Page 73 - Read Online

Morisada et al. Plast Aesthet Res 2024;11:35 https://dx.doi.org/10.20517/2347-9264.2023.119 Page 5 of 9

and integrity of the remaining native strut. When there is only deviation of the posterior septal angle from
the maxillary crest, the septum can be released sharply, repositioned at midline or with a slight
[12]
overcorrection, and reattached at the new position with 4-0 PDS to nasal spine periosteum . If there is not
enough periosteum for fixation, a fixation hole can be bored at the nasal spine with either a large-gauge
needle, a small drill bit, or a piercing towel clamp to anchor the suture.

Correction of a bowed or deviated caudal septal strut can be performed through multiple techniques. When
there is excess height of the caudal septum causing bowing, a sliver of caudal septal strut from the posterior
angle can be resected to allow for tensionless straightening of the residual caudal strut [8,12] . Scoring of the
concave portion of the cartilage can also help to release tension and allow straightening of the cartilage.
However, this technique is rarely effective when used alone as it weakens the cartilage and increases
susceptibility to buckling. Septal batten grafting using cartilage or thin bone can be utilized to straighten and
reinforce the corrected caudal septal cartilage [Figure 3] [13,14] . These grafts should span the deviation and are
stabilized with mattress suturing with 5-0 PDS or nylon sutures. Bone grafts are often predrilled with
multiple small holes using an 18-gauge needle for ease of suture fixation.

Finally, for the most severe nasal septal deviations, advanced reconstruction techniques including
extracorporeal septoplasty and caudal nasal septal replacement grafting stabilized with extended spreader
grafts may be necessary [15,16] . For extracorporeal septoplasty, the full cartilage L-strut is resected and rebuilt
ex vivo prior to reimplantation . The external rhinoplasty approach is typically required for adequate
[17]
exposure and fixation to the keystone region. While nasal septal cartilage and bone can be used, costal
[18]
cartilage is frequently needed to provide adequate structure . Once the reconstructed L strut is created, it
must be fixated at the anterior spine and keystone regions. For the anterior spine attachment, a midline
groove can be created using an osteotome and then secured as described above. The newly constructed
dorsal septum is fixated to a small area of preserved native dorsal septum in the keystone region or to the
predrilled caudal nasal bones using 4-0 PDS or nylon suture in a horizontal mattress fashion. The upper
lateral cartilages must then be secured to the newly constructed septal strut. Intranasal splinting is often
done for 1-2 weeks postoperatively [19-21] .

Another technique preferred by the authors for advanced septal reconstruction is caudal septal replacement
with extended spreader grafting. Benefits of this technique include preservation of the native dorsal septum
9
and keystone region, which are technically more challenging to reconstruct. This technique requires
preserving a dorsal strut measuring at least 1.5 centimeters long and 1 centimeter tall without disruption of
the keystone. A caudal septal replacement graft is created from septal cartilage or costal cartilage 2-3
centimeters in length, 1 centimeter tall, and 1-2 millimeters thick. The graft is then fixed caudally at the
nasal spine and extended spreader grafts stabilize the graft at the anterior septal angle.

Clocking suture
A clocking suture or septal rotation suture is one technique to correct a mild but persistent deviation of the
nasal tip. A horizontal mattress suture is placed obliquely from the upper lateral cartilage cephalic edge
(contralateral to the deviated tip) to the caudal septum at the anterior septal angle using a 4-0 or 5-0 nylon
or PDS suture [22,23] . If a spreader is present, the clocking suture caudal component should include both the
spreader and septum. The suture is then tightened sufficiently to reposition the anterior septal angle toward
the anchoring contralateral upper lateral cartilage [Figure 4]. Minor positioning variations like moving
more caudally on the septum and cranially on the upper lateral cartilage can increase the tension and cause
the septum to move laterally and cranially.