Mastering Advanced Rhinoplasty

40
2
a
b
c
d
.
. Fig. 2.1  (a–d) Straightening of the septum with suture techniques

Chapter 2 · Secondary Septoplasty

41
2
a
c
e
d
b
.
. Fig. 2.2  (a–e) Endonasal splinting of the scored anterior septum with a thinned transplant from the central septum
2.1 · Surgical Principles

42
2
a
b
c
.
. Fig. 2.3  (a–c) Extracorporeal straightening with thinned out perpendicular plate and spreader grafts

Chapter 2 · Secondary Septoplasty

43
2
a
c
b
d
.
. Fig. 2.4  (a–d) Sandwich graft from the concha used as septal extension graft
a
b
.
. Fig. 2.5  (a, b) Septal extension graft from the central septum fixed to the anterior spine
2.1 · Surgical Principles

44
2
a
b
.
. Fig. 2.6  (a, b) Extracorporeal septal reconstruction for a deformed anterior border. The neoseptum is replaced in a more anterior position to
correct the columellar retraction
a
c
b
.
. Fig. 2.7  (a–c) Extracorporeal septal reconstruction in an overresected anterior border with spreader grafts from the auricle and correction of the
retracted columella with a sandwich graft

Chapter 2 · Secondary Septoplasty

45
2
a
c
d
b
.
. Fig. 2.8  (a–d) Extracorporeal reconstruction of a straight septal frame using a unilateral spreader graft from the residual septum for the dorsum and
both an onlay graft from the septum to the anterior border and a sandwich graft from the auricle for reconstruction of a retracted columella
2.1 · Surgical Principles

46
2
a
c
e
d
b
.
. Fig. 2.9  (a–e) Straightening with a thinned bone graft from the perpendicular plate with multiple drill holes for fixation and stabilization

Chapter 2 · Secondary Septoplasty

47
2
a
c
b
d
.
. Fig. 2.10  (a–d) Extracorporeal septal reconstruction in a multiple fractured septum, which had healed in dislocation. The separated straight
pieces are fixed onto a PDS foil keeping it straight by spreader grafts, which are kept in position for suturing with a modified Aiach clamp
2.1 · Surgical Principles

48
2
a
c
e
b
d
.
. Fig. 2.11  (a–e) Extracorporeal septal reconstruction: straightening by a contralateral bent conchal cartilage graft used as a unilateral spreader
graft

Chapter 2 · Secondary Septoplasty

49
2
a
c
b
d
.
. Fig. 2.12  (a–d) Total reconstruction of a stable septal framework by doubling conchal grafts
a
b
.
. Fig. 2.13  (a, b) Reconstruction of a neoseptum from the residual septal components in combination with a conchal graft, both being fixed onto
PDS foil
2.1 · Surgical Principles

50
2
.
. Fig. 2.14  Reconstruction of the internal valve using bended
polydioxanone (PDS) foil

Chapter 2 · Secondary Septoplasty

51
2
2.2
Case Studies
2.2.1 Case 1: Technique: Splinting
of a Scored Septum with Ethmoid Bone
The ethmoid bone was thinned with a cylindrical motor drill
and then perforated with multiple drill holes and applied
with a Lindemann fraise. Fixation could then be performed
using multiple back-and-forth mattress sutures.
A 42-year-old woman presented after two previous rhi-
noplasties. Despite previous septal scoring, there was a slight
persistent septal deviation to the right. The deviation was
eliminated using a thinned perpendicular plate splint that
had been perforated with multiple drill holes for easier fixa-
tion to the septum itself and by using multiple back-and-­
forth mattress sutures for long-term stabilization. Using this
technique, satisfactory straightening of the dorsum was
accomplished (. Fig. 2.15a–d).
2.2 · Case Studies

52
2
.
. Fig. 2.15  (a) Thinned ethmoid bone for splinting. (b) Front view pre-
op/post-op after splinting the scored septum with ethmoid bone graft.
(c) Profile view pre-op/post-op after splinting the scored septum with
ethmoid bone graft. (d) Base view pre-op/post-op after splinting the
scored septum with ethmoid bone graft
a
b

