COSMETIC

Control of Nasal Tip Position: Quantitative

Assessment of Columellar Strut versus Caudal
Septal Extension Graft
Rajendra Sawh-Martinez,
Background: Control and maintenance of nasal tip position are critical in rhi-
M.D., M.H.S.
noplasty. Two frequent methods of exerting tip control are columellar strut
Kevin Perkins, B.A.
and caudal septal extension graft. However, no quantitative data exist com-
Sarika Madari, B.A. paring the two methods over time. The purpose of this study was to analyze
Derek M. Steinbacher, maintenance of tip projection and rotation following either columellar strut
D.M.D., M.D. or septal extension graft.
New Haven, Conn. Methods: A retrospective cohort study of patients undergoing rhinoplasty was
reviewed. Three-dimensional photogrammetric evaluation of patients with ei-
ther columellar strut or septal extension graft to increase tip projection was
performed. Anthropometric points were analyzed in a blinded fashion. Out-
come variables were tip projection, nasal length, the Goode ratio, and tip
rotation. Results were stratified based on technique and compared statistically.
Results: One hundred six patients were included. Overall, 66 percent were
female, with an average age of 34.5 years. A columellar strut was used in 42
percent of cases (n = 45), and a septal extension graft was used in 57 percent
(n = 61). Analysis showed greater maintenance of tip rotation over time with
the septal extension graft compared with the columellar strut [−1.01 percent
change (p = not significant versus −5.08 percent change (p = 0.009)]. Tip pro-
jection, nasal length, and the Goode ratio decreased over time for both groups,
but the differences were not statistically different.
Conclusions: Nasal tip projection and rotation appear to decrease from the
immediate postoperative position. In this study, both septal extension graft and
columellar strut exhibit similar changes in tip projection with time; however,
septal extension graft is better able to preserve tip rotation compared with the
columellar strut.  (Plast. Reconstr. Surg. 144: 772e, 2019.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

R
hinoplasty is one of the most requested facial Nasal tip position, control, and maintenance
aesthetic procedures, with over 200,000 per- are among the most critical elements of a suc-
formed each year in the United States. The cessful rhinoplasty and are influenced by surgical
nose is the aesthetic cornerstone of the face, and approach, maneuvers, and postsurgical healing.1,2
a successful rhinoplasty is regarded as one of the Tip support relies on the length and strength of
most challenging aesthetic procedures to perform the crura, intercrural ligament integrity, skin/
successfully. The open rhinoplasty is a powerful soft-tissue thickness, domal suture techniques,
approach to access the nasal structures, perform a tip grafts, and, perhaps most powerfully, grafts to
variety of maneuvers, and place grafts, to achieve achieve lower limb support between the paired
reproducible results in rhinoplasty. medial crus and infralobule.

From the Department of Surgery, Section of Plastic Surgery,

Yale University School of Medicine. Disclosure: The authors have no financial interest
Received for publication April 24, 2018; accepted March to declare in relation to the content of this article.
14, 2019.
Presented in part at The Rhinoplasty Society Annual Meet-
ing 2017, in San Diego, California, April 27, 2017.
Copyright © 2019 by the American Society of Plastic Surgeons Related digital media are available in the full-text
version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000006178

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 Volume 144, Number 5 • Control of Nasal Tip Position

