689
Fig. 15.19 Septal deviation can take
place at along the entire length of
septum: the mid-septum, dorsal septum,
and caudal septum
Operative Techniques of Deviated Nose
690
Correction of the Mid-Septal Deviation
SMR is the traditional solution to mid-septal deviation that remains the most popular option, which resects the deviated
septal cartilage and bone while leaving the dorsal and caudal L-strut intact (Fig. 15.20). The resected cartilage is used for tip
plasty or spreader graft.
With adequate protection of mucoperichondrium, an L-shaped incision is made in the quadrangular cartilage while leav-
ing behind a minimum of 10–12 mm of L-strut. However, the width of L-strut should be inversely proportional to the strength
of the septal cartilage. A robust L-strut is the only prevention against saddle-nose deformity, with the dorsal portion of L-strut
being more important than the caudal portion. A weak L-strut may not lead to any problem in the early postoperative period
but can, over several years, lead to collapse of dorsal septum and upper lateral cartilages, as well as columella retraction.
The transition should be curved between the dorsal and caudal L-strut and also between the perpendicular plate of eth-
moid and the dorsal L-strut because the curved line can support the mid-vault more strongly compared to a right angle
(Fig. 15.21). The L-incision should be made using sharp scissors from cephalic to caudal direction (Fig. 15.22). Quadrangular
cartilage can be separated easily from the perpendicular plate and vomer with gentle pressure from the D-knife or septal
elevator. The cartilage should be dislocated from the tongue-and-groove junction using the same instrument. Subsequently,
the cartilage portion of septum can be brought out of the space. If the cartilage is not harvested to be used as a graft, the
amount of resection should be kept to a minimum to lower the risk of nasal obstruction.
a
b
Fig. 15.20 Submucosal resection (SMR)
Fig. 15.21 Curved transitions are
recommended for stronger support of
the mid-vault. Instead of sharp angles,
the curved transitions are made between
the dorsal and caudal L-strut and also
between the dorsal L-strut and the
perpendicular plate of ethmoid
15 Deviated Nose Correction and Functional Rhinoplasty
691
After the cartilage resection, the deviated portions of bony septum (ethmoid bone, vomer, maxillary crest) are removed in
small sections, using septal forceps or bone rongeur. Forceful handling of bony ethmoid plate with forceps can transmit the
stress over to the cribriform plate, which can lead to cribriform plate fracture and CSF rhinorrhea. Some surgeons microfrac-
ture the deviated bony septum for centralization. However, the author does not recommend this method as it can lead to
cribriform plate fracture.
If withdrawing a piece of resected septal cartilage or bone is met with resistance, there usually is a soft-tissue attachment
that prevents the action. Forceful removal of the cartilage or bone fragment can result in mucoperichondrial tear. Therefore,
the mucoperichondrium should be released further completely in case of resistance.
Any extraneous cartilage that is not used as a graft can be banked posterior to the caudal strut between the mucoperichon-
drial flaps.
It is very important to preserve the attachment between the dorsal cartilaginous septum and the bony septum at the key-
stone area to avoid collapse of dorsal septum.
Septal tilt is linear deviation of the septum without any curvature, where the septum is dislodged from the maxillary crest
of the vomer and tilted to one side. In case of septal tilt, the dislodged portion of posterior septal cartilage should be excised
completely to decrease the risk of nasal obstruction in the respective nasal cavity.
Septoplasty is a method that minimizes septal cartilage excision. The cartilaginous septum is dislocated from the vomer
and maxillary crest. The extraneous cartilage is carefully trimmed from the cephalic and posterior portion and swung around
with the keystone area as the pivot (Fig. 15.23). In addition, the deviated portions of septal cartilage can be straightened using
scoring incision and wedge resection (Fig. 15.24).
In practice, septoplasty is not frequently employed among Asian rhinoplasty surgeons for the following reasons. The
extent to which septoplasty can straighten out a deviated dorsum is not clear in each case, with long-term predictability low.
In Asian patients, deviated nose correction is usually performed along with nasal tip plasty, which requires ample amount of
harvested septal cartilage.
a
b
c
Fig. 15.22 Steps in SMR (cartilage portion)
Operative Techniques of Deviated Nose
692
Fig. 15.23 Dislocation of septal
cartilage from bony septum and trimming
of excess cartilage for septoplasty
Fig. 15.24 Scoring and wedge resection of
cartilaginous septum for septoplasty
15 Deviated Nose Correction and Functional Rhinoplasty
693
Bony Spur
If a nasal obstruction is caused by focal bony spur, simple excision of the bony spur is sufficient in resolving the obstruction.
A bony spur can be removed using Takahashi forceps, but larger spurs will need to be removed using guarded osteotome.
Bony spurs are usually present near the vomer and maxillary crest and require mucoperichondrial elevation prior to removal.
The mucoperichondrium adheres tightly to the bone and can easily be torn around the spur. As such, it is easier and safer to
elevate the mucoperichondrium from the concave side.
Correction of the Caudal Septal Deviation
The caudal septum is the most important part of the septal correction for deviated nose. Caudal septal deviation induces nar-
rowing of the internal and external valve and causes nasal obstruction. It also causes columellar deviation, along with nostril
and tip asymmetry.
Caudal septal deviation can manifest as a form of anteroposterior deviation and cephalocaudal deviation.
