A Comparative Study of Septal Extension Graft versus Derotation Graft for Short Nose Correction in Asian Rhinoplasty

Abstract

Background:

Precise nasal tip refinement is a cornerstone of Asian rhinoplasty that addresses characteristics such as bulbous tips, short columellas, and flared nostrils. The septal extension graft (SEG) and the derotation graft (DRG) are commonly used to enhance tip projection; however, comparative analyses are lacking. The authors assessed the outcomes of the SEG and the DRG in Asian patients who underwent tip-plasty.

Methods:

In this retrospective study, the authors analyzed 729 patients who underwent nasal tip-plasty using the SEG or the DRG between January of 2011 and December of 2017. Postoperative complications were assessed after a minimum follow-up of 6 months. For patients with long-term follow-up (≥24 months), nasal tip projection (NTP) and columellar-labial angle were measured preoperatively and postoperatively using the Goode and the Byrd methods.

Results:

Among 287 SEG and 142 DRG cases, both techniques showed significant postoperative improvements: SEG (ΔNTP-Goode = 0.036, P = 0.001; ΔNTP-Byrd = 0.036, P < 0.001) and DRG (ΔNTP-Goode = 0.047, P = 0.005; ΔNTP-Byrd = 0.053, P < 0.001). No significant differences were noted for NTP ratios (Goode, P = 0.954; Byrd, P = 0.452) or columellar-labial angle (P = 0.116). Complications included more tip-columella deviations in the SEG group (5.23% versus 1.41%) and higher tip drooping (4.53% versus 8.45%; adjusted P = 0.040) and supratip deformity (0% versus 2.82%; adjusted P = 0.010) in the DRG group.

Conclusions:

Longitudinal analysis shows that both the SEG and the DRG effectively preserve tip projection over time. The SEG is more prone to tip and columellar deviations, whereas the DRG is associated with tip drooping and supratip deformity, with no difference in tip-shortening relapse. Technique selection should be customized to the patient’s anatomical features and the surgeon’s experience to minimize complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.

Asian rhinoplasty is often confronted with unique structural challenges because of distinct anatomical features prevalent among Asian populations, specialized rhinoplasty techni such as a short columella, inadequate columellar support, bulbous nasal tips enveloped by thicker skin, an acute nasolabial angle, and flared nostrils.¹ In addition, anatomical studies have shown that the size of septal cartilage available for grafting is much smaller in Asian people than in White people.^2–4 These characteristics necessitate specialized rhinoplasty techniques to enhance tip projection and rectify a short nose appearance.^5–9 Since the early 2000s, various methods, including the use of tip extension sutures, onlay cartilage grafts, and columellar strut grafts, the septal extension graft (SEG), and the derotation graft (DRG), have been increasingly adopted in Asia for their efficacy in addressing these complexities.¹⁰

Among these, the SEG has emerged as a predominant technique because of its robust support of the weak alar cartilage, thus allowing for refined control over the nasal tip projection and contour (Fig. 1, left).^11–15 Although the SEG is lauded for its capacity to maximize tip projection and facilitate a broad rotation range, it also carries the risk of producing an overly stiff or unnatural appearance, such as an artificially pronounced tip on smiling, particularly in Asian patients.^16,17

Fig. 1.

Schematic diagrams of the SEG (left) and DRG (right) techniques.

To mitigate these drawbacks, the DRG method was developed (Fig. 1, right).¹⁸ This method uses the auricular cartilage that is affixed to the caudal end of the septal cartilage and anchored to the repositioned lower lateral cartilage, thus offering a more dynamic and natural tip animation. Beyond its role in extending the nasal tip without necessitating the use of rib cartilage, the DRG can confer multiple advantages for tip-plasty.¹⁸ However, the DRG may exhibit a higher propensity for tip droop recurrence and may not always provide the required length for significant nasal elongation.¹⁹

Despite the widespread use of these 2 grafting techniques for enhancing tip projection and correcting short noses in Asian rhinoplasty, direct comparative studies examining their long-term efficacy and associated complications are lacking. We aimed to fill this gap by scrutinizing postoperative complications stemming from short-nose corrections in a cohort of 429 patients, each with a postoperative follow-up of at least 6 months. Moreover, we assessed the enduring effectiveness of both the SEG and the DRG techniques through a detailed anthropometric evaluation of changes in nasal tip projection (NTP) and columellar-labial angle (CLA) in a subset of 39 patients monitored for a minimum of 24 months after surgery. To the best of our knowledge, this is the first clinical investigation comparing the outcomes and potential adverse events of these 2 graft techniques.

