Caudal septum replacement grafting is an essential tool in structure, ethnic, custom, revision and reconstructive rhinoplasties, whenever the septum is totally or subtotally missing or, alternatively, needs to be completely redesigned and replaced, 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 restore 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; however it is very unlikely this option is feasible if not enough remaining septum is available.
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.
It is considered a highly demanding technique of high difficulty, long 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.