• Mucosal contact; relief of pain or pressure with application of topical anesthetic and decongestant helpful in predicting successful result

Techniques

• Typically performed via an endonasal approach

• Incisions

1. Killian: unilateral L-shaped incision made just posterior to mucocutaneous junction

2. Hemitransfixion: unilateral incision made at the mucocutaneous junction on the caudal border of the septal cartilage; allows for better access to the caudal septum

3. Full transfixion: bilateral incision started at the mucocutaneous junction on one side and extended through to the contralateral mucocutaneous junction; allows for access to the caudal septum, columella, and medial crura; can theoretically lead to loss of tip support through disruption of septocolumellar ligament

4. External rhinoplasty/degloving: used for advanced maneuvers necessary to address nasal dorsum and/or caudal septum

• Endoscopic-assisted septoplasty

1. Advantages: magnification of field, improved access and visualization of posterior nasal cavity, ability for limited dissection in cases of isolated spur

2. Limitations: Unable to address severe deviations of anterior and caudal septum

• Surgical steps

1. Decongest, then inject local anesthesia into subperichondrial plane bilaterally

2. Make incisions down to cartilage, identify subperichondrial, avascular plane

3. Elevate mucoperichondrial flaps using broad sweeping movements

4. Disarticulate septal cartilage from bony septum at the bony-cartilaginous junction

5. Make a dorsal cut through the cartilage, parallel to the nasal dorsum, leaving at least 1 cm for structural support

6. Resect bony and cartilaginous deviation as necessary

7. Gently pulverize cartilage segment for reimplantation

8. Replace excised cartilage into mucoperichondrial pocket, taking care not to cause further obstruction

9. Repair rents primarily using absorbable suture

10. Close approach mucosal incision first (typically with 4-0 plain gut suture) to prevent shortening of the mucoperichondrial flap

11. Close septal layers by performing a quilting stitch with absorbable suture (such as 4-0 caprosyn)

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