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Quick Septoplasty: Surgical Technique and Learning Curve

Article  in  Aesthetic Plastic Surgery · August 2009

DOI: 10.1007/s00266-009-9388-y · Source: PubMed

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Aesth Plast Surg (2009) 33:814–818
DOI 10.1007/s00266-009-9388-y
ORIGINAL ARTICLE
Quick Septoplasty: Surgical Technique and Learning Curve
Luca D’Ascanio Æ Marco Manzini
Received: 24 March 2009 / Accepted: 2 June 2009 / Published online: 7 July 2009
Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2009
Abstract
Background The importance and technical difficulties of
septal surgery often are underestimated. Although septo-
plasty is among the most common procedures in nasal
surgery, it is poorly taught and developed.
Methods Septoplasty was performed for 1,035 consecu-
tive white patients (789 males and 246 females) with a
mean age of 35.7 years (range, 6–62 years) using a new
personal surgical technique. Septal surgery was associated
with functional endoscopic sinus surgery (FESS) in 157
cases and rhinoplasty in 416 cases. Preoperative otorhino-
laryngologic examination using flexible nasal endoscopy,
anterior active rhinometry (AAR), and occasional com-
puted tomography of the paranasal sinuses was performed.
Postoperative AAR was carried out. Septoplasty operative
time was measured.
Results A significant reduction in nasal breathing resis-
tances with respect to preoperative conditions was found in
1,017 patients (98%) after AAR (p \ 0.001). No septal
perforation, nasal infection, or bleeding was noticed post-
operatively. Three cases of turbinoseptal synechiae were
observed. The mean septoplasty operative time was
13.83 ± 4.22 min (range, 8–31 min). A short learning
curve (20 septoplasty procedures) for this new septoplasty
technique was found.
Conclusion The proposed septoplasty technique is an
effective and rapid procedure for the correction of septal
deviations in both adults and children. Reproducible and
L. D’Ascanio (&)
M. Manzini
Department of Otolaryngology—Head and Neck Surgery,
Città di Castello Civil Hospital, Via Engels,
06012 Città di Castello, Perugia, Italy
e-mail: l.dascanio@gmail.com
123
easily learned, this technique can be associated with other
surgical procedures such as FESS and rhinoplasty.
Keywords Complications
Learning curve

Rhinoplasty
Septoplasty
Surgical time
Septoplasty, often given to young residents to perform, is
dismissed as a simple procedure [8, 11]. According to
junior surgeons, however, septoplasty is poorly taught and
should not be considered a simple procedure in which one
approach fits all [8, 11].
Past centuries have seen a steady interest in the cor-
rection of the dislocated and deviated nasal septum [17].
The reason for this interest is undoubtedly represented by
the prominent role of septoplasty in modern nasal surgery.
The concept that ‘‘the nose goes as the septum goes’’
confirms the importance of septal deviations in the devel-
opment of dysmorphisms of the nasal pyramid and there-
fore the absolute necessity of correcting septal deformities
during rhinoplasty procedures [1].
The importance of septal surgery also has increased in
recent decades relative to the extension of septoplasty indi-
cations, such as correction of nasal obstruction for an easier
transnasal approach to the pituitary fossa or for improved
access to the middle meatus in functional endoscopic sinus
surgery (FESS) [18]. Furthermore, septal surgery is a major
cause of legal controversy for otolaryngologists, plastic
surgeons, and maxillofacial surgeons because of the possible
morbidity and aesthetic consequences related to this surgical
procedure [8]. Aesthetic changes, noted in up to 21% of
patients who undergo septoplasty, represent one of the most
common causes of reoperation in nasal surgery [8, 19].
Despite the number of septoplasty techniques described in
Aesth Plast Surg (2009) 33:814–818
past centuries, controversies still remain about the best
approach to the deviated septum [1, 3, 6, 8–10, 12, 13, 15–18].
In the current report, a personal septoplasty technique,
together with its technical details and results, is described.
The operative time for the septoplasties performed by the
junior author (L.D.) was analyzed to determine the learning
curve of the proposed septoplasty technique.
Materials and Methods
Patients
Between 1999 and 2008, we performed septoplasty for
1,035 consecutive white patients (789 males and 246
females) with a mean age of 35.7 years (range, 6–
62 years). Of these patients, 462 were submitted to septo-
plasty alone, and 157 were treated with septoplasty asso-
ciated with FESS because of chronic sinusitis, whereas for
416 subjects, the septoplasty was performed in association
with a rhinoplasty procedure. Turbinoplasty was performed
in cases of hypertrophy of the inferior turbinates.
