Septal Extension Graft
This page is intended as general information for patients and practitioners with an interest in rhinoplasty technique. It does not constitute medical advice. All cosmetic surgery involves risks and individual results vary.
The septal extension graft is the most versatile structural tool in tip rhinoplasty. A single piece of cartilage — fixed to the caudal end of the nasal septum and extending toward the nasal tip — can set tip projection, control tip rotation, lengthen or shorten the nose, correct asymmetry, stabilise the lateral crura, and provide a rigid midline platform for dome modification. No other graft in rhinoplasty accomplishes so many objectives simultaneously from a single construct.
Understanding the septal extension graft in detail is important for any patient considering rhinoplasty involving significant tip work — it is the graft most likely to be used, and its placement determines the structural foundation on which the final nasal tip rests for the remainder of the patient’s life.
Anatomy and Structural Logic
The nasal tip is supported by a tripod — two lateral crura extending toward the alar rims, and the conjoined medial crura descending to the columella. In the native nose, the tip’s position, projection, and rotation are determined by the length, strength, and orientation of these crural limbs and by the position of the caudal septum to which the medial crura attach.
In rhinoplasty, when the surgeon modifies the tip — dividing domes, reducing or augmenting projection, correcting rotation, narrowing the tip — the native structural relationships are disrupted. The tip cartilages, once freed from their attachments, can drift. Swelling and scar contracture during healing apply unpredictable forces. Without a rigid structural anchor, the final tip position cannot be reliably controlled.
The septal extension graft solves this problem by creating a fixed, stable midline platform. By attaching the medial crural footplates — or the newly constructed tip complex — to a graft that is itself rigidly fixed to the septum, the surgeon establishes a structural foundation that resists the contractile forces of healing and holds the tip in its planned position as the nose settles over twelve to eighteen months.
Septal extension graft — schematic showing graft placement and fixation to the caudal septum. View full image →
Graft Design and Fixation
The septal extension graft is harvested from the nasal septum — the same operation that provides access to the caudal septum via an open rhinoplasty approach also provides direct access to the posterior quadrangular cartilage, which is the preferred donor site. The graft is shaped as a rectangle or trapezoid, typically 15–25 mm in length and 8–12 mm in width, with the dimensions determined by the degree of tip change required and the available donor cartilage.
Fixation to the existing caudal septum is achieved with mattress sutures through overlapping cartilage — the graft is placed end-to-end or in an overlapping configuration depending on the original caudal septal position and the surgeon’s preference. The overlapping configuration provides greater rigidity and stability than end-to-end placement, at the cost of slightly greater thickness at the junction point. Multiple sutures at different levels prevent rotation and rocking of the graft.
Where septal cartilage is insufficient — revision cases, prior septoplasty, or cocaine-related destruction — ear cartilage or rib cartilage may be used. Rib cartilage provides the greatest rigidity but requires careful carving to prevent warping. Irradiated cadaveric rib allograft is an option in appropriate cases, avoiding the donor site morbidity of autologous rib harvest.
Clinical Applications
1. Setting tip projection
Tip projection — the distance the tip protrudes from the face — is determined by the length of the medial crura and their attachment point to the caudal septum. By extending the caudal septum forward with a septal extension graft, the medial crura are effectively lengthened — the new attachment point is more anterior, and the tip protrudes further. Conversely, by placing the graft to hold the medial crura at a more posterior position, projection can be reduced. The degree of projection change is directly controlled by the length of the graft and the position at which the medial crural footplates are sutured to it.
2. Controlling tip rotation
Tip rotation — the degree to which the tip points upward or downward — is controlled by the angle of the graft relative to the dorsal septum. A graft angled caudally (downward) rotates the tip downward, lengthening the nose. A graft angled cephalically (upward) rotates the tip upward, shortening the apparent nasal length. In patients with a drooping or ptotic tip — one of the most common tip complaints in the Australian patient population — a septal extension graft set at a slightly cephalic angle provides controlled, stable tip elevation that holds through the healing process.
3. Nasal lengthening
The short nose — characterised by excessive tip rotation, a short upper lip, and visible columellar show — is one of the more challenging deformities in rhinoplasty, particularly in the revision setting where scarring and contracture resist lengthening. The septal extension graft is the primary structural tool for nasal lengthening. By extending the caudal septum inferiorly and anteriorly, it repositions the tip-columella complex downward and forward, reducing tip rotation and increasing nasal length. The stability of the construct is critical — without a rigid anchor, the contractile forces of healing will pull the lengthened tip back upward.
4. Deprojection
In the over-projected nose — where the tip protrudes excessively from the face — deprojection requires not only reducing the length of the medial crura but ensuring the shortened tip is held at its new position. A septal extension graft placed at the appropriate length provides the fixed reference point to which the repositioned medial crura are sutured. Without this anchor, the deprojected tip has no stable structure to rest against and may drift back toward its original position as the nose heals.
