Practice Essentials
Anatomic deformities can affect both the aesthetic and functional qualities of the nose. A saddle-nose deformity is most visibly characterized by a loss of nasal dorsal height. This deformity has also been described as a pug nose or boxer's nose, both of which refer to various degrees of nasal dorsal depression. This often accompanies a shortened nose and compromised nasal support structures (see the images below). [1]
Findings typical of a moderate-to-severe saddle nose include nasal dorsal concavity, shortened vertical nasal length, and loss of nasal tip support and projection.
Patient with a history of relapsing polychondritis and severe saddle-nose deformity (type 4).
Close-up view of auricular cartilage damage secondary to relapsing polychondritis with a saddle nose in the background.
The descriptive definition of the saddle-nose deformity represents a wide range of severity. Other features commonly observed in patients with significant saddle-nose deformities include the following:
-
Depression of the middle vault and dorsum
-
Loss of nasal tip support and definition
-
Shortened (vertical) nasal length
-
Overrotation of the nasal tip
-
Retrusion of the nasal spine and caudal septum
Workup in saddle-nose deformity
The standard series of photographs should be obtained prior to surgical planning for rhinoplasty. Endoscopic nasal examination can facilitate an accurate survey of the endonasal structures.
Management of saddle-nose deformity
Depending on the degree of saddling, different reconstructive options can be used. For patients with no nasal airway obstruction and minor-to-moderate nasal dorsal saddling, onlay grafting techniques can be used.
Fundamental to reconstructing the moderate-to-severe saddle nose is restoring middle vault function, reversing any internal valve narrowing, and reinforcing nasal tip and dorsal support mechanisms. The placement of spreader grafts is usually sufficient to address the internal nasal valve and middle vault collapse.
The reconstitution of dorsal-caudal and tip support structures can be achieved using the concept of the dorsal L-shaped strut, that is, the L-shaped dorsal-caudal nasoseptal support structure that should be present in the nose. An intact septum in the normal, nontraumatized nose sufficiently serves this function. In the structurally compromised nose, new support structures must be constructed.
History of the Procedure
The oldest recorded text on the diagnosis and treatment of nasal deformities can be found in the Edwin Smith surgical papyrus from ancient Egypt, which dates to some 30 centuries ago. In approximately 800 BC, Ayur Veda of Sushruta (India) described a nasal reconstruction approach based on the transfer of a pedicled forehead skin flap. In the 16th century, Tagliacozzi of Bologna, Italy, used brachial-based delayed flaps to reconstruct the nose.
The science and art of rhinoplasty, as understood by most surgeons, remained essentially stagnant until the 19th century. In the 1840s, approaches to correcting nasal dorsal concavities were used by early pioneers, including Dieffenbach, who used a buried forehead flap to cover the nasal dorsum. The first paper on the treatment of the saddle nose can be attributed to John Orlando Roe's original article in 1887, "The deformity termed 'Pug-Nose' and its correction, by a simple operation." [2] In 1892, Robert F. Weir published his techniques for correcting the saddle nose. [3] In 1896, Israel applied a tibial bone graft to the nose. Treatment of the saddle-nose deformity tested the creativity of early nasal surgeons like Jacques Joseph. The treatment of saddle-nose deformities has continued to benefit from the contributions of countless pioneers in nasal surgery.
An image depicting saddle-nose deformity can be seen below.
Findings typical of a moderate-to-severe saddle nose include nasal dorsal concavity, shortened vertical nasal length, and loss of nasal tip support and projection.
Problem
Anatomic deformities can affect both the aesthetic and functional qualities of the nose. A saddle-nose deformity is most visibly characterized by a loss of nasal dorsal height. This deformity has also been described as a pug nose or boxer's nose, both of which refer to various degrees of nasal dorsal depression. This often accompanies a shortened nose and compromised nasal support structures (see the images below). [1]
Findings typical of a moderate-to-severe saddle nose include nasal dorsal concavity, shortened vertical nasal length, and loss of nasal tip support and projection.
Patient with a history of relapsing polychondritis and severe saddle-nose deformity (type 4).
Close-up view of auricular cartilage damage secondary to relapsing polychondritis with a saddle nose in the background.
