Wedge resection and modified mattress suture for correcting anterior septal deviation: how we do it

Wedge Osteectomy of Bony Cap in Rhinoplasty: Minor Nasal Bone Hump Reduction

BACKGROUND

Hump reduction with traditional ostectomy is an invasive procedure performed in aesthetic rhinoplasty. Natural and flawless nasal dorsum can be obtained with wedge ostectomy (WO) technique.

OBJECTIVE

The objective of this study is to describe the nasal dorsum WO technique and examine its effectiveness in correcting nasal dorsum with absent and minor humps in patients undergoing aesthetic rhinoplasty.

MATERIALS AND METHODS

Senior author performed 488 rhinoplasty and septorhinoplasty operations from April 2009 to April 2021. After exclusion of major hump patients, the remaining 312 patients had a secondary evaluation for suitability for wedge ostectomy. After secondary examination, 87 patients, including 19 with absent humps (0 mm) and 68 with small humps (1-3 mm) were operated.

RESULTS

Nasal bone hump reduction with WO has proven satisfactory results in majority of patients, minimal revision in done in five patients but no complications were occurred related to this method.

CONCLUSIONS

Nasal dorsum WO provides lesser invasive approach to bony hump reduction in selected patients, ensuring bone cortex continuity in nasal dorsum. It decreases possible dorsal nasal irregularities associated with conventional coronal plane ostectomies. At the same time, it provides a natural and anatomically accurate nasal dorsum.

The Effectiveness of Releasing the Lower Lateral Cartilage Through Intranasal Z-plasty Incision on the Vestibular Web During Secondary Correction of Nasal Deformities in Complete Unilateral Cleft Lip and Palate

The primary goal in the secondary correction of unilateral cleft lip nose deformity is to achieve symmetry of the nose and nostril. This study aimed to investigate the efficacy of freeing the lower lateral cartilage from the pyriform ligament through an intranasal Z-plasty incision on the vestibular web in adult patients with complete unilateral cleft lip and palate. Thirty-six patients with complete unilateral cleft lip and palate, who underwent open rhinoplasty between August 2014 and December 2021, were identified retrospectively. Five parameters for nose form and nostril symmetry were measured on basal views through 2-dimensional photographic analysis. The patients were divided into subgroups with or without septoplasty. Cleft-to-non-cleft ratios between the Z (13 patients) and non-Z groups (23 patients) were compared using the Mann-Whitney U test. The mean follow-up was 12.9 months (6-31 mo). In the Z group, there were significant differences between the preoperative and postoperative values for nostril angulation, regardless of septoplasty (all P <0.05). Despite septoplasty, significant differences in the postoperative changes in nostril angulation were found between the Z and non-Z groups (all P <0.05). Intranasal Z-plasty on the plica vestibularis is an effective technique for releasing the lower lateral cartilage, improving the nostril asymmetry in cleft lip nose deformity.

Correcting Caudal Septal Deviation with a Modified Horizontal Mattress Suture

Correction of caudal septal deviation remains surgically challenging, given its imperative function as a nasal tip stabilizer and factor in tip projection, as well as its impact on the nasolabial angle and length of the nose. Although various procedures have been devised to repair the caudal septum using grafting techniques, correction with minimally invasive isolated suture techniques is limited. In this case report, we describe a modified horizontal mattress suture to correct caudal septal deviation in a patient undergoing revision septorhinoplasty. The patient followed up for 2 years after the surgery, and correction of the anterior caudal septum deviation remained intact.

North American survey and systematic review on caudal Septoplasty

Background

Surgical correction of caudal septal deviation is a technically challenging step of functional rhinoplasty. Multiple surgical techniques have been described in the literature but comparing the efficacy of each in relieving obstruction presents a challenge. Outcome measures are necessary to adequately compare techniques. This study aims to describe the current caudal septoplasty techniques of Otolaryngologists and Facial plastic and reconstructive surgeons (FPRS), as well as their use of outcome measures, and to compare these practices with surgical trends described in the literature.

