CLINICAL STUDY
A Novel Technique for Short Nose Correction in Asians:
M-Shaped Conchal Cartilage Combining With Septal
Extension Graft
Yang An, MD, PhD, Ning Feng, MD, Lujia Chen, MD, Xin Yang, MD, Xiao Yang, MD,
Youchen Xia, MD, Hongyu Xue, MD, and Dong Li, MD
Background: Multiple techniques are available for short nose
deformity correction. The septal extension graft represents the
commonest method employed in Asians. However, a large number
of surgeons hardly obtain esthetically satisfactory results since the
majority of designs do not reflect the normally encountered surface
anatomy of the nasal tip cartilage.
Objective: The authors designed a novel technique, which
combined the M-shaped conchal cartilage with the septal
extension graft for overcoming the above shortcoming in Asians.
Methods: Between February 2013 and March 2016, 33 patients
presenting short nose deformity were surgically treated with the M-
shaped conchal cartilage combined with the septal extension graft. The
graft was an altered septal extension graft using the septal cartilage
alongside the conchal cartilage. The harvested septal cartilage was
located to the caudal septum and fixed with sutures. The conchal
cartilage was trimmed into 2 strips, which were sutured together in an
M-shape and firmly fixed in a bilateral manner to the caudal septal
extension graft. Then, the alar cartilage was fixed with the M-shape
graft. In all patients, nasal lengths, nasal tip projections, and nasolabial
angles were assessed before and after surgery, respectively.
Results: Nasal tip projections and nasal lengths showed remarkable
increases, while columellar-labial angles were overtly decreased, in
individuals surgically treated by the novel technique.
Conclusions: This study presents a new method for correcting short
nose deformity in Asians. The M-shaped conchal cartilage combined
with the septal extension graft may effectively lengthen the nose
while closely representing the actual surface of the esthetic nasal tip.
Key Words: Asians, M-shaped conchal cartilage graft, short nose
(J Craniofac Surg 2019;30: 1560–1562)
From the Department of Plastic Surgery, Peking University Third Hospital,
Beijing, China.
Received December 21, 2018.
Accepted for publication February 15, 2019.
Address correspondence and reprint requests to Dong Li, MD, Youchen
Xia MD, Hongyu Xue MD, Department of Plastic Surgery, Peking
University Third Hospital, 49 North Garden Road, Haidian District,
Beijing, China; E-mail: lidong9@sina.com
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005543
1560 The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
M ultiple techniques are available for short nose deformity
correction, and the septal extension graft represents the
commonest method in Asian individuals. However, the majority
of Asians possess too little septal cartilage, which alone can hardly
be employed efficiently as a septal extension graft.1 Several tech-
niques have been propounded, with many dropped due to undesir-
able long-term changes and structural instability. A large number of
surgeons do not obtain esthetically satisfactory results since the
majority of designs do not reflect the normally encountered surface
anatomy of the nasal tip cartilage; meanwhile, control and mainte-
nance of nasal tip position and shape likely constitutes the most
critical criterion for assessing success in rhinoplasty.
To achieve optimal refinement, nasal tips of Asians require more
materials to project into the thick skin; indeed, large cartilage graft
amounts are needed, as well as a more stable technique providing
support to the tip structure compared with the sole use of columellar
struts.2 Therefore, we designed a novel technique, which combined
the M-shaped conchal cartilage with the septal extension graft for
overcoming the above shortcoming in Asians. The technique allows
a closer representation of the normal surface of the esthetic nasal tip.
The current study discloses a novel paradigm for Asian tip
operation, exclusively employing the M-shaped cartilage in com-
bination with the septal extension graft. This technique resulted in
markedly lengthened nasal tip, with better contouring and texture of
the nasal tip compared with using a shield or cap cartilage graft by
fixing the M-shaped cartilage with a lengthened nasal septum. This
report presents the surgical method for rhinoplasty as well as results
for representative cases.