5. Providing a midline anchor for dome division
Dome division — the transection of the lower lateral cartilages at the dome to allow independent repositioning of the tip-defining points — is a powerful technique for tip narrowing and symmetry correction. Once the domes are divided, however, the tip cartilages are free-floating structures. The septal extension graft provides the rigid midline reference to which the divided and repositioned dome segments are sutured. Each dome is fixed to the graft at the precise position determined by the surgical plan — the inter-dome width, the tip projection, and the degree of tip definition are all set at this suturing step. The graft converts what would otherwise be an unstable, unpredictable construct into a fixed, three-dimensional structure.
6. Tensioning the lateral crura — Lateral Crural Tensioning (LCT)
In the bulbous or boxy tip, the lateral crura are often convex — bowed outward and laterally oriented rather than directed toward the alar rims. Narrowing this type of tip requires repositioning the lateral crura medially and cephalically, and tensioning them against a fixed medial reference point. The septal extension graft provides that reference point.
In the lateral crural tensioning technique — Dr Roth’s preferred approach for bulbous and boxy tip correction — the lateral crura are released from their scroll and soft tissue attachments, the medial crura are fixed to the septal extension graft at the desired projection and rotation, and the lateral crura are then drawn medially and fixed under tension. This simultaneously flattens the convexity of the lateral crura, narrows the inter-dome width, improves tip definition, and reduces alar convexity. The septal extension graft is what makes the tensioning mechanically possible — without a rigid midline anchor, there is no fixed point against which the lateral crura can be tensioned.
7. Correcting tip asymmetry
Tip asymmetry — whether from asymmetric native anatomy, asymmetric prior surgery, or trauma — is reliably corrected only when both domes are fixed to a common rigid midline structure. The septal extension graft provides this common reference. Each dome is sutured to the graft independently, allowing the surgeon to set each dome’s position precisely and symmetrically. The result is a tip construct where the inter-dome width, each dome’s height and projection, and the overall tip position are set by suture rather than left to the unpredictable forces of healing.
8. Stabilising the columella and nasal base
The columella — the strip of tissue between the nostrils — is supported by the medial crura. When the medial crura are mobile or weakened, the columella can retract or deviate during healing. By fixing the medial crura to the septal extension graft, columellar stability is maintained throughout the healing process, supporting a straight, centrally positioned columella and symmetric nostril sill.
The Septal Extension Graft in Revision Rhinoplasty
Revision rhinoplasty presents particular challenges for the septal extension graft. Prior surgery may have depleted septal cartilage, scarred the tissue planes around the caudal septum, or left a shortened, stiffened nasal skin envelope that resists the tip changes being planned. Despite these challenges, the septal extension graft remains the structural foundation of revision tip work.
Where septal cartilage is unavailable, rib cartilage — either autologous or irradiated cadaveric allograft — provides the rigidity required. The carved rib graft is fixed to the remnant caudal septum or, where the septum is absent, to the anterior nasal spine directly. The fixation must be secure — in revision surgery the contractile forces the construct will face during healing are greater than in primary cases, and a loosely fixed graft will fail.
The short nose following over-aggressive primary rhinoplasty — one of the most challenging revision deformities — requires a long septal extension graft, often of rib cartilage, placed under significant tension against a scarred skin envelope. This is technically demanding work and the outcomes, while meaningful, are less predictable than in primary rhinoplasty. Honest counselling about realistic expectations is essential.
Septal Extension Graft vs Columellar Strut
The columellar strut is a simpler and more widely used graft — a piece of cartilage placed between the medial crural footplates to provide columellar support and modest projection increase. It is not fixed to the septum and does not rigidly set tip position. It is appropriate for cases requiring columellar support and minor projection augmentation, but it does not provide the precise, stable tip control that the septal extension graft achieves.
In Dr Roth’s practice, the columellar strut is used for less complex tip cases where structural support rather than significant position change is the goal. The septal extension graft is used wherever precise control of tip projection, rotation, or position is required — which in practice means the majority of cases involving significant tip work.
Dr Roth’s Clinical Perspective
The septal extension graft has become the foundation of tip rhinoplasty in my practice — and I think it is the single most important technical development in rhinoplasty of the past twenty years. The ability to set tip position with a suture to a fixed midline structure, rather than relying on the inherently unpredictable behaviour of free cartilage during healing, changes what is achievable and how consistently it can be reproduced.
The lateral crural tensioning application is where I find it most powerful. The bulbous, boxy tip — which is the most common tip concern I see in Australian patients — requires the lateral crura to be repositioned and held under tension. You cannot do that without a rigid midline anchor. The SEG gives you that anchor, and the combination of SEG with lateral crural tensioning produces consistent, durable tip narrowing and definition that holds over years rather than months.
Patients sometimes ask whether they need cartilage grafts and whether that makes the surgery more complicated. The honest answer is that a well-placed septal extension graft makes the surgery more predictable, not more complicated — it is the structure that allows me to position the tip precisely and confidently rather than hoping the healing process cooperates.
— Dr Jason Roth, MBBS, FRACS (ORL-HNS), IBCFPRS
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Specialist Otolaryngologist & Head and Neck Surgeon
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