Mohamad Chaaban, MDa, Anil R. Shah, MDb,*
a Department of Otolaryngology, Head and Neck Surgery, University of Chicago Hospitals, 5841 S Maryland Avenue E-102, Chicago, IL 60637, USA b Division of Facial Plastic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Chicago, 845 N. Michigan Avenue, Suite 934, E. Chicago, IL 60611, USA * Corresponding author. E-mail address: [email protected] (A.R. Shah).
Open septoplasty Deviated nasal septum
Rhinoplasty Septal repair Septal surgery
Nasal obstruction Septoplasty surgery
Open septoplasty is the use of open rhinoplasty approach to address the septum. Open rhinoplasty’s history is long. Open rhinoplasty probably first started in 600 BC when Sushutra and Samhita practiced in India.1 The first transcolumellar incision approach to the nasal tip was described by Rethi from Budapest in 1921. He described a method of using a high transverse columellar incision that joins two marginal incisions.2 Rethi did not extend the incision to expose the whole nasal pyramid. His idea was not accepted because of the easier utility of the subcutaneous operation on the nasal tips. Sercer of Zagreb in 19563 extended the incision and described what was known at that time as ‘‘decortication’’ of the nose and defined it as a temporary separation of the nasal skin from the nasal pyramid. Although the earlier manifestations of open rhinoplasty were used to address nasal tip deformities, Padovan, Sercer’s successor at Zagreb3 was the first to describe the utility of the open approach to the septum. Goodman in 1973 made the open approach to the nose more systematic and expanded on the indications and included the combined external deformities of the nose and the septum as one of the indications. Andersen and Wright are generally credited with popularizing open rhinoplasty and its use with open septoplasty techniques.4
The nasal septum is composed of cartilaginous and bony parts (Fig. 1). The bones that make up the septum are the perpendicular plate of the ethmoid bone posterosuperiorly and the vomer, together with the crests of the maxillary and palatine bones, posteroinferiorly. The perpendicular plate of the ethmoid unites superiorly with the cribriform plate and anterosuperiorly with the frontal and nasal bones. The vomer articulates superiorly with the sphenoid and the perpendicular plate of ethmoid; and inferiorly with the maxillary and palatine crests. The septal cartilage comes in contact with both the perpendicular plates of ethmoid and the vomer posteriorly and the maxillary bone inferiorly. The septal cartilage itself has an anterior, middle, and posterior septal angle, which relates to the nasal tip and its support. The relationship between the fibrous attachments of the septum and lower lateral cartilages clearly impact the support and projection of the nose. The septum may play a larger role in nasal tip support than previously described. A study by the senior author (ARS) suggests that even routine septoplasty maneuvers can lead to loss of nasal tip support. Advanced septoplasty maneuvers are more likely to impact the projection of the nose. Therefore, surgeons should have the ability to either maintain or adjust nasal tip projection if necessary, especially with more advanced techniques described here.
In the normal nose, the maximal airflow is through the middle meatus. Poiseuille’s law states that the laminar flow of a gas in a tube is inversely proportional to one half of its diameter to the fourth power. Although the nasal flow in the nose is turbulent, the law is generally applicable. For this reason, the primary determinant of the nasal airflow is the minimal cross-sectional area of the nasal cavity, which is well determined to be the internal nasal valve. The internal nasal valve is defined by the area created by the junction of the nasal septum and the upper lateral nasal cartilages. Narrowing of this area by an anterior septal deviation or high dorsal deflection will thus create high resistance in the nasal airway.
Fig. 1. A nasal symmetry grid is created by drawing a line connecting the pupils as well as two lines perpendicular to the Frankfort Horizontal line from the medial canthus. Several points are then placed including: (Point A) central portion of pupil line; (Point B) subnasale; (Point C) philtrum of upper lip; (Point D) midportion of chin. To determine, nasal symmetry, a line is connected from Point A to Point B.