Of 1,035 septoplasties, 58 were performed by the junior
author (L.D.), whereas the remaining 977 procedures were
carried out by the senior surgeon (M.M.). A careful history
and complete otorhinolaryngologic examination with flex-
ible nasal endoscopy were performed preoperatively for all
the patients. Anterior active rhinometry (AAR) was per-
formed for all the patients preoperatively and 3 months
after surgery [7]. Computed tomography (CT) of the par-
anasal sinuses and allergologic assessment were performed
when indicated on the basis of the patients’ clinical history.
The duration of the septoplasty procedure was measured
for all the patients. Informed consent was obtained from
each patient or the parents of children participating in the
study.
Surgical Technique
Septoplasty can be performed with children younger than
16 years under general anesthesia (GA) and adults under
local anesthesia (LA). Local infiltration of mepivacaine 2%
with epinephrine (1:200000) is performed along the frame
of the nasal septum. A hemitransfixion incision is per-
formed on the left side of the nasal septum (by the right-
handed surgeon) about 2 mm behind its caudal border
using a no. 15 blade. The mucoperichondrium and muco-
periosteum are elevated on the left side of the nasal septum
using a Killian nasal speculum and a bayonet aspirating
dissector. Such elevation should be extended as high as
possible and also to the floor of the left nasal cavity to
expose the maxillary crest on its left side. The caudal end
of the inferior border of the cartilaginous septum is
815
separated from the premaxilla by making the aspirating
dissector slide between these two structures. This area is
addressed as the ‘‘G point.’’ Such a procedure is allowed by
the peculiar anatomic organization of the complex ‘‘infe-
rior end of the septal cartilage-premaxillary bones.’’ The
inferior border of the septal cartilage and the premaxillary
wings on which it rests are held in close approximation by
fibrous tissue but are not fused into a single unit. The
cartilage is enveloped by a perichondral and submucosal
fascial sheath, which extends around and under the carti-
lage from one side to the other. This sheath therefore
separates the cartilage completely from its bony support
inferiorly and also from a too intimate connection with the
membranous septum (Fig. 1) [10].
After the caudal end of the septum’s inferior border has
been separated from the premaxilla, the aspirating dissector
is raised on the right side of the caudal border of the car-
tilagineous septum in the subperichondral plane. In this
way, the perichondrium is elevated off the caudal border of
the septal cartilage on its right side as well, whereas the
mucoperichondrium is left attached to the remaining por-
tion of the right side of the septal cartilage [4]. The inferior
border of the cartilagineous septum then is separated from
the maxillary crest by making the aspirating dissector slide
from the ‘‘G point’’ forward between the septal cartilage
(above) and the maxillary crest (below).
During this procedure, the excess in the vertical
dimension of the septal cartilage (responsible for septal
deviations on the vertical plane) bends out of the maxillary
crest (Fig. 2). Such cartilage in excess is fractured with the
aspirating dissector or cut with scissors and then removed
(inferior chondrotomy). The posterior edge of the septal
Fig. 1 Anatomy of the ‘‘septal cartilage–premaxilla’’ complex. G
(‘‘G point’’), area separating the inferior border of the cartilaginous
septum from the premaxilla; S, premaxilla; P, periosteum; M, mucosa
123
816
Fig. 2 Luxation of the excess in the vertical dimension of the septal
cartilage (responsible for septal deviations on the vertical plane)
obtained from the maxillary spine by making the aspirating dissector
slide between the septal cartilage (above) and the maxillary crest
(below)
cartilage is separated from the vomer and ethmoid per-
pendicular lamina (posterior chondrotomy). In this way,
the cartilagineous septum remains attached only to the
upper lateral cartilages with its upper border, thus realizing
Metzenbaum’s ‘‘swinging-door’’ concept [10].
The mucoperiosteum is elevated from the bony septum
on the right side (Fig. 3). Deformations and spurs of the
vomer and ethmoid perpendicular lamina are removed with
Weil forceps. In cases of deviation or deformity of the
maxillary crest, the mucosal lining is elevated also from the
right side of the crest (Fig. 4) and its deviated portion is
removed with an osteotome.
In case of excess in the horizontal dimension of the septal
cartilage (responsible for septal deviations on the horizontal
plane) or deformity of the septal caudal end, the anterior
border of the quadrangular cartilage is removed with scis-
sors (anterior chondrotomy). If some bending of the septal
cartilage still is noted after those chondrotomies, incisions
of the cartilage can help straighten the septum, thus real-
izing a series of vertical pillars (‘‘cartilage splitting’’) [5].
