Technical Refinements and Outcomes of the Modified Anterior Septal Transplant

Key Points

Question

When performing reconstruction after extracorporeal septoplasty, can the caudal septum be bypassed during reconstruction and still maintain a stable repair by using extended spreader grafts and a columellar strut?

Findings

In this case series, 71 patients showed subjective improvement in nasal obstruction with this modified anterior septal transplant technique. In addition, 32 patients showed stable repair 1 year after surgery based on photographic analysis.

Meaning

Reconstruction of the caudal septum after this new modified extracorporeal septoplasty technique can be accomplished without rigid fixation to the nasal spine, potentially decreasing postoperative stiffness and the amount of cartilage needed for reconstruction.

Abstract

Importance

Severe anterior septal deviation and resultant nasal obstruction represent a difficult surgical task to correct. The goal of surgery is to straighten the anterior dorsal and caudal struts, while maintaining nasal tip and midvault support. This study presents a novel extracorporeal septoplasty technique to straighten the crooked anterior septum.

Objective

To describe the novel anterior septal transplant technique, which consists of complete resection of the caudal septum and reconstruction with extended spreader grafts and a columellar strut, without a separate caudal septal replacement graft.

Design, Setting, and Participants

This study was a retrospective case series at a tertiary academic referral center. Participants were sequential adult patients undergoing anterior septal transplant from January 1, 2008, to December 31, 2015.

Main Outcomes and Measures

Patient-reported nasal obstruction using Nasal Obstruction Symptom Evaluation (NOSE) scores and objective photographic analysis. Nasal tip deviation, projection, and rotation were measured. Preoperative and postoperative outcomes were compared. Complications are reported.

Results

Seventy-one patients (mean age, 46 years [age range, 16-72 years]; 48 [67.6%] female and 23 [32.4%] male) were included in the case series. Postoperative NOSE scores (mean [SD], 24.00 [24.58]) were significantly better than preoperative NOSE scores (mean [SD], 72.25 [14.55]) (P < .001). A separate cohort of 32 patients (mean age, 42 years [age range, 13-72 years]; 23 [71.9%] female and 9 [28.1%] male) had photographs available for analysis. In the frontal view, nasal deviation improved from a mean (SD) of 2.9 (2.0) degrees before surgery to a mean (SD) of 1.4 (1.7) degrees after surgery (P = .004). In the base view, the deviation was corrected from a mean (SD) of 4.9 (2.8) degrees to a mean (SD) of 1.7 (1.2) degrees (P < .001). Tip rotation and projection were unchanged after surgery. Four patients had mild dorsal irregularities after surgery.

Conclusions and Relevance

Anterior septal transplant by the described technique is a safe and effective treatment option for severe anterior septal deviation.

Level of Evidence

4.

This case series describes the novel anterior septal transplant technique, which consists of complete resection of the caudal septum and reconstruction with extended spreader grafts and a columellar strut, without a separate caudal septal replacement graft.

Introduction

Extracorporeal septoplasty can be necessary in the treatment of nasal obstruction in cases of severe septal deviation. The procedure is distinct from traditional septoplasty. In an extracorporeal technique, the cartilaginous septum is completely removed and subsequently replaced by a new and straighter septum. The replanted septum is fixated caudally at the nasal spine and cephalically to any remnant dorsal septum and to the upper lateral cartilages. The extracorporeal septoplasty operation is technically difficult given the extensive deconstruction and reconstruction of the nose. Failure to adequately suspend and support the new septum can lead to loss of stability at the keystone area, resulting in dorsal irregularities and saddling. In a 2005 case series of extracorporeal septoplasty for markedly deviated septum, Gubisch reported that 15% of his patients had contour irregularities. An additional limitation for this technique is securing enough material to reconstruct the septal strut for support, particularly in cases of prior septoplasty.

Modifications to extracorporeal septoplasty to facilitate reconstruction and minimize complications have been previously described. Notably, techniques that resect the caudal septum, while preserving the dorsal strut, have been advocated by surgeons in an effort to minimize dorsal irregularities and saddling by stabilizing the keystone region. In 1994, Toriumi first described a subtotal resection of the nasal septum performed during extracorporeal septoplasty, in which the entire caudal septum is removed but part of the dorsal strut is preserved. To reconstruct the septum, an L-shaped caudal septal replacement graft is used, which is fixated to the truncated remnant dorsal septum superiorly and to the nasal spine inferiorly and anteriorly. In 2006, Most described preservation of the entire dorsal strut and reconstruction with the anterior septal reconstruction graft, with subsequent analysis of outcomes by Surowitz et al. The anterior septal reconstruction graft is placed parallel to the dorsal strut and functions as a spreader graft on one side. Fixation of this graft is to both the dorsal strut and the nasal spine. Preservation of the dorsal strut in extracorporeal septoplasty is also advocated in other publications, notably a 2012 article by Persichetti et al.

