[Skip to Content]
[Skip to Content Landing]
Figure 1.
Subtotal Septal Reconstruction in a Patient Undergoing Rhinoplasty
Subtotal Septal Reconstruction in a Patient Undergoing Rhinoplasty

Preoperative (left) and 1-year postoperative (right) frontal (A and B), lateral (C and D), oblique (E and F), and base (G and H) views showing significant improvement in symmetry and shape using subtotal septal reconstruction technique.

Figure 2.
Subtotal Septal Reconstruction Technique
Subtotal Septal Reconstruction Technique

Significant caudal septal deviation suspected on the preoperative base view (A) was confirmed intraoperatively (B). Septal cartilage removed en bloc less a 1.5-cm dorsal strut (C). Five-millimeter osteotome used to create notch in nasal spine (D) for caudal septal replacement graft (E). Dorsal septal remnant and caudal septal replacement graft seen before (F) and after (G) connecting with bilateral spreader grafts. Lower lateral cartilage secured to caudal septal extension graft (H). Septal deviation corrected after subtotal reconstruction (I).

Figure 3.
Measurements on 3-Dimensional Imaging
Measurements on 3-Dimensional Imaging

A, Nasal length (45.31 mm in this patient shown in frontal view) was measured as the distance between the nasion and tip-defining point (green line). B, Nasal tip projection was measured as the distance between the tip-defining point and the subnasale (20.21 mm seen in this patient on lateral view) (green line). C, Nasolabial angle seen on three-quarters view to be 96.4° in this patient (green line). D, Tip symmetry compares the absolute value of the difference between the distance from the tip-defining point and the lateral most aspect of the alar-facial groove on the left and right (green line). E, Alar-columellar association was studied by creating an imaginary plane that corresponded to the long axis of the visible nostril on lateral view (white line). Measurement was made from this plane to a point along the alar rim at the area of maximal alar retraction (2.01 mm in this patient) and to a midline point at the area of maximal columellar show (2.27 mm in this patient) (green line).

