Research

Original Investigation

A Modified Septal Extension Graft for the Asian Nasal Tip

Jinde Lin, MD; Xiaoping Chen, MD; Xin Wang, MD; Xia Gao, MD; Xiangyu Zheng, MD;
Xin Chen, MD; Yugang Yuan, MD

IMPORTANCE Septal extension graft is an effective procedure in tip plasty because it can
provide stable structural support for the nasal tip. However, in Asian patients septal cartilage
is much weaker, thinner, and smaller than that of white people, causing the existing caudal
septal cartilage and the septal extension graft to deviate to the opposite side of graft
placement.

OBJECTIVE To introduce an effective and reliable modified septal extension graft in tip plasty.

DESIGN, SETTING, AND PARTICIPANTS Observational study of a total of 143 patients (84
undergoing primary rhinoplasty and 59 undergoing secondary rhinoplasty).

INTERVENTION A modified septal extension graft technique in combination with other

procedures, including tip graft and implant augmentation.

MAIN OUTCOME AND MEASURE Subjective evaluation based on photographic analysis.

RESULTS This procedure was applied in 143 Asian patients, with substantial improvement
seen in the nasal tip of all patients except for 3 (1 for the overprojected nasal tip and 2 for
bending of existing caudal septum). Other complications included infection in 1 patient and
implant deviation in 1 patient; the implant and grafts were removed 10 days after surgery in
the patient with infection. The other patient underwent revision 3 months after surgery for
the deviated implant.

CONCLUSIONS AND RELEVANCE This technique is an effective method to provide long-term,

stable nasal tip support. It helps to set the existing caudal septum and the septal extension Author Affiliation: Nanjing
grafts exactly at the anterior midline and decrease the deviation of the nasal tip. Friendship Plastic Surgery Hospital,
Nanjing Medical University, Nanjing,
China.
LEVEL OF EVIDENCE 4.
Corresponding Author: Jinde Lin,
MD, Nanjing Friendship Plastic
JAMA Facial Plast Surg. 2013;15(5):362-368. doi:10.1001/jamafacial.2013.1285 Surgery Hospital, Nanjing Medical
Published online July 25, 2013. University, 146 Hanzhong Rd,
Nanjing, China (hzljd@sohu.com).

C
ontrolling and reshaping the nasal tip are important
parts of rhinoplasty procedures. Byrd et al1 first re-
ported that the septal extension graft could control the
projection, shape, and rotation of the nasal tip. There are 3 ba-
sic types of septal extension grafts: spreader, batten, and di-
rect caudal. In addition, many modified techniques for septal
extension graft are described in rhinoplasty, including unilat-
eral or bilateral septal extension graft and symmetrical or asym-
metrical septal extension graft.2-11 The grafts used for the sep-
tal extension procedure are septal cartilage, 1-11 conchal
cartilage, 1 2 homologous costal cartilage, 1 3 alloplastic
materials,14,15 and bone.16
In Asian patients, the most common donor site for septal
extension graft is the septum; however, septal cartilage is much
weaker, thinner, and smaller in Asian people than in white
people.2,16 Because of the limitation of useful septal carti-
lage, the most common septal extension graft is the unilat-
eral graft and some types of bilateral grafts. In the unilateral
septal extension graft, the graft is placed on one side of the L-
shaped existing septal cartilage.17 This procedure is apt to cause
the nasal tip to deviate to the extension graft placement side
in patients with thick and strong septal cartilage because the
septal extension graft is not placed at the anterior midline. On
the contrary, in some patients with very thin and weak septal
cartilage, the septal extension graft and existing caudal sep-
tal cartilage will deviate to the opposite side of the septal ex-
tension graft. Therefore, the nasal tip will deviate in the uni-
lateral septal extension graft technique, and when the patients
undergo concurrent implant augmentation, this technique may
sometimes cause implant deviation. Bilateral spreader grafts
may be the most stable septal extension grafts, but they need
much more cartilage and can only be used in the few patients

