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Saddle Nose Deformity

Definition

Saddle nose deformity is a concave depression of the nasal dorsum resulting from loss of structural support of the nasal framework — bony, cartilaginous, or both — with subsequent collapse. The profile resembles the shape of a horse saddle, with depression of the mid-dorsum and a relatively prominent tip and radix.

Anatomy of the Nasal Framework

The nasal dorsum is supported by three components in continuity:

Bony vault — nasal bones
Middle vault — upper lateral cartilages (ULC) + dorsal septum (L-strut)
Lower vault — lower lateral cartilages (LLC) + columellar strut

The L-strut (dorsal + caudal limb of the septum) is the critical central support. Its destruction is the common pathway in most saddle deformities.

Normal nasal profile (lateral):
     ___
    /   \      ← Bony dorsum
   /     \___  ← Cartilaginous dorsum
  |       __/  ← Tip
   \____/

Saddle deformity:
     ___
    /   \
   /  ↓  \     ← Dorsal collapse (concavity)
  |  _  __/   ← Prominent tip
   \_____/

Aetiology

Mnemonic:ISTIC

Category	Examples
Iatrogenic	Over-resection of septal cartilage, rhinoplasty over-reduction
Septal haematoma	Untreated → avascular necrosis of septal cartilage
Trauma	Nasal fracture with disruption of L-strut
Infective / Inflammatory	Syphilis (tertiary — gumma), leprosy, TB, cocaine-induced midline destructive lesion (CIMDL), GPA (Wegener's), Relapsing polychondritis
Congenital	Congenital syphilis, chondrodysplasias
Cartilage destruction	Malignancy, septal abscess

Key exam point: Septal haematoma is the most preventable cause — urgent drainage prevents cartilage ischemia and subsequent saddle deformity.

Clinical Features

Fig 1. Saddle nose deformity (lateral view) — note the concave dorsal profile with relative prominence of the nasal tip

Saddle nose deformity lateral view — concave nasal dorsum with prominent tip

(Harrison's Principles of Internal Medicine, 22e — image courtesy Marcela Ferrada, MD)

Fig 2. Lateral profile demonstrating dorsal depression in post-rhinoplasty saddle deformity

Saddle nose deformity lateral — post-rhinoplasty dorsal concavity

(Cummings Otolaryngology, Fig 34.11)

Symptoms:

Cosmetic: dorsal concavity, tip over-rotation, columellar retraction, widened dorsum on frontal view
Functional: nasal obstruction (due to internal nasal valve collapse), septal perforation

Classification (Becker/Romo)

Grade	Involvement
Type I	Supratip soft tissue loss only
Type II	Cartilaginous vault collapse
Type III	Bony and cartilaginous vault collapse
Type IV	Combined with external skin deficit

Assessment

Full rhinological history (trauma, cocaine use, prior surgery)
Workup for systemic disease: ANCA (GPA), VDRL/TPHA (syphilis), skin biopsy (leprosy)
Nasal endoscopy — septal perforation, mucosal disease
CT scan — extent of bony vs cartilaginous loss
Standardised photography (lateral, base, frontal views)

Surgical Management

Principle: Re-establish the septal L-strut to restore dorsal height and structural integrity.

Step-wise approach:

1. Graft Material Selection (Preferred: Autologous)

Septal cartilage — first choice (limited if septum already destroyed)
Auricular cartilage — small defects
Costal (rib) cartilage — preferred for large defects requiring structural support
Calvarial bone / iliac crest — bony vault reconstruction
Alloplasts (Gore-Tex, Silastic) — if autologous unavailable; higher extrusion risk

2. Surgical Techniques

Extended spreader grafts — widen and elevate the middle vault, reconstruct the dorsal septum
Caudal septal replacement graft — re-creates the caudal L-strut
Canoe-shaped dorsal onlay graft — placed in a subperiosteal pocket; cephalic margin at nasal starting point, caudal margin at supratip; lateral edges beveled to minimize visibility
Osteotomies — to close open roof if dorsal reduction precedes augmentation
Temporalis fascia overlay — camouflages contour irregularities in thin-skinned patients

Fig 3. Intraoperative view: extended costal cartilage spreader grafts + caudal septal replacement graft reconstructing the L-strut

Intraoperative reconstruction of L-strut with costal cartilage spreader grafts

(Cummings Otolaryngology, Fig 34.13)

Staging: In severe cases with extensive septal surgery + osteotomies, a two-stage approach is preferred — structural reconstruction first, augmentation implant at second sitting.

Prevention

Drain septal haematoma within 24–48 hours
During rhinoplasty: preserve minimum 1 cm L-strut (dorsal + caudal limbs)
Avoid over-resection of cartilaginous dorsum (>3 mm reduction compromises the middle vault)

Summary Box

Aspect	Key Point
Definition	Dorsal concavity from loss of nasal framework support
Commonest preventable cause	Untreated septal haematoma
Systemic causes	GPA, syphilis, cocaine, relapsing polychondritis
Preferred graft	Autologous cartilage (rib for large defects)
Core surgical principle	Reconstruct L-strut; extended spreader + caudal replacement grafts

Sources: Cummings Otolaryngology Head and Neck Surgery; Harrison's Principles of Internal Medicine 22e; KJ Lee's Essential Otolaryngology

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