Effect of Extended Teo Strut Graft on Tip Rotation and Projection in Open Rhinoplasty: A Case-Series Study

A well-defined and adequately supported nasal tip is essential for achieving an aesthetically balanced nose and satisfactory rhinoplasty outcomes. The ptotic (drooping) nasal tip deformity represents cosmetic concern and contributes to functional nasal obstruction. Static (weak cartilaginous support and short septum) and dynamic factors (depressor septi nasi muscle activity) play a role in tip ptosis​ [1]. Achieving and maintaining the desired tip rotation (nasolabial angle; NLA) and projection over time remain challenging aspects of rhinoplasty​ [2]. Standard manoeuvres often disrupt native tip support mechanisms, risking postoperative tip droop if not adequately reconstructed​ [2,3]. The challenge is exacerbated in patients with a congenitally short caudal septum with limited cartilage length to support or elongate the tip. In such cases, a simple columellar strut graft may provide only minimal or short-lived improvement, as the strut has little stable support on a short septal base [3].

Multiple techniques have been developed to augment tip support and counteract tip ptosis. Columellar strut grafts placed between the medial crura can buttress the tip. Still, they often do not significantly increase tip projection by themselves and may not prevent long-term tip drop [3,4]. In contrast, septal extension grafts (SEGs), anchored to the caudal septum, effectively controlled the tip position. By overlapping and extending the septum, SEG can set the tip at a new rotation and projection and maintain it by rigid fixation to the septum [5]. Clinical studies have demonstrated that SEGs provide superior long-term tip stability compared to columellar struts​ [6,7]. A recent retrospective comparison study found that at one year post-rhinoplasty, patients with SEGs had no loss of tip projection and minimal (~1°) loss of rotation.

In contrast, those with columellar struts showed measurable decreases in both​ [7]. These findings underscore the importance of robust septal-based support for lasting tip elevation. However, traditional SEG is difficult in patients with a short or deficient septum as there may be insufficient caudal septal length or cartilage stock to secure an extension graft. In such conditions, surgeons have devised modifications, like floating or hinged struts and composite grafts, to achieve tip support but consensus on the optimal approach remains debated​ [8].

Teoman Dogan introduced the Teo Strut Graft (TSG) in 2023 as part of a minimalist rhinoplasty philosophy aimed at maximizing tip support with minimal tissue disruption. The TSG is designed with a triangular configuration, wider at its base and tapering to a narrow apex [9], unlike the rectangular blocks used in classic SEGs​ [10]. This design provides a strong base that contacts the septum, while the narrowed apex fits beneath the tip cartilages to support them without excessive rigidity [2]. Dogan’s technique fixes the graft to the tip-defining points, effectively integrating the lower lateral cartilages with the septum as one unit [9]. A similar strategy reconstructing a robust yet flexible central nasal support helps maintain long-term tip projection and rotation [2].

Building on this concept, we aimed to develop an extended TSG technique to address patients with drooping tips and short septal anatomy specifically. Also, we modified Dogan’s original approach [9] by securing the triangular cartilage strut to the intermediate crura (dome region) and anchoring it using a Tongue-In-Groove (TIG) method to the caudal septum. Adding the TIG fixation, which sutures the medial crura to the septum/graft complex, provides further stability and precise control of tip position. Unlike the original Teo strut, our modification aimed to extend the graft caudal to the caudal edge of the septum.

Study Design and Setting

A prospective, quasi-experimental case series study was used to evaluate the extended Teo strut technique in primary rhinoplasty. Patients presenting with ptotic tips and/or short septal anatomy were enrolled via convenience sampling. Among the 43 patients selected, 5 missed the follow-up and the remaining 38 patients were enrolled in the study. All procedures were performed by a single surgeon at Sulaimani Burn, Reconstructive and Plastic Surgery Hospital and Royal Private Hospital, Sulaimaniyah, Iraq, from March 2021 to June 2023.

Sample Size Calculation

A general formula for calculating sample size was used as:

where, n = sample size, Z = Z-score (95% confidence), p = estimated proportion (0.5) and E = margin of error (0.05 for a 5% margin).

Inclusion Criteria

A drooping nasal tip (NLA <90° in males or <95° in females, with a visually ptotic tip) and/or a short septum with inadequate tip support (reduced columellar-to-lip distance and difficulty achieving tip rotation with sutures alone). Those that had primary (first-time) rhinoplasty with the availability of standardized profile photographs both preoperatively and at least 12 months postoperatively.