The two most common grafts to establish the of nasolabial angle). The Goode ratio measured
lower limb, and serve as an anchor for the new nasal projection to the nasal length (ideal projec-
tip position, are the columellar strut and sep- tion = 0.66 length). Nasal projection was measured
tal extension grafts. The columellar strut graft is from the piriform to pronasale, and nasal length
usually inset, “floating” into a soft-tissue pocket was measured from radix to pronasale. Nasolabial
between the medial crura, down to the anterior angle was defined using three points (tip, subna-
nasal spine.3–5 The septal extension graft is fixed sale, and Cupid’s bow).
to the caudal septum and extends dorsal to the
anterior septal angle, as a stable graft on which to Nasal tip: pronasale to the anteriormost project-
affix the new domal elements and medial crura.6–10 ing point of the nasal tip.
Both approaches allow for control of nasal tip sup- Subnasale: measured at the posteriormost point
port and can increase tip projection, shape the of the nasolabial crease as observed on lateral
medial crura, and change the degree of columel- imaging.
lar show.11 These grafts support the lower limb of Cupid’s bow: labiale superius, the most project-
the tripod for nasal tip support.2,12,13 ing aspect of the lip at the vermillion cutaneous
The purpose of this study was to three-dimen- junction, coincident with the inferiormost por-
sionally analyze the maintenance of tip projection tion of the Cupid’s bow arc in the midline.
and rotation following open rhinoplasty using
either columellar strut or septal extension graft. Results were stratified based on technique and
We hypothesize that both projection and rotation timing of measurement. Data analyzed over time
decrease with time. A corollary goal of this study included from preoperatively (time 0), early post-
was to predict the amount by which tip position operatively (time 1 at 6 weeks), and late postop-
changes. Both grafts are known to powerfully con- eratively (time 2 at ≥12 months postoperatively).
trol nasal tip position, but a direct quantitative Statistical analysis was performed using IBM SPSS
comparison has not before been reported. Version 23 (IBM Corp., Armonk, N.Y.). Analysis
of variance was carried out to evaluate the sig-
nificance of multigroup analysis, and compared
PATIENTS AND METHODS statistically using independent t tests when com-
A retrospective cohort study of patients under- paring between graft techniques and dependent
going open rhinoplasty was undertaken (Yale Uni- t test when comparing between time points, with
versity Institutional Review Board 1101007932). values of p < 0.05 recognized as being statistically
Open rhinoplasty with three-dimensional data significant.
and use of either columellar strut or septal exten- Key surgical maneuvers and approach to rhi-
sion graft were collated. Excluded were closed noplasties were equal in both groups. An open
rhinoplasty, cleft rhinoplasty, prior nasal surgery, approach was used with separation of components.
tip rhinoplasty only, cases where deprojection or Dorsal reduction and mucoperichondrial flaps
derotation was implemented, and cases without were elevated to allow for septal harvest, which
adequate follow-up data. All patients included was used as the source of cartilage graft. Columel-
underwent osteotomies, tip projection, tip rota- lar strut grafts were secured in a pocket inferiorly
tion, and matched endonasal graft numbers/ toward the anterior nasal spine, and affixed to the
placement in equal rates between the cohorts, medial crus of the lower lateral cartilages. The
with the principal variable being use of either a columellar strut is placed in an anterior pocket
columellar strut or septal extension graft. toward the anterior nasal spine, and is secured to
Three-dimensional photogrammetric evalua- the medial crus using polydioxanone sutures and
tion of nasal tip position was performed preop- using plain gut on a septal needle through vestib-
eratively and postoperatively (Vectra; Canfield ular skin, both medial crura, and columella strut.
Scientific, Parsippany, N.J.). Images were analyzed Septal extension grafts were secured to the sep-
anthropometrically at three time points (preop- tal L-strut cartilage. The septal extension graft is
eratively, 6 weeks postoperatively, and at least 12 fixed in three locations: a suture overlapping the
months postoperatively). Standard anthropomet- septal extension graft and caudal septum; a suture
ric points were placed and measured by two sepa- overlapping the cephalic border of the septal
rate observers in a blinded fashion. extension graft and the dorsal border of the sep-
Outcome variables were tip projection [linear tum (near the anterior septal angle); and a hori-
measure (subnasale to tip) and as a function of zontal mattress affixing the septal extension graft
the Goode ratio] and tip rotation (as a function and caudal lateral septum. The septal extension

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 Plastic and Reconstructive Surgery • November 2019

