A, Type 1 has minor supratip or cartilaginous dorsal depression. B, Type 2 has moderate to severe cartilaginous dorsal depression, with a prominent lower third. C, Type 3 has pan-nasal defect with severe bony dorsal deficiency, in combination with a lower third deficit. D, Type 4 has pan-nasal defect and a relatively prominent tip projection only by the lower lateral cartilage.
A, Preoperative lateral view; B, 48-month postoperative lateral view.
A, Preoperative lateral view;
B, 24-month postoperative lateral view.
A, Preoperative lateral view; B, 24-month postoperative lateral view.
A, Preoperative lateral view; B, 5-month postoperative lateral view.
A, One extended spreader graft was sutured on one side of the existing L-strut, and one caudal septal extension graft was placed contralaterally. B, Bilateral spreader grafts and 2 batten grafts were sutured on the both sides of the existing L-strut. C, Bilateral extended spreader grafts were placed on both sides of the existing L-strut, and one caudal septal extension graft was sandwiched between them.
Occurrence of unsuccessful outcomes was lowest in type 3, but there was no statistical significance according to the saddle nose classification (P = .33).
Hyun SM, Jang YJ. Treatment Outcomes of Saddle Nose Correction. JAMA Facial Plast Surg. 2013;15(4):280-286. doi:10.1001/jamafacial.2013.84
Many valuable classification schemes for saddle nose have been suggested that integrate clinical deformity and treatment; however, there is no consensus regarding the most suitable classification and surgical method for saddle nose correction.
To present clinical characteristics and treatment outcome of saddle nose deformity and to propose a modified classification system to better characterize the variety of different saddle nose deformities.
Design, Setting, and Participants
The retrospective study included 91 patients who underwent rhinoplasty for correction of saddle nose from April 1, 2003, through December 31, 2011, with a minimum follow-up of 8 months. Saddle nose was classified into 4 types according to a modified classification.
Main Outcome and Measure
Aesthetic outcomes were classified as excellent, good, fair, or poor.
Patients underwent minor cosmetic concealment by dorsal augmentation (n = 8) or major septal reconstruction combined with dorsal augmentation (n = 83). Autologous costal cartilages were used in 40 patients (44%), and homologous costal cartilages were used in 5 patients (6%). According to postoperative assessment, 29 patients had excellent, 42 patients had good, 18 patients had fair, and 2 patients had poor aesthetic outcomes. No statistical difference in surgical outcome according to saddle nose classification was observed. Eight patients underwent revision rhinoplasty, owing to recurrence of saddle, wound infection, or warping of the costal cartilage for dorsal augmentation.
We introduce a modified saddle nose classification scheme that is simpler and better able to characterize different deformities. Among 91 patients with saddle nose, 20 (22%) had unsuccessful outcomes (fair or poor) and 8 (9%) underwent subsequent revision rhinoplasty. Thus, management of saddle nose deformities remains challenging.
Level of Evidence
Saddle nose deformity results from disruption of the septal support and is characterized by middle vault depression and widening, columellar retrusion, tip overrotation, deprojection, and nasal shortening.1 Nasal obstruction caused by collapse of the upper and lower cartilages is also a frequent finding.2 Saddle nose is a common deformity encountered in rhinoplasty, yet it remains one of the most challenging deformities to treat.3 Although several articles2,4,5 that introduce surgical techniques for saddle nose correction are available, few articles address the surgical outcomes and difficulty of saddle nose correction.
Many valuable classification schemes for saddle nose have been suggested that integrate clinical deformity and treatment, including those by Vartanian,6 Tardy et al,7 and Daniel and Brenner.8 Overall, there is no consensus regarding the most suitable classification and surgical method for saddle nose correction. In our rhinoplasty practice for Asian nose, we identified many patients whose saddle noses do not fit exactly into the classification systems proposed previously. Therefore, we developed a modified saddle nose classification to supplement the limitations of previous classifications.