PATIENTS AND METHODS

Study Subjects

The study protocol was approved by the institutional review board of our facility (2019GR0448), and the study was performed in full accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients, and all data were deidentified.

This observational cohort study analyzed data from 729 consecutive patients who underwent short-nose correction using either the SEG or the DRG for aesthetic purposes at our institution between January of 2011 and December of 2017, and the follow-up period exceeded 6 months. All procedures were performed by a single senior surgeon (M.K.S.). Preoperative and postoperative clinical photographs and medical records were systematically reviewed.

Patients were selected based on the following inclusion criteria: (1) availability of both preoperative and postoperative photographs; (2) absence of any additional rhinoplasty procedures beyond tip-plasty, and (3) a minimum of 6 months of follow-up. A total of 429 patients fulfilled the inclusion criteria. Within this group, 287 patients were treated using the the SEG technique, whereas 142 patients were treated using the DRG technique. This study specifically focused on evaluating unsatisfactory outcomes associated with each surgical method.

Moreover, to ascertain the longevity of the outcomes attributable to the respective surgical techniques, a subgroup of 39 patients with more than 24 months of follow-up was thoroughly examined. This assessment addressed changes in the NTP and CLA (Fig. 2).

Fig. 2.

Flowchart of patients included in the study.

Operative Techniques

SEG

After infiltrating 2% lidocaine with 1:100,000 epinephrine submucoperichondrially, septal cartilage was harvested by means of the medial crural approach (Fig. 3). Following bilateral mucoperichondrial flap elevation, adequate septal cartilage was obtained and a 10- to 12-mm dorsal and caudal L-strut were preserved for midvault support. Graft shape and orientation were customized based on surgical objectives and patient preferences.

Fig. 3.

(Above) Harvesting of the SEG source from the nasal septum. (Below) Harvesting of the DRG source from the cymba concha.

The graft was positioned on the caudal dorsal septum, anterior septal angle, and when needed, the distal dorsal septum. Initial fixation used 5-0 polydioxanone sutures between the graft and both dorsal and caudal septum. A figure-of-8 suture at the graft–L-strut junction enhanced vertical stability. After 2 to 4 additional securing sutures, the graft was trimmed to achieve desired nasal dimensions. Lower lateral cartilages were adequately released to facilitate projection and lengthening.

Once the graft was in position, the released upper lateral cartilages were fixed to the graft with 5-0 polydioxanone suture. The dome of the lower lateral cartilage was placed at the most caudal and anterior end of the graft, and the suture of the medial crura proceeded to the anterior end of the graft. The graft end was tucked under the dome with an interdomal suture, using 5-0 Prolene suture. (See Figure, Supplemental Digital Content 1, which shows operative sequence for the SEG. [Above, left] Batten type of SEG for the columellar projection. The inferior portion is designed to be longer for columellar projection. [Above, right] Fixation of the batten type of SEG, before insertion. [Below, left] Fixation of the batten type of SEG. [Below, right] The pivot locking suture fixes the SEG to the cephalic and caudal margin of the L-strut of the septum, using a figure-of-8 suture, https://links.lww.com/PRS/H879. See Video 1 [online], which demonstrates the surgical techniques of the SEG.)

Video 1. This video demonstrates the surgical techniques of the SEG.

Download video file ^{(51.5MB, mp4)}

DRG

The anterior approach was used to harvest the conchal cartilage. To avoid scar formation and ear deformity, an incision was made 2 mm medial to the antihelix crus. Considering the nature of the DRG, the cymba concha was used instead of the cavum concha because of its longer and more oval shape. The sizes of the grafts used were 1.2 to 1.8 cm in length and 0.6 to 0.8 cm in width (Fig. 3).