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 Septal Extension Graft for Asians
Figure 1. Triangle Septal Extension and Stripped Grafts
A B
L-Shaped
L-Shaped existing septum
existing septum
x x
x x
Triangle septal x x
x
x extension graft
extension graft x x
x x
A, The triangle septal extension graft was placed on one side of the L-shaped
existing septum. B, The stripped graft was placed on the other side of the
L-shaped existing septum. Both grafts have almost the same dorsal length and
dorsal border. C, Cephalic ends of both grafts were near the middle junction of
who have large septal cartilage. Bilateral direct caudal grafts
or batten grafts are the less stable grafts, especially in pa-
tients with weak and thin septal cartilage. To solve these prob-
lems in tip plasty, we introduce an effective and reliable modi-
fied septal extension graft, which is different from all other
techniques previously described.
Methods
Patients
A total of 143 patients underwent this modified septal exten-
sion graft (primary rhinoplasty in 84 patients and secondary
rhinoplasty in 59 patients). The study included 135 women and
8 men. The patients ranged in age from 19 to 35 years (mean,
26.2 years). The follow-up period ranged from 6 to 36 months
(mean, 26.4 months).
Anatomy in Asian Noses
Nasal anatomy in Asian patients is different from that in white
patients. The weaker alar cartilages render their tips structur-
ally inadequate, and the nasal tip depends more on ligamen-
tous and soft tissue support than alar cartilage.2 Actually, the
septum is more important in Asian nasal tip support. A large
thick septum can render adequate support to the nasal tip2;
however, in Asian noses, the septum is weaker, thinner, and
smaller; the dorsal and caudal borders of the septum are of-
ten retracted; the anterior septal angle is overobtuse; and the
septum cannot provide sufficient support to the nasal tip.
Technique and Design
Our technique is designed based on the anatomy of the
Asian nose, which has limited useful septal cartilage. Two
factors must be considered for septal extension graft in the
Asian nose. First, the septal cartilage and alar cartilages are
smaller and weaker, the anterior septal angle is overobtuse,
and the dorsal and caudal aspects of the septum and the
anterior septal angle need to be extended. Second, the septal
cartilage is weaker, thinner, and smaller; therefore, bilateral
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Original Investigation Research
C
Dorsal septum
Upper lateral
cartilage
Stripped septal
extension graft
Triangle septal
Triangle septal
extension graft Stripped septal
extension graft
the dorsal septum and upper lateral cartilages. The cephalic ends of both grafts
must be fixed with the dorsal septum and upper lateral cartilages together to
stabilize both grafts and the L-shaped existing septal cartilage.
septal extension grafts should be recommended to render
adequate support to the nasal tip. Unilateral or bilateral bat-
ten grafts or direct caudal grafts are less stable grafts and
may not provide adequate and long-term stable strength for
the nasal tip.
Our technique is an asymmetrical bilateral septal exten-
sion grafts. The big triangle graft is placed on one side of the
L-shaped existing septum and extended beyond the dorsal and
caudal aspects of the septum and the anterior septal angle,
which renders main and adequate support to the nasal tip
(Figure 1A).The small one is a stripped graft, which is approxi-
mately 4 to 5 mm in width and has the same length as the dor-
sal border of the triangle septal graft. It is designed like a con-
ventional spreader graft but is shorter. It is placed on the other
side of the L-shaped existing septum to compensate for the bulk
of the triangle septal extension graft. It helps to consolidate
the triangle septal extension graft and existing caudal sep-
tum (Figure 1B). Cephalic ends of both grafts are near the
middle junction of the dorsal septum and upper lateral carti-
lages, where the vault is much narrower than that at the key-
stone area. Cephalic ends of both grafts must be fixed with the
dorsal septum and upper lateral cartilages together to stabi-
lize the grafts and existing caudal septal cartilage. Both grafts
have almost the same dorsal lengths and borders. This proce-
dure helps to set the existing caudal septal cartilage and sep-
tal extension grafts exactly at the anterior midline and avoid
the existing septal cartilage and septal extension graft devia-
tion (Figure 1C).
Implant
Used in 128 of 143 patients, the implant was silicone in 42 pa-
tients and expanded polytef (polytetrafluoroethylene) in 86
patients. The implant was shaped according to the patient’s
specifications and intraoperative designing.
Anesthesia
All patients were underwent tracheal intubation anesthesia and
local anesthesia. Local anesthesia consisted of lidocaine with
epinephrine hydrochloride (1:100 000), 2%. Both infraorbital
JAMA Facial Plastic Surgery September/October 2013 Volume 15, Number 5 363
 Research Original Investigation
Figure 2. Septal Cartilage Graft
A B
C D
E
nerves were blocked using local anesthesia, and the muco-
perichondrium of the septum was infiltrated.
Surgical Technique
Transcolumellar incision was preferred in all patients. Five min-
utes after local anesthesia, a transcolumellar incision across
the narrowest portion of the columella was made, and the in-
cision was connected to the marginal incisions. Then the colu-
mellar flap was created along the plane overlying the lower lat-
eral cartilages. Once the columella flap was elevated, the medial
and intermediate crura and the caudal aspect of the nasal sep-
tum were exposed. The dorsal pocket underlying the nasal dor-
sal fascia was made for the placement of the implant. In some
patients with tight skin and short nose, the whole nasal skin
was elevated to help the skin flap move caudally. Before dis-
secting the septum mucosa, local anesthetic agent was in-
jected between the medial crura and both sides of the sep-
tum, making dissection easier.
When harvesting the septal cartilage, bilateral mucoperi-
chondrium of the septum was elevated to the junction be-
