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ORIGINAL ARTICLE

Open Septorhinoplasty: Operative Technique and

Grafts
B S Gendeh, MS ORL-HNS, Vincent E S Tan, MD

Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia

SUMMARY of the nasal osteocartilaginous framework without anatomic

In this case series, the senior author details his series of distortion, therefore allowing proper remodeling of the nasal
patients who had undergone open septorhinoplasty for framework. The surgeon can be assured of accuracy while
functional and/or aesthetic purposes in the performing detail suturing and resection manipulation. It
Otorhinolaryngology Department at the Hospital Universiti also offers unparalleled accuracy for structural diagnosis and
Kebangsaan Malaysia (HUKM), Kuala Lumpur between placement or manipulation of graft, if needed, under direct
January 2003 and September 2005. There were 23 patients, vision. Being a tertiary referral centre, the open approach also
consisting of 15 men and 8 women from different Malaysian facilitates the teaching and learning of nasal anatomy and
ethnic groups. Discussion on open septorhinoplasty with surgical techniques. The open approach is also recommended
regards to operative technique, grafts and implants is for revision or secondary septorhinoplasty. On contrary,
presented from an otorhinolaryngologists point of view. opponents argued that the transcolumellar incision used for
surgical access in this technique produces scarring2. However,
KEY WORDS: given all these advantages, the transcollumellar incision scar
Open septorhinoplasty, Technique, Grafts is indeed a small price to pay.

Here, the senior author, a proponent of the open

INTRODUCTION septorhinoplasty approach, reviews his surgical patients who
Septorhinoplasty surgery remains as one of the most had undergone this approach for various reasons.
challenging operations in the field of facial plastic surgery - a
domain gradually embarked upon by the contemporary
otorhinolaryngologists. Despite the advances and the MATERIALS AND METHODS
multiple techniques that have been described in the All cases of open septorhinoplasty for functional and
literature, it can be a steep learning curve and a daunting task cosmetic purposes presenting at Hospital Universiti
no less for the aspiring rhinoplasty surgeon. While it is said Kebangsaan Malaysia (HUKM), Kuala Lumpur between
that beauty is in the eye of the beholder, the surgeons January 2003 and September 2005 performed by the senior
attention to functional, reconstructive, and aesthetic author were reviewed. Cases where the transcollumellar
principles is paramount in ensuring optimum endonasal transseptal approach was used as a neurosurgical
septorhinoplasty results, much to the satisfaction of both the access were excluded from this study. There were a total of 23
patient and the surgeon. patients, of which 15 (65.2%) were males and 8 (34.8%) were
females. Mean age at presentation was 30 years (range 16-54).
Septorhinoplasty is a complex operation that requires precise Indians constituted 69.6% of the patients (16/23), Chinese
preoperative diagnosis to select the appropriate surgical 17.4% (4/23), and Malays 13.4% (3/23). The patients were
technique, partly because of its dual role and central reviewed with respect to nasal deformity on presentation,
importance for both nasal function and facial form. As the surgical technique, types of grafts used and the postoperative
debate between the open and closed approach and the ideals outcome.
of facial contour rages on, new techniques are formulated
with greater attention to the nasal anatomic variability in
men and women across different ethnic groups. Proponents RESULTS
of the closed or endonasal approach emphasize on its The demographic data of all the patients who underwent
advantages namely absence of external incisions, and less open septorhinoplasty are shown in Table I.
dissection required, therefore, minimizing soft tissue trauma
and subsequent scarring. It is less dependence on On presentation to the Otorhinolaryngology Clinic at
postoperative steroids to reduce postoperative swelling. HUKM, the patients were assessed by the senior author. All
However, exposure of the surgical field is very limited and tip the above patients complained of nasal blockage and/or
supporting mechanism tends to be compromised with time1. cosmetic inadequacies. A detailed history was obtained;
physical examination and nasal endoscopy was performed. In
On the other hand, the open or external approach offers a a twisted nose, whether post-traumatic (Fig. 1 and 2) or non-
much more superior exposure of the nasal tip for inspection traumatic (Fig.3), nasion and nasal tip are in the same vertical

