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Two-stage revision cartilage septorhinoplasty in an Asian female patient with severe short and saddle-nose: a case report of difficult revision rhinoplasty

  • Beta Subakti Nataatmadja ,
  • Loelita Marcelia Lumintang ,
  • Nyoman Bayu Widiartha ,
  • Nyoman Wawan Tirtha Yasa ,
  • Sang Nyoman Suriana ,


Background: Iatrogenic short-nose and saddle-nose deformities due to previous alloplastic implants remain the most challenging secondary rhinoplasty, particularly among Asian patients. Cartilage framework reinforcement, dorsal augmentation, sufficient nasal tip projection, and proportional nasal length are considered essential for Asian features. This study aimed to elaborate on full rib and ear cartilage revision rhinoplasty in a patient with those problems.

Case Presentation: A difficult case of a 31-year-old female with short-saddle-nose deformity due to infected silicone implant rhinoplasty is presented. A history of nose filler and thread lift was also reported. We noted a short and under-projected nose, indented scarring, dorsal irregularities, retracted columella, severe septal losses, and high trans-columellar incision scars. We conducted two stages of revision: (1) Secondary septorhinoplasty with the seventh costal graft and right concha cartilage, then alar-plasty and (2) Tip-plasty and columellar shield graft with left concha cartilage. Anatomic improvements, complications, and patient satisfaction responses were documented. The improvement of nasal length (39-46-48 mm), nasal tip projection index (0.5-0.59-0.63), nasofrontal angle (150-137-137°), nasolabial angle (117-85-93°), columella-lobular angle (60-45-42°), columellar show (0-0.5-2 mm), and alar flare (4.5-2.6-2.3 mm) on the pre-operative, first, and second stage were noted. No sign of significant absorption and wrapping was observed in both stage.

Conclusions: Short and saddle-nose deformity is considered one of the most challenging issues in rhinoplasty surgery. This finding is expected to create grounded perspectives among the young surgeons, also well-balanced and sensible beliefs on the final results among the patients.


