Accounts of surgical procedures designed to establish a normal anatomic nasal airway can be found as far back as the late 19th century. In fact, some of the most recognized names in surgery have been associated with descriptions of surgical techniques and innovations to improve nasal airway surgery, including Asch, Killian, Freer, Metzenbaum, Cottle, Converse, and Goldman among others.

Nonetheless, success and patient satisfaction rates reported within the literature often hover around 70%. This would suggest that the way we think about the problem and the teaching of the surgical correction of the nasal airway must be revisited, broadened, and continually honed.

Any number of structural deformities might affect the nasal septum. The obstruction might be cartilaginous, bony, or both. One might see tilts to the septum, curves, spurs, twists, angulations, telescoping segments, or any combination of these. Septal deviations might occur within a nasal framework that is externally straight, crooked, twisted, or collapsed. The airway might be compromised at the internal nasal valve, the external nasal valve, both, or neither. Considered in this light, it is simplistic to think that there might be one operation to correct all nasal airway problems. Furthermore, it becomes self-evident that routinely applying a single “standard” operation to all patients presenting with nasal obstruction and a deviated septum is doomed to fail in a significant number of cases from the outset. In essence, there is no “one-size-fits-all” solution to this variable, complex, and often underappreciated challenge.

“Septoplasty” is best thought of as a reconstructive procedure. Only then does one begin to do away with the notion of any single “standard” excisional procedure and instead proceed more creatively to design an operation tailored to the particular needs of and unique deformity in each patient. At the same time, this very construct makes it virtually impossible to describe how to address all possible circumstances that the surgeon might encounter. At the very least, however, a foundation for more thoughtful, considered surgery will provide a basis upon which surgical experience can be developed, and with greater surgical experience, more consistent outcomes and more grateful patients will inevitably follow. With that in mind, I will endeavor to provide some general guidelines for the more basic or routine deformities. Equally importantly, I will endeavor to provide some recommendations on how to identify circumstances that are less routine and that would warrant more advanced surgical intervention in order to minimize failure and maximize success rates.

Upon completion of the physical examination, the surgeon should be able to describe or classify the septal deformity in detail. Limited descriptions such as “deviated nasal septum (DNS), left” or “nasoseptal deviation (NSD), right” are so vague in specifics as to be meaningless for they offer little guidance for the operation. It would be akin to saying simply “cancer, head and neck” or “disease, middle ear,” which would provide no direction to the head and neck surgeon or otologist, respectively.

If all septal deflections were fundamentally similar and one generic operation could be used for all patients, then perhaps such nondescript narratives would suffice. If, on the other hand, we go back to the concept that the correction of septal deflections is a calculated reconstructive procedure individualized for each particular patient, then detailing observations such as angulations, curvatures, spurs, findings within the valve region, and caudal septal irregularities will inevitably begin to focus a more targeted surgical strategy, which in turn should result in improved outcomes.

Imaging is not routinely necessary to diagnose septal or nasal valve pathology but is warranted if there is any suspicion of an alternative obstructive or inflammatory nasal mass.

In order to succeed, the surgeon must begin by knowing when the “routine” septoplasty will fail. The preoperative identification of more complex, high-risk circumstances or sites of potential failure is therefore paramount. With the physical examination complete, the surgeon should ask the following questions:

And finally—given all this information, is the correction of this patient’s deformity within the surgeon’s skill set, or should this be referred on to someone with the requisite experience needed for this particular case?

The patient is seen preoperatively in the holding area to review the goals of the operative procedure and the postoperative care and to verify elements of the physical examination that are best done in the awake patient such as nasal sidewall stability with inspiration. After consent is signed, the patient is instructed to use a nasal decongestant spray (e.g., oxymetazoline)—two sprays to each side of the nose, about 15 minutes prior to being taken back to the operating room.

Following the induction of general anesthesia, an oral RAE tube, secured down the midline, is used since the preformed contour allows it to sit easily and tension free in the midline. A standard endotracheal tube, on the other hand, is generally taped to one side or the other and can exert at least some pull on the nasal base and columella toward that side, which is felt to be counterproductive to the goal of establishing a centered nasal septum. A single dose of an intravenous antibiotic is given prior to making the incision.

I then once again use a nasal speculum to examine the nose to confirm the observations from the initial office consultation, and I palpate the caudal septum to reevaluate its strength, stability, and orientation.

Beginning posteriorly, I inject the nasal septum (and turbinates if reductions are planned) bilaterally with 1% lidocaine with 1:100,000 epinephrine. In order to benefit from the vasoconstrictive effect of the epinephrine, it is more important to widely distribute the local anesthetic through multiple points of injection than it is to concern oneself with attempting to forcefully distribute the local anesthesia via a single injection site at the caudal septum. The volume of the injection can also be used constructively to inflate or hydrodissect the septal mucosa from within deep grooves, angles, or crevices if present. Once the intranasal injections are completed, oxymetazoline-soaked pledgets are placed in each side of the nose. The operating table is then turned and the patient positioned appropriately for surgery and prepped and draped in a sterile fashion.

Through a hemitransfixion incision (Fig. 2.1) made at the free edge of the caudal septum, complete bilateral submucoperichondrial and submucoperiosteal flaps are elevated. As a right-handed surgeon, I prefer to start with a left hemitransfixion incision, but if the caudal septal edge is moderately or significantly displaced to the right side making it relatively inaccessible from the left, then a right-sided incision is made without hesitation. Flap elevation can be done using a Woodson, Freer, Cottle or suction elevator. I prefer to begin with a Woodson elevator (very sharp edges, very useful for getting into the proper plane of dissection and for teasing tethered mucosa from fracture lines or deep grooves), and I transition to a Cottle elevator further posteriorly in the nose when it becomes difficult to see over the curve of the spatulated end of the Woodson elevator.

Some surgeons prefer a Killian incision (an incision through septal mucoperichondrium parallel and 5 to 8 mm cephalic to the hemitransfixion incision just above the mucocutaneous junction) arguing that it preserves the mucosal attachments and blood supply to the caudal septum (Fig. 2.1). For septal deflections requiring any kind of manipulation or adjustment of the caudal septum, however, this access is limiting. More importantly, oftentimes subtle (but clinically relevant) abnormalities of the caudal septum are not fully apparent until complete exposure is achieved. By choosing to limit exposure of the caudal septum through a Killian incision, the surgeon risks leaving an unappreciated caudal septal deflection unaddressed. Furthermore, if one is planning on elevating complete flaps from both sides of the septum (which I do routinely), a hemitransfixion incision allows one to transition around the caudal edge of the septum with greater ease.

There are three reasons to routinely elevate bilateral mucoperichondrial flaps off of the septum as opposed to working through the elevation of one side only.