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Correction of the severely deviated septum: extracorporeal septoplasty.

While classic techniques are often successfully employed to address mild to moderate deflections of the nasal septum, the severely distorted septum represents a unique challenge for the surgeon. Patients frequently present with both aesthetic and functional concerns, often as a result of trauma, previous surgery, and/or congenital malformations (figure 1).

Several techniques have been proposed to address the severely deviated septum, including septal modification, (1) crossbar and camouflage grafis, (2,3) swinging door technique, (1) splinting of the septum with autologous or synthetic materiais, and extracorporeal septoplasty. (4) The latter represents a novel and evolving technique for the surgical correction of the severely deviated septum.

Extracorporeal septoplasty begins with initial exposure via both marginal and columellar external rhinoplasty incisions. The domes of the lower lateral cartilages are separated from one another. The upper lateral cartilages are released from the dorsal septum, facilitating wide exposure of the septum. Submucoperichondrial flaps are then elevated bilaterally. Care is taken to raise the flaps down to the maxillary crest and extend them back to the bony-cartilagenous junction of the perpendicular plate of the ethmoid, vomer, and quandrangular cartilage (figure 2).

The traditional extracorporeal septoplasty technique as described by Gubisch in 1995 suggested explant of all of the septal cartilage. (5) This technique was then modified by Most to maintain a 1.0- to 1.5-cm dorsal cartilagenous strut in the anterioposterior dimension. (2) The crooked septum is resected and the explanted septal remnant(s) (figure 3) are placed on the back table. An "L-strut" is fashioned, utilizing cartilage scoring, partial-thickness tension-releasing incisions, wedge excision, (6) or complete fragmentation and restoration on PDS foil (PDS, Ethicon; Norderstedt, Germany). (4,7)

Once the neoseptum has been reconstructed, the graft is placed onto the most concave aspect of the remaining dorsal strut, or the side opposite the deviation. The preservation of this dorsal strut at this "keystone" area allows the surgeon to secure the reconstructed septal L-strut to the native keystone cartilage. The graft is then sutured with 4-0 PDS or clear nylon between the remaining dorsal strut and the upper lateral cartilage. The contralateral upper lateral cartilage may be secured to the remnant dorsal strut or, in cases of internal valve collapse, a spreader graft (figure 4) may be placed to assist in support of the neoseptum. Final graft position is demonstrated in figure 5.

The mucoperichondrial flaps are then placed back into original position and secured to the neoseptum with a quilting suture (4-0 Chromic), thereby further securing the reimplanted septum, closing dead space, and reapproximating the nasal mucosa. The nasal tip and medial crus of the lower lateral cartilages are secured to native position using 5-0 PDS suture. The columellar incision is then closed with 5-0 Monocryl, followed by 7-0 nylon, and the marginal incisions with 5-0 Chromic. Bilateral silastic splints are left in for up to 7 days postoperatively. Standard external taping and splint are applied.

Extracorporeal septoplasty is a valuable tool in the armamentarium of the nasal surgeon for the reconstruction of the severely deviated septum. Modifications to the original technique seek to improve stabilization of the dorsal septum, thereby decreasing the potential for aesthetic complications (e.g., saddle-nose deformity). Extracorporeal septoplasty offers the surgeon the opportunity to correct the septum under direct visualization, shape the nasal vault, and address the nasal dorsum with the ultimate goal of providing both form and function for the patient with a complex septal deviation.

References

(1.) Fettman N, Sanford T, Sindwani R. Surgical management of the deviated septum: Techniques in septoplasty. Otolaryngol Clin North Am 2009;42(2):241-52.

(2.) Most SE Anterior septal reconstruction: Outcomes after a modified extracorporeal septoplasty technique. Arch Facial Plast Surg 2006;8(3):202-7.

(3.) Persichetti P, Toto V, Marangi GE Poccia I. Extracorporeal septoptasty: Functional results of a modified technique. Ann Plast Surg 2012;69(3):232-9.

(4.) Gubisch W. Extracorporeal septoplasty for the markedly deviated septum. Arch Facial Plast Surg 2005;7(4):218-26.

(5.) Gubisch W. The extracorporeal septum plasty: A technique to correct difficult nasal deformities. Plast Reconstr Surg 1995;95(4): 672-82.

(6.) Senyuva C, Yucel A, Aydin Y, et al. Extracorporeal septoplasty combined with open rhinoplasty. Aesthetic Plast Surg 1997;21(4): 233-9.

(7.) Bonisch M, Mink A. Healing process of cartilage attached to a polydioxanone implant [in German]. HNO 2000;48(10):743-6.

Toby Steele, MD; Jamie L. Funamura, MD; Benjamin C. Marcus, MD; Travis T. Tollefson, MD, MPH

From the Department of Otolaryngology-Head and Neck Surgery, University of California, Davis Medical Center, Sacramento (Dr. Steele, Dr. Funamura, and Dr. Tollefson); and the Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin, Madison (Dr. Marcus).
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Title Annotation:FACIAL PLASTIC SURGERY CLINIC
Author:Steele, Toby; Funamura, Jamie L.; Marcus, Benjamin C.; Tollefson, Travis T.
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Sep 1, 2013
Words:774
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