  1. Kim EK, Daniel RK. Operative techniques in Asian rhinoplasty. Aesthet Surg J. 2012;32(8):1018-1030.
  2. Kim H, Han K. Asian Rhinoplasty: Correction of the Short Nose with a Septal Integration Graft. Semin Plast Surg. 2015;29(4):269-277.
  3. Lee SH, Koo MG, Kang ET. Septal Cartilage/Ethmoid Bone Composite Graft: A New and Improved Method for the Correction Underdeveloped Nasal Septum in Patients with Short Noses. Aesthetic Plast Surg. 2017;41(2):388-394.
  4. Han SE, Han K, Choi J, Yun TB. Modified Direct-Type Septal Extension Grafts: Their Stability and Usefulness in Asian Rhinoplasty. Ann Plast Surg. 2017;78(3):243-248.
  5. Lam SM. Aesthetic facial surgery for the asian male. Facial Plast Surg. 2005;21(4):317-323.
  6. Li D, An Y, Yang X. An Overview of Asian Rhinoplasty. Ann Plast Surg. 2016;77 Suppl 1:S22-S24.
  7. Moon KC, Han SK. Surgical Anatomy of the Asian Nose. Facial Plast Surg Clin North Am. 2018;26(3):259-268.
  8. Kim DW, Attenello NH. Reconstruction of the Nasoseptal L-Strut in Rhinoplasty. JAMA Facial Plast Surg. 2015;17(6):457-458.
  9. Lan MY, Jang YJ. Revision Rhinoplasty for Short Noses in the Asian Population. JAMA Facial Plast Surg. 2015;17(5):325-332.
  10. Park JH, Mangoba DC, Mun SJ, Kim DW, Jin HR. Lengthening the short nose in Asians: key maneuvers and surgical results. JAMA Facial Plast Surg. 2013;15(6):439-447.
  11. Kim JH, Park SW, Oh WS, Lee JH. New classification for correction of alar retraction using the alar spreader graft. Aesthetic Plast Surg. 2012;36(4):832-841.
  12. Lee SH, Koo MG, Kang ET. Septal Cartilage/Ethmoid Bone Composite Graft: A New and Improved Method for the Correction Underdeveloped Nasal Septum in Patients with Short Noses. Aesthetic Plast Surg. 2017;41(2):388-394.
  13. Gunter JP, Rohrich RJ. Lengthening the aesthetically short nose. Plast Reconstr Surg. 1989;83(5):793-800.
  14. Scattolin A, Galzignato PF, Longari F, D'Ascanio L. Septal extension graft in "closed" revision rhinoplasty: A simplified technique. Am J Rhinol Allergy. 2017;31(4):260-264.
  15. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the columellar strut in rhinoplasty: indications and rationale. Plast Reconstr Surg. 2012;129(1):118e-125e.
  16. Rohrich RJ, Kurkjian TJ, Hoxworth RE, Stephan PJ, Mojallal A. The effect of the columellar strut graft on nasal tip position in primary rhinoplasty. Plast Reconstr Surg. 2012;130(4):926-932.
  17. Paik MH, Chu LS. Correction of short nose deformity using a septal extension graft combined with a derotation graft. Arch Plast Surg. 2014;41(1):12-18.
  18. Gruber RP. Surgical correction of the short nose. Aesthetic Plast Surg. 2002;26 Suppl 1:S6.
  19. Wee JH, Park MH, Oh S, Jin HR. Complications associated with autologous rib cartilage use in rhinoplasty: a meta-analysis. JAMA Facial Plast Surg. 2015;17(1):49-55.
  20. Varadharajan K, Sethukumar P, Anwar M, Patel K. Complications Associated With the Use of Autologous Costal Cartilage in Rhinoplasty: A Systematic Review. Aesthet Surg J. 2015;35(6):644-652.
  21. Wee JH, Park MH, Jin HR. Post-Rib Harvesting Pain Should be Considered as a Potential Significant Morbidity in Reconstructive Rhinoplasty-Reply. JAMA Facial Plast Surg. 2015;17(3):226.
  22. Gibson T, Davis W. The distortion of autogenous cartilage grafts: its cause and prevention. Br J Plast Surg 1957;10:257-274.
  23. Samizadeh S, Wu W. Ideals of Facial Beauty Amongst the Chinese Population: Results from a Large National Survey. Aesthetic Plast Surg. 2018;42(6):1540-1550.
  24. Wu WT. The Oriental nose: an anatomical basis for surgery. Ann Acad Med Singap. 1992;21(2):176-189.
  25. Zingaro EA, Falces E. Aesthetic anatomy of the non-Caucasian nose. Clin Plast Surg. 1987;14(4):749-765.
  26. Hwang SM, Lim O, Hwang MK, Kim MW, Lee JS. The Clinical Analysis of the Nasal Septal Cartilage by Measurement Using Computed Tomography. Arch Craniofac Surg. 2016;17(3):140-145.
  27. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast Surg Clin North Am. 2007;15(3):293-v.
  28. Tham C, Lai YL, Weng CJ, Chen YR. Silicone augmentation rhinoplasty in an Oriental population. Ann Plast Surg. 2005;54(1):1-7.
  29. Peled ZM, Warren AG, Johnston P, Yaremchuk MJ. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr Surg. 2008;121(3):85e-92e.
  30. Sajjadian A, Naghshineh N, Rubinstein R. Current status of grafts and implants in rhinoplasty: part II. Homologous grafts and allogenic implants. Plast Reconstr Surg 2010;125(3):99e–109e
  31. Kim HS, Park SS, Kim MH, Kim MS, Kim SK, Lee KC. Problems associated with alloplastic materials in rhinoplasty. Yonsei Med J 2014;55(6):1617–1623
  32. Gerow FJ, Stal S, Spira M. The totem pole rib graft reconstruction of the nose. Ann Plast Surg 1983;11(4):273–81.
  33. Yabe T, Muraoka M. Treatment of saddle type nasal fracture using Kirschner wire fixation of nasal septum. Ann Plast Surg 2004;53(1):89–92.
