COSMETIC

Changing Role of Septal Extension versus

Columellar Grafts in Modern Rhinoplasty
Rod J. Rohrich, M.D.
Summary: Effective control of nasal tip projection and rotation is a key compo-
Paul D. Durand, M.D.
nent in modern rhinoplasty. Tip projection is a product of several anatomical
Erez Dayan, M.D.
factors: length and strength of lower lateral cartilages, the suspensory ligament,
Dallas, Texas fibrous connections to the upper lateral cartilages, and the anterior septal
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angle. Several cartilage grafts have been described for effectively altering nasal
tip projection and rotation. Columellar struts and septal extension grafts are
both commonly used in modern rhinoplasty to affect projection and rotation
of the nasal tip. Although columellar strut grafts have shown moderate efficacy
in maintaining tip projection and unifying the tip complex, their effect on
increasing tip projection has been shown to be very limited. In comparison,
septal extension grafts have been shown to effectively control tip projection,
rotation, and shape by securing the nasal tip to the septum. Varieties of septal
extension grafts have been described to support the medial crura and control
tip shape, all of which depend on the presence of a stable caudal septum. The
type of graft used is dependent on the specific characteristics of the underly-
ing tip structures. The authors’ aim is to provide an updated classification of
cartilage grafts for altering nasal tip projection and rotation, and an algorith-
mic approach for their implementation. Although both columellar struts and
septal extension grafts offer the modern rhinoplasty surgeon a way to alter tip
projection and rotation, they do vary in efficacy. Understanding which graft to
use and in what setting is key in successfully controlling projection, rotation,
and shape of the nasal tip.  (Plast. Reconstr. Surg. 145: 927e, 2020.)

E
ffective control of nasal tip projection and the type of effect one is trying to achieve on the
rotation is a key component in modern rhi- nasal tip. For example, a floating columellar strut,
noplasty. Tip projection is a product of sev- although effective in unifying the nasal tip and
eral anatomical factors: length and strength of maintaining its position, is not nearly as efficient
lower lateral cartilages, the suspensory ligament, in increasing projection.1,4,5
fibrous connections to the upper lateral cartilages, In comparison, septal extension grafts have
and the anterior septal angle. The tripod concept been shown to effectively control tip projection,
of relying solely on the lower lateral cartilages for rotation, and shape by securing the nasal tip to
altering tip projection without the addition of car- the septum.1,5 This article provides an updated
tilage grafting has been slowly falling out of favor classification of cartilage grafts for altering nasal
in modern rhinoplasty. Augmentation of the sep-
tum is now considered the predominant factor in
augmenting tip projection and rotation.1–3 Disclosure: Dr. Rohrich receives instrument royal-
Several cartilage grafts have been described ties from Eriem Surgical, Inc., and book royalties
for effectively altering nasal tip projection and from Thieme Medical Publishing, is a clinical and re-
rotation. Columellar struts and septal extension search study expert for Allergan, Inc., Galderma, and
grafts are both commonly used in modern rhi- MTF Biologics, is a medical monitor for Merz North
noplasty to affect projection and rotation of the America, and is the owner of Medical Seminars of
nasal tip. The extent to which each of these alters Texas, LLC. No funding was received for this article.
nasal tip projection and rotation is dependent on Dr. Durand and Dr. Dayan have no financial inter-
the composition of the underlying structures and ests to declare in relation to the content of this article.

From the Dallas Plastic Surgery Institute. Related digital media are available in the full-text
Copyright © 2020 by the American Society of Plastic Surgeons version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000006730

www.PRSJournal.com 927e
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 Plastic and Reconstructive Surgery • May 2020