The present study retrospectively analyzed 91 patients with saddle nose for cause, treatment methods, and aesthetic outcomes, according to a modified classification scheme. This study could provide insight into the management of saddle nose for rhinoplasty surgeons.
This study was approved by the institutional review board of Asan Medical Center in Seoul, South Korea. We retrospectively analyzed 91 patients (63 males; mean age, 35.1 years; age range, 16–65 years) who underwent rhinoplasty for correction of saddle nose from April 1, 2003, through December 31, 2011. All operations were performed by one surgeon (Y.J.J.). The follow-up period ranged from 8 to 105 months (mean, 45.5 months).
Saddle nose classification focused primarily on the dorsal deformity observable on the lateral view. The nasal dorsum was divided into bony dorsum, cartilaginous dorsum, and lower third. Saddle noses were classified into 4 types (Figure 1 and Table 1): 1, minor supratip or cartilaginous dorsal depression (Figure 2); 2, moderate to severe cartilaginous dorsal depression with prominent lower third (Figure 3); 3, pan-nasal defect with severe bony dorsal deficiency in combination with lower third deficit (Figure 4); and 4, pan-nasal defect, with prominent tip projection by only the lower lateral cartilage (Figure 5).
All operations were performed via an external rhinoplasty approach. After skin flap elevation, the lower lateral cartilages were fully separated. Septoplasty and septal harvest were performed. Both upper lateral cartilages were separated from the dorsal septum, and osteotomy was performed if necessary. To correct the saddle nose and to strengthen the septal support, several grafts were used.
Three different methods were used for septal reconstruction. The first method used one extended spreader graft and one caudal septal extension graft. The extended spreader graft (the spreader graft extending beyond the caudal border of anterior septal angle) was sutured between the septum and upper lateral cartilage with 5-0 polydioxanone sutures. A caudal septal extension graft was placed on the contralateral caudal septum, and both grafts met as close to 90° as possible. The caudal septal extension graft was sutured with the extended spreader graft, septum, and soft tissues around the anterior nasal spine (Figure 6A).
The second method for septal reconstruction used bilateral spreader grafts and bilateral batten grafts. Two spreader grafts were sutured bilaterally between the septum and upper lateral cartilage with 5-0 polydioxanone sutures. Two batten grafts were placed bilaterally on the caudal part of the L-strut and fixed with 5-0 polydioxanone sutures to the caudal septum and soft tissue around the anterior nasal spine (Figure 6B).
The third method used 2 extended spreader grafts and 1 caudal septal extension graft. The 2 extended spreader grafts were sutured bilaterally between the dorsal septum and upper lateral cartilages in the same fashion as the first method. The caudal septal extension graft was sandwiched between the 2 extended spreader grafts and sutured with the end of the caudal septum (Figure 6C).
In patients with severe septal deformity or totally absent septal support, extracorporeal reconstruction of the septum was used according to the methods described in a previous article.9 Selection of a specific technique in each patient was determined by the availability, shape, and size of the cartilage grafts. Shape and strength of the damaged septal L-strut and desired shape of the nose after surgery were other determining factors in the selection of a specific technique.
After the septal framework was reconstructed, dorsal augmentation was performed by several materials, such as blocked cartilage, crushed or diced cartilage, Tutoplast-processed fascia lata (TPFL; 30 × 40 mm; Tutoplast, Tutogen Medical GmbH), combined use of cartilage and processed fascia, waterproof fabric (Gore-Tex; W. L. Gore and Associates), and silicon. If there is enough cartilage left after septal reconstruction and tip plasty, we tried not to use an alloplastic implant. Use of TPFL was preferred in many patients because it was useful for creating smooth dorsal contour.
All preoperative and postoperative photographs taken at the last follow-up were analyzed by 2 otolaryngologists who were not involved in any of the operations. On the basis of their consensus, postoperative outcomes in terms of nasal deformity correction were classified as excellent, good, fair, or poor. Fair and poor were considered unsuccessful outcomes. Medical records were assessed for postoperative complications and functional outcomes.
