A novel technique for short nose correction: hybrid septal extension graft. Journal of Craniofacial Surgery.

1. Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
A Novel Technique for Short
Nose Correction: Hybrid Septal
Extension Graft
Jong Seol Woo, MD,Ã
Nguyen Phan Tu Dung, MD PhD,y
and Man Koon Suh, MDÃ
Background: There are many techniques for correcting short nose
deformities and the septal extension graft is the most commonly
Brief Clinical Studies The Journal of Craniofacial Surgery Volume 27, Number 1, January 2016
e44 # 2015 Mutaz B. Habal, MD
performed technique among Asians. In many Asian patients septal
cartilage, however, is too small and insufficient to perform an
effective septal extension graft. Therefore, we designed a novel
technique, named hybrid septal extension graft to overcome this
pitfall in Asian tip plasty.
Methods: From February 2010 to March 2013, 41 patients with
primary (N ¼ 30) or secondary (N ¼ 11) short nose deformity
underwent a hybrid septal extension graft. The hybrid septal
extension graft is a modified septal extension graft which uses
the small septal cartilage along with irradiated homologous costal
cartilage. Irradiated homologous costal cartilage was carved into a
shape of a thin batten and securely fixed bilaterally to the caudal
septum. Harvested septal cartilage was located between the 2 irra-
diated homologous costal cartilage batten grafts and fixed with
sutures. Then, the alar cartilage was fixed at the end of the septal
cartilage graft. The nasal lengths, nasal tip projections, and naso-
labial angles were measured pre- and postoperatively.
Results: The hybrid septal extension graft showed enough nose
lengthening and a decreased nostril show, even in cases with a very
small septal cartilage.
Conclusions: The authors present a novel technique for correction
of short nose deformity in Asians. The hybrid septal extension graft
provides good results with minimal complications and overall
patient satisfaction was very high.
Key Words: Asians, hybrid septal extension graft, short nose
Correction of short nose deformity consists of several important
steps, such as release of alar cartilage from the upper lateral
cartilage, wide undermining and release of dorsal skin flap, and
fixation of lengthened alar cartilage. For the fixation of length-
ened alar cartilage, septal extension graft is one of the most secure
and most commonly performed techniques. Harvested septal
cartilage should be more than 25 mm in length, although this
may vary according to the needs of the patient. Most Asian
patients have very small and insufficient septal cartilage which
makes it difficult to be used as an effective septal extension graft.
For this reason, autogenous rib cartilage or irradiated homologous
costal cartilage (IHCC) may be used as an alternative. These
alternatives, however, have disadvantages. An autogenous rib
cartilage may evoke the patient’s worries about a scar on the chest
wall and they are often hesitant to go under general anesthesia.
Moreover, an autogenous rib cartilage or IHCC may lead to a very
rigid nasal tip.1,2
The hybrid septal extension graft is a modified technique of
septal extension graft that can use even a very small septal cartilage
for septal extension by using IHCC or conchal cartilage simul-
taneously to supplement the small septal cartilage. In this study, we
describe a novel technique of the hybrid septal extension graft for
correcting short nose deformities in Asian patients.
From the ÃJW Plastic Surgery Center, Seoul, South Korea; and yJW Plastic
Surgery Vietnam Clinic, Ho Chi Minh City, Vietnam.
Received June 16, 2015.
Accepted for publication August 16, 2015.
Address correspondence and reprint requests to Man Koon Suh, MD, JW
Plastic surgery Center, Samsin Building, 836 Nonhyeon-ro, Gangnam-
gu, Seoul 135-893, South Korea; E-mail: smankoon@hanmail.net The
authors report no conflicts of interest.