After harvesting, the cymba concha cartilage was typically divided into 2 or 3 portions. These pieces were used as a DRG, a columella strut graft (medial crural strut), and/or a shield graft. The upper portion of the cymba cartilage was scored halfway to allow for folding along its length, creating a straight strut secured with multiple stitches. This prepared columella strut graft served as the medial crural strut. Meanwhile, the lower portion of the divided cymba cartilage was used as the DRG.

The columella strut graft was placed between the medial crura, functioning as the medial crural strut, whereas the DRG was placed between the fixed structure (dorsal septum) and the caudally repositioned lower lateral cartilages. The procedures for the release of the lower lateral cartilage and skin envelope were the same as those for the SEG as described earlier. (See Figure, Supplemental Digital Content 2, which shows the DRG using conchal cartilage. [Above] Illustration of the DRG technique. After releasing the lower lateral cartilage and skin envelope, the DRG was placed between the fixed structure and the caudally repositioned lower lateral cartilage, and the columella strut graft was positioned between the medial crura, functioning as the medial crural strut. [Below] The harvested cymba concha cartilage is divided into 3 pieces: DRG, columella strut graft [medial crural strut], and shield [onlay] graft, https://links.lww.com/PRS/H880. See Figure, Supplemental Digital Content 3, which shows operative sequence for the DRG. [Above] The lower lateral cartilages are released from the scroll area and hinge complex. The columellar strut graft is prepared by folding the conchal cartilage lengthwise. The prepared graft is placed between the medial crura. The dome of lower lateral cartilage is pulled caudally with traction suture. With the lower lateral cartilage under traction, the DRG is placed on the dorsal septal cartilage and upper lateral cartilage. The first fixation suture to the underlying cartilage is started at the most cephalic part of the graft. [Below] Subsequent sutures are placed serially toward the caudal direction at a 2- to 3-mm interval. The caudal two-thirds of the graft is now sutured to underlying lateral crura, https://links.lww.com/PRS/H881. See Video 2 [online], which demonstrates the surgical techniques of the DRG.)

Video 2. This video demonstrates the surgical techniques of the DRG.

Download video file ^{(54.9MB, mp4)}

Outcome Evaluation

Primary Outcome: Assessment of Unsatisfactory Results with a Minimum of 6 Months’ Postoperative Follow-Up

Within the cohort of 429 patients who were available for follow-up at a minimum of 6 months postoperatively, the occurrence of postoperative complications following short-nose correction procedures was examined. “Unsatisfactory results” were identified in cases where (1) the patient necessitated revision surgery or (2) the patient exhibited suboptimal outcomes characterized by 1 or more of the following 9 clinical features: “witch’s nose”; tip-columellar deviation; tip drooping; relapse of shortened tip; protrusion of the caudal end of the graft; pinched tip; supratip deformity; nasal obstruction; and saddle nose deformity. These outcomes were classified as unsatisfactory based on the professional judgment of the surgeon despite patient acceptance of their results without consideration for revision surgery.

Secondary Outcome: Anthropometric Comparative Analysis for Long-Term Outcomes

A longitudinal study assessed the long-term effectiveness of the SEG and the DRG techniques in a subgroup of 39 patients with over 24 months of follow-up, analyzing changes in NTP and CLA. Clinical photographs of 20 SEG and 19 DRG patients were compared preoperatively and at least 24 months postoperatively. Specifically, clinical photographs of all patients at 2 time points (preoperatively versus >24 months postoperatively) were compared. Addressing magnification issues when standardizing the photographs was crucial to ensure the reliability of the study; therefore, we standardized the distances between the anthropometric landmarks, following protocols from prior research.^13,20–23 To obtain objective measurements, photographic images were assessed with the modified MDS 3.0 software (Morpheus Co Ltd, Seoul, Republic of Korea) that we have used in previous studies.^13,21–23

The NTP ratios were computed using 2 established methodologies that included the Goode^24–26 and the Byrd methods.^11,27,28 The Goode method calculates the NTP ratio by dividing the distance from the nasal tip (pronasale) to the alar crease by the distance from the nasal tip to the nasion.²⁴ Conversely, the Byrd method calculates the NTP ratio by dividing the distance from the nasal tip to the alar crease by the distance from the nasion to the upper lip.^11,27,28 The CLA was determined according to the angle formed between the inferior lobule, subnasale, and labiale superius.^13,29,30 (See Figure, Supplemental Digital Content 4, which shows illustration of anthropometric analysis: [left] NTP ratio by the Goode method; [center] NTP ratio by the Byrd method; [right] CLA method, https://links.lww.com/PRS/H882.)

