- Facial Surgery
- by admin
Septoplasty and turbinectomy combined are essential elements for successful practise. Surgeons who quickly build a reputation are those who ease the blocked noses. In the author’s experience of over 6,000 nasal procedures and the experience of others like Maran, there is no septoplasty without partial trimming of the inferior turbinates. It is very disappointing to see patients returning to the ENT clinic complaining of blocked nose only a few months after septal correction, upon examination of the nose one sees bulky engorged inferior turbinates!!! The author does not believe in submucous diathermy nor cautery to inferior turbinates. Septoplasty and partial mucosa and bone trimming, of inferior turbinates is our standard technique. The turbinates should not be overtrimmed in order to avoid the complaints of sore throat, feeling of a blocked nose and crustation at a later date. Nor undertrimmed in order to avoid recurrence, if only the mucous is removed, the mucosa will regrow. A segment of the bony concha should always be trimmed.
Many current septal corrective techniques have been introduced such as the formation of struts, strip excision, slicing, shaving and splinting. In the author’s opinion these current techniques are suitable mainly for children or in adults with mild septal deviation and if rhinoplasty is expected to be performed at a later date. We are regularly faced with difficult cases of grossly deviated, angled, buckled, twisted, cupped and bowed nasal septum. The best technique which the author has learned in his early residency at the Radcliffe Infirmary, Oxford, is to leave adequate dorsal and caudal margin and removal of the obstructing cartilage and bony spurs with preservation of the dorsum bony-cartilagenous junction. The author found that the current techniques have failed to correct marked septal deviation and have a high recurrence rate of over 50%. This is due to residual bowing, overlapping of the segments and the cartilage memory to regrow to its former shape. Many of these surgeons who talk about their success in the current techniques are in reality doing the modified submucous resection.
Our goal in septoplasty is to achieve patent airways and prevent problems such as saddling, columellar retraction and dropped tip. These problems are avoided by preservation of dorsum and caudal margin, superior septal angle and dorsum bony cartilagenous junction and consideration of columellar strut and septocolumellar suture.
In septorhinoplasty the aim is to obtain good functional and cosmetic results. The same septoplasty technique is used with variation in the incisions and the additional tip plasty, hump removal, osteotomies, augmentation and as required nares narrowing.
|Fig. 16 – 1. Septoplasty incision:|
|Fig. 16 – 2. Recommended septoplasty: Correct deflections and spurs, leave adequate dorsal and caudal margins and correct caudal dislocation.|
|Fig. 16 – 3. Correction of deviated septum: removal of deflected and obstructive portions of the quadrilateral plate, vomer, perpendicular plate and prominent spurs along maxillary crest. Leave adequate dorsal and caudal margin of at least one cm to avoid supratip collapse and columellar retraction.|
- The incisions:
- Killian incision: is made one cm beyond the caudal end of the septum. Used when there is no rhinoplasty or caudal dislocation. (Fig. 16 – 1)
- Freer incision (hemitransfixion): is made at the caudal end of the septum that has the advantage of exposing the entire cartilagenous septum. It is useful in septorhinoplasty and caudal dislocation.
- Full transfixion incision: is made at the caudal end of the septum permitting access to both sides. (Figs. 5 – 1,2)
- Flap elevation:
Once the incision is made using blade 11, the mucoperichondreal flap is elevated at the concave side by identifying the right plane with sharp Freer elevator. The mucoperichondreal and the mucoperiosteum flaps are elevated from the quadrilateral cartilage, perpendicular plate and the maxillary crest.
- Correction of deviation:
- Removal of the portion of quadrilateral plate which are deflected and obstructive, with preservation of adequate caudal and dorsal struts.
- Removal of the obstructive and deflected bony components of the vomer and perpendicular plate. (Fig. 16 – 3)
- Removal of prominent spurs along the maxillary crest. The cartilagenous component is first removed by sharp elevator then the bony spurs are removed by a fish tail chisel.
- Leave adequate dorsal and caudal margins of at least one cm to avoid supratip collapse and columellar retraction. (Fig. 16 – 2)
- Avoid dislocation of the dorsum cartilage _ bone junction. This may follow excessive pulling on the septum (cartilage, perpendicular plate) which leads to supratip collapse and saddling. Excessive pulling may also fracture the olfactory plate which causes loss of smell.
- Preserve as much cartilage and bone as you can which may be used in rhinoplasty for augmentation.
- Correction of caudal dislocation.
- Conservative trimming of the deflected caudal septum. (Fig. 16 – 4A)
- Insertion of the excised caudal portion or 20mm x 2mm septal graft into a pocket between the two medial crura, through a small midcolumellar marginal incision. This will preserve the tip projection and prevent
|Fig. 16 – 4. Correction of caudal septum dislocation. The following technique is recommended:|
(A) Conservative trimming of the deflected caudal septum with a required septoplasty by leaving adequate caudal and dorsum septum. (B & C) Insertion of the excised caudal portion or septal graft into a pocket between the two medial crura through a small mid-columellar marginal incision. This will preserve tip projection and prevent columellar retraction. The redundant septocolumellar soft tissue is excised and septocolumellar sutures are applied with the knots opposite to the side of deviation.
- columellar retraction. (Figs. 8 – 39,47,60, Figs. 9 – 1,20,21 and Fig. 16 – 4B)
- The redundant septocolumellar soft tissue is excised and septocolumellar sutures are applied. (Fig. 16 – 6)
- Correction of C-shaped dorsum deformity:
- Approach via intercartilagenous and hemitransfixion incisions.
