15 Revision Septoplasty
The nasal septum is part of the medial nasal wall. It is composed anatomically of various bony and cartilaginous structures: the perpendicular plate of the ethmoid bone, the vomer, the posterior nasal spine, the transverse palatine suture, the maxilla with the anterior nasal spine, the incisive bone, the caudal rim of the anterior piriform aperture, and the quadrangular cartilage. It is common for these elements to move and shift relative to one another during cranial growth. Multiple components are always involved in bowing of the medial nasal wall. 1 The septal cartilage functions as a kind of “crumple zone” for absorbing unphysiologic stresses ( Fig. 15.1 ).
Septal deviation may occur during periods of special “tec-tonic unrest” in cranial growth (e.g., during puberty) or may result from trauma relating to nasal, septal, or midfacial fractures. Postoperative septal deviation may develop because the original surgeon ignored this problem during the primary rhinoplasty, or may result from inadequate fixation, scar traction, or incomplete relaxation of the cartilage. Besides bowing, the septum may also be too long or too high for the nasal cavity in certain of its dimensions, resulting in septal subluxation or a tension septum. The nasal septum is attached to the bony nasal pyramid in the keystone area. It also has firm attachments to the upper lateral cartilages and alar cartilages. The septal cartilage and upper lateral cartilages form an anatomic unit. The cartilaginous septum joins with the anterior edge of the upper lateral cartilages to form the “internal nasal valve,” which is the narrowest part of the nasal airway.
The nasal septum is important in revision septorhinoplasties for several reasons:
Its functional importance for nasal breathing
Its function as a “pillar” to support the nasal dorsum
Its role in shaping the nasal tip (tip support mechanism)
Its role in maintaining the position of the nasal tip
The attachment of the cartilaginous septum to the midface in the keystone area
Its involvement in axial deviations and crooked noses
15.1 Functional Importance of the Nasal Septum
15.1.1 Functional Importance for Nasal Breathing in Revision Surgery
Since ~ 20 to 30% of patients complain of impaired nasal breathing or dry membranes after functional rhinoplastic surgery, the concept of septal surgery should be continually reviewed. 2 What should functional surgery look like? A curved septum in itself will not necessarily cause breathing problems. The goal of septal surgery should be a centrally positioned septum that divides the vestibule and nasal cavity into two airways of approximately equal size.
15.1.2 Supportive Function
Slight bowing, especially in the thin, fragile cartilage of the nasal septum, may generate intrinsic forces that contribute significantly to the overall supportive function of the cartilaginous nose. 3 If the cartilage is weakened at one site or a gentle curve is straightened, this may cause the cartilage to give way and produce dorsal saddling. The mechanical strength of the septal cartilage may be evident preoperatively and can be assessed by internal and external palpation, but often its supportive properties can be fully appreciated only during the operation.
15.1.3 Shape and Position of the Nasal Tip
The tip support mechanisms critically influence the shape and position of the nasal tip. For example, the attachment of the medial crural footplates to the anterior edge of the caudal septum significantly affects the projection and protection of the nasal tip and the configuration of the three septal angles. The rhinosurgeon should understand the various ways in which the projection, shape, position, and rotation of the nasal tip can be modified by septal surgery. 4 – 7 The major and minor tip support mechanisms described by Tardy are still of crucial importance and are outlined below. 7
Major tip support:
Size, shape, thickness, and resilience of the alar cartilages
Attachment of the upper lateral cartilages to the cephalic margin of the alar cartilages
Wrap-around attachment of the medial crural footplates to the caudal septum
Minor tip support (may contribute major support in some anatomic variants):
Anterior septal angle
Skin of the nasal tip
Membranous septum
Caudal septum
Nasal spine
Ligamentous sling spanning the paired domes of the alar cartilages
Sesamoid cartilage complex extending the support of the lateral crura to the piriform margin
The area of the rhinion is rightly called the keystone area because, like the architectural keystone in a gothic arch, it supports the entire nasal dome and attaches it to the piriform aperture. If that attachment is released and is not repaired, an inverted-V deformity will result due to separation of the cartilaginous nose from the piriform aperture.
15.1.4 Axial Deviations and the Crooked Nose
Gustave Aufricht summarized the role of the nasal septum by noting that “Where the septum goes, there goes the nose.” While it is true that a septoplasty cannot correct all deformities, nothing can be accomplished without it. This applies equally to the functional tension nose, the reconstruction of saddle deformities, and the correction of a cartilaginous crooked nose. In all these cases, the selective release of tension or a stable reconstruction of the septum is the key to a successful outcome.