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Changes to the angle of the internal nasal valve, which is normally between 15–20 degrees, alters airflow and subsequently causes obstruction. Causes of obstruction include but are not limited to: wide or deviated nasal septum, collapse of the internal nasal valve, tip ptosis, and loss of the upper lateral cartilages.5 It has been shown that correcting the septum, together with the internal nasal valve, helps in improving airflow flow five times than when compared with correcting the septum alone.6 Open septoplasty provides an excellent exposure to the internal nasal valve, nasal tip and the cartilaginous and bony vaults. It has been shown that the point of maximum thickness of the septum is at the anteriosuperior angle.6
One of challenges of the surgeon is diagnosing the septal deflection. Anterior rhinoscopy alone is inadequate means of determining the severity of the deviated septum. A combination of skills is necessary to accurately diagnose a severely deviated septum including visualization, palpation, and endoscopy. The diagnosis of septal deviations begins with taking an adequate history from the patient. This history should include a history of trauma to the nose, nasal airway problems, and prior nasal surgeries. Visualization of the external appearance of the nose is vital. On frontal view, a deviated septum will sometimes manifest with an external deviation. Standardized photography will allow for accurate digital measures to be performed. When taking the frontal view photograph, the authors suggest that the patient’s head be calibrated with Frankfort horizontal line, including lining up the external auditory canals to be parallel to the horizon line. The senior author (ARS) has developed a method of distinguishing facial asymmetry from nasal asymmetry. He finds it is imperative not only identify asymmetry within the nose, but how it relates to the face. First, a line is drawn from pupil to pupil. Two lines perpendicular to this line are drawn from the medial canthus inferiorly. A measured point is created at the exact middistance between the pupils (Point A). Additional points are created at the subnasale (Point B), phitrum of the lip (Point C), and midline of the chin (Point D). A line is created by joining Point A and Point B to determine the nasal asymmetry. Deviation of the nose can be compared on either side of this line. Further evaluation of the nose can be seen by dividing the nose into thirds by placing lines dividing the nasal bones from the middle vault and middle vault from the nasal tip. This evaluation can be useful in distinguishing bony deviation from middle vault and septal deviation (see Fig. 1; Fig. 2). A perfectly straight nose on an asymmetric face will not appear symmetric. The nose must relate to the face. To help determine facial symmetry an additional line can be created by connecting Point A to the line which bisects Point B and Point C. The nose will appear to fit with the face if it relates to this line rather than a line perpendicular to the Frankfort horizontal line. The baseview of the nose can also reveal information regarding the degree of deviation in the nose. A deviated columella often correlates to a deviated septum. In addition, a footplate seen comprising the airway will often correlate to a deviated septum lateralizing the footplate. Anterior rhinoscopy is important to allow for visualization of the septum and its relationship to the remainder of the nose. However, there are recognized limits of anterior rhinoscopy. Endoscopy can be helpful to visualize the posterior aspect of the septum and more precise visualization of the internal nasal valve. Open Septoplasty: Indications and Treatment 515
Visualization alone is not sufficient to diagnose the degree of septal deviation. Palpation of the anterior septal angle, middle septal, and posterior septal angle will help to determine the type of caudal septal deflection. In particular, the posterior septal angle may or may not be fixed to the nasal spine or maxilla. Also, the nasal tip should be balloted to help determine how significant the nasal tip strength.
TECHNIQUE OPEN SEPTOPLASTY
The operation is typically performed under either general anesthesia or intravenous sedation. The authors prefer the use of general anesthesia because of the airway protection provided by an endotracheal tube. If general anesthesia is used, then injections of 1% lidocaine with epinephrine 1:100,000 are performed at the level of the glabella, columella, nasolabial fold and the septum.3 Hydrodissection plays a critical component in septoplasty and the surgeon should see a whitish blanch as well as note separation of the mucoperichondrial flap from the underlying septum. The authors use topical Afrin on pledgets after injection for further vasoconstriction of the mucoperichondrial tissues. First an inverted V-shaped incision with a no. 11 blade is fashioned on the columella. The superior aspect of the incision should always be below the apex of the nostril and typically begin at the narrowest portion of the columella. A marginal incision is made with a 15 blade along the caudal edge of the alar cartilages. The location of the caudal edge usually is at the cephalic boundary of the hair-carrying portion of the vestibule.3
In revision rhinoplasty, patients with ‘‘soft lower lateral cartilages’’ determination of the caudal edge may not be straightforward. In these instances, the surgeon can avoid the marginal incision and dissect on top of the lower lateral cartilages in an incremental fashion.
With the use of the skin hooks and converse scissors, the nasal tip skin is elevated off the columellar infrastructure. Care is taken to keep the thin skin over the medial crura intact. The dissection is continued to over the nasal tip where the nasal tip is
Fig. 2. Asymmetries within each portion of the nose can be seen by dividing: the bony portion from the middle vault; and middle vault from nasal tip.
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lifted with a two-pronged hook and later by the ala protector with lip. This dissection is performed starting medially and then moving laterally. The soft tissue envelope is lifted up in the subperichondrial plane, which reduces bleeding and enhances healing.
Exposure of the septum can take place in a variety of methods depending on the location of the deviation. In cases where the nasolabial angle will be altered, significant changes in projection, large septal deflections within the nose and in anterior septal deflections, dissection takes place between the medial crus. Here the fibrous attachments of the medial crus are separated until the anterior septal angle is identified. This is the most common method of accessing septal deflections. In cases where there is only a dorsal deflection, dissection of the septum can take place by separating the upper lateral cartilages and placing spreader grafts. This indication is rather limited and seldom incorporated. In cases where the septal deflection is located within the central portion of the cartilage, exposure can take place from a hemitransfixion or Kilian incision. The robust blood supply of the nose allows for separate Kilian incision to be made even in open rhinoplasty.