MATERIALS AND METHODS
Patients
From June 2013 to March 2016, a total of 33 nasal tip surgeries
in both women (N ¼ 27) and men (N ¼ 6) were performed. The
patients were 22 to 46 years old, averaging 28 years. Of these 33
patients, 29 and 4 were primary and secondary rhinoplasties,
respectively. All the patients with different degrees of short nose
underwent surgery using the M-shaped conchal cartilage combined
with the septal extension graft. Combined surgeries comprised
dorsal augmentation employing a silicone implant (N ¼ 18) and
polytetrafluoroethylene (N ¼ 15). Corrective rhinoplasty was car-
ried out for individuals with deviated noses.
METHODS OF CLINICAL TREATMENT
Photometric Assessment
To assess postoperative results objectively, photogrammetric
analysis was performed. Standardized three-dimensional (3D)
photographs (Canfield Scientific Inc., Fairfield, NJ) were acquired
both preoperatively and postoperatively, identifying the glabella,
sellion, subnasale, pronasale, and pogonion (Fig. 1). Proportional
The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019
FIGURE 1. The points and measured indices. Glabella, the most prominent
point in the midline between the brows; sellion, the deepest point of the
nasofrontal angle at the intersection of the forehead and nasal slopes; pronasale,
the most prominent point of the nasal tip; subnasale, the point beneath the nose
where the columella merges with the upper lip in the midsagittal plane;
pogonion, the most anterior point of the chin.
parameters, including the nasal bridge length- and nasal tip projec-
tion indices, were assessed, as well as the columella-labial angle.
The various indexes were evaluated pre- and post-operation
(Table 1-SDC) (See Supplemental Digital Content, SDC
Table 1, http://links.lww.com/SCS/A492). Paired t test was used
for comparing pre- and postsurgical values. SPSS 20.0 (USA) was
employed for statistical analysis.
Operating Procedure
The patients underwent operations after general anesthesia
induced with propofol and midazolam administered intravenously.
Short nose deformity correction consisted of many steps, for
example, alar cartilage separation from the upper lateral cartilage,
dorsal skin flap separation, and fixation of the M-shaped conchal
cartilage and the septal extension graft. The open rhinoplasty
technique was performed as follows:
1. Acquisition of autogenous conchal cartilage:
The cartilage was collected from the conchal cavity via an
incision in the posterior conchal skin. The obtained cartilages
measured approximately 35  6 mm.
2. Exposure of the septal cartilage (surgical approach):
A reverse V-shaped transcolumellar incision or a surgical cut
paralleling the former rhinoplasty-associated scar was per-
formed with upward extension paralleling the anterior margin
of the medial crus and the caudal margin of the alar dome area,
and lateral extension paralleling the caudal margin of the lateral
crus. Dissection was performed to the deep layer of the
subcutaneous tissue. Via dissection of the interdomal ligament
between the medial crura of the lower lateral cartilages, the
anterior end of the nasal septal cartilage was revealed.
A wide subperiosteal and supraperichondrial dissection was
carried out for releasing and lengthening the skin envelope.
Separation of the skin envelope from the scar tissue/capsule
allowed skin expansion for covering the stretched alar cartilage.
3. Acquisition of autogenous septal cartilage:
The whole caudal septum was well-exposed, preparing the
septum for harvest and septal extension graft reception. Septal
cartilages were collected, with 10 to 12 mm of the L-strut left.
4. Cartilage construction:
The harvested septal cartilage was located to the caudal septum
and fixed with sutures (Fig. 2A). The conchal cartilage was
trimmed into two strips, which were sutured together in an M-
shape (Fig. 3A) and firmly fixed in a bilateral manner to the
caudal septal extension graft. Then, the alar cartilage was fixed
# 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Short Nose Correction in Asians
FIGURE 2. Schematic drawing of the operation with the M-shaped conchal
cartilage combined with the septal extension graft. A, the harvested septal
cartilage was located to the caudal septum and fixed with sutures. B, the two strips
of the conchal cartilage were sutured together in an M-shape and securely fixed
bilaterally to the caudal septal extension graft. Then, the alar cartilage was fixed with
the M-shape graft. C, at the end of the operation, the marginal incision was closed.
with the M-shape graft (Figs. 2B and 3B). Therefore, the nasal
base shape could be precisely controlled. Meanwhile, dorsal
augmentation was performed with 2.0 to 5.0 mm thick silicone
implants or polytetrafluoroethylene.