Associations among nasal deformity, surgical procedure, subjective outcomes, and saddle type were examined using Pearson χ2 tests. Statistical analyses were performed with SPSS statistical software (version 12.0; SPSS Inc), and differences with P < .05 were considered statistically significant.
Of the 91 patients, 80 (88%) underwent primary rhinoplasties, and 11 (12%) underwent secondary rhinoplasties (ie, they had undergone previous rhinoplasties at other hospitals). Saddle nose was classified into 4 types. There were 22 type 1 deformities (24%), 35 type 2 deformities (38%), 17 type 3 deformities (19%), and 17 type 4 deformities (19%). Therefore, type 2 was the most common deformity, followed by types 1, 3, and 4.
Trauma (n = 45) and prior surgical procedures (n = 28) were the most common causes of saddle nose deformity, followed by idiopathic injury (n = 10), septal injury due to intranasal button battery (n = 3), septal infection (n = 3), and electrocautery to treat epistaxis (n = 2). Most cases of saddle nose caused by previous septoplasty involved types 1 (43%) and 2 (29%) saddle nose. All the saddle noses caused by button battery were type 3, and all cases caused by electrocautery were type 2. The causes of saddle nose were statistically different according to the type of saddle nose (P = .03) (Table 2).
In 57 patients (63%), the septum was deviated and required septoplasty. In 36 patients (40%), deviated nose was present and required additional procedures to correct external nose deviation. The frequencies of septal deviation and deviated nose were not statistically different according to the type of saddle nose. Septal perforation was encountered in 15 patients (16%), including 6 patients with type 3 and 5 patients with type 1 deformities (P = .04). Autologous costal cartilage was used in 40 patients (44%), including 18 patients with type 2, 14 patients with type 3, and 2 patients with type 1 deformities (P < .001). Twenty patients underwent major septal reconstruction by the first method (n = 3), second method (n = 9), and third method (n = 8) as described in Methods. In addition, 9 patients underwent extracorporeal septoplasty. Major septal reconstruction was conducted in 1 patient with type 1 (3%), 11 patients with type 2 (38%), 9 patients with type 3 (31%), and 8 patients with type 4 (28%), and significant between-types differences were observed in performing major septal reconstruction (P = .005) (Table 3).
All patients underwent dorsal augmentation by blocked cartilage (n = 15), crushed or diced cartilage (n = 16), crushed cartilage with TPFL (n = 39), TPFL only (n = 10), and others (n = 11). No statistical differences were found in surgical outcome by different dorsal augmentation methods (P = .43).
Sixty-six patients (72%) had nasal obstruction preoperatively. Forty-one patients (62%) had septal deviations and compensatory turbinate hypertrophy, 8 patients (12%) had septal perforation, 2 patients (3%) had external nasal valve collapse, and 15 patients (23%) had a combination of these anatomical abnormalities, including internal nasal valve narrowing. Among them, only 1 patient (2%) had persistent nasal obstruction after surgery. The others showed improvement of nasal obstruction.
We assessed surgical outcomes according to saddle nose type under consensus rating by 2 independent otolaryngologists (Table 4). Among the 22 type 1 saddle noses, there were 8 excellent outcomes (36%), 9 good outcomes (40%), and 5 fair outcomes (23%). Among the 35 type 2 saddle noses, there were 10 excellent outcomes (29%), 16 good outcomes (46%), 8 fair outcomes (23%), and 1 poor outcome (3%). Among the 17 type 3 saddle noses, there were 5 excellent outcomes (29%), 11 good outcomes (65%), and 1 fair outcome (6%). Among the 17 type 4 saddle noses, there were 6 excellent outcomes (35%), 6 good outcomes (35%), 4 fair outcomes (24%), and 1 poor outcome (6%). No statistical difference was found in surgical outcomes according to saddle nose classification (P = .72).