graft overlaps one side of the caudal/lateral sep- Three-dimensional analysis demonstrated
tum. The domes were defined with intradomal maintenance of tip rotation that was preserved
and interdomal suturing of the middle crura of over time in the septal extension graft group
the lower lateral cartilages in a similar fashion compared with the columellar strut group [−1.01
for both groups. (See Figure, Supplemental Digi- percent change (p = not significant) versus −5.08
tal Content 1, which shows Gunter diagrams and percent change (p = 0.009)] (Fig. 2).
clinical examples of the technique and fixation of
the septal extension graft and the columellar strut Nasal Length
graft, http://links.lww.com/PRS/D739.) The nasal length measurements for the colu-
mellar strut group were 46.3 ± 3.7 mm at time 0,
RESULTS 50.3 ± 11.9 mm at time 1, and 49.89 ± 11.4 mm at
time 2. Nasal length change between time 1 and
One hundred six patients were studied. The
time 2 was 0.88 percent (p = 0.85, not significant)
overall cohort was 66 percent female and 34 per-
for the columellar strut group.
cent male, with an average age of 34.5 years. Of
The septal extension graft nasal length was
these, a columellar strut was used in 42 percent
measured to be 46.2 ± 4.9 mm at time 0, 49.2 ±
(n = 45) and a septal extension graft was used
9.7 mm at time 1, and 47.4 ± 8.2 mm at time 2. The
in 57 percent (n = 61). The septal extension
percentage change of the nasal length between
graft cohort was composed of 71 percent female
time 1 and time 2 was −3.64 percent (p = 0.27, not
patients, with an average age of 34 years. The
significant) for the septal extension graft group
columellar strut cohort was 58 percent female,
(Fig. 3).
with an average age of 35 years. Average follow-
up time was 16.5 ± 3.1 months for the columellar
Goode Ratio
strut group and 15.8 ± 3.4 months for the septal
extension graft group. The ratio of the nasal projection to the nasal
length defines the Goode ratio. For the columel-
Tip Projection lar strut group, this ratio was found to be 0.70 ±
0.07 at time 0, 0.72 ± 0.10 at time 1, and 0.71 ±
For the columellar strut group, tip projection
0.08 at time 2. The percentage change between
was measured to be 32.3 ± 3.1 mm at time 0, 35.7
time 1 and time 2 was −1.25 percent (p = 0.63, not
± 7.3 mm at time 1, and 35.1 ± 7.3 mm at time 2.
significant) for the columellar strut group.
Tip projection percentage change between time 1
The septal extension graft Goode ratio was
and time 2 was −1.7 percent (p = 0.69, not signifi-
measured to be 0.68 ± 0.08 at time 0, 0.68 ± 0.05 at
cant) for the columellar strut group.
time 1, and 0.69 ± 0.04 at time 2. The percentage
The septal extension graft tip projection was
change of the Goode ratio between time 1 and
measured to be 31.2 ± 4.1 mm at time 0, 33.8 ±
time 2 was 1.22 percent (p = 0.36, not significant)
6.4 mm at time 1, and 33.0 ± 5.9 mm at time 2.
for the septal extension graft group (Fig. 4).
Tip projection percentage change between time 1
The postoperative changes between early
and time 2 was −2.2 percent (p = 0.50, not signifi-
(time 1) and late (time 2) postoperative changes
cant) for the septal extension graft group (Fig. 1).
in position measurements was noted to be statisti-
cally significant for a decrease in tip rotation for
Tip Rotation
the columellar strut group (Table 1). All other
Defined by the nasolabial angle, tip rota- positional changes during the postoperative
tion was measured preoperatively and at the two period were not statistically significant.
defined postoperative time points. The columel-
lar strut group had an average nasolabial angle of
107.3 ± 17.3 degrees at time 0, 118.5 ± 10.4 degrees DISCUSSION
at time 1, and 112.5 ± 11.0 degrees at time 2. Predictability and control of nasal tip position
The septal extension graft group had an aver- are essential for achieving the desired outcome in
age nasolabial angle of 115.1 ± 13.1 degrees at rhinoplasty. Open rhinoplasty leads to loss of tip
time 0, 116.3 ± 12.1 degrees at time 1, and 115.8 ± projection if steps are not taken to resecure the
15.0 degrees at time 2. Comparing time 1 to time divided supporting ligaments and attachments.
2, the septal extension graft group had a −1.01 Maneuvers, including domal suturing and graft-
percent change (p = 0.64, not significant). The ing, are needed to place and maintain the tip into
columellar strut group demonstrated a −5.08 per- the desired position. It is accepted that tip posi-
cent change from time 1 to time 2 (p = 0.009). tion and rotation fall to some extent following

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 Volume 144, Number 5 • Control of Nasal Tip Position

Fig. 1. Changes in nasal tip projection over time for patients who had either a colu-
mellar strut (CS) or a septal extension graft (SEG), preoperatively (T0), early postop-
eratively (T1), and late postoperatively (T2).

