Achieving a Strong and Straight Septal Extension Graft: A Novel Four-step Surgical Approach in Rhinoplasty

Di Giuli R, Mafi P, Belloni LM, Vaccari S, Klinger F, Roxo CW.

PubMed 39421678 Publisher (DOI)Free full text (PMC)

What this paper says

Across 753 patients treated with a four-step septal extension technique, no cases of tip drop occurred, infection was 0.40 percent and satisfaction averaged 9.3 at one year.

Overview

A septal extension graft lengthens the septum to set the tip in a chosen position. The authors argue that conventional septoplasty often ignores appearance and long term stability, leaving recurrent deviation, a drooping tip and returning blockage. They present a systematic four step technique aimed at aligning the septum and holding it stable while also controlling the tip.

Sections of note

Design: retrospective analysis of 753 patients with a minimum of 6 months of follow up.
Step one: freeing the caudal septum, the front lower edge.
Step two: placing the septal extension cartilage graft.
Step three: positioning an ethmoidal bone graft.
Step four: redefinition using an intermediate cartilage.
Residual columellar asymmetry occurred in 1.73 percent of cases and tip asymmetry in 0.66 percent.
Infection rate: 0.40 percent. No cases of tip drop were identified.
Overall satisfaction on the Rhinoplasty Outcomes Evaluation at 12 months: 9.3.

What it means for a patient

Tip drooping over time is one of the recognized late problems after rhinoplasty, and none occurred in this series.
Adding a bone graft from the ethmoid to a cartilage graft creates a stiffer support than cartilage alone.
Complication rates were low, though residual asymmetry of the strip between the nostrils was the most common issue.
Limits: retrospective, no comparison group, single technique, minimum follow up of only 6 months, and satisfaction reported as a single average without a distribution.

Why this paper matters

Tip support determines whether a rhinoplasty result holds its shape, and septal extension grafts are the current standard for it. A series of 753 patients is unusually large for a technique report and gives meaningful complication rates. Without a comparison group, whether the four step sequence outperforms simpler approaches is unresolved.

Terms

Septal extension graft: cartilage fixed to the septum that carries the tip in a set position.
Caudal septum: the front lower edge of the wall dividing the two sides of the nose.
Ethmoid bone: the bone forming the upper rear part of the septum.
Columella: the strip of tissue between the nostrils.
Tip drop: the nasal tip losing projection and settling downward over time.
Rhinoplasty Outcomes Evaluation: a patient questionnaire scoring satisfaction with the nose.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

Abstract

Background: Septal extension grafts allow the precise elongation of the nasal septum to attain facial harmony and optimize aesthetic outcomes. In this context, septal surgery requires meticulous design to address both functional and aesthetic goals. Traditional septoplasty techniques often overlook aesthetic considerations and postoperative nasal structural stability, resulting in unresolved or recurrent deviations, nose tip drooping, and obstruction recurrences. Despite advancements in surgical techniques, achieving simultaneous septal alignment and long-term stability remains a significant challenge.

Methods: This study introduces a systematic 4-step technique. The procedure encompasses caudal septum liberation, placement of the septum extension cartilage graft, positioning of an ethmoidal bone graft, and redefinition through an intermediate cartilage.

Results: A retrospective analysis of outcomes involving 753 patients was conducted with a minimum follow-up of 6 months. During follow-up visits, 1.73% of cases exhibited residual columellar asymmetry, and 0.66% showed tip asymmetries. The infection rate was 0.40%, with no cases of tip drop identified. The overall satisfaction rating on the Rhinoplasty Outcomes Evaluation questionnaire at 12 months postoperative was 9.3.

Conclusions: The technique provides a systematic approach to integrate functional and aesthetic objectives, emphasizing septal stability and alignment while concurrently addressing tip projection and stability. The study provides comprehensive insights into the principles, methodology, and advantages of this rhinoplasty technique. The outcomes underscore the efficacy of the technique, presenting a reliable and long-term stable solution.

Abstract as indexed by PubMed; the article is open access (PubMed Central).