A saddle nose deformity derives its name from the appearance of the nose on lateral view as the dorsal curve resembles the depression in a horse’s saddle. The gross deficiency that exists in the dorsum of the nose, no matter the etiology, creates an obvious and progressive scooped-out deformity. When viewed frontally, an illusory excessive width exists across the bridge. The first paper written on the treatment of saddle nose deformity was John Orlando Roe’s original article in 1887, “The deformity termed ‘Pug-Nose’ and its correction by a simple operation.” The first attempt at correction of saddle nose deformity occurred when Robert F. Weir implanted the breastbone of a duck into the shrunken nose of a syphilitic patient in 1892. In 1896, Israel was the first to use a human bone graft to the nose. Many authors have published articles detailing the etiology, classification, and treatment of this deformity. Most recently, Daniel and Brenner published a classification of saddle nose deformity with a focus on septal saddling. In this article, the authors describe their approach to the treatment of these deformities as they address each component separately.
The term “saddle nose deformity” is a pathologic entity resulting from loss of dorsal height, caused by a substantial decrease in the cartilaginous vault and/or bony vault. It may include any of a variety of features: (1) middle vault and dorsal depression, (2) loss of tip support and definition, (3) columellar retrusion, (4) shortened vertical length, (4) tip overrotation, and (5) retrusion of the nasal spine and caudal septum. Regardless of the etiology, the central underlying defect is lost integrity of the bony and cartilaginous dorsum resulting in a short nose with compromised support.
Saddle nose deformity can occur following a variety of nasal pathologic conditions. The majority of saddle nose deformities are acquired (secondary to trauma, septal hematoma, septorhinoplasty to correct traumatic injuries, cocaine abuse, infection, and cosmetic septorhinoplasty), but congenital causes do exist (i.e., Binder syndrome). Although it is difficult to assess the true prevalence of nasal saddling in any given population, certain groups of patients seem to be particularly prone. Facial trauma victims, cocaine abusers, and patients who have undergone previous septorhinoplasty, particularly following traumatic injury, seem to be at highest risk.
No matter which classification system is followed, nasal saddling exists along a spectrum. Tardy has described a three “M” category classification system: minimal, moderate, and major. Minimal saddling demonstrates modest tip–supratip differential with a supratip depression greater than the ideal 1 to 2 mm. The bony nasal hump is mildly accentuated, the nose is wide, and minimal columellar retraction exists. Moderate saddling shows depression secondary to lost dorsal height in the quadrangular cartilage. Columellar retraction results in an acute nasolabial angle. Major saddling is a more severe deformity often secondary to massive blunt frontal trauma, resulting in a twisted nose with severe septal deviation. Vartanian categorized saddling into four types, based on the degree of existing anatomic deficit. Type 1 describes minor supratip or dorsal nasal depression with preservation of lower third projection. Type 2 has moderate to severe dorsal depression with a prominent lower third. Type 3 has moderate to severe dorsal depression and lower third deficits resulting in loss of tip support. Type 4 refers to a pan-nasal defect with severe middle nasal dorsal deficiency, in combination with deficits of the upper and lower thirds.
Daniel recently expanded on these earlier classification systems, attempting to integrate the external appearance of the nose, the degree of compromise of septal support, and selection of surgical treatment into what is referred to as septal saddle nose . Septal support is determined by pressing the nasal tip inward — if the tip remains supported, then septal support is adequate; if the tip compresses against the premaxilla, then the support is inadequate. This classification system thus consists of a subset within the broader saddle nose classification systems and is defined by the combination of a dorsal depression and inadequate septal support:
Type 0 (Pseudosaddle)
These patients present with depression of the cartilaginous vault following a prior rhinoplasty and is invariably due to overresection of the cartilaginous vault, a relative depression of the cartilaginous dorsum due to a prominence of the bony vault, or a combination of the two. The etiology is not due to lost septal support but rather to aggressive dorsal changes. Septal support is excellent and there is a negative septal support test.