Fig. 2. Changes in nasal tip rotation over time for patients who had either a columel-
lar strut (CS) or a septal extension graft (SEG), preoperatively (T0), early postopera-
tively (T1), and late postoperatively (T2). NLA, nasolabial angle.

rhinoplasty, and most surgeons therefore “over- postoperatively (seen as reduced projection and
correct” the tip position. However, this assertion, rotation), and therefore overcorrection is needed;
and the need to do this, has never been objec- and (2) compare the type, extent, and magnitude
tively quantified three-dimensionally. Morpho- of tip change between columellar strut and septal
metric analysis comparing the two most popular extension graft (among patients who underwent
intracrural grafting techniques (columellar strut planned projection and rotation increase).
and septal extension graft) has also not before The initial objective was to measure the
been performed. In this study, we sought to (1) degree to which nasal tip characteristics change
confirm the concept that nasal tip position falls postoperatively (in all patients: both columellar

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 Plastic and Reconstructive Surgery • November 2019

Fig. 3. Changes in nasal length over time for patients who had either a columellar
strut (CS) or a septal extension graft (SEG), preoperatively (T0), early postoperatively
(T1), and late postoperatively (T2).

Fig. 4. Changes in Goode ratio over time for patients who had either a columellar
strut (CS) or a septal extension graft (SEG), preoperatively (T0), early postoperatively
(T1), and late postoperatively (T2).

strut and septal extension graft) (Figs. 5 and 6). finding, including edema resolution, intrinsic
We postulated—in line with the popularly held skin thickness, elasticity, and other changes.1,3,14,15
rhinoplasty lore—that nasal tip position would This decrement in tip position with time con-
contract over time (i.e., decrease in both projec- forms with the widely accepted notion that some
tion and rotation). Serial measurements, to over deprojection and derotation of the tip occur com-
12 months, indeed showed a uniform decrement pared with the immediate postoperative position.
of nasal tip parameters as a function of time (to It can be concluded then, that some amount of
a steady state). Nasal tip projection, nasal length, “overcorrection” should be worked into the final
and Goode ratio all decreased, from early postop- rhinoplasty tip result. Beyond this in concept, this
eratively (time 1, 6 weeks) to later postoperatively study is the first to ascribe some numeric value
(time 2, >12 months) (Tables 1 and 2). These to the amount or degree of expected change.
changes occurred in both columellar strut and The results indicate that tip deprojection and
septal extension graft groups. Variables in addi- derotation (of up to 1 mm and approximately 2
tion to graft type alone likely contributed to this to 6 degrees, respectively) should be anticipated

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 Volume 144, Number 5 • Control of Nasal Tip Position

