Aesth. Plast. Surg. 31:512513, 2007 DOI: 10.

1007/s00266-006-0254-x

Discussion

A Simplied Use of Septal Extension Grafts to Control the Nasal Tip Location

H. Steve Byrd, M.D.

Dallas Plastic Surgery Institute, 411 N. Washington Avenue, Suite 6000, Dallas, TX 75246, USA

I congratulate the authors for further dening the indications and use of septal extension grafts in rhinoplasty. They report a large experience of 72 cases, in which 85% of the patients obtained satisfactory tip projection. The authors methods distinguish themselves from those described in prior publications [1, 2] in that unilateral single-batten or bilateral asymmetric batten grafts were used instead of paired grafts. The authors thought these modications minimized stiness of the nasal tip and thickening of the septum in the nasal valve area. In our 6-year review of septal extension graft use, we also noted undesirable widening in the distal midvault and supratip area when paired extension grafts were placed in the spreader position. This undesirable feature can be eliminated by allowing the distal extension of the graft to fall below the projecting line of the dorsal septum. This permits narrowing of the upper lateral cartilage and lower lateral cartilage complex in the supratip. We continue to use the paired spreader extension grafts with this modication, particularly for dorsal septal deviation and for patients with midvault collapse. In both instances, improvement of the internal valve function and stability of septal repositioning is achieved. We certainly concur with the authors that extension grafts may be asymmetrically placed, with the choice and position of the grafts dictated by the skeletal needs. We do believe that the extended portion of the graft needs to reach the aesthetic midline. Occasionally, a unilateral graft will have enough

Correspondence to H. marta.traugott@dpsi.org

Steve

Byrd,

M.D.;

email:

distal curvature to fall precisely in the aesthetic midline. When this does not occur, paired extensions still are used to bring the grafts to the aesthetic midline. In these cases, the tip lobule complex is brought over the extended grafts so that skin contact is with the normal anatomy. It is true that there is added stiness to the tip lobule complex, but we accept this as a desirable consequence to obtaining stable projection and shape. The authors noted that ve patients (7%) had loss of their columellar break point. Although we have not seen that particular complication, we have observed caudal elongation of the columella lobule angle. We believe the caudal projection of this angle should be controlled by suture placed at the junction of the middle and medial crura axed to the lower border of the extension graft. With the second suture at the dome, the columellalobule angle and the infratip lobule are well controlled. Finally, the indication for septal extension grafts involves the necessity of controlling tip projection and shape. A stable caudal septum is necessary for an extension graft to predictably maintain projection. Rotation and shape can be dened by shaping the extension graft like a jig to which the alar cartilage complex is sutured. Patients with midvault collapse (inverted V deformity), dorsal septal deviation, and short nose are ideally suited for extended spreader grafts. When caudal septal deviation is present, a batten across the caudal septum alone or in combination with extended spreaders is indicated. We agree with the authors that preservation of the caudal septums anterior angle is an eective way to secure the tip and control shape for patients with long noses that require shortening. We thank the authors for calling attention to this useful adjunct in rhinoplasty.

H. S. Byrd

513

References
1. Byrd HS, Andochick S, Copit S, Walton G: Septal extension grafts: A method of controlling tip projection. Plast Reconstr Surg 100:9991110, 1997

2. Ha RY, Byrd HS: Septal extension grafts revisited: 6-year experience in controlling nasal tip projection and shap. Plast Reconstr Surg 112:19291935, 2003