日 鼻 誌 58（1）：1～ 7，2019

Review

Contemporary Septoplasty Techniques

Jong Ik Lee, Yong Ju Jang

Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea

（Received: January 18, 2019, Accepted: February 7, 2019）

paper classifies this condition into 5 types and have found Introduction this system to be very practical8). These are: The most common cause of a nasal obstruction is a devia- 1. Focal projection or deviation due to a bony spur or ridge tion of nasal septum1). This condition can also affect nose (Fig. 1). This type is characterized by the presence of a functions such as humidification, olfaction, air filtering and bony spur or ridge in the vomer or maxillary crest only temperature regulation and thereby has significant quality of and not accompanied by a cartilaginous deviation. Focal life impacts2). If conservative medical management is unsuc- resection of protruding bony portions may be sufficient cessful in relieving the symptoms of a nasal obstruction, to correct this type of deformity. surgical intervention to correct the septal deformity is indicated3). 2. Deviation of mid or posterior septum (Fig. 2). Correction The rigid framework supporting the nasal airway is provided is relatively easy and can be achieved by removal of the by the bony and cartilaginous septum and paired nasal bones. deviated bone and cartilage whilst leaving a sufficient The bony septum consists of the vomer, perpendicular plate L-strut. of the ethmoid bone, and maxillary crest4). Nasal septal 3. Caudal septal deviation (Fig. 3). Because the caudal deviations vary greatly in shape and location among patients. Thus, successful correction of the deviated septum cannot be achieved using the same surgical approach in all affected individuals. Different surgical techniques such as submucosal resection, conventional septoplasty, and endoscopic septo- plasty has thus been described to treat this condition5). When one consider the anatomical subsite of the nasal septal devia- tion, correction of the caudal septal deviation is one of the most important and challenging area for a correction using septoplasty. In this present review, we aimed to highlight some of the recent developments in septal surgery with a particular emphasis on caudal septal management.

Classifications of Septal Deviation

Although many different classification systems have been suggested for a septal deviation, including those Fig. 1 Focal projection of a bony spur to the right side of the descried by Guyuron6) and Mladina7), the senior author of this nasal cavity

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Fig. 2 Septal deviation of the mid-part due to a bony deviation to Fig. 4 High septal deviation to the right side the right side

preservation of a sufficient L-strut is the best approach to correct this. 5. Mixed deviation: In reality, it is difficult in most cases to make a clear distinction between the four types of devia- tions described above. A mixed type of deviation is most commonly encountered in clinical practice8).

Surgical Treatment of a Caudal Septal Deviation

1. Caudal septal batten grafting using septal cartilage A hemitransfixion incision is made at concave side of caudal septum, at the end of the caudal septal cartilage. Submucoperichondrial flap is found and elevated using an Iris scissors and Freer elevator. Elevation of the flap continues in the cephalic and anterior directions. The deviated portion of the septal cartilage and bone is then harvested by excision. A Fig. 3 Caudal septal deviation to the left side sufficient L-strut should remain for septal support. If there is still caudal septal deviation, a contralateral septum is important for nasal support, resection of deviated flap is elevated via a hemitransfixion incision site without caudal part as a correction approach is practically im- making an additional incision on the opposite side. After possible. This type of deviation is therefore the most bilateral flap elevation, a subperichondrial dissection into the difficult to correct. Additional surgical techniques other nasal floor is performed to form a pocket in which a graft can than simple resection of deviated portion are thus often be inserted. Harvested septal cartilage is usually used for a required to modity this problematic deviation. batten graft, which has a counter-curvature location on the 4. High septal deviation (Fig. 4). The most common cause concave side and is stitched using a few 5-0 polydioxanone of high septal deviation is a secondary change from the sutures. The gap between the posterior portion of the batten deviated perpendicular plate of the ethmoid bone. Resection graft and the caudal septum is approximated through-and of the deviated bone and bordered septal cartilage with through transcartilage sutures (Fig. 5)9).