Anteroposterior Deviation of the Caudal Septum
Anteroposterior deviation of caudal septum exists in many types, which dictate the corrective technique employed.
1. The type in which caudal septum is on the ANS, while caudal septal cartilage has an excess length with C- or S-shaped
deviation (Fig. 15.25):
a
b
Fig. 15.25 Caudal septal deviation in which caudal septum is on the ANS, while caudal septal cartilage has an excess length
Operative Techniques of Deviated Nose
694
Double-Mattress Suture
If the caudal L-strut is slightly long, 1–3 horizontal mattress sutures (convexity control suture) are sufficient in straightening
of deviated caudal septum. However, this technique is not as reliable (Fig. 15.26).
a
b
Fig. 15.26 (a) Intraoperative photograph of a deviated septum. (b) The deviated septum is straightened using convexity control sutures (double-
mattress suture)
15 Deviated Nose Correction and Functional Rhinoplasty
695
Scoring and Batten Graft
The concave side of caudal septal cartilage is scored. The pliant septum is then splinted using cartilage graft or PDS plate
(Fig. 15.27).
Scorings and suture techniques are unreliable, when used in isolation. Their efficacy can only be ensured when the result-
ing construct is stabilized with batten grafts.
a
b
c
d
e
Fig. 15.27 Scoring and batten graft for septal deviation. (a) A patient with deviated columella and tip. (b) The caudal and dorsal septum is devi-
ated to the right side. (c, d) The caudal septum is straightened by scoring incision and placement of batten graft on the right side. (e) Postoperative
photograph demonstrates correction of columella and tip deviation
Operative Techniques of Deviated Nose
696
Fig. 15.28 Shortening of caudal septum
Segmental Resection of Caudal Septal Cartilage
The posterior portion of caudal L-strut is dislocated from the ANS and maxillary crest. Redundant length in the strut is
resected segmentally, and the shortened caudal L-strut is fixed to the periosteum of the ANS (Figs. 15.28, 15.29 and 15.30).
The amount of resection must be exact, which requires conservative approach of removing small bits of the cartilage at a
b
a
c
d
e
g
f
Fig. 15.29 Correction of deviated caudal septum. (a, b) This patient has an upturned nasal tip due to scar contracture from a previous rhinoplasty
operation, along with columellar deviation and nostril asymmetry. (c) Caudal septum is deviated to the left, and the posterior end of septum sits on the
ANS. (d) The excessively long caudal septum is shortened with segmental resection. (e) Caudal septum is straight after shortening. (f, g) Postoperatively,
the nasal tip and columella are at the midline, with symmetric nostrils. The contracted short nose has been corrected with the septal extension graft
15 Deviated Nose Correction and Functional Rhinoplasty
697
a
b
c
d
Fig. 15.30 Caudal septal shortening and convexity control suture. (a) Caudal septal deviation and nostril asymmetry. (b) Deviated caudal septum.
(c) The septum is straightened with segmental resection of caudal septum and double-mattress suture. (d) Postoperative photograph
time. Excessive resection that causes a gap between caudal septal cartilage and ANS can result in delayed appearance of
saddle nose. The fixation is performed using figure-of-eight suture with 5-0 PDS, between the caudal end of septal cartilage
and soft tissue of the ANS. To facilitate this, the dissection must leave adequate amounts of soft tissue at the ANS. Denuding
the ANS not only makes it difficult to fixate the caudal septum but also creates the need to drill into the ANS to create an
anchor hole. If the segmental resection does not spontaneously resolve the septal curvature, scoring incisions are placed on
the concave side, followed by splinting batten graft or double-mattress suture (Fig. 15.30).
Operative Techniques of Deviated Nose
698
Cut-and-Suture Technique
As an alternative to segmental resection of caudal L-strut, the caudal strut is cut at the convex-most part, and the cut ends are
overlapped and sutured with 5-0 PDS (Fig. 15.31). If the overlapping portion is too narrow to guarantee stability of the result-
ing septal construct, a splinting graft should be prepared from the removed septal cartilage and placed on the concave side to
further support and straighten the septum (Fig. 15.32).
For the methods described above, silicone splint should be placed in the nasal cavity for 1–2 weeks to maintain a straight
septum.
a
b
c
d
Fig. 15.31 Cut-and-suture technique for the deviated caudal septum. (a, b) This patient has a deviated tip/columella and nostril asymmetry. (c)
Exploration reveals discrepancy in the height of medial crura, with right medial crus longer than the left. (d) Caudal septum is deviated to the left.
(e) Illustration of the cut-and-suture technique. (f) The caudal septum is straightened after the cut-and-suture technique. (g) The right medial crus
is shortened with segmental resection. (h) Columellar strut graft has been placed. (i, j) Postoperatively, the central column of the nose is no longer
deviated, with relative symmetry restored to the nostrils
15 Deviated Nose Correction and Functional Rhinoplasty
699
Fig. 15.31 (continued)
e
f
g
h
i
j
Operative Techniques of Deviated Nose
700
2. The type in which caudal septum is dislocated from ANS and maxillary crest
The posterior end of caudal septum is resected to an appropriate length. The septal end is fixated to the periosteum of ANS
using 5-0 PDS (Fig. 15.33). For this technique to be effective, the ANS must be located at the midline. If the ANS is not at
the midline, the following three methods are used to overcome the problem.