In conclusion, a ‘‘back-to-front’’ mattress suture in
Vicryl Rapid 3/0 is used to fix the mucoperichondrial flap
to the septum (Fig. 5) and close the hemitransfixion inci-
sion to unite the septal cartilage to the membranous sep-
tum. If a laceration in the mucoperichondral flap has
occurred accidentally during flap elevation at the beginning
123
Aesth Plast Surg (2009) 33:814–818
Fig. 3 Axial view of the nose. The mucoperichondrium is elevated
only on the left side of the septum, whereas it remains attached to the
septal cartilage on the right side. The mucoperiosteum is elevated on
both sides of the bony septum after separation of the posterior edge of
the septal cartilage from the vomer and ethmoid perpendicular
lamina. rpbt, right posterior bone tunnel; lpbt, left posterior bone
tunnel; lat, left anterior tunnel; amp, attached mucoperichondrium
of surgery, the mattress suture also is used to approximate
the edges of the tear, thus preventing postoperative septal
perforations. No nasal packing is used generally if septo-
plasty is performed as a single procedure under LA. If it is
performed under GA or in association with rhinoplasty or
FESS, nasal packing is applied and removed on the first
postoperative day.
Results
Of our patients, 1,017 (98%) displayed improvement in
their nose-breathing function, as shown by a reduction in
nasal breathing resistances at postoperative AAR (0.27 ±
0.09 Pa/cm3/s at 150 Pa) compared with preoperative con-
ditions (1.02 ± 0.58 Pa/cm3/s at 150 Pa; p \ 0.001). No
complication in terms of septal perforation, nasal infection,
or bleeding was noticed at postoperative follow-up evalua-
tion. Three cases of turbinoseptal synechiae were noted
among the patients who underwent turbinoplasty.
The mean septoplasty operative time, excluding local
anesthesia injection and other surgical procedures associ-
ated with septal surgery such as FESS, turbinoplasty, or
Aesth Plast Surg (2009) 33:814–818
Fig. 4 Elevation of the mucosal lining on both sides of the maxillary
crest. rit, right inferior tunnel; lit, left inferior tunnel
Fig. 5 ‘‘Back-to-front’’ mattress suture in Vicryl Rapid 3/0 used to
fix the mucoperichondrial flap to the septum and close the
hemitransfixion incision. If a perforation in the mucoperichondral
flap has accidentally occurred during flap elevation, the mattress
suture also is used to approximate the edges of the perforation to
prevent postoperative septal perforations
rhinoplasty, was 13.83 ± 4.22 min (range, 8–31 min). No
significant difference in surgical operative time for septo-
plasty was noted between LA and GA. As to the learning
817
Fig. 6 Learning curve of the new septoplasty technique. Duration of
septoplasty procedures (ordinate) in relation to the number of surgical
operations (abscissa) performed by the junior author (L.D.)
curve of the septoplasty technique we propose, the duration
of the first septoplasty performed by the junior author was
31 min, with the operative time progressively decreasing as
his experience with this septoplasty technique increased
(Fig. 6). In particular, after 20 septoplasties, the duration of
the surgical procedures performed by the junior author
began to approximate the range represented by the mean
operative time ±2 standard deviations of the procedures
performed by the more experienced surgeon (5.39–
22.27 min). No significant difference in postoperative
AAR was found among patients who underwent surgery by
the senior or junior surgeon.
Discussion
Septonasal deviations are a normal variant in human nasal
anatomy. Most do not cause airway problems unless they
obliterate at least 50% to 60% of the anterior inferior part
of the nasal airway [6]. Because septonasal dysmorphisms
may vary, several authors have tried to classify septal
deviations and propose a different surgical approach for
each [6]. The septoplasty technique described in this report
has proved to be effective for the correction of practically
all types of septal deviations.
Our septoplasty technique is based on the principle that
all septal deviations can be corrected by using a single
tunnel on the left side of the septal cartilage. This is pos-
sible because the flexibility and elasticity of the quadran-
gular cartilage make the septal cartilage straighten after the
surgeon has removed (chondrotomies) the excess length
and height of the cartilage, which can be performed with a
‘‘single-tunnel’’ approach.
In 1946, Fuchs [4] already understood the utility of
leaving the mucoperichondrium attached to the septal car-
tilage on one side to prevent postoperative septal perfora-
tions. In addition, leaving the mucoperichondrium attached
to the septum on the right side offers some intraoperative
advantages as well. First, such mucosal lining increases the
123
818
stability of the septal cartilage, which makes luxation of the
inferior border of the cartilagineous septum from the max-
illary crest, execution of the inferior chondrotomy, and
incisions of the septal cartilage easier for the surgeon.
Second, the adhesion of the mucosal lining to the right side
of the septal cartilage offers the surgeon the possibility to
check, after every surgical step, whether the septum has
been straightened or whether further maneuvers (such as
cartilage splitting) are needed. We avoid excessive resec-
tions of the septal cartilage [4] to preserve a sufficient support
for the cartilagineous nasal pyramid and to prevent the dorsal
saddling caused by more radical procedures (i.e., Killian’s
‘‘submucous septum resection’’) [9]. Such a ‘‘conservative’’
approach is extremely appropriate for the correction of septal
deviations not only in adults, but also in children, for whom
avoiding excessive resections of the septal cartilage is of the
utmost importance to prevent alterations in the postoperative
maxillofacial development [2].
