Saddle nose & nasal reconstruction.

With a saddle nose the bridge — usually in the middle and lower third — has collapsed. In profile the characteristic “saddle” appears, the nose looks shortened and the tip is often raised. The cause is a lack of supporting structure: cartilage or bone that would normally hold the nose in shape is missing or has lost stability.

The reasons range from accidents and injuries through previous operations to inflammatory diseases or a constitutional weakness. Because the support of the nose also carries its function, a saddle nose is not infrequently associated with obstructed breathing.

The nose stands not because its skin is taut but because a framework carries it from within. The most important element of this framework is the nasal septum: a plate of cartilage and bone standing vertically in the middle. Its front and its upper margin together form an L-shaped strut — it holds the nose bridge at height and the nasal tip in position. If this strut gives way, the nose collapses in on itself.

That is precisely what a saddle nose is. The nose bridge sinks, above all in the middle and lower third, and the characteristic hollow appears in profile. Because the support also holds the tip, the tip frequently rotates upwards with it; this makes the nose look additionally shortened and the nostrils more visible from the front. In pronounced cases the alar base also widens, because the collapsed framework pushes the soft tissue outwards.

Three degrees of severity are broadly distinguished, and they call for very different operations. Mild: only the line of the nose bridge has sunk, the load-bearing structure is intact at its core — here an onlay of cartilage is often enough to restore the profile. Moderate: the strut has lost height and the tip is affected as well — this requires building up and fresh support for the tip. Pronounced: the load-bearing L-strut is largely lost — it has to be rebuilt, as a rule from rib cartilage, because only rib cartilage provides the necessary quantity and firmness.

We make this assessment during the examination — from the outside, from the inside and by palpation. It determines the extent of the work, the source of cartilage, the duration of the operation and the period within which you can expect the final result.

The most important distinction with a saddle nose is the one between filling and carrying. A hollow on the nose bridge can be evened out visually with an onlay — that looks good at first, but it does not change the fact that the nose no longer has any support on the inside. Over the years it sinks further, the nasal tip rotates further upwards, and the onlay becomes visible as a foreign body beneath thin skin. Our principle is therefore this: we rebuild the strut, not the surface.

Rebuilding the L-strut. If the load-bearing structure of the nasal septum is lost, it is replaced: a strong strip of cartilage along the front edge, a second along the nose bridge, both firmly joined to one another and to the remaining bone. This construction then carries the entire nose — its height, its length and the position of the tip all depend on it.

Building up the nose bridge. The dorsal line is modelled on the restored strut. Depending on the height required, this is done with a carved block of cartilage, with layered strips, or with finely diced cartilage filled into a thin outer cover of the body's own tissue — the last of these above all with thin skin, because the surface then stays particularly soft and no edges show through.

Cartilage-supported stabilisation of the nasal tip. Because with a saddle nose the tip is almost always affected as well, it forms part of the reconstruction. We stabilise the nasal tip using modern cartilage-supported techniques. This markedly reduces the risk of the tip dropping again over the years — and the new position into which we bring it is not the one it grew into, so it needs particularly reliable hold.

Securing the airways. With the strut, the width of the internal nasal valve also returns. Where necessary, narrow strips of cartilage are additionally inserted to hold the valve open.

A nasal augmentation is therefore almost always an operation at the upper end of the time range. A rhinoplasty with us takes one to four hours; this range is deliberate, because we operate in our own operating theatres and therefore without time pressure — for as long as it takes until every detail is right. How long a procedure takes is decided by the findings, not by the schedule.

Four in ten nose operations at the Kuzbari Centre are revision rhinoplasties on a nose that has already been operated on. These procedures call for particular experience: the tissue is scarred, cartilage is sometimes missing, and the starting point is different for every patient. We deliberately take on such cases.

In a nasal augmentation these difficulties come together. The tissue layers that can be separated cleanly from one another in a first operation are fused together by scarring — exposing them takes longer and demands greater care, especially beneath thin skin. The nasal septum is often no longer available as a source of cartilage, which is why ear or rib cartilage is needed. And scar tissue contracts: an augmentation has to be built more stably than a first operation, because it has to hold out against this pull.

For the same reason, healing takes longer. After an augmentation on a previously operated nose, the final result is to be expected at twelve to eighteen months rather than at six. We say this before the operation, plan the check-ups accordingly and follow the course with photographic documentation.

In hardly any other condition are shape and breathing as closely linked as in the saddle nose. The structure that carries the nose bridge also holds the inner airways open. If it collapses, the internal nasal valve narrows — the narrowest point of the entire airway, a slim gap between the nasal septum and the upper lateral cartilages. Many of those affected therefore describe not only a dented nose but also the feeling that the air “gets caught somewhere”, particularly during sport and when lying down.

For the procedure this means that rebuilding the structure is at the same time the treatment of the breathing. With the restored strut the width of the nasal valve returns; where necessary we additionally insert narrow strips of cartilage that hold it open. A deviated or partly lost nasal septum is realigned in the same step.

We expressly examine the breathing at every consultation — narrow point by narrow point: nasal septum, turbinates, internal and external nasal valve. And we tell you which part of your symptoms will benefit from the augmentation and which will not, so that you do not expect the operation to bring an improvement that has a different cause.

After an injury. Immediately after an accident, acute care comes first — above all the question of whether blood has collected in the nasal septum, because that is one of the few genuine emergencies in nasal surgery. Once a saddle nose has developed, by contrast, there is no time pressure: reconstruction is carried out when the tissue has healed completely and the situation is stable.

After previous surgery. As a matter of principle we wait until the preceding operation has healed — as a rule at least twelve months. Scar tissue is still changing during this time, and an augmentation on unfinished tissue would be harder to plan. This waiting time is not a lost year: it is the precondition for a result that lasts.

With an underlying disease. If an inflammatory disease attacks the cartilage, reconstruction follows only once it is stably controlled. We coordinate this with the specialists treating you.

Age and everyday life. There is no upper age limit; what matters are your general health and the quality of your tissue. Allow two to three weeks in which you do not have to be in the public eye, and with an augmentation expect a longer path to the final result than with a purely shape-correcting procedure — twelve months is the rule, and after previous surgery rather eighteen.

Readily achievable: a nose bridge that regains its height and its line. A nasal tip that stands in position again and is held there. A nose that no longer looks collapsed in profile. And breathing that, with the restored structure, often improves markedly.

There are limits, too. The skin has to carry the new height with it: if it has shrunk or scarred over the years, it cannot be stretched indefinitely, and the augmentation has to be correspondingly more restrained. Transplanted cartilage can change minimally over the years — this cannot be ruled out entirely. And where there is an underlying disease, it must first be stably controlled, otherwise the augmentation will not last.

What we advise against: an augmentation that only fills the hollow without restoring the load-bearing structure — it looks good at first and does not last. And an augmentation that is too high: it tightens the skin, makes contours look hard and increases the risk of something showing through.

A small proportion of all nose surgery requires a fine correction. With an augmentation this proportion is naturally higher than with a straightforward shape-correcting procedure — we say so beforehand and assess such a question no earlier than twelve months.

An initial consultation with three-dimensional simulation, a technique that suits your nose, and an operating time that follows the findings — this effort is the reason why rhinoplasty with us has its price. It is also the reason why the result is meant to hold: for a lifetime, not for a few years.