The descriptive definition of the saddle-nose deformity represents a wide range of severity. Other features commonly observed in patients with significant saddle-nose deformities include the following:
-
Depression of the middle vault and dorsum
-
Loss of nasal tip support and definition
-
Shortened (vertical) nasal length
-
Overrotation of the nasal tip
-
Retrusion of the nasal spine and caudal septum
Epidemiology
Frequency
The prevalence of saddle-nose deformities is difficult to assess. The prevalence is higher in population groups prone to facial trauma (ie, boxers, criminals, athletes), in persons with a history of intranasal cocaine use, and in individuals with a history of nasal surgery (eg, radical submucous septal resection, reductive rhinoplasty). A flat or concave nasal dorsal contour can resemble a saddle nose and is more prevalent in certain familial and racial groups. Some saddled noses may be more subtle, owing to thickened nasal skin soft-tissue envelope.
Etiology
A saddle-nose deformity can be congenital or acquired. Various degrees of nasal dorsal depression can be noticed as a part of individual, familial, syndromic, and racial characteristics. Most saddle-nose deformities are acquired. A common theme in all acquired saddle-nose deformities is a structural compromise of the nasoseptal cartilage leading to decreased dorsal nasal structural support. The most common causes of saddle-nose deformities are traumatic and iatrogenic.
Trauma
Direct trauma to the nose can fracture the cartilaginous and/or bony septum, hence compromising important support structures. [4] Nasal bone depression due to trauma can also lead to a depressed dorsum. An unrecognized posttraumatic septal hematoma may become infected, causing irreversible cartilage damage and loss of support. In a study by Jalaludin, saddling was noted in 14% of patients with unrecognized or untreated septal abscesses. [5] In that study, the leading cause of a nasal septal abscess was trauma. Birth-related nasoseptal trauma can also appear with various degrees of nasal deformity that may be erroneously labeled as being congenital.
Surgical causes
Changes made to the nose after rhinoplasty or submucous resection of septal cartilage can result in a number of undesirable deformities, including a saddle-nose deformity. Tzadik and colleagues noted that, depending on the surgeon's skill, saddling rates varied from 0% to 2.6% (average, 0.4%) in patients who had undergone submucous resection of the nasal septum. [6]
Overresection of septal cartilage can lead to collapse of the middle vault and saddling. Removing too much septal cartilage can compromise the structural integrity of the dorsal L-shaped strut and increase the probability of postoperative or traumatic saddling of the nasal dorsum. No cartilage should be resected anterior to an imaginary vertical line drawn from the rhinion (osseocartilaginous junction) to the nasal spine. During septal cartilage resection, leaving a minimum of a 10-mm dorsal-caudal L-shaped margin of cartilage is important. Arching the incisions, instead of creating right-angled corners, can also impart slightly greater structural integrity to the dorsal L-shaped strut.
Surgical overreduction of a nasal dorsal hump can produce an overly concave nasal dorsum. Additionally, an unidentified open roof deformity can further contribute to middle vault depression. Disharmonious changes in the nasal contour (eg, an overly projected nasal tip, an exaggerated supratip break) can also impart the impression of saddling. Inadequate support of the upper lateral cartilages and the middle vault may lead to its settling and relative saddling of the middle vault with time.
A study by Eweiss suggested that the use of spreader grafts or flaps in rhinoplasty could be a risk factor for the development of saddle-nose deformity. In a cohort of 80 patients who underwent a spreader graft and/or flap procedure, five (6.25%) were seen to have postoperative saddle-nose deformity. [7]
A case-control study by Lee et al indicated that in patients who undergo septoplasty, risk factors for intraoperative saddle-nose deformity include female sex (odds ratio [OR] = 3.39), severe caudal septal deviation (OR = 2.22), and the intraoperative discovery of fractured septal cartilage (OR = 3.96). [8]
Medical causes
A number of medical conditions affecting the nose can result in damage to the septum and cartilaginous structures. The common pathway is damage to the cartilage; compromise in the structure; and various degrees of subsequent nasal dorsal saddling, as clinically observed. A number of conditions can affect the nasal septum and lead to a saddle-nose deformity.
-
Relapsing polychondritis
-
Leprosy (Hansen disease)
-
Syphilis
-
Ectodermal dysplasia
Intranasal cocaine use leading to large septal perforation and cartilage loss can also produce saddling of the nose.
Wegener granulomatosis is characterized by necrotizing granulomas and vasculitis of the upper and lower respiratory tracts, including the nasal septum. The cycle of necrotizing granulomatous lesion and microabscess formation leads to cartilage destruction.