Chapter 2 · Secondary Septoplasty

53
2
c
d
.
. Fig. 2.15  (continued)
2.2 · Case Studies

54
2
2.2.2 Case 2: Technique: Septal Extension
Graft
A septal extension graft (SEG) can be used for a variety of
indications, including nasal lengthening, lower level cartilages
(LLC) contouring, tip support, or augmentation of a weak or
overresected anterior septum. A strong and straight piece of
septal cartilage is preferred for the creation of an SEG. Suture
fixation of the graft can be performed in two different ways,
depending upon the anatomy. When the caudal septum is rea-
sonably strong and stable, the SEG can be sutured directly to
the caudal septum in a side-to-side configuration for secure
immobilization. Alternatively, the SEG can be stabilized using
a single (or paired) extended spreader graft or splinting grafts
(single or paired from bone or cartilage) when septal support
has been compromised or when aggressive nasal lengthening
is desired. However, care must be taken to contour the SEG to
fit the anterior septal contour precisely.
A 35-year-old female presented after several failed rhino-
plasty surgeries. Profile examination revealed a hanging
­columella, an overresected bony dorsum, and an overpro-
jected lower nose. Frontal examination revealed a deviated
nose with an inverted-V deformity, an oblique columella
with dislocation from the anterior nasal spine (ANS) into the
left nasal vestibule, and asymmetrical nostrils with bilateral
alar retraction.
Upon exploration with the open rhinoplasty approach,
copious fibrous scar tissue was found covering a weak and
unstable caudal septum. Consequently, a large piece of
­cartilage was harvested from the posterior quadrangular
septum and sutured to the caudal septum as a septal exten-
sion graft (. Fig. 2.16a). Using transverse drill holes cre-
ated in the ANS, the base of the caudal septum was then
sutured in the midline to the ANS (. Fig.  2.16b). To
straighten the dorsal L-strut, 8  cm of the ninth rib was
harvested and cut diagonally into 1.5  mm wide strips,
which were used as extended spreader grafts. In addition
to straightening the middle vault, extended spreader graft
placement stabilized the septal extension graft and elimi-
nated the inverted-V deformity. Tip deprojection was per-
formed using a lateral crural overlap technique followed
by tongue-in-groove fixation of the medial crura to the
septal extension graft for elimination of the hanging colu-
mella. Asymmetrical alar rim grafts were placed to correct
tip asymmetry and to contour and strengthen the alar
rims. The remaining cartilage was finely diced and used as
onlay graft material to smooth the nasal dorsum
(. Fig. 2.16c–e).

Chapter 2 · Secondary Septoplasty

55
2
.
. Fig. 2.16  (a) Endonasal stabilizing of a weak caudal septum with a
septal extension graft. (b) Straightening the weak anterior septum with
septal extension graft and fixing it in the midline. (c–e) Front view, profile
view, base view pre-op/post-op
a
b
2.2 · Case Studies

56
2
c
d
.
. Fig. 2.16  (continued)