This article was accepted: 5 December 2006

Corresponding Author: Balwant Singh Gendeh, Department of Otorhinolaryngology-Head & Neck Surgery, Faculty of Medicine, UKM Hospital, Jalan Yaacob
Latif, 56000 Cheras, Kuala Lumpur

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Original Article

plane with the mid-vault deviated to one-side. In contrast, in of allergic rhinitis in 34.5% of the patients, the incidence
a crooked nose, the nasion, mid-vault and the nasal tip are in being more in the non-traumatic group.
a straight line off the vertical plane. A saddle nose, owing to
the loss of the dorsal aspect of the quadrilateral cartilage, has All patients were orotracheally intubated and head was
supratip depression, shortening of the nose and often, slightly extended. With an oropharyngeal pack in place, both
overrotation of the tip. On the contrary, an overprojection of nostrils were packed with cotton pledgets soaked in cocaine
the nasal dorsum results in a dorsal hump deformity. The and adrenaline (1:1000 concentration) for vasoconstriction.
nasal tip can also be deformed in many ways- underprojected, Local anesthesia in the form of ropivacaine 2mg/ml and
overprojected, rotated, abnormally shaped among others. adrenaline 1:80,000 was injected into the nasal tip, columella,
Photographs for preoperative documentation were taken nasal septum, along the site for the proposed marginal
from 5 views: frontal, base, top, right and left 45o oblique. incision, and along the lateral nasal wall. Bilateral transoral
The nasal deformity on presentation can be summarized as in greater palatine block was performed then. All cases were
Table II. approached via a combined either inverted V or Z-shaped
transcollumellar incision with bilateral alar marginal
Majority (60.9%) of the patients presented with twisted nose. incisions using a size-15 scalpel blade. The marginal incision
There were two patients (patients 1 and 19) who underwent along the caudal margin of the lateral crura was extended
endonasal septoplasty earlier elsewhere but the residual down the columella to meet the columellar incision. With
deformity in the form of crooked nose and prominent dorsal the aid of an Aufricht retractor and a small curved scissors,
hump compelled correction via the open septorhinoplasty the soft tissue plane was dissected below the superficial
approach. There was history of obvious nasal trauma elicited muscular aponeurotic system (SMAS) superiorly and laterally
in 7 of the 23 (30.4%) patients. All of the patients had to expose the upper lateral cartilage and the lateral crura
deviated nasal septum of varying severity. There was a history respectively. The middle nasal vault was exposed in the

Table I: Patient Data

Patient Age Sex Race Trauma Deformity Graft/Implant Hospital Complication Follow up
Stay (days) (as of June 06)
1 16 F M + crooked nose QCSG 4 - 9 months
2 24 F I + twisted nose QCSG 4 tip paraethesia, depressed alar
deformity 40 months
3 24 M C + twisted nose SBG 4 nasal obstruction 3 months
4 35 M C + saddle nose SBG 4 - 3 months
5 37 M C - crooked nose QCSG 5 - 32 months
6 19 F I - crooked nose QCSG 4 alar deformity 32 months
7 38 M I + twisted nose QCSG 5 tip paraethesia + alar deformity 31 months
8 16 M I - twisted nose MSG 4 synechae 23 months
9 44 M I - underprojected tip MSG 4 - 22 months
10 16 M I - twisted nose MSG 5 - 20 months
11 26 F I - twisted nose QCSG 4 - 20 months
12 32 M I - twisted nose QCSG 4 - 9 months
13 20 F I - crooked nose QCSG 5 - 3 months
14 22 F I - saddle nose MSG 4 - 15 months
15 16 M I + twisted nose QCSG 5 - 14 months
16 46 F I - saddle nose MDSG + CCSG 5 alar deformity 14 months
17 45 M I - twisted nose QCSG 6 - 12 months
18 54 F I - twisted nose QCSG 4 - 12 months
19 40 M I - dorsal hump MSG 5 - 11 months
20 22 M M - twisted nose QCSG 6 - 10 months
21 38 M I - twisted nose + MDSG+ 7 - 9 months
dorsal hump QCSG
22 35 M C - twisted nose MSG 5 - 9 months
23 22 M M + twisted nose MDSG+ QCSG 3 - 9 months
QCSG = Quadrangular cartilage spreader graft
SBG = Septal bone graft
MSG = Medpore spreader graft
MDSG = Medpore dorsal support graft
CCSG = Conchal cartilage spreader graft