Table.  
NOSE Scores for Patients Undergoing Subtotal Septal Reconstruction for Severe Septal Deviation
NOSE Scores for Patients Undergoing Subtotal Septal Reconstruction for Severe Septal Deviation
1.
Rees  TD.  Surgical correction of the severely deviated nose by extramucosal excision of the osseocartilaginous septum and replacement as a free graft.  Plast Reconstr Surg. 1986;78(3):320-330.PubMedArticle
2.
King  ED, Ashley  FL.  The correction of the internally and externally deviated nose.  Plast Reconstr Surg (1946). 1952;10(2):116-120.PubMedArticle
3.
Toriumi  DM.  Subtotal reconstruction of the nasal septum: a preliminary report.  Laryngoscope. 1994;104(7):906-913.PubMedArticle
4.
Gubisch  W.  The extracorporeal septum plasty.  Plast Reconstr Surg. 1995;95(4):672-682.PubMedArticle
5.
Gubisch  W, Constantinescu  MA, Grüner  M.  The relevance of extracorporeal septoplasty in cleft nose correction.  J Craniomaxillofac Surg. 1998;26(5):294-300.PubMedArticle
6.
Gubisch  W.  Extracorporeal septoplasty for the markedly deviated septum.  Arch Facial Plast Surg. 2005;7(4):218-226.PubMedArticle
7.
Gubisch  W.  Twenty-five years experience with extracorporeal septoplasty.  Facial Plast Surg. 2006;22(4):230-239.PubMedArticle
8.
Gubisch  W, Sinha  V.  Extracorporeal septoplasty-how we do it at Marienhospital Stuttgart Germany.  Indian J Otolaryngol Head Neck Surg. 2008;60(1):16-19.PubMedArticle
9.
Gubisch  W.  Treatment of the scoliotic nose with extracorporeal septoplasty.  Facial Plast Surg Clin North Am. 2015;23(1):11-22.PubMedArticle
10.
Senyuva  C, Yücel  A, Aydin  Y, Okur  I, Güzel  Z.  Extracorporeal septoplasty combined with open rhinoplasty.  Aesthetic Plast Surg. 1997;21(4):233-239.PubMedArticle
11.
D’Andrea  F, Brongo  S, Rubino  C.  Extracorporeal septoplasty with paramarginal incision.  Scand J Plast Reconstr Surg Hand Surg. 2001;35(3):293-296.PubMedArticle
12.
Wilson  MA, Mobley  SR.  Extracorporeal septoplasty: complications and new techniques.  Arch Facial Plast Surg. 2011;13(2):85-90.PubMedArticle
13.
Most  SP.  Anterior septal reconstruction.  Arch Facial Plast Surg. 2006;8(3):202-207.PubMedArticle
14.
Boenisch  M, Nolst Trenité  GJ.  Reconstructive septal surgery.  Facial Plast Surg. 2006;22(4):249-254.PubMedArticle
15.
Surowitz  J, Lee  MK, Most  SP.  Anterior septal reconstruction for treatment of severe caudal septal deviation.  Otolaryngol Head Neck Surg. 2015;153(1):27-33.PubMedArticle
16.
Kim  DW, Attenello  NH.  Reconstruction of the nasoseptal L-strut in rhinoplasty.  JAMA Facial Plast Surg. 2015;17(6):457-458.PubMedArticle
17.
Cakmak  O, Emre  IE, Ozkurt  FE.  Identifying septal support reconstructions for saddle nose deformity.  JAMA Facial Plast Surg. 2015;17(6):433-439.PubMedArticle
18.
Toriumi  DM.  Subtotal septal reconstruction.  Facial Plast Surg. 2013;29(6):492-501.PubMedArticle
19.
Stewart  MG, Witsell  DL, Smith  TL, Weaver  EM, Yueh  B, Hannley  MT.  Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale.  Otolaryngol Head Neck Surg. 2004;130(2):157-163.PubMedArticle
20.
Stewart  MG, Smith  TL, Weaver  EM,  et al.  Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study.  Otolaryngol Head Neck Surg. 2004;130(3):283-290.PubMedArticle
21.
Toriumi  DM, Dixon  TK.  Assessment of rhinoplasty techniques by overlay of before-and-after 3D images.  Facial Plast Surg Clin North Am. 2011;19(4):711-723, ix.PubMedArticle
22.
Dixon  TK, Caughlin  BP, Munaretto  N, Toriumi  DM.  Three-dimensional evaluation of unilateral cleft rhinoplasty results.  Facial Plast Surg. 2013;29(2):106-115.PubMedArticle
23.
Bared  A, Rashan  A, Caughlin  BP, Toriumi  DM.  Lower lateral cartilage repositioning.  JAMA Facial Plast Surg. 2014;16(4):261-267.PubMedArticle
24.
Caughlin  BP, Been  MJ, Rashan  AR, Toriumi  DM.  The effect of polydioxanone absorbable plates in septorhinoplasty for stabilizing caudal septal extension grafts.  JAMA Facial Plast Surg. 2015;17(2):120-125.PubMedArticle
25.
Lübbers  HT, Medinger  L, Kruse  A, Grätz  KW, Matthews  F.  Precision and accuracy of the 3dMD photogrammetric system in craniomaxillofacial application.  J Craniofac Surg. 2010;21(3):763-767.PubMedArticle
26.
Gunter  JP, Rohrich  RJ, Friedman  RM.  Classification and correction of alar-columellar discrepancies in rhinoplasty.  Plast Reconstr Surg. 1996;97(3):643-648.PubMedArticle
27.
Paul  N, Messinger  K, Liu  YF, Kwon  DI, Kim  CH, Inman  JC.  A model to estimate L-strut strength with an emphasis on thickness.  JAMA Facial Plast Surg. 2016;18(4):269-276.PubMedArticle
28.
Kim  DW, Egan  KK, O’Grady  K, Toriumi  DM.  Biomechanical strength of human nasal septal lining.  Laryngoscope. 2005;115(8):1451-1453.PubMedArticle
29.
Rhee  JS, Sullivan  CD, Frank  DO, Kimbell  JS, Garcia  GJ.  A systematic review of patient-reported nasal obstruction scores.  JAMA Facial Plast Surg. 2014;16(3):219-225.PubMedArticle
30.
Lipan  MJ, Most  SP.  Development of a severity classification system for subjective nasal obstruction.  JAMA Facial Plast Surg. 2013;15(5):358-361.PubMedArticle
Views 739
Citations 0
Original Investigation
September 14, 2017

Long-term Outcomes of Subtotal Septal Reconstruction in Rhinoplasty

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, Chicago
JAMA Facial Plast Surg. Published online September 14, 2017. doi:10.1001/jamafacial.2017.1127
Key Points

Question  What are the long-term functional and aesthetic outcomes in rhinoplasty when using the subtotal septal reconstruction technique for severe deviation?

Findings  In a medical record review of 144 patients, Nasal Obstruction Symptom Evaluation scores showed improvement in all 5 categories of nasal obstruction. Aesthetic results were measured with 3-dimensional imaging, showing no long-term loss in nasal length, projection, symmetry, or alteration in the alar-columellar association but a small decrease in postoperative rotation.