Chapter 2 · Secondary Septoplasty

57
2
e
.
. Fig. 2.16  (continued)
2.2 · Case Studies

58
2
2.2.3 Case 3: Technique: Suture Fixation
of the Neoseptum to the ANS Using
Osseous Drill Holes
Secure fixation of the septal construct after extracorporeal
septal reconstruction is essential. In addition to secure
cranial fixation of the construct to the ULC and nasal
bones, stable caudal fixation to the ANS is equally impor-
tant. In order to facilitate stable fixation of the septal con-
struct directly to the ANS, a small transverse drill hole is
placed to permit passage of the fixation sutures. Whenever
possible, this is also combined with the creation of a sagit-
tally oriented groove created within the ANS to further
stabilize the neoseptal construct. The neoseptum is also
sutured with at least three passes of 4-0 permanent suture
placed at different points within the construct to increase
stability.
A 53-year-old male patient presented for revision sur-
gery. Examination revealed a bulky tip and a deviated nose
secondary to a severe residual deformity of the nasal septum,
including dislocation of the caudal septum into the left nasal
vestibule with an oblique columella. An overprojected dor-
sum and an overly narrow cartilaginous dorsum with col-
lapse of the internal nasal valve were also observed.
Using the open rhinoplasty approach, we observed an
“accordion-like collapse of the medial crura.” Owing to the
severity of the septal deformity, an extracorporeal septal
reconstruction was required, including doubling of the ante-
rior septum to create a straight caudal L-strut. Spreader grafts
were then used to widen the pinched middle vault, and the
neoseptum was sutured to the ULC, nasal bones, and ANS
after a transverse drill hole and osseous sagittal groove were
created in the ANS.
In order to compensate for septal shortening after folding
the anterior septum, a double-layered conchal “sandwich”
graft was used to lengthen the caudal septum and to provide
a strut for the LLC. Tip refinement was accomplished using
lateral crural underlay technique (cephalic fold-under flaps),
spanning sutures, and a non-integrated shield graft. Rim
grafts were used to enhance alar rim contour, and a single
layer of allogenic fascia lata was used to smooth the nasal
dorsum (. Fig. 2.17a–d).

Chapter 2 · Secondary Septoplasty

59
2
.
. Fig. 2.17  (a) Extracorporeal septal reconstruction with fixation to the ANS via a drill hole, sandwich graft from the concha and shield graft for
contouring the tip. (b–d) Front view, profile view, base view pre-op/post-op
a
b
2.2 · Case Studies

60
2
c
d
.
. Fig. 2.17  (continued)

Chapter 2 · Secondary Septoplasty

61
2
2.2.4 Case 4: Technique: Creation
of a Neoseptum with PDS Foil,
Restoration of Strong Tip Support
Using a Sandwich Graft
from the Concha
The conchal cartilage was cut through to the perichondrium
of the opposite side, and then the straight pieces were fixed to
PDS foil. Using this technique, a stable anterior septum was
created.
For additional tip support, a sandwich graft from the con-
cha was used. By suturing reciprocal curves of the conchal
cartilage to balance opposing forces and create a strong,
straight graft, long-term stability is ensured. We use the
­modified Aiach clamp and suture the cartilage with a 4-0
nonresorbable suture on a sharp Keith needle.
A 37-year-old man presented with severe deformity of
the external and internal nose after four previous rhinosepto-
plasties.
The nose was significantly deviated to the right with
asymmetrical nasal bones, asymmetrical nostrils, and an
asymmetrical tip. The anterior septum was overresected,
with drooping of the tip and a slightly retracted columella.
Concavity of both alae was also observed.
Because of initial overresection of the septum, prior sep-
tal reconstruction was undertaken with rib cartilage, but
inadequate rib thinning and rib warping resulted in an unsat-
isfactory outcome. Consequently, the rib graft was removed,
and the septum was reconstructed using a concha graft in
which the cartilage was cut for straightening; the perichon-
drium was preserved intact. The now straightened conchal
cartilage was then fixed to PDS foil scaffold for support. After
osteotomies, the neoseptum was replanted and fixed to the
upper lateral cartilage as well as to the nasal bones and the
anterior nasal spine. For additional support, a sandwich graft
from the second concha was also used. This was positioned
using guiding sutures and then fixed to the anterior-most end
of the PDS foil scaffold. The concavity of the lateral crura was
eliminated using a lateral crural overlay technique. Tip nar-
rowing was attempted using suture techniques, but the carti-
lage was too thick, so that a dome division with secondary
suturing was required (. Fig. 2.18a–f).
2.2 · Case Studies