The rates of unsuccessful outcomes (ie, fair or poor) for each deformity were 23% (n = 5) for type 1, 26% (n = 9) for type2, 6% (n = 1) for type 3, and 29% (n = 5) for type 4 (Figure 7). Overall, cosmetic outcomes for the 91 patients were excellent in 29 (32%), good in 42 (46%), fair in 18 (20%), and poor in 2 (2%). Therefore, 20 patients (22%) were deemed to have had unsuccessful outcomes.
Of the 91 patients, 8 (9%) requested revision surgery and were categorized as having unsuccessful outcomes. Of those 8 patients, 5 (62%) had a recurrence of saddle nose, 2 (25%) had costal cartilage warping, and 1 (12%) had a wound infection.
Saddle nose is a common deformity encountered by rhinoplasty surgeons. Many surgeons find correction of saddle nose difficult; however, few studies have reported surgical outcomes after correction. In the present study, the rate of successful outcomes for saddle nose correction was 78%.
A simple and descriptive classification of the saddle nose would be of great benefit to the analysis and characterization of pathologic abnormalities. Tardy et al7 proposed a practical saddle nose classification scheme that was divided into 3 categories, as follows: (1) minimal: supratip depression greater than the ideal 1- to 2-mm tip-supratip differential; (2) moderate: moderate degrees of saddling due to loss of dorsal height of the quadrangular cartilage, usually with septal damage; and (3) major: more severe degree of saddling, with major cartilage loss and major stigmata of saddle nose deformity. This classification was simple and practical, but it did not include the deformity of the nasal bone or lower third deficit.
In 2006, Daniel and Brenner8 introduced a more detailed scheme that classified saddle nose deformities into 5 categories: (1) supratip depression and columellar retraction; (2) loss of tip projection and septal support; (3) total loss of cartilaginous vault integrity and flattening of the nasal lobule; (4) progression, with involvement of the bony vault; and (5) catastrophic deformity. This classification integrated the external appearance of the nose, the degree of compromise of the septal support, and the selection of surgical treatment. However, it was not applicable to our 17 patients who belong to type 4 in our modified classification, and there was difficulty discerning between types 2 and 3.
Accordingly, we have suggested a modification of this previous classification. Type 1 is minor supratip or cartilaginous dorsal depression, which is similar to the previous type 1. Type 2 is moderate to severe cartilaginous dorsal depression with a prominent lower third, which is the sum of the previous types 2 and 3. Type 3 is pan-nasal defect with severe bony dorsal deficiency combined with a lower third deficit, which is similar to the previous type 4. The newly suggested category, type 4, is a pan-nasal defect with a relatively prominent tip projection by only the lower lateral cartilage. Our modified classification scheme is simple and includes a new category. In addition, it helps improve appreciation of different types of saddle nose; however, it also has some limitations. First, it lacks an objective standard of classification. In particular, we could not suggest an objective boundary between types 1 and 2, which leads to overlap between these 2 types. Second, this classification scheme could not represent the degree of septal support because we classified saddle nose using only facial photographs without a septal support test. Third, because this classification scheme was based only on a lateral photograph, it has the inherent weakness of not representing other typical deformities of saddle nose, such as dorsal widening, columellar retraction, tip overrotation, deprojection, nasal shortening, and external nasal valve collapse. Fourth, because our patient group included only ethnic Asians, our modified classification scheme may be more suitable to Asian nose.
Various pathologic conditions may lead to saddle nose deformity. Trauma and prior surgical procedures are reported to be the most common causes,10 as we also found in the present data. Two patients who experienced electrocautery for epistaxis had septal perforation and type 2 saddle nose deformity. Nasal cautery at approximately the same location could cut off the blood supply and cause ischemic necrosis of the septum11 and disruption of septal support. Electrocautery may cause thermal injury to the septum, resulting in septal chondritis and destruction of the septal support. Three patients, who had experienced button battery insertion in the nasal cavity during their childhood, had septal perforation and type 3 saddle nose deformity. A button battery in the nose may lead to mucosal ulceration and cartilage and inferior turbinate necrosis within 24 hours by electrolyte leakage, de novo alkali production from external currents, mercury toxicity, and pressure necrosis.12
We also evaluated treatment outcomes after saddle nose correction in 91 patients (mean follow-up, 45.5 months). We found that 78% of patients showed aesthetic improvement after the operation (ie, excellent or good outcomes), whereas 22% of patients had unsuccessful outcomes (ie, fair or poor outcomes). A few studies have reported surgical outcomes of saddle nose. In a review of 20 saddle nose cases, Mao et al13 reported that only 5% had unsuccessful surgical results.
