Caudal septum lengthening grafting is an essential tool in structure, ethnic, custom, revision and reconstructive rhinoplasties, whenever the nasal septum is short leading to misbalance of the nasal pyramid and tip, producing deformities like short nose syndrome, tip over rotation, piggy nose, upturned tip nose, certain ethnicities, sunken columella, poorly supported and defined tip, etc.
The caudal septum is a cornerstone element in nasal shape, therefore any rhinoplasty should aim to preserve such feature, improve it or repair it if damaged; furthermore the septum is the main stand point for many other subsidiary rhinoplasty techniques in need of a well balanced and firm septum to be successful.
With that said there are different methods and strategies to lengthen, reconstruct, augment or rebuild a septum, which rarely are pure septal lengthening aimed maneuvers; in the vast majority of cases a septum needs lengthening is to be used as pillar to which rely other anatomical structures.
This explains the variety of options existent to add support with cartilage grafting at the caudal septum, being the ideal donor sites the deep nasal septum, ear concha and the rib; the most basic one is the one on one septal lengthening graft, consisting of a trapezoid and flat grafting sutured to the caudal edge of the septum, which provides slight to moderate support force making it suitable when the length to be gained is not much and the overlying skin and nose are not very firm and rigid.
Should a firmer support be required then a pair of caudal extension grafts are fixed between the upper lateral cartilages and the dorsum septum, acting as well as dorsum spreader or spacer grafts; in fact only just one caudal extension graft may suffice if it is firm and strong enough and not much dorsal spread is intended; in this modality the support power is very high, mostly if the grafts are strong cartilages, since they caudal extension grafts are supported not only by the remaining septum but also by the cartilaginous walls of the nasal pyramid, making this option optimal when the overlying skin and nose are really collapsed and unsupported.
An evolution of the former is the septocolumella graft in which a pair of caudal septal extension grafts are assembled with a vertical support tip graft forming an L shaped scaffold which will lengthen the septum and nose as well as provides nasal tip lengthening or projection.
There are other atypical septal extension needs, customized to every particular case, sharing all of them the same goal to add additional projection to the septum in any spatial direction wished, to a longer or shorter extent.
Extended columella strut grafting is an essential tool in structure, ethnic, custom, revision and reconstructive rhinoplasties, whenever the tip of the nose and its underlying columella support needs to be totally redesigned, providing the location, prominence, shape, size, angle or specific custom look desired by the patient or deemed technically required by the surgeon, from an ambitious change up to a totally brand new custom made tip and columella projection; common indications are the poorly supported tip due to weak columella, short septum, short nose, ethnic noses, revision of poor results, feminization cases, sunken columella, upturned noses, droopy tip, poorly defined tip, aging tip, associated with tip grafting, etc.
This kind of extended columella strut grafting is inserted between and along the entire the inner side of the medial cruras from the bottom at the maxilla to the top at the nasal tip, then the tip projection assessed and adjusted, and finally securing the assembly by means of suturing them three en bloc to act as a firm tip projection and columella reinforcement element, with or without combination with tip grafting, being the ideal donor sites the nasal septum, ear concha and the rib.
Normally the caudal septum and the medial cruras are separated, floating free and forming the frontier between the mobile tip and annexes unit and the stable immobile pyramid parts of the nose, with the mere separation of the subseptum soft areolar tissue, making the tip support and projection fully dependant on the lateral and medial cruras of the lower lateral cartilages, however mainly on the medial cruras. The extended columella strut graft is an additional pillar for that supportive role or reinforces the previously existing one and makes the tip, or at least the medial cruras and the tip solidary and firmly conjoined to the graft.
The extended columella strut graft technical reshaping power comes from the securing and firm fixation of the medial cruras and tip against or towards the graft, which is a very stable and firm projection point.
The extended columella strut graft technique is indicated when it is deemed unsafe, unstable, unpredictable or unlikely successful letting the tip, the columella and the nasolabial angle float free to acquire their shape, position, projection and angle or alternatively when other less interventionist maneuvers with the same purpose are unreliable, unfeasible or have already failed, like simple suture plications; it is one of the most powerful and versatile maneuvers which can be performed on a nose.
For its performance a non short septum is required or, alternatively, rebuild the septum length with caudal septal extension grafts or septocolumella grafts and assemble the extended columella strut graft in them, with or without an associated tongue in groove maneuver to form an L shape scaffold called septocolumella graft.
With that said there are clear and necessary indications of the extended columella strut graft, in those noses with undoubted an undisputable requirement of extraordinarily firm projecting and support of the tip and columella, as long as they are managed by highly experienced surgeons.
It is considered a highly demanding technique of high difficulty of calibration but of low to medium difficulty in its execution, short time consuming in the operating room and pretty much artistic in terms of its versatility, allowing full deployment of creativity reshaping noses.
This gesture can be done by either closed or open approach rhinoplasties, notwithstanding the open approach is a must of safety, reliability and precision for its execution.
Patients warning: only highly experienced surgeons who have underwent optimal training and have performed already a large number of closed and open approach structure and non structure rhinoplasties should execute high end rhinoplasty cases, should they feel capable and comfortable with the challenge.