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Caudal Septoplasty for Treatment of Septal Deviation Aesthetic and Functional Correction of the Nasal Base

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Caudal Septoplasty for Treatment of Septal Deviation Aesthetic and Functional Correction of the Nasal Base ORIGINAL ARTICLE Caudal Septoplasty for Treatment of Septal Deviation Aesthetic and Functional Correction of the Nasal Base Jack D. Sedwick, MD; Andres Bustillo Lopez, MD; Byron J. Gajewski, PhD; Robert L. Simons, MD Objectives: To describe our technique in the treat- termine the severity of caudal deviation and the postop- ment of significant caudal septal deviation; to evaluate erative result. By photographic evaluation, we found that the effectiveness of our technique of caudal septoplasty all but 3 patients had significant improvement in their in the treatment of caudal septal deviations. postoperative appearance. Twenty-six patients had no evi- dence of residual asymmetry. The rate of revision was 5 Design: Retrospective review of cases taken from a da- (8%) of 62 patients. tabase of more than 2000 patients who underwent rhi- noplasty performed by 1 surgeon in a private facial plas- Conclusions: The caudal septoplasty technique is ef- tic surgery practice. fective, relatively easy to perform, and shows long-term reliability in correcting caudal septal deviation. In prop- Results: Medical charts were reviewed to determine the erly selected patients, the technique is effective in im- rate of preoperative nasal obstruction in 59 (95%) of 62 proving cosmesis and nasal airflow. patients as well as nasal obstruction postoperatively 11 (17%) of 62 (PϽ.001). Photographs were reviewed to de- Arch Facial Plast Surg. 2005;7:158-162 HE CORRECTION OF CAU- METHODS dal septal deviations can be a challenging problem. Of- ten, these defects cause PATIENT ENROLLMENT both an aesthetic distor- Patients were selected from a rhinoplasty da- Ttion of the nasal base and nasal obstruc- tabase in which information regarding pa- tion. The fact that so many techniques have tient demographic characteristics, preopera- been described and tested to correct cau- tive analysis, operative techniques, and dal septal deflections speaks to the diffi- complications were recorded. All patients un- culty of correcting this problem. If it were dergoing rhinoplasty by the senior author over easily corrected, 1 technique would prob- the last several years were entered into the da- ably be used more universally. tabase without intentional bias. A total of 2043 The present study describes a tech- cases were available for review and inclusion nique used by the senior author (R.L.S) in this study. All operations were performed for more than 20 years and evaluates its in either a community hospital or an office- based surgery suite. effectiveness in managing caudal septal All patients were entered into the rhino- deviations. We believe that effective treat- plasty database in a randomized fashion, with- ment of caudal septal deviations sig- out any consideration given to use of these data nificantly improves outcomes in rhino- in the present study or any other study. The plasty. The deviated caudal septum original database of 2043 patients was searched Author Affiliations: changes lobular and columellar relation- for patients with caudal septal deviation noted Department of Otolaryngology, ships and has a significant effect on tip po- and recorded in the preoperative evaluation of University of Florida, sition and symmetry. In some cases, treat- patient photographs. This search was then Gainesville (Dr Sedwick); ment of the caudal septum can significantly matched with patients who had a caudal sep- Department of Otolaryngology, improve a twisted nose. In selected cases, toplasty for treatment of caudal septal devia- University of Miami, Miami, Fla tion. In virtually all cases, the caudal septo- (Dr Lopez); and University of this may be the most important element plasty was performed in conjunction with an Kansas, Kansas City in treating a twisted nose. The present re- endonasal cosmetic rhinoplasty. (Dr Gajewski). Dr Simons is in view concentrates on the effect of caudal These search parameters yielded 147 pa- private practice in North Miami septoplasty on the appearance of the base tients (8%) who had a caudal septal deviation Beach, Fla. of the nose and on breathing. treated with a caudal septoplasty. All of these (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 7, MAY/JUNE 2005 WWW.ARCHFACIAL.COM 158 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 medical charts were reviewed. Complete charts were included in this study, along with complete preoperative and postop- A With Nasal Obstruction Without Nasal Obstruction erative photographic information, documentation of subjec- 100 n = 59 tive breathing status before and after surgery, and at least 6 months of postoperative follow-up records. Patients treated n = 51 with turbinate reduction, internal or external nasal valve re- 80 pair, or any technique designed to improve breathing other than caudal septoplasty were excluded from the review. A 60 total of 62 patients met these criteria and were included in the study. These 62 charts were reviewed