Saddle Nose Deformities

Dr. Sam Rizk, a NYC rhinoplasty surgeon, defines a "saddle" deformity of the nose as an unsightly or unacceptable concavity of the nasal dorsum. It is considered a partial deformity when it affects primarily either the bony or cartilaginous vault and is referred to as a combined deformity when both the bony and cartilaginous structures are affected. The cause of the defect may be developmental, infectious, or traumatic, or from a previous rhinoplasty.

The developmental saddle nose deformity is quite rare and affects the entire dorsum; it is usually associated with underdevelopment of the entire nose. Such a defect may go unnoticed in childhood, and usually becomes apparent only after puberty.

More common is the saddle deformity brought on by infection. One or two generations ago this condition was often associated with tertiary syphilis, in which only the bony dorsum was affected. Nowadays, infection that may lead to a saddle deformity (of the cartilaginous dorsum only) is secondary to a septal abscess. The deformity may be caused by the rapid destruction of septal cartilage, with resultant loss of support of the upper lateral cartilages, and aggravated by scar contraction. Dr. Sam Rizk, a New York rhinoplasty specialist and double board certified facial plastic surgeon; states that in some cases the septal abscess may spread to involve the upper lateral cartilages as well.

Trauma is probably the most common cause of depressions of the nasal dorsum, and may affect either the bony or the cartilaginous components or both. Not infrequently the cause is iatrogenic-sometimes a consequence of an aggressive rhinoplasty or septoplasty where not enough dorsal support was left. It is considered safe to leave 1-1.5cm of dorsal septal cartilage support in the septum.

Management of acute septal abscess- After a septal abscess has been drained surgically and the infection has been brought under control with antibiotics-as evidenced by a sterile culture-the destroyed septal cartilage may be reconstructed without further delay by means of an ethmoidal or vomerine bone graft.

Surgical collapse of cartilaginous dorsum-If, during the course of septoplasty, it is observed that the cartilaginous dorsum has sagged, producing a depression above the lobule, it is prudent to reverse the deformity before completing the operation. If the cause of the depression is considered to be a dislocation of the cartilaginous strut off its articulation with the maxillary crest, the basal edge of the cartilage should be replaced on the crest and secured in place with through-and-through sutures. In the event that there is insufficient support for the septal strut inferiorly or when too much cartilage has been removed from the dorsal edge of the septum, it is best to build up the depressed dorsum of the nose by creating a pocket under the skin of the dorsum and inserting into it a septal cartilage graft.

Preoperative evaluation-Dr. Sam Rizk, who specializes in rhinoplasty in NYC, recommends a detailed examination of the nose and getting a detailed history which will enable the surgeon to determine the cause of an established saddle nose deformity, which should help in the planning of the corrective procedure. In the preoperative planning of partial saddling of the nasal dorsum-when the deformity is primarily either cartilaginous or bony - Dr. Sam Rizk considers the possible likelihood that the depressed part of the dorsum may well form an acceptable part of a reduced dorsal projection. Stated differently, a cartilaginous saddle may only appear to be a deformity in relationship to an existing bony bump which, if removed, may provide the patient with a satisfactory dorsal projection overall. The same may be true of an apparent bony dorsal depression in the presence of a prominent convexity of the cartilaginous dorsum. In some cases of partial saddling in which both the depressed and the unaffected parts of the nasal dorsum may require correction, both problems may be corrected by using the reduced tissue of the prominence as a graft for the depression, possibly and preferably pedicled on some of the attached soft tissue.

Surgical correction-the approach to surgical correction, according to rhinoplasty surgeon Dr. Sam Rizk, of a saddle nose deformity depends on whether the defect is primarily affecting only the cartilaginous vault, on the one hand, or the bony vault, or both. The reason for this is that certain surgical techniques are more applicable to correction of the cartilaginous dorsum, while other methods may be more successful for bony or combined defects. Certain principles are applicable to the placement of all nasal dorsal grafts or implants.

1. The recipient pocket must be of the correct size and shape, so as to preclude movement of the graft.
2. The graft must be the correct size and shape to fit the recipient pocket snugly.
3. Because all organic material tends to absorb to some degree, some over-correction of the defect is recommended.
4. If more than one piece of material is used to fill the defect, there should be very little space, if any, between the pieces, to preclude eventual shrinkage and distortion.
5. In the event that the recipient pocket turs out to be too large for the graft, then the graft should be secured by some means, usually sutures.
6. Because there is the risk of producing an uneven surface contour (especially in thin-skinned individuals) when grafting multiple pieces, the grafted material may need to be sculpted well. Dr. Sam Rizk, a NYC nose job surgeon, sculpts his grafts with a new power-sanding tool which gives round edges and eliminates sharp edges. Additionally, the grafted material may need to be overlaid with Alloderm, fascia, crushed cartilage or periosteum. These soft overlaying materials soften the edges of the grafts.