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3. Cutting and suturing technique for the caudal septum Elevation of the bilateral septal mucoperichondrial flaps and resection of the deviated the septal cartilage and bone are done as described above. When the caudal septum is severely deviated, the caudal strut is cut using straight scissors at the most convex area in the caudocephalic direction. The excess portions of the upper and lower caudal strut are overlapped slightly, and the overlapping cartilages are fixed together using 3 to 4 stitches (5-0 polydioxanone sutures). Straightening Fig. 5 Septal batten graft is placed on the concave side of the caudal septum of the caudal septum can be evaluated immediately after this technique. The degree of overlapping cartilage is adjusted individually so that the original vertical distance is not short- 2. Caudal septal batten grafting using septal bone ened. If the stability of the newly created caudal septum is of A hemitransfixion incision and removal of deviated concern, cartilaginous or bony batten grafting is done from septal cartilage and bone, and an elevation of the conralateral the harvested autologous septum to reinforce the septal mucoperichondrial flap are achieved in the same manner as support, also usually on the concave side. After closure of the cartilaginous batten grafting technique. The amount of the hemitransfixion incision, 2 or 3 through-and- through harvestable septal bone should be sufficient to cover the full transmucosal sutures (4-0 polydioxanone) are used to hold both length of the caudal septum. After this, subperichondrial flap mucosa tightly to the newly created caudal septum (Fig. 6)11). is extended to subperiosteal elevation of the nasal floor to generate a sufficient space to insert bony graft. The harvested 4. Caudal septal division and interposition batten grafting septal bone is customized to the width and length of the Elevation of the bilateral septal mucoperichondrial flap remnant caudal septum and multiple small holes are drilled and resection of the deviated septal cartilage and bone are done to enable easy suturing. The caudal septal batten graft is with the same technique described above. The remaining positioned in the desired location, usually on the concave side caudal L-strut is cut at the most convex portion. A batten and fixed with 5-0 polydioxanone sutures. To minimize the graft with harvested septal cartilage or bone is then inter- gap between the bony batten graft and the caudal septum, posed between the cut ends of the caudal L-strut, mobilizing 1 or 2 through-and-through transcartilage and transbony (5-0 the upper part of the caudal septum toward the concave side polydioxanone) sutures and 2 or 3 through-and-through trans- of the nasal cavity. The newly created caudal septum with mucosal (4-0 chromic gut) sutures are applied to the newly the upper and lower parts of the caudal septal cartilage and created caudal septum10). interposed batten graft are adjusted to reproduce the original vertical distance of the caudal septum. The realigned caudal

Fig. 6 Cutting and suturing technique for the caudal septum. (A) An incision is made at the convex-most part. (B) Cut-ends of the septal cartilage are overlapped and sutured. (C) A batten graft can be placed at the concave side to provide additional support.

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Fig. 7 Illustration of the surgical procedure. (A) Cutting of a caudal L-strut at the most-bent portion. (B) Interposition of a batten graft between the cut ends of 2 septal cartilage flaps and fixation with PDS sutures.

L-strut and batten graft are then fixed with 5-0 polydioxanone can also be a cause of postoperative obstruction. If there sutures until sufficient stability is obtained. If the strength is persistent nasal obstruction with a straight septum, of the caudal septum is insufficient, additional batten grafting other causes may be considered such as allergic rhinitis is done at the original concave side to obtain more support or paranasal sinusitis. In our experience, insufficient (Fig. 7). correction of the caudal septum is the most common cause of persistent nasal obstruction, due to the supposed 5. Modified expracorporeal septoplasty (ECS) difficulty in correcting a caudal deviation with conven- A deviated nasal septum that is difficult to correct with tional septoplasty8). the endonasal approach, due to a severe septal deviation that 2. Septal hematoma. This refers to the collection of blood will likely prevent preservation of the L-strut, is the major under the mucoperichondrium or mucoperiosteum of indication for an ECS. In this procedure, the osseocartilaginous the nasal septal cartilage or bone. An iatrogenic septal septum is exposed using an open rhinoplasty approach. The hematoma can arise as a complication of nasal surgeries. septum is then freed from the extrinsic forces of the deformed If the patient feels a persistent nasal obstruction, pain, upper and lower lateral cartilages. The septal cartilage is or tenderness, the surgeon must perform an immediate removed except for the remaining few millimeters of keystone exam of the nasal cavity. Focal bulging and fluctuation of area so as not to destroy the bony-cartilaginous relationship. the septum are typical features of a septal hematoma8). A Multiple techniques are next performed to straighten the hematoma also acts as an ideal medium for bacterial excised cartilage. The dorsal and caudal end of the newly proliferation and colonization and can become infected created septal L-strut are designed into a V-shape and an within 72 hours if left untreated, leading to the forma- inverted V-shape by suturing one cartilage strip contralaterally. tion of a septal abscess. A septal hematoma should be The preserved cartilage at the keystone area and anterior drained urgently to avoid such complications13). nasal spine is placed between the arms of the V-shaped and 3. Septal perforation. The etiology of perforations is varied, inverted V-shape cartilage and then fixed with 4-0 or 5-0 but the majority arise due to iatrogenic injury following polydioxanone sutures. After fixation of the new L-strut, the septal surgery14), mainly as a result of mucosal injury. dorsal aspect of the septal cartilage is reconnected to the The nasal mucosa can be easily torn during dissection upper lateral cartilages with 4-0 polydioxanone sutures to if faced both sides torn, a deficit in the blood supply provide additional stability (Fig. 8)12). occurs, and if the possibility of postoperative perforation is increased. To prevent this, a careful elevation of the Complications and Possible Solutions submucoperichondrial flap is important, particularly pro- 1. Nasal obstruction. Incomplete correction of the septal truding areas such as the septal spur or ridge. A one-sided deviation is the most common cause of postoperative tear is usually not problematic but if tearing on both persistent nasal obstruction. Overcorrection of the septum sides occurs, an interfacing graft should be considered