tip projection and rotation and an algorithmic Although useful in properly selected patients,
approach for their implementation. The rationale columellar struts can have significant drawbacks.
for when to use a columellar strut or a particular Any structure placed in between the medial crura
septal extension graft is also discussed. can serve to inadvertently widen the columella.
Depending on the type of strut used, clicking
against the anterior nasal spine has been reported.
COLUMELLAR STRUTS
As with any cartilage graft, warping is always a pos-
The role of the columellar strut in altering sibility, which may result in the loss of tip projec-
nasal tip projection has been a recurrent point of tion and symmetry. Finally, although columellar
discussion in the rhinoplasty literature. Although struts have been found unreliable in increasing
fixed columellar struts have fallen out of favor in tip projection, it is the lack of control over nasal
aesthetic rhinoplasty, floating columellar struts tip rotation that is their single most important
are still commonly used. Rohrich et al. specifi- limitation.4,6
cally looked at the effect of floating columellar
struts in increasing tip projection and found
that such effect, if any, was minimal.4 Columel- SEPTAL EXTENSION GRAFTS
lar struts should instead be seen as an effective Byrd et al. introduced septal extension grafts
tool for unifying the nasal tip and maintaining as a more reliable method of controlling tip
its position in the presence of three distinct projection, shape, and rotation, particularly in
structural characteristics: weak medial or middle patients with weak lower lateral cartilages. Colu-
crura, asymmetric lower lateral cartilages, and mellar struts had proven ineffective in providing
short medial crura (Fig. 1). such control, which is particularly evident in noses
It is the degree of nasal tip projection and characterized by a weak midvault, a plunging tip,
structural integrity of the lower lateral cartilages and drawn-up alae. Septal extension grafts were
that dictates how the columellar strut should be proposed as a way of redefining the skeletal rela-
used. Different types of struts have been previ- tionship between the nasal tip and dorsum. Creat-
ously described. Their proper design and place- ing structural support for the tip complex based
ment is dependent on careful analysis of these on the anterior septum allows for predictable con-
two variables. For example, adequate nasal tip trol of tip projection and/or rotation.1,5
projection in the presence of weak or asymmet- Varieties of septal extension grafts have been
ric cartilages warrants placement of a shorter strut described to support the medial crura and control
to strengthen and unify tip elements, rather than tip shape, all of which depend on the presence of
a longer floating strut more suitable for tips that a stable caudal septum. Although these differ in
also lack tip projection. their shape and points of fixation to the septum,
they have similar points of fixation within the tip-
lobule complex. It is important to note that points
of septal fixation indeed vary depending on sta-
tus of the midvault, septal stability, and amount of
available cartilage, whereas the distance that the
graft extends beyond the dorsal septum is contin-
gent on the thickness of the overlying skin.1
To be effective, septal extension grafts should
extend beyond the anterior septal angle into the
interdomal space. The most caudal and inferior
portion of the graft is placed on the cephalic bor-
der of the medial crus at the columellar-lobular
angle. The most important point of fixation is
inferior to the divergence of the middle crura,
where the cephalic borders of the medial crura
abut each other. At this point, the graft incorpo-
rates the desired columellar-lobular angle. A point
of interdomal fixation can then be used to con-
trol wanted interdomal distance and projection.
If supratip break is desired, graft fixation to the
Fig. 1. Columellar strut graft. lower lateral cartilage should allow for a marked

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 Volume 145, Number 5 • Septal Extension versus Columellar Graft

differential between the domes and nasal dorsum. lateral cartilages with the septum at a 45-degree
Although an excellent tool in the appropriate angle from the anterior septal angle and extend
patient, septal extension grafts are not indicated diagonally across the caudal and dorsal L-strut
for noses with heavy lower lateral cartilages and of the septum. Proper suture anchorage is cru-
normal or excessive tip projection.1,5,7 [See Video cial for overall graft stability and to prevent rota-
(online), which demonstrates the septal exten- tion (Fig. 3).
sion graft placement for nasal tip projection and Unilateral septal batten grafts have also been
rotation.] described to control tip projection and rota-
tion. These require less cartilage than paired
Paired Extended Spreader Grafts grafts, and their intrinsic curvature can be used
Paired extender spreader grafts can be used to to correct asymmetries inherent in this unilateral
alter both tip projection and rotation in settings design. In turn, unilateral septal batten grafts are
of midvault collapse or narrowing. An increase particularly useful in cases of where tip deviation
in internal nasal valve angle is often achieved by is secondary to the anterior septum1,5 (Fig. 4).
placement of these grafts at the junction of the
upper lateral cartilage and septum in a parallel
line to the nasal dorsum. Any horizontal excess
in cartilage should be recessed 1 to 2 mm below
the plane of the dorsum to avoid excessive dor-
sal widening. To increase tip projection, the dis-
tal segments of the graft need to extend vertically
beyond the level of the dorsum. Finally, suturing
the tip-lobule complex to the graft establishes the
desired tip projection or rotation1,5 (Fig. 2).

Septal Batten Grafts

Bilateral septal batten grafts can serve to
change both nasal tip rotation and projection.1,5
Although these cannot address issues pertaining
to the internal valve or midvault, septal batten
grafts require significantly less cartilage than
extended spreader grafts. Paired septal batten
grafts require a strong caudal septum. The grafts Fig. 3. Bilateral septal batten graft.
are placed below the junction of the upper

Fig. 2. Paired extended spreader graft. Fig. 4. Unilateral septal batten graft.

