Correction of caudal septal deviation: use of a caudal septal extension graft.

A grossly deviated caudal septum can create an unappealing, asymmetric columella and cause significant nasal obstruction secondary to external valve collapse (figure 1, A). The treatment of nasal airway obstruction secondary to a severely deviated caudal nasal septum can be extremely challenging. Nevertheless, techniques such as septal cartilage scoring, morselizing, repositioning on the nasal spine, and even extracorporeal septal reconstruction (1) can be effective.

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Another option is placement of a caudal septal extension graft (CSEG) via an external or an endonasal approach. This is a versatile and reliable method of correcting a deviation and stabilizing the base of the nose. (2)

Surgical correction begins with elevation of bilateral submucoperichondrial flaps through a standard hemi-transfixion incision (figure 2, A). Quadrangular (septal) cartilage is carefully harvested with preservation of a dorsal and caudal strut (usually at least 7 mm in length). A pocket is created between the medial crura with gentle scissors dissection (figure 2, B). Dissection is facilitated by proper retraction with a small, double-prong retractor, which is used to evert the ipsilateral medial crus. The caudal septum is then freed from the anterior maxillary crest (figure 3), and the inferior edge is trimmed 2 mm and swung toward the midline.

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A CSEG is harvested from septal cartilage and cut to exact shape (figure 4). The graft overlaps the concave surface of the deviated caudal septum to alleviate obstruction on the affected side. It is secured in place with three 4-0 clear nylon sutures and three 5-0 monofilament polydioxanone sutures (PDS; Ethicon; Somerville, N.J.). The caudal septum and graft complex are positioned in the midline and stabilized with a 2-0 PDS suture to either the periosteum or through a drill hole in the nasal spine (figure 5). Graft stability can be enhanced by using two splinting or extended spreader grafts. (2)

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Using the tongue-in-groove technique to improve nasal-tip stability, (3) the surgeon secures the entire CSEG between the medial crura by placing two 5-0 PDS sutures and three 4-0 chromic sutures through-and-through the nasal vestibular skin (figure 6). Closure of the mucosal incisions and quilting of the septal flaps is completed with 5-0 and 4-0 chromic sutures, respectively. Bilateral Silastic splints are then placed for 5 to 7 days.

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The CSEG is a valuable tool in the armamentarium of the rhinoplastic surgeon. Maintaining an intact septal L strut and keystone area (i.e., the junction of the dorsal quadrangular cartilage and the perpendicular plate) is imperative in order to prevent nasal-tip collapse. Proper graft placement can alleviate structural nasal obstruction secondary to a severely deflected caudal septum while maintaining a stable foundation for the lower third of the nose (figure 1, B).

References

(1.) Most SP. Anterior septal reconstruction: Outcomes after a modified extracorporeal septoplasty technique. Arch Facial Plast Surg 2006;8:202-7.

(2.) Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8:156-85.

(3.) Kridel RW, Scott BA, Foda HM. The tongue-in-groove technique in septorhinoplasty. A 10-year experience. Arch Facial Plast Surg 1999; 1:246-56.

Annette M. Pham, MD; Travis T. Tollefson, MD, FACS 

From the Department of Otolaryngology--Head and Neck Surgery, University of California-Davis Medical Center. Sacramento.