Table 1.   Postoperative Changes between Morphometric results revealed a greater

Preoperative, Early Postoperative, and Late angular decrease in tip rotation in the columel-
Postoperative Changes in Position Measurements* lar strut patients compared with septal extension
CS SEG graft patients postoperatively (statistically signifi-
cant). Tip projection also fell to a greater extent
Tip projection
 T0, mm 32.3 ± 3.1 31.2 ± 4.1 in the columellar strut patients, but this was not
 T1, mm 35.7 ± 7.3 33.8 ± 6.4 statistically significant. Considered together, these
 T2, mm 35.1 ± 7.3 33.0 ± 5.9 findings seem to suggest a greater preservation in
 T1 vs. T2 change, % −1.7 (p = 0.69, NS) −2.2 (p = 0.50, NS)
Tip rotation nasal tip position when using the septal extension
 T0, deg 107.3 ± 17.3 115.8 ± 13.1 graft compared with the columellar strut. How-
 T1, deg 118.5 ± 10.4 116.3 ± 12.1
 T2, deg 112.5 ± 11.0 115.1 ± 15.0 ever, this impact appears less for tip projection
 T1 vs. T2 change, % −5.08% (p = 0.009) −1.01 (p = 0.64, NS) (where columellar strut and septal extension graft
Nasal length techniques are nearly equivalent in this param-
 T0, mm 46.3 ± 3.7 46.2 ± 4.9
 T1, mm 50.3 ± 11.9 49.2 ± 9.7 eter). Although most changes were not statisti-
 T2, mm 49.89 ± 11.4 47.4 ± 8.2 cally significant, there was a numerical decrease
 T1 vs. T2 change, % 0.88 (p = 0.85, NS) 3.64 (p = 0.27, NS) in the measurement of tip projection of 0.5 to
Goode ratio
 T0 0.70 ± 0.07 0.68 ± 0.08 1 mm for both groups. The statistically significant
 T1 0.72 ± 0.10 0.68 ± 0.05 decreased tip rotation with the columellar strut
 T2 0.71 ± 0.08 0.69 ± 0.04
 T1 vs. T2 change, % −1.25 (p = 0.63, NS) 1.22 (p = 0.36, NS) graft (approximately 6 degrees) suggests this to be
CS, columellar strut; SEG, septal extension graft; T0, time 0 (preop- a critical measure to overcorrect when using this
eratively); T1, time 1 (early postoperatively); T2, time 2 (late postop- graft (or consideration for using a septal exten-
eratively); NS, not significant. sion graft when significant tip rotation is sought
*Percentage change was noted to be statistically significant for a
decrease in tip rotation for the columellar strut group. All other posi- in a patient).
tional changes during the postoperative period were not statistically The larger magnitude of tip derotation
significant. Nasal tip projection, nasal length, and Goode ratio all (approximately 6 degrees) in the columellar strut
decreased, from early postoperatively (time 1, 6 wk) to later postop-
eratively (time 2, >12 mo). These changes occurred in both columel- group was likely a function of no suture fixation
lar strut and septal extension graft groups. being used from this graft to the caudal septum or
other fixed/stable structure. A floating columellar
in open rhinoplasty patients. Moving further, we strut is placed in a pocket between the two medial
wished to stratify the findings, based on graft type, crura, the base of which abuts the soft-tissue at the
to identify whether the postoperative “settling” subnasale, just under the anterior nasal spine, but
differs dependent on columellar strut versus sep- is not directly fixed to a base structure or the sep-
tal extension graft. tum.3,17 In this study, no cases of “fixed” columel-
The choice of columellar strut versus septal lar struts were used (no Kirschner wire or other
extension graft in rhinoplasty is dependent mostly fixation to the anterior nasal spine or caudal sep-
on surgeon preference, and to our knowledge, no tum).18 The columellar strut and medial crura are
head-to-head comparison of these grafts has been typically sutured together as a unit, adding greater
performed. Both grafts are reported to control the rigidity, but are still not fixed to a stable structure.
tip and enable increases in both projection and This helps explain the less effective ability of the
rotation. Proponents of the columellar strut note columellar strut to maintain tip rotation. The lack
the ability of the graft to achieve nasal tip support of connection and fixation between the cephalic
without palpability or overstiffening the nose.4,5,16 border of the columellar strut/medial crural com-
Those who favor septal extension grafts recognize plex to any stable structure cephalad enables the
that the more fixated construct may permit a “stay tip complex to pivot downward/caudally (i.e., to
where you place it” component to tip position- impart some derotation). Meanwhile, the colu-
ing.6,8,9 One aim of this study was to compare these mellar strut does provide a “stake” onto which the
two commonly used methods for tip control. Open domes and medial crura are affixed, explaining
rhinoplasty patients undergoing planned tip pro- why tip projection is maintained with a columellar
jection and rotation increase, by means of either strut (similar to septal extension graft).
columellar strut or septal extension graft, were The septal extension graft, in contrast (differ-
analyzed. Although these techniques are inher- ent from the columellar strut), is firmly attached
ently different in their fixation and placement, and directly sutured (in at least three locations)
they both allow for increased support and mainte- to the caudal septum. The caudal septum, in turn,
nance of tip position by bolstering the medial crus- is anatomically fixed to the anterior nasal spine at
columellar limb of the tripod. the posterior septal angle, providing a very rigid

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 Plastic and Reconstructive Surgery • November 2019

Fig. 5. Clinical examples demonstrating long-term results of patients who underwent rhinoplasty with the use of a columellar
strut graft.

