COSMETIC

Superiority of the Septal Extension Graft

over the Columellar Strut Graft in Primary
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Rhinoplasty: Improved Long-Term Tip Stability

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Justin L. Bellamy, MD
Background: Columellar strut grafts and septal extension grafts are commonly
Rod J. Rohrich, MD used support structures; however, their relative effectiveness remains debated.
Dallas, TX The purpose of this study was to compare the long-term stability of septal exten-
sion grafts to that of columellar strut grafts.
Methods: A retrospective review of all primary rhinoplasties performed by the
senior author (R.J.R.) from 2016 to 2019 was performed. All adult patients
undergoing primary open rhinoplasty with at least 1 year of follow-up were
included. Revision cases and those in whom rib grafts were used were excluded.
Standardized postoperative imaging was assessed at 2 months (early) and at
12 months (long-term) to measure projection/rotation change over time.
Univariate and multivariable statistical comparisons were performed.
Results: The chart query yielded 133 patients. Of these, 40 patients were treated
with a columellar strut and 37 patients were treated with a septal extension
graft. Projection loss at 1 year was 4.7% for the columellar strut group com-
pared with 0.2% for the septal extension graft group (P < 0.0001). On multivari-
able logistic regression, there was a 5.1-fold increased risk of greater than 4%
projection loss when using a columellar strut (P < 0.005). Mean rotation loss for
the columellar strut group was 4.9 degrees compared with 1.3 degrees for the
septal extension graft group (P < 0.0001). The independent effect of columel-
lar strut use resulted in a 2.8-fold increased risk of rotation loss greater than or
equal to 5 degrees (P < 0.05).
Conclusions: Septal extension grafts result in effectively no loss of projection
and minimal loss in rotation. A small degree of projection and rotation loss
can be expected with the use of a columellar strut alone. These long-term graft
tendencies should be anticipated and accounted for appropriately. (Plast.
Reconstr. Surg. 152: 332, 2023.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

I
n an operation of millimeters, optimized nasal is beneficial to resupport the tip elements at the
tip control, consistency, and stability over time time of rhinoplasty with structural tip grafts.2–4
remain essential components of excellent and When further attempting to manipulate tip posi-
long-lasting rhinoplasty results. Although the ideal tion, projection, or shape, structural tip grafts
rhinoplasty approach has been debated exten- become an essential and powerful tool. It follows
sively, open rhinoplasty provides the best visual- that the value of a structural tip graft is directly
ization of (and access to) the malpositioned or related to its capacity to affect and maintain tip
deformed nasal anatomy, at the expense of some position over time.
degree of disruption of ligamentous architecture Two structural tip grafts fulfill this role as a
when compared with the endonasal approach.1 central scaffold: the columellar strut graft and
For this reason, regardless of tip shaping goals, it the septal extension graft. The columellar strut
graft is typically secured in a soft-tissue pocket
made between the medial crura, extending
From the Dallas Plastic Surgery Institute.
Received for publication January 17, 2021; accepted May
24, 2022. Disclosure statements are at the end of this article,
Copyright © 2023 by the American Society of Plastic Surgeons following the correspondence information.
DOI: 10.1097/PRS.0000000000010147

332 www.PRSJournal.com
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 Volume 152, Number 2 • Superiority of Septal Extension Grafts

toward but not directly abutting the anterior against the fixed-floating septal extension graft.
nasal spine, and sutured directly to the medial We hypothesized that the columellar strut graft
crura cartilage. It directly augments the colu- would have greater loss of projection and rota-
mella to support the tip position. Alternatively, tion between the early and late postoperative
the septal extension graft takes advantage of the periods.
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much more robust caudal septal cartilage as a