62
2
.
. Fig. 2.18  (a) Extracorporeal septal reconstruction with PDS foil and
conchal cartilage. (b) Sandwich graft from concha used as columellar
strut. (c) Removal of the bended rib graft; convexity of both lateral crura,
structuring the tip with sandwich graft, dome division after lateral ­crural
­overlay technique, then suturing. (d–f) Front view, profile view, base view
pre-op/post-op
a
b

Chapter 2 · Secondary Septoplasty

63
2
c
d
.
. Fig. 2.18  (continued)
2.2 · Case Studies

64
2
e
f
.
. Fig. 2.18  (continued)

Chapter 2 · Secondary Septoplasty

65
2
2.2.5 Case 5: Technique: Straightening
by Splinting with Thinned
Perpendicular Plate
Deviated septal cartilage can be straightened by splinting with
or without scoring. An ideal material for splinting is the
thinned perpendicular ethmoid plate. By using an electric
drill with a cylindrical-shaped bit, thinning is easily done. The
prethinned bone is perforated with as many multiple drill
holes as possible to make the fixation easier. For that purpose,
we use a straight Keith needle with 4-0 nonresorbable suture.
Multiple drill holes are necessary because at the end of the
surgery, multiple through-and-through back-and-­forth
sutures are placed through the replanted septum for stabiliza-
tion, and the holes must be located by blind palpation.
A 38-year-old female presented following previous correc-
tive nasal surgery 15 years earlier. Initially the result was satis-
factory until 3 years ago, when a recurrence of the deviation
occurred. On examination, we observed a slight deviation to the
right with an asymmetrical tip and a seagull deformity of the left
ala. The columella was oblique, and the anterior septal border
was dislocated into the right nostril, resulting in nostril asym-
metry. In addition, there was a slight malformation of the left
nasal entrance with a missing sill and a retraction of the left ala.
Intraoperatively, we found a slightly deviated septal carti-
lage, since during the previous operation only a spur had
been resected. We harvested a large graft from the perpen-
dicular plate, thinned it, perforated it, and fixed it to the devi-
ated dorsal segment of the septum. The septum itself was
very weak, which facilitated correction with the application
of ethmoid splinting grafts. Furthermore, the anterior septal
border had not been relocated and secured to the anterior
spine during the primary procedure, which was now per-
formed. In addition, paramedian, percutaneous transverse,
and low-to-low lateral osteotomies were performed to
straighten the bony pyramid.
During the previous operation, a dome division tech-
nique had been used for narrowing the tip. The application of
this technique led to the seagull deformity of the left ala;
therefore, we reconstructed the domes using an overlapping
technique that enabled us to simultaneously correct the
seagull deformity. For stabilization of the weak cartilage, we
inserted a batten graft on the right lateral crus. The wide col-
umellar base was narrowed by direct suturing of the foot-
plates. The retraction of the left ala could have been corrected
by a composite graft from the inner side of the anterior helix,
but the patient declined this aspect of the reconstruction
(. Fig. 2.19a–e).
2.2 · Case Studies

66
2
.
. Fig. 2.19  (a) Straightening recurrent deviation with perpendicular bone graft. (b) Reconstruction of the tip framework with overlap technique
and batten graft. (c–e) Front view, profile view, base view pre-op/post-op
a
b

Chapter 2 · Secondary Septoplasty

67
2
c
d
.
. Fig. 2.19  (continued)
2.2 · Case Studies

68
2
e
.
. Fig. 2.19  (continued)