Fig. 6. Clinical examples demonstrating long-term results of patients who underwent rhinoplasty with the use of a septal exten-
sion graft.

point of attachment for the domes and medial Although the data suggest that the septal exten-
crura. This seems to impart a predictable, stable sion graft may produce a more predictable nasal
tip construct, and the morphometric data confirm rotation result, the decision to use this graft may
the robustness of maintained tip rotation using a not be right in all hands. The potential downside of
septal extension graft. the septal extension graft technique is the firm (less

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 Volume 144, Number 5 • Control of Nasal Tip Position

Table 2.  Percentage Change from Late limitations of this study. It is a retrospective review
Postoperatively versus Early Postoperatively* of the senior author’s (D.M.S.) work. The role of
CS (%) SEG (%)
other variables (e.g., swelling, scarring, and carti-
lage strength between the groups) may confound
Rotation −5.08 −1.01
Projection −1.68 −2.22 the data, although with a large enough sample
Length −0.88 −3.64 size, these factors should even out. Diagnoses and
Goode ratio −1.25 1.22 treatment goals were similar in each group, but
CS, columellar strut; SEG, septal extension graft. a subconscious selection bias could have been in
*p < 0.05.
play when deciding on one graft versus the other.
There was also an overall smaller degree of rota-
compressible, soft) nasal tip that is created. These tion on average in the septal extension graft group
advantages, predictabilities, and downsides must all compared with the columellar strut group in the
be weighed against one another. In addition to the immediate postoperative period. The findings
stiffness of the nasal tip described above, a septal of this study can be strengthened with a larger
extension graft may portend columellar asymmetry cohort; multiyear follow-up; and a prospective,
if not properly performed. The typical description randomized, multisurgeon study.
of placement includes on one or the other side of
the caudal septum. If the caudal septum is already
thick, or a deviated graft is placed, this may widen CONCLUSIONS
the columella on the side of increased thickness, Nasal tip projection and rotation appear to
and may give rise to nostril asymmetry. If the septal decrease from the immediate postoperative posi-
extension graft is properly fashioned and thinned tion. In this study, both septal extension graft and
properly and oriented within the concavities of the columellar strut exhibit similar changes in tip
caudal septum, this thickness/asymmetry will not projection with time, although the septal exten-
occur. Other means of avoiding thickening include sion graft is better able to preserve tip rotation
end-to-end placement against the caudal septum compared with the columellar strut. These results
(held with small cartilage shavings).19,20 It is impor- shed light on expected changes to the nasal tip
tant not to have the dorsal/tip extension of the sep- position postoperatively.
tal extension graft protruding past the domal units. Derek M. Steinbacher, D.M.D., M.D.
Ideally, the graft is fashioned shy of the goal tip 330 Cedar Street
position and the domes brought just past the graft. New Haven, Conn. 06520
This ensures a less firm tip and impalpable graft. [email protected]
The columellar strut has the advantage of Twitter: @SteinBeastMD
achieving good and reproducible tip projection, Instagram: @dereksteinbacher
without requiring as much dissection and takedown
of all attachments along the caudal septum. In cases PATIENT CONSENT
where tip projection and a modest amount of tip Patients provided written consent for the use of their
rotation are sought, and there is no or little devia- images.
tion or deformity of the caudal septum, the colu-
mellar strut may be ideal. An improperly placed
columellar strut may have the downside of “clicking” REFERENCES
when the patient smiles, animates the lips, or “wig- 1. Pavri S, Zhu VZ, Steinbacher DM. Postoperative edema reso-
gles” the nose. This is because of the unfixed nature lution following rhinoplasty: A three-dimensional morpho-
and the base-end being moving back and forth or metric assessment. Plast Reconstr Surg. 2016;138:973e–979e.
clicking off of the anterior nasal spine. This may be 2. Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The
unpleasant for some patients and, in extreme cases, deviated nose: Optimizing results using a simplified clas-
sification and algorithmic approach. Plast Reconstr Surg.
even audible. Both graft types play an important 2002;110:1509–1523; discussion 1524–1525.
role in the techniques available to the rhinoplasty 3. Rohrich RJ, Kurkjian TJ, Hoxworth RE, Stephan PJ, Mojallal
surgeon, and can be used to achieve excellent and A. The effect of the columellar strut graft on nasal tip position
predictable results (certainly with regard to tip pro- in primary rhinoplasty. Plast Reconstr Surg. 2012;130:926–932.
jection).21,22 This study, however, does seem to sug- 4. Bitik O, Uzun H, Kamburoğlu HO, Çaliş M, Zins JE.
Revisiting the role of columellar strut graft in primary open
gest that septal extension grafts allow for a greater
approach rhinoplasty. Plast Reconstr Surg. 2015;135:987–997.
preservation of tip rotation with time. 5. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the colu-
Although analysis of stratified morphometric mellar strut in rhinoplasty: Indications and rationale. Plast
data over time is enlightening, there are several Reconstr Surg. 2012;129:118e–125e.