securing post. Several modifications have been
described; however, the most commonly used PATIENTS AND METHODS
are as follows: (1) sutured abutting the caudal A retrospective cohort study of all patients
L-strut and extending beyond the anterior septal undergoing open primary rhinoplasty performed
angle to directly set the new tip position,5 or (2) by the senior author (R.J.R.) between June of
as direct caudal septal extensions6 without direct 2016 and November of 2019 was undertaken with
overlap. We prefer and use the former/abutting institutional review board approval. These dates
version, which can control tip position depen- encompassed a 3.5-year interval centered around
dent on its angle of placement (Fig. 1). Although a change in the senior author’s practice from
some use this graft bilaterally (on both sides of primarily using columellar strut grafts to primar-
the septum) and/or secure the graft to the ante- ily using the septal extension graft to support
rior nasal spine (termed “fixed”), we find that tip position, while also allowing at least 1-year
this creates a stiff and bulky construct. We prefer follow-up for all patients at the time of study
to use the septal cartilage graft unilaterally and execution (December of 2020). Inclusion crite-
“floating” above the anterior nasal spine, sim- ria included all adult patients undergoing pri-
ply secured with enough overlap of the anterior mary open rhinoplasty. To minimize the complex
nasal angle to provide a stable post. This “fixed- array of confounding variables, this study focused
floating” construct has minimized the limitations on primary rhinoplasty and excluded revision
of the septal extension graft while taking advan- cases and those using fresh frozen rib graft, as
tage of the enhanced stability. these patients tend to represent a distinct group
At present, both columellar strut and sep- of rhinoplasty patients. In addition, patients
tal extension grafts are widely used support who also underwent tip grafting were excluded
structures; however, their relative effectiveness to reduce introduced confounding. Patients
remains debated.7–10 In 2018, we transitioned undergoing simultaneous face lift with rhino-
from primarily using the columellar strut graft plasty were excluded, as the intratragal incision
to primarily using the septal extension graft. The directly involves a reference point used in photo-
purpose of this study was to evaluate the relative graphic comparison (as subsequently discussed).
long-term stability of the columellar strut graft Patients without adequate short- and long-term

Fig. 1. Example of digital measurements. (Left) Relative pixel position x and y coordinates of the most projecting point of tip, where
the alar base represents pixel coordinates (0 and 0). Tip projection in pixels is determined trigonometrically with these coordinates.
(Center) Reference distance of tragus-to-cornea distance determined similarly and used to normalize tip projection measurements
between photographs. (Right) Nasolabial angle measurement using the points where the Cupid’s bow meets the vermilion border,
the posteriormost aspect of the nostril aperture, and a line tangential to the long axis of the ala.

333
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 Plastic and Reconstructive Surgery • August 2023