Copyright # 2015 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002307
MATERIALS AND METHODS
Patients
From February 2010 to March 2013, 41 patients, both women
(N ¼ 38) and men (N ¼ 3), with a different degree of short nose
underwent a hybrid septal extension graft. All 41 patients required
septal extension graft for short nose correction. Because their septal
cartilages were too small to be used as a septal extension graft, we
performed a hybrid septal extension graft using autogenous septal
cartilage combined with IHCC in 39 patients and a conchal cartilage
in 2 patients. The patients were divided into 30 primary cases and
11 secondary cases. Combined operations consisted of dorsal
augmentation with silicone implant (N ¼ 35), Gore-tex (N ¼ 2),
and dermofat (N ¼ 3). Corrective rhinoplasty was performed in
2 patients with deviated nose.
METHODS
Photometric Evaluation
We used proportional indices that were described by previous
report of Kim et al3
to evaluate the postoperative outcomes. Pre-
and postoperative lateral views were obtained from each patient
and the glabella, sellion, subnasale, pronasale, and pogonion were
identified. The proportional indices, such as nasal bridge length
index and nasal tip projection index, were measured (Fig. 1).
Also the columella-labial angle was measured. All indices were
obtained before and after surgery (Table 1). We used the paired t-test
to compare differences in these values before and after surgery.
The statistical analyses were performed by SPSS (version 19.0,
IBM, Armonk, NY).
Modified Septal Extension Grafting (Hybrid
Septal Extension Graft)
All patients were operated under local anesthesia with intrave-
nous sedation using propofol and midazolam.
Open rhinoplasty technique was performed as follows; an
inverted V-shape transcolumella incision or incision along the
previous open rhinoplasty incision scar was made and was extended
upward along the anterior margin of the medial crus, caudal margin
of alar dome area and then laterally extended along the caudal
margin of the lateral crus. In primary cases, dissection was done
above the supraperichondrial plane and the alar cartilage was fully
FIGURE 1. The points and measured indices. Glabella, the most prominent
point in the midline between the brows; sellion, the deepest point of the
nasofrontal angle at the intersection of forehead slope and nasal slope;
pronasale, the most prominent point on the nasal tip; subnasale, the point
beneath the nose where the columella merges with the upper lip in the
midsagittal plane; and pogonion, the most anterior point on the chin.

2. Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery Volume 27, Number 1, January 2016 Brief Clinical Studies
# 2015 Mutaz B. Habal, MD e45
exposed. Subperiosteal dissection over the nasal bone was done
when a dorsal augmentation was planned. Wide subperiosteal and
supraperichondrial dissection was performed to release and
lengthen the skin envelope. Transverse nasalis muscle was released
bilaterally at the pyriform aperture to further lengthen the skin
envelope. Then, the lower lateral cartilage was released for its
caudal repositioning. First, the scroll area between the upper and
lower lateral cartilage was released by a Metzenbaum scissors. This
release was done so that the thin whitish vestibular mucosa alone
was left between the upper and lower lateral cartilages. Also, a
disconnection of the accessory ligament was done if the lengthening
of the lower lateral cartilage was not sufficient with the scroll area
dissection alone. In addition, dissection of membranous septum was
sometimes necessary for a more caudal release of the lower lateral
cartilage. In secondary rhinoplasty, the release of lower lateral
cartilage was not different from that of primary case, even though
the abundant scar tissue usually makes it more difficult and time
consuming. Dual plane dissection was carried out to lengthen the
skin envelope. After elevating the scar tissue and the skin envelope,
we separated the skin envelope from the underlying scar tissue or
capsule, allowing the skin to lengthen and cover the extended alar
cartilage. The septal cartilage was harvested leaving 10 to 12 mm of
L-strut, depending on the strength of the septum.
The carved IHCC, approximately 1.0 mm in thickness and 10 to
15 mm in length, was grafted on both sides of the caudal septum
(batten type) (Fig. 2A). Ear cartilage could be used as an alternative
to IHCC. 5–0 PDS anchoring sutures were used in 3 to 4 locations
to fixate the grafts firmly. The harvested small septal cartilage was
located between the 2 IHCC batten grafts and rigidly fixated using
5–0 PDS (Fig. 2B). The tip tripod was then caudally pulled for
fixation with 5–0 PDS sutures between the bilateral alar domes and
the anterior edges of the septal cartilage graft (Fig. 3A). If the
harvested septal cartilage was exceptionally small (less than 10 mm
length), it was pulled more caudally between the IHCC grafts,
without touching the caudal septum (Fig. 3B). Tip onlay graft or
shield graft was performed for further tip projection, if necessary.