Chapter 2 · Secondary Septoplasty

69
2
2.2.6 Case 6: Technique: Covering
the Reconstructed Septum with Free
Diced Cartilage (FDC)
Irregularities of the dorsum have been the most common
problem using the technique of extracorporeal septal recon-
struction. One option to get a smooth dorsum is using fine
diced cartilage, which is applied via a tuberculin syringe after
suturing the flap back so that it can be used like a paste to
mold the dorsum.
A 42-year-old female presented after previous rhino-
plasty for revision surgery. Examination revealed a deviated
and overprojected nose, an underprojected tip, an oblique
columella with dislocation of the anterior septal border to
the left side, and deviation of the quadrangular septum to
the right. In addition, the tip was bulbous and the nostrils
were asymmetrical. On profile view, the tip was overly
round, the ­dorsum was overprojected, and the radix was
overly deep.
Using the external approach, the dorsal septum was first
lowered, and then deviated segments of septal cartilage were
straightened using a thin piece of perforated ethmoid bone.
The bony pyramid was then straightened using low-to-low lat-
eral and transverse osteotomies. Autospreader flaps were then
used to widen the internal nasal valves and recontour the dorsal
aesthetic lines. Free diced cartilage was then used to augment
the radix and provide further refinement to the nasal dorsum.
To support the tip, a sandwich graft harvested from the
concha was sutured to the medial crura. Prior to fixation, a
deformed portion of the intermediate crus was excised to
correct nostril asymmetry. The stumps were then sutured to
the sandwich graft in an end-to-end configuration. A shield
graft was then placed to increase tip projection and strengthen
tip support (. Fig. 2.20a–d).
2.2 · Case Studies

70
2
.
. Fig. 2.20  (a) Straightening recurrent deviation with a perpendicular ethmoid bone graft and free diced cartilage (FDC) for dorsal camouflage.
(b–d) Front view, profile view, base view pre-op/post-op
a
b

Chapter 2 · Secondary Septoplasty

71
2
c
d
.
. Fig. 2.20  (continued)
2.2 · Case Studies

72
2
2.2.7 Case 7: Technique: Lengthening
of the Septum by Extracorporeal
Technique
Owing to previous overresection of the caudal septum,
reduced septal height resulted in inadequate tip support.
After removing the entire residual septum, measurements
revealed a septal height at the cartilaginous bony junction of
approximately 35 mm, indicating sufficient length for recon-
struction of the dorsum. The length of the original dorsum
was only 20 mm. There was also sufficient size for simultane-
ous replacement of the anterior septal border. Therefore, the
explanted septum was turned by 90°.
A 44-year-old woman presented after previous rhinosep-
toplasty abroad. On examination, a severe polly-beak defor-
mity with asymmetrical nasal tip and prominence on the
right side, irregularities of the dorsum, insufficient tip sup-
port with underprojection, and a septal perforation were all
observed.
Intraoperatively, we found an overshortened anterior sep-
tum that was vertically too tall and resulted in dislocation of
the caudal septum to the left side, creating a septal spur on
that side. Therefore, the entire septum was removed and
rotated 90° so that the bony cartilaginous junction became the
new dorsum and the dorsal septum became the new anterior
border. The reoriented septum was replanted within the septal
perforation so that after closure of the mucosa, an anatomic
reconstruction was achieved. Because the bony cartilaginous
junction was unusually thick, separate spreader grafts were
not required because nasal valve width was adequate. Because
of short upper lateral cartilages, fixation of the replanted sep-
tum to the upper lateral cartilages was insufficient, and addi-
tional fixation to the nasal bones was necessary.
Usually we begin drill hole placement on the dorsal part
of the right nasal bone and make as many holes as possible to
the adjacent bony dorsum of the neoseptum. Then we take a
curved 4-0 needle and go through the drill hole on the right
side as well as a drill hole through the bony dorsum and
observe where the tip of the needle hits the opposite side. At
the contact point, we make a final drill hole through the left
nasal bone. With this simple method, fixation of the replant
to the nasal bone is fast and easy. These days, we would prefer
the “crisscross technique” (7 see Fig. 1.8).
After fixation, we vertically shortened the caudal septum
so that it fitted precisely into the groove previously created
within the nasal spine. Additionally, a horizontal drill hole
was also made through the spine so that we could reattach
the caudal septum. Next we covered the new dorsum with
previously harvested perichondrium to camouflage the
reconstruction. The nasal tip was contoured with a trans-
domal suture. To straighten the weak lateral crura, a thick
piece of septal cartilage was divided and used as a batten graft
for both sides so that the ala became strong. Spanning sutures
and tip suspension sutures were also used. Finally, to avoid
any imperfections with the new structure, a soft-tissue graft
was also applied to the nasal tip (. Fig. 2.21a–i).