Table II: Nasal deformity at presentation

Nasal deformity Trauma Non trauma Total
AR Non-AR AR Non- AR
Crooked nose 1 1 2 - 4
Dorsal hump - - 1 - 1
Twisted nose 1 3 2 8 14
Twisted nose & Dorsal hump - - - 1 1
Saddle nose - 1 1 - 2
Underprojected tip - - - 1 1
AR = Allergic rhinitis

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Open Septorhinoplasty: Operative Technique and Grafts

Table III: Types of grafts used for various nasal deformities

Deformities Grafts Number
Crooked nose Quadrangular cartilage spreader graft 4
Dorsal hump Medpor spreader graft 1
Septal bone graft 1
Quadrangular cartilage spreader graft 8
Twisted nose Medpor spreader graft 3
Medpor dorsal support graft + Quadrangular cartilage spreader graft 1
Twisted nose & dorsal hump Medpor dorsal support graft + Quadrangular cartilage spreader graft 1
Medpor spreader graft 1
Medpor dorsal support graft + conchal cartilage spreader graft 1
Saddle nose Septal bone graft 1
Underprojected tip Medpor spreader graft 1

Fig. 1: A, C, E, Preoperative view of a 38 year-old Indian patient Fig. 2: A, C, E, Preoperative view of a 33-year old Chinese patient
with a non-traumatic twisted nose and dorsal hump. B, D, with a posttraumatic twisted nose. B, D, F, Postoperative
F, Postoperative views after surgery (Medpor dorsal views after surgery (Medpore spreader graft was used).
support graft and quadrangular cartilage spreader graft
were used).
cartilage. Bilateral mucoperichondrial flap of the
cartilaginous septum was elevated, with the dissection
continuing over the perpendicular plate of the ethmoid bone
and vomer upward and extends over the nasal crest of the
maxillary bone and medial floor of the nose downward. After
completion of the degloving exposure, bipolar electrocautery
was used for hemostasis. The entire osteocartilaginous
framework was then evaluated.

Suitable grafts in the forms of autograft (septal bone, conchal

cartilage, quadrangular cartilage spreader grafts) or allograft
(porous high-density polyethylene- Medpor, Porex Surgical,
Georgia, USA) were placed in the area of defect. The types of
grafts used for various nasal deformities are shown in Table
III. Autogenous graft in the form of spreader graft from the
septal cartilage was the graft of choice. It was used in 14
(60.1%) patients. In another three (13.0%) patients, more
than one graft was used, mainly as quadrangular cartilage
spreader graft and Medpore as dorsal support graft or spreader
Fig. 3: A, C, E, Preoperative view of a 35-year old Chinese patient graft.
with a congenital non-traumatic twisted nose. B, D, F,
Postoperative views after surgery (Medpore spreader The patients with an underprojected tip and saddle nose had
graft was used). tip-recontouring performed to elevate the nasal tip. On
(Note: Consent have already been obtained from all patients) completion, the skin flap was returned to its normal
anatomical position and the transcolumellar incision closed
midline. The interconnecting ligaments over the medial with nylon 5/0 sutures while the bilateral alar marginal
crura were split exposing the caudal portion of the septal incision with Vicryl 4/0 sutures.