Meaning  Subtotal septal reconstruction yields improved functional and aesthetic outcomes and has the potential to be a useful tool for the rhinoplasty surgeon in the treatment of severe septal deviation.

Abstract

Importance  Significant nasal septal deviation may require complex reconstruction to achieve complete correction. Subtotal septal reconstruction is a method for addressing deviations in the L-strut.

Objectives  To review the long-term outcomes of subtotal septal reconstruction and provide objective evidence of functional and aesthetic improvement.

Design, Setting, and Participants  This medical record review obtained data on 144 patients who underwent subtotal septal reconstruction from September 1, 2008, to September 1, 2013. Data analysis was performed from September 1, 2013, to September 1, 2014.

Main Outcomes and Measures  Functional outcomes were measured using the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, and objective aesthetic outcomes were measured using 3-dimensional (3-D) stereophotogrammetry. Follow-up times were classified as time point 1 (TP1; preoperative), time point 2 (TP2; early postoperative), and time point 3 (TP3; final postoperative).

Results  Of the 144 patients who underwent subtotal septal reconstruction, 104 (72.2%) were female; the mean (SD) age was 37.3 (13.7) years; 57 underwent primary septorhinoplasty; and 87 (60.5%) underwent revision septorhinoplasty. The NOSE scores improved in all 5 categories of nasal obstruction, with mean (SD) survey completion at 270 (260.1) days. Aesthetic results were measured with 3-D imaging after a mean (SD) follow-up of 613.5 (434.4) days postoperatively. No statistically significant loss was found in mean (SD) nasal length over time (TP2 to TP 3, −0.16 [1.36] mm; 95% CI, −0.54 to 0.22 mm; P = .41) or between mean (SD) postoperative loss of projection (TP2 and TP3, −0.19 [0.92] mm, 95% CI, −0.45 to 0.07 mm; P = .17). An increase in mean (SD) rotation (nasolabial angle) generated with septorhinoplasty (4.24° [11.08°]; 95% CI, 1.14°-7.34°; P = .01) and a mean (SD) decrease in rotation detected during postoperative healing (−2.63° [6.96°]; 95% CI, −4.63° to −0.63°; P = .01) were found. Although measurement of symmetry was improved in the early postoperative period (TP1 to TP2, −0.16 [1.26] mm; 95% CI, −0.52 to 0.20 mm; P = .40), this finding did not become statistically significant until the final measurement (TP1 to TP3, −0.43 [1.07] mm; 95% CI, −0.73 to −0.13 mm; P = .007; TP2 to TP3, −0.28 [0.87] mm; 95% CI, −0.53 to −0.03 mm; P = .03). A mean (SD) decrease in columellar show was achieved with surgery (−0.66 [1.37] mm; 95% CI, −1.05 to −0.27 mm; P = .001). No statistically significant change was found in the alar-columellar association from TP2 to TP3 in this patient population, confirming no unwanted alar or columellar retraction over time (0.10 [0.61] mm; 95% CI, −0.07 to 0.27 mm; P = .25). A total of 114 patients (79.2%) required costal cartilage harvest for adequate reconstruction.

Conclusions and Relevance  Subtotal septal reconstruction yields improved functional and aesthetic outcomes and has the potential to be a useful tool for the rhinoplasty surgeon in the treatment of severe septal deviation.

Level of Evidence  4.

Introduction

Significant nasal septal deviation may often require complex reconstructive techniques to achieve complete correction. Most experienced nasal surgeons are comfortable addressing deviations in the septum as long as the L-strut is not involved in the deviation. Manipulation of the L-strut (the 1.5-cm piece of cartilage following the shape of the dorsal profile, extending from the ethmoid bone to the nasal spine) during septoplasty or septorhinoplasty is a more complex maneuver that requires thorough understanding of nasal anatomy. Often surgeons may be hesitant to alter cartilage in this portion of the septum for fear of destabilizing the support structures of the nose and creating deformity, such as a saddle, polybeak, dorsal deviation, short nose, or retracted columella. Failure to adequately address deviations in this portion of the septum, however, can result in continued nasal obstruction with or without aesthetic deformity. Multiple techniques have been previously described117 to achieve correction of the deviated L-strut, with a comprehensive approach to subtotal septal reconstruction also previously published by one of us (D.M.T.).18