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 Plastic and Reconstructive Surgery • May 2020

Direct Caudal Septal Extension Grafts

Toriumi described the use of caudal exten-
sion grafts in cases of caudal septal deficiency.8
In the foreshortened nose or in the setting of
columellar retraction, caudal extension grafts
can decrease tip rotation and alter the alar-
columellar relationship. Grafts are traditionally
fixed directly to the anterior nasal angle and
thus inherently unstable. Several techniques can
be used to address this issue. Suture fixation in
at least three points is essential, while using a
significant amount of cartilage allows for greater
degree of overlap between the graft and the
caudal septum. In addition, extended spreader
grafts can be used to help stabilize the graft
(Fig. 5).

Tongue-In-Groove Technique
The tongue-in-groove technique was first Fig. 6. Tongue-in-groove technique.
described by Guyuron and Varghai as a way to
effectively improve tip projection in the setting
of a severely shortened nose.9 It allows for nasal DISCUSSION
lengthening, ensures tip alignment with the rest Effectively controlling tip position, rotation,
of the nose, and avoids tip rigidity. To accomplish and shape remains a key component of modern
this, bilateral spreader grafts extending beyond rhinoplasty. Columellar struts were once used as
the caudal septum are sutured to the septum. a way to increase tip projection. Recent litera-
A columellar strut is then placed in the groove ture suggests that these grafts are unable to reli-
formed by the extensions of the spreader graft. ably achieve this and should instead be seen as
The medial crura are then sutured to a portion an effective tool for unifying the nasal tip and
of the columellar strut. To prevent excessive colu- maintaining its position. Columellar struts are
mellar show when using the tongue-and-groove indicated in noses with a weak medial or middle
technique, it is necessary to properly mobilize the crura, asymmetric lower lateral cartilages, and/or
lower lateral cartilages10 (Fig. 6). a short medial crura.
Byrd et al. introduced septal extension grafts
as a more reliable method of controlling tip pro-
jection, shape, and rotation.1 These were pro-
posed as a way to redefine the skeletal relationship
between the nasal tip and dorsum. Different types
of septal extension grafts have been described
with variations in shape and points of septal fixa-
tion. The type of graft used is dependent on the
specific characteristics of the underlying tip struc-
tures (Fig. 7).
Columellar struts and septal extension grafts
offer the modern rhinoplasty surgeon a way to
alter tip projection and rotation. As mentioned
previously, each of these varies in what it can
accomplish and to what extent. Nonetheless, it
should be noted that although each is very use-
ful, these grafts come at the potential tradeoff of
increasing tip rigidity. Understanding which graft
to use and in what setting is key for successfully
controlling projection, rotation, and shape of the
Fig. 5. Direct caudal septal extension graft. nasal tip.

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 Volume 145, Number 5 • Septal Extension versus Columellar Graft

Fig. 7. Algorithm for cartilage graft use in nasal tip projection and rotation. LLC, lower lateral cartilage; INV, internal nasal valve.

Rod J. Rohrich, M.D. tip position in primary rhinoplasty. Plast Reconstr Surg.
Dallas Plastic Surgery Institute 2012;130:926–932.
9101 North Central Expressway, Suite 600 5. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year
Dallas, Texas 75231 experience in controlling nasal tip projection and shape.
[email protected] Plast Reconstr Surg. 2003;112:1929–1935.
Twitter: @DrRodRohrich 6. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the colu-
Instagram: @Rod.Rohrich mellar strut graft: Indications and rationale. Plast Reconstr
Surg. 2012;129:118e–125e.
7. Akkus AM, Eryilmaz E, Guneren E. Comparison of the
‍REFERENCES effects of columellar strut and septal extension grafts for tip
1. Byrd HS, Andochick S, Copit S, Walton KG. Septal extension support in rhinoplasty. Aesthetic Plast Surg. 2013;37:666–673.
grafts: A method of controlling tip projection shape. Plast 8. Toriumi DM. Caudal septal extension graft for correction of
Reconstr Surg. 1997;100:999–1010. the retracted columella. Oper Tech Otolaryngol Head Neck Surg.
2. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: 1995;6:311–318.
Correction and prevention of alar rim deformities in rhinoplasty. 9. Guyuron B, Varghai A. Lengthening the nose with a tongue-
Plast Reconstr Surg. 2002;109:2495–2505; discussion 2506–2508. and-groove technique. Plast Reconstr Surg. 2003;111:1533–
3. Anderson JR. A reasoned approach to nasal base surgery. 1539; discussion 1540–1541.
Arch Otolaryngol. 1984;110:349–358. 10. Ponsky DC, Harvey DJ, Khan SW, Guyuron B. Nose elonga-
4. Rohrich RJ, Kurkjian TJ, Hoxworth RE, Stephan PJ, tion: A review and description of the septal extension tongue-
Mojallal A. The effect of the columellar strut graft on nasal and-groove technique. Aesthet Surg J. 2010;30:335–346.

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