To reduce the potential for investigator bias, the standard anthropometric points were independently identified by 2 blinded observers. In addition, each measurement was performed in triplicate by the investigators to ensure reliability, with the mean of these measurements recorded as the final data.

Statistical Analyses

The results were analyzed using R software version 4.1.2. Changes in the NTP ratio and CLA after surgery were compared using the paired t test or Wilcoxon signed rank test. To compare changes in NTP ratios, CLA, and unpleasing postoperative results between the 2 graft techniques, statistical comparisons were performed using 2-sample t tests, Mann-Whitney U tests, and Fisher exact tests, as appropriate.

In addition, logistic regression analysis was performed to adjust for differences in patient demographics, including surgical history (primary versus secondary rhinoplasty). The Firth bias-reduced logistic regression model was applied to minimize bias in subgroup analyses with small sample sizes. The adjusted odds ratios and corresponding P values were calculated. All statistical tests were 2-sided, with significance set at P < 0.05.

RESULTS

The baseline characteristics of the patients undergoing short-nose correction with either the SEG or the DRG technique exhibited no significant disparities (Table 1). The median age was 31 years (interquartile range [IQR], 25 to 37 years) in the SEG group and 34 years (IQR, 22 to 36 years) in the DRG group. Of these, 139 (48.43%) in the SEG group and 45 patients (31.69%) in the DRG group had not undergone previous rhinoplasty procedures. The median follow-up duration in the SEG group and the DRG group was 12 months (IQR, 9 to 13 months) and 12 months (IQR, 11 to 13 months), respectively.

Table 1.

Patient Demographics

Characteristic	SEG	DRG	P
No.	287	142
Age, yr			0.564a
Median	31	34
IQR	25−37	22−36
Sex, no. (%)			0.713b
Male	23 (8.0)	13 (9.2)
Female	264 (92.0)	129 (90.8)
Operation history, no. (%)			0.001b
Primary	139 (48.4)	45 (31.7)
Secondary	148 (51.6)	97 (68.3)
Follow-up duration, mo			0.897a
Median	12	12
IQR	9−13	11−13

^aMann-Whitney test, with P < 0.05 considered statistically significant.

^bFisher exact tests, with P < 0.05 considered statistically significant.

Unsatisfactory Results

A comparative analysis between the SEG and DRG techniques showed no significant differences in most outcomes (Table 2). Tip-columellar deviation occurred in 6.48% (SEG group) versus 2.22% (DRG group) for primary cases and 4.05% (SEG group) versus 1.03% (DRG group) for secondary cases, with no statistical significance (unadjusted P = 0.455 and P = 0.249; adjusted P = 0.118).

Table 2.

Comparison of Displeasing Results between SEG and DRG Groups

	Primary (n = 184)			Secondary (n = 245)			Adjusted Pb
	SEG (%)	DRG (%)	P a	SEG (%)	DRG (%)	P a
No.	139	45		148	97
Witch’s nose	0 (0)	0 (0)	1.000	1 (0.68)	0 (0)	1.000	0.676
Tip-columellar deviation	9 (6.48)	1 (2.22)	0.455	6 (4.05)	1 (1.03)	0.249	0.118
Tip drooping	9 (6.48)	7 (15.56)	0.072	4 (2.70)	5 (5.16)	0.325	0.040
Mild relapse of shortened tip	8 (5.76)	2 (4.44)	1.000	2 (1.35)	2 (2.06)	0.649	0.929
Protrusion of caudal end of graft	1 (0.72)	0 (0)	1.000	0 (0)	0 (0)	1.000	0.939
Pinched tip	0 (0)	0 (0)	1.000	2 (1.35)	0 (0)	0.520	0.426
Supratip deformity	0 (0)	1 (2.22)	0.245	0 (0)	3 (3.09)	0.061	0.010
Nasal obstruction	2 (1.44)	0 (0)	1.000	2 (1.35)	0 (0)	0.520	0.297
Saddle nose deformity	1 (0.72)	0 (0)	1.000	0 (0)	0 (0)	1.000	0.939

^aFisher exact tests, with P < 0.05 considered statistically significant.