Evidence-based medicine has begun to pervade facial plastic surgery to allow the nasal surgeon to practice in a more systematic fashion. The Nasal Obstruction Symptom Evaluation (NOSE) questionnaire is a validated quality-of-life instrument that can be routinely used to help quantify nasal breathing outcomes after intervention in the absence of pure objective measurements.19,20 The rhinoplasty surgeon should also critically analyze his or her aesthetic results. Three-dimensional (3-D) stereophotogrammetry technology is one of the newest methods for the surgeon to objectively quantify the aesthetic changes accomplished with rhinoplasty.2124 This technology uses multiple 2-dimensional photographs at different angles to form a composite 3-D image that can be measured accurately, eliminating potential measurement errors, including patient positioning, magnification, lighting, and subject-to-camera distances. This technology has been proven to be an accurate modality for consistent measurement on the submillimeter level.25

The goals of this investigation were to review the long-term outcomes of subtotal septal reconstruction and provide objective evidence of functional and aesthetic improvement. Although this technique has a high level of complexity, the study aims to demonstrate its utility for patients with septal deviation that cannot be corrected with less conservative techniques.

Methods

A medical record review of patients undergoing septorhinoplasty using an external approach by one of us (D.M.T.) was performed for the 5-year period from September 1, 2008, to September 1, 2013. A total of 144 patients were found to have required subtotal septal reconstruction (Figure 1). Data on demographic information, indications for surgery, operative details, adverse events, and functional and aesthetic results were obtained. Data analysis was performed from September 1, 2013, to September 1, 2014. The institutional review board at the University of Illinois at Chicago granted approval for the retrospective review of patients undergoing nasal surgery. Informed consent was not required for data analysis only. Informed consent was obtained for publication of photographs that were identifiable. All other data was deidentified.

Surgical Technique

A previously described operative technique was used.18 In brief, if deviation of the cartilaginous septum involves the dorsal or caudal struts and cannot be straightened with sutures, cross-hatching, or splinting, the subtotal septal reconstruction technique should be used (Figure 2). Fractures along the dorsal or caudal L-strut are the most consistent indication for subtotal septal reconstruction. In these cases of significant deviation, the entire septum should be exposed using an external rhinoplasty approach (retracting the medial crura laterally, raising bilateral mucoperichondrial-mucoperiosteal flaps, and freeing the dorsal septum from the upper lateral cartilages). If less invasive methods of correction can be used, deviated cartilage or bone may at this point be removed, leaving a strong dorsal and caudal L-strut intact. However, if it is clearly evident that these portions of cartilage are involved, the entire septum less a 1.5-cm segment attached to the perpendicular plate of the ethmoid bone (avoiding disruption at the keystone area) is removed. En bloc removal of the septal cartilage in this manner creates a more favorable grafting environment for the surgeon than does a piecemeal harvesting scenario. The nasal spine should then be analyzed to ensure that it is in the midline and the proper adjustments performed if needed. A 5-mm straight osteotome should then be used to enlarge a notch for the caudal septal replacement graft to be placed. The caudal septal replacement graft should be secured to the nasal spine with two 4-0 polydioxanone sutures and to the dorsal strut remnant with bilateral extended spreader grafts. It is critical to understand that the length and angle of these grafts control the nasal length, tip rotation, and tip projection. If there is a gap between the dorsal strut and caudal septal replacement graft, small additional segments of cartilage can be added for strength before resecuring the upper lateral cartilages and medial crura of the lower lateral cartilages back to the septum. We use the caudal septal replacement graft in these cases as we would a caudal septal extension graft to control rotation and projection in the postoperative period. The surgeon must also analyze the vector of the patients’ smile to prevent upper lip creasing and should preoperatively discuss increased postoperative tip stiffness to palpation. Further tip contouring in rhinoplasty can then be performed after the nose has a stable base.

Statistical Analysis
NOSE Analysis

To analyze the functional outcomes of the nasal operations performed, an attempt was made to have all patients complete a NOSE questionnaire preoperatively and at each postoperative follow-up visit. The NOSE scores range from 0 to 4 for each of the 5 questions, with a higher score indicating a higher degree of nasal obstruction. All clinic scenarios have dynamic variables involved in data recording, and many patients are not always able to adhere to the recommended follow-up schedule based on their work or social schedules or geographic challenges. Sixty-nine of the 144 patients had preoperative and at least 1 postoperative NOSE questionnaire completed for analysis. The NOSE scores were isolated by questions on congestion, blockage or obstruction, breathing through nose, trouble sleeping, and breathing during exercise. The preoperative questionnaire was compared to the last completed postoperative questionnaire for statistical analysis. These variables were assessed as mean (SD) with significant digits, and 95% CIs were calculated. Variables were then compared using the 2-tailed, paired t test, with P < .05 determined to be statistically significant.