In relapsing polychondritis (see the images below), recurrent episodes of autoimmune cartilage inflammation and destruction result in damage to the cartilaginous structure of the ears, nose, larynx, trachea, and peripheral joints. In this rare disease, fibrotic tissue replaces collagen, elastin, and other matrix proteins found in normal cartilage; this process leads to the loss of healthy cartilage. [9] Ferrada et al divided relapsing polychondritis into three subgroups, with type 1 alone characterized by saddle-nose deformity. Patients in this subgroup also displayed ear chondritis, tracheomalacia, and subglottic stenosis, as well as the highest disease activity. [10]
Patient with a history of relapsing polychondritis and severe saddle-nose deformity (type 4).
Close-up view of auricular cartilage damage secondary to relapsing polychondritis with a saddle nose in the background.
Overall, Hansen disease, or leprosy, is rare in the United States. However, it may be more common in the Gulf states (Texas and Louisiana), and it is endemic in certain areas of the world. The nasal mucosa is frequently involved, and septal ulceration and perforations are common. Nasal deformities, including saddling, are common in advanced cases.
Syphilis can cause intranasal ulcerative lesions that can lead to osteochondritis; cartilage damage; and, eventually, saddle-nose deformity.
Pathophysiology
General findings
Patients with saddle-nose deformities may have various degrees of nasal obstruction. Middle vault collapse is commonly observed in moderate-to-severe saddle noses. The inferomedial collapse of the upper lateral cartilages and corresponding narrowing of the internal nasal valve can produce significant obstruction that impairs nasal breathing. Large septal perforations often result in nasal saddling. Saddle-nose deformities with septal perforations can appear with nasal crusting, nasal obstruction, and whistling upon nasal airflow. In individuals in whom nasal airway compromise is noted, nasoseptal reconstruction should address important functional, as well as aesthetic, deficits of the patient's nose. An exact understanding of the deformity and dysfunction can allow for the proper selection of the best reconstructive option.
Classification
Regardless of the etiology, categorizing the severity of the saddle nose is helpful. The authors use a simplified system that classifies saddle-nose deformities on the basis of the anatomic deficits (see the image below), as follows:
Saddle-nose classification based on anatomic deficits. (1) Normal nose, appropriate nasal dorsal height, tip projection, and vertical nasal height. (2) Type 1 saddle-nose deformity, minor supratip or nasal dorsal depression, with normal projection of lower third of the nose. (3) Type 2 saddle-nose deformity, depressed nasal dorsum (moderate to severe) with relatively prominent lower third. (4) Type 3 saddle-nose deformity, depressed nasal dorsum (moderate to severe) with loss of tip support and structural deficits of the lower third of the nose. (5) Type 4 saddle-nose deformity, catastrophic (severe) nasal dorsal loss with significant loss of the nasal structures in the lower and upper thirds of the nose.
See the list below:
-
Type 1 - Minor supratip or nasal dorsal depression, with a normal projection of lower third of the nose
-
Type 2 - Depressed nasal dorsum (moderate to severe) with relatively prominent lower third
-
Type 3 - Depressed nasal dorsum (moderate to severe) with loss of tip support and structural deficits in the lower third of the nose
-
Type 4 - Catastrophic (severe) nasal dorsal loss with significant loss of the nasal structures in the lower and upper thirds of the nose
Most patients with a type 2, 3, or 4 saddle-nose deformity have functional nasal airway obstruction.
A practical classification method described by Tardy divides saddle-nose deformities into 3 categories, as follows:
-
Minimal - Supratip depression greater than the ideal 1-2 mm tip-supratip differential
-
Moderate - Moderate degrees of saddling due to loss of dorsal height of the quadrangular cartilage, usually with septal damage
-
Major - More severe degree of saddling with major cartilage loss and major stigmata of a saddle-nose deformity
Presentation
Complete history taking and physical examination is an important first step in evaluating the patient with a saddle-nose deformity. In particular, the history should include an investigation of the suspected etiology of the deformity, any history of nasal airway obstruction, any history of antecedent nasal trauma, the number of previous nasal surgeries, and any history of any autoimmune diseases. The use of intranasal cocaine or heroin should be investigated in patients with nasoseptal perforations.
Upon physical examination, the degree and location of saddling, the state of the nasal septum, the status of the internal and external nasal valves, and the structural integrity of the nasal support structures must be evaluated. A higher rate of septal perforations is found in patients who have a saddle noses. Endoscopic nasal examination can facilitate an accurate survey of all endonasal structures. The standard series of photographs should be obtained prior to surgical planning for rhinoplasty.
