6. Septoplasty
1. Incision and Exposure
The commonly used incisions for septoplasty include the Killian incision, performed 1-2 cm behind the caudal septal margin; the modified Killian incision, performed 3-4 mm from the caudal end; and the hemitransfixion incision, made very close to the caudal end margin. However, these terms only describe the anterior-posterior position of the incision, and the location can be adjusted if a different incision is more effective for correcting the deviation. Nonetheless, incisions too close to the columella, in front of the caudal end, are not recommended as they may leave visible scars externally after surgery. Additionally, if the procedure is intended to correct a caudal deviation, it is preferable to make an incision at the caudal end, such as the hemitransfixion incision, to fully expose the septal cartilage. If rhinoplasty is performed using an open external incision, septoplasty can be carried out by identifying the septal cartilage between the columella, allowing for a full view of the septum and the ability to harvest cartilage.
Once the septal cartilage is exposed, the surgical plane must be identified in the subperichondrial plane. If this step is neglected and approached through the supraperichondrial plane, excessive bleeding may occur, obscuring the surgical view throughout the procedure. While it may take time to elevate the perichondrium properly, it is essential for maintaining a clean surgical field. If the exposed cartilage has a reddish tint, it is likely that tissue covering the cartilage remains, and in such cases, the 15-blade should be used to gently lift it. The D knife can then be employed to lift perichondrial tissue in the plane. If this process is done correctly, the septal membrane can be easily elevated using the Freer elevator.
Once the subperichondrial plane is secured, the Freer elevator is used to dissect the mid-superior portion. Then, the mucosa on bony septum is dissected in the subperiosteal plane. After returning to the anterior portion, the inferior portion is dissected. Dissection below the caudal strut exposes the maxillary crest, and further dissection along the maxillary crest towards the posterior completes the dissection of the inferior tunnel. Most septal spurs are located at the junction of the maxillary crest and septal cartilage, and mucosal tears frequently occur during dissection in this area. To prevent mucosal tears, it is advisable to first dissect the mid and superior portions and then complete the dissection of the inferior tunnel before carefully dissecting the spur region.
2. Separation of Bony Septum and Septal Cartilage
Before correcting a deviated septum, it is essential to separate the septal cartilage from the bony septum. In typical septoplasty procedures—where only one side of the mucosal plane is elevated (in cases where a septal extension graft is required, both sides of the mucosa must be elevated)—the septal cartilage and bony septum are separated, and the mucosa on the opposite side of the bony septum can be elevated from the separated margin. For the correction of the bony septum, the bony septum must be removed, and after elevating the opposite side’s mucosa in this manner, resection can be performed. Separating the septal cartilage from the bony septum is essential not only for dissection but also to release the septal cartilage from the tension caused by the curvature of the bony septum. As observed in septal growth, when the bony septum is deviated, the posterior part of the septal cartilage aligns with the curvature of the bony septum. Therefore, removing part of the bony septum at the junction is necessary to realign the septal cartilage in the desired direction.
3. Correction of Bony Septal Deviation
Bony septal deviation can be corrected by resecting the curved area. The ethmoid perpendicular plate, which forms the bony part of the superior septum, should not be forcefully removed using forceps at the outset, as this can damage the cribriform plate and cause cerebrospinal fluid leakage. Instead, the dorsal portion should first be resected with a Jansen or scissors, and then the area can be gently manipulated for removal. In the inferior portion, the maxillary crest should be carefully removed, as septal spurs are often present in this region, and there are frequently deviation at the bone-cartilage junction. Removal of the maxillary crest can be done relatively easily using a mallet and chisel if the inferior tunnel has been properly dissected.
4. Correction of Cartilaginous Septal Deviation
After resecting the bony septal deviation, the remaining cartilaginous septal deviation is often due to deviation in the dorsal strut, which was connected to the upper bony septum, or excess cartilage causing curvature in the caudal strut. However, there are also cases where the cartilage itself is deviated. In such instances, the deviation can be easily corrected by resecting all but the L-strut, as deviations in the cartilaginous septum outside of the L-strut can usually be corrected through simple resection. Furthermore, deviations in the cartilaginous septum outside of the L-strut often resolve after separation from the bony septum, so it is advisable to first separate the cartilage from the bony septum, correct the bony septal deviation, and then reassess the need for correction (Figure 1-8).
Previously, methods such as crosshatching incisions or scoring incisions, where incisions were made on one side of the cartilage to correct curvature, were commonly performed. However, based on the author’s experience, these methods do not significantly help in correcting septal cartilage deviation. The crosshatching incision may only be used to weaken the deviated portion of the L-strut before placing a batten graft. The primary technique for correcting cartilaginous deviation is the correction of the caudal and dorsal struts, which is essential for septoplasty and should be mastered by any surgeon performing septal surgery.