  34. Tardy ME, Schwartz M. Saddle Nose Deformity: Autogenous Graft Repair. Facial Plastic Surgery 1989;6(2):121–33.
  35. Hyun SM, Jang YJ. Treatment Outcomes of Saddle Nose Correction. JAMA Facial Plastic Surgery 2013;15(4):280–6.
  36. Calloway HE, Heilbronn CM, Gu JT, Pham TT, Barnes CH, Wong BJ. Functional outcomes, quantitative morphometry, and aesthetic analysis of articulated alar rim grafts in septorhino- plasty. JAMA Facial Plast Surg. 2019;21(6):558-565.
  37. Sawh-Martinez R, Perkins K, Madari S, Steinbacher DM. Control of nasal tip position: quantitative assessment of columellar strut versus caudal septal extension graft. Plast Reconstr Surg. 2019; 144(5):772e-780e.
  38. Apaydin F. Projection and deprojection techniques in rhinoplasty. Clin Plast Surg. 2016;43(1):151-168
  39. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8(3):156-185.
  40. Ballin AC, Kim H, Chance E, Davis RE. The articulated alar rim graft: reengineering the conventional alar rim graft for improved contour and support. Facial Plast Surg. 2016; 32(4):384-397.
  41. Kovacevic M, Riedel F, Go ̈ksel A, Wurm J. Options for middle vault and dorsum restoration after hump removal in primary rhi- noplasty. Facial Plast Surg. 2016;32(4):374-383.
  42. Kim HI, Lee WJ, Roh TS, Suh MK. A Novel Technique of Asian Tip Plasty: Rein-Shaped Columellar Strut Graft. Aesthetic Plast Surg. 2019;43(5):1301-1309.
  43. Kim MH, Choi JH, Kim MS, Kim SK, Lee KC. An introduction to the septal extension graft. Arch Plast Surg. 2014;41(1):29-34.
  44. Hwang NH, Dhong ES. Septal Extension Graft in Asian Rhinoplasty. Facial Plast Surg Clin North Am. 2018;26(3):331-341.
  45. Nataatmadja BS, Lumintang LM, Widiartha NB, Yasa NWT, Suriana SN. Septorhinoplasty in an Asian-Caucasian pediatric patient with neglected nasal deviation from previous traumatic injury: a case report. Bali Medical Journal. 2023;12(1):352-359.
  46. Beck DO, Kenkel JM. Evidence-based medicine: Rhinoplasty. Plast Reconstr Surg. 2014;134(6):1356-1371.
  47. Daniel RK. Rhinoplasty: creating an aesthetic tip. A preliminary report. Plast Reconstr Surg. 1987;80(6):775-783.
  48. Sheen JH. Rhinoplasty: personal evolution and milestones. Plast Reconstr Surg. 2000;105(5):1820-1853.
  49. Kerolus JL, Nassif PS. Treatment protocol for compromised nasal skin. Facial Plast Surg Clin North Am. 2019;27(4):505-511.
  50. Çakır, B, Öreroğlu, AR, Doğan, T, Akan, M. A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments. Aesthet Surg J. 2012;32(5):564–574.
  51. Lee W, Koh IS, Oh W, Yang EJ. Ocular complications of soft tissue filler injections: a review of literature. J Cosmet Dermatol. 2020;19(4):772-781.
  52. Adamson PA, Smith O, Tropper GJ, McGraw B. Analysis of alar base narrowing. Am J Cosmet Surg. 1990;7(4):239-243.
  53. Daniel RK. Rhinoplasty and the male patient. Clin Plast Surg. 1991;18(4):751-761.
  54. Becker DG, Weinberger MS, Greene BA, Tardy ME. Clinical study of alar anatomy and surgery of the alar base. Arch Otolaryngol Head Neck Surg. 1997;123(8):789-795.
  55. McCollough EG. Altering the Alar Base: Nasal Plastic Surgery.Philadelphia, Pa: WB Saunders Co; 1994:247-255.
  56. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg. 2003;111(3):1322-1341.
  57. Szachowicz E 2nd, Kridel RW. Adjunctive measures to rhinoplasty. Otolaryngol Clin North Am. 1987;20(4):895-912.
  58. Porter JP. The average African American male face: an anthropometric analysis. Arch Facial Plast Surg. 2004;6(2):78-81.
  59. Tardy ME Jr, Patt BS, Walter MA. Alar reduction and sculpture: anatomic concepts. Facial Plast Surg. 1993;9(4):295-305.
  60. TebbetsJB. Primary Rhinoplasty: A New Approach to the Logic and the Techniques. St Louis, Mo: CV Mosby Co; 1998:481-492.
  61. Choi JY. Alar Base Reduction and Alar-Columellar Relationship. Facial Plast Surg Clin North Am. 2018;26(3):367-375.
  62. Sheen JH. Secondary rhinoplasty. Plast Reconstr Surg. 1975;56(2):137-145.
  63. AufrichtG. A few hints and surgical details in rhinoplasty. Laryngoscope.1943;57(5):317-335.

How to Cite

Nataatmadja, B. S., Lumintang, L. M., Widiartha, N. B., Yasa, N. W. T., & Suriana, S. N. (2022). Two-stage revision cartilage septorhinoplasty in an Asian female patient with severe short and saddle-nose: a case report of difficult revision rhinoplasty. Bali Medical Journal, 11(3), 2033–2042.




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Beta Subakti Nataatmadja
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Loelita Marcelia Lumintang
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Nyoman Bayu Widiartha
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Nyoman Wawan Tirtha Yasa
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Sang Nyoman Suriana
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