First, the shortened caudal septum can be repositioned and fixed to either side of the ANS that is closer to midline
(Fig. 15.34). Second, the ANS can be osteotomized as a greenstick fracture and repositioned to midline. Third, the ANS is
removed, after which the septum is sutured to the periosteum of maxilla. However, care must be taken not to remove too
much of the ANS, to minimize the injury risk to the anterior maxillary nerve (upper lip numbness).
a
b
c
d
Fig. 15.32 Cut-and-suture technique plus batten graft. (a) Intraoperative photograph of caudal septal deviation. (b) The caudal septum is cut,
overlapped, and sutured. (c, d) Batten graft is applied to left side of caudal septum for added strength
15 Deviated Nose Correction and Functional Rhinoplasty
701
a
b
c
d
e
Fig. 15.33 Shortening of caudal septum and repositioning to the ANS. (a) Deviated caudal septum and nostril asymmetry. (b) The caudal septum
is dislocated from ANS. (c) Illustration for shortening and repositioning of caudal septum. (d) The caudal septum is straightened by the technique.
(e) Postoperative photograph demonstrates correction of septal deviation and asymmetric nostrils
Fig. 15.34 ANS positioned
away from the midline
Operative Techniques of Deviated Nose
702
S-Shaped Deviation of the Caudal Septum
If the anteroposterior deviation of the caudal septum exists in an “S”-shape, the caudal septum is shortened first. Then, the
concave surfaces are scored and straightened out with a splinting graft (Fig. 15.35). If the ANS is not at the midline, it should
be moved to midline using greenstick osteotomy or excised.
Fig. 15.35 S-shaped
deviation of caudal septum. In
addition to septal shortening,
the concave surfaces are
scored. The straightened
cartilage is supported with a
splinting graft
15 Deviated Nose Correction and Functional Rhinoplasty
703
Cephalocaudal Deviation of the Caudal Septum
Usually, cephalocaudal deviation of the caudal septum has an acute angulation from septal fracture or contains a C-shaped
convexity. This type of septal deviation occurs along with dorsal septal deviation, septal tilt, and dislocation from vomerine
groove. The cephalocaudal deviation can be corrected by vertical sleeve resection or the swinging-door technique.
An incision is placed along the delineation between the straight portion (cephalic septum) and the deviated portion (cau-
dal septum). Then the deviated cartilage is moved to midline. To facilitate this movement, a wedge excision can be made
along the initial incision or a partial resection can be performed towards the floor (Fig. 15.36). The mobilized portion of
septum is fixated to the ANS. The incision between the cephalic and caudal septum is repaired using double-mattress suture
or using batten graft (Figs. 15.37 and 15.38).
Fig. 15.36 Swing-door
technique. To facilitate the
swing movement, a wedge
excision can be placed near
the incision, or the excess
cartilage near the floor can be
resected
Operative Techniques of Deviated Nose
704
a
b
c
d
e
f
Fig. 15.37 Correction of caudal septal deflection. (a) In this patient, the nostril asymmetry is caused by deviated caudal septum. (b) An old frac-
ture was the cause of caudal septal deflection. (c) Double-mattress suture was placed after an incision was made along the old fracture. (d) The
caudal septal deviation has been corrected. The dorsal septum remains deviated. (e) Dorsal septum is being straightened by clocking suture. (f) The
nostril asymmetry is corrected
15 Deviated Nose Correction and Functional Rhinoplasty
705
a
b
c
d
e
f
g
h
i
j
Fig. 15.38 Correction of caudal septal
deflection. (a, b) This patient has a
deviated nasal axis and caudal septal
deviation. (c, d) Exploration reveals
severe deflection in the caudal septum.
(e) Excess cartilage of the floor is
resected to facilitate the swing-door
movement. (f) Deflected caudal and
dorsal septum is straightened after
applying a full-thickness incision along
the demarcation between deflected and
straight portions of the septum. The
caudal septum is brought to midline. (g)
Batten graft is applied to support the
straightened septum. (h) The resulting
reconstructed septum is straight and
midline. (i, j) Nasal axis has been
straightened by the osteotomy. The
caudal septal deviation has been
corrected as well
Operative Techniques of Deviated Nose
706
Severely Deformed Caudal Septum
A severe deviation of the caudal septum is addressed by removing the irregular portion of the septal cartilage and by recon-
structing the remaining septum using straight portions of septal cartilage or auricular cartilage (Fig. 15.39).
Fig. 15.39 Reconstruction of severely deformed caudal septum
15 Deviated Nose Correction and Functional Rhinoplasty
707
Correction of Dorsal (High) Septal Deviation (Correction of ULC Deviation)
Mid-vault deviation (ULC deviation) also implies deviation of the dorsal septum. Dorsal septal deviations will manifest as mid-
vault asymmetry or upper lateral cartilage deviation, and may demonstrate internal valve narrowing and airway obstruction.
The dorsal septal deviation will improve with SMR and correction of caudal septal deviation. As such, dorsal septal devia-
tion should be corrected only after these procedures have been performed.
Double-Mattress Suture
This technique is applicable for minor deviation of the dorsal septum.