Chapter 2 · Secondary Septoplasty

73
2
.
. Fig. 2.21  (a) The anteriorly overshortened septum slipped to the left
side; the explanted septum is turned 90°. (b) Drilling a hole and a groove
into the anterior nasal spine (ANS) for fixation of the septum. (c) Splitting
septal cartilage to create thin batten grafts. (d) Contouring the domes by
transdomal sutures. (e, f) Refinements of the batten grafts using a cylin-
drical drill. (g–i) Front view, profile view, base view pre-op/post-op
a
b
2.2 · Case Studies

74
2
c
d
.
. Fig. 2.21  (continued)

Chapter 2 · Secondary Septoplasty

75
2
e
f
.
. Fig. 2.21  (continued)
2.2 · Case Studies

76
2
g
h
.
. Fig. 2.21  (continued)

Chapter 2 · Secondary Septoplasty

77
2
i
.
. Fig. 2.21  (continued)
2.2 · Case Studies

78
2
2.2.8 Case 8: Technique: Reconstruction
of an Overresected, Deformed Anterior
Septum
The bony cartilaginous junction of the nasal septum is nearly
always long enough to reconstruct the dorsal L-strut. Even
when previous surgery results in an excessive reduction in
dorsal length, the entire septum can be rotated by 90° so that
the surgically shortened dorsum becomes the new caudal
septum and the unaltered bony cartilaginous junction
becomes the new dorsal septum.
A 23-year-old female presented for revision surgery after
suffering childhood nasal trauma. Corrective surgery was
attempted (elsewhere) during adolescence but proved unsuc-
cessful. At the time of revision surgery, a severe septal defor-
mity was found, obstructing the nasal airway. Absence of the
anterior septum also resulted in inadequate tip support with
tip ptosis and formation of a pseudo-hump. Treatment
involved removing the residual septum and rotating the
specimen 90° so that the bony cartilaginous junction became
the new dorsum and the existing dorsum became the new
caudal septum. After fixation of the new septal partition, the
nasal dorsum was covered with a single layer of allogenic fas-
cia lata for camouflage. Overresected lateral crural were
reconstructed using batten grafts fashioned from the concha
cymba (. Fig. 2.22a–e).

Chapter 2 · Secondary Septoplasty

79
2
.
. Fig. 2.22  (a) Extracorporeal septal reconstruction of an anteriorly
overresected septum by rotating the explanted septum by 90°. (b) The
overresected lateral crura are reconstructed using batten grafts. (c–e)
Front view, profile view, base view pre-op/post-op
Severe septal deformity with
destruction of the anterior border
Plan of reconstruction
a
b
Ala reconstruction
with batten grafts
from the cymba
Replanted septum
2.2 · Case Studies

80
2
c
d
.
. Fig. 2.22  (continued)

Chapter 2 · Secondary Septoplasty

81
2
e
.
. Fig. 2.22  (continued)
2.2 · Case Studies

82
2
2.2.9  Case 9: Technique: Reconstruction
of a Neoseptum with Ethmoid Bone
Grafting
A 20-year-old male presented after three rhinoplasties with a
C-shaped dorsal deviation to the right, an overprojected dor-
sum with a hump deformity and both palpable and visible
irregularities, and an acute nasolabial angle with a partial
columellar retraction. On basal view alar asymmetry and a
left seagull deformity were seen.
The patient also complained about right-sided nasal air-
way obstruction. On examination, a severe rightward devi-
ation of the residual septum accounted for the unilateral
airway obstruction. Hypertrophy of the left lower turbinate
was also found. The deviation of the residual septum was
corrected by splinting with a thinned and perforated splint-
ing graft from the perpendicular ethmoid plate. Multiple
drill holes helped to make fixation easy. In addition, the
caudal septum was also splinted with a perforated ethmoid
bone graft. After harvesting conchal cartilage, a sandwich
graft was constructed to support the tip and improve the
nasolabial angle. For straightening the bony pyramid, per-
cutaneous paramedian, transverse, and low-to-low osteoto-
mies were all performed. After creating a straight line with
spreader grafts taken from the concha, the neoseptum was
replanted and fixed to the upper lateral cartilage as well as
to the anterior spine. The conchal sandwich graft was then
positioned in front of the neoseptum to serve as a columel-
lar strut. The medial crura was then sewn to the sandwich
graft. For narrowing the domes, transdomal sutures were
applied just above the sandwich graft. The tip was con-
toured with spanning sutures, and the position of the tip
was secured by tip suspension sutures. For camouflaging
minor irregularities that could be seen through the thin
skin, we then placed two layers of allogenic fasciae
(. Fig. 2.23a–f).