3-D Analysis

An attempt was made to capture 3-D imaging using the 3dMD system (3dMD Inc) for each patient in all preoperative and postoperative clinic visits. The 3-D image constructs were analyzed on the 3dMD Vultus imaging software (3dMD Inc). Aesthetic outcomes after nasal surgery can be analyzed objectively with this tool because landmark points on the nose can be measured in all 3 dimensions (x, y, and z planes). A previous study25 reported that calibration allows for submillimeter accuracy.

The aesthetic variables of the nose analyzed in this review included nasal length, tip projection, rotation, tip symmetry, and alar-columellar association. The analysis was begun by calibrating surgical naive areas of the face (eg, cheek, chin).21 The imaging software aligned the images and calculated the root mean square error to assess the variation of the 2 surfaces that were selected. As the root mean square value approaches 0, the accuracy of preoperative and postoperative alignment increases. Root mean square values of less than 0.5 are desirable and recommended by the manufacturers. In this study, we accepted only values less than 0.5 to ensure adequate calibration. For measurement acquisition, the investigator can be precise by zooming in on the image and rotating the image in the x, y, and z axes to ensure that point placement is accurate. Subjective variability among human operators was eliminated by having one of us (S.A.A.) perform all measurements (Figure 3).

Nasal length was measured by selecting 2 points (nasion and tip-defining point) on the 3-D construct. The nasion was defined as a point in the midline on frontal view that corresponded to the deepest area of the radix when rotating the image in the other axes. Tip projection was measured by selecting 2 different points (tip-defining point and subnasale) on the 3-D construct. These were both midline points, with the tip-defining point corresponding to the most anterior projecting point and the subnasale with the deepest point where the columellar base transitions to the upper lip. Rotation was determined by measuring the nasolabial angle by defining 3 midline points (infratip break, subnasale, and vermillion border of the lip). The infratip break was defined as the point at which the columella begins to angle superiorly, corresponding to transition between the medial and intermediate crura of the lower lateral cartilages. Tip symmetry was determined by comparing the distances between the tip-defining point and a point placed at the lateral-most aspect of the alar-facial groove on the left and right. The absolute value of this number was used for statistical analysis. The alar-columellar association was analyzed by creating an imaginary plane corresponding to the long axis of the visible nostril on lateral view. A first point was then chosen along the alar rim at the area of maximal alar retraction and measurement performed to the previously defined plane. A second point was chosen in the midline at the area of maximal columellar show and measurement performed to the previously defined plane. These alar and columellar measurements were analyzed separately, and their sum was also analyzed.

The aesthetic variables of the nose were analyzed at 3 intervals. Time point 1 (TP1) refers to the preoperative images. Time point 2 (TP2) references an early postoperative result that represents the nose after much of the initial surgical swelling has resolved but before the contraction phase of healing has taken place (69.8 [62.7] days). Time point 3 (TP3) represents the farthest postoperative result (613.5 [434.4] days). Patients without images at these 3 time points were excluded from aesthetic analysis. Patients were also excluded from analysis if their TP3 images were not at least 6 months from the time of their surgery to ensure adequate healing had occurred. Finally, if the 3-D composite images were pixilated or blurry from patient movement during the time of capture, they were excluded from analysis. This variable and the dynamic variable in patients’ ability to follow up after surgery led to the wide time range of TP2. Forty-eight of the patients met all inclusion criteria for objective aesthetic statistical analysis.

Results

Of the 144 patients who underwent subtotal septal reconstruction, 104 (72.2%) were female, and the mean (SD) age was 37.3 (13.7) years. A total of 57 (39.6%) underwent primary septorhinoplasty, and 87 (60.5%) underwent revision septorhinoplasty. Of the 57 patients undergoing primary septorhinoplasty, 27 (47.4%) required septal cartilage and 30 (52.6%) required costal cartilage. Of the 87 patients undergoing revision septorhinoplasty, 3 (3.4%) required septal cartilage and 84 (96.6%) required costal cartilage. In the 69 patients who completed the preoperative and at least 1 postoperative NOSE questionnaire, improvement was found in all 5 categories of nasal obstruction (Table). The farthest time point after surgery that the NOSE questionairre was completed was at 270 (260.1) days.

Aesthetic results were analyzed in 48 patients who had satisfactory 3-D images at TP1, TP2, and TP3. Mean (SD) root mean square for image synchronization was 0.29 (0.14). Time point 2 occurred 69.8 (62.7) days after the operation was performed, and TP3 occurred 613.5 (434.4) days after the operation was performed.

Nasal length was found to increase slightly (0.99 [3.16] mm) from TP1 to TP2 (95% CI, 0.09-1.89; P = .04) (eTable in the Supplement). No statistically significant difference (0.83 [3.05] mm) was found between preoperative (TP1) and the farthest postoperative (TP3) time points (P = .07). In addition, no statistically significant decrease was found in nasal length over time (TP2 to TP, −0.16 [1.36] mm; 95% CI, −0.54 to 0.22 mm; P = .41).

