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The Septal Strut for Nasal Projection Following Closed Rhinoplasty (Septal Strut Aesthetic Surgery)

Maintenance with nasal tip projection and rotation following closed rhinoplasty may be unpredictable. While the columella lip angle is critical to the aesthetic appearance of the nose, one of the most difficult aspects of rhinoplasty is to accurately manipulate the position of the tip lobule complex. Individuals with large dorsal resections have an increased tendency for the tip to rotate postoperatively. Hence, one of the most difficult aspects of the operation also tends to be the most unpredictable thus compounding the surgeon’s difficulty in optimizing the final result. In order to stabilize tip projection and minimize postoperative rotation we describe a technique that utilizes the septum, which is modified caudally to act as a collumelar strut. This technique allows the surgeon to maintain optimal control of the tip lobular complex postoperatively.


From January 2001 to December 2003 we performed 123 closed rhinoplasty procedures. Septal struts were used in 76 patients with a perceived tendency for the tip to rotate following surgery in an attempt to enhance tip position postoperatively. The follow up of all patients is a minimum of one year.

Operative Technique

All patients underwent closed rhinoplasty. After modification of the nasal dorsum and tip the cartilaginous septum was exposed with an incision in the membranous septum. A submuco perichondrial dissection is performed bilaterally and characteristically an inverted triangle of septal cartilage is removed to facilitate a cephalic rotation of the nasal tip. Following the resection of the caudal septum an additional dissection of the muco perichondrium is performed to expose an additional 1.0cms of the septum. The bovie scratch pad is then utilized to reduce the width of the caudal septum. This is done to construct a ledge on which to place the cephaled portion of the inferior crus lower lateral cartilages, which are sutured in a tongue-and-groove manner to facilitate stability in seating of the cartilages. By dissecting the lateral skin off the cartilage the lateral aspect of the medial crus of the lower lateral cartilage are exposed. The right and left crus, medially, are separated under direct vision. The cartilages are then seated into the portion of the septum that has been prepared as previously described and secured using vertical mattress stitches of 4-0 PDS or 5-0 PDS.


No instance of postoperative infection was noted. Adequate projection was noted in 74 of 76 patients. Average follow up for patients was 2.4 ± .4 years.


The intra-nasal approach to rhinoplasty was by John Roe at the end of the nineteenth century. Peck and Sheen describe the basic approach to closed rhinoplasty where the most important “goal” was to create a pleasing tip that would stand out gracefully from the straight nasal bridge. Further, Adams et al have shown that with increased septal manipulation there is a loss in tip support. Disruption of the caudal septal attachments to the lower lateral cartilages correlates with increased loss of projection and rotation to the tip. Surgical disruption of the fibrous attachments from the upper lateral cartilages to the lateral crus of the lower lateral cartilages combined with disruption of the ligamentous attachments from the septum to the medial crus of the lower lateral cartilages sets up a situation with minimal support to the tip. The resection of a large dorsal hump either bony and/or cartilaginous reduces any tensile strength that the skin would have supplied to maintenance of tip projection and rotation postoperatively. Skin support in any case is rather minimal. In the absence of tip support a commonly observed phenomena is caudal rotation combined with decreased projection of the lower lateral cartilages postoperatively.Numerous investigators have offered solutions to this surgical dilemma by applying a variety of struts between the lower lateral cartilage and the upper lateral cartilage or struts placed between the lower lateral cartilage to facilitate projection of the tip following open rhinoplasty. Placement of the strut grafts to the tip following closed rhinoplasty may result in distortion of the columella postoperatively and in most cases of closed rhinoplasty are not feasible. An advantage of the septal strut described above is that it restores anatomic continuity between the septum and the lower lateral cartilages, specifically between the septum and the medial crus of the lower lateral cartilage. Placement of the lower lateral cartilages in a tongue and groove joint improves the quality of the fixation which minimizes rotation of the tip postoperatively while enhancing the projection of the lower lateral cartilages.

We reasoned the ideal source for stabilization of the lower lateral cartilages should be a graft, which is stable and does not deteriorate with time. Further the source should be narrow enough to avoid widening of the columella as we have seen in many cases of secondary rhinoplasty and should be relatively facile to place intra-operatively. The septum is vascularized and inherently stable. The unmodified septum is too wide to utilize as a graft in the columella in that lateral migration of the medial crus of the lower lateral cartilages and subsequent widening of the inferior cura of the lower lateral cartilages and of the columella would occur following placement. In order to circumvent the problem of columellar bulk the septal width was reduced and a tongue-and-groove joint constructed. The fixation of the connection established between the septum and the lower lateral cartilages using permanent or long-lasting suture is desirable to facilitate early and lasting stabilization. We have found that the procedure described herein is safe and highly effective. The two failures were early in the series. In one case the suture cut through the septum. To correct this we moved the placement of the suture 5mm further cephaled from the caudal margin of the septum in all patients. The second patient picked at the suture, which resulted in the knot unraveling at 72 hours.

The plication stitch to seat the lower lateral cartilage can also be adjusted to facilitate rotation of the tip lobule component. If the mattress stitch is placed in an asymmetric manner with one side of the stitches being placed caudal to the contra lateral side this will effect the rotation of the tip and provide an added degree of refinement of the procedure. The side of the mattress stitch that is cephaled will be the side towards which the rotation occurs.


The caudal septum can be modified and used as an autogenous strut to preserve the rotational position and projection of the lower lateral cartilages following closed rhinoplasty. The procedure provides an effective solution to enhance the overall projection and stability of the tip with minimal complications and increased precision.



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