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Fig. 8 (A) Septal cartilage was removed except for the remaining few millimeters of the dorsal strip at the keystone area. Newly shaped septal cartilage L-strut by multiple techniques, including scoring, wedge excisions, and cartilage splinting. (B) Caudal septum stability was obtained by fixing newly shaped septal cartilage L-strut to soft tissue around anterior nasal spine like inverted Y. Anterior nasal spine was sandwiched in middle. Dorsal aspect of newly created septal cartilage L-strut was designed in Y-shape by suturing one cartilage strip to existing L-strut. Preserved cartilage tail at keystone area was sandwiched between arms of newly designed Y-shaped dorsal L-strut.

to prevent septal perforations8). frequent nasal crusting from the septum. A small defect 4. Infection. Postoperative pain usually decreases over could be expected to heal spontaneously, but a large time but could indicate an infection such as chondritis if defect of the septal mucosa should be repaired with a it persists. If such an infection does not get treated in a mucosal or skin graft8). timely manner, many serious sequelae can arise such as 6. External nasal deformity. Septal cartilage and bone play a saddle nose deformity. Once an infection is suspected, a critical role in supporting the external nose. The easiest definitive management strategies must be implemented way to correct a deviation is resection but if this is immediately, and both medical and surgical interven- performed carelessly it can result in a nasal deformity. tions should be considered8). The main causes of deformities are a dislocation between 5. Unilateral mucosal defect with cartilage exposure. A the caudal septum and the anterior nasal spine which tightly placed silastic sheet or nasal packing could result can cause instability in the external nose support, an in a defect of the septal mucosa. Too much pressure insufficient L-strut, or disruption of the keystone area of this nature leads to a decreased blood flow to the during the resection of deviated septal structures. Hence, septal mucoperichondrial flap and can ultimately cause preservation of the junction between the caudal septum mucosal injury. The most common symptom of this is and ANS, resection of the deviated portion leaving a

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sufficient L-strut, and careful manipulation around the approach. First, to perform this technique, the formation of keystone area are important for avoiding postoperative the L-strut by removing the central part of the cartilage is changes to the external nose. If there is an immediate required in all cases; even straight cartilage should be removed. deformity during the operation, an endonasal technique Second, suture material–related complications such as chon- such as dorsal augmentation via a marginal or intercarti- dritis or stitch granuloma can occur. Third, the length of the laginous incision will be helpful for correction8). caudal septum can be over-shortened due to too much overlap or loosening of the fixation. Fourth, because the original Discussion structure is damaged by the cutting procedure, care must We have here described different types of septal devia- be taken in terms of the long-term stability of the caudal tion and different surgical methods to correct them. We now support. However, this can be strengthened by an additional discuss the advantages and disadvantages of each method. batten graft11). The cartilaginous batten graft has several advantages. Interposition batten grafting has several notable advan- First, it preserves the relationship between the caudal septum tages. First, as compared with cutting and suture techniques, and the anterior nasal spine and the natural caudal support is the caudal septal height can be made longer or shorter with this maintained. In such a stable state, the correction of the devia- technique. The caudal septal height can be readily adjusted tion is made by the batten graft. Second, if the cartilage is by modifying the fixation points of the upper and lower needed for revision surgery, this technique makes it possible parts of the caudal septum, centered by the interposed batten since it saves the harvested cartilage. Third, the outcome graft. Second, this technique can be useful in cases of a of the correction can be immediately evaluated during the deviated anterior nasal spine and columellar asymmetry. The operation. The most important concern with this technique is positioning of interposed batten graft to the nasal floor, the narrowing of the external nasal valve at the graft side9). lateral to the anterior nasal spine, can result in symmetry of Septal bony batten grafting also has many advantages. the nostril base width with correction of the caudal septal First, the septal bone is usually thinner than the septal cartilage deviation. There are some disadvantages of this technique. and the bony batten graft is thus less likely to interfere with First, it will increase the thickness of the caudal septum. In the airflow compared to the use of cartilage. Second, bone is our clinical experience however, none of the patients we stronger than cartilage and can be more helpful for correction have treated with this approach have ever complained of a of a deviation. Third, the use of a bony batten graft can save nasal obstruction. However, we did experience one patient the harvested septal cartilage in the space between both who complained of step formation at the caudal septum, flaps for possible revision surgery. The major concern with which brought about frequent nasal crusting from the caudal the use of the septal bone is the possibility of bone resorption septum. Hence, attempts to avoid irregularities in the caudal which would be indicated by a deviation recurrence. A nasal septum should be made when performing this technique. stiff sensation is another concern with bony grafting. Because Second, the interposed graft can be tilted because it is fixed bone is stronger than cartilage, this is one of the most with the divided cartilage of the caudal septum from either unavoidable side effects. Also, because of the requirement side. If there are concerns about this, it is better to put the for more suturing material for fixing a bony batten graft and batten graft on the concave side. achieving bilateral subperichondrial flap elevation, the risk A modified ECS also has some advantages. Because this of postoperative infection is higher with this procedure technique involves an open rhinoplasty approach, it provides compared to conventional septoplasty10). a view of the whole septal structure and makes it easy to The cutting and suture powerful technique which breaks correct the dorsal septum, which is technically difficult with the bending memory of cartilage. By using this technique, the an endonasal technique. A unique feature of our method is cartilage loses its strong disposition to return to its original the remnant dorsal cartilage of the keystone area, which form, and this in turn reduces the risk of a deviation recur- provides stability just by suturing the new L-strut and dorsal rence. An immediate intraoperative judgment with regard to cartilage and not through a difficult procedure such as drilling straightening the caudal septum is also possible, like the of the perpendicular plate. A possible disadvantage of this batten graft. There are however some disadvantages of this method is the instability of the anterior nasal spine and key-