TABLE 1. Patient Information
Case Age (year) Sex Follow-up (Month)
Length Index Projection Index Nasolabial Angle
Preop Postop Preop Postop Preop Postop
1 21 F 16 33.33 36.84 7.89 10.53 113 97
2 37 F 12 31.58 38.71 8.77 11.29 104.5 94
3 35 F 14 30.77 37.29 8.46 11.02 109 89.5
4 23 F 36 31.69 35.93 8.39 10.93 105 93.9
5 27 F 12 32.05 37.32 7.52 11.23 106.5 92
6 41 F 24 31.38 36.85 7.9 10.61 108.5 96.5
7 31 F 15 33.16 38.03 8.95 11.34 106 92.5
8 33 F 12 31.37 37.42 8.42 10.38 103.5 94
9 20 F 12 31.74 38.03 8.51 11.27 108 90.5
10 29 M 14 32.63 37.82 8.06 10.78 106 94.5
11 53 F 13 30.92 36.37 8.47 11.23 110.5 92.5
12 34 F 12 31.86 36.31 8.12 11.03 107 97.5
13 27 F 16 31.54 36.88 8.64 11.45 109 97
14 19 F 12 31.77 37.13 8.83 11.26 107.5 99.5
15 35 M 13 32.47 36.95 8.19 10.66 111 96.5
16 26 F 23 33.06 38.34 8.05 10.13 106.5 98
17 36 F 15 32.75 37.29 7.62 10.51 109.5 96.5
18 42 F 12 31.77 36.01 8.71 11.2 107 93
19 23 F 36 30.56 36.42 8.54 11.16 107.5 91.5
20 37 F 12 31.23 36.97 8.69 11.05 108.5 94
21 33 F 18 31.63 37.31 8.26 10.48 109.5 93.5
22 58 F 13 31.28 38.04 8.17 10.77 105 96.5
23 28 F 12 31.26 36.75 7.83 11.12 109 96.5
24 35 F 13 30.76 59.92 8.42 11.37 105.5 97.5
25 30 F 20 32.36 37.18 8.29 10.93 107 94.5
26 24 F 16 31.52 36.82 8.34 11.28 107.5 95
27 43 F 12 31.48 38.62 8.65 10.97 110.5 96.5
28 38 F 24 32.33 37.48 8.61 11.33 106.5 94.5
29 45 F 14 31.29 38.31 8.9 11.15 108.5 96
30 22 F 12 30.86 37.25 8.34 11.2 106.5 93.5
31 19 F 12 33.16 37.03 8.79 11.16 104.5 93
32 23 F 12 32.05 38.03 8.41 10.74 105.5 96
33 34 F 18 31.72 38.36 8.53 11.04 109.5 95.5
34 32 F 14 30.58 37.71 7.71 10.85 106 96.5
35 58 F 12 31.89 38.67 8.29 11.36 107.5 97.5
36 30 F 34 31.32 36.78 8.74 11.52 111.5 96
37 29 F 21 31.07 38.42 8.58 11.29 106.5 93.5
38 27 M 12 30.95 37.47 8.45 10.86 107 96.5
39 40 F 15 31.61 36.28 8.27 11.29 104 91.5
40 25 F 12 31.27 37.79 8.07 11.16 105.5 93.5
41 33 F 14 32.19 38.32 7.94 11.24 106 95
M, male; F, Female; Preop, preoperative; Postop, postoperative.

3. Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies The Journal of Craniofacial Surgery Volume 27, Number 1, January 2016
e46 # 2015 Mutaz B. Habal, MD
FIGURE 3. The hybrid septal extension graft. A, The harvested septal cartilage is
located between the 2 irradiated homologous costal cartilage batten grafts. B, If
the harvested septal cartilage is exceptionally small, septal cartilage can be fixed
with irradiated homologous costal cartilage without touching the caudal septum.