Scoring and Splinting Graft
On the side of concavity, multiple scoring incisions can be made in the dorsal septum, after which the septum is moved to
midline (Fig. 15.40). Scoring alone leads to low predictability of postsurgical construct. To increase the strength of the dorsal
septum, a splinting graft is placed on the side opposite from scoring incisions (Figs. 15.41 and 15.42). This splinting graft
also serves as a spreader graft.
a
b
Fig. 15.40 Scoring of the dorsal septum. (a) A patient with dorsal septal deviation. (b–d) Illustration of scoring used to straighten the dorsal
septum. (e) Intraoperative photograph of partial-thickness scoring incision. (f) Straightened dorsal septum after scoring incisions
Operative Techniques of Deviated Nose
708
c
d
e
f
Fig. 15.40 (continued)
15 Deviated Nose Correction and Functional Rhinoplasty
709
Fig. 15.41 Septal scoring
and splinting graft
Operative Techniques of Deviated Nose
710
a
c
d
b
e
f
g
Fig. 15.42 Septal scoring and spreader graft. (a)
This patient has a deviated nasal axis. (b) Upper
lateral cartilages are deviated towards the left. (c)
Dorsal and caudal septa are also deviated to the
left. (d) Scoring incisions are placed on the left
dorsal septum. (e) The dorsal septum became
more straight with the scoring incisions. (f)
Splinting spreader graft is placed to the right side
of septum. The nasal bones are mobilized with
osteotomy (not shown). (g) Nasal bone and upper
lateral cartilage have been straightened
15 Deviated Nose Correction and Functional Rhinoplasty
711
Fig. 15.43 Scoring incisions performed in cephalocaudal
direction
The scoring is usually performed in the anteroposterior direction but can also be performed in the cephalocaudal direction
depending on the direction of deviation in the dorsal septum (Fig. 15.43).
Operative Techniques of Deviated Nose
712
Swing-Door Technique
The posterior and caudal portion of septal cartilage is resected, and the released septum is rotated towards midline. As men-
tioned during the discussion of caudal septal deviation, the caudal septum needs to be released from ANS, and the excessive
length of septum must be removed.
Most cases of dorsal septal deviation can be corrected using the techniques described above. However, a dorsal septal
deviation with excessive length and significant curvature will require the following procedures.
Wedge Excision
A dorsal septal cartilage with excessive length can be excised in a wedge shape (Fig. 15.44). The technique is performed with
either the double-horizontal-mattress suture or the splinting graft.
Fig. 15.44 Wedge excision and mattress suture or splinting graft. (a, b) A patient with dorsal and caudal septal deviation. (c, d) A wedge excision
has been performed on the dorsal septum. (e) Three double-mattress sutures are placed. (f) The septum is straight and in midline. (g) The technique
is performed with splinting graft
a
b
c
15 Deviated Nose Correction and Functional Rhinoplasty
713
d
e
f
g
Fig. 15.44 (continued)
Operative Techniques of Deviated Nose
714
Cut-and-Suture Technique
Instead of an excision, the dorsal strut can be cut at the convex-most portion, and the cut ends are overlapped and sutured
together using 5-0 PDS (Fig. 15.45).
The stability of dorsal septum is much more important than that of the caudal septum. As such, the technique requires the
use of splinting graft, which also serves as a spreader graft.
a
b
Fig. 15.45 Cut-and-suture technique for correction of dorsal septal deviation
15 Deviated Nose Correction and Functional Rhinoplasty
715
Spreader Graft
The spreader graft is used along with the techniques mentioned above for addressing deviated cartilaginous dorsum. This has
been discussed in detail in Chap. 9.
The graft is placed between the dorsal septum and the upper lateral cartilage on the concave side (Fig. 15.46). The most
important function of spreader graft is its ability to straighten dorsal septum. It also serves to camouflage the dorsum by
spreading the sunken upper lateral cartilage camouflage. The ancillary function of the graft is strengthening of the dorsal
a
b
c
d
Fig. 15.46 Spreader graft for deviated dorsal septum. (a) A patient with deviated nose. (b, c) A spreader graft (septal cartilage) is placed on the
left side of dorsal septum after scoring incisions have been placed on the right surface of dorsal septum. (d) Postoperative photographs at 2 months
Operative Techniques of Deviated Nose
716
septal cartilage weakened by scoring, wedge resection, or cutting and suture technique. The graft improves the brow-tip
dorsal aesthetic line, prevents or corrects inverted-V deformity, and widens the internal nasal valve.
Septal cartilage is the most ideal donor for this graft, followed by auricular cartilage and costal cartilage. Spreader graft
is usually performed unilaterally in deviated nose, but bilateral spreader grafts are needed for inverted-V deformity and in
shortage of the upper lateral cartilage width of the opposite side after midline repositioning of the dorsal septum.
If the spreader grafts are placed bilaterally, the graft should be wider on the concave side. Multiple pieces of cartilage may
need to be placed on each side, depending on the thickness of graft and degree of asymmetry. Using a 5-0 PDS suture, the
graft is secured first to the dorsal septum and then to the upper lateral cartilage.
The placement of spreader graft on the concave side can spread out the sunken dorsum. In contrast, excessive convexity
of the dorsal septum can be addressed by the resection of the transverse wing (Fig. 15.47).
