2017-18 HSC Section 4 Green Book

Plastic and Reconstructive Surgery • March 2017

Fig. 3. Anterior septal angle position contribution to nasal tip projection.

what one needs to take and, more importantly, what and how much one should leave to prevent a long- term saddle deformity. Although leaving a 15-mm strut is often adequate, conservatism is encouraged when harvesting septal cartilage. Resecting only what is needed leaves more dorsal support, and also spares the septum for potential further graft harvest. In addition, in patients with a weak sep- tum, maneuvers such as leaving a 15-mm strut or rounding the angles created by septal resection can strengthen the construct. 11 Nasal Tip Projection The septal angle contributes to tip projection when it projects to the level of the lower lateral cartilages in patients with a high anterior sep- tal angle. This was noted by Constantian when he described obligatory tip augmentation after dorsal reduction in the setting of a high sep- tal angle. 12 When the dorsal septum is reduced on a patient with a high septal angle, the nasal tip is deprojected because of lessened septal Nasal Tip

contribution to tip projection. Constantian pro- poses preservation of the septal angle in these patients with creation of a straight dorsum. All of this starts with the dissection of the anterior septal angle, proper visualization, and reducing it if needed to control tip projection in conjunc- tion with the length and strength of the lower lateral cartilages (Fig. 3). Byrd et al. used the approach to the anterior septal angle to describe the use of septal exten- sion grafts to control tip projection and shape. 13 In this study, the relationship of the tip and dor- sal septum was analyzed in 20 patients who were considered “high-risk” for tip deprojection. It was found that transection of the interdomal ligament and placement of floating columellar strut grafts resulted in 0.5 to 2.0 mm of tip deprojection. The underlying reason was dissociation of the tip from the caudal septum. Subsequently, using a cadaveric study, Byrd et al. developed the sep- tal extension graft, which functionally extended the septum to a point determined by the surgeon, essentially reconstructing the anterior septal angle. The authors found that this was a much

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