photographically documented follow-up were Surgical Method

excluded. Demographic information (age, sex, All patients underwent a standardized and
race) and specific intraoperative interventions algorithmic open rhinoplasty approach, with
were extracted from chart review. Collected open septal cartilage harvest, component dorsal
intraoperative interventions included tip support reduction, percutaneous osteotomy, tip shaping
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grafts used (columellar strut, septal extension, or with suture, cephalic trim, and graft techniques
none), adjunct tip grafts used (infratip, shield), (as indicated), followed by alar base resec-
whether the lower lateral cartilages were tran- tion (as indicated). All grafts used were of the
sected, and whether alar bases resections were patient’s own cartilage. In a minority of cases,
performed. medial crural transection was performed when
required to decrease projection and/or improve
tip shape. Columellar strut grafts were sutured
Patient Photography Assessment
with 5-0 polydioxanone into a pocket between
All photographic comparisons were made medial crura without directly abutting the ante-
between the “early” and “late” postoperative rior nasal spine. Septal extension grafts were
periods, defined as 2 months and 12 months, placed unilaterally and as a fixed-floating septal
respectively. In addition, each patient’s photo- extension graft, secured to the lateral wall of the
graphs were assessed preoperatively to allow caudal L-strut with several 5-0 polydioxanone
rhinoplasty-type classification. All photographs sutures and without directly abutting the nasal
were standardized professional photography floor (Fig. 2).
images assessed on true profile. Measurements
were performed in a blinded fashion by a single
reviewer (J.L.B.) for each side of the face, nor- Statistical Analysis
malized, and averaged. Images were evaluated Differences in baseline characteristics com-
digitally using a standard 1920 × 1080–pixel reso- paring columellar strut and septal extension
lution monitor in full-screen mode. Digital mea- graft arms were examined using two-sample t
surements of projection (pixels) and rotation tests for continuous variables. For categorical
(degrees) were performed using the graphic variables, a chi-square or Fisher exact test was
measurement tool PicPick (NgWin, v5.1.3), as used.
shown in Figure 1. Using univariate unadjusted models, we
Projection was defined as the distance from analyzed the effect of using the columellar strut
the posteriormost aspect of the ala to the most graft rather than the septal extension graft
projecting point of the tip (Fig. 1, left). To on the risk of clinically significant projection
account for mild variability in subject distance loss. For the purposes of quantifying the risk
between photographs, a static measurement of clinically significant projection loss, “clini-
distance between photographs was required to cally significant projection loss” was defined as
normalize measurements. We used the distance greater than 4% projection loss (or approxi-
between the posteriormost aspect of the tragus mately 1.5 mm). Subsequently, the indepen-
and the anteriormost aspect of the cornea as the dent effect of using a columellar strut graft
normalizing measurement (Fig. 1, center), as it on the risk of clinically significant projection
was consistently available in all images and unaf- loss was estimated using a multivariable logistic
fected by the surgical operation or healing pro- regression model to control for confounding
cess over time. bias. Variables were considered for inclusion
Rotation was measured as the nasolabial angle, as relevant confounders if they were statisti-
defined as the angle between the points where cally significantly associated (P < 0.1) with both
the Cupid’s bow meets the vermilion border, the the exposure (graft type) and the outcome
posteriormost aspect of the nostril aperture, and (projection loss). In addition, variables that
a line tangential to the long axis of the ala (Fig. 1, failed these criteria but were considered clini-
right). Although this value is consistently more cally relevant were included. This exploratory
acute than typically discussed nasolabial angle val- analysis resulted in inclusion of male sex and
ues, we found this the most consistent way to mea- rhinoplasty type as confounders, as the other
sure nasolabial angle in photography. Because all collected variables failed to meet model selec-
statistical evaluation were relative comparisons, tion criteria. All statistical analyses were per-
consistency between measurements was the most formed using Stata/SE, version 12 (StataCorp,
important feature. College Station, TX).

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 Volume 152, Number 2 • Superiority of Septal Extension Grafts
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Fig. 2. (Left) Fixed-floating septal extension graft placement abutting the caudal septum. Graft
placement can be declined as low as 45 degrees (relative to the dorsum) to derotate the nose,
or angled at 90 degrees or more to rotate the nose. (Right) Four key sutures secure position and
stabilize rotation. (Illustration by Edward Chamata, MD. Copyright © 2023 by Rod J. Rohrich, MD.)

RESULTS Table 1. Baseline Characteristics

Septal Columellar
Baseline Characteristics Extension Strut Graft
Chart query yielded 133 unique patients who Graft (%) (%) P
met inclusion and exclusion criteria. Of these, 40 No. 37 40
patients were treated with a columellar strut graft, Demographics
and 37 patients were treated with a septal exten-  Mean age, yr 30.2 33.4 0.851
sion graft, with the remainder receiving tip sutur-  Male sex, % 5.4 22.5 <0.05a
ing alone. Women represented 86% of the study  White race, % 78.4 57.5 0.051
Intraoperative factors, %
cohort, with 67% of patients being white, and the
 Crural transection 13.5 5.0 0.194
mean age was 32 years. Baseline characteristics for
 Alar base resection 54.0 45.0 0.427
the columellar strut group versus the septal exten- Rhinoplasty projection
sion group patients are shown in Table 1. There ­classificationb
was no significant difference in demographic char-  Neutral rhinoplasty (45%) 13 (35.1) 22 (55.0) 0.125
acteristics between the two groups, with the excep-  Deprojection 15 (40.5) 14 (35.0) 0.125
tion of male sex. There was a greater representation rhinoplasty (37%)
of men in the columellar strut group (22.5% ver-  Increased projection 9 (24.3) 4 (10.0) 0.125
rhinoplasty (17%)
sus 5.4%; P < 0.05). There were no significant dif- Rhinoplasty rotation
ferences in surgical techniques used between the ­classificationc
two groups, including lower lateral cartilage tran-  Neutral rhinoplasty (45%) 24 (64.9) 11 (27.5) <0.005a
section, alar base resection, or use of adjunct tip  Derotation 1 (2.7) 3 (7.5) <0.005a
grafts. There was no difference in rhinoplasty pro- rhinoplasty (5%)
jection type between study groups; however, there Increased rotation 12 (32.4) 26 (65.0) <0.005a
rhinoplasty (49%)
was a greater representation of patients undergo- a
Statistical significance of at least P < 0.05.
ing rotation, increasing rhinoplasty in the columel- b
Projection-type classification according to threshold of ±4% from
lar strut group (65% versus 32%; P < 0.005). preoperative to early postoperative period.
c
Rotation-type classification according to threshold of ±5 degrees
from preoperative to early postoperative period.
Tip Position
Univariate analysis results for tip position are Projection
shown in Tables 2 through 5, and multivariable Measured projection loss at 1 year was 4.7%
analysis results are shown in Table 6. These are for the columellar strut graft group compared
summarized below. with 0.2% for the septal extension graft group