Dorsal augmentation was done using silicone implants or Gore-
TexR
with 2.0 to 4.0 mm thickness. Silicone wrapped by deep
temporal fascia or dermofat graft harvested from buttock was used
in patients who presented with thin skin.
RESULTS
The range of nasal lengthening in 41 patients was between 3 to
10 mm (mean, 5.6 mm). There were no perioperative complications,
such as infection, resorption, warping or asymmetric tip or colu-
mella. All patients were followed up for an average of 15 months
(range 12 months to 3 years). No major complications associated
with the implants, such as exposure or migration of the implants,
necrosis of the overlying tissues, or infection caused by the implants
were noted during the follow-up period. Three cases needed minor
revision because of inadequate lengthening and tip projection. Two
patients complained of high tip projection whereas 1 patient
complained of low tip projection. Trimming of septal cartilage
and cephalic rotation of alar cartilage were performed to correct the
high projected tip. An onlay graft using the conchal cartilage was
performed to correct low tip projection.
There were statistically significant differences between the pre-
and postoperative values in nose length and nose tip projection. Also,
thenasolabialanglewassignificantlyreduced(Table2).Mostpatients
were satisfied with their nasal contour and tip projection (Fig. 4).
FIGURE 4. Cases of rhinoplasty with hybrid septal extension graft. Case 1a,
preoperative and 1b, 18-month postoperative (left). Case 2a, preoperative and
2b, 12-month postoperative (center). Case 3a, preoperative and 3b, 30-month
postoperative (right).
DISCUSSION
In this study, the hybrid septal extension graft for short nose patients
showed enough nasal lengthening and tip projection, even in
patients with a very small septal cartilage. Autogenous cartilages,
such as septal and conchal cartilages are optimal as graft materials
for nasal tip projection and derotation.4–7
In short nose corrections,
the septal cartilage is most commonly used for the septal extension
graft.8,9
Septal cartilage is used most commonly as donors because
it can directly extend and strongly support the alar cartilage and it
can be harvested easily in the same operative filed.10
Septal extension graft is an effective procedure for tip projection
and lengthening during rhinoplasty. Septal extension graft was first
reported by Byrd et al11
which was classified according to the
stability of the caudal septum and the amount of septal cartilage.
Subsequently, a few modified techniques were reported such as
tongue-and-groove technique by Guyuron et al12
and extensive
harvest technique by Kim et al.3
In these techniques, however, large
amount of septal cartilage is needed.
In Asians, however, the adequate septal cartilage harvesting is
not always possible because of insufficient quantity, deviation,
weakness, and severe ossification.13
A septal extension graft for
short nose correction needs a septal cartilage of more than 20 mm in
length. The mean septal cartilage which could be harvested was
12.1 mm  18.0 mm if the remained L-strut was of 10 mm width in a
Korean cadaver study by Kim et al.3
The harvested septal cartilage
however, is usually too small to be used as an effective septal
extension graft. Moreover, in these patients, more septal cartilage
should be preserved as an L-strut for the stability of the nasal
framework.9
In these cases, ear cartilage or rarely rib cartilage can
be used for the septal extension graft. Even though ear cartilage can
be used for septal extension, its predictability is somewhat low
because of its size and curvature. Rib cartilage on the contrary, is
abundant, durable, and stronger than septal cartilage. Rib cartilage,
however, is not widely used as it is a more invasive procedure
requiring general anesthesia and warping is one of the major
disadvantages of autogenous rib cartilage grafts.2
We applied a new technique to overcome a very small septal
cartilageasa troublesomeobstacleinAsian shortnosecorrection.Itis
called hybrid septal extension graft and requires only 10 to 15mm
length of septal cartilage. With this technique it is possible to achieve
sufficient tip projection and extension. We named this new technique
as hybrid septal extension graft (hybrid SEG), as it uses 2 different
kinds of cartilage for the modified type of septal extension graft.