In addition to subtotal resections, novel fixation techniques have been used for reconstruction in extracorporeal septoplasty. To maintain alignment of the caudal replacement graft, fixation of the caudal septal replacement graft superiorly with the use of extended spreader grafts was described by Toriumi. In addition, different techniques have been described to secure the graft inferiorly. Most procedures advocated for the creation of a notch in the nasal spine to avoid suture fixation. Ross Mobley and Long described “non-complex” fixation, where the inferior and caudal aspect of the reconstructed septum is positioned over soft tissue on the premaxilla, which reduces postoperative rigidity and helps support the nasal tip.

The present study describes a new modified extracorporeal septoplasty technique. In this operation, the septal dorsal strut is preserved, and the caudal septum is resected. Subsequently, a columellar strut fixated to extended spreader grafts is used for reconstruction, without a separate caudal septal replacement graft (Figure 1). Prior anterior septal reconstructions have used a larger surface area to reconstruct the entire caudal septum. The reconstruction graft can be fashioned to replace the caudal septum, in which case a columellar strut can be added for tip support or can be designed with a caudal extension to allow the medial crura to be suspended to the graft. In the technique described herein, the nasal spine is bypassed, and the columellar strut is positioned in the premaxilla without rigid or suture fixation. The entirety of caudal strut support is maintained by the columellar strut in isolation, measuring 2 to 4 mm in width and 25 to 30 mm in length. An advantage of this technique is the economical use of available septal cartilage. The columellar strut carries the load of a caudal strut, allows for tongue-in-groove suspension of the medial crura, and adds stability to the columella. One of us (T.D.W.) has been using this technique for the last 8 years of practice.

Figure 1. Anterior Septal Transplant.

Resection (A) and reconstruction (B) during anterior septal transplant.

Our case series describes technical details of how to perform the anterior septal transplant and presents patient-reported nasal obstruction before and after surgery. In addition, to ensure adequate tip and midvault support, patient photographs before surgery and 1 year after surgery are analyzed.

Methods

Surgical Technique

The Oregon Health & Science University Institutional Review Board approved the study for waiver of consent. An open rhinoplasty approach is performed in the standard fashion via an inverted-V incision. A sub–superficial muscular aponeurotic system dissection plane is performed atop the upper and lower cartilages to the rhinion. The interdomal ligament is transected, and the anterior and posterior septal angles are identified and isolated from surrounding soft tissue. A submucoperichondrial plane is elevated on either side of the quadrangular cartilage past the bony-cartilaginous junctions superiorly, inferiorly, and posteriorly. The upper lateral cartilages are then disarticulated from the dorsal septum.

With this exposure, a subtotal resection of the quadrangular cartilage is performed, while completely resecting the caudal septum and leaving an approximately 10-mm dorsal strut, with the base slightly broader at its attachment to the bony-cartilaginous junction. To calculate the length of the extended spreader, a cotton-tipped applicator is placed at the rhinion between one upper lateral cartilage and the dorsal remnant, while the lower lateral cartilages are manipulated into the correct position with a forceps. A mark with a surgical marking pen is made on the cotton-tipped applicator at the caudal border of the domes. For the columellar strut, a dissection pocket is then created between the medial crura to the premaxilla. The applicator is subsequently placed into this pocket, and a similar mark is made at the dome on the applicator. Using the applicator markings as a guide for length, the columellar strut and bilateral extended spreaders are incised from the quadrangular cartilage, measuring approximately 2 to 4 mm in width and 25 to 30 mm in length.

The bilateral extended spreader grafts are then fixated into place in the usual position with 5-0 polydioxanone suture (PDS) in interrupted fashion. The columellar strut graft is placed between the extended spreader grafts, with the base resting in the previously dissected premaxillary dissection pocket between the medial crura. The extended spreader graft and the columellar strut are secured to each other with 5-0 PDS. The medial crura are then sutured to the columellar strut in a tongue-in-groove fashion with 4-0 plain gut interrupted sutures. After this fixation, the L-strut reconstruction is complete. The domes are then reapproximated, and any additional tip suturing, grafting, valve support, or other maneuvers are performed before closure.

