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Septoplasty via the external rhinoplasty approach
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SEPTOPLASTY VIA THE EXTERNAL RHINOPLASTY APPROACH WILLIAM RUSSELL RIES, MD
Conventional approaches for routine septal surgery are. adequate for most obstructing nasoseptal deformities. However, the rhinoplastic surgeon will occasionally encounter a severe deformity in which greater exposure would facilitate completion of the procedure. Such deformities are often the result of blunt nasal trauma in which the main impact is sustained by the nasal base.' Severe caudal deflections of the quadrangular cartilage, loss of tip support, and retraction of the columella suggest fracture/dislocations of the quadrangular cartilage. Deviation of the nasal spine may also be seen. Forthese types of deformities, the surgeon may consider performing the septoplasty via an external rhinoplasty approach. Some surgeons will undoubtedly take issue with this idea because they feel that all necessary septal repairs can be accomplished through the standard septal incisions (eg, Killian, hemitransfixion, or transfixion). Important tip support mechanisms are not violated when standard septal incisions are used. The external rhinoplasty approach provides unparalleled exposure to the structural components of the nasal base and allows for much easier manipulation and reconstruction of the columella-caudal septum complex. The septocolumellar and interdomal soft tissues are disrupted in the external approach to the septum, but they are reconstituted during the closure.
PROCEDURE After standard injection of the nasal base and septal mucous membranes, a notched incision is made through the columellar skin approximately 3 mm above the flared ends of the medial crura. The central notch (inverted V) is made with a no. 11 blade and all other incisions are made using a no. 15 blade. The lateral aspects of the transcolumellar incision join incisions made along the caudal ends of the medial crura. The vestibular skin is
From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN. Address reprint requests to William Russell Ries, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN 372322559. © 1990 by W.B. Saunders Company. 1043-1810/90/0104-0023$05.00/0
244
lightly scored at this juncture to provide a demarcation that ensures proper reapproximation during the closure. Marginal incisions are made along the caudal margins of the lower lateral crura, and the medial aspect joins the superior aspect of the vertical medial crura incision. Undermining of the columellar skin is performed using angled Converse scissors. The skin and soft tissue overlying the alar cartilages are elevated from lateral to medial until only the tissue of the soft-tissue triangles remains attached. Careful dissection is required at this point to prevent injury to the soft-tissue triangles that could cause notching of the nostril postoperatively (Fig 1). The domes of the lower lateral cartilages are retracted laterally. The fibrous tissue (so-called ligament) that joins them is dissected sharply until the caudal end of the septum is encountered (Fig 2). Mucoperichondrial flaps are then elevated, and the extent of elevation depends on the position and severity of the deformity. If the septal deformity is posterior, then the mucoperichondrial and mucoperiosteal flaps are elevated from both sides of the deformed area, but one mucoperichondrial flap is left attached anteriorly (Fig 3A). Bilateral septal flaps are elevated when the entire septum must be straightened, or when dealing with severe anterior septal bowing or anterior cartilage fracture/dislocations. The mucosal attachments to the upper lateral cartilages will prevent the mucosa from prolapsing into the nose (Fig 3B). A Killian-type resection of the septal cartilage and/or bone is then performed. Bowing of the anterior cartilage is usually treated by morselizing both sides of bent carti-
b.
FIGURE 1. External rhinoplasty incisions: (A) Transcolumellar incision outlined. (B) Inverted "V" incision made with no. 11 blade. (C) Incisions along caudal margin of medial crura. (D) Scoring of tissue past their junction to demarcate lateral closure point. (E) Marginal incisions. (F) Dissection of columellar flap. (Courtesy of Thieme, Inc.)
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OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 4 (DEC), 1990: PP 244-245
I ge. Vertical angulated fractures of the anterior septal ~rtilage are best treated by direct excision of the frac~ured segment. If the distal segment becomes freefloating, it should be sutured to the proximal segment of cartilage. Dislocations of the anterior-inferior aspect of the quadrangular cartilage from the maxillary crest are most often excised (swinging-door procedure). This maneuver allows the remaining segment to be positioned in the midline. Excessive lipping of the maxillary crest can be removed using a rongeur, Metzenbaum chisel, or drill. Nasal spine deformities are treated by partial resection of the spine. Complete avulsion of the nasal spine should not be done since the spine is an important structure in septal support. 2 Interrupted or continuous transseptal mattress sutures (4-0 plain gut with a short Keith needle) are used to reapproximate the mucoperichondrial and mucoperiosteal flaps. The remaining dorsal and caudal cartilage struts should be incorporated in these sutures (Fig 4). If a swinging-door procedure has been done, then two Wright sutures are placed to secure the inferior cartilaginous border to the midline. Columellar struts may be placed easily using this approach if needed. The interdomal and septocolumellar attachments are repaired using the 4-0 plain gut. The caudal end of the septum is further stabilized by bilateral splints of exposed x-ray film secured transseptally using a 4-0 Vicryl suture on a long Keith needle (Fig 5). These splints are removed 1 week, after surgery. If no turbinate surgery has been performed, then packing is not used. If turbinate surgery is done, then rolled pieces of Telfa coated with Bacitracin ointment are placed along the nasal floor between the neoturbinate and the septum. These packs are removed 24 hours after surgery.