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Original Article

Postoperatively, the patients were prescribed a course of supportive septum. It is important to address the septal
amoxycilin/clavulanate for ten days. Adhesive dressing (Steri- deformity for an otorhinolaryngologist to achieve optimum
strip) was applied to all noses post-surgery to minimize soft results. Also, an adequate L-shaped dorsal and strut of the
tissue swelling and graft displacement. Patients who also quadrilateral cartilage (about 6-8mm) should be maintained
underwent osteotomy had additional Plaster of Paris (POP) at all times to preserve the dorsal and caudal support. Very
applied to the nasal dorsum for about a week. The average often, grafts (autograft or allograft) are needed to resist the
length of stay in the hospital was 4.6 days (range 3 -7 days). memory effect and prevent recurrence of the curved septum
in this group of patients. A septum dislocated off the
The patients were followed up postoperatively. The removal maxillary crest should be repositioned.
of the transcollumellar sutures, Steri-strip and POP was
performed on the 7th day post -surgery. On follow-up, the To simplify the understanding of the osteocartilaginous
patients were reviewed with respect to his/her improvement framework, one can divide the external nose structure into
in symptom scores for nasal patency and aesthetic thirds. The upper third comprises the nasal bones and
improvement. While the patients satisfaction was entirely extends down to the osseocartilaginous junction (rhinion);
subjective, nasal endoscopy was performed to evaluate the middle third, also called the middle nasal vault, is made
patency of the nasal airway. At present, 17 (73.9%) patients up of the upper lateral cartilages (ULCs) and septum, and the
are still on active follow-up with a mean duration of 13 lower third comprises the lower lateral cartilages (LLCs) and
months while 6 (26.1%) defaulted at an average of three the anterior septal angle/caudal septum. Most twisted noses
months. One patient had intranasal synechae formation, have some form of anatomic distortion of the lower two-
which was released later at follow-up using local anaethesia. thirds4. The internal nasal valve is another region that must
Two patients had transient tip paraethesia with minimal alar not be overlooked in the preoperative assessment. It is
depression. Another two had alar deformity which required bordered medially by the septum, inferiorly by the nasal
revision surgery. So far, there have been no cases of infection, floor, laterally by the inferior turbinate, and superiorly by the
implant extrusion or epistaxis. Functionally, all except one caudal border of the ULC. Any compromise in the
patient experienced subjective improvement in the nasal surrounding boundaries would render the valve susceptible to
airway. Therefore the postoperative nasal obstruction rate was collapse, resulting in nasal obstruction by the patient. Once
1 of 17 (5.9%) patients. the boundary of the nasal valve area is interfered, repair by
autogenous grafts or allografts is essential.
The scale of patients level of satisfaction was subjective3.
Among those still on active follow-up, 13 of 17 (76.4%) Deformity of the upper third involving the nasal bones in 6
patients were satisfied (their result met or exceeded their of the 18 patients with twisted noses required medial and
expectations) with the cosmetic improvement. However, two lateral osteotomies prior to spreader grafts insertion. As
patients (patients no. 2 and 7) with minimal alar depression evidenced by the two patients who still had some deformity
were moderately satisfied (would have hoped for more despite an earlier septoplasty, involvement of the middle
improvement but generally accepted the result and do not third in twisted or saddle noses was more difficult to correct
wish to have it revised). Two (11.7%) patients had obvious due to the inherent tension memory effect of the ULC and
alar deformities and underwent revision surgery. After the septum. The ULC needed to be mobilized away from the
revision surgery, one patient (no. 6) was still dissatisfied with septum but the mucoperiochondrium has to be kept intact to
the looks whereas the other patient (no. 16) was moderately maintain the vascularity to the mobilized ULC and prevent
satisfied. Both remained on follow-up for possible revision scarring in the nasal valve region4,5. However, in the presence
surgery in the near future. of a crooked dorsum, predicting the anatomy of the ULC and
their relation to the septal dorsum may not be that
straightforward. Furthermore, when separating the ULC from
DISCUSSION the dorsal septum, it can be difficult or impossible to create a
Trauma accounted for most cases of twisted nose4, with other straight medial margin without resecting even more ULC,
causes being congenital or prior nasal surgery, although in therefore making a spreader graft mandatory5.
this series the majority was non-trauma patients. Besides the
obvious cosmetic defect, patients with twisted nose Deformity of the lower third is usually caused by deformity in
frequently have troublesome nasal obstruction due to the the caudal septum or the nasal tip. An open approach would
narrowed airway. As such, history of allergies (eg. allergic allow direct visualization of the tip problem and subsequent
rhinitis) should be elicited and proper medical management tip-plasty under direct vision. In this case if the nasal valve
commenced before the definitive corrective functional area is not compromised, the use of spreader graft may not be
surgery. This will allow the surgeon to determine the severity necessary.
of the functional problems contributed by the structural
defect. While autogenous grafts are the gold standard for
augmentation in open septorhinoplasty, allograft can still be
The gateway to the nose for the otorhinolaryngologist is the used for well-selected patients. The patient should be
septum. Twisted nose comprises distortion of the midvault counseled regarding the available options for the graft.
osteocartilaginous framework in various possible Appropriate graft selection should be a joint decision between
combinations. Majority of patients with twisted noses in this the surgeon and the patient. Autogenous materials incite
series have significantly deviated septum4. The objective of much less inflammatory response with low rates of
surgery is to achieve or restore a straight, midline and resorption, extrusion and infection, though it may be