This technique is used in conjunction with other techniques used for correction of dorsal septal deviation.
a
b
c
d
Fig. 15.47 Shaving the transverse wing of dorsal septum. (a) Deviation of upper lateral cartilage/dorsal septum to the right. (b) The right side of
dorsal septal cartilage is shaved to decreased convexity on the right side. (c) A spreader graft (septal cartilage) has been placed to the left of dorsal
septum to correct the concavity. (d) Illustration of shaving the transverse wing (right side) and spreader graft (left side)
15 Deviated Nose Correction and Functional Rhinoplasty
717
Clocking Suture (Septal Rotation Suture)
This is a horizontal mattress suture anchored at the cephalic portion of upper lateral cartilage. The suture is passed through the
spreader graft and the caudal part of deviated dorsal septal cartilage. Tension across this suture pulls the dorsal septum towards
midline. One or two clocking sutures are applied (Fig. 15.48). Once the tension is adjusted and the deviated upper lateral
cartilage is pulled to the midline, the upper lateral cartilage on the opposite side is sutured to the straightened dorsal septum.
Fig. 15.48 Clocking suture (septal rotation suture). (a, b) Dorsal septum is deviated. (c) Spreader graft is applied to the right side of dorsal sep-
tum. A clocking suture is placed between the right upper lateral cartilage and dorsal septum. (d) As the clocking suture is tied, the dorsal septum
is pulled and repositioned towards the midline. (e) Illustration of clocking suture
a
b
c
d
Operative Techniques of Deviated Nose
718
e
Fig. 15.48 (continued)
15 Deviated Nose Correction and Functional Rhinoplasty
719
Combination of Above Techniques
Deviation of dorsal septal cartilage is corrected using a combination of the techniques mentioned above (Fig. 15.49). A
majority of dorsal septal deviations are accompanied by deviation in the caudal septum. This requires correction of both
dorsal and caudal septum (Fig. 15.50).
a
b
c
d
e
Fig. 15.49 Combination of several techniques for the deviated dorsal septum. (a) A patient with deviated dorsal septum and ULC. (b) Scoring
incisions are placed on the right surface of dorsal septum. (c) Spreader graft is placed to the left side of dorsal septum. (d) The first clocking suture
is placed. (e) The second suture was placed
Operative Techniques of Deviated Nose
720
a
b
c
d
e
f
g
h
i
j
Fig. 15.50 Correction of S-shaped nasal axis deviation and dorsal/caudal septal deviation. (a–c) This patient’s nasal dorsum is crooked in the
S-shape, and his nostrils are asymmetric from the deviated caudal septum and columella. (d) Dorsal septum is deviated to the left, while caudal
septum is deviated to the right and dislocated from ANS. (e) Scoring incision is placed on the left side of dorsal septum. (f) The dorsal septum has
become more straight, and caudal septum is now repositioned on ANS after segmental resection. (g) Clocking suture is placed to finalize the cor-
rection of dorsal septal deviation. (h–j) Photographs at 6 weeks after osteotomy, correction of septal deviation, dorsal augmentation using dermofat
graft, and tip plasty with interdomal suture and conchal cartilage onlay graft
15 Deviated Nose Correction and Functional Rhinoplasty
721
Fig. 15.51 High deviation of
bony septum
Correction of High Bony Septal Deviation
The deviation in the cartilaginous portion of dorsal septum is relatively easy to address using the techniques mentioned
above. However, deviation in the bony portion of dorsal septum is not as easy to correct (Fig. 15.51). Deviated high bony
septum commonly occurs at the cartilage-bony junction. This high deviation must be corrected for the following two
reasons:
1. High bony septal deviation is a cause for nasal obstruction.
2. If uncorrected, the deviated bony septum makes it more likely for osteotomized nasal bone segment to be pushed back
out, with resultant recurrence of nasal bone deviation over time.
The deviation of high septal bone not only blocks repositioning of the osteotomized nasal bone but also causes nasal
obstruction.
Forceful fracture of the high bony septum with Walsham forceps or Asch forceps can injure the cribriform plate. The safer
approach is to create a high septal osteotomy and secure the high septum using a double-mattress suture. This technique is
performed in the following manner (Fig. 15.52).
From the bony-cartilaginous junction of high septum, a half-thickness osteotomy is placed in the cephalic direction, using
a 2 mm osteotome. The osteotomy is created from the anterior 1/3rd of bony septum, parallel to the undersurface nasal bone.
The osteotomy is directed posteriorly once beyond the deviated bony septum.
A 23-gauge needle is used to create two holes in the bony septum for double-mattress suture. The mattress suture is placed
using 4-0 nylon. The convex bony-cartilage portion is straightened out by pushing it to midline (Fig. 15.53).
Operative Techniques of Deviated Nose
722
a
b
c
Fig. 15.52 High septal osteotomy and double-mattress suture. (a) High septal deviation of cartilaginous and bony septum around the keystone
area. (b) A half-thickness osteotomy is placed from the bony-cartilaginous junction along the deviated portion of the high bony septum in the
cephalic direction. (c) A double-mattress suture is placed to straighten the convex bony-cartilage portion towards the midline
15 Deviated Nose Correction and Functional Rhinoplasty
723
a
b
c
d
e
f
g
h
i
j
k
l
m
Fig. 15.53 Correction of high cartilage-bony septal deviation. (a, b) This patient has a deviated dorsum and caudal septum. (c, d) CT imaging
demonstrates the mid-septum and dorsal septum to be deviated to right side, which correlates with symptoms of nasal obstruction. (e, f) The upper
lateral cartilage is deviated to the left, while the high dorsal septum and mid-septum are deviated to the right. (g) High cartilage-bony septal junc-
tion area (keystone area) protrudes to the right. (h) After high septal osteotomy, double-mattress sutures are placed to mobilize the protruding
cartilage-bony junction towards midline. (i) Spreader graft is placed on to the right of dorsal septum. Clocking suture is placed. The patient also
underwent osteotomy of nasal bone and tip plasty with columellar strut graft (not shown). (j, k) At 5 months, the dorsal deviation has been cor-
rected. (l, m) Postoperative CT demonstrates improvements in high septal deviation
Operative Techniques of Deviated Nose
724
Extracorporeal Septoplasty
If the septum is severely deformed, the whole septal cartilage can be extracted out of the nasal cavity, straightened out, and
restored to the central location in the cavity (Fig. 15.54). This is especially useful for severe fracture or deformation of the
caudal septum.