Chapter 2 · Secondary Septoplasty

83
2
.
. Fig. 2.23  (a) Extracorporeal septal reconstruction with ethmoid
bone grafting. (b) The L-shaped, mainly bony neoseptum. (c) Preparing
a double-layered sandwich graft from concha used as columellar strut.
(d–f) Front view, profile view, base view pre-op/post-op
a
b
2.2 · Case Studies

84
2
c
d
.
. Fig. 2.23  (continued)

Chapter 2 · Secondary Septoplasty

85
2
f
e
.
. Fig. 2.23  (continued)
2.2 · Case Studies

86
2
2.2.10 Case 10: Septal Correction with
Ethmoid Splinting Graft, Septal
Extension Graft from Double-Layered
Conchal (Sandwich) Graft, and
Maxillary Augmentation
A 42-year old patient presented after severe nasal trauma and
previous rhinoplasty. Examination revealed a widened dor-
sum with a saddle nose deformity, and a retracted and oblique
columella following loss of the anterior septum. The premax-
illa was also deficient with a nasolabial angle of only 60°, and
the tip was overly broad with asymmetric nostrils.
Using the external rhinoplasty approach, surgical explo-
ration revealed a severely deformed caudal septum with a
sharp angulation located 6  mm below the anterior septal
angle. Large portions of the quadrangular septum were also
missing, but a large ethmoid (splinting) graft was harvested
from the bony septum and thinned using a cylindrical drill
bit. Multiple drill holes were then added for easier fixation,
and the graft was used to straighten and stabilize the
deformed caudal septum. Paired spreader grafts fashioned
from conchal cartilage were also used to reinforce the nar-
row and weak dorsal L-strut. The widened bony pyramid
was then narrowed using paramedian medial osteotomies
created with a Lindeman bur, followed by transverse and
(low-to-low) lateral osteotomies using the percutaneous
technique. The premaxilla was then augmented with multi-
ple layers of MersileneR mesh. (5 years later the Mersilene
was replaced with a DC-F graft fashioned from allogenic fas-
cia lata and autologous rib cartilage). The opposite concha
was then harvested to create a double-layered septal exten-
sion graft which was positioned anterior to the reconstructed
caudal septum on top of the Mersilene mesh. The tip was
then contoured using transdomal and spanning sutures and
then covered with a layer of allogenic fascia lata. A DC-F
graft, fashioned from diced residual ear cartilage wrapped in
allogenic fascia lata, was then used to correct the saddle
deformity (. Fig. 2.24).

Chapter 2 · Secondary Septoplasty

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Anterior septum deformed and weak
Harvesting and thinning of the
perpendicular plate
Straight and strong anterior septum
a
.
. Fig. 2.24  (a–c) Stabilizing of the anterior septum with ethmoid bone splint. (b) Double layered conchal graft used as septal extension graft. (c)
Manufacturing a DCF graft from ear cartilage and allogenic fascia lata. (d–f) Front view, profile view, base view pre-op/post-op
2.2 · Case Studies

88
2
.
. Fig. 2.24  (continued)
c
b

Chapter 2 · Secondary Septoplasty