- Vertical scoring of the concave dorsum strut.
- Spreader graft on the concave side. (Fig. 9 – 9)
- Shaving of the convex side.
- Bilateral spreader grafts in severe deformity. (Fig. 9 – 10)
- Correction of C-shaped dorsum deformity:
- Killian incision usually not sutured.
- Hemitransfixion incision is sutured with 4/0 Vicryl.
- Full transfixion incision is sutured with 4/0 Vicryl and supported by septocolumellar suture.
- Shah intranasal splints or shaped sterile x-ray sheets are applied on each side of the nasal septum and held together by a loose suture.
- Light nasal pack is applied and removed the next morning.
- Early septal haematoma and abscess formation:
Manage by drainage and antibiotic cover.
- Loss of smell:
Allergic rhinitis and neuro-vascular reflexes may cause loss of sense of smell. Also due to fracture of the olfactory plate caused by excessive pulling on the septum.
- Supratip collapse:
Caused by dislocation of the dorsum bone-cartilage junction as the result of excessive pulling on the septum or due to leaving a narrow dorsum strut. Managed by supratip conchal graft. (Fig. 9 – 8 and Figs. 13 – 11,12)
- Columellar retraction:
Due to overtrimming of the caudal septum. Managed by columellar strut.(Fig. 13 – 12)
- Dropped tip:
Due to excessive trimming of the superior septal angle, dorsum and caudal septum and the use of full transfixion incision. Managed by tip plasty of new dome creation, scoring, suture fixation, columellar strut, tip graft and septocolumellar sutures.
Fig. 16 – 6. Correction of caudal dislocation achieved by septoplasty, conservative caudal trimming of the septum and columellar strut inserted between the two medial crura.
- Septal perforation:
Due to injury of the bilateral flaps. Prevented by accurate identification of the right plane of dissection which should be subperichondreal and subperiosteal and by meticulous slow dissection.
- Complications of postoperative infection:
Bleeding _ adhesions _ polyps formation or very rarely, intra-cranial spread of infection by the emissary veins causing multiple abscess formation.
- Turbinectomy was first described by Jones in 1895. In 1900, Holmes described his experience with over 1,500 patients. Freer in 1911, reported that there was no atrophic rhinitis noted following turbinectomy but there was prolonged crustation.
- Septal deviation is often associated with hypertrophy of the inferior turbinates. The hypertrophy often involves mucosa and bone. Trimming is best achieved by right angle turbinectomy scissors with the cut being made through the mucosa and bone, in order to obtain long term airway relief. Recently, the C02 and KTP lasers have been used to remove the thickened mucosa, most authors (Selkin, Jukutake, Levine) reported nasal airway improvement for only up to one year after surgery.
Partial trimming on Inferior Turbinates
- Should be the last step of rhinoplasty procedure.
- First, infracturing the turbinate using Hill’s or Freer’s elevator.
- Do partial trimming:
A useful tip is not to remove too much or too little, holding turbinectomy scissors at a 450 angle on the turbinates directed posterior and inferior and then to cut through mucosa and bone.
- Remove trimmed portion of the turbinates in one piece by wide forceps. Avoid removing turbinates in pieces as this will cause necrosis, infection and bleeding.
- Ensure that the anterior end is adequately trimmed. A bulky anterior end will cause obstruction even if most of the middle or posterior end of the turbinates are removed. The nasal cavity gets wider posteriorly so there is no point in excessive trimming of the middle and posterior portions. In 1984, a study of 408 patients by Rohrich, showed that removal of the anterior two thirds of the inferior turbinate was sufficient to relieve nasal obstruction. (Fig. 17 – 19)
- Use the endoscope. This will allow accurate trimming of the anterior, middle and posterior portions of the inferior turbinates in one piece. It helps to avoid remnants, in particularly the posterior end which if left behind may cause early postoperative bleeding and later airway obstruction.
- Use light nasal packs of two small Sofratulle (10cm x 10cm) on each side. It has been reported that there is increased intraoperative or postoperative bleeding, however, the author has not found this to be the case. The percentage of bleeding in turbinectomy with rhinoplasty is less than that for turbinectomy alone, because the nose is preoperatively well prepared by nasal constrictors and the pressure applied on the turbinates is doubled by the nasal pack inside and the cast on the outside. The author’s percentage of postoperative bleeding is approximately one in sixty.
- Use intranasal splints:
Shaped sterile x-ray sheets or Shah intranasal splints are routinely used in our practice, when septorhinoplasty is combined with turbinectomy in order to avoid postoperative adhesions.
- Intraoperative and postoperative bleeding.
- Prolonged crustations:
Manage by daily nasal wash. Sea water sprays are recommended.
The use of intranasal splints reduce this problem. Manage by division and resplinting for two weeks. Postoperative infection is a main cause of adhesions.
- Problems related to excessive trimming:
Continuous sore throat, feeling of blocked nose and crustation.
- Rarely, atrophic rhinitis:
Turbinectomy should be avoided in patients with a previous history of crustation. Cautiously, limited trimming should be performed on patients living in a dry climate and in high altitude towns.
- Loss of sense of smell:
This is very rare, but it has been reported in the literature. It could be due to allergic rhinitis or neuro-vascular reflexes during removal of the turbinates causing severe vasoconstriction leading to ischaemia of the olfactory neural ends. Blindness has also been reported due to reflexes and constriction of the retinal artery causing retinal damage.
Septoplasty — Turbinectomy