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Open rhinoplasty approach
Lateral displacement of the domes of the lower lateral cartilage allows excellent visualization of the septal angle and the attachment of the dorsal septum to the upper lateral cartilages. Caudal exposure is obtained by separating the medial crura, thus, exposing the entire length of the caudal border of the septum and its attachment to the nasal spine
Remove posterior septum leaving a 1 cm L-strut
The deviated caudal septum is then released inferiorly along the maxillary crest and nasal spine
When the caudal septal deflection extends superiorly to the nasal dorsum, the caudal septum is completely divided from its dorsal attachment
The freed caudal septum is often sparingly trimmed in the region of the nasal spine to obtain a straighter edge
The straightened caudal septum is then realigned to its correct anatomical position and stabilized by first fixating it to the anterior nasal spine inferiorly using a 5-0 clear polypropylene (Prolene) suture
A cartilage plating graft is used to rigidly secure the superior end of the caudal septum to the remaining dorsal septum
The graft is fixated into place using a 5-0 polypropylene suture
The newly aligned dorsal-caudal septal complex is further stabilized by securing it to the upper lateral cartilage using a 5-0 clear polypropylene suture.
The septal flaps are then closed using the basting suture technique with a 4-0 plain catgut suture on a Keith needle
"columelloplasty"
simple suture technique which, when subluxation is not severe, will correct this caudal displacement
Complete transfixion incision
Intercartilaginous incision and a marginal incision to perform the endonasal rhinoplasty
Deviated septum removed with 1 cm L strut left
The caudal septum was positioned over the nasal spine in the midline and straightened
Length: shortened the most posterior aspect of the caudal strut so that it could be placed without deviation over the nasal spine
Malposition: repositioned the septum to one side or the other of the nasal spine
Securing: newly positioned caudal strut was then secured to the columella using 4-0 chromic gut suture on a straight needle to hold it in the midline position while healing took place
Multiple septal columella sutures can be placed, although 1 or 2 sutures are usually sufficient. The caudal septum was not secured to the nasal spine
2 days of Telfa packs
Hemitransfixion incision on the concave nasal cavity
Deviated septum removed with 1.5 cm L strut left
Contralateral flap was raised from the caudal aspect of the cartilage without making an incision on the contralateral side; Flap elevation was facilitated by retracting the nasal mucosa just caudal to the hemitransfixion incision using a small double-pronged retractor
After bilateral flap elevation, the caudal strut was cut using scissors at the convex-most region in the caudocephalic direction
The excess portions of the upper and lower caudal strut were then overlapped, and the overlapping cartilages were sutured together using 3 to 4 stitches (5-0 polydioxanone sutures; Ethicon)
The degree of overlapping cartilage was adjusted such that the vertical height of the original caudal septum was not shortened as a result of overlapping
If the stability of the newly created caudal septum was questionable, a septal batten graft made from cartilage removed from the central part was placed for further support, usually on the concave side
Closure of the hemitransfixion incision was performed using 5-0 chromic gut, and 2 or 3 through-and-through transmucosal sutures (4-0 polydioxanone sutures) were used to hold both mucosa tightly to the newly created caudal septum
"modified spreader graft"
modified spreader graft interlocked on the convex side
A single-interlocked graft inserted by 2 through-and-through serial sections of the quadrangular cartilage (applied over the misshapen convex side previously scred on the concave side) facilitated adjustment of the distal septum
The strip of cartilage of the desired height and width acted as a spring graft and may be placed at the desired height of the caudal septal area to exactly counteract the eventual tendency of the most deviated area to warp over time
"caudal septoplasty" (floating columellar strut)
Unilateral incision in the anterior portion of the nasal septum. The incision is preferably done on the side where the nasal septum deviation was most pronounced
Remove the entire anterior deviated portion, and also part of the posterior cartilage, enough to make the graft which will be used to rebuild the nasal tip with some strut left
A columellar strut graft is shaped from the part removed from the nasal septum, using the portion that is intact
It must be rectangular in shape, with 0.5 to 1.0 cm in width
The graft height must be assessed in each case and it must have at least the same height of the patient's nasal tip before surgery
Make a tunnel between the mucosal walls of the columella, separating the medial crus of the alar cartilages, a tunnel big enough to accommodate the graft.
From the anterior portion of the columella pass two 3-0 nylon wires, inside the tunnel, through the graft and coming back from inside the tunnel and the columella
Transfixion suture with 5-0 monocryl wire in order to stabilize the graft
No splint or packing
Hemitransfixion incision
Elevate bilateral septal submuchoperichondrial flaps around the anterocaudal septum
Initial exposure of the septum in this manner allows the surgeon to confirm the preoperative determination that the anterocaudal septum is too severely deviated for standard L-strut septoplasty
External approach rhinoplasty
Separate the medial crura
Release the upper lateral cartilages from the dorsal septum
Preserve a variable portion of the most distal portion of the dorsal strut at the anterior septal angle
At least 2 cm of the dorsal strut is preserved, and in some cases, the entire strut may be preserved
The vertical height of this dorsal strut is 1.5 cm adjacent the keystone, tapering to 1 cm at the anterior septal angle
Preservation of the keystone is of critical importance, as this preserves structural integrity for the ASR graft and maintains the dorsal profile
Incise and remove the cartilage inferior to this dorsal strut
If a posterior bony deviation is present, it is also removed in continuity with the cartilaginous septum
The septal cartilage is then fashioned into an ASR graft, using the straightest possible portion when possible
In the event the excised septal cartilage is not suitable for use, or if inadequate septal cartilage remains, as is often the case in revision procedures, autologous or homologous rib cartilage may also be used to fashion the ASR graft
Expose the anterior nasal spine using monopolar cautery, preserving the overlying periosteum
A 2- to 4-mm straight osteotome is then used to carefully split the spine to a depth of 2 to 3 mm
A notch is created just posterior to the neo-posterior septal angle on the ASR graft, and this is placed into the groove within the nasal spine and on the concave side of the midvault, such that it acts as a spreader graft
The ASR graft is secured to the dorsal strut using three 5-0 nonabsorbable monofilament sutures
In most cases, no additional suture is required to secure the ASR graft into the cleft of the nasal spine. In the event that a suture is necessary for additional security, a single 5-0 nonabsorbable monofilament suture is used to secure the graft to the overlying periosteum of the spine
Additional spreader grafts may be placed if necessary
The medial crura are then repaired to the ASR graft in a standard tongue-in-groove fashion using 5-0 nonabsorbable monofilament suture
The upper lateral cartilages are repaired to the dorsum using the same suture
The tip is repaired using dome binding sutures, and often an alar spanning suture is placed for additional tip support
Place intranasal silastic splints and secured to the ASR graft using a through-and-through 4-0 nonabsorbable monofilament suture
Tape and splint the external nose
The intranasal silastic splints, columellar sutures, external tape, and splint are removed 1 week postoperatively
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