Septal deflections have traditionally being addressed by endonasal techniques. Open septoplasty describes using the open rhinoplasty approach to address septal deflections and deficiencies. Accordingly, the authors will highlight the history of open septoplasty, anatomic aspects, diagnosis of septal deflections, and technical nuances in performing open septoplasty. Accordingly, authors will highlight the history of open septoplasty, anatomic aspects, diagnosis of septal deflections, indications and technical nuances in performing open septoplasty.
History
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. 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. 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 1956 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 Zagreb 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.
Anatomy
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.
Anatomy
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.
Physiology
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.
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. 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.
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.
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