FIGURE 2. Caudal septum exposed after dissection and lateral retraction of mucoperichondrial flaps that contain the medial crura. (Courtesy of Thieme, Inc.)
FIGURE 5. Shape and position of the exposed x-ray film splints. The notch allows placement over the pyriform rim. Secured with Vicryl suture and removed 1 week postoperatively. (Courtesy of Thieme, Inc.)
FIGURE 6. Rhinoplasty dressing: (A)iMicrofoam tape over the dorsum and lateral nasal walls. (B) Steri-Strip to sling the tip. (C) Sling crimped. (D) Additional Steri-Strips used to secure the sling and to provide an adherent surface for the Aquaplast. (E) Completed dressing with Aquaplast in place. Dressing is removed 1 week after surgery. (Courtesy of Thieme, Inc.)
,. .
( a. FIGURE 3. (A) Unilateral mucoperichondrial flap elevation for posterior septal deformities. (B) Bilateral mucoperichondrial flap elevation for isolated anterior septal deformities and when entire septum requires correction. (Courtesy of Thieme, Inc.)
WILLIAM RUSSELL RIES
FIGURE 4. Transseptal mattress sutures used to coapt the mucochondrial and mucoperiosteal flaps. Note the incorporation of the caudal and dorsal cartilage struts. (Courtesy of Thieme, Inc.)
The external columellar incisions are closed with interrupted 6-0 fast-absorbing plain suture (Ethicon) and one or two 4-0 plain sutures are used to close the marginal incisions. Two postage-stamp-sized pieces of Surgicel, impregnated with Bacitracin are placed bilaterally beneath the domes to reposition the skin in this area. An external nasal dressing is applied. This consists of Mastisol, Microfoam tape (1 inch), Steri-Strips (V2 inch) and Aquaplast (Fig 6). This dressing is removed at 1 week.
REFERENCES 1. Cotton JJ, Beekhuis GJ; Management of nasal fractures. Otolaryngol CIin North Am 19:73-85, 1986 2. Anderson JA, Ries WR: Rhinoplasty: Emphasizing the External Approach. New York, NY, Thieme Inc, 1986
245
SEPTOPLASTY VIA THE EXTERNAL RHINOPLASTY APPROACH WILLIAM RUSSELL RIES, MD
Conventional approaches for routine septal surgery are. adequate for most obstructing nasoseptal deformities. However, the rhinoplastic surgeon will occasionally encounter a severe deformity in which greater exposure would facilitate completion of the procedure. Such deformities are often the result of blunt nasal trauma in which the main impact is sustained by the nasal base.' Severe caudal deflections of the quadrangular cartilage, loss of tip support, and retraction of the columella suggest fracture/dislocations of the quadrangular cartilage. Deviation of the nasal spine may also be seen. Forthese types of deformities, the surgeon may consider performing the septoplasty via an external rhinoplasty approach. Some surgeons will undoubtedly take issue with this idea because they feel that all necessary septal repairs can be accomplished through the standard septal incisions (eg, Killian, hemitransfixion, or transfixion). Important tip support mechanisms are not violated when standard septal incisions are used. The external rhinoplasty approach provides unparalleled exposure to the structural components of the nasal base and allows for much easier manipulation and reconstruction of the columella-caudal septum complex. The septocolumellar and interdomal soft tissues are disrupted in the external approach to the septum, but they are reconstituted during the closure.
PROCEDURE After standard injection of the nasal base and septal mucous membranes, a notched incision is made through the columellar skin approximately 3 mm above the flared ends of the medial crura. The central notch (inverted V) is made with a no. 11 blade and all other incisions are made using a no. 15 blade. The lateral aspects of the transcolumellar incision join incisions made along the caudal ends of the medial crura. The vestibular skin is
From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN. Address reprint requests to William Russell Ries, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN 372322559. © 1990 by W.B. Saunders Company. 1043-1810/90/0104-0023$05.00/0
244
lightly scored at this juncture to provide a demarcation that ensures proper reapproximation during the closure. Marginal incisions are made along the caudal margins of the lower lateral crura, and the medial aspect joins the superior aspect of the vertical medial crura incision. Undermining of the columellar skin is performed using angled Converse scissors. The skin and soft tissue overlying the alar cartilages are elevated from lateral to medial until only the tissue of the soft-tissue triangles remains attached. Careful dissection is required at this point to prevent injury to the soft-tissue triangles that could cause notching of the nostril postoperatively (Fig 1). The domes of the lower lateral cartilages are retracted laterally. The fibrous tissue (so-called ligament) that joins them is dissected sharply until the caudal end of the septum is encountered (Fig 2). Mucoperichondrial flaps are then elevated, and the extent of elevation depends on the position and severity of the deformity. If the septal deformity is posterior, then the mucoperichondrial and mucoperiosteal flaps are elevated from both sides of the deformed area, but one mucoperichondrial flap is left attached anteriorly (Fig 3A). Bilateral septal flaps are elevated when the entire septum must be straightened, or when dealing with severe anterior septal bowing or anterior cartilage fracture/dislocations. The mucosal attachments to the upper lateral cartilages will prevent the mucosa from prolapsing into the nose (Fig 3B). A Killian-type resection of the septal cartilage and/or bone is then performed. Bowing of the anterior cartilage is usually treated by morselizing both sides of bent carti-
b.