Specific Indications and Applications of Open Septoplasty Some authors feel that open septoplasty allows the surgeon to have a better look at the osseocartilaginous framework of which deformities can be accurately diagnosed.4
The authors contend that a thorough physical examination will allow for accurate diagnosis of septal deviation and deformity and that open septoplasty is not to be used for diagnosis. In addition, there is not a hard-set rule of when a nose should be opened under any circumstances, including for a septal deflection.
A severely deviated anterior septum located within the anterior 2 cm of the caudal septum is typically a reason enough to open a nose. A noticeable exception to a deviated deflection here would be a straight caudal deflection, which may be more amenable to being repositioned via swinging door technique. Many anterior septal deflections can be repaired by repositioning the septal cartilage and securing it to the periosteum of the nasal spine. Cartilaginous deflections with a significant concavity or convexity may require excision and replacement of this component.
Disarticulation and repair of the entire septum, although necessary in some instances, may require large amounts of cartilage but should only be performed in select cases.
Another indication for open septoplasty is the deviated dorsal septum. Here, a variety of maneuvers can be performed in order to straighten the dorsal component.
Sometimes, a unilateral spreader graft, placed on the concave surface, can assist in providing enough strength to help straighten the septum. Other times, asymmetric spreader grafts may be required to provide further strength. For even more dramatic deviations, an excision and replacement of the deviated component may be necessary to provide sufficient correction of the deviation.
Patients with ‘‘short’’ nasal septums often benefit from extension of the existing septum. One maneuver, which can extend a septum, is the caudal extension graft. It can be used to adjust septal rotation and projection to help contribute to the position of the nasal tip. In patients with a poorly projected nasal tip, often times open septoplasty is necessary to allow for sufficient manipulation of the tip position to adequately project the nose. Some patients with poorly projected noses will have a ptotic nose as well. These patients may notice improvement in breathing with restoration of the nose with a more obtuse nasolabial angle.
The significantly deviated septum may require near total excision of the deviated septum and reconstruction. Although some authors remove the entire septum, the authors of this article contend that maintaining a small cartilaginous attachment to the bony septum is a safer and more effective means of repairing septal deviations.
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Attaching cartilaginous elements to bony elements is difficult and can lead to slight shifts in reapproximation, while attaching cartilage to an existing piece of cartilage can lead to improved overall stability.
Another reason for open septoplasty is complete separation of the bony and cartilaginous components of the septum. In this case, the cartilaginous elements of the nose must be reapproximated to the bony elements of the nose. A previous author described a classification system to help identify and repair entire separation of the bony cartilaginous septum.5 The senior author believes this state is under diagnosed and has identified six cases of complete disarticulation of the bony cartilagionus septum. The repair consists of drilling holes through the bony septum, placement of bilateral spreader grafts, and a soft augmentation graft over the bony cartilaginous septum. This is important as the connection between the cartilage and bone may create a small depression less than 1 mm at one year and requires soft tissue camouflage
Open septoplasty represents a powerful approach to septal deflections. Septoplasty is the critical foundation of rhinoplasty and functional improvement in the nose. Judicious use of open septoplasty and incorporation of advanced septoplasty maneuvers may help improve septal deflections.
1. Mc Dowell F. Ancient ear lobe and rhinoplastic operations in India (from Sushruta Samhita). In: The source book of plastic surgery. Baltimore (MD): Williams Wilkins Cy; 1977.
2. Rethi A. Operation to shorten an excessively long nose. Rev Chir Plast 1934;2: 85–7.
3. Mangat DS, Smith BJ. Septoplasty via the open approach. Facial Plast Surg 1988; 5(2):161–6.
4. Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg 1997;99(3):863–7.
5. Gunter M. Surgery of the nasal septum. Semin Plast Surg 2006;22(4):223–9.
6. Ashmit G, Gupta A, Brooks D, et al. Surgical access to the internal nasal valve.
Arch Facial Plast Surg 2003;5:155–8.
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Fig. 3. Patient with intraoperative separation of bony cartilaginous junction. Her nasal
profile was preserved by connecting supporting the middle third of the nose through drill holes created in the nasal bones. In addition, soft tissue onlay at bony cartilaginous junction is placed to ensure a smooth dorsum long term. Patient seen preoperatively (A) and postoperatively (B), with smooth dorsal profile at 1-year postoperative visit.
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