Our surgical technique is characterized by a lower rate
of complications than with other approaches [14], thanks to
some operative tips. First, leaving the mucoperichondrium
attached to the septal cartilage on the right side preserves
the blood supply to the cartilage, thus preventing possible
postoperative septal perforations. Second, the mattress
suture performed at the end of the operation enables clo-
sure of possible mucoperichondrium lacerations on the one
side, preventing postoperative suffering of the septal car-
tilage, and attachment of the perichondrium of the qua-
drangular cartilage on the other side, preventing
postoperative septal hematoma. Furthermore, the hemo-
static effect of the suture helps to avoid postoperative nasal
packing for patients who have surgery under LA and
allows removal of nasal packing on the first postoperative
day for patients treated under GA, which significantly
reduces patient discomfort in the postoperative period.
Because the suture is performed with Vicryl Rapid 3/0, it
reabsorbs spontaneously within a few days, thus reducing
the risk of postoperative septal infections [14] and the need
for medications.
Conclusion
Our results show that a short surgical time is needed to
perform the proposed septoplasty procedure. Such a short
operative time results in a reduced duration of GA (if the
procedure is performed with the patient under GA) and in
increased surgery tolerability for patients treated under LA,
123
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Aesth Plast Surg (2009) 33:814–818
together with a reduction in surgical costs. In case of rhi-
noseptoplasty, the short septoplasty operative time allows
the surgeon to correct septal deviations quickly and focus
on the ‘‘rhinoplasty part’’ of the operation before nasal
edema develops, with obvious advantages. Furthermore, as
shown by the learning curve reported earlier, the septo-
plasty procedure we propose is easy to teach, reproducible,
and practical also for junior surgeons.
References
1. Cottle M (1955) Changing concepts in rhinoplastic surgery. Ann
Otol Rhinol Laryngol 64:632–633
2. Derkay CS (1999) A conservative role for septoplasty in young
children. Arch Otolaryngol Head Neck Surg 125:702–703
3. Edwards N (1975) Septoplasty: rational surgery of the nasal
septum. J Laryngol Otol 89:875–897
4. Fuchs J (1956) A rapid approach to the deviated septum in rhi-
noplasty. Plast Reconstr Surg (1946) 18:133–140
5. Goldman IB (1955) Septal surgery in relation to rhinoplasty. Eye
Ear Nose Throat Mon 34:458
6. Guyuron B, Uzzo CD, Scull H (1999) A practical classification of
septonasal deviation and an effective guide to septal surgery.
Plast Reconstr Surg 104:2202–2209
7. Huizing EH, De Groot JAM (2003) Functional reconstructive
nasal surgery. Thieme, Stuttgart, New York
8. Marshall AH, Johnston MN, Jones NS (2004) Principles of septal
correction. J Laryngol Otol 118:129–134
9. Masing H, Lehmann W, Stadler J (1978) On secondary opera-
tions following submucous septum resection. Laryngol Rhinol
Otol Stuttg 57:931–935
10. Metzenbaum M (1929) Replacement of the lower end of the
dislocated cartilage versus submucosal resection of the dislocated
end of the septal cartilage. Arch Otolaryngol 9:282
11. Oakley RJ, El-Alami M, Rowe-Jones JM (2003) Septal surgery:
were you trained? R Coll Surg Bull 84:15–17
12. Peer L (1937) An operation to repair lateral displacement of the
lower border of the septal cartilage. Arch Otolaryngol 25:475–481
13. Pirsig W (1982) Septum deviation 1882: beginning of systematic
submucous septum surgery. Laryngol Rhinol Otol Stuttg 61:547–551
14. Rettinger G, Kirsche H (2006) Complications in septoplasty.
Facial Plast Surg 22:289–297
15. Rudert H (1984) From Killian’s submucous septum resection and
Cottle’s septoplasty to modern plastic septum correction and
functional septo-rhinoplasty. HNO 32:230–233
16. Sciuto S, Bernardeschi D (1999) Excision and replacement of
nasal septum in aesthetic and functional nose surgery: setting
criteria and establishing indications. Rhinology 37:74–79
17. Tepan MG (1970) Septoplasty: a new technique. J Laryngol Otol
84:1133–1146
18. Urquhart AC, Bersalona F (1997) Septoplasty: correcting the
nasal valve. Laryngoscope 107:537–539
19. Vuyk HD, Langenhuijsen KJ (1997) Aesthetic sequelae of sep-
toplasty. Clin Otolaryngol Allied Sci 22:226–232