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Open Septorhinoplasty: Operative Technique and Grafts

associated with donor site morbidity and longer operating mechanical stabilization, with less risk for infection and
time. More often, autogenous grafts are used for extrusion. It is easily available locally in numerous shapes
reconstruction. First described by Sheen6, spreader graft was and sizes, and is readily sculpted after being soaked in hot
designed to address the aesthetics of the dorsal lines and the water. Besides being malleable, it incites minimal foreign
problem of nasal valve collapse with subsequent nasal body reaction as compared to silicone implant (no
obstruction. The graft acts to widen the nasal valve angle and capsulation occurs) 10. As such, it is the senior authors
significantly improve the nasal airway. In the literature, the preferred choice of allograft, if need be.
spreader grafts were found to be most successful in correcting
severe middle nasal vault deformity and internal nasal valve Silastic, a silicone-based implant, was never used as it is
related airway problems7,8. In this series, nine selected notorious for the high rates of infection and extrusion,
patients were predisposed to excessive narrowing of the especially in thin-skinned individuals12, due to lack of fibrous
middle nasal vault and nasal valve collapse. In the patient or vascular ingrowth into the implant. Other complication
with both twisted nose and prominent dorsal hump, spreader like graft migration and dorsal cyst formation had also been
graft was used along with Medpor in an attempt to prevent documented13.
future vestibular contraction, as advocated by Sheen6.
Gore-Tex, composed of fibrillated polytetrafluoroethylene
The graft was harvested from the quadrilateral cartilage and (PTFE), shares common advantages as the Medpor. It is highly
subsequently trimmed and shaped according to the size of the biocompatible, allowing tissue ingrowth, with minimal
defect and the strength of support needed. Using the inflammatory response, and low rates of infection, extrusion
quadrangular septal cartilage is advantageous to the and resorption. However, with its soft consistency, it does
otorhinolaryngologists because it is locally available in the not provide a robust structural integrity for augmentation10.
same surgical field and the ease of contouring the cartilage. If Again, the senior author has no experience with this implant
quadrangular septal cartilage is inadequate, the conchal in this case series.
cartilage can be harvested instead. The spreader graft was
then placed unilaterally or bilaterally between the upper Ethnicity is also a factor to be taken into consideration during
lateral cartilage and the septum with Prolene 5/0 suture septorhinoplasty as it significantly affects the surgical
fixation. Other options described include placing the graft in techniques used and the eventual outcome. In this series,
mucoperichondrial pockets with no suture fixation, but both incidentally, majority of the patients were of Indian origin. As
methods were equally effective8. compared to the Malays or Chinese, they tend to possess the
nasal geometry of the Caucasians rather than the Oriental
Onlay ("camouflage") grafts harvested from conchal cartilage due to their ancestral roots. Caucasian nose is more greatly
was indicated in 1 patient with saddle nose as the ULC and projected at tip and nasion as compared to the Oriental
nasal bone was depressed9. An onlay graft is particularly nose14. On the contrary, non-Caucasian noses have thick skin,