Type I (Minor—Cosmetic Concealment)
These cases have excessive supratip depression and columellar retraction but normal septal support. Cosmetic concealment is possible provided the septal compromise is static and not progressive.
Type II (Moderate—Cartilage Vault Restoration)
The dominant factor is compromise of septal support, which leads directly to cartilaginous vault collapse, columellar retraction, and loss of tip support.
Type III (Major—Composite Reconstruction)
In major cases, there is a total absence of septal support for the cartilaginous vault, columellar, nasal tip, and external valves. Flattening of the nose is obvious in all views.
Type IV (Severe—Structural Reconstruction)
These cases represent the end stage of septal collapse. They are compounded by bony vault disruption and severe contracture of the nasal lining often associated with major septal perforations. Septal collapse has occurred resulting in cartilage vault depression and columellar shortening. The nasal tip has lost its projection and the nostrils are broad. There is no support to the vestibular and nostril valves with dramatic compromise of the external airway. The nasal loblule is often rotated upward. The nose is short in absolute terms and further emphasized by an acute nasolabial angle. Depression of the bony vault is a major factor that may limit support for the reconstruction.
TYPE V (Catastrophic—Nasal Reconstruction)
The majority of these cases have progressed from reconstructive aesthetic rhinoplasty to aesthetic reconstruction of the nose and its adjacent tissues. Many will require forehead flaps for either lining or skin coverage. Equally significant, the bony deformity extends farther into the facial skeleton, warranting some type of degloving approach and extensive bone grafting and/or plating. These cases are best referred to surgeons who have a high degree of special expertise.
The surgical correction of saddle nose deformity should be approached and planned in the same intricate manner as any major nasal reconstruction case. Burget and Mennick have worked extensively to develop an algorithmic approach to rebuilding complex nasal defects. Preoperative deficiencies in bony and cartilaginous support, internal nasal lining, and external coverage must all be determined. Less severe deformities, where supporting structures remain strong, can be simply treated with dorsal onlay grafts. When upper lateral cartilage weakness exists, middle vault integrity must be reestablished. Spreader grafts help restore the internal nasal valve ( Figures 23-1 and 23-2 ); severe upper lateral cartilage collapse may require replacement Batten grafts. Obviously every patient will be unique in all of these categories, dictating a slightly different plan for each operation. The basic components to consider follow:
Reestablishing support: When the quadrangular cartilage is no longer able to support the nasal roof, it must be either buttressed or, better yet, replaced. Autologous rib cartilage is the ideal material for this purpose since it is abundant in supply and extremely strong in form.
Addressing the airway: As the degree of saddling becomes more severe, there appears to be an increasing need for restoration of both the internal and external nasal valves. Spreader grafts must be used as part of the reconstruction, frequently in concert with the septal support and/or replacement grafts. When external valve collapse occurs or the upper lateral cartilages are no longer sufficient, batten grafts should be used to reestablish the requisite support. With severe scarring, as occurs in the multiply operated patient and the advanced cocaine nose, large batten grafts from the eighth costal cartilage frequently work the best. For patients with compromised nasal lining and alar retraction, skin–cartilage ear composite grafts work well to augment the lining and prevent recurrent retraction. In severe cases, the addition of alar rim grafts may be necessary.
The nasal tip: Support is essential. With the exception of septal replacement grafts, the columellar strut is the most important determinant of long-term tip support and projection ( Figure 23-3 ). In saddle noses, the scarring is severe and ear cartilage clearly lacks the requisite strength to resist the inevitable contractile forces of the skin envelope. A large post of costal cartilage works extremely well as a columellar strut. For the best aesthetic reconstruction, it is wise to place this graft as a stand-alone graft instead of incorporating it or attaching it to the septal replacement graft. Once the support is reestablished, then the tip structure can be defined by either suturing the existing alar cartilages or replacing them with tip grafts.