Abstract
Objectives
The purposes of the study were to describe an objective technique for the evaluation of caudal septum deviation (CSD) and to evaluate the effectiveness of an open septorhinoplasty technique for treatment of CSD.
Study design
A retrospective review of septorhinoplasty cases involving CSD was performed. For all patients, preoperative basal view photographs were analyzed. All patients underwent an external septorhinoplasty approach for treatment of their CSD. After a minimum of 4 months, postoperative basal view photographs were analyzed.
Results
Seventeen patients had significant CSD and airway obstruction. The mean change in their caudal septum angle of deflection was 22° ( P < .05). All patients had subjective improvement in their nasal airway obstruction. There were no complications.
Conclusion
We describe a method to objectively analyze CSDs in septorhinoplasty candidates. An external approach using nasal base reconstruction techniques results in an improvement of CSD and subsequent nasal airway patency.
1
Introduction
Surgery for caudal septum deviation (CSD) is significantly more challenging than a more posterior septum deviation . The caudal septum provides support for the nasal tip structures. If caudal septum malformation is unrecognized and treated as a standard septoplasty, resection and weakening of the caudal septum will lead to disastrous functional and aesthetic results for the patient, as tip ptosis and asymmetry are likely to occur . Thus, recognition and analysis of the CSD are extremely important before organizing a surgical plan. Much has been written on the formal analysis of the basal view of the nose, but no standard analysis or measurement has been used to describe the CSD.
Multiple techniques, both external and endonasal, have been published for treating a CSD . The “swinging door” technique is one of the more popular endonasal approaches where the inferior septum is resected and then sutured to the nasal spine. Pastorek and Becker described a “modified swinging door” technique where rather than septum resection, the septum is swung over the nasal spine that then acts as a “doorstop” in securing and straightening the septum. Other endonasal techniques include cartilage scoring or morselization. Although the endonasal approach works well if only the inferior portion of the caudal septum is displaced from the nasal crest, more often, the entire vertical length is weak and malformed. If this portion of the caudal septum is not addressed, there will still likely be a deflection and lack of appropriate tip support. The chances for a successful correction of a CSD in this scenario are improved if the entire caudal septum is addressed. This is difficult to do with an endonasal approach. An external approach allows for complete analysis and treatment of the deviation and the increased likelihood of functional and aesthetic success.
Our preferred technique for treating a caudal septum deviation is via an external approach. Access to the caudal septum is attained by dissecting between the medial crura and releasing their attachments to the septum. The entire nasal spine is exposed, ensuring that the periosteum overlying the spine is left undisturbed. Once fully exposed, the deflection is analyzed; and the correction is carried out. If the deviation is due to excess septum that has fallen off the maxillary crest, then this portion is removed; and the remaining septum is sutured to the nasal spine, similar to the described “swinging door technique.” More often though the entire caudal septum is malformed; this then requires resection of the entire caudal septum with reconstruction using the resected quadrangular cartilage. Once the caudal septum is reconstructed, the medial crura are reattached to the new caudal septum to prevent long-term weakening and ptosis of the nasal tip.
The purpose of this article is to describe a formal objective analysis of the CSD and retrospectively report on our results in 17 patients undergoing an external septorhinoplasty for CSD.
2
Methods
Patients were selected from a rhinoplasty database gathered by the senior author (ML) over a 4-year period. All patients with identified CSD were included in the study. All procedures were performed in an outpatient, same-day surgery setting. Preoperative and postoperative photographs were analyzed. Minimum time to postoperative photograph documentation was 4 months. All patients signed informed consents for their images to be analyzed.
The measurement of the caudal septum angle of deflection (CSAD) requires a standard basal view of the nose. A vertical line through midline tip of the nose is made in a perpendicular fashion to a horizontal line through the base of the nose at the subnasale ( Fig. 1 ). A third line extending tangentially from the caudal deviation to the vertical line then creates the CSAD ( Fig. 2 ). This angle was measured pre- and postoperatively on each patient.
External septorhinoplasty was performed on each patient. An inverted “V” midcolumellar incision was combined with bilateral marginal incisions. The soft tissue envelope was elevated off of the lower and upper lateral cartilages ( Fig. 3 ). The medial crura were dissected free of the caudal septum ( Fig. 4 ). Bilateral mucoperichondrial and mucoperiosteal flaps were raised posteriorly along the entire cartilaginous and bony septum. Inferiorly, the nasal spine was widely exposed.
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