Methods

An online survey was sent to three Otolaryngology and FPRS associations in Canada and the United States. A systematic review was conducted on SCOPUS and PubMed to classify the caudal septoplasty techniques described in the literature and the outcome measurement tools used.

Results

Our survey identified that caudal septoplasty is more commonly performed by surgeons with an FPRS training background. The most common techniques were the swinging door technique (69.5%), extracorporeal septoplasy (46.7%), cartilage scoring (45.3%), and splinting with bone (25.4%). Despite using a vast array of surgical techniques, North American physicians rarely rely on standardized outcome assessment tools. Patient reported outcome measures (PROMs) are used almost twice as frequently in the literature as they are by surgeons in their clinical practice.

Conclusion

We recommend that future studies of caudal septoplasty include an assessment of both form and function using a validated PROM such as the Standardized Cosmesis and Health Nasal Outcomes Survey.

Outcomes of Endonasal Septoplasty and Extracorporeal Septal Reconstruction in Anterocaudal Septal Deviation

OBJECTIVE

The aim of this study was to compare the functional and aesthetic outcomes of endonasal septoplasty (ES) and extracorporeal septal reconstruction (ESR) in anterocaudal septal deviation.

METHODS

In this study, patients (n = 46) who underwent nasal septoplasty surgery due to anterocaudal septal deviation during February 2015 to August 2017 were analyzed; 23 patients underwent ES and the others (n = 23) underwent ESR. The decision of whether to use the ES or ESR was randomized by random number table method. Nasal obstruction symptoms evaluation (NOSE) scores, total nasal resistance (TNR), aesthetic visual analog scale (VAS), nasal anatomical angles, and incidence of complications were used to assess the patients in 2 groups.

RESULTS

The NOSE scores, TNR, aesthetic VAS, tip deviation angle (TDA), nasolabial angle (NLA), nasofrontal angle (NFA) in the ESR group were significantly improved from preoperative to postoperative 1 year, whereas in the ES group, except aesthetic VAS, NLA, NFA, all other postoperative outcomes were improved from preoperative values. The objective and subjective postoperative results of ESR group were better than the ES group except TDA. The incidence of complications was not significantly different between the 2 groups.

CONCLUSION

Our study have compared the nasal functional and aesthetic outcomes of 2 septoplasty techniques in a randomized controlled trial. The ESR technique is more effective than ES technique in correcting functional and aesthetic disorders caused by anterocaudal septal deviation.

Triangular excision and submucosal rejoining to correct horizontally folded caudal nasal septum

BACKGROUND

Surgical correction of severe caudal deviation of nasal septum using an endonasal approach is challenging for surgeons. Among cases of severe caudal septal deflection, fracture lines along the horizontal direction are occasionally encountered during the surgery. We devised a simple and efficient technique called "triangular excision and submucosal rejoining" to address this kind of deformity.

METHODS

A total of 9 patients with severe caudal septal deflection underwent "triangular excision and submucosal rejoining." After the removal of the deformed posteroinferior portion of the quadrangular cartilage, 2 incision lines were made on the remaining caudal septum, starting from a point at the most anterior portion of the fracture line and diverging posteriorly above and below the fracture line. After removing a triangular cartilaginous piece, the upper and lower remaining cartilage segments were approximated using a single or 2 simple interrupted sutures. Sutures exiting the mucosa were re-entered from the exit point so that all the sutures were buried underneath the mucosa while the mucosal flap was elevated only unilaterally.

RESULTS

This technique was effective in all cases. Septal batten grafts were applied in 3 patients, in whom the remaining quadrangular cartilage was weak and thin. One patient showed a mildly recurred septal deviation, but the nasal cavities remained patent with no symptoms. Serious complications such as dorsal saddling or tip ptosis did not occur in any cases.

CONCLUSION

"Triangular excision and submucosal rejoining" may be a safe and efficient septoplasty technique to correct a horizontally folded caudal septum.