tween the upper lateral cartilages and septum. The upper lat-
eral cartilages could be dissected from the dorsal margin of the
nasal septum without damaging the mucosa.
Part of the septal cartilage was harvested, leaving an ap-
proximately 1.0-cm L-shaped caudal and dorsal cartilage to
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Septal Extension Graft for Asians
A and B, The septal cartilage was cut
into 2 pieces of cartilage that were
used for septal extension grafts.
C and D, The septal cartilage was cut
into 3 pieces of cartilage, and 2 pieces
of cartilages were used for septal
extension graft and 1 piece for the tip
graft. The septal cartilage was smaller
and was used as a triangle septal
extension graft. E, Two pieces of
conchal cartilage were harvested:
1 for stripped septal extension graft
and 1 for the tip graft.
support the lower nose. If the septal cartilage collected was
smaller, the auricular conchal cartilage was also harvested ac-
cording to the method described by Han et al.18
After septal cartilage was collected, the medial and inter-
mediate crura of the lower lateral cartilage were freed with-
out damaging the mucosa. The collected septal cartilage was
trimmed into 2 pieces of cartilage, both of which were used for
the septal extension graft (Figure 2, A and B). Sometimes, if
the septal cartilage harvested was big enough, it was trimmed
into 3 pieces of cartilage; 2 pieces of cartilage were used for the
septal extension graft and 1 for the tip graft (Figure 2, C and
D). If the septal cartilage harvested was smaller, it was just used
for the triangle septal extension graft. Therefore, the auricu-
lar conchal cartilage was harvested and cut into 2 pieces of car-
tilage: 1 for the stripped graft and 1 for the tip graft (Figure 2,
E). The method to fix the stripped graft (from auricular carti-
lage) and the triangle graft was the same as that to fix the
stripped graft (from septal cartilage) and the triangle graft.
The stripped extension graft was 4 to 5 mm in width, which
is the same length as the dorsal border of the triangle exten-
sion graft (Figure 1). To increase the graft’s stability, both sep-
tal extension grafts should be long enough to be fixed with the
dorsal septum and upper lateral cartilage but should not go be-
yond the middle junction of the dorsal septum and upper lat-
eral cartilage cephalically because then they would widen the
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 Septal Extension Graft for Asians
Figure 3. Triangle and Stripped Septal Extension Grafts
C extension graft
midvault. The septal extension grafts extended caudally be-
yond the caudal margin of the L-shaped existing septum into
the area between the medial and intermediate crura. It was
preferable to leave the grafts slightly larger than expected. Then
the grafts were trimmed after they had been sutured into the
position. The first suture was to fix both the septal extension
grafts with the dorsal septum. The second suture was to fix the
triangle septal extension graft with the existing caudal sep-
tum. Before the second suture was performed, the angle be-
tween the dorsal border of the septum and the triangle septal
extension graft was adjusted to obtain optimal nose length, op-
timal tip projection, and appropriate nasolabial angle. Once the
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Original Investigation Research
Triangle septal
extension graft
Dorsal septum
Triangle septal
extension graft
Stripped septal
extension graft
Dorsal septum
Stripped septal
Triangle septal
extension graft
A, Triangle septal extension graft.
B, Stripped septal extension graft.
C, Both septal extension grafts from
the front view.
triangle septal extension graft was in its final position, other
sutures to fix the septal extension graft with the L-shaped ex-
isting septum were finished (Figure 3). The upper lateral car-
tilages should be fixed to the septum so that the septal exten-
sion grafts are sutured together. Special care was taken to
secure the existing septum and both septal extension grafts
at the aesthetic midline of the nose. If necessary, the graft’s
position was modified to prevent deformity. Then the alar car-
tilages were controlled directly on the septal extension grafts
(Figure 3). The columella flap was replaced to determine the
tip shape, projection, rotation, and nasal shape. Then the im-
plant was shaped and inserted into the dorsal pocket. Its dis-
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 Research Original Investigation
Figure 4. A 27-Year-Old Girl Who Underwent Rhinoplasty With Modified Septal Extension Graft, Implant Augmentation, and Tip Graft
A B
E F
A-D, Preoperative views. E-H, Postoperative views at 21 months.
tal end was fixed to the medial crura and the septal extension
grafts. It was necessary to place a tip graft over the medial and
intermediate crura to adjust the tip-lobular relationship and
to increase its contact surface. After estimating the ideal pro-
jection of the tip and contour of the nose, the columellar skin
flap was returned into position without tension. Finally, the
skin incision was closed with 7-0 nylon sutures. Internal na-
sal splints and external nasal splints were applied. A drainage
strip was maintained for 24 hours in all cases. Antibiotics were
used for 3 to 5 days, and the suture was removed 7 days after
surgery.
Results
The length of septal cartilage harvested was 1.3 to 3.2 cm (mean,
1.92 cm). The width of septal cartilage harvested was 1.1 to 2.5
cm (mean, 1.65 cm). The dorsal length of cartilage used for the
triangle septal extension graft was 1.3 to 2.5 cm (mean, 1.83 cm).
The length of the stripped septal extension graft was 1.3 to 2.5
cm (mean, 1.83 cm). The width of the stripped septal exten-
sion graft was 0.4 to 0.6 cm (mean, 0.51 cm).
All triangle septal extension grafts were collected from sep-
tal cartilage. Of 143 patients, the stripped extension graft was
harvested from septal cartilage in 59 patients or conchal car-
tilage in 84 patients. The tip graft was chosen from remnant
septal cartilage in 17 patients and conchal cartilage in 126 pa-
tients.
Patients were followed up for 6 to 36 months (mean, 23
months). Results were evaluated mainly by subjective evalu-