Patient Population

This study was a retrospective case series at a tertiary academic referral center. A review of the electronic medical records from January 1, 2008, to December 31, 2015, was performed to identify sequential adult patients who underwent septorhinoplasty for nasal obstruction via the anterior septal transplant technique by one of us (T.D.W.) at Oregon Health & Science University and had follow-up for more than 1 year after surgery. In this period, 543 patients underwent septorhinoplasty. Clinicodemographic data and adjunctive procedures were collected. History of prior septoplasty or rhinoplasty was documented. Nasal Obstruction Symptom Evaluation (NOSE) scores were available for patients from 2013 onward. Patients with preoperative NOSE scores and postoperative NOSE scores with more than 6-month follow-up were included in the study.

Photographic Analysis

Measurements of the preoperative and postoperative photographs were performed by 3 of us (M.L., J.D.M., and R.J.L.) who were uninvolved with the operations. The degree of deviation was measured in frontal and base views. In the frontal view, an angle was drawn between a vertical reference line from the center of the radix down to the cupid’s bow, and a line was drawn from the center of the radix to the middle of the nasal tip. In the base view, the angle was drawn between a line drawn from the center of the columella perpendicular to a line drawn to the alar base and a line from the center of the columella to the middle of the nasal tip. On the profile view, the nasolabial angle was calculated for tip rotation. Tip projection was measured using the method by Goode. The mean of both measurements was used to decrease interexaminer variability. Last, the profile view was examined and qualitatively rated for the presence or absence of dorsal asymmetries.

Statistical Analysis

Wilcoxon rank sum test was used to compare anthropometric measurements before and after surgery. For NOSE score comparison, paired t test assuming normal distribution and 2-tailed hypothesis were used. Statistical analyses were performed with a software program (SPSS, version 16.0; SPSS Inc), and 2-sided P < .05 was regarded as statistically significant.

Results

Clinicodemographic Information and Patient-Reported Outcomes

Seventy-one patients met inclusion criteria in the case series by having a preoperative NOSE score and a minimum follow-up of 6 months. The mean age of patients at the time of surgery was 46 years (age range, 16-72 years). Forty-eight patients (67.6%) were female, and 23 patients (32.4%) were male. Approximately half of the cases (34 cases [47.9%]) were primary surgical procedures, and half (37 cases [52.1%]) were revisions. All patients underwent surgery to improve their breathing, and one-third of patients (21 [29.6%]) also elected to have cosmetic changes. Additional surgical maneuvers performed at the time of septorhinoplasty are listed in the Table. On average, the length of the graft for the anterior septal transplants was 27.50 mm (95% CI, 26.79-28.21 mm) for the columellar strut and 27.44 mm (95% CI, 26.65-28.23 mm) for the extended spreader graft. An example of a patient with a crooked nose before and after surgery is shown in Figure 2.

Table. Additional Procedures and Surgical Techniques Performed in Conjunction With the Anterior Septal Transplant During Septorhinoplasty.

Variable	No. (%) of Patients
	With NOSE Scores (n = 71)	With Photographs (n = 32)
Butterfly graft	63 (88.7)	26 (81.3)
Nasal tip suture modification	29 (40.8)	18 (56.3)
Nasal tip graft	13 (18.3)	10 (31.3)
Nasal osteotomies	28 (39.4)	12 (37.5)
Hump reduction	16 (22.5)	7 (21.9)
Dorsal onlay	20 (28.2)	5 (15.6)
Alar rim graft	9 (12.7)	7 (21.9)
Lower lateral crura suturing or grafting	27 (38.0)	19 (59.4)
Turbinate reduction	68 (95.8)	20 (62.5)
Endoscopic sinus surgery	8 (11.3)	2 (6.3)
Autologous rib graft	1 (1.4)	1 (3.1)

Abbreviation: NOSE, Nasal Obstruction Symptom Evaluation.

Figure 2. Preoperative and Postoperative Views in a Patient With a Crooked Nose.

The preoperative view shows a left-sided deviation of the nasal tip (A), corrected with the anterior septal transplant technique (B and C). This patient also underwent nasal osteotomies to straighten the nasal dorsum.

The mean (SD) preoperative NOSE score was 72.25 (14.55) (95% CI, 68.81-75.69), and the mean (SD) postoperative NOSE score was 24.00 (24.58) (95% CI, 18.18-29.82). Improvement in NOSE scores was statistically significant (P < .001 by paired t test). Postoperative NOSE scores were obtained at a mean of 14 months (range, 6-33 months) after surgery.