a
b
c
d
e
f
g
h
i
j
Fig. 15.54 Extracorporeal septoplasty. (a, b) In this patient, the deviation is present in upper lateral cartilage, dorsal septum, and caudal septum.
(c) Intraoperative photograph of the deviation through the entire length of the septum. (d) The entire septal cartilage is removed from the internal
nose. (e) The cartilage is trimmed, and twisted portions are straightened with multiple double-mattress sutures. (f, g) The straightened septum is
secured back to the septal stump. (h) Two layers of spreader graft are placed to the right of dorsal septum to support the connecting area and to
spread out the upper lateral cartilage. (i, j) Photographs at 8 month after operation
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The septal cartilage is disconnected from all adjoining cartilage and bony tissue. From the extracted cartilage, the deformed
sections are removed. If possible, the portion of septal cartilage that connects to the nasal bone should be preserved. From
the resected septal cartilage, the flatter portions are used to reconstruct an L-strut, which is introduced back into the septal
space. The fixating sutures should be made secure at the nasal bone and at the ANS in order to prevent saddle-nose deformity
and dorsal deviation. Once the central element is secure, the upper lateral cartilages are repaired to the reconstructed
septum.
Complications of Septal Surgery
Complications of septal surgery include mucosal synechiae, septal hematoma, septal infection, septal perforation, and saddle
nose.
Mucoperichondrial Tearing
Primary repair of mucosal injury using suture not only is difficult but can also worsen the situation by increasing the size of
the tearing. It is important to remember that a unilateral tearing does not require any intervention. This is also the case if
tearing exists in both layers of mucosa but do not overlap each other because these will not lead to septal perforation. If,
however, the mucosa injuries overlap each other, the risk of septal perforation is relatively high. A septal cartilage, a segment
of ethmoid bone, or a PDS plate should be placed in between the torn mucosal layers. A silicone sheet should be placed
bilaterally for 2–3 weeks while the mucosa heals.
Mucosal Synechiae
After turbinate reduction, a contact between the turbinate mucosal wound and the septal mucoperichondrial tearing will
induce the formation of synechiae (Fig. 15.55). Because of this, a silicone sheet should be placed to keep these two mucosal
layers separated for 2 weeks after the operation.
Fig. 15.55 Mucosal synechiae
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726
Septal Hematoma
Septal hematoma has the potential for septal perforation, septal infection, and abscess formation (Fig. 15.56). Also, a small hema-
toma can undergo fibrosis, which can result in septal thickening and nasal obstruction. A large hematoma can impair the diffusion
of nutrients from the mucosa to the cartilage, resulting in resorption of septal L-strut and saddle-nose deformity. For these reasons,
meticulous hemostasis is required for septal surgery. In the immediate postoperative period, the septum should be compressed using
Merocele® packing or silicone sheet.
A septal hematoma requires immediate drainage. Most can be aspirated using an 18-gauge needle and a syringe.
If the hematoma cannot be aspirated, a 1 cm incision can be created in the mucoperichondrium near the floor. The
hematoma is drained through this incision, and the septum is compressed with intranasal packing. The incision must
be placed in the mucoperichondrium and should not extend into the contralateral layer of the mucoperichondrium.
The packing can be removed after 1–2 days.
Fig. 15.56 Septal hematoma
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Septal Infection
Severe septal infection can lead to resorption of septal cartilage, resulting in severe deformation. A true septal infection
requires surgical drainage and wide-spectrum antibiotic treatment (Fig. 15.57).
Fig. 15.57 Septal infection
Operative Techniques of Deviated Nose
728
Impairment of Olfaction
Post-rhinoplasty olfactory dysfunction can be caused by the following reasons:
1. Transient olfactory impairment can be caused by mucosa edema, increased rhinorrhea, and crusting, even after removal
of packing and splint.
2. Synechiae between septum and middle turbinate that prevents the air from reaching the olfactory cleft.
3. Deficient aeration to olfactory groove by turbinate deformity (out-fracture, atrophy).
4. Injury to olfactory neuroepithelium or cribriform plate.
5. Psychogenic etiology.
6. Unknown origin.
Most olfactory impairment spontaneously resolves between 6 and 18 months. It is important to reassure the patient and
wait for olfaction to improve. Oral steroid can be helpful. Steroid can decrease the inflammation within the nasal cavity and
is also known to directly affect olfactory epithelial cells, though the mechanism is unknown. Surgical management is needed
for the presence of synechiae in the cephalic area of nasal cavity.