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 Plastic and Reconstructive Surgery • August 2023

Table 2. Projection Loss (Unadjusted) (N = 77) Table 3. Rhinoplasty Type Classification

Mean Projection Mean Projection (Unadjusted)a
Loss (%) Loss (%) P Mean Loss
Demographics No. Degrees P
 Race White [52 (2.8)] Nonwhite [25 (2.4)] 0.683
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 Sex Male [11 (6.5)] Female [66 (1.9)] <0.0001a Intraoperative projection type 0.064
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Intraoperative  Neutral 35 3.1

factors  Deprojection 29 1.6
 Crural Yes [7 (1.5)] No [70 (2.6)] 0.776  Projection 13 1.1
transection a
Projection-type classification according to threshold of ±4% from
 Alar base Yes [38 (2.4)] No [39 (2.7)] 0.634 preoperative to early postoperative period.
resection
 Graft type SEG [37 (0.2)] CS [40 (4.7)] <0.0001a
SEG, septal extension graft; CS, columellar strut graft. P < 0.005). Male sex conferred a 1.83-fold increased
a
Statistical significance of at least P < 0.05. risk of clinically significant projection loss, indepen-
dent of graft type used or intraoperative projection
(P < 0.0001). Male sex was also significantly asso- changes (95% CI, 1.03 to 3.26; P = 0.05).
ciated with projection loss, with an average 6.5%
projection loss at 1 year compared with only 1.9% Rotation
in women (P > 0.0001). Other demographic vari- Summary of rotation loss outcomes are shown
ables (age, race), and surgical variables (crural in Tables 4 and 5. Measured rotation loss at 1 year
transection, alar base resection), were not signifi- was significantly greater with the use of a colu-
cantly associated with projection loss. mellar strut graft, with patients on average losing
Summary of unadjusted univariate logistic 4.9 degrees for the columellar strut graft group
regression results are shown in Tables 2 and 3. compared with 1.9 degrees for the septal exten-
The cumulative incidence of clinically significant sion graft group (P < 0.0001). Rotation loss was
projection loss (>4%) was 55% in columellar strut also significantly greater in men compared with
graft patients compared with only 8% in septal women (5.0 degrees versus 2.9 degrees; P < 0.05)
extension graft patients (P < 0.0001). Male sex was on unadjusted analysis. Performance of alar base
also significantly associated with clinically signifi- resection approached but did not reach statistical
cant projection loss compared with women (73% significance for rotation loss (3.6 degrees versus
versus 26%; P = 0.002). On subgroup analysis by 2.7 degrees; P = 0.141). The type of rhinoplasty
graft type, the cumulative incidence of clinically performed was also associated with long-term
significant projection loss was 88.9% for men in rotational changes on univariate analysis. Neutral
the columellar strut group, whereas there were no rotation rhinoplasty had minimal long-term
cases for men in the septal extension graft group. change (0.8 degree), whereas both positive and
Multivariable logistic regression results for the negative intraoperative rotational changes were
risk of clinically significant projection loss (defined associated with long-term rotation loss greater
at >4% loss) are shown in Table 6. After adjusting for than 3 degrees (Tables 4 and 5) (P < 0.002). All
patient sex and intraoperative projection changes, other evaluated demographic and surgical factors
the independent effect of columellar strut use were not significantly associated with rotation loss.
resulted in a 5.13-fold increase in the risk of clini- Multivariable logistic regression results of
cally significant projection loss compared with the clinically significant rotation loss (defined as
use of a septal extension graft (95% CI, 1.64 to 16.0; ≥5 degrees loss) are shown in Table 6. After

