A Counterbalancing Manoeuvre on the Side-to-Side Fixated Extension Graft for Inclination Towards the Midline

Abstract

Objective: Nasal tip stabilisation is one of the key components of a successful rhinoplasty. Extension grafting is one of the most reliable techniques for tip stabilisation. If the caudal septum retains a slight tilt after septo plasty, the extension graft can be fixated on the opposite side of the septal tilt to achieve midline alignment. Despite these measures, the sidetoside fixation of an extension graft may still necessitate counterbalancing. In this study, a novel counterbalancing manoeuvre is described with its preliminary results. Materials and Methods: Primary rhinoplasty patients who had a slight tilt after septoplasty between March 2022 and April 2024 were included in this study. The patients were candidates for sidetoside fixation of a counterbalancing graft that was harvested from the basal part of the nasal septum in all patients. This specific portion of the septal cartilage thickens and widens as it nears its attachment to the vomerine bone, giving it a unique inverted drumstick appearance in the transverse plane. An L shaped or golf stick shaped graft form was created by sculpting the harvested cartilage; thus, counterbalancing was maintained with the help of this structured graft. If the tilt was towards the left, the extension graft was fixated on the right side of the septum, and the thickened base of the graft was discarded from the right side. If the tilt was towards the right, the extension graft was fixated on the left side of the septum, and the thickened base was removed from the left side. The demographic details of the patients were recorded, and the late operative outcomes of the patients were evaluated using standard photographs. Any tilts of the tip were recorded. Results: A total of 134 primary rhinoplasty operations were performed using the proposed L shaped extension graft with sidetoside fixation. Seventy six patients were female, whereas 58 were male. In 93 cases, the extension graft was fixated on the right side of the nasal septum, whereas in 41 cases, fixation occurred on the left side. The mean followup was 21 months (9–34 months). Conclusion: By using the unique anatomy of the septal base, the proposed manoeuvre enables precise coun terbalancing of the graft, ensuring stable nasal tip alignment and symmetry.