Hybrid SEG uses the IHCC or conchal cartilage as a bilateral batten
graft fixed to caudal septum and it provides more extension to caudal
septumandprovidesbasisforseptalextensiongrafts.Harvestedsmall
septal cartilage is fixed between the bilateral IHCC (or conchal
cartilage), even a small septal cartilage can act as a strong septal
extension graft based on the lengthened caudal septum.
FIGURE 2. Thecarvedirradiatedhomologouscostalcartilage(A)andtheirradiated
homologous costal cartilage located in both sides of the caudal septum (B).
TABLE 2. The Results of the Photometric Evaluation of Indices
Preop (N ¼ 41) Postop (N ¼ 41) P
31.70 Æ 0.7 37.90 Æ 3.6 0.001
8.40 Æ 0.4 11.00 Æ 0.3 0.001
Length index
Projection index
Nasolabial angle index 107.40 Æ 2.1 94.9 Æ 2.2 0.001
Preop, preoperative; Postop, postoperative.

4. Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery Volume 27, Number 1, January 2016 Brief Clinical Studies
# 2015 Mutaz B. Habal, MD e47
This hybrid SEG has several advantages: the nasal tip is softer
and mobile than in cases using autogenous rib cartilage or IHCC
alone. Compared to the conventional septal extension the graft
deviation is much less, since septal cartilage is centrally located
between the 2 IHCC or ear cartilage in hybrid SEG. The grafted tip
receives pressure from the alar cartilage in a very parallel direction
compared with the unilaterally fixed graft. Therefore, a chance of
nasal tip deviation is extremely low for these 2 reasons. Compared
to IHCC use alone, a deformity or relapse because of this technique
would be much smaller in case the IHCC would be unexpectedly
resorbed, because hybrid SEG uses a smaller amount of IHCC than
the septal extension graft using IHCC only. If the resorption rate is
the same, a deformity would be smaller in case of using less volume
of IHCC than in case of using a larger volume. Recently, there are
many reports about the IHCC graft for rhinoplasty. Irradiated
homologous costal cartilage is easy to manipulate and has low
donor site morbidity compared to autogenous rib cartilage. And
multiple grafts are possible because of its abundant quantity.
Therefore, the IHCC graft is increasingly used as graft material
especially in patients with short nose deformities with limited donor
because of previous operation. The use of IHCC grafts, however, is
still controversial in terms of resorption, warping, and infections.10
Somepapersshowthattheabsorption rateisnotsignificantlydifferent
from autogenous cases,14–16
but other reports insist that 100% of the
IHCC graft were completely absorbed.17
Suh et al1
reported minimal
2-year follow-up cases where the use of IHCC solemnly showed no
sign of resorption and its original shape was maintained. They
recommended to select the dense area of the IHCC and to do a tight
fixation of the grafts. Warping may occur immediately or delayed
after cartilage graft. In short nose patients, delayed warping of
cartilage graft may be more common because of skin tension. To
avoid immediate and delayed warping, we waited at least for 1 hour
after cutting the cartilage before insertion to check for immediate
warping of cartilage. To minimize delayed warping, we grafted
cartilage bilaterally and folded the cartilage onto the same surface.
Commercially supplied IHCC does not have an intrinsic uniform
density; some area is dense while the other area is crumbly. The
crumbly area is a degenerative area and has no visible lacunae or
chondrocyte, even though the chondrocyte itself inside the IHCC is
not a living cell. During hybrid SEG, we selected only the dense
area of the IHCC and rigid fixation sutures were done in more than 3
points between the bilateral grafts and the septal cartilage graft. We
used a minimal size of IHCC as bilateral batten grafts that acted as a
‘‘bridge’’ to locate the septal cartilage in a stable and proper position
for the septal extension graft. It may cause less deformity of the
nasal tip even if there is any unexpected resorption of IHCC,
because IHCC is less contributable to septal extension in hybrid
SEG than in SEG using IHCC alone. The use of ear cartilage instead
of IHCC may cause much less worries about resorption.
