Caudal Septal Extension Graft
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This is my second facial plastic surgery blog. And today I’m going to talk about one specific topic within rhinoplasty. It is known as the cuddle septal extension graft. Why do I spend a whole time talking about just one simple graft? To me, this is probably the, the biggest achievement or breakthrough in the last few years for rhinoplasty. I want to sort of have you understand what it is. Rhinoplasty is one of the most complicated subjects out there and it’s very hard to digest and just talk about one particular graft seems a little bit overkill, but I think it’s such a huge breakthrough that it’s worth talking about. So let me give you a little history here. The understanding first is that the nasal tip is very mobile. If you just touch your nasal tip, your tip of your nose, you can feel you can move it a lot.
The problem with that is after you put in a graft in there to support the tip out after rhinoplasty, the graft that has been used in the past, known as a colleague, Miller’s strut is a free mobile graft sewn to the colleague or the area between the nose to provide support. And the reason for that is that the nose is actually weaker after you’ve opened the nose than when you left it. If you just open the nose to do your fancy maneuvers and leave, your nose will collapse cause is much weaker. So you actually have to strengthen a nose after you’ve opened it and done your rhinoplasty. So the traditional way of strengthening your nose was to put what’s called a columella strut, a strut or a piece of cartilage taken from the septum place between, what’s called a medial Crow or that, that’s the just pic, just pinch your nostrils together.
That little area between the two nostrils is where the strut went and that’s what I’ve done for close to 20 years. The problem with that is that you have to overcompensate a little bit and then let watch the nose fall after about a month. There’s a lot of variability. It’s not as precise. You don’t know exactly where that Tip’s gonna sit after a month or two or even after a week or two. So you always have to sort of overdue a nose and then let it fall back. And that variability is a bit disconcerting because you never know if it’s over done one way or the other way. Well, in the last few years, there has been a movement towards something called the cuddle septal extension graft and it’s something that I’ve completely adopted and it’s changed my rhinoplasty completely. So let’s break down the word cuddle.
Septal extension, graft cuddle that means tail and that is the bottom portion of the nose. So like again, the portion between your nostrils is the caudal portion septum. That’s the dividing cartilage between the two nostrils extension. It actually extends that septum down and you say, why would that be important? We’ll explain in a second. And it’s a graft. So this is actually using for the, for the majority of times I’m using actually septum taken from inside, which has no structural support that to extend the septum. Other times I’m using ear cartilage or I’m using a categoric rib or rib graft to do this. So let’s have you understand this. Again, this is going to be hard to understand without a visual, but let me just see if I can break it down. So the septum is the dividing point between the two nostrils and that septum is incredibly fixed.
It does not move. It is stuck to the inside of your nose. It’s not gonna slide. So instead of putting this free floating graft between the nostrils and then seeing what happens after a week to a month, you’re actually taking that same graft. It has to be larger graft and then you’re actually tying it to the septum, sewing it to the septum using from, in my cases, all double stitches. So that graft is no longer free floating. It is now anchor to the septum. So when you now put the tip cartilages onto that, graft it there, you get a very, very precise outcome. So that graft is not going to go down after a month or rotate too much. It’s fixed, you know, that is the position of the graft. That’s why the predictability of a caudal septal extension graft is so amazing that that is really what I love now.
So I get exactly what I want on the table is what the patient will have in a month or two from now. Now the other thing, great thing with the cuddle septal extension graft besides accurate positioning, and I can constantly just read just the tip on the table to where I like it. But also you can do what’s called lateral tensioning. So what that means is because the structure is so strong, the outer nostrils that can be pulled and tightened on here because it’s so well anchored that you can actually get a better, a curvature of the outer nostril and a better shape. Now, a lot of this is very esoteric and it may be hard for you to understand and I don’t mean for you to understand everything about rhinoplasty. My assistants who’ve been with me 14, 15 years working on noses with me probably don’t understand every little detail of what I’m doing surgically either, just because it is extremely complicated from an anatomy standpoint, but I think this graft is such a huge development that it’s worth discussing.
Now, is there a trade off of using this graft besides technical skill and a little bit more time to execute on the graft? A few things. One is it requires a larger graft. You cannot just put a tiny graft in there. So I have to have enough grafting material to do it. So occasionally I have to use ear grafts. Sometimes I have to use rib graft or categoric or in other words, you don’t have to harvest from yourself. But usually there’s enough separate graft for me to do the work to get this structured. The other thing is the tip will feel firmer. So that’s something that is a trade off. And I tried to, my patients says, when you touch your tip, it’s not going to be as mobile. A a good way to describe it as if you touch the top of your nose, how firm that is, your tip will feel firmer as well.
So it’s something you need to know as a tradeoff. When you smile, it doesn’t turn down as much. For most people, that’s actually a really good thing. Even with the columella strut, the older technique, people smiling would also not turn down as much, but this is very well anchored. So, I think it’s an amazing new development. Actually, I was just got back from San Diego, heard some amazing lectures and I think I heard 10 lectures on the caudal septal expression graft and one lecture by a gentleman who was saying that he likes the old color mellow stride, which is fine. And these are just tools for any surgeon to develop and to use for maximal effect. So hopefully that is a good little blog on a simple graph. And if you have questions when you come in for consultation, I’d be happy to explain it more in detail.