provide additional support in pre-venting collapse of the cartilaginous vault and indeed

can address the concomitant collapsed nasal valve. Thenewly created strong middle third of the nose acts as astrong bar to counter rotate the often over-rotated tip,and the neoseptum does provide support for increasednasal projection. The tongue-in-groove technique helpsrecreate the nasal tip support mechanisms so thatadequate tip position and shape can be achieved.

In our experience we have not had any exposure ofthe graft even when there is minimal septal cartilagepresent as careful and extensive dissection of the septalmucosal flaps is performed. If there is a concomitantseptal perforation present, then careful and more exten-sive mucosal dissection onto the nasal floor andupstanding wall allows mobilization of the mucosal flapsand approximation of the perforation edges. In suchcases the costal cartilage graft can act as an interposedscaffold as an aid in closure of the perforation.21

While using this technique in 14 patients, we havenot had any incidences of postoperative deformity due tograft warping, resorption, visibility, or displacement.One must be aware that although the tendency might beto provide the best possible support, the neoseptum andthe caudal attachments of the extended spreader graftsmust be thinned down so as not to leave too much bulkin the caudal nasal septum and valve area. Our experi-ence has reinforced the concept of harnessing thewarping forces inherent to shaped rib grafts so as to pro-duce a strong L-shaped midline support for saddle nosedeformities.

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