Septal extension grafts play a pivotal role in controlling nasal tip projection and rotation in rhinoplasty. Achieving ideal nasal tip positioning is essential for facial harmony and patient satisfaction. This can be accomplished by balancing nasal length, projection, and rotation. Septal extension grafts, typically harvested from the patient’s own septal cartilage, offer a reliable method for extending the caudal septum and reinforcing nasal tip support. They are commonly preferred due to their structural strength and versatility. This panel will explore the various types of septal extension grafts, their design options, and indications. Practical considerations, including patient selection, surgical technique, and complications, will also be discussed. Emphasis will be placed on integrating functional and aesthetic outcomes through evidence-based practices. Participants will gain insight into optimizing nasal tip outcomes using different graft configurations in diverse clinical scenarios.

this panel will consist of tip approaches by various speakers

Septal extension grafts (SEGs) are structural grafts placed along the septal cartilage to stabilize and define nasal tip projection, rotation, and shape. Originally described by Toriumi nearly three decades ago as a caudal septal extension graft primarily for correcting columellar retraction, the technique was later modified by Byrd et al. to address nasal tip control, offering three distinct graft variations. Byrd’s version introduced superior projection at a 45° angle, which unfortunately positioned the graft’s axis vertically against the forces acting on the nasal tip, unlike Toriumi’s more force-aligned concept.

In endonasal rhinoplasty, Margulis and Harel (2007) introduced the “horizontal columellar strut,” a conceptually similar SEG applied through a closed approach. However, both external and endonasal SEG techniques continued to evolve. In my practice, I found that repositioning the graft from a horizontal (cephalocaudal) to a vertical (inferosuperior) orientation increased its mechanical stability and simplified fixation to the caudal septum.

SEGs provide superior control of nasal tip dynamics compared to traditional columellar struts, which lack firm anchorage to the septum and thus offer limited long-term support. However, drawbacks such as reduced nasal tip flexibility and potential asymmetry from unilateral grafting exist. These limitations can be mitigated through bilateral grafting or by thinning the distal portion of the graft to preserve elasticity.

My surgical approach avoids a one-size-fits-all philosophy. I adapt my technique intraoperatively based on septal shape and asymmetry. For instance, in cases of caudal septal concavity, I carve a graft to match the curve. If symmetry is still an issue, bilateral grafts are employed. Rather than relying on excessive tension from medial crura to increase projection, I often use cap grafts or ANSA banner-type SEGs (as per Perez et al.) to achieve a natural yet stable nasal tip.