5. Postoperative nursing:
Upon completing the surgical procedure, marginal incision
closure was performed (Fig. 2C), followed by packing of the
nasal cavity. Hematoma occurrence was avoided while
maintaining the nasal shape, by addition of bolster sutures to
the nasal dorsum for a week.
RESULTS
Follow-up was between 1 and 36 months, with an average of 12
months. A total of 87.9% patients were satisfied with the procedure,
and 1 patient suffered from infection (3%). The majority of treated
individuals expressed satisfaction with the nasal contour and tip
projection. The average nasal lengthening in the 33 patients was
about 4 mm. Implant-associated complications were minor; indeed,
no implant exposure/migration, necrosis of the overlying tissues,
and infection, were noted during the follow-up period.
In the photometric evaluation, nasal tip projection and nasal
length showed marked increases, and the columellar-labial angle
was overtly reduced, in individuals surgically treated by the novel
technique (Table 1). The majority of patients expressed satisfaction
with the nasal contour and tip projection (Fig. 4).
DISCUSSION
The septal cartilage represents the commonest tool for the septal
extension graft in short nose correction.3 It is widely employed as
the donor since it directly extends and firmly supports the alar
cartilage; in addition, it is readily available in the same surgical
field.4 The septal extension graft is efficient for tip projection and
lengthening in rhinoplasty, and was firstly described by Byrd et al.5
Then, alternative methods have been assessed, including the ton-
gue-and-groove technique by Guyuron and Varghai et al6 and the
extensive harvest technique by Kim et al.7 In the above methods,
FIGURE 3. The conchal cartilage was trimmed into 2 strips, which were sutured
together in an M-shape and securely fixed bilaterally to the caudal septal
extension graft (A). Then, the alar cartilage was fixed with the M-shape graft (B).
1561
An et al
TABLE 1. The Results of the Photometric Evaluation of Indices
Preop (N ¼ 14) Postop (N ¼ 14)
Length index 32.59  1.7 36.04  2.0
Projection index 14.84  0.9 16.21  0.7
Nasolabial angle index 103.6  7.1 103.1  5.0
Preop, Preoperative; Postop, postoperative.
however, important septal cartilage amounts are required. More-
over, Asians suffer from multiple nasal base shape issues, including
over-or under-rotation, altered alar-columellar proportion, and sub-
standard nasolabial angle,8 which require a septal extension graft to
fundamentally change the nasal base shape.
Indeed, nasal anatomies considerably differ between Caucasians
and Asians. For example, the nose in Asians has insufficient structural
support resulting in the refinement shown by the Caucasian nasal tip:
the weak alar cartilage of Asians makes the nasal tip structurally
suboptimal and more relying upon ligaments and soft tissues rather
than the alar cartilage itself. This adds to the thick skin found in
Asians; at the nasal tip, there is a tendency to hide the fragile contour
alterations to the weak alar cartilage.9 The Asian nasal tip needs
pronounced alterations with large graft amounts to traverse the thick
skin, yielding an overt refinement. To achieve optimal strength,
extending the cartilage graft is expensive, and often requires more
than the available septal cartilage, as that collected in Asians is often
too little to be efficiently employed as a septal extension graft.
Meanwhile, a good portion of septal cartilage should be kept as an
L-strut for stabilizing the nasal framework.3 Therefore, the conchal
cartilage is widely employed as a supplementary graft tissue.
The autogenous rib cartilage may constitute an alternative,
although with multiple shortcomings. The patient might worry about
a chest wall scar. In addition, general anesthesia is often apprehended.
Moreover, such an alternative might yield a very rigid nasal tip.
The M-shaped graft constitutes an adaptable method for base
profile modifications. With adequate graft shaping and placement,
and proper alar cartilage placement on the graft, the nasal base could
be optimally changed. This efficient technique can solely control the
different base shape indexes, such as projection and rotation, alar to
columellar proportion, and nasolabial angle position and shape.
FIGURE 4. Patients of rhinoplasty treated with the hybrid septal extension graft.