Cartilaginous saddle nose-the defect over the cartilaginous dorsum may be corrected by means of grafts, implants, or flaps derived from either the upper or lower lateral cartilages.

Free grafts -The most suitable grafting material for the cartilaginous vault is cartilage, harvested either from the septum or from the auricle. If the deformity is secondary to a septal abscess, very little septal cartilage may be available for this purpose; however, a rib bank provides cartilage processed with FDA-approved methods. Conchal (ear cartilage) taken through a postauricular incision, should include perichondrium over its conves surface, which should help it its take, particularly if placed in contact with the skin. Depending on the concavity to be augmented, layers of cartilage may need to be stacked, sutured together, and trimmed to shape; however, the graft must fit quite closely into the dorsal concavity; to that it will not be able to rock in its bed. The challenge of placing and securing a graft over the cartilaginous dorsum will be greatly facilitated through the open or transcolumellar approach.

However, depending on where the defect or saddle is located, the endonasal approach may work very well. Other materials are available for augmenting the cartilaginous dorsum such as implants including irradiated rib cartilage available from a rib bank, demineralized bone, and alloplastic substances.

Cartilaginous flaps - The saddle deformity of the isolated cartilaginous depression may be corrected with great success by swinging forward bilateral, medially based flaps, which are created from the upper lateral cartilages or from the lateral crura of the lower lateral cartilages and sutured together over the dorsum. The operation is greatly facilitated through an open approach.

Upper lateral cartilage flaps-after the skin is elevated over the dorsum, Dr. Sam Rizk, a New York rhinoplasty surgeon, will estimate how wide the flaps need to be relative to the amount of maximal depression, and then he will make a sloping incision in the upper lateral cartilage on each side, taking care not to cut through the underlying perichondrium. The flaps are then bent toward each other like two pages of a book and fixed together with at least two horizontal mattress sutures, keeping these away from the edges which invariably need to be adjusted.

Lower lateral cartilage flaps-preferably through the use of the open approach, paired; medially based flaps may be designed from the upper portion of each lateral crus, leaving the underlying perichondrium behind on the vestibular skin. The flaps are swung upward and sutured in place along the midline. The leading, sutured edges are then trimmed to match the rest of the dorsal projection. In selecting patients for this procedure, Dr. Sam Rizk states that the lateral crura must have a direct relationship to the extent of defect.

Bony and combined defects-saddling of the bony pyramid or combined saddle deformities affecting both the bony and cartilaginous vaults of the nose are probably best corrected with a well-placed bone graft. Autologous bone grafts-certain general principles apply to successful take of a bone graft over the nasal dorsum.

1. It is best if the graft consists of a single piece of bone.
2. Grafts from flat (membrane) bones take better than those obtained from long bones.
3. The greater the surface contact of the graft with hose bone, the greater percentage of take.
4.  Although cancellous bone is supposed to take better than cortical bone, this principle seems to apply only to the type of bone that is in direct contact with host bone.
5. A bone graft seems to take better when it is provided with a periosteal covering.
6. The bone graft requires adequate mobilization, a circumstance that is not always obtained in all cases. To insert a bone graft into place, care should be taken to elevate the periosteum off the bony defect, so as to provide a highly desirable cover for the bone graft, and to prepare a clean bony surface for contact with the graft. If the periosteum cannot be raised sufficiently to provide the necessary space for the graft, vertical relief incisions may need to be made along its lateral attachments. In some cases of combined deficiency, the bony dorsum may need to be rasped flat in order to lower its level to the cartilaginous dorsum and provide a flat surface for more close contact with the bone graft and rasp away any soft tissue that may interfere with a good take. In most cases of combined saddle defects, there is insufficient support of the anterior septal angle for the inferior tip of the bone graft. Since this may lead to depression of the lower part of the dorsum, it is prudent to reinforce the caudal edge of the septum in order to provide support for this part of the graft.

Radiated cartilage from rib cartilage affords the facility of creating a single block for the implant and if obtained from a young cadaver is extremely easy to carve. On the other hand this cartilage does not always attach to host tissue and in some cases it moves and needs therefore to be secured adequately for stability.

Alloplastic implants include medpor and silicone (solid) in the nasal dorsum. Dr. Sam Rizk, a NYC double-board certified rhinoplasty surgeon, recommends selecting patients with thick skin for implant coverage. In spite of this, some rejection can occur and the implant must be removed. The great advantage of alloplastic implants is the lack of absorption of medpor or silicone. Dr. Rizk custom sculpts the medpor implant to fit your nose during your procedure, It is not a one size fit all implant.