Failure to control the projection, shape, and rotation of the nasal tip is a common occurrence among patients with weak lower lateral cartilages. These patients' noses are characterized by a weak midvault, a plunging tip with "Polly beak," and drawn-up alae. The purpose of our study was to identify methods for controlling the position and shape of the nasal tip in these high-risk patients. Twenty patients at risk of losing nasal tip projection were retrospectively identified, and measurements made from their preoperative and postoperative photographs were compared. Loss of tip projection occurred in all but one patient whose columella strut was fixed to the caudal septum. Prompted by these failures, we studied the relationship between the dorsum and tip in cadaveric specimens with and without a supratip break. From our observations, a structural extension of the septum-an anterior septal extension graft-was developed to predictably control this relationship. The clinical application of septal extension grafts in open rhinoplasty was subsequently evaluated in 20 patients who were deemed to be at risk of losing tip projection. Postoperative photographic analysis showed nasal tip projection to be maintained or increased in all but one patient with the use of septal extension grafts. A stable caudal septum is essential to the success of the technique.

Correcting the crooked nose remains one of the most challenging problems in rhinoplasty. When faced with a twisted nose, rhinoplasty surgeons tend to be divided into those who perform an anatomic reconstruction and those who prefer camouflage techniques. Regardless of the approach used, the revision rate remains fairly high. An anatomic correction of the twisted nose through an open approach was performed. The septum was freed from the extrinsic forces of the deformed nasal bones and upper and lower lateral cartilages. The residual true septal injury was then evaluated. The septal deformity was addressed through quadrangular cartilage resection, repositioning of the caudal septum in the anatomic midline, and correction of the dorsal septal deformity with horizontal control sutures. The skeletal support was then reconstructed with the use of a spreader-extension graft on the concave side and a batten graft on the opposite side. The nasal tip was set relative to the dorsum by fixation to the extension grafts. Residual lateral crus deformities were corrected by a combination of lateral crural spanning sutures or alar spreader grafts. With this approach, straightening the crooked nose without compromising skeletal support or nasal aesthetics was successful.

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The authors review the anatomical indications in which they found this technique to be simple, reproducible, and effective in shaping the dorsal midvault while preserving the function of the internal valve. Autospreader flap rotation should be considered when dorsal reduction is required.

Tissue expansion in children has been associated with complication rates of 20 to 40 percent. A critical analysis of 6 years' (1988-1993) experience with 180 expanders placed in 82 consecutive children was performed to identify those factors which predispose to complications. Major and minor complications each occurred in 9 percent of patients. The factors associated with a statistically significant increase in complications were burns and soft-tissue loss, patient age under 7 years, use of internal expander ports, and a history of two or more prior expansions. In addition, complications were significantly more likely to occur within the first 90 days than during any subsequent expansion. Factors that did not influence complication rate included patient gender, wound drainage upon expander insertion or removal, intraoperative use of antibiotic irrigation, number of expanders placed, use of customized expanders, and operating surgeon.