Saddle nose correction remains a challenging procedure for rhinoplasty surgeons due to both aesthetic and functional issues. The most common causes of saddle nose are nasal trauma and prior septal surgery, and a defective relationship between the caudal septum and the anterior septal spine is the principal postoperative pathology. The authors propose their own classification system for saddle nose with one new category and several approaches to deal with this condition in accordance with the level of severity. They strongly advocate major septal reconstruction for most cases of saddle nose, either by placing extended spreader grafts, caudal extension grafts, or a new extracorporeally made L strut. For extreme cases, integrated dorsal implant with columellar strut can successfully bypass the saddled nasal dorsum without dissecting the septal mucoperichondrial pocket and achieve adequate dorsal height. Further dorsal augmentation can be achieved by applying side/gap grafts or dorsal onlay grafts in different forms. In cases with retracted columella, a premaxillary plumping graft is another useful technique. Finally, in autoimmune-related saddling patients, the evidence indicates that their aesthetic problems can be managed safely with surgery as long as the disease is well under control.
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