―6― 日 鼻 誌 58（1），2019 stone area. We therefore suture using a V-shape and inverted 2202‒2209; discussion 2210‒2202. V-shape with a contralateral cartilage strip for reinforcement12). 7） Mladina R : The role of maxillar morphology in the All contemporary septoplasty methods have advantages development of pathological septal deformities. and disadvantages, and it is important to choose the surgical Rhinology 1987 ; 25 : 199‒205. approach that is appropriate to the patient’s anatomical varia- 8） Lee SB, Jang YJ : Treatment outcomes of extracor- tions, and to the surgeon’s experience. poreal septoplasty compared with in situ septal correction in rhinoplasty. JAMA Facial Plast Surg Funding and Conflict of Interests 2014 ; 16 : 328‒334. None. 9） Kim JH, Kim DY, Jang YJ : Outcomes after endo- nasal septoplasty using caudal septal batten grafting. Acknowledgments Am J Rhinol Allergy 2011 ; 25 : E166‒E170. None. 10） Kim DY, Nam SH, Alharethy SE, et al : Surgical outcomes of bony batten grafting to correct caudal References septal deviation in septoplasty. JAMA Facial Plast 1） Angelos PC, Been MJ, Toriumi DM : Contemporary Surg 2017 ; 19 : 470‒475. review of rhinoplasty. Arch Facial Plast Surg 2012 11） Jang YJ, Yeo NK, Wang JH : Cutting and suture ; 14 : 238‒247. technique of the caudal septal cartilage for the 2） Karatzanis AD, Fragiadakis G, Moshandrea J, et al manage ment of caudal septal deviation. Arch : Septoplasty outcome in patients with and without Otolaryngol Head Neck Surg 2009 ; 135 : 1256‒ allergic rhinitis. Rhinology 2009 ; 47 : 444‒449. 1260. 3） Shah J, Roxbury CR, Sindwani R : Techniques in 12） Jang YJ, Kwon M : Modified extracorporeal septo- septoplasty: Traditional versus endoscopic approaches. plasty technique in rhinoplasty for severely deviated Otolaryngol Clin North Am 2018 ; 51 : 909‒917. noses. Ann Otol Rhinol Laryngol 2010 ; 119 : 331‒ 4） Schuman TA, Senior BA : Treatment paradigm for 335. nasal airway obstruction. Otolaryngol Clin North Am 13） Gupta G, Mahajan K : Nasal Septal Hematoma. In: 2018 ; 51 : 873‒882. StatPearls [Internet]. Treasure Island (FL): StatPearls 5） Mutlu V : A novel surgical technique: Crushed septal Publishing; 2017: https://www.ncbi.nlm.nih.gov/ cartilage graft application in endonasal septoplasty. books/NBK470247/. Accessed November 1, 2018. Auris Nasus Larynx 2019 ; 46 : 218‒222. 14） Dayton S, Chhabra N, Houser S : Endonasal septal 6） Guyuron B, Uzzo CD, Scull H : A practical classifi- perforation repair using posterior and inferiorly cation of septonasal deviation and an effective guide based mucosal rotation flaps. Am J Otolaryngol to septal surgery. Plast Reconstr Surg 1999 ; 104 : 2017 ; 38 : 179‒182.

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