^bLogistic regression tests, with P < 0.05 considered statistically significant. Adjustments were conducted using the Firth logistic regression for surgical history (primary or secondary).

Tip drooping was higher in the DRG group (6.48% versus 15.56% for primary cases; 2.70% versus 5.16% for secondary cases), with logistic regression showing a significant difference (adjusted P = 0.040). Supratip deformity was also more frequent in the DRG group (0% versus 2.22% for primary cases; 0% versus 3.09% for secondary cases), with a significant association (adjusted P = 0.010). Other complications, including mild relapse of shortened tip, protrusion of the caudal end of the graft, pinched tip, nasal obstruction, saddle nose deformity, and witch’s nose, showed no statistically significant differences (adjusted P > 0.05).

Anthropometric Analyses

Evaluation of NTP ratios before and after surgery revealed significant alterations using both methodologies (Fig. 4). For patients treated with the DRG, the Goode NTP ratio increased notably from a median of 0.511 (IQR, 0.480 to 0.535) preoperatively to 0.558 (IQR, 0.524 t 0.578) postoperatively, and this change was statistically significant (P = 0.005). Similarly, the SEG group exhibited an increase in the good NTP ratio from 0.536 (IQR, 0.480 t 0.572) to 0.573 (IQR, 0.531 to 0.613) that was also statistically significant (P = 0.001).

Fig. 4.

NTP ratio changes in the SEG and the DRG groups. Goode ratio (left) and Byrd ratio (right).

In terms of the Byrd NTP ratios, a significant increase in the DRG cohort was observed, from 0.311 (IQR, 0.301 to 0.327) to 0.364 (IQR, 0.350 to 0.380), with a value of P < 0.001. The Byrd NTP ratio similarly increased, from 0.325 (IQR, 0.309 to 0.342) to 0.361 (IQR, 0.354 to 0.399), with a value of P < 0.001. However, when comparing the 2 techniques, no significant differences were observed in the postoperative Goode NTP ratio (P = 0.954) or Byrd NTP ratio (P = 0.452).

Both groups exhibited significant postoperative increases in CLA measurements (Fig. 5). The median CLA in the DRG group increased from 72.5 (IQR, 66.0 to 78.2) to 84.6 (IQR, 81.5 to 90.9), with a statistically significant change (P < 0.001). The median CLA of the SEG group increased from 73.6 (IQR, 67.9 to 78.7) to 80.3 (IQR, 76.1 to 92.4), and this was also statistically significant (P < 0.001). Nevertheless, the difference in the postoperative CLA changes between the DRG technique and the SEG technique was not statistically significant (P = 0.116).

Fig. 5.

CLA changes in the SEG and the DRG groups.

DISCUSSION

Byrd et al. first introduced the SEG technique as an efficient means to achieve desired tip positioning, and it has since become a predominant approach for correcting low tips and short noses in Asian populations.^11,31–35 The primary challenge in nasal tip correction within this demographic is the inherently weak support structures,^36–40 which are exacerbated by thicker dorsal skin and underdeveloped nasal cartilages and complicate grafting procedures.^41–43 Consequently, numerous innovative techniques have been devised for Asian rhinoplasty since the 2000s, including tip extension sutures,⁴⁴ strut grafts,⁴⁵ onlay grafts,⁴⁶ SEGs,⁴⁷ and DRGs,^10,48 all of which are now widely used across Asia, either in isolation or in combination.^{33–35,49–51}

Among these techniques, the SEG has been the most widely adopted for both primary and secondary rhinoplasty in Asia,^52,53 because of its capacity for maximum tip projection, extensive rotation range, and ample support. However, potential drawbacks include the creation of an overly rigid and uncomfortable nasal tip and columella, particularly when the medial crura of the alar cartilage are fixed to the SEG, as this may reduce flexibility and result in an unnatural appearance during facial expressions.¹⁷ In addition, the SEG can lead to a narrow, pinched nasal tip and alar retraction,^18,54 possibly resulting in complications such as overrotation of the nasal tip, tip-columellar deviation, or tip drooping.^52,55,56