There could be several reasons why the surgical results of the study by Mao et al were considerably better than ours. First, different evaluation methods for the surgical outcomes were used between the 2 studies. In the study by Mao et al, the aesthetic surgical outcomes were subjectively evaluated by the patients. In our study, these outcomes were evaluated by 2 otolaryngologists who were not involved in any of the operations. Three patients in the study by Mao et al had moderately depressed dorsa postoperatively, but their subjective satisfaction was rated as high. In the present study, if a dorsum remained depressed after surgery, then the case was classified as a fair or poor surgical outcome. Second, different inclusion criteria were used between the 2 studies. Mao et al included only minor saddle nose deformities, whereas we included all types of saddle nose deformities. These differences in the evaluation method and inclusion criteria may explain the observed discrepancies in surgical outcomes between the 2 studies.
We classified the current cases using our modified classification system. Type 2 (38%) was the most common deformity in our patient series. Type 3 deformity was associated with the lowest proportion of unsuccessful outcomes (6%). Regardless, analysis showed that the frequency of unsuccessful outcomes was not statistically different according to the saddle nose classification.
Autologous costal cartilages were used in 40 patients (44%), which included only 2 type 1 deformity cases (P < .001). Most type 1 deformity cases had a relatively intact septal support, which can be corrected by using remnant septal or conchal cartilage. These cartilages are often insufficient for other saddle nose types. Saddle nose results from the disruption of the septal support, and reconstruction of the strong septal framework is the key to correcting deformities. The remnant septal and conchal cartilages are often too weak to rebuild strong and stable septal frameworks. Moreover, some patients have little remnant quadrangular cartilage as a result of a previous surgery or combined septal perforation. Hence, for correcting saddle nose, the aggressive use of rib graft should be considered in cases other than type 1 deformity.
Our study had several limitations. We used a postoperative rating approach, which carries a risk of lack of reliability and validity. In addition, the patients had a wide range of follow-up periods (8-105 months).
To the best of our knowledge, no study has reported the surgical outcomes of saddle nose according to saddle nose classification. We found that 22% of patients had unsuccessful outcomes, and surgical outcomes did not differ according to the saddle nose type. For the correction of saddle nose deformities, use of a rib graft should be considered to make a strong and stable septal cartilage framework, especially for types 2 to 4 saddle deformities.
Saddle nose is one of the most challenging deformities faced by rhinoplasty surgeons. We proposed a modified saddle nose classification scheme that is simpler, easier to apply, and better able to characterize different deformities. We have analyzed the outcomes of saddle nose corrections and conclude that it remains difficult to obtain satisfactory surgical outcomes for correction of saddle nose deformities.
Accepted for Publication: January 15, 2013.
Corresponding Author: Yong Ju Jang, MD, PhD, Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-2dong, Songpa-gu, Seoul 138-736, South Korea (firstname.lastname@example.org).
Published Online: May 16, 2013. doi:10.1001/jamafacial.2013.84.
Author Contributions:Study concept and design: Hyun and Jang.
Acquisition of data: Hyun and Jang.
Analysis and interpretation of data: Hyun.
Drafting of the manuscript: Hyun.
Critical revision of the manuscript for important intellectual content: Jang.
Statistical analysis: Hyun.
Study supervision: Jang.
Conflict of Interest Disclosures: None reported.
Correction: This article was corrected online June 26, 2013, for a missing Level of Evidence paragraph in the abstract.