Plastic Surgery Principles in Septorhinoplasty—Importance of the Caudal Septum in the Treatment of Caudal Septal Deviation—

Abstract

We have used the technique of open septorhinoplasty since in combined surgery in collaboration with ENT surgeons, as to improve nasal function and esthetics. This approach covers a wide variety of nasal pathologies including nasal valve obstruction, post-traumatic nasal obstruction, caudal septal deviation, and post-conventional septoplasty with worsening of nasal obstruction. Here, we describe the importance of manipulating the caudal septum in treatment of caudal septal deviation. Operation: Thorough a transcolumellar incision with infra-cartilagenous extension, the interdomal ligament was divided to approach the anterior angle of the septal cartilage to obtain access for sub-mucoperichondrial dissection. Septoplasty and conchal surgery are performed as needed by an ENT surgeon. If caudal deviation is moderate, it can be straightened by freeing the septum from the upper lateral cartilages. If the posterior angle of the septum is dislodged from the anterior nasal spine ANS , the posterior septal angle is freed, trimmed and sutured to the ANS. If the posterior septal angle is toward the ANS, the length of the caudal septum can be adjusted in the middle and reinforced with a batten graft. Discussion: The pathologies of the anterior septal angle without dislocation from the anterior nasal spine are relative overload on the caudal septum from the dorsal cartilaginous component of the nose, which includes a frail septum, misbalance of the septal cartilage and surrounding bony structures, and intrinsic torsional memory of the cartilage. If septal cartilage is dislodged from the ANS, the pathology is more likely to be due to a previous trauma. Understanding the pathology of caudal septal deviation is essential in straightening and centralizing the septal cartilage.

Caudal Septal Deviation

“…In cases of minor septal deviation and if the cartilage was not dislocated at the anterior nasal spine (ANS), the cartilage was released from the upper lateral cartilage to ease the deviation. If the cartilage was not sufficiently straightened at this point, and in cases where the cartilage was already dislocated at the ANS, an incision at the ANS was made to release the remaining tension of the caudal septum, resulting in the anterior rotation of the caudal septum, causing a slight anterocaudal movement of the ASA and flattening of the supratip (“release and rotation method”) 13 . In cases where the cartilage at the posterior septal angle (PSA) overlapped the maxillary crest, adapting at the caudal end of the PSA was performed (Fig.…”

“…1), in addition to minor trimming at the anterocaudal edge, if the PSA protruded the LLC. After this, the cartilage was fixed to the ANS with a 4.0 PDS, using the “back and forth” suture technique, previously describe by the senior author 13 . In cases where a preexisting crack was found in the caudal septal cartilage, a cut along the crack was made and the length of the cartilage was adjusted and stabilized with an autologous batten graft following the “cut and suture method.” 14 If the cartilage still deviated at the ASA, the cartilage was centered and fixed to the upper lateral cartilage using a mattress suture 9 …”

“…If the cartilage was not sufficiently straightened at this point, and in cases where the cartilage was already dislocated at the ANS, an incision at the ANS was made to release the remaining tension of the caudal septum, resulting in the anterior rotation of the caudal septum, causing a slight anterocaudal movement of the ASA and flattening of the supratip ("release and rotation method"). 13 In cases where the cartilage at the posterior septal angle (PSA) overlapped the maxillary crest, adapting at the caudal end of the PSA was performed (Fig. 1), in addition to minor trimming at the anterocaudal edge, if the PSA protruded the LLC.…”