Photographic Analysis

A separate cohort of 32 patients who had preoperative photographs and a minimum of 1-year postoperative photographs was studied. The mean age of patients was 42 years (age range, 13-72 years); 23 patients (71.9%) were female, and 9 patients (28.1%) were male. Eight patients (25.0%) had revision surgery. All patients underwent surgery to treat nasal obstruction, and 12 patients (37.5%) also elected to have cosmetic changes. All patients were considered to have a caudal septal deflection on preoperative examination, and 26 patients (81.3%) had an external deviation. Other surgical maneuvers and procedures performed at the time of septorhinoplasty are listed in the Table. The mean time to the follow-up photographs after surgery was 17 months (range, 12-31 months).

Measurements of nasal tip deviation, projection, and rotation were compared between preoperative and 1-year postoperative photographs. Nasal deviation was significantly improved 1 year after surgery. In the frontal view, nasal deviation improved from a mean (SD) of 2.9 (2.0) degrees (95% CI, 2.2-3.6 degrees) off midline to a mean (SD) of 1.4 (1.7) degrees (95% CI, 0.8-2.0 degrees) (P = .004). In the base view, nasal deviation improved from a mean (SD) of 4.9 (2.8) degrees (95% CI, 3.9-5.9 degrees) off midline to a mean (SD) of 1.7 (1.2) degrees (95% CI, 1.3-2.1 degrees) (P < .001). Preoperative and 1-year postoperative projection and rotation were not significantly different. Projection was 0.60 (95% CI, 0.58-0.62) before surgery and 0.59 (95% CI, 0.57- 0.61) after surgery (P = .67), while rotation was 98.5 degrees (95% CI, 93.6-103.3 degrees) before surgery and 98.5 degrees (95% CI, 93.6-103.3 degrees) after surgery (P = .95). Dorsal irregularities were present in 4 patients (12.5%) at their last follow-up appointment. One of the dorsal irregularities is shown in Figure 3.

Figure 3. Dorsal Irregularities After Surgery.

One year after septorhinoplasty with the anterior septal transplant technique, results are shown in 2 patients without (A) vs with (B) dorsal irregularities.

Discussion

Aesthetically or functionally debilitating anterior quadrangular cartilage deviation can be a difficult problem to correct. Anatomic abnormalities involving this crucial region can adversely affect the major tip support mechanisms, narrow the internal nasal valve, and alter the aesthetic nasal landmarks. To correct this condition, King and Ashley first described the concept of extracorporeal septoplasty in 1952. The technique was popularized a generation later, notably by Gubisch. Extracorporeal septoplasties allowed for the correction of severe deviations that other techniques, such as cartilage scoring or suture procedures, often failed to correct.

The basic tenets of extracorporeal septal reconstruction include excision of the quadrangular cartilage, creation of reconstruction grafts, and subsequent reimplantation of the cartilage grafts to construct midline dorsal and caudal support struts. Designing and reimplanting the septal replacement grafts is critical to maintaining support of the nose. Techniques that perform subtotal resections of the nasal septum have been published. Surowitz et al described preserving the dorsal strut and completely resecting the caudal septum and subsequently reconstructing it with a singular anterior septal reconstruction graft. In this technique, an osteotome is used to notch the nasal spine to allow for placement of the anterior septal reconstruction graft with sutureless fixation at the posterior septal angle. Those authors noted significant improvement in the subjective NOSE scale scores after surgery. Different reconstruction techniques after extracorporeal septoplasty have been published. Toriumi described a subtotal septal resection with the use of extended spreader grafts as a means to simultaneously extend the rigid support of the preserved dorsal strut, widen the internal nasal valve, and fixate the caudal replacement graft. Ross Mobley and Long highlighted the need for flexibility during the creation of an L-shaped neoseptum in extracorporeal septoplasty to prevent excessive nasal tip rigidity. The authors noted that rigid fixation of an anterior septal reconstruction graft is not always necessary when adequate fixation is achieved with tongue-in-groove techniques. Further reports of extracorporeal septoplasty reconstruction techniques advocate for the use of alloplastic materials to bolster the grafts and maintain alignment. Gevorgyan and Smith described using a wire through the reimplanted cartilage to straighten it, while Gubisch used folded PDS foil placed on either side of the dorsal septum.