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 Plastic and Reconstructive Surgery • November 2019

6. Byrd HS, Andochick S, Copit S, Walton KG. Septal extension 15. Ilhan AE, Sozen T, Caypinar Eser B, Cengiz B. Association
grafts: A method of controlling tip projection shape. Plast of skin thickness with alar base reduction in patients under-
Reconstr Surg. 1997;100:999–1010. going lateral crural repositioning and strut grafting. JAMA
7. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year Facial Plast Surg. 2017;19:516–521.
experience in controlling nasal tip projection and shape. 16. Gandy JR, Manuel CT, Leary RP, Wong BJ. Quantifying opti-
Plast Reconstr Surg. 2003;112:1929–1935. mal columellar strut dimensions for nasal tip stabilization
8. Hwang SH, Hwang K. Supporting strength of septal exten- after rhinoplasty via finite element analysis. JAMA Facial Plast
sion grafts. J Craniofac Surg. 2011;22:2323–2326. Surg. 2016;18:194–200.
9. Kim MH, Choi JH, Kim MS, Kim SK, Lee KC. An introduction 17. Gunter JP, Landecker A, Cochran CS. Frequently used grafts
to the septal extension graft. Arch Plast Surg. 2014;41:29–34. in rhinoplasty: Nomenclature and analysis. Plast Reconstr
10. Karadavut Y, Akyıldız I, Karadaş H, Dinç AE, Tulacı G, Tastan Surg. 2006;118:14e–29e.
E. Effectiveness of caudal septal extension graft application in 18. Gunter JP, Clark CP, Friedman RM. Internal stabilization of
endonasal septoplasty. Braz J Otorhinolaryngol. 2017;83:59–65. autogenous rib cartilage grafts in rhinoplasty: A barrier to
11. Shah A, Pfaff M, Kinsman G, Steinbacher DM. Alar-
cartilage warping. Plast Reconstr Surg. 1997;100:161–169.
columellar and lateral nostril changes following tongue-in- 19. Toriumi DM. New concepts in nasal tip contouring. Arch
groove rhinoplasty. Aesthetic Plast Surg. 2015;39:191–198. Facial Plast Surg. 2006;8:156–185.
12. Anderson JR. A reasoned approach to nasal base surgery. 20. Bared A, Rashan A, Caughlin BP, Toriumi DM. Lower lateral
Arch Otolaryngol. 1984;110:349–358. cartilage repositioning: Objective analysis using 3-dimen-
13. Petroff MA, McCollough EG, Hom D, Anderson JR. Nasal tip sional imaging. JAMA Facial Plast Surg. 2014;16:261–267.
projection: Quantitative changes following rhinoplasty. Arch 21. Chen YY, Jang YJ. Refinements in saddle nose reconstruc-
Otolaryngol Head Neck Surg. 1991;117:783–788. tion. Facial Plast Surg. 2018;34:363–372.
14. Perkins K, Shah A, Patel A, Steinbacher D. The effect
22. Kang JG, Ryu J. Nasal tip surgery using a modified septal
of nasal tip rotation on upper lip length. Aesthet Surg J. extension graft by means of extended marginal incision.
2017;37:504–510. Plast Reconstr Surg. 2009;123:343–352.

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