Refinements in Saddle Nose Reconstruction

Abstract

Saddle nose correction remains a challenging procedure for rhinoplasty surgeons due to both aesthetic and functional issues. The most common causes of saddle nose are nasal trauma and prior septal surgery, and a defective relationship between the caudal septum and the anterior septal spine is the principal postoperative pathology. The authors propose their own classification system for saddle nose with one new category and several approaches to deal with this condition in accordance with the level of severity. They strongly advocate major septal reconstruction for most cases of saddle nose, either by placing extended spreader grafts, caudal extension grafts, or a new extracorporeally made L strut. For extreme cases, integrated dorsal implant with columellar strut can successfully bypass the saddled nasal dorsum without dissecting the septal mucoperichondrial pocket and achieve adequate dorsal height. Further dorsal augmentation can be achieved by applying side/gap grafts or dorsal onlay grafts in different forms. In cases with retracted columella, a premaxillary plumping graft is another useful technique. Finally, in autoimmune-related saddling patients, the evidence indicates that their aesthetic problems can be managed safely with surgery as long as the disease is well under control.

Keywords

saddle nose - classification - augmentation rhinoplasty - nasal septal reconstruction

Financial Support

None.

• References

• 1 Daniel RK, Brenner KA. Saddle nose deformity: a new classification and treatment. Facial Plast Surg Clin North Am 2006; 14 (04) 301-312 , vi
• 2 Pribitkin EA, Ezzat WH. Classification and treatment of the saddle nose deformity. Otolaryngol Clin North Am 2009; 42 (03) 437-461
• 3 Lee HJ, Jang YJ. Correction of saddle and short noses. Curr Opin Otolaryngol Head Neck Surg 2016; 24 (04) 294-299
• 4 Yeo NK, Jang YJ. Rhinoplasty to correct nasal deformities in postseptoplasty patients. Am J Rhinol Allergy 2009; 23 (05) 540-545
• 5 Yi JS, Kim MJ, Jang YJ. An Asian perspective on improving outcomes for nasal bone fractures by establishing specific treatment options. Clin Otolaryngol 2017; 42 (01) 46-52
• 6 Fry H. Nasal skeletal trauma and the interlocked stresses of the nasal septal cartilage. Br J Plast Surg 1967; 20 (02) 146-158
• 7 Dyer II WK, Beaty MM, Prabhat A. Architectural deficiencies of the nose: treatment of the saddle nose and short nose deformities. Otolaryngol Clin North Am 1999; 32 (01) 89-112
• 8 Vartanian AJ. . Saddle nose rhinoplasty. Available at: https://emedicine.medscape.com/article/840910-overview-0104 . Accessed December 15, 2017
• 9 Tardy Jr ME, Schwartz M, Parras G. Saddle nose deformity: autogenous graft repair. Facial Plast Surg 1989; 6 (02) 121-134
• 10 Hyun SM, Jang YJ. Treatment outcomes of saddle nose correction. JAMA Facial Plast Surg 2013; 15 (04) 280-286
• 11 Kim DY, Nam SH, Alharethy SE, Jang YJ. Surgical outcomes of bony batten grafting to correct caudal septal deviation in septoplasty. JAMA Facial Plast Surg 2017; 19 (06) 470-475
• 12 Kim JH, Jang YJ. Use of diced conchal cartilage with perichondrial attachment in rhinoplasty. Plast Reconstr Surg 2015; 135 (06) 1545-1553
• 13 Jang YJ, Kwon M. Modified extracorporeal septoplasty technique in rhinoplasty for severely deviated noses. Ann Otol Rhinol Laryngol 2010; 119 (05) 331-335
• 14 Lee SB, Jang YJ. Treatment outcomes of extracorporeal septoplasty compared with in situ septal correction in rhinoplasty. JAMA Facial Plast Surg 2014; 16 (05) 328-334
• 15 Jang YJ, Wang JH, Sinha V, Song HM, Lee BJ. Tutoplast-processed fascia lata for dorsal augmentation in rhinoplasty. Otolaryngol Head Neck Surg 2007; 137 (01) 88-92
• 16 Na HG, Jang YJ. Dorsal augmentation using alloplastic implants. Facial Plast Surg 2017; 33 (02) 189-194
• 17 Jang YJ, Min JY, Lau BC. A multilayer cartilaginous tip-grafting technique for improved nasal tip refinement in Asian rhinoplasty. Otolaryngol Head Neck Surg 2011; 145 (02) 217-222
• 18 Cotch MF, Hoffman GS, Yerg DE, Kaufman GI, Targonski P, Kaslow RA. The epidemiology of Wegener's granulomatosis. Estimates of the five-year period prevalence, annual mortality, and geographic disease distribution from population-based data sources. Arthritis Rheum 1996; 39 (01) 87-92
• 19 Erickson VR, Hwang PH. Wegener's granulomatosis: current trends in diagnosis and management. Curr Opin Otolaryngol Head Neck Surg 2007; 15 (03) 170-176
• 20 Qian SY, Malata CM. Avoiding pitfalls in open augmentation rhinoplasty with autologous L-shaped costal cartilage strut grafts for saddle nose collapse due to autoimmune disease: the Cambridge experience. J Plast Reconstr Aesthet Surg 2014; 67 (08) e195-e203
• 21 Coordes A, Loose SM, Hofmann VM. , et al. Saddle nose deformity and septal perforation in granulomatosis with polyangiitis. Clin Otolaryngol 2018; 43 (01) 291-299
• 22 Vogt PM, Gohritz A, Haubitz M, Steiert A. Reconstruction of nasal deformity in Wegener's granulomatosis: contraindication or benefit?. Aesthetic Plast Surg 2011; 35 (02) 156-161
• 23 Congdon D, Sherris DA, Specks U, McDonald T. Long-term follow-up of repair of external nasal deformities in patients with Wegener's granulomatosis. Laryngoscope 2002; 112 (04) 731-737
• 24 Haug MD, Witt P, Kalbermatten FD, Rieger UM, Schaefer DJ, Pierer G. Severe respiratory dysfunction in a patient with relapsing polychondritis: should we treat the saddle nose deformity?. J Plast Reconstr Aesthet Surg 2009; 62 (02) e7-e10