Rhinoplasty: Saddle Nose Deformity

Saddle nose deformity is due to loss of nasal dorsal height and support, leading to a collapsed and short nose. Dr. Vartanian has used a number of techniques to repair such nasal deformities.  Here is Dr. Vartanian's classification system for saddle noses:

Classification

Regardless of the etiology, categorizing the severity of the saddle nose is helpful. Dr. Vartanian uses a simplified system that classifies saddle-nose deformities on the basis of the anatomic deficits as follows:

• Type 1 - Minor supratip or nasal dorsal depression, with a normal projection of lower third of the nose






• Type 2 - Depressed nasal dorsum (moderate to severe) with relatively prominent lower third






• Type 3 - Depressed nasal dorsum (moderate to severe) with loss of tip support and structural deficits in the lower third of the nose






• Type 4 - Catastrophic (severe) nasal dorsal loss with significant loss of the nasal structures in the lower and upper thirds of the nose

Most patients with a type 2, 3, or 4 saddle-nose deformity have functional nasal airway obstruction.

A practical classification method described by Tardy divides saddle-nose deformities into 3 categories, as follows:

• Minimal - Supratip depression greater than the ideal 1-2 mm tip-supratip differential






• Moderate - Moderate degrees of saddling due to loss of dorsal height of the quadrangular cartilage, usually with septal damage






• Major - More severe degree of saddling with major cartilage loss and major stigmata of a saddle-nose deformity
  
  
  

  Indications for nasal reconstruction must be tempered by patient selection, the surgeon's experience, and the etiology of the deformity. Indications for surgery can be functional, aesthetic, or, most commonly, both. Examples are as follows:

  
  
  
  
  
  
  
  
  
  
  
  
  • Nasal airway obstruction secondary to middle vault collapse and/or incompetency of the internal or external nasal valve in a patient with a saddle-nose deformity
  
  
  
  
  
  
  • Nasal airway obstruction secondary to perforation of the loss of septal cartilage in the patient with a saddle-nose deformity
  
  
  
  
  
  
  • The patient's desire for aesthetic improvement
    
    
    

    Persons with contraindications for repairing a saddle-nose deformity include the following:

    
    
    
    
    
    
    
    
    
    
    
    
    • Patients with malignant, chronic, or autoimmune disease conditions (eg, relapsing polychondritis) in whom the reconstructed nose is at risk for continuing damage
    
    
    
    
    
    
    • Persons who abuse drugs intranasally and who have not demonstrated at least 12 months of sobriety (Nasal reconstruction is contraindicated in patients who have not definitively demonstrated complete rehabilitation from their substance abuse.)
    
    
    
    
    
    
    • Patients who are poor candidates for rhinoplasty in general, including unhealthy patients with poor perioperative risk profile and patients whose ability to follow the postoperative care regimen is limited (ie, patients with severe schizophrenia)
    
    
    
    
    
    
    • Patients with unrealistic expectations
    
    
    
    
    
    
    
    
    
    
    
    

    Patients with relative contraindications include the following:

    
    
    
    
    
    
    
    
    
    
    
    
    • The patient with multiple previous rhinoplasties who now has scarred-down thin skin (The history of smoking or an unrealistic expectation by such a patient can also serve as reason[s] to delay or dissuade the patient from surgery.)
    
    
    
    
    
    
    • Aesthetic rhinoplasty in patients younger than 16 years
    
    
    
    
    
    
    • Patients who are expected by habit or profession (mixed martial artists, boxers) to experience repeated nasal trauma
    
    
    
    
    
    
  
  
  
  
  
  

Dr. John Vartanian prefers the use autogenous cartilage grafts from the septum, ear, and if need be, costal (rib) cartilage for reconstructing saddled noses.  Usually an external rhinoplasty approach is chosen.  For more details please refer to the author's website: /