Table 4. Rotation Loss (Unadjusted) (N = 77)

Mean Rotation Loss Mean Rotation Loss
No. Degrees No. Degrees P
Demographics
 Race White (n = 52) 2.9 Nonwhite (n = 25) 3.8 0.875
 Sex Male (n = 11) 5.0 Female (n = 66) 2.9 0.028a
Intraoperative factors
 Crural transection Yes (n = 7) 1.6 No (n = 70) 3.3° 0.894
 Alar base resection Yes (n = 38) 3.6 No (n = 39) 2.7° 0.141
 Graft type SEG (n = 37) 1.3 CS (n = 40) 4.9 <0.0001a
SEG, septal extension graft; CS, columellar strut graft.
a
Statistical significance of at least P < 0.05.

336
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 Volume 152, Number 2 • Superiority of Septal Extension Grafts

Table 5. Rhinoplasty Type Classification (Unadjusted)a modifications to the caudal septal extension graft
Mean Loss were separately described by Byrd et al.5 and by
No. Degrees P Toriumi6 as more stable alternatives to the colu-
Intraoperative rotation type <0.002
mellar strut graft.
Both columellar strut grafts and septal exten-
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 Neutral 35 0.8
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 Derotation 4 3.7 sion grafts serve as workhorse tip support grafts

 Rotation 38 3.3 in rhinoplasty. Their strength as a central post
a
Intraoperative rotation-type classification according to threshold of on which the tip elements are secured serves two
±5 degrees from preoperative to early postoperative period. purposes: (1) control of tip shape and position
and (2) stability of the tip elements over time.
Table 6. Multivariable Logistic Regression Proponents of the columellar strut cite its suf-
ficiency to preserve tip support while maintain-
95% CI
ing a soft tip, whereas proponents of the septal
RR Lower Upper P
extension graft claim superiority of stability and
Significant projection loss a
improved effectiveness when significant control
 Septal extension graft Ref — — — of tip position is desired.2,3,5,6,10 Because both
 Columellar strut 5.13 1.64 16.0 <0.005b
grafts are otherwise quite comparable in terms
 Male sex 1.83 1.03 3.26 <0.05b
of the logistics of their use, determination of
 Neutral-projection Ref — — —
rhinoplasty which to use has largely been based on surgeon
 Deprojection 0.57 0.25 1.31 0.184 preference. More recently, direct comparison of
rhinoplasty the two grafts with regard to longevity of tip sup-
 Projection rhinoplasty 1.10 0.41 2.98 0.845 port has been published by Sawh-Martinez et al.8
Significant rotation lossc They retrospectively analyzed three-dimensional
 Septal extension graft Ref — — — photographs (Vectra) in 106 primary rhinoplasty
 Columellar strut 2.79 1.16 6.72 <0.05b
patients. Projection and rotation were compared
 Male sex 0.87 0.41 1.78 0.677
between the early postoperative period (6 weeks)
 Neutral-rotation Ref — — —
­rhinoplasty and late postoperative period (1 year). They were
 Derotation rhinoplasty d d d
— able to identify a significant improvement in
 Rotation rhinoplasty 2.53 1.08 5.94 <0.05a maintenance of tip rotation but were unable to
RR, relative risk; Ref, reference. demonstrate any significant difference in tip pro-
a
Significant projection loss defined as >4% projection loss. jection over time.
b
Statistical significance of at least P < 0.05.
c
Significant rotation loss defined as ≥5-degree loss. We sought to explore this debate further. The
d
Insufficient observations. senior author primarily used the columellar strut
until the middle of 2018, when he made a sum-
adjusting for patient sex and rhinoplasty rotation mary switch to the use of a fixed-floating septal
type, the independent effect of columellar strut extension graft, in which the graft is secured abut-
use resulted in a 2.79-fold increased risk of clini- ting the caudal septum unilaterally and floats
cally significant rotation loss compared with the above the anterior nasal spine. This provided
use of a septal extension graft (95% CI, 1.16 to a unique opportunity to evaluate the impact of
6.72; P < 0.05). Male sex was not independently graft use while holding all other variables con-
associated with decreased rotation loss after stant. Importantly, this also allowed retrospective
adjusting for graft type. Larger intraoperative graft evaluation without the selection bias intro-
rotational changes were associated with greater duced by using dynamic clinical criteria to dictate
rotation loss long term, independent of graft type graft selection.
used (relative risk, 2.53; P < 0.05). In this study, we again demonstrated the long-
held observation that rhinoplasty patients tend to
lose some degree of projection and rotation over
DISCUSSION time. However, the columellar strut and septal
Restoring support of the tip after open rhi- extension grafts are not equivalent in their abil-
noplasty is an essential component of consistent ity to maintain tip position over time. Specifically,
and stable rhinoplasty. Several methods of tip we found that the maintenance of both projec-
support have been described. Historically, colu- tion and rotation was improved in the septal
mellar strut grafts have been workhorse grafts for extension graft group compared with the colu-
lower limb support during open rhinoplasty.4,10 In mellar strut graft group. Proponents of the sep-
the 1990s, the caudal septal extension graft and tal extension graft have long held that the septal