Saddle-Nose Deformity
Saddle nose represents collapse of dorsal and caudal L-strut (Fig. 15.58). Saddle nose develops from an L-strut that is too
narrow. As such, SMR should leave an L-strut of adequate width. The deformity can occur over a number of years, and to
avoid this problem the L-strut should be wider than 10–12 mm. In Asian patients, the L-strut must be wider than L-struts used
for Caucasian patients.
After caudal septal shortening, the caudal septum should be securely fixed to the ANS. The use of batten graft is helpful
in minimizing the risk of saddle nose after scoring incisions placed in dorsal and caudal septum.
During hump reduction or high septal osteotomy, the keystone area must not be injured. Management of acute keystone
injury is discussed in Chap. 17. Correction of saddle-nose deformity is discussed in Chap. 16.
Fig. 15.58 Saddle-nose deformity
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CSF Rhinorrhea
Reports of CSF rhinorrhea as a complication of septal surgery are very rare in the literature. When this does occur, the CSF
leak is due to cribriform plate fracture, which is caused by twisting or rocking of the perpendicular plate of the ethmoid. To
avoid this troublesome complication, the perpendicular plate should not be fractured by twisting motion. Instead, the plate
should be carefully cut using turbinate scissors or septum scissors.
Postoperative CSF rhinorrhea can develop at any time after an operation from the recovery room to several months. In
certain cases, the CSF leak is misdiagnosed as simple rhinorrhea for months to years, after which the atypical presentation
of paroxysmal rhinorrhea or neurologic symptoms prompts the appropriate workup leading to proper diagnosis. CSF rhinor-
rhea can lead to more serious complications such as meningitis, intracranial abscess, and pneumocephalus. As such, prompt
diagnosis and treatment are extremely important. Even in the absence of CSF rhinorrhea, a suspected cribriform plate injury
should prompt CT scan to evaluate for pneumocephalus.
CSF leakage can be confirmed by a positive β2-tranferrin testing. CT can identify a bony defect but is not extremely sensi-
tive. At times, a nasal endoscopy or CT cisternogram may be required.
A CSF leak can resolve with bed rest in supine position but requires IV antibiotics as prophylaxis against meningitis. If
the conservative treatment does not improve the CSF leak, the bony defect should be accessed by elevating the overlying
mucosa. The defect is sealed using fat, fascia, or dermal allograft, and is covered by mucosal graft or nasoseptal flap. The
repaired area is subsequently bolstered with Gelfoam® or Surgicel®.
Deviated Nose Correction in Patients with Small Nasal Bone
In Asian patients, small nasal bone is not a rare feature. Correction of deviation is challenging for small nasal bone. A small
nasal bone is much more likely to collapse after an osteotomy. In a patient with small nasal bone, deviated nose should be
corrected using the following methods.
Camouflage Technique
Camouflage technique is applicable for minor nasal bone deviation.
In this technique, the small protrusion of nasal bone is filed down with a rasp, and the sunken part of the bone is camouflaged
using a cartilage graft (Fig. 15.10). The camouflage graft can be performed using septal cartilage, auricular cartilage, or rib car-
tilage. In patients with thin skin, the cartilage graft should be crushed to minimize the risk of graft becoming visible through the
skin. The camouflage can be performed using fascia or dermal allograft, but this approach is less predictable due to resorption.
Medial and Intermediate Osteotomy
In small nasal bones, complete lateral and medial osteotomy is more likely to lead to bony collapse and further narrowing of
bony base. To avoid this, the nasal bone on concave side should be freed by medial osteotomy and mobilized laterally, fol-
lowed by placement of extended spreader graft into resulting bony gap. On the convex side, the nasal bone is freed with
intermediate osteotomy and mobilized medially. This is an effective method of addressing deviation of small nasal bone,
with little chance of bony collapse or decreased bony base width (Fig. 15.59).
Deviated Nose Correction in Patients with Small Nasal Bone
730
a
b
e
c
d
Fig. 15.59 Osteotomy in small nasal bone with deviation. (a) This patient has a deviated nose. The nasal bone is very small. (b, c) Illustration of the
medial osteotomy for out-fracture and intermedial osteotomy for in-fracture. (d) Intraoperative picture shows bony gap made by out-fracture (medial
osteotomy). (e) Nine months postoperatively after the medial and intermedial osteotomy, along with radix augmentation (conchal cartilage graft)
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Deviated Nose Correction and Dorsal Augmentation
In Asians, deviated nose is frequently accompanied by flat nasal dorsum. As such, deviated nose correction is often per-
formed along with dorsal augmentation (using dermofat, fascia, crushed cartilage, or diced cartilage wrapped in temporal
fascia) (Fig. 15.60).
However, patient preference or clinical context may dictate the use of implant. Mucosal lining injury from medial oste-
otomy precludes implant use because of the increased risk of infection.
a
d
b
c
e
f
Fig. 15.60 Osteotomy and radix augmentation. (a–c) In this
patient, the nose is deviated with dorsal hump and low radix.