There are many methods to measure the outcome after rhino-
plasty.18–20
It is hard to convince all patients to regularly visit the
hospital and to measure indices directly even though it is the best way
to estimate the outcome of surgery. Therefore, we took clinical
pictures of the lateral viewsof the patientsbeforeand after rhinoplasty
andmeasuredthechangeoftipprojectionandnasallengthonthebasis
of 2 points; glabella and pogonion (Fig. 1). In the photometric
evaluation, the projection of nasal tip and nasal length were signifi-
cantlyincreasedand the columellar-labial angle was alsosignificantly
decreased in patients who underwent hybrid SEG.
CONCLUSIONS
Small septal cartilage is the most common obstacle a surgeon must
overcome during short nose corrections in Asian patients. With our
novel technique, surgeons may effectively lengthen the nose even in
patients with small septal cartilage.
REFERENCES
1. Suh MK, Ahn ES, Kim HR, et al. A 2-year follow-up of irradiated
homologous costal cartilage used as a septal extension graft for the
correction of contracted nose in Asians. Ann Plast Surg 2013;71:45–49
2. Kim SK, Kim HS. Secondary Asian rhinoplasty: lengthening the short
nose. Aesthet Surg J 2013;33:353–362
3. Kim JS, Han KH, Choi TH, et al. Correction of the nasal tip and columella
in Koreans by a complete septal extension graft using an extensive
harvesting technique. J Plast Reconstr Aesthet Surg 2007;60:163–170
4. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St Louis, MO:
Quality Medical Publishing; 1998
5. Marin VP, Landecker A, Gunter JP. Harvesting rib cartilage grafts for
secondary rhinoplasty. Plast Reconstr Surg 2008;121:1442–1448
6. Jang YJ, Yu MS. Rhinoplasty for the Asian nose. Facial Plast Surg
2010;26:93–101
7. Gunter JP, Rohrich RJ. Lengthening the aesthetically short nose. Plast
Reconstr Surg 1989;83:793–800
8. Lin J, Chen X, Wang X, et al. A modified septal extension graft for the
Asian nasal tip. J Am Med Assoc Facial Plast Surg 2013;15:362–368
9. Paik MH, Chu LS. Correction of short nose deformity using a septal
extension graft combined with a derotation graft. Arch Plast Surg
2014;41:12–18
10. Cochran CS, Gunter JP. Secondary rhinoplasty and the use of
autogenous rib cartilage grafts. Clin Plast Surg 2010;37:371–382
11. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a
method of controlling tip projection shape. Plast Reconstr Surg
1997;100:999–1010
12. Guyuron B, Varghai A. Lengthening the nose with a tongue-and-groove
technique. Plast Reconstr Surg 2003;111:1533–1539
13. Jeong JY. Obtaining maximal stability with a septal extension technique
in East Asian rhinoplasty. Arch Plast Surg 2014;41:19–28
14. Lefkovits G. Irradiated homologous costal cartilage for augmentation
rhinoplasty. Ann Plast Surg 1990;25:317–327
15. Demirkan F, Arslan E, Unal S, et al. Irradiated homologous costal
cartilage: versatile grafting material for rhinoplasty. Aesthetic Plast Surg
2003;27:213–220
16. Kridel RW, Ashoori F, Liu ES, et al. Long-term use and follow-up of
irradiated homologous costal cartilage grafts in the nose. Arch Facial
Plast Surg 2009;11:378–394
17. Welling DB, Maves MD, Schuller DE, et al. Irradiated homologous
cartilage grafts. Long-term results. Arch Otolaryngol Head Neck Surg
1988;114:291–295
18. Dhong ES, Kim YJ, Suh MK. L-shaped columellar strut in East Asian
nasal tip plasty. Arch Plast Surg 2013;40:616–620
19. Park JH, Mangoba DC, Mun SJ, et al. Lengthening the short nose in
Asians: key maneuvers and surgical results. JAMA Facial Plast Surg
2013;15:439–447
20. Huang J, Liu Y. A modified technique of septal extension using a septal
cartilage graft for short-nose rhinoplasty in Asians. Aesthetic Plast Surg
2012;36:1028–1038