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Agrawal et al. Total septal reconstruction using costal cartilage

Figure 5: Placement of neoseptum

step in post septoplasty or post traumatic rhinoplasty
cases. King et al. first described extracorporeal
[3]
septoplasty in 1952 which generally produces good
results. In this procedure, popularized by Gubisch in the
early 1980s, the cartilaginous and bony septum were Figure 6: Schematic diagram of the technique. A: Reconstructed
nasal septum with L-strut; B: collapse at the keystone area which
removed intact, redundant cartilage and fracture lines may occur in L-strut due to inadequate suture fixation or failure
were excised, and the remaining pieces were sutured of suture; C: C-shaped septal strut with two vertical limbs on both
together. [4,5] The main indication for extracorporeal ends provides better stability; D: total septal plate replacement
with costal cartilage graft. Multiple box sutures are used to hold the
septoplasty is severely deviated crooked septum cartilage grafts together and prevent warping
causing both functional as well as cosmetic deformity. In
majority of cases, the deformed native septum provides nasal spine (ANS) caudally and nasal bone proximally,
enough cartilage or bony plate by which a strong neo- leaves no space for postoperative saddling, which
septum can be rebuilt. L-strut [Figure 6A] or neo-septum is common with L-strut due to loosening or breaking
can be made by either septal cartilage or the bony plate, of suture [Figure 6B]. Authors strongly advocate the
or a combination thereof. [6] replacement of either complete septal plate [Figure 6D]
or a C-shaped septal strut [Figure 6C] with two vertical
An easier option to rebuild a neo-septum is limbs on both ends (unlike L-strut which has only one
polydioxanone sulfate (PDS) plate, on which small vertical limb supported on ANS while the stability of
fragments can be sutured to act as a scaffold. [7-9] In cephalic end is largely dependent on suture fixation,
case of paucity of septal cartilage, conchal cartilage which is not always reliable).
can also be used. In the first case, due to previous
septoplasty, enough cartilage and bone could not be Replacing the complete septum is advantageous
found to reconstruct a neo-septum. The second case because it prevents primary sinking and collapse
was severe post traumatic nasal deformity. Here too, at the keystone area which may occur in L-strut due
only fragments of cartilage and bony plate could be to inadequate suture fixation or failure of suture,
found, which could not be used to build a neo-septum. secondary sinking of septum or shortening of nose due
to development of fibrosis in empty space and vibration
Although PDS plate could have been used for the of empty mucoperichondrial flaps. It also provides a
[9]
reconstruction but in the first case, the authors were solid support to the nose, and if required later, makes
caught unawares and had to resort to the technique the subsequent surgical dissection easier (since it is
being described. The success of first case encouraged easy to separate mucochondrial flaps from cartilage
the use of the technique in second case. The than from each other).
replacement of full cartilaginous plate which is resting
over vomer bone or in the vomerine groove akin to This procedure is simple, easy to understand and
the native septum, and fixed properly to the anterior reproducible. Though this is a very small series, authors
Plastic and Aesthetic Research ¦ Volume 3 ¦ September 20, 2016 309