Questionable Effect of Crosshatching Incision in Septoplasty

Objectives

Crosshatching incision has been considered a useful method for correcting cartilaginous septal deviation. The aim of this study was to determine the utility and limitations of this approach.

Methods

This retrospective case-control study included 353 patients who underwent septoplasty performed by a senior surgeon between January 2004 and December 2010. Patients were classified into two groups according to whether crosshatching incision was performed (n=151) during septoplasty or not (n=202). All other techniques performed during septoplasty were identical. The parameters of surgical success (improvement of nasal obstruction, correction of deviation, and acoustic rhinometry results) and adverse effects were compared between the groups.

Results

There were no significant differences in the parameters of surgical success between the groups (improvement of nasal obstruction, P=0.333; correction of deviation, P=0.608; acoustic rhinometry results, P=0.322 for the difference in the minimal cross-sectional area; P=0.919 for difference in volume). Relative to patients who did not undergo the cross-hatching incision, patients with whom the technique was performed showed a significantly higher incidence of saddle nose (0/202 vs. 4/151 cases, P=0.033) and overcorrection (0/202 vs. 5/151 cases, P=0.014).

Conclusion

Crosshatching incision during septoplasty did not produce better surgical outcomes; however, it caused adverse effects such as saddle nose and overcorrection. Therefore, the use of crosshatching incision should be re-evaluated.

Use of a crossing suture to correct caudal septal deviations

BACKGROUND

Septoplasty usefully treats patients with nasal obstructions caused by septal deviations. However, correction of a caudal septal deviation remains surgically challenging; no standard procedure is available, although various procedures have been introduced. In this work we propose a simple, safe, and time-saving technique for patients with caudal septal deviations.

METHODS

The medical records of 50 patients with caudal septal deviations who underwent septoplasty using a crossing-suture technique from October 2016 to October 2018 were retrospectively reviewed. Postoperative nasal obstruction status and patient satisfaction with their surgical outcomes were subjectively evaluated using the Nasal Obstruction Symptom Evaluation (NOSE) score and telephone interview, respectively. Pre- and postoperative endoscopic findings were evaluated and postoperative complications developing during follow-up were recorded.

RESULTS

The NOSE scores of all patients improved after septoplasty. The mean score fell from 13.46 to 3.97, and this change was significant (p < 0.0001). No complication related to use of the crossing suture was encountered.

CONCLUSION

The crossing-suture technique is a simple, safe, and useful surgical option for correction of caudal septal deviations.

Combined use of scoring incisions and 2-octylcyanoacrylate adhesive during endonasal septoplasty to correct cartilaginous deviations

BACKGROUND

Applying 2-octylcyanoacrylate (2-OCA) tissue adhesive onto scoring incisions may increase efficacy and prevent concavity recurrence after septal deviation treatment. The present study evaluates the utility of 2-OCA adhesive application during endonasal septoplasty.

METHODS

The postoperative outcomes were compared between two consecutive periods in a single surgical department. Between March 2011 and March 2012, 23 consecutive patients underwent septoplasty using scoring incisions without 2-OCA application (scoring alone group), and between April 2012 and April 2013, the scoring incision gaps were filled with 2-OCA in 27 patients (scoring + CA group). The patients were followed up for more than six months.

RESULTS

A straight septum was achieved in 37.0% of patients in the scoring alone group versus 58.3% in the scoring + CA group. The postoperative symptom score for nasal obstruction was significantly improved in both groups. Persistent septal swelling developed in three (12.5%) patients in the scoring + CA group. Neither group experienced major complications such as septal hematoma, abscess, or septal perforation.

CONCLUSIONS

Application of 2-OCA adhesive onto scoring incisions appears to be a reliable and effective technique to correct deviated cartilage during endonasal septoplasty. However, the volume of 2-OCA applied onto the septum should be minimized to avoid potential foreign body reaction. A long-term follow-up study is warranted.