To address these concerns, the DRG technique was developed.^10,48 Using the inherent flexibility of ear cartilage grafts, the DRG offers a less rigid nasal tip and minimizes the risk of membranous septal disruption. The DRG is particularly effective for elongating the nose (even with a short caudal septum) and provides numerous advantages for tip-plasty, including correction of columellar retraction.¹⁸ However, the DRG may lack sufficient tip projection or support.⁵⁷

Literature detailing the comparative strengths and weaknesses of these techniques is scant, and their selection often depends on the preferences and familiarity of the surgeon. Previous studies have primarily focused on the efficacy of each technique independently or their various adaptations, rather than providing direct comparisons between the SEG and the DRG.⁵⁸ Although there are studies, such as those conducted by Namgoong et al.,¹³ that have focused on comparisons of SEGs using diverse sources of cartilage, and Suh et al.,¹⁵ who have investigated the distinctions between SEGs using L-strut septum versus concha extension grafts, direct comparative studies between SEG and DRG methodologies remain scarce.^59,60

Our study is the first comparative analysis of these 2 predominantly Asian tip-plasty techniques conducted by a single surgeon with relatively long-term follow-up. We observed significant improvements in NTP and CLA in both SEG and DRG groups. However, the comparative analysis indicated no significant differences between the groups in the degree of change in NTP ratios, CLA levels, or postoperative complications. Thus, this study supports the conclusion that both SEG and DRG techniques are effective for tip-plasty without significant variance in postoperative outcomes (Figs. 6 and 7).

Fig. 6.

(Left) Preoperative views of a 29-year-old woman who underwent rhinoplasty for short nose correction using an SEG. (Right) After 12 months of postoperative follow-up, satisfactory results were obtained without any clear signs of complications.

Fig. 7.

(Left) Preoperative views of a 24-year-old man who underwent rhinoplasty for short nose correction using a DRG. (Right) After 12 months of postoperative follow-up, satisfactory results were obtained without any clear signs of complications.

During postoperative evaluations, a trend toward a more rigid nasal tip was observed in the majority of SEG cases. Conversely, tips in the DRG cohort were noted to be comparatively softer. However, the precise incidence of nasal tip rigidity was not quantified because of its subjective assessment. Furthermore, the incidence of a witch’s nose deformity (a condition typically manifesting when the patient smiles) was anticipated to be more prevalent following SEG procedures than DRG procedures. However, this hypothesis remains conjectural, with only 1 instance of a witch’s nose identified among the 287 SEG cases, which occurred in a secondary rhinoplasty rather than a primary operation. To clarify the association between SEG and DRG techniques and the occurrence of witch’s nose, further in-depth research focusing on postoperative facial animation is essential.

Our study used both the Goode and the Byrd methods for NTP analysis, leveraging the Goode method’s ratio-based measurements from the nasal tip to the vermilion-cutaneous junction of the upper lip, which eliminates the need for physical measuring tools in photographic evaluations.^48,49 This method, although precise for nasal dorsum angles, overlooks lip length and overall facial height.⁶¹ In contrast, the Byrd method, by measuring NTP and nasal dorsal length, suggests an optimal two-thirds ratio for these dimensions to achieve aesthetic harmony in rhinoplasty outcomes.⁶²

Dobratz et al. observed a diminution in nasal tip projection over time, often seen when comparing short-term to long-term postoperative outcomes, primarily because of the subsidence of postsurgical edema within the first year.⁶³ Therefore, considering long-term results is crucial for accurately evaluating the effectiveness of tip-plasty techniques. However, securing long-term follow-up can be challenging, especially for patients undergoing rhinoplasty for cosmetic purposes. Our extended anthropometric evaluation included a subset of 39 individuals observed for at least 24 months, allowing for a more robust analysis of long-term surgical outcomes.

Regarding the patient assignment to either the SEG or the DRG group, it was a change in practice prompted by the need to overcome the shortcomings observed with the SEG technique. In our early years of practice in short-nose correction, we predominantly used the SEG technique. However, over time, we encountered several drawbacks with the SEG technique during longer follow-up periods, such as rigid nasal tips or nasal tip/columella deviation. To address these issues, we began using the DRG technique as an alternative to the SEG technique.

