A Counterbalancing Manoeuvre on the Side-to-Side Fixated Extension Graft for Inclination Towards the Midline

Year 2025, Volume: 35 Issue: 3, 129 - 133, 25.09.2025

Aret Çerçi Özkan , Erol Kozanoğlu

https://doi.org/10.26650/Tr-ENT.2025.1603217

Abstract

Objective: Nasal tip stabilisation is one of the key components of a successful rhinoplasty. Extension grafting is one of the most reliable techniques for tip stabilisation. If the caudal septum retains a slight tilt after septo plasty, the extension graft can be fixated on the opposite side of the septal tilt to achieve midline alignment. Despite these measures, the sidetoside fixation of an extension graft may still necessitate counterbalancing. In this study, a novel counterbalancing manoeuvre is described with its preliminary results.

Materials and Methods: Primary rhinoplasty patients who had a slight tilt after septoplasty between March 2022 and April 2024 were included in this study. The patients were candidates for sidetoside fixation of a counterbalancing graft that was harvested from the basal part of the nasal septum in all patients. This specific portion of the septal cartilage thickens and widens as it nears its attachment to the vomerine bone, giving it a unique inverted drumstick appearance in the transverse plane. An L shaped or golf stick shaped graft form was created by sculpting the harvested cartilage; thus, counterbalancing was maintained with the help of this structured graft. If the tilt was towards the left, the extension graft was fixated on the right side of the septum, and the thickened base of the graft was discarded from the right side. If the tilt was towards the right, the extension graft was fixated on the left side of the septum, and the thickened base was removed from the left side. The demographic details of the patients were recorded, and the late operative outcomes of the patients were evaluated using standard photographs. Any tilts of the tip were recorded.

Results: A total of 134 primary rhinoplasty operations were performed using the proposed L shaped extension graft with sidetoside fixation. Seventy six patients were female, whereas 58 were male. In 93 cases, the extension graft was fixated on the right side of the nasal septum, whereas in 41 cases, fixation occurred on the left side. The mean followup was 21 months (9–34 months).

Conclusion: By using the unique anatomy of the septal base, the proposed manoeuvre enables precise coun terbalancing of the graft, ensuring stable nasal tip alignment and symmetry.

Keywords

Extension graft , sidetoside fixation , rhinoplasty , tip plasty

References

• IncreasingSciegienka S, Hanick A, Spataro E. Nasal tip support and management of the tip tripod complex. Clin Plast Surg 2022;49(1):6170. google scholar
• Chun MJ, Kumar T, O'Connell S, Metzinger S. Increasing nasal tip projection using structural Grafts: A Review of Outcomes. South Med J 2022;115(10):76572. google scholar
• Rohrich RJ, Savetsky IL, Avashia YJ. The role of the septal extension graft. Plast Recons Surg Glob Open 2020;8(5):e2710. google scholar
• Brandstetter M, Bhatt M, Pham M, Gubisch W, Haack S. Comparative analysis and longterm results of various septal extension graft types. Facial Plast Surg 2020;36(03):26367. google scholar
• Hosnani H, Bastaninez S, Golchin A, Givzadeh H. Evaluation of the results of septum extension batten graft in patients referred for septorhinoplasty. Int Arch Otorhinolaryngol 2023;27(4):60207. google scholar
• Sazgar AA, Kheradmand A, Razfar A, Hajialipour S, Sazgar AK. Different techniques for caudal extension graft placement in rhinoplasty. Braz J Otorhinolaryngol 2021;87(2):18892. google scholar
• Rochrich R, Ahmad J, Kurkjian TJ, Byrd HS. Predictable control of tip projection and rotation: septal extension grafts. In: Rochrich R, Adams WP, Ahmad J, Gunter JP. Dallas Rhinoplasty, 3rd edn. QMP CRC press St.Louis, Missouri/Boca, Florida, pp 495514. google scholar
• Bilgili AM, Çerçi Özkan A. Comparative clinical study with a novel technique for stabilization of the nasal tip projection and rotation: fixation of the septum and the strut graft through the septal cartilage autoextension. Eur Arch Otorhinolaryngol 2020;277:334956. google scholar
• Samibut P, Meevassana J, Suwajo P, Nilprapha K, Promniyom P, Lamphongsai S, et al. The anatomical study of the nasal septal cartilage with its clinical implications. Aesthetic Plast Surg 2021;45(4):170511. google scholar
• Bahman G, Xia TY. Evolution and Versatility of the Bilateral Extended Spreader Graft: A Review and an Update to the TongueandGroove Technique. Aesthetic Plas Surg 2023;47(5):20238. google scholar
• Özkan AÇ, Bilgili AM, Kozanoğlu E, Çiçek MM. The inverted T shaped columellar strut graft: A New technique for tip stabilization in short or shortened caudal septum. BENT 2024;20(2): 8593. google scholar