Nasal tip projection did not significantly change after surgery (0.31 [1.93] mm; 95% CI, −0.24 to 0.86 mm; P = .28). The aesthetic outcome achieved was not compromised by postoperative loss of projection because there was no statistically significant difference between TP2 and TP3 (−0.19 [0.92] mm; 95% CI, −0.45 to 0.07 mm; P = .17).

Rotation was determined by measuring nasolabial angle. There was a statistically significant degree of rotation generated during septorhinoplasty (4.24° [11.08°]; 95% CI, 1.14° to 7.34°; P = .01). A statistically significant amount of counterrotation was detected during postoperative healing (−2.63° [6.96°]; 95% CI, −4.63° to −0.63°; P = .01).

Although measurement of symmetry was improved in the early postoperative period (TP1 to TP2, −0.16 [1.26] mm; 95% CI, −0.52 to 0.20 mm; P = .40), this finding did not become statistically significant until the final measurement (TP1 to TP3, −0.43 [1.07] mm; 95% CI, −0.73 to −0.13 mm; P = .007; TP2 to TP3, −0.28 [0.87] mm; 95% CI, −0.53 to −0.03 mm; P = .03). This finding likely correlates clinically with tip edema typically taking the longest time to resolve and the memory of the skin and soft-tissue envelope finally contracting down over the new cartilaginous structure created in the tip.

The alar-columellar association was altered with surgery, with less alar retraction postoperatively (−0.32 [0.86] mm; 95% CI, −0.56 to −0.08 mm; P = .01). By supporting the tip with adequate grafting, no increase occurred in alar retraction over time (−0.05 [0.55] mm; 95% CI, −0.20 to 0.10 mm; P = .55), a common stigmata after reductive rhinoplasty.26 A decrease in columellar show occurred after surgery (−0.33 [1.02] mm; 95% CI, −0.62 to −0.04 mm; P = .03), which increased slightly by the final postoperative measurement but not to a statistically significant degree (TP2 to TP3, 0.15 [0.60] mm; 95% CI, −0.02 to 0.32 mm; P = .09). When combining the measurements for alar retraction and the amount of columella extending below the long axis of the nostril to determine the overall association between the two, a decrease in the measurement of columellar show was achieved after surgery (−0.66 [1.37] mm; 95% CI, −1.05 to −0.27 mm; P = .002). No change from TP2 to TP3 occurred, which confirms that the technique does not lead to unwanted levels of columellar retraction (0.10 [0.61] mm; 95% CI, −0.07 to 0.27 mm; P = .25).

Of the 144 patients undergoing subtotal septal reconstruction, 14 chose postoperatively to have elective minor nasal revisions that required anesthesia (9.7% revision rate). These cases were extensively studied to determine surgical indication. Thirteen were for minor contour irregularities of the tip or middle vault, 12 of which were previously revision cases in which tiny irregularities in the skin and soft-tissue envelope were possible. Four of these cases would likely not have occurred except that the patients chose to undergo operations for other primary indications (face-lift, fat grafting to face, blepharoplasty, and chin implant). In only one minor revision was manipulation of the septum necessary. This patient had good symmetry on frontal view but slight residual deviation of the columella on base view, which was corrected. One postoperative infection was found among these 144 patients. This revision case was treated with surgical exploration and washout as well as antibiotic therapy.

Discussion

In this study, we examine the long-term outcomes of a previously described technique for subtotal reconstruction of the septum.18 Analysis of the functional NOSE scores and aesthetic parameters measured using 3-D stereophotogrammetry offers quantitative data to suggest that this is a sound technique. To our knowledge, this is the first septal reconstruction study to use 3-D imaging to validate results. One of the strengths of the 3-D stereophotogrammetry analysis software is that it reduces error in comparison measurements in the dynamic areas of surgical alteration by calibrating multiple images via overlay of the other static regions on the face; this function allows patients to serve as their own controls at multiple time points (early and late follow-up). With the length of follow-up in this review (613.5 [434.4] days), we are confident that these patients will maintain their correction long term.