FIGURE 1. External rhinoplasty incisions: (A) Transcolumellar incision outlined. (B) Inverted "V" incision made with no. 11 blade. (C) Incisions along caudal margin of medial crura. (D) Scoring of tissue past their junction to demarcate lateral closure point. (E) Marginal incisions. (F) Dissection of columellar flap. (Courtesy of Thieme, Inc.)
_-1'\\
\
d.
f.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 4 (DEC), 1990: PP 244-245
I ge. Vertical angulated fractures of the anterior septal ~rtilage are best treated by direct excision of the frac~ured segment. If the distal segment becomes freefloating, it should be sutured to the proximal segment of cartilage. Dislocations of the anterior-inferior aspect of the quadrangular cartilage from the maxillary crest are most often excised (swinging-door procedure). This maneuver allows the remaining segment to be positioned in the midline. Excessive lipping of the maxillary crest can be removed using a rongeur, Metzenbaum chisel, or drill. Nasal spine deformities are treated by partial resection of the spine. Complete avulsion of the nasal spine should not be done since the spine is an important structure in septal support. 2 Interrupted or continuous transseptal mattress sutures (4-0 plain gut with a short Keith needle) are used to reapproximate the mucoperichondrial and mucoperiosteal flaps. The remaining dorsal and caudal cartilage struts should be incorporated in these sutures (Fig 4). If a swinging-door procedure has been done, then two Wright sutures are placed to secure the inferior cartilaginous border to the midline. Columellar struts may be placed easily using this approach if needed. The interdomal and septocolumellar attachments are repaired using the 4-0 plain gut. The caudal end of the septum is further stabilized by bilateral splints of exposed x-ray film secured transseptally using a 4-0 Vicryl suture on a long Keith needle (Fig 5). These splints are removed 1 week, after surgery. If no turbinate surgery has been performed, then packing is not used. If turbinate surgery is done, then rolled pieces of Telfa coated with Bacitracin ointment are placed along the nasal floor between the neoturbinate and the septum. These packs are removed 24 hours after surgery.
FIGURE 2. Caudal septum exposed after dissection and lateral retraction of mucoperichondrial flaps that contain the medial crura. (Courtesy of Thieme, Inc.)
FIGURE 5. Shape and position of the exposed x-ray film splints. The notch allows placement over the pyriform rim. Secured with Vicryl suture and removed 1 week postoperatively. (Courtesy of Thieme, Inc.)
FIGURE 6. Rhinoplasty dressing: (A)iMicrofoam tape over the dorsum and lateral nasal walls. (B) Steri-Strip to sling the tip. (C) Sling crimped. (D) Additional Steri-Strips used to secure the sling and to provide an adherent surface for the Aquaplast. (E) Completed dressing with Aquaplast in place. Dressing is removed 1 week after surgery. (Courtesy of Thieme, Inc.)
,. .
( a. FIGURE 3. (A) Unilateral mucoperichondrial flap elevation for posterior septal deformities. (B) Bilateral mucoperichondrial flap elevation for isolated anterior septal deformities and when entire septum requires correction. (Courtesy of Thieme, Inc.)
WILLIAM RUSSELL RIES
FIGURE 4. Transseptal mattress sutures used to coapt the mucochondrial and mucoperiosteal flaps. Note the incorporation of the caudal and dorsal cartilage struts. (Courtesy of Thieme, Inc.)
The external columellar incisions are closed with interrupted 6-0 fast-absorbing plain suture (Ethicon) and one or two 4-0 plain sutures are used to close the marginal incisions. Two postage-stamp-sized pieces of Surgicel, impregnated with Bacitracin are placed bilaterally beneath the domes to reposition the skin in this area. An external nasal dressing is applied. This consists of Mastisol, Microfoam tape (1 inch), Steri-Strips (V2 inch) and Aquaplast (Fig 6). This dressing is removed at 1 week.
REFERENCES 1. Cotton JJ, Beekhuis GJ; Management of nasal fractures. Otolaryngol CIin North Am 19:73-85, 1986 2. Anderson JA, Ries WR: Rhinoplasty: Emphasizing the External Approach. New York, NY, Thieme Inc, 1986
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