ation based on photographic analysis. The improvement on the
nasal tip was successfully achieved in most patients, except
for 3 (1 patient underwent secondary surgery for an overpro-
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Septal Extension Graft for Asians
C D
G H
jected nasal tip and 2 underwent revision for distortion of ex-
isting caudal septum). These complications occurred only in
our early experiences. Other complications included infec-
tion in 1 patient and implant deviation in another patient. The
implant and grafts were removed 10 days after surgery in the
patient with infection. The other patient underwent revision
3 months after surgery for the deviated implant (Figure 4 and
Figure 5).
Discussion
The septal extension graft is an effective procedure in nasal
tip plasty because it can control the projection, shape, and ro-
tation for the nasal tip. Byrd et al1 first described 3 basic forms
of septal extension graft: spreader, battent, and direct cau-
dal. Many modified techniques of septal extension graft have
been described in rhinoplasty, including unilateral3,9 and bi-
lateral grafts.2,15,19 The bilateral septal extension grafts may be
symmetrical2,15,19 or asymmetrical.3 They all have advan-
tages and disadvantages. Bilateral spreader grafts may be the
most stable septal extension grafts, but bilateral spreader grafts
need much more cartilage and can be only applied in a few
noses in Asian people because of the limitation of useful sep-
tal cartilage.17 Batten grafts or direct caudal grafts are less stable
and may not render adequate and long-term stable strength
for nasal tip in patients with weak and thin septum and alar
cartilages. Other techniques similar to septal extension graft,
such as the caudal septal advancement technique, are also used
in tip plasty, but these techniques break the septal integrity and
influence its stability.20,21
The most common material used for septal extension graft
is autologous septal cartilage. Conchal cartilage is often used
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 Septal Extension Graft for Asians
Figure 5. A 25-Year-Old Girl Who Underwent Secondary Rhinoplasty, Including Replacement of Implant, Modified Septal Extension Graft,
and Tip Graft
A B
E F
A-D, Preoperative views. E-H, Postoperative views at 12 months.
as a tip graft; autologous costal cartilage has been used in pa-
tients with severe structural deformities.22 In some patients,
the unilateral septal extension graft is sufficient to control the
nasal tip. However, in more than half of these patients, this
single graft needs to be strengthened.3 Unilateral septal ex-
tension graft cannot set the septal extension graft at the an-
terior midline; unilateral graft placement may cause the na-
sal tip to deviate to the graft placement side in patients with
thick and strong septal cartilage. However, in patients with thin
and weak septal cartilage, the unilateral septal extension graft
can make the existing caudal septal cartilage and the septal ex-
tension graft deviate to the opposite side of the graft place-
ment. Therefore, this single graft needs to be strengthened with
bilateral grafts. The bilateral spreader graft may be the most
stable graft and can strengthen the caudal septum and grafts,
but the bilateral spreader grafts are just 5 cm wide, so they can-
not successfully extend the caudal and dorsal aspects of the
septum and the anterior septal angle at same time. The bilat-
eral spreader grafts cannot be applied in all patients. Only 18.2%
of patients had septal cartilages 25 mm long that could be used
as bilateral spreader grafts.17 Furthermore, the conventional
bilateral spreader grafts are often applied to improve the na-
sal valve, which may widen the midvault of the nose. Bilat-
eral batten grafts and direct caudal grafts were only used in
cases of limited cartilage. The grafts are affixed directly to the
anterior septal angle or the caudal septum. These grafts are the
potentially less stable type of the septal extension graft. They
are more susceptible to cause deviation of the tip over time,
especially in patients with weak and thin septal cartilage and
alar cartilages.
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Original Investigation Research
C D
G H
Under these circumstances, we applied a new technique
that can give the existing caudal septum and septal exten-
sion grafts considerable stability and does not need a large
amount of septal cartilage. This technique is different from all
other techniques previously described in publications. The
technique consists of a combined triangle septal extension graft
and a stripped septal extension graft. The triangle septal ex-
tension graft can extend beyond the dorsal and caudal sep-
tum and the anterior septal angle. It goes into the area be-
tween the medial crura and intermediate crura to consolidate
the alar cartilages and control the tip. The triangle septal ex-
tension graft provides main support to the alar cartilages and
nasal tip. The stripped septal extension graft is used to com-
pensate for the bulk of the triangle septal extension graft place-
ment and consolidate the triangle septal extension graft and
existing caudal septum. The cephalic ends of the 2 grafts are
fixed with the dorsal septum and upper lateral cartilage to-
gether, which can greatly increase the existing stability of the
caudal septum and grafts. Both grafts have almost the same
dorsal length and coincident dorsal border. They help to set
the existing caudal septum and extension grafts exactly at the
anterior midline. In addition, this procedure needs less carti-
lage. It can be applied in almost every patient who needs a sep-
tal extension graft. The placement of 2 grafts can effectively
increase the stability for the nasal tip. Moreover, it can ensure
the dorsal implant is in the correct position and avoid im-
plant deviation.
Widening the supratip or midvault area after implanta-
tion of a bilateral extension graft has been considered, espe-
cially in patients with short nasal bones.3 In our study pa-
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 Research Original Investigation Septal Extension Graft for Asians