Despite overall shifts in rhinoplasty philosophy, with most surgeons moving away from reductive techniques to performing more structural cartilage grafting, there still may be some hesitancy to disturb the L-strut of the septum. Previous concerns regarding manipulation of the L-strut during nasal surgery were based on anecdotal experience. The L-strut must be re-created if disturbed, but deviations in this portion of the septum should not be left uncorrected. Not only should the septal L-strut be re-created if manipulated but it should also be strengthened from its original configuration. Although we know that the width of the dorsal and caudal struts is important, thickness may also play a critical role in the strength of the reconstruction.27 The blood supply to septal cartilage comes from its perichondrium, and if bilateral mucoperichondrial flaps have been elevated, the cartilage must revascularize no matter how much or how little manipulation is performed.28

The hypothetical concerns regarding failure to revascularize, nasal collapse, saddling, loss of tip support with polybeak formation, columellar retraction, severe nasal deviation, and infection have not been validated. Although there was a clinically significant degree of nasolabial angle change found in our patient population over time, this may have been attributable to the decrease in long-term swelling because this technique requires a significant amount of manipulation in this region of the nose. We have not found this 2° change to be clinically significant, although the P value was statistically significant. The mean (SD) nasolabial angle changed from 108.1° (9.3°) at TP2 to 105.5° (9.5°) at TP3.

Limitations

Patients who underwent subtotal septal reconstruction had a significant decrease in nasal obstruction for all 5 questions of the NOSE questionnaire. Overall, the mean NOSE scores correlated with what would be expected for subjective nasal obstruction preoperatively. Improvement in nasal obstruction was also in line with what would be expected with surgical intervention.29 The classification system means for disease severity decreased overall from severe preoperatively to mild postoperatively.30 Although there could be a selection bias in the subgroup of patients that we analyzed, this bias is unlikely because these patients would typically be more likely to follow up with nasal obstruction concerns. Selection bias is also unlikely for potential aesthetic deformity because, anecdotally, the aesthetically unhappy rhinoplasty patient is often seen more frequently than the happy patient. The other techniques used during the septorhinoplasty were difficult to control for in regard to their contribution to decreasing nasal obstruction (ie, batten grafts, spreader grafts).

The greatest obstacle to adoption of this technique may be the recognition that patients with severe septal deviation require a significant amount of grafting material to be able to incite the appropriate degree of change. Although this specific technique may require less cartilage than splinting the caudal strut, repair of the severely deviated nose in general requires that the surgeon and patient be prepared for potential cartilage harvest from separate donor sites (eg, costal cartilage, ear). This scenario is especially true in revision cases in which the septal cartilage has been previously removed but deviation still exists in the area of the dorsal and caudal struts. Another drawback to this technique is that an inexperienced surgeon may not have the precision required in this maneuver. When the caudal septum has been removed, the surgeon must place a caudal septal replacement graft of the appropriate length, location, and rotation. Precision is required in performing this technique to control the nasal length, rotation, projection, and supratip break and to prevent unintended deformity (overrotation or overprojection). Re-creation of a stable, midline L-strut is necessary for maximizing nasal function and creating a straight nose.

Conclusions

Although there are several reported descriptions of various techniques for manipulation of the L-strut of the septum,118 to our knowledge this is the first study that demonstrates quantitative functional and objective aesthetic outcomes. Although the 3-D analytic equipment is not widely available because of cost restraints, these data should lend confidence to the surgeon in need of a more powerful technique for the severely deviated septum. This technique should only be used when other, less invasive techniques are not effective, and the surgeon must ensure adequate cartilage is available to complete the reconstruction. Caution is important when trying this technique for the first time because all parameters of the nose are easily manipulated.

Subtotal septal reconstruction yields improved functional and aesthetic outcomes and has the potential to be a useful tool for the rhinoplasty surgeon in the treatment of severe septal deviation.

Back to top
Article Information

Corresponding Author: Dean M. Toriumi, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, 1855 W Taylor St, MC 648, Room 2.42, Chicago, IL 60612 (dtoriumi@uic.edu).

Accepted for Publication: May 10, 2017.

Published Online: September 14, 2017. doi:10.1001/jamafacial.2017.1127

Author Contributions: Drs Asher and Toriumi had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Asher, Toriumi.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Asher, Toriumi.

Statistical analysis: All authors.

Obtained funding: Toriumi.

Administrative, technical, or material support: Toriumi.