Exclusion Criteria

Patients requiring major dorsal reconstruction or severe septal deviations necessitating extracorporeal septoplasty and revision rhinoplasty cases.

Surgical Technique

We performed all procedures via an open rhinoplasty approach under general anaesthesia. After performing dorsal hump reduction or modification, we turned attention to the nasal tip and then the extended TSG was employed as follows:

• Cartilage Harvest: Septal cartilage was the preferred donor material for the strut graft. We harvested a strip measuring ~20-25 mm long and 10-15 mm wide from the posterior septum or inferior septal angle, ensuring that at least a 10 mm dorsal and caudal septal L-strut was preserved for structural support. Then, this strip was carved into a triangular cross-section, thicker at the base (2-4 mm) and tapering toward the apex (1-2 mm). The final graft measured 13-20 mm in length and 10-13 mm in width (Figure 1). Maintaining a thicker base with a tapered tip provided the necessary rigidity at the septal attachment while preserving flexibility at the nasal tip, consistent with the original Teo strut concept

Figure 1(a-b): Extended Teo Strut Graft Dimensions, Showing Measurements of (a) Length and (b) Width

• Placement: We positioned the extended TSG unilaterally along the caudal septum. The choice of side (left or right) was based on the patient's tip dynamics and overall nasal anatomy; we often favored the concave side of any septal deviation or whichever side best corrected tip asymmetry. This approach was especially critical in patients with a short septum, who commonly exhibit a ptotic tip due to inadequate support. After customizing the graft, the ideal fixation point to achieve the desired tip rotation and projection was determined. Once the correct orientation is confirmed, position the graft along the septum with its tapered end beneath the dome. Then, deliberately advanced the graft 1-3 mm caudal to the septum's natural edge and extended it anteriorly to the anterior edge. This modification enhanced tip support by providing a robust anchor for the medial crura and allowed controlled adjustment of tip projection and the tip-breaking point

Fixation: The strut was anchored to the caudal septum in a side-to-side manner using 6-0 Prolene horizontal mattress sutures (Figure 2).

Figure 2: ETSG advanced 3 mm caudally and fixated to the septum with three 6-0 polypropylene mattress sutures

Typically, three sutures secured the graft to the septum, thereby minimizing the risk of graft instability. Subsequently, we secured the graft's free (caudal) end to both medial crura using a TIG suture technique (Figure 3), which enhanced tip support and created a smooth contour. Following this, a figure-of-eight suture was placed for internal fixation; once the internal stitch was applied, we wrapped its free ends around the apex of the strut, securing both domes to the graft. Then, two additional loop sutures were added for extra stability. With the apex carved thinner, the tip retained flexibility when moved cephalically yet remained resistant to caudal displacement; effectively preventing tip droop. Final tip definition was achieved with interdomain or other tip sutures as needed to ensure symmetrical dome positioning and robust tip support

Figure 3: Tongue-in-groove suture securing both medial crura to the graft

• Adjuncts: Where indicated, a cephalic trim of the lateral crura was performed to address tip bulbosity. Additional lateral crural steal or spanning sutures may have been employed to refine tip projection and rotation further. Then, the septum was evaluated for residual deviations and minor deflections were corrected to maintain a straight strut and aligned columellar. Finally, the incisions were closed and standard postoperative taping was done along with an external splint and internal nasal splints for 10 days

Outcome Measurements

NLA: The NLA was measured on standardized profile photographs as the angle formed at the subnasale by two lines; one drawn from the subnasale to the columellar apex (columellar point) and the other from the subnasale to the labiale superius [11]. A single investigator performed all measurements using the protractor feature in Image-J (NIH) software [12]. The ideal female NLA was often cited as ~100-110° and 90-105° for males [11], so postoperative NLAs within this range were considered aesthetically favourable.

Nasal Tip Projection: The tip projection was quantified using Goode’s method [13], which is the ratio of the distance from the nasal tip to the nasion (or alar root, as per the method) divided by the total nasal length. Goode’s ratio is typically reported to be ~0.55-0.60 [13], although this cohort’s baseline value was higher (0.68), likely reflecting distinct facial proportions. We obtained measurements preoperatively, immediately postoperatively and at one year using standardized profile photographs and analyzed changes based on relative differences rather than an absolute ideal value.