Patients 1a and 2b, 12-month postoperatively (center); patient 3a,
preoperatively; patient 3b, 30-month postoperatively (right).
1562
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019
The method has several advantages, including tip support stability
and adaptability in nasal tip alteration. It could be used for correcting
P
multiple tip deformities in Asian patients. Meanwhile, the postopera-
<0.001
tive nasal tip shows increased softness and mobility compared with
<0.001
cases employing peltate or imbricate grafts, which often lead to a rigid
0.564
nasal tip and a clear cartilage outline, especially in thin skin patients.
Additionally, compared with the conventional septal extension, graft
deviation is significantly reduced, since the M-shaped cartilage is
centrally located between the 2 septal cartilages in the SEG. The
grafted tip is pressurized by the alar cartilage in a more parallel
direction in comparison with the unilaterally fixed graft. Conse-
quently, the odds of nasal tip deviation are minimal.
Multiple techniques for assessing rhinoplasty’s outcomes are
available.10–12 Convincing every patient to undergo regular hospital
visits for direct index measurements is challenging, although this
represents the most accurate tool for estimating surgical outcomes. In
this work, we acquired clinical 3D images of lateral views pre- and
post-rhinoplasty, and assessed tip projection and nasal length altera-
tions based on 2 points, including the glabella and pogonion (Fig. 1).
In the 3D photometric assessment, nasal tip projection and nasal
length showed marked increases, while the columellar-labial angle
was overtly reduced, in individuals surgically treated by the M-
shaped conchal cartilage combined with the septal extension graft.
CONCLUSIONS
The current clinical findings suggest open rhinoplasty with the M-
shaped conchal cartilage combined with the septal extension graft is
effective for treating short nose deformities. Employing this new
method, surgeons might efficiently increase nose length while
closely representing the normal surface of the esthetic nasal tip.
The new technique yields a more stable tip support as well as a
softer and mobile nasal tip for weak alar cartilages, and can be
adapted to multiple nasal tip deformities in Asians.
REFERENCES
1. Woo JS, Dung NP, Suh MK. A novel technique for short nose correction:
hybrid septal extension graft. J Craniofac Surg 2015;27 (1.)
2. Kang JG, Ryu J. Nasal tip surgery using a modified septal extension
graft by means of extended marginal incision. Plast Reconstr Surg
2009;123:343–352
3. Paik MH, Chu LS. Correction of short nose deformity using a septal
extension graft combined with a derotation graft. Arch Plast Surg
2014;41:12–18
4. Cochran CS, Gunter JP. Secondary rhinoplasty and the use of
autogenous rib cartilage grafts. Clin Plast Surg 2010;37:371–382
5. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method
of controlling tip projection shape. Plast Reconstr Surg 1997;100:
999–1010
6. Guyuron B, Varghai A. Lengthening the nose with a tongue-and-groove
technique. Plast Reconstr Surg 2003;111:1533–1539
7. Kim JS, Han KH, Choi TH, et al. Correction of the nasal tip and
columella in Koreans by a complete septal extension graft using an
extensive harvesting technique. J Plast Reconstr Aesthet Surg
2007;60:163–170
8. Leong SC, White PS. A comparison of aesthetic proportions between
the Oriental and Caucasian nose. Clin Otolaryngol Allied Sci
2004;29:672–676
9. Lee KC, Kwon YS, Park JM, et al. Nasal tip plasty using various
techniques in rhinoplasty. Aesthetic Plast Surg 2004;28:445–455
10. Dhong ES, Kim YJ, Suh MK. L-shaped columellar strut in
East Asian nasal tip plasty. Arch Plast Surg 2013;40:616–620
11. Park JH, Mangoba DC, Mun SJ, et al. Lengthening the short nose in
Asians: key maneuvers and surgical results. JAMA Facial Plast Surg
2013;15:439–447
12. Huang J, Liu Y. A modified technique of septal extension using a septal
cartilage graft for short-nose rhinoplasty in Asians. Aesthetic Plast Surg
2012;36:1028–1038
# 2019 Mutaz B. Habal, MD