Advanced Septoplasty: Correction of Caudal Septal Deflection

The Problem

Nasal septal deviation is a common cause of nasal obstruction, a problem that can significantly impact an individual’s quality of life. Traditional septoplasty is adequate for treating the majority of septal deviations. However, deviation of the anterior septum poses unique anatomic challenges and renders traditional septoplasty insufficient.

These challenges include high rates of associated internal nasal valve (INV) stenosis as well as aesthetic deformity related to dorsal or columellar irregularities associated with caudal stenosis, both problems that, when present, must be addressed in order to achieve optimal results. Additionally, the keystone area—a term that refers to the attachment of the caudal septum to the bony dorsum and upper lateral cartilages—represents another challenge of addressing caudal septal deviation as destabilization of the keystone can result in compromised dorsal integrity and saddle deformity.

The Background

Numerous surgical techniques have been described for management of the caudally deviated septum. In 1929, Metzenbaum described the “swinging door” technique, in which a vertical piece of cartilage on the deviated side of the septum is removed, after which the caudal septum is repositioned toward midline. Additional described management options include use of biosynthetic material, such as polydioxanone foil, and use of autologous materials such as Medipore and silicone.

Perhaps the most widely known method for repairing severe septal deviation is extracorporeal septoplasty, a technique that was first described by King and Ashley in 1952. In this method, the entire cartilaginous septum is removed and then reconstructed. Gubisch has described this ­technique in detail and divides it into three main steps: (1) exposure and resection of the native septum; (2) reconstruction of the removed septum to create as straight as possible a graft; and (3) reimplantation of the septum, re-creation of the nasolabial angle with tongue-in-groove setback, and securing of the implant with transseptal sutures. Gubisch showed this technique to be highly effective, though did note a 9% revision rate. Revision was shown to most frequently be due to contour irregularity at the rhinion, which is the result of technical challenges in reforming the bony-cartilaginous attachment at the keystone, an area in which even small irregularities are visible.

The Indications

Anterior septal reconstruction (ASR), a technique described by Most, is a modification of extracorporeal septoplasty. This technique follows the same guiding principles as extracorporeal septoplasty with the exception that, in ASR, a dorsal strut is preserved, obviating the need for keystone reconstruction. This method thereby allows correction of severely deviated anterocaudal septal deviation while minimizing the risk of cosmetic deformity associated with notching at the rhinion.