useful in cases where the ULC or nasal bones are depressed weak cartilage, flat broad dorsum with underprojected tip,
without associated airway problem4. Conchal cartilage is widened alar base and shorter nasal bones15. Thickness of the
easily available, easy to carve, has low donor site morbidity skin affects the prominence of the underlying cartilages, ease
and less metabolically demanding, thus undergoes less of tissue dissection and the degree of nasal tip sculpting. The
resorption10. transcollumellar incision should also be placed lower in the
non-Caucasian noses because augmentation will advance the
Bone grafts were used in three patients where more rigid columellar skin cephalically15.
augmentation was needed. Septal bone was easily available
within the same surgical field from either the bony septum, In his critical analysis of his rhinoplasty experience, Foda3
sphenoid rostrum or the maxillary crest. Iliac crest bone documented his complication rates as follows: septal flap tear
provides ample supply of relatively flat bone, but is associated 2.8%, alar cartilage injury 1.8%, post-operative nasal trauma
with donor site morbidity like pain and hematoma. The 1%, epistaxis 2%, infection 2.4%, prolonged edema 17%,
rigidity of bone grafts makes them less suitable for areas like nasal obstruction 0.8%, and unsightly transcolumellar scar
the nasal tip. Iliac bone graft was not utilized in this case 0.8%. The overall patient satisfaction rate was 95.6%. So far
series. in this series, while the complication rates for residual
deformity was higher; there have been no cases of post-
Synthetic grafts have the advantage of being in abundant operative epistaxis, infection, graft extrusion or keloid scar
supply, reduces operating time and donor site morbidity. formation.
Previous surgery or patients apprehension about increased
surgical morbidity from a second operative site may The biggest limitation of the evaluation of this series is the
contribute to the surgeons decision to use a non-autogenous fact that it is non-blinded and the only evaluator is the
graft11. In the literature, other than Medpor, other materials surgeon. Assessment was also purely subjective, whether
that have been used include expanded cosmetic or functional. Therefore in the future, patients
polytetrafluoroethylene (Gore-Tex, W.L. Gore and Associates) should undergo acoustic rhinomanometry to objectively
and dimthylsiloxane polymer (Silastic, Dow Corning Corp.) document the improvement in the nasal airway. Lack of
long-term follow-up in this study is another limitation. Some
Medpor allograft offers some advantages in nasal patient also defaulted soon after the surgery with no
reconstruction. The internal pores of varying sizes facilitate meticulous follow-up to assess for long-term results and
fibrous and vascular tissue ingrowth, therefore allowing possible complications.

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CONCLUSION 6. Sheen JH: Rhinoplasty: personal evolution and milestones. Plast Reconstr
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Septorhinoplasty continues to evolve through various new 7. Sheen JH. Spreader graft: A method of reconstructing the roof of the
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efforts for the betterment of the patients must be balanced by traumatic crooked nose. Facial Plast Surg Clin North Am 1995; 3: 421-48.
10. Khurana D, Sherris D. Grafting materials for augmentation
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