Through long-term follow-up of both procedures, we identified some unsatisfactory outcomes associated with each technique. Therefore, in the current research, we aimed to compare the SEG and the DRG, in terms of complication analysis and anthropometric analysis. We excluded cases where both SEG and DRG techniques were applied simultaneously to ensure a clear comparison between the SEG and the DRG.

The present study demonstrated that tip or columella deviation is more frequent in SEGs, while tip drooping and supratip deformity are more frequent in DRGs. However, both techniques have proven to be effective in nasal tip projection, with no significant differences in relapse. Based on our experience, to avoid any possible drawbacks from each of the 2 surgical techniques, the most important anatomical variants of the Asian nose to consider are the availability and characteristics of cartilage. When patients desire a relatively movable and soft nasal tip, our primary choice is the DRG technique. However, if the patient seeks a dramatic change in nasal tip projection and has ample septal cartilage, our preference is the SEG technique. In cases where the patient has a thick skin envelope in the nasal tip area, very small ears (thus, a small amount of conchal cartilage is available), or if the ear cartilage is too pliable, we opt for the SEG alone or in combination with a DRG. Our algorithmic approach for short-nose correction in Asian rhinoplasty, taking into consideration the patient’s desired nasal tip change, the availability of cartilages, and the characteristics of the tissue envelope such as skin thickness and the extent of extension needed, is presented in Figure 8.

Fig. 8.

The authors’ algorithmic approach to short nose correction in Asian rhinoplasty.

Our study has certain inherent limitations because of its retrospective design. In the context of elective cosmetic surgery, conducting a randomized, controlled prospective study is challenging because standardizing surgical techniques is impractical. Consequently, variations in patient surgical histories and the diverse characteristics of their tissues are confounding factors that cannot be uniformly controlled.

To address these limitations, we performed logistic regression analysis to adjust for differences in patient demographics, particularly rhinoplasty history, and excluded cases involving additional rhinoplasty procedures beyond tip-plasty. Despite these efforts, the potential effects of confounding factors, such as altered tissue texture or cartilage availability in secondary cases, cannot be eliminated entirely. Furthermore, differences in the time frames during which each technique was predominantly used may have introduced selection bias, which is inherent in the nonrandomized, retrospective nature of this study.

Future research should aim to overcome these limitations by conducting controlled prospective studies with larger patient cohorts and extended follow-up durations. Given that many postoperative nasal deformities emerge months to years after surgery, long-term follow-up is essential to evaluate and compare outcomes comprehensively. Moreover, our study population was exclusively Asian, which may limit the generalizability of our findings to individuals from other ethnic backgrounds.

Despite these considerations, our research represents the first comparative analysis of SEGs versus DRGs, the predominant techniques in Asian tip-plasty. To the best of our knowledge, no previous study has directly compared SEG and DRG techniques with a relatively long-term follow-up performed by a single surgeon, thereby minimizing biases associated with varying surgical expertise. We believe this provides valuable insights to the literature.

CONCLUSIONS

Both SEG and DRG techniques are effective for achieving long-term nasal tip projection. Tip/columellar deviation was more frequently associated with the SEG, whereas tip drooping and supratip deformity were more commonly observed with the DRG. No significant differences in tip-shortening relapse were found between the groups. Optimal technique selection should consider the patient’s desired nasal tip changes, cartilage availability, tissue envelope characteristics, and the surgeon’s expertise to minimize complications and achieve the best possible outcomes.

DISCLOSURE

The authors have no financial interests to disclose.

PATIENT CONSENT

Patients provided written informed consent for the use of their images.

ACKNOWLEDGMENT

The authors would like to express their gratitude to Soon Young Hwang, PhD, research professor at Korea University Guro Hospital, Seoul, Republic of Korea, for valuable contributions to the statistical analysis in this study.

Supplementary Material

prs-156-349e-s003.pdf ^{(8.5MB, pdf)}

prs-156-349e-s004.pdf ^{(8MB, pdf)}

prs-156-349e-s005.pdf ^{(9.5MB, pdf)}

prs-156-349e-s006.pdf ^{(5.4MB, pdf)}