Study supervision: Toriumi.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Rees  TD.  Surgical correction of the severely deviated nose by extramucosal excision of the osseocartilaginous septum and replacement as a free graft.  Plast Reconstr Surg. 1986;78(3):320-330.PubMedArticle
2.
King  ED, Ashley  FL.  The correction of the internally and externally deviated nose.  Plast Reconstr Surg (1946). 1952;10(2):116-120.PubMedArticle
3.
Toriumi  DM.  Subtotal reconstruction of the nasal septum: a preliminary report.  Laryngoscope. 1994;104(7):906-913.PubMedArticle
4.
Gubisch  W.  The extracorporeal septum plasty.  Plast Reconstr Surg. 1995;95(4):672-682.PubMedArticle
5.
Gubisch  W, Constantinescu  MA, Grüner  M.  The relevance of extracorporeal septoplasty in cleft nose correction.  J Craniomaxillofac Surg. 1998;26(5):294-300.PubMedArticle
6.
Gubisch  W.  Extracorporeal septoplasty for the markedly deviated septum.  Arch Facial Plast Surg. 2005;7(4):218-226.PubMedArticle
7.
Gubisch  W.  Twenty-five years experience with extracorporeal septoplasty.  Facial Plast Surg. 2006;22(4):230-239.PubMedArticle
8.
Gubisch  W, Sinha  V.  Extracorporeal septoplasty-how we do it at Marienhospital Stuttgart Germany.  Indian J Otolaryngol Head Neck Surg. 2008;60(1):16-19.PubMedArticle
9.
Gubisch  W.  Treatment of the scoliotic nose with extracorporeal septoplasty.  Facial Plast Surg Clin North Am. 2015;23(1):11-22.PubMedArticle
10.
Senyuva  C, Yücel  A, Aydin  Y, Okur  I, Güzel  Z.  Extracorporeal septoplasty combined with open rhinoplasty.  Aesthetic Plast Surg. 1997;21(4):233-239.PubMedArticle
11.
D’Andrea  F, Brongo  S, Rubino  C.  Extracorporeal septoplasty with paramarginal incision.  Scand J Plast Reconstr Surg Hand Surg. 2001;35(3):293-296.PubMedArticle
12.
Wilson  MA, Mobley  SR.  Extracorporeal septoplasty: complications and new techniques.  Arch Facial Plast Surg. 2011;13(2):85-90.PubMedArticle
13.
Most  SP.  Anterior septal reconstruction.  Arch Facial Plast Surg. 2006;8(3):202-207.PubMedArticle
14.
Boenisch  M, Nolst Trenité  GJ.  Reconstructive septal surgery.  Facial Plast Surg. 2006;22(4):249-254.PubMedArticle
15.
Surowitz  J, Lee  MK, Most  SP.  Anterior septal reconstruction for treatment of severe caudal septal deviation.  Otolaryngol Head Neck Surg. 2015;153(1):27-33.PubMedArticle
16.
Kim  DW, Attenello  NH.  Reconstruction of the nasoseptal L-strut in rhinoplasty.  JAMA Facial Plast Surg. 2015;17(6):457-458.PubMedArticle
17.
Cakmak  O, Emre  IE, Ozkurt  FE.  Identifying septal support reconstructions for saddle nose deformity.  JAMA Facial Plast Surg. 2015;17(6):433-439.PubMedArticle
18.
Toriumi  DM.  Subtotal septal reconstruction.  Facial Plast Surg. 2013;29(6):492-501.PubMedArticle
19.
Stewart  MG, Witsell  DL, Smith  TL, Weaver  EM, Yueh  B, Hannley  MT.  Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale.  Otolaryngol Head Neck Surg. 2004;130(2):157-163.PubMedArticle
20.
Stewart  MG, Smith  TL, Weaver  EM,  et al.  Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study.  Otolaryngol Head Neck Surg. 2004;130(3):283-290.PubMedArticle
21.
Toriumi  DM, Dixon  TK.  Assessment of rhinoplasty techniques by overlay of before-and-after 3D images.  Facial Plast Surg Clin North Am. 2011;19(4):711-723, ix.PubMedArticle
22.
Dixon  TK, Caughlin  BP, Munaretto  N, Toriumi  DM.  Three-dimensional evaluation of unilateral cleft rhinoplasty results.  Facial Plast Surg. 2013;29(2):106-115.PubMedArticle
23.
Bared  A, Rashan  A, Caughlin  BP, Toriumi  DM.  Lower lateral cartilage repositioning.  JAMA Facial Plast Surg. 2014;16(4):261-267.PubMedArticle
24.
Caughlin  BP, Been  MJ, Rashan  AR, Toriumi  DM.  The effect of polydioxanone absorbable plates in septorhinoplasty for stabilizing caudal septal extension grafts.  JAMA Facial Plast Surg. 2015;17(2):120-125.PubMedArticle
25.
Lübbers  HT, Medinger  L, Kruse  A, Grätz  KW, Matthews  F.  Precision and accuracy of the 3dMD photogrammetric system in craniomaxillofacial application.  J Craniofac Surg. 2010;21(3):763-767.PubMedArticle
26.
Gunter  JP, Rohrich  RJ, Friedman  RM.  Classification and correction of alar-columellar discrