Septoplasty is the alteration of the nasal septum to straighten the airway and/or remove cartilage for cartilage grafting. The nasal septum is a structure composed of cartilage in bone in the middle of your nose. Ideally, the septum divides the nose in half so that equal and symmetric airflow can occur. In 80% of the population, the septum is deviated, meaning a portion of the septum goes into the airway. One third of those patients are symptomatic with signs such as mouth breathing with sleep, exercise,snoring, and a a dry mouth.
Figure 1. CT scan overlaying face demonstrating deviation of septum to the patient’s left. It is clear that the airway is compromised due to the position and shape of septum and size of the turbinates. Second image depicts septum with deviation to left, while last image depicts septum after correction with septoplasty.
There are many variations of septoplasty. Perhaps the most common form of nasal septoplasty is a submucous resection commonly called an SMR. This is where the surgeon removes a window of cartilage, presumably the deviated portion in a an effort to correct the breathing, most typically preserving an L-shaped strut. Dr. Shah does not subscribe to this standard SMR incision because he believes it is too destabilizing to the nose. He performed a study demonstrating that certain areas of the nose are necessary for support and appearance. Many surgeons may not recognize this as most do not routinely take photographs of patients for septoplasty.
Standard SMR Incision (shown in red)
Dr. Shah Variant of Incision (shown in red)
Why is this concept flawed of SMR for every deviated septum? Simply removing the cartilage from the nose in this location will not correct the majority of septal deviations. Unfortunately, many surgeons use this as their approach to all septal deviations.
A well thought out approach to the location of the septal deviation is necessary. If it is located in the anterior portion of the nose, This deviation will must be corrected or the patient will likely not have enough of an improvement postoperatively. It is important for surgeon’s to straighten the nose so that portion responsible for the deviation are corrected.
An analogy which can be helpful in understanding septal deviation is to think of the septum as a wood deck. The surgeon’s goal is to use a technique which is the least invasive to create a stable an straight deck. In some cases, this might mean removing a portion of the deck to try and striaghten it. In other cases, it may involve trying to sand down a portion or use cables in an attempt to straigthten it. Placement of stronger pieces of wood or steel may help straighten the deck as well. Finally, in some caes removal of the entire deck and replacement with a new structure may be necessary.
There are a variety of procedures the surgeon can do to straighten this including a swinging door, modified swinging door, and a total septal reconstruction, socring and placement of sutures.
Swinging Door Technique
Common Swinging Technique | Dr. Shah Swinging Door Variant
A swinging door technique is where the anterior portion of the septum is crooked and the surgeon attempts to swing the septum from one side to the other. There are a few variations of this technique. In the most commonly used variation, the surgeon removes a segment of cartilage along the floor of the nose creating a gap along the floor. The surgeon than either tries to move the septum to the midline or to the opposite side. Dr. Shah belief is that this is too destabilizing to the nose and advocates a variation of this technique. He suggests freeing the inferior portion of the septum from the floor of the nose and preserving the cartilage prior to swinging the cartilage to the opposite side. This allows for more support and less chance for loss of nasal tip support. While the swinging door technique can be a powerful technique, it is best used in specific circumstances. This is when the anterior portion of the septum is straight and does not have a significant bend within the shape of the cartilage itself. If there is a prominent bend in the cartilage, the septal cartilage will retain this bend and swining the cartilage from one side to the other will not significantly improve the airway.
Cartilage Scoring and Suture Placement
Some surgeons use scoring and sutures to help straighten septal deviations. This may be appropriate in milder cases of deviation, but will not work in severe deviations. In our deck analogy, we can see that using procedures to weaken the septum must be due judicioulsy as it may interfere with structureal support. Long term use of sutures or absorable plates such as PDS plating in straightening septums is not known. Structural, septal cartilage has a high resilence and more often these techniques are not to be used in major structural deviations.
Use of Nasal Grafts
Sometimes, placement of cartilage grafts alongside the septum can help straighten out a septal deviation. The concept here is similar to the warped deck where placemet of a stronger material is sutured to the weaker material. This may be strong enough to striaghten the nose in cases where the septum has a stronger bend anteriorly or along the bridge of the nose. Such grafts include caudal extension grafts, spreader grafts. Dr. Shah uses a variety of grafts here to straighten the nose, many of which have not been described in the scieintific literature to help straighten the nose.
Resection and Replacement
In cases of severe septal deviations, the septum may need to be resected and replaced. A new L-strut is created and placed in the nose. This is a more invasive procedure, but may be necessary in select individuals with major septal deviations.