The anterior septal reconstruction described herein is an alternative to prior extracorporeal septal reconstruction techniques by bypassing the caudal septum and proceeding with a reconstruction with a columellar strut. This strut is placed in a narrow soft-tissue premaxillary pocket. The nasal spine is bypassed, and rigid fixation is not used at the posterior septal angle. By using this soft-tissue pocket, the risk of excessive rigidity of the nasal tip after surgery is minimized. To stabilize the columellar strut, extended spreader grafts are used to fixate the graft to the remnant dorsal strut, and the graft is placed in a tongue-in-groove technique between the medial crura. The bilateral extended spreader grafts provide additional airway patency, can allow for manipulation of dorsal aesthetic lines, and reinforce symmetry. The symmetry is an important benefit given the high prevalence of crooked nose malformations among the patient population requiring anterior septal reconstruction. The tongue-in-groove fixation of the graft to the medial crura provides nasal tip support. By bypassing the nasal spine and the caudal septum, the cartilage available for grafting can be used economically to provide a stable reconstruction, with benefits both dorsally and caudally. This technique in primary surgery provides enough cartilage to create 2 extended spreaders and a columellar strut and typically leaves behind ample cartilage for additional grafting as needed (eg, tip grafting and dorsal onlay grafting). The anterior septal transplant technique can be viewed in the Video.

Video. Anterior Septal Transplant Technique.

Download video file ^{(125.3MB, mp4)}

One of us (T.D.W.) is seen performing a modified anterior septal transplant. The area of the septum resected and the preserved septal strut are shown. The reconstruction that connected the dorsal strut to a columellar strut with an extended spreader graft is also shown.

In this case series, the effectiveness of the technique is seen in the analysis of the postoperative photographs and with patient-reported improvement in nasal obstruction. Objective photographic analysis demonstrates improved nasal tip alignment before and after surgery in both frontal and base views. In addition, statistically significant improvement in NOSE scores was demonstrated with the use of this technique. A limitation in measuring the result of extracorporeal septoplasty in the treatment of nasal obstruction in the study is the use of adjunctive techniques during surgery, such as inferior turbinate reduction or lower lateral crural struts. Because bypassing the caudal septum could potentially present a problem with the stability of the repair, 6 months was the minimum follow-up for patient-reported scales, and only photographs more than 1 year after surgery were examined.

Stable nasal tip projection and rotation were documented in the photographic analysis. Saddling was not seen in the profile photographs. Dorsal irregularities were noted in 4 patients in the case series. These irregularities were slight asymmetries seen overlying the cartilaginous dorsum and likely were secondary to the concomitant butterfly grafts placed to stent the internal nasal valve. In the original description of extracorporeal septoplasty by Gubisch, dorsal irregularities and saddling were the most common cause of revision after this technique (37 of 404 cases [9.2%]). In a more recent series, Gubisch reported a 10% complication rate, with the most common complication being dorsal irregularities. To prevent irregularities, the midvault should be inspected and palpated after resuspension of the upper lateral cartilages to the dorsal septal strut and spreader grafts. Support of the dorsal strut is key to prevent saddling. Weakened caudal strut support after bypassing this region and proceeding to columellar strut reconstruction did not appear to contribute to postoperative patient dissatisfaction.

We are not able to estimate the difference in structural support that is afforded with the columellar strut and the extended spreader grafts compared with a 1-cm to 1.5-cm caudal septum replacement graft. As the L-strut decreases in size, the stability of the septum also decreases, as confirmed in a prior study using human cadaveric heads and computer simulation. However, septal support depends not only on the amount of cartilage present in the septum but also on support of additional surrounding anatomic structures of the nose. It is possible that articulating the columellar strut to the medial crura and extending the spreader grafts into the nasal tip can compensate for the loss of support that results from the use of a smaller L-strut reconstruction. If the reconstruction did not provide sufficient support for the midvault or the nasal tip, postoperative dorsal saddling, irregularities, and nasal tip redeviation, ptosis, or deprojection would be expected.

Limitations

Despite our enthusiasm for the anterior septal transplant, this technique should be used judiciously. Patients with anterior septal fractures or severe anterior septal deviation are good candidates for the procedure. Those with adequate midline L-strut support do not require disruption of these key support structures, and a less invasive approach should thus be used.

Conclusions

The anterior septal transplant is a safe and effective treatment for severe anterior septal deviation. The technique is a modified extracorporeal technique, in which the caudal septum is resected and a dorsal strut is preserved. Extended spreader grafts articulating to the columellar strut are used to reconstruct the caudal septum, and the columellar strut is placed into a premaxillary soft-tissue pocket without fixation. Improvement in patient-reported nasal obstruction is demonstrated, and long-term nasal tip and dorsal support are maintained with this technique.