Photographic Standardization: Profile photographs were obtained with patients in a natural head position, 1.5 m from the camera, under consistent lighting and distance settings. All pictures were taken by a single individual using identical camera settings. We reproduced the same camera angle and patient posture at a one-year follow-up. We avoided any smile or animation during these photographs to ensure accurate angle measurement. All images were calibrated against a ruler for scale in Image-J to allow distance measurements for projection calculations.

Statistical Analysis

Data analysis was done using Statistical Package for Social Science (SPSS, IBM Corp, USA, version 26). Descriptive statistics (mean, standard deviation and range) were computed for key variables (NLA and tip projection) at each time point. Paired t-tests were used to compare preoperative versus immediate postoperative values and immediate postoperative versus one-year values. Because the differences between the immediate postoperative and one-year measurements were minimal, the Wilcoxon signed rank test was applied to confirm no significant median shift. An Independent-sample t-test was used for subgroup comparisons (females vs. males, right vs. left strut placement). Pearson or Spearman correlation analyses were done to assess relationships among changes in angle/projection. A p<0.05 was considered significant and a p<0.001 as highly significant.

Patients’ Characteristics

Among 38 patients, 89.5% were females with a mean age of 23.7±6.7 years (ranging from 18-48). The mean preoperative NLA was 83.62±8.01° (84% had an NLA <90°) and the mean tip projection (Goode’s ratio) was 0.634±0.055 (Table 1). Six patients (16%) had a short nose (mean NLA 105°) and inadequate septal length determined intraoperatively. Cartilage for the extended Teo strut was exclusively harvested from the septum and placed on the right in 35 patients and the left in three, with all patients undergoing additional refinement manoeuvres during the operative time (2.5-3.5 hours) and no intraoperative complications were recorded.

Table 1: Demographic and surgical characteristics of the study cohort

Early Postoperative Outcomes

Paired t-tests indicated a significant increase from preoperative to immediate postoperative measurements for NLA and tip projection (p<0.001). Immediately post-surgery (before splinting), the NLA rose to 104.21±7.43° (a mean gain of ~20.6°, p<0.001), with 89% achieving gender-specific ideal values (females ~105°; males ~98°). The mean tip projection improved to 0.724±0.053, reflecting a mean gain of ~0.09 (p<0.001). Strong positive correlations were observed between preoperative and immediate postoperative values for both NLA (r = 0.620, p<0.001) and tip projection (r = 0.558, p<0.001) (Figure 4).

Figure 4(a-b): (a) Scatter plot of preoperative vs. immediate postoperative nasolabial angle, showing strong positive correlation (r = 0.656, p<0.001) and (b) Scatter plot of preoperative vs. immediate postoperative Goode’s ratio, showing significant positive correlation (r = 0.589, p<0.001)

One-year stability

At a mean follow-up of 13.5 months (ranged from 8-24), the mean NLA was 103.45±7.37° (p = 0.18 vs. immediate) and tip projection was 0.714±0.061 (p = 0.013 vs. immediate). While this slight decrease in tip projection (-0.010) reached a significance level, the net improvement relative to the preoperative value remained large (p<0.001 for both NLA and projection vs. preoperative) (Figure 4).

Spearman’s correlations confirmed high stability between immediate postoperative and one-year measurements (r = 0.949 for NLA and r = 0.917 for projection (p<0.001). No tip ptosis recurrence or functional compromise was noted; nasal breathing improved or remained stable subjectively (Figure 5).

Figure 5: Longitudinal changes in nasolabial angle (NLA) and nasal tip projection (Goode’s ratio) following rhinoplasty with the extended TSG

Green and navy lines represent mean values for NLA and Goode’s ratio, respectively, recorded preoperatively, immediately postoperatively and at one-year follow-up. Both parameters demonstrated significant improvement postoperatively (p<0.001), with sustained outcomes at one year. Minor regression in tip projection was noted (p = 0.013), while NLA remained stable (p = 0.18)

Subgroup Analysis

No significant differences in outcomes were observed based on graft placement side (right vs. left: mean NLA change 21° vs. 19°, p = 0.67), gender (NLA change: p = 0.115; tip projection change: p = 0.940) or graft width (ANOVA, p>0.40 for both NLA and projection changes). Multivariable regression did not identify any independent predictors of postoperative NLA or tip projection change (p>0.05). Subgroup comparisons of NLA and tip projection (Goode’s ratio) changes across gender and TSG placement side using a dual-axis boxplot. No significant differences were observed across subgroups for either parameter (p>0.05) (Figure 6).