Before (left) and After (right) of patient with crooked nose deformity
*Actual Patient
Intraop photographs of patient with severe septal deviation (left) and with new L-strut (right)
*Actual Patient
Dr. Shah’s belief is to use the least invasive procedure to provide the straightest version of your nose. Dr. Shah frequently sees patients who have had septoplasty in the past who still can not breathe well. This is why a thorough evaluation of both the anatomic and medical workup of the nose is necessary to help determine the cause of diffficulty breathing.
Frequently Asked Questions
In cases of severe septal deviations, the septum may need to be resected and replaced. A new L-strut is created and placed in the nose. This is a more invasive procedure, but may be necessary in select individuals with major septal deviations.
What is septoplasty?
Septoplasty is the alteration of the septum to straighten the airway and/or remove cartilage for cartilage grafting. The most common form of this is a submucous resection. This is where the surgeon preserves an L-shaped strut of cartilage in an effort to not change the nasal appearance. The surgeon then removes the cartilage which is presumably causing the nasal obstruction.
Why is this concept flawed?
Simply removing the cartilage from the nose in this location will not correct the majority of septal deviations. Unfortunately, many surgeons use this as their approach to all septal deviations. A well thought out approach to the location of the septal deviation is necessary. If it is located in the anterior portion of the nose, This deviation will must be corrected or the patient will likely not have enough of an improvement postoperative. There are a variety of procedures the surgeon can do to straighten this including a swinging door, modified swinging door, and a total septal reconstruction.Some surgeons use scoring and sutures. This may be appropriate in milder cases of deviation, but will not work in severe deviations.The most difficult area to address is if the dorsal (top) part of the septum is deviated. Commonly spreader grafts can be placed aside the septum to attempt to straighten it. Sometimes, total septal reconstruction is necessary to straighten the septum. For this reason, many surgeons have difficulty with the crooked nose deformity. Even if the septum is completely replaced, it still may be crooked postoperative.
I just want to breathe better, will my nose look the same after surgery?
Maybe. Dr. Shah just performed a study looking at nasal tip projection with septoplasty on cadavers. All of the noses lost projection after completion of a more advanced SMR techniques. It is critical that if your nose has an advanced septal deviation, that an expert in external as well as intenral support of the nose can perform the surgery. Your surgeon should be able to reestablish projection in case there is noticeable change. If he can not, consider looking elsewhere.
In addition, if you require support of the nasal valves, your nose will likely become slightly fuller alongside the nasal tip. Usually this is temporary fullness, but in patients with sufficient collapse requiring larger grafts this fullness may be permanent.
My plastic surgeon wants to use an ENT to do the septoplasty and he is going to do the rhinoplasty, any concerns?
Yes, you should be very concerned. If your rhinoplasty surgeon can not perform a septoplasty he can probably should not be doing a rhinoplasty. The septum plays a fundamental role in rhinoplasty. The septum lays the foundation for the rest of your nose. You would not go to a builder who could not lay down foundation. If your septum is crooked and not corrected properly (see above) you will be left with a crooked nose.
What are septal spurs?
Along the floor of the nose, their may be bony or cartilaginous projection into the nose which can cause nasal obstruction. These can be removed by a variety of methods to open the airway including osteotomies or powered instrumentation.
If my septum is crooked, how come I can’t see it?
You may or may not be able to see it depending on what portion is crooked. If the very anterior portion (front) of the surface is crooked, you may notice on the base view or the nasal tip with slight deviation. If the dorsal portion (top of the septum) is crooked, you may notice that the nose is crooked as well.
What is a septal deviation?
A septal deviation is a septum which obstructs the airway. It can be tilted to one side, curved to one side, curved and recurved.
Why do people have deviated septums?
No one really knows. Some people speculate that birth trauma plays a role. Trauma later in life can also lead to deviation. One study cites 80% of the adult population has a deviated septum. A deviated septum in and of itself is not a problem unless it causes nasal obstruction or deformity.
What does Dr Shah do with the cartilage he removes?
In some cases, he uses the cartilage for other areas of the nose or septum to support the nose. This can support the valves of the nose, provide aesthetic improvments, or help straighten the septum. If none of these changes are necessary, Dr. Shah will crush the cartilage and place it back in the septum. He does this for a variety of reasons. Cartilage in between the flaps can help prevent floppy septum syndrome. Cartilage placed back in the nose can serve a functional or aesthetic purpose if a procedure is needed in the future due to a traumtic accident.
Should I do my septoplasty at the same time or differnet time than my rhinoplasty?
Patients should always do a rhinoplasty and septoplasty at the same time. First of all, some of the deviated portions of cartilage can help support the nose post procedure and make aesthetic changes to the nose. Not having this portion of cartilage, may make a subsequent rhinoplasty more complex and may necessiate the use o either ear or rib cartilage. In addition, combination of the two procedures allows for one recovery. Finally, it is typically less costly to perform a rhinoplasty with a septoplasty with insurance than a rhinoplasty alone.