He underwent hump reduction, lateral and medial osteotomy,
radix augmentation (septal cartilage graft), and tip plasty with
columellar strut graft (septal cartilage). (d–f) Postoperative
photograph demonstrates the correction of nasal deviation and
dorsal hump
Deviated Nose Correction and Dorsal Augmentation
732
a
b
Fig. 15.61 Elevation of the mucosa from overlying bone to avoid injury from medial osteotome
For safe use of implant with osteotomy, the following should be observed to minimize osteotomy-related mucosal injury:
1. Mucosal inflation with local anesthetic prior to osteotomy
2. Mucosal elevation from overlying bone prior to osteotomy (Fig. 15.61)
3. Use of double-guarded osteotome to protect the skin and underlying mucosa (Fig. 8.94)
As mentioned above, the underlying mucosa should be evaluated for any injury, prior to the insertion of an implant. If the
mucosa is intact, it is possible to simultaneously address the deviated nose and the flat nasal dorsum (Figs. 15.62 and 15.63).
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Fig. 15.62 Deviated-nose correction and dorsal augmentation. (a–d) This patient has a nasal deviation with low dorsum. The columella is also
deviated, with asymmetric nostrils. (e–g) The patient underwent lateral and medial osteotomies on both sides, long spreader graft, clocking suture,
double-mattress suture of deviated caudal septum, tip revision with suture techniques, and dorsal augmentation using dermal allograft (MegaDerm®,
L&C Bio, Seoul, Korea). (h–k) Postoperative photograph demonstrates straight dorsum, defined radix, and symmetric nostrils
a
b
c
d
f
g
e
h
i
j
k
Deviated Nose Correction and Dorsal Augmentation
734
a
b
Fig. 15.63 Deviated nose and dorsal augmentation. (a) This patient with nasal deviation and low dorsum underwent lateral and medial osteotomy,
dorsal augmentation (silicone implant), and tip plasty (septal cartilage). (b) Postoperative photograph demonstrates markedly improved
appearance
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735
Correction of Deviated Tip and Columella in the Deviated Noses
Nearly all cases of deviated nose are accompanied by tip and columella deviation, as well as nostril asymmetry (Fig. 15.64).
In such deviated noses, the operator should focus on correcting all of the deviations from top to bottom, as asymmetry of one
region of the nose will ruin the symmetry of all other sections.
The asymmetric tip and nostril are not just a product of asymmetry in lower lateral cartilages but also a consequence of
deviated septum. Most cases of deviated tip, columella, and nostril asymmetry are closely related with deviated caudal and
dorsal septum. Therefore, the management of columella and nostril asymmetry requires the correction of caudal and dorsal
septum in addition to correction of the lower lateral cartilage asymmetry (Fig. 15.65).
The most sure way of straightening twisted and deviated medial crura is to deploy the columellar strut graft (Fig. 15.66),
with the septal cartilage as preferred donor source. The columella strut graft is placed between the medial crura, and the graft
is fixed to the medial crura. At this point, the most important reference point for nostril symmetry is the apex. Thus, the
medial crura should be fixated to the strut graft such that the nostril apex is at the same height. The remaining asymmetry in
the dome or lateral crura is addressed with suture technique or segmental resection (Fig. 15.67). If the dome or lateral crura
are addressed first, the nostril height may not be symmetric across the midline, which cannot be resolved in a retrospective
manner.
Tip and nostril asymmetry secondary to septal deviation cannot be addressed with simple manipulation of lower lateral
cartilage but also requires septal surgery, which applies to most cases of tip deviation and nostril asymmetry with nasal devia-
tion (Fig. 15.68).
a
b
Fig. 15.64 Nearly all instances of nasal deviation are accompanied by deviation of the tip and columella deviation with nostril asymmetry
Deviated Nose Correction and Dorsal Augmentation
736
a
b
Fig. 15.65 Correction of columellar deviation and nostril asymmetry. (a) In this patient, the columella deviation and nostril asymmetry are con-
sequences of caudal septal deviation. She underwent correction of caudal septal deviation and columellar strut graft (septal cartilage). (b) After
3 years, the columella remains straight and in midline, with symmetric nostrils
a
b
Fig. 15.66 Correction of twisted medial crura using columellar strut graft (septal cartilage)
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737
a
b
c
d
e
f
Fig. 15.67 Reference points for nostril symmetry. (a) Columellar deviation and nostril asymmetry. (b) Exploration reveals caudal septal deviation
and twisted asymmetric medial crura as causes of columella deviation and nostril asymmetry. (c) Columellar strut graft (septal cartilage) is placed
to straighten medial crura. The nostril apexes are at the same height. (d) Having matched the height of nostril apex first, the asymmetry in the lateral
crura can be corrected by shortening the right lateral crus. (e) Both the nostril apex and lateral crura are symmetric. (f) Postoperative photograph
demonstrates symmetric nostrils and correction of columella deviation
Deviated Nose Correction and Dorsal Augmentation
738
a
b
c
d
e
Fig. 15.68 Deviated nose, tip/columella deviation, and nostril asymmetry. (a, b) A patient with deviated nasal axis, deviated tip/columella, and
nostril asymmetry. (c) Illustration of operative steps performed in this patient: lateral and medial osteotomy and spreader graft (septal cartilage).
(d) Intraoperative view of the deviated dorsal and caudal septum. (e) The transverse wing of left dorsal septal cartilage is shaved. (f) Scoring inci-
sions are made in the left surface of dorsal septum. (g) Spreader graft is placed to the right of dorsal septum. (h) Caudal septal deviation. (i, j) The
caudal septum is shortened and fixated to the ANS. (k, l) Postoperative photographs demonstrate straight dorsum and columella, with symmetric
nasal tip and nostrils
15 Deviated Nose Correction and Functional Rhinoplasty