337
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 Plastic and Reconstructive Surgery • August 2023

extension graft provides a “put it where you want photography to make all measured compari-
it” approach to tip shaping2,5–7,11 compared with sons. Although not used here, three-dimen-
alternative methods. With an average projection sional stereophotogrammetry using Vectra or
loss of only 0.2% and rotation loss of 1.9 degrees similar technology has been described in a
when using a septal extension graft, our findings similar study8 and provides certain precision
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further support that claim. benefits12,13 when measuring absolute values.

We found that male sex was also indepen- However, by using relative measurements as we
dently associated with greater loss of projec- do here, we have accounted for measurement
tion over time compared with women. In fact, variability/randomness inherent in manual
nearly 90% of men who underwent columellar measurement and minimized their effect on
strut graft surgery had greater than 4% projec- study outcome measures.
tion loss (which translates to approximately
>1.5 mm). Rotation loss, however, appeared to
CONCLUSIONS
be more dependent on graft-type selection than
on patient sex, with no significant difference Septal extension grafts result in effectively
between men and women after adjusting for graft no loss of projection and minimal rotation loss
type. The observation of greater projection loss long term, allowing the surgeon to intraopera-
in men is likely explained by the thicker skin tively place the nose where desired. When using
and greater overall forces exerted on the skeletal a columellar strut graft alone, a small degree
framework of the male nose, whereas the rela- of projection loss can be expected. These long-
tively stable rotation differences between men term graft tendencies should be anticipated and
and women may be a result of the more modest accounted for appropriately during rhinoplasty.
nasolabial angles used on the male nose. This is In our practice, columellar strut grafts have
conjecture, however, as this study was not primar- been relegated to an adjunct graft role, being
ily designed to evaluate this subgroup, and thus, used as a smaller, floating graft in addition to
more directed studies are needed to elucidate a septal extension graft in select patients who
this observation. However, we may surmise that are otherwise at-risk for columellar retraction or
emphasis on providing strong tip support and/or deformity.
slight overcorrection of tip position is even more In this article, we present our series, and along
important in the male patient. with that of Sawh-Martinez et al., this remains one
The senior author transitioned from primarily of the first to compare these two grafts head to
using the columellar strut for tip support to pri- head. We strongly encourage other authors with
marily using the septal extension graft. Because significant rhinoplasty experience to do the same
this was a summary change in technique in a to further our understanding of long-term tip
single-surgeon cohort of patients, this provided dynamics with different techniques.
a unique opportunity to compare these two graft Rod J. Rohrich, MD
techniques head to head without the selection Dallas Plastic Surgery Institute
bias that often accompanies such retrospective 9101 North Central Expressway, Suite 600
comparisons. In addition, this study is the only to Dallas, TX 75231
rod.rohrich@dpsi.org
perform a multivariable logistic regression analy-
sis of projection and rotation outcomes related to
graft selection, further quantifying the impact of DISCLOSURE
graft selection on tip stability. The impact of graft Dr. Rohrich receives instrument royalties from Eriem
selection appears to be even more important in Surgical, Inc., and book royalties from Thieme Medical
male patients, who saw the greatest loss in tip pro- Publishing; he is a clinical and research study expert for
jection when a columellar strut graft was used. Allergan, Inc., Galderma, and MTF Biologics, and the
This study was limited by its retrospective owner of Medical Seminars of Texas, LLC. Dr. Bellamy
nature, although we attempted to minimize has no financial disclosures to report. No funding was
study bias in our design. By using consecutive received for this article.
patients centered temporally on a summary
shift in graft technique, we mitigated selec-
REFERENCES
tion bias; in addition, the temporal limitation
1. Adams WP, Rohrich RJ, Hollier LH, Minoli J, Thornton LK,
of a retrospective study was not relevant here, Gyimesi I. Anatomic basis and clinical implications for nasal
given the nature of the exposure and outcome. tip support in open versus closed rhinoplasty. Plast Reconstr
This study used professional two-dimensional Surg. 1999;103:255–261; discussion 262–264.

