Correcting Various Nasal Tip Deformities #3: Tip and Columellar Deviation from a Tilted Septal Extension Graft

Correction of Various Nasal Tip Deformities

01 Contracted nose (upturned nose) ▶ Extension graft (SEG), derotation graft 

02 Pinched tip ▶ Lateral crural strut graft (LCSG)

For correcting nasal tip pinching (pinching & notching) and

external nasal valve damage: Lateral Crural Strut Graft (LCSG)

Causes of a tilted columella and tip include

1) Displacement of the silicone implant to one side

2) Improper manipulation during tip plasty

3) Deviation of the septum

4) Tilting of the septal extension graft

and other factors.

Which of these is the cause must be examined carefully to reach an accurate diagnosis.

Only by checking whether a septal extension graft was placed previously and whether the tip is fixed and stiff,

and so distinguishing the cause, can appropriate surgery and results be achieved.

In particular, whether the deviation of the tip and columella is due to a deviated caudal septum

or to a tilted septal extension graft can be told apart by checking the mobility of the tip and whether septal cartilage was used.

Columella deviated as the septal extension graft tilted

PH

2007: silicone implant + ear cartilage onlay to the tip => implant became crooked; dissatisfied with the shape

2014: silicone implant + Medpor + extension graft with septal cartilage.

CC

Crooked silicone implant, implant show-through at the tip, tilted tip and columella.

P/E

Crooked silicone implant, tilted tip and columella, nostril asymmetry, stiff tip.

The silicone implant was displaced to the right, and septal cartilage and mesh had been applied in 2 layers

as a septal extension graft; the extension graft attached to the end of the septum was unstable and had tilted to the right.

The caudal end of the septal cartilage (caudal septum) was also deviated to the right,

so the tip could not help but shift to the right.

OP

The silicone implant, the capsule, and both layers of the extension graft were all removed. The septal cartilage was straightened, moved to the midline,

and fixed. Lateral crural strut graft and external nasal valve graft using septal cartilage.

After surgery, the dorsum looks natural, and the nostrils and columella are centered.

The tilted columella was straightened, and nostril symmetry was achieved.

The tip, which had been shifted to the right, became symmetric and centered.

The tip shape looks natural.

PH

2010: silicone implant + extension graft with septal cartilage (open approach)

2022: silicone implant + ear cartilage + donor costal cartilage + reuse of septal cartilage (open approach)

CC

Red, painful tip; frequent swelling; the right nostril feels blocked and uncomfortable.

P/E

Silicone implant displaced to the left; tip and columella tilted to the left;

septum protruding inside the right nasal cavity.

Because of a chronic inflammatory response, there was a large amount of thick scar tissue.

Donor costal cartilage had been stacked in two layers and set up as a septal extension graft,

and as it tilted from right to left, the tip had tilted to the left with it.

In other words, as the septal extension graft tilted, the tip fixed to it tilted as well.

This shows the nose after all scar tissue, capsule, and inflamed tissue were removed, along with the extension graft.

After removal, the cartilages of the columella and tip remained well symmetric,

so they were simply sutured together and repositioned.

The bridge and tip returned well to the midline.

The columella and tip, which had tilted to the left, returned to the midline,

the septal extension graft that had protruded inside the right nasal cavity was cleanly gone after its removal,

and breathing improved. Nostril symmetry improved markedly.

PH

8 months ago: dorsal rasping + silicone implant + extension graft with septal cartilage + ear cartilage to the tip (open approach)

CC

The tip shows through and feels tight. Tilted tip and columella; nostril asymmetry.

P/E

The tip is excessively high and under tension. The tip and columella are tilted to the left.

The tip is fixed and firm.

The silicone implant was displaced diagonally and there was a large amount of scar tissue; all of it was removed.

Septal cartilage had been applied to both sides of the caudal end of the septum as an extension graft. This was also removed entirely.

The tip, columella, and bridge are now straight overall. 

The tension in the taut tip is gone and the tip has softened. The upturned tip has also come down.

The tip and columella sit straight in the midline,

and the tip, which had been too high and under severe tension, looks natural.

The height of the nose returned to its original state and looks natural.

The tip, which had been pointed and too high, looks natural.