Innovative septum suspension technique with a cantilever graft for effective keystone region reconstruction

Saddle nose deformity caused by disruption of the keystone area remains surgically challenging. We developed a septum suspension technique using a rib bone cantilever graft to restore keystone continuity and improve airflow.

We retrospectively reviewed 41 consecutive cases (2016-2024) undergoing the suspension technique. Deformity type, etiology, concomitant procedures, complications, and CT findings were recorded. Outcomes included visual analogue scale (VAS) scores for nasal ventilation and appearance, and radiological evaluation of graft integrity. Paired analyses were conducted at 12 months using Wilcoxon tests, Hodges-Lehmann estimates, effect sizes, and sensitivity analysis (≥6 months).

The cohort comprised 31 men and 10 women (mean age 38.5 years). Ventilation VAS improved from 2.0 to 9.0 (HL +7.0; p < 0.01) in nine paired cases, with very large effect sizes (Hedges' g = 3.01). All patients achieved the minimal clinically important difference (MCID). Appearance VAS improved from 3.0 to 10.0 in four paired cases (HL +7.0), with all reaching MCID, though underpowered for significance. Sensitivity analyses confirmed consistent improvements. Complications occurred in five patients (trauma, n = 1; screw loosening, n = 3; hypertrophic donor-site scarring, n = 1). No pneumothorax or infection was observed.

Septum suspension with a rib-bone cantilever graft provided substantial and robust improvement in nasal ventilation, with aesthetic gains also observed. The technique was particularly useful in post-septoplasty saddle nose. Despite limitations of sample size and incomplete follow-up, findings suggest this method is a safe and effective option warranting validation in larger prospective studies.