338
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 152, Number 2 • Superiority of Septal Extension Grafts

2. Rohrich RJ, Durand PD, Dayan E. Changing role of septal columellar strut versus caudal septal extension graft. Plast
extension versus columellar grafts in modern rhinoplasty. Reconstr Surg. 2019;144:772e–780e.
Plast Reconstr Surg. 2020;145:927e–931e. 9. Toriumi DM. Discussion: control of nasal tip position: quan-
3. Johnson CMJ, Toriumi DM. Structure Rhinoplasty: Lessons titative assessment of columellar strut versus caudal septal
Learned in Thirty Years. Chicago: DMT Solutions; 2019. extension graft. Plast Reconstr Surg. 2019;144:781e–783e.
4. Johnson CMJ, Toriumi DM. Open Structure Rhinoplasty. 10. Rohrich RJ, Kurkjian TJ, Hoxworth RE, Stephan PJ, Mojallal
oj/YxqT7M+MRuyxYefR8D74+EUkfqdo2PwtKJ8TMun8B2YTiyxaMGBGpcjhe6Zqyld/0KZf5pdfO2VUZSP6Si on 08/31/2023
Downloaded from http://journals.lww.com/plasreconsurg by pTu3Qmc1HhYz+6LGW88PRO7axVUiNPgM25dhZ2tqBh1

Philadelphia: Saunders; 1989. A. The effect of the columellar strut graft on nasal tip position
5. Byrd HS, Andochick S, Copit S, Walton KG. Septal extension in primary rhinoplasty. Plast Reconstr Surg. 2012;130:926–932.
grafts: a method of controlling tip projection shape. Plast 11. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year
Reconstr Surg. 1997;100:999–1010. experience in controlling nasal tip projection and shape.
6. Toriumi DM. Caudal septal extension graft for correction of Plast Reconstr Surg. 2003;112:1929–1935.
the retracted columella. Oper Tech Otolaryngol Head Neck Surg. 12. Lübbers H-T, Medinger L, Kruse A, Grätz KW, Matthews
1995;6:311–318. F. Precision and accuracy of the 3dMD photogrammetric
7. Akkus AM, Eryilmaz E, Guneren E. Comparison of the system in craniomaxillofacial application. J Craniofac Surg.
effects of columellar strut and septal extension grafts for tip 2010;21:763–767.
support in rhinoplasty. Aesthetic Plast Surg. 2013;37:666–673. 13. Toriumi DM, Dixon TK. Assessment of rhinoplasty tech-
8. Sawh-Martinez R, Perkins K, Madari S, Steinbacher DM. niques by overlay of before-and-after 3D images. Facial Plast
Control of nasal tip position: quantitative assessment of Surg Clin North Am. 2011;19:711–723, ix.

339
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.