Wedge Graft: Derotational Septo-Columellar Graft

Purpose: Tip surgery remains the most difficult part of rhinoplasty in Asians because of the weak lower lateral cartilage characteristics and thick skin. Septal extension graft with septal cartilage or rib cartilage is the most widely used technique to lengthen the cartilagenous tip structure.¹ But in many cases, nasal tip rigidity caused by fixed graft and a small amount of septal cartilage harvest are the major drawbacks of septal extension graft.² Columellar strut graft is another good option of controlling tip position,³ but it cannot provide enough projection and lengthening of the tip structure due to the tendency of a counter-clockwise rotation.⁴ To avoid these shortcomings, after fixating columellar strut graft, the author inserted a piece of wedge-shaped ear cartilage graft (wedge graft) between septum and columellar to obtain a less stiff nasal tip with sufficient nasal tip elongation.

Methods and materials: To obtain proper lengthening and projection of the nasal tip, the lower lateral cartilages were released from caudal border of the upper lateral cartilages. The columellar strut, harvested from the ear cartilage, was fixed between the medial crus. A piece of remnant ear cartilage was trimmed into a wedge shape, and inserted between the alar cartilages and caudal septum to add the projection and play a role of cushion buffer avoiding a counter-clock wise rotation.

Results: From April 2014 to March 2018, wedge graft was performed in 113 patients via the open nasal approach. The duration of follow-up ranged from 1 month to 3 years, with an average of 8.2 months. Excellent results were achieved in 96(85%) patients. 17(15%) patients had unsatisfactory results requiring a revision surgery because of overcorrection, or undercorrection of tip rotation, and poor tip projection.

Conclusions: Wedge graft is a simple, effective ancillary procedure for short nose correction and prevention with less post-operative nasal tip rigidity and derotation.

References

1. Seyhan, A., Ozden, S., Ozaslan, U., Sir, E. A simplified use of septal extension graft to control nasal tip location. Aesthetic plastic surgery 2007;31:506-511; discussion 512-503.
2. Suh, Y. C., Jeong, W. S., Choi, J. W. Septum-Based Nasal Tip Plasty: A Comparative Study between Septal Extension Graft and Double-Layered Conchal Cartilage Extension Graft. Plastic and reconstructive surgery 2018;141:49-56.
3. Rohrich, R. J., Kurkjian, T. J., Hoxworth, R. E., Stephan, P. J., Mojallal, A. The effect of the columellar strut graft on nasal tip position in primary rhinoplasty. Plastic and reconstructive surgery 2012;130:926-932.
4. Paik, M. H., Chu, L. S. Correction of short nose deformity using a septal extension graft combined with a derotation graft. Archives of plastic surgery 2014;41:12-18.