to determine the subjec- 40 tive rates of nasal obstruction before and after treatment in a of Patients Percentage retrospective manner. Two independent observers evaluated 20 n = 11 the severity of preoperative caudal septal deviation and the effect of surgical intervention. The rate of revision surgery in n = 3 0 this patient group and the length of follow-up were recorded Preoperatively Postoperatively as well. B 60 n = 33 50 SURGICAL TECHNIQUE n = 26 40 Caudal septoplasty was performed in conjunction with endo- 30 nasal rhinoplasty in each case. Patients who underwent turbi- 20 nate reduction or internal or external valve repair were ex- 10 Percentage of Patients Percentage n = 3 cluded from this study. The septum was accessed via a complete n = 0 0 transfixion incision. In each case, this incision was ultimately Total (1) Marked (2) Mild or Condition used in conjunction with an intercartilaginous incision and a None (3) Worsened (4) marginal incision to perform the rhinoplasty. Bilateral muco- Improvement perichondrial flaps were elevated via a complete transfixion in- cision in each case. Bilateral flap elevation allows the surgeon Figure 1. Patient self-reports of nasal obstruction (A) and physician complete bilateral access to the caudal septum from the ante- photographic evaluations of aesthetic improvement (B). A, Improvement in rior septal angle to the nasal spine. nasal obstruction was significant (PϽ.01, McNemar test). B, The aesthetic After the septum was accessed via the complete transfix- surgical results were evaluated on a 4-point scale: 1, little or no photographic evidence of residual caudal septal deviation (total improvement); 2, marked ion incision, deviated cartilage was excised using standard improvement; 3, only mild or no improvement; and 4, condition made worse. septoplasty technique leaving at least a 1-cm caudal and dor- In none of the present cases was the condition made worse. Improvement sal strut to preserve the structural function of the caudal and was statistically significant (PϽ.001). dorsal septum. Next, the caudal septum was exposed to the nasal spine via the complete transfixion incision using bilat- eral mucoperichondrial flaps. With this access, the caudal RESULTS septum was positioned over the nasal spine in the midline and straightened. Often the length of caudal septal strut contributes to the de- The patients’ charts were reviewed to evaluate the rate viation. When this occurred, we shortened the most posterior of subjective nasal obstruction preoperatively. Figure 1A aspect of the caudal strut so that it could be placed without de- summarizes these results. The initial result indicated that viation over the nasal spine in the midline. In cases where the 59 (95%) of the 62 patients complained of nasal obstruc- caudal septum was malpositioned without additional length con- tion during their initial consultation. The degree of na- tributing to the deviation, we repositioned the septum to one sal obstruction could not be recorded owing to the ret- side or the other of the nasal spine. Through the access pro- rospective manner in which the charts were reviewed. vided by the complete transfixion incision, the septum can be The charts were reviewed for postoperative complaints repositioned to the midline with bilateral visual verification of of nasal obstruction as well. Charts in which patients’ sub- its position. jective opinions regarding the status of their airway at Once the caudal septum was successfully repositioned in the midline, it was secured in that position so that the newly their last follow-up appointment were not clearly docu- straightened caudal septum remained in its proper position. The mented were excluded from the study. Fifty-one (82%) newly positioned caudal strut was then secured to the colu- of 62 patients reported no postoperative nasal airway ob- mella using 4-0 chromic gut suture on a straight needle to hold struction. All of the patients with residual airway ob- it in the midline position while healing took place. Multiple struction reported improvement in their breathing sta- septal columella sutures can be placed, although 1 or 2 su- tus. The difference between the rates of preoperative and tures are usually sufficient. The caudal septum was not se- postoperative nasal obstruction was statistically signifi- cured to the nasal spine. Closure of the posterior portion of the cant (PϽ.01). transfixion incision was meticulously performed to provide The results of the surgery with respect to improve- added strength and support prior to continuing with the rhi- ment of the caudal deviation were evaluated using the noplasty. We believe that placement of Telfa packs (Tyco Health Care, Mansfield, Mass) at the conclusion of the procedure helps base photographic view. In all cases, the most recent to support the incisions, including the complete transfixion in- photographs were used to evaluate the postoperative cision and the intercartilaginous incision. Telfa sponges are left result. All patients without photographic evaluation at in place for 2 days in all cases. Standard casting is performed least 6 months after surgery were excluded from the postoperatively. study.
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