信恩美醫診所部落格

A stable nasal base can ensure a solid foundation for the lower third of the nose. Anatomically, the nasal base is mainly composed of the caudal septum, medial crural footplates and nasal spine. A deficient or unstable nasal base may result in ptotic or underprojected nasal tip, columellar retraction, overly acute nasolabial angle or short nose. Hence, stabilization of the nasal base is critical to durably support the tip against forces of scar contracture, gravity, reacting force, and facial musculature.

                   
Conventionally, the main techniques for nasal base stabilization include: (1) Securing the medial crura onto the caudal septum; (2) Caudal extension graft; (3) Sutured-in place columellar strut; (4) Extended columellar strut. However, all of these techniques rely on the stability of the septum to stabilize the tip. Therefore, the caudal septum itself must be structurally intact and securely attached to the nasal spine and maxillary crest in order to ensure durable stabilization. In Asian patients, the septal cartilage is much smaller, thinner, and shorter than in Whites. Occasionally we noted that some primary or secondary rhinoplasty patients presented with underdeveloped, flimsy, pliable or deviated caudal septum . Conventionally in these situations, we may firstly need to strengthen or straighten the caudal septum with batten graft internally or externally in order to build up a stable nasal base. However, in Asians, the very limited supply of donor septal cartilage graft or conchal cartilage grafts may make the surgeon struggle to perform caudal septoplasty and subsequent procedures.

In 2007, Dini described caudal septal advancement technique for nose elongation. His method can not only restore the stability of the nasal base, but also save the amount of the needed cartilage grafts because the advanced caudal septum can work as extended columella strut. We modified this method and apply it in patients who request nose elongation or nasal tip projection while presenting with underdeveloped, unstable or deviated caudal septum.

 
多次矽膠隆鼻合併感染造成鼻形鑾縮


鼻中隔尾端前移術+Gore-Tex+耳軟骨移植,術後2個月

The basic operative procedures of our modified caudal septal advancement include: 
(1) Resection of central-posterior septal cartilage that will be used as a spreader graft. (2) Removal of the L-shaped caudal septal component from its attachments around the nasal spine. To avoid destabilization of the middle nasal vault, a stable dorsal strut was preserved at least 1.5 cm in length along its anteroposterior axis and 1 cm in width. (3) Caudal septoplasty to strengthen and straighten the weak or deviated caudal septum. The batten graft was harvested from the resected central-posterior septum or conchal cartilage depending on the availability of the donor cartilage. (4) Reintroduction of the reconstructed L-shaped caudal septum with its inferior aspect sutured to the periosteum around the nasal spine or to the cancellous nasal spine by drilling two holes with a 21-gauge needle. Fixation must prevent the caudal septal strut from slipping out of the midline. (5) Placement of the spreader grafts that were harvested from the thickest posterior septal base or thinner central septum. When the donor septal cartilage was too small or depleted, the conchal cartilage graft was chosen. In some patients who had a prior extension grafting procedure, the extension graft was carefully dissected and recycled as spreader grafts. The spreader grafts were fixated to the dorsal strut at the keystone area and L-shaped caudal septum, respectively. Finally, solid nasal base was completed with medial crura sutured to the caudal margin of the advanced septal graft.

 
多次矽膠隆鼻合併感染造成鼻形鑾縮


鼻中隔尾端前移術+Gore-Tex+耳軟骨移植,術後2個月

The potential complications of caudal septal advancement technique include collapse of middle nasal vault and caudal nasal deviation or the “click” when the patient smiles resulting from caudal septum slipping out of midline.

Based on more than 70 cases experience, we believe that the application of the caudal septal advancement method can more predictably and efficiently provide a stable nasal base support than the conventional extension graft, spreader grafts, or extended spreader grafts when Asian patients present with weak or deviated caudal septum or a limited supply of donor conchal or septal cartilage and request nose lengthening or nasal tip projection. This paper reports the author’s experience in treating Oriental patients with the modified caudal septal advancement technique with or without combined external septoplasty, the complications encountered during a 3-year observation period, and the aesthetic results.


多次矽膠隆鼻合併感染造成鼻形鑾縮


鼻中隔尾端前移術+Gore-Tex+耳軟骨移植,術後2個月,鼻頭尚有些腫大肥厚,預期數月之後會再進一步改善.