Indications
Indications for nasal reconstruction must be tempered by patient selection, the surgeon's experience, and the etiology of the deformity. Indications for surgery can be functional, aesthetic, or, most commonly, both. Examples are as follows:
-
Nasal airway obstruction secondary to middle vault collapse and/or incompetency of the internal or external nasal valve in a patient with a saddle-nose deformity
-
Nasal airway obstruction secondary to perforation of the loss of septal cartilage in the patient with a saddle-nose deformity
-
The patient's desire for aesthetic improvement
Relevant Anatomy
In-depth knowledge of the nasal anatomy is essential. The morphologic changes observed in a saddle nose are due to the loss of nasal skeletal support structures. These pathologic processes are discussed in the Pathophysiology section. The osseocartilaginous support framework includes the nasal bones, the upper and lower lateral nasal cartilages, the septum, the premaxilla, and their attachments to each other (see the first image below). The nasal septum plays a robust role in supporting the middle and lower thirds of the nose (see the second image below).
Nasal anatomy. The shape and function of the middle and lower thirds of the nose depend on the integrity of the nasal septum and on the quality and shape of the upper and lower lateral cartilages.
Lateral view of the nasal septum. The primary support for nasal dorsal height and tip projection is determined by the size and integrity of the nasal septum.
Contraindications
Persons with contraindications for repairing a saddle-nose deformity include the following:
-
Patients with malignant, chronic, or autoimmune disease conditions (eg, relapsing polychondritis) in whom the reconstructed nose is at risk for continuing damage
-
Persons who abuse drugs intranasally and who have not demonstrated at least 12 months of sobriety (Nasal reconstruction is contraindicated in patients who have not definitively demonstrated complete rehabilitation from their substance abuse.)
-
Patients who are poor candidates for rhinoplasty in general, including unhealthy patients with poor perioperative risk profile and patients whose ability to follow the postoperative care regimen is limited (ie, patients with severe schizophrenia)
-
Patients with unrealistic expectations
Patients with relative contraindications include the following:
-
The patient with multiple previous rhinoplasties who now has scarred-down thin skin (The history of smoking or an unrealistic expectation by such a patient can also serve as reason[s] to delay or dissuade the patient from surgery.)
-
Aesthetic rhinoplasty in patients younger than 16 years
-
Patients who are expected by habit or profession (mixed martial artists, boxers) to experience repeated nasal trauma
-
Findings typical of a moderate-to-severe saddle nose include nasal dorsal concavity, shortened vertical nasal length, and loss of nasal tip support and projection.
-
Patient (former boxer) with moderate-to-severe (type 3) saddle-nose deformity.
-
Patient with a history of relapsing polychondritis and severe saddle-nose deformity (type 4).
-
Close-up view of auricular cartilage damage secondary to relapsing polychondritis with a saddle nose in the background.
-
Saddle-nose classification based on anatomic deficits. (1) Normal nose, appropriate nasal dorsal height, tip projection, and vertical nasal height. (2) Type 1 saddle-nose deformity, minor supratip or nasal dorsal depression, with normal projection of lower third of the nose. (3) Type 2 saddle-nose deformity, depressed nasal dorsum (moderate to severe) with relatively prominent lower third. (4) Type 3 saddle-nose deformity, depressed nasal dorsum (moderate to severe) with loss of tip support and structural deficits of the lower third of the nose. (5) Type 4 saddle-nose deformity, catastrophic (severe) nasal dorsal loss with significant loss of the nasal structures in the lower and upper thirds of the nose.
-
Nasal anatomy. The shape and function of the middle and lower thirds of the nose depend on the integrity of the nasal septum and on the quality and shape of the upper and lower lateral cartilages.
-
Lateral view of the nasal septum. The primary support for nasal dorsal height and tip projection is determined by the size and integrity of the nasal septum.
-
Conchal cartilage can be used as layered or sandwich grafts to fill defects on the nasal dorsum and to reconstruct columellar support.
-
Spreader grafts are rectangular sculpted pieces of cartilage placed between the upper lateral cartilages and septum. They serve to widen the internal nasal valve, widen the middle vault, and prevent collapse of flail upper lateral cartilages. Also, they can provide additional support to the dorsum.
-
Rib cartilage can be sculpted to serve as an onlay graft to augment the nasal dorsal contour.
-
A columellar strut can be assembled with a boat-shaped dorsal graft to reconstruct dorsal-columellar L-shaped strut. Rib cartilage can be used to carve both components of the graft.
