Septorhinoplasty

Description:

Septorhinoplasty refers to surgical modification of the nasal septum and the bony, cartilaginous, and soft tissue structures of the nose, in order to achieve a more desirable cosmetic or functional result. Functional septorhinoplasty aims to improve nasal airflow and relieve nasal obstruction by correcting anatomic conditions such as septal deviation and nasal valve collapse. There are multiple approaches to septorhinoplasty; the external (open) technique is discussed in this chapter. Because rhinoplasty should be tailored specifically to each patient's individual anatomy, this chapter gives only a basic overview of the procedure.

Indications for Surgery:

  • Cosmetic
    • Dorsal hump
    • Saddle nose
    • Low radix
    • Asymmetric nasal pyramid (common after trauma)
    • Wide alar base
    • Flaring nostrils
    • Tip hypertrophy, asymmetry, overprojection, underprojection, incomplete development and/or deviation
  • Functional
    • Obstruction at nasal valve or obstruction more superiorly due to asymmetry or shift of bony pyramid

Contraindications to Surgery:

  • Medical comorbidities that would preclude surgical or anesthesia risk
  • Psychiatric instability

Pre-Operative Evaluation:

  • Physical examination should include assessment of skin quality, tip recoil, and palpation of the cartilaginous structures of the nose.
  • A flexible fiberoptic nasoendoscopic examination is useful for assessing the septum, turbinates, and internal nasal valves.
  • Detailed photographs should be taken of the entire face from multiple angles.
  • Informed consent should be obtained after thorough discussion of the goals and limitations of surgery.

Anesthesia:

Monitored anesthesia care (MAC) or general anesthesia

Surgical Technique:

  1. The patient is placed supine on the operating table and intravenous sedation is given.
  2. The nasal cavities are vasoconstricted with application of oxymetazoline-soaked pledgets.
  3. Local anesthesia is achieved via injection of 1% lidocaine with 1:100,000 epinephrine at multiple sites, including several stab injections along the caudal edge of the upper lateral cartilages. The nasal dorsum is then anesthetized, followed by the base of the nose, the columella, and the nasal tip.
  4. The septum is injected with local anesthetic in a submucoperichondrial plane, resulting in hydraulic dissection that assists with elevation of the septal flap.
  5. For the external rhinotomy approach, a transverse, notched ("inverted gull-wing") columellar incision is marked and made with a knife. This is carried laterally, following the rim of the nose, along the inferior border of the lower lateral cartilages. Care is taken to avoid injury to the medial crura of the lower lateral cartilages.
  6. The skin and soft tissue over the nasal tip and inferior-to-mid nasal dorsum are elevated, exposing the nasal cartilages. Structural attachments between cartilaginous structures are released (e.g., the lower lateral cartilages are divided from the upper lateral cartilages, the upper lateral cartilages are released from the septum).
  7. Any cartilaginous or bony deformities are noted. If a bony hump is present, the periosteum is elevated over the affected region, and the hump is taken down using an osteotome or a rasp.
  8. If septal deviation or septal spurs are present, a septoplasty may be performed by elevating a flap in the submucoperichondrial plane on one side via a hemitransfixion incision. The cartilage is then incised, and submucoperichondrial dissection is carried out on the opposite side. This should be done after any dorsal modifications.
  9. A portion of the quadrangular cartilage is removed, encompassing any regions of deviation, taking care to leave dorsal and caudal septal struts of at least 10 mm each.
  10. If the caudal anterior septum is displaced off the maxillary crest (resulting in tip deviation), a wedge of cartilage may be excised inferiorly to enable the septal base to be repositioned and sutured to the maxillary crest periosteum.
  11. If internal nasal valve collapse is present, spreader grafts may be placed to widen the nasal dorsum and enlarge the internal valves. Spreader grafts are rectangular pieces of cartilage created from the previously harvested septal cartilage and placed between the septum and the upper lateral cartilage. They are secured in place with horizontal mattress sutures.
  12. If enhancement of nasal tip projection is necessary, a columellar strut graft may be fashioned from the previously resected septal cartilage. The strut graft is placed between the medial crura and secured in place with horizontal mattress sutures. Additional subcutaneous cartilaginous grafts may be placed to alter tip height or contour, as necessary.
  13. If the nose is twisted, the bony dorsum is overly wide, or an open roof is created by hump reduction, osteotomies are required to allow repositioning of the nasal bony side walls. A lateral osteotomy is made along the frontal process of the maxilla on both sides, beginning at the piriform aperture. After the osteotomies are made, manual pressure can be exerted to in-fracture the bones, thus narrowing the nasal dorsum. A medial osteotomy is made by guiding the osteotome along the septum and driving it superiorly until the nasal process of the frontal bone is reached. This frees the nasal bone and assists with in-fracturing.
  14. At the conclusion of the procedure, the septal flaps are approximated with a quilting suture. The hemitransfixion incision is repaired, and the skin and soft tissue of the nose are redraped. The external rhinotomy incision is closed with interrupted sutures.
  15. Steri-strips are cut to fit the contour of the nose and placed over the dorsum in a horizontal, overlapping fashion. A thermoplastic splint is then fitted over the dorsum of the nose. A mustache dressing is applied to absorb any bloody nasal drainage.
  16. Care of the patient is returned to the anesthesiologist for recovery.

Post-Operative Care

  • Septorhinoplasty may be performed on an elective, outpatient basis.
  • Cool compresses may be applied to both eyes for the first 48 hours after surgery.
  • The thermoplastic splint is kept in place for 1 week after surgery.
  • The patient is advised to keep the head in an elevated position when supine and to avoid strenuous activity for 2-4 weeks after surgery.
  • The patient is instructed to avoid nose-blowing and excessive movement of the upper lip. If the patient needs to sneeze, it should be done with the mouth open.
  • A short course of nasal decongestant spray may be prescribed.

Complications:

  • Bleeding
  • Infection
  • Prolonged postoperative bruising around nose and eyes
  • Prolonged postoperative edema
  • Nasal obstruction
  • Septal perforation
  • Unsatisfactory cosmetic result








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