tients, the midvault and supratip areas are not widened too
much. First, the original midvault area at the middle junction
of the septum and upper lateral cartilages is much narrower
than that of the keystone area. The length of the septal exten-
sion grafts is shorter than that of the spreader graft. Further-
more, the placement of both septal extension grafts in our pro-
cedure is different from the placement of the conventional
spreader graft. Cephalic ends of both extension grafts in our
technique do not go cephalically beyond the middle junction
of the dorsal septum and upper lateral cartilages, where the
midvault is much narrower. The conventional spreader graft
is placed near the keystone area, which would widen the mid-
vault. Second, the harvested cartilage is relatively thin. Its
thickness is approximately 1 mm in Asian patients.23 The con-
chal cartilage is also approximately 1 mm, although the post-
operative midvault at this site is composed of 5-layered carti-
lages, including 2-layered septal extension cartilages, 2-layered
upper lateral cartilages, and 1-layered dorsal septum; their total
thickness is approximately 6 mm. The supratip area is not wid-
ened. After 2 septal extension grafts are placed, the new dor-
sal septum near the supratip area consists of 2 layered carti-
lages; its thickness is only approximately 2 to 3 mm.
Furthermore, sometimes, if the septal cartilage used for the
septal extension graft is somewhat thick, then the septal car-
tilage can be thinned to decrease the postoperative thickness
of the midvault and supratip areas. Third, in Asian patients,
who commonly have saddle nose, even if the middle vault is
somewhat widened, the implant placement can camou-
flaged this defect.
In conclusion, this technique is an effective method to pro-
vide long-term, stable support of the nasal tip. It helps to set
the existing caudal septum and septal extension grafts ex-
actly at the aesthetic midline and decreases the deviation of
the nasal tip. This technique can be used in Asian patients.

ARTICLE INFORMATION
Accepted for Publication: February 22, 2013.
Published Online: July 25, 2013.
doi:10.1001/jamafacial.2013.1285.
Author Contributions: Study concept and design:
Lin, Xiaoping Chen.
Acquisition of data: Lin, Gao, Zheng, Xin Chen,
Yuan.
Analysis and interpretation of data: Lin, Wang.
Drafting of the manuscript: Lin, Xiaoping Chen, Gao,
Zheng, Xin Chen, Yuan.
Critical revision of the manuscript for important
intellectual content: Lin.
Statistical analysis: Lin, Wang, Gao, Zheng, Xin
Chen, Yuan.
Administrative, technical, and material support:
Xiaoping Chen.
Conflict of Interest Disclosures: None reported.
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