Saddle Nose Deformity
Saddle nose is a nasal deformity characterized with loss of height of the nasal bridge. Sometimes, saddle noses are also called “boxer’s nose” or “pug nose”. These terms hint at the deformity’s relationship with trauma and the up-turned and foreshortened nose. The saddle nose deformity is relatively rare. In addition to the depression of the nasal bridge, classic features of the saddle nose include widened tip, up-turned tip, short nose, nasal obstruction, nasal crusting and discharge and possibly poor odor. Reasons for the development of saddle nose deformities include inborn abnormalities, trauma, cosmetic rhinoplasty, cancer surgery, infections and other destructive diseases. Almost uniformly, damage of the nasal septum plays a role and a large septal perforation is found.
Treatment of the Saddle Nose
First, the plastic surgeon has to investigate why the saddle nose developed in the first place. If the underlying disease is active, failure of surgical management may occur.
Mild saddle noses without impairment of nasal function pose aesthetic problems only. Augmentation rhinoplasty is performed. This procedure usually involves raising the dorsum and possibly tip-plasty. Materials that can be considered to augment the nose are multifold (see below).
Moderate deformities usually co-exist with functional impairment (nasal obstruction, nasal discharge etc.) making function rhinoplasty necessary. Therefore, in addition to raising the dorsum of the nose, airway reconstruction is important. This may include septal repair and repair of nasal vestibular stenosis.
Severe saddle nose deformities are challenging problems. The septum may have a large perforation or may even be absent which is difficult to reconstruct. The skin envelope may have shrunk to a point where expansion is limited. Perfect results are rare, improvements common.
Materials Available for Build-up of the Nose
The perfect material to introduce into the nose has yet to be discovered. Therefore, options are available and are commonly presented to the patient with a reasonable bias due to the rhinoplasty surgeon’s own preference. Grafts are materials placed where there are naturally not found. Nasal grafts can be categorized based on origin: from patient’s own body (i.e. bone and cartilage), from other humans (bone, cartilage and skin) and man-made artificial implants (Silastic, Gore-Tex, Medpore).
Auto-graft: Many rhinoplasty surgeons prefer the patient’s own grafting material, usually cartilage. Possible sites to harvest cartilage from include the ear and rib. Auricular cartilage may be sufficient if small amounts suffice. For larger defects, rib cartilage is necessary. Advantages include no compatibility issues, abundance (in case of costal cartilage), smallest infection rate and minimal (maybe no) absorption afterwards. Disadvantages are primarily due to the additional procedure necessary for harvesting the cartilage. Some surgeons prefer bone from the skull (calvarial bone graft). Skull bone may absorb with time eliminating part of the benefit. Because calvarial bone is rarely used for nasal reconstruction, data is based on relatively small series of patients.
Home-graft: Tissues taken from other humans always carry concerns for viral infections. In addition, the body will recognize these tissues as foreign which may lead to a higher absorption rate. Most commonly, irradiated rib cartilage and acellular dermis (Alloderm) are used. Alloderm longevity appears limited; irradiated rib may not be readily available. Homografts do not require additional graft harvesting surgery.
Implants: Artificial implants have been used successfully in the face for decades (i.e. chin, cheeks). Available materials include Silastic, Goretex (polytetrafluoroethylene) and Medpore. Silastic implants are most frequently used in Asia for augmentation in Asian rhinoplasty with good results. In the U.S., Goretex implants are most commonly used for saddle nose rhinoplasty if the surgeon chooses artificial materials. Goretex can be supplied in sheets of various thicknesses. The implant is then shaped to match the patient’s needs. Any time implants are used in the nose, one is concerned with infection, shifting of the implant and implant extrusion.
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