15.1.5 The Vomeronasal Organ—the Seventh Sense?
The term “pheromones” was coined by A. Butenandt for molecules that are produced by a species and evoke certain reactions in animals of that species. The vomeronasal organ (Jacobson′s organ) is essential for the social and mating behaviors of all mammals. 8 Many observations and studies have shown that pheromones also transmit signals in humans.
The vomeronasal organ has been identified as a pair of tiny, blind-terminating canals located in the anterior nasal septum. Morphologic findings suggest that the vomeronasal organ consists of functioning sensory epithelium ( Fig. 15.2 ). Further studies are needed to identify its central projections to the hypothalamus and determine its functional importance.
15.2 Brief History of Septoplasty
In 1867, Leinhardt described the first submucous resections of the nasal septum for correction of the anterior septum. Hart-mann and Petersen expanded the method, also applying it to deviations of the posterior septum. 9 , 10 Gustav Killian (1860–1920) injected a cocaine–epinephrine solution beneath the two mucosal layers to separate the mucosa from the cartilage on both sides and developed the technique of the submucous septal resection. 11 The overresection of healthy cartilage from the anterior septum led to late complications such as depression of the cartilaginous nasal dorsum and retraction of the columella, with the functional and aesthetic problems of a saddle nose and hidden columella. Mucosal lesions related to the overresection or poor vascularity of the scarred mucosal layers predisposed patients to perforations. As an alternative to the Killian resection, therefore, Maurice Cottle (1896–1981) introduced his cartilage-conserving technique, which was better able to preserve the supportive function of the septal cartilage. 12 In modern parlance the Cottle septoplasty is considered to be synonymous with cartilage-conserving septal surgery. Today the classic “maxilla–premaxilla approach for extensive septal surgery” no longer has this connotation and is no longer practiced in the classic manner. Some authors advocate a conservative approach while others report good results with an extracorporeal septoplasty in which the septum is removed from the nose, straightened externally, and reimplanted.
15.3 Preoperative and Intraoperative Analysis
A functional and morphologic analysis provides an important basis for developing an individual surgical plan. 6 , 7 , 13 , 14 Special rules apply to surgery of the pediatric nasal septum (see Chapter 6, Section 6.1). 15 It is important in revision surgery to evaluate the extent of cartilage defects, residual or recurrent deviations, and scarring and hydration of the mucosa. Because deviations are so varied in their morphology and relevance, a variety of surgical techniques should be available. There is no such thing as a standard septal operation. The less traumatizing the procedure, the fewer problems will arise in wound healing. For this reason, the reorientation and trimming of deviated segments should always be considered as an initial option before proceeding with an external septoplasty.
15.4 Swinging-Door and Swinging Double-Door Techniques
Mobilizing the septal cartilage in a swinging-door fashion after a horizontal and vertical chondrotomy is the standard technique for the correction of anterior deviations. Mucosal tunnels are developed, and the anterior nasal spine is exposed. The quadrangular cartilage is then released from the bony nasal floor, perpendicular plate, and vomer by vertical and horizontal incisions ( Fig. 15.3 ).
Often the septum can be straightened in this approach by resecting slivers of cartilage to achieve shortening and relaxation and by the removal of ridges and spurs. It should be noted that permanently straightening a deviated cartilage by making scoring incisions on the concave side is rarely successful in revision settings. Preexisting and new scar contractures tend to redeflect the cartilage toward the deviated side. Transseptal mattress sutures can be placed to counteract this tendency during postoperative healing. Scoring also weakens the biostatic properties of the cartilage and compromises its mechanical stability.
Fig. 15.4 shows the main intraoperative details for a septal correction through a hemitransfixion incision, which is perhaps the most widely used rhinosurgical approach in general.
Vertical division of the deviated cartilage at the apex of the curve is an effective technique that yields good long-term results. It allows the fragmented cartilage to be repositioned in the midline without tension. The swinging-door technique is suitable for this procedure.
Tips and Tricks
Superior tunnel: This route is useful for a previously corrected septum with basal deviation. The mucoperichondrium is elevated above the basal problem zone, preferably on the concave side of the deviation, and a tunnel is developed through which scars and patchy adhesions can be sharply divided.
Posterior access: Working through the superior tunnel, the surgeon can more easily undermine the mucoperichondrium in a posterior-to-anterior direction.
Freer test: “Free fall” of a Freer elevator into the nasopharynx at the end of the septoplasty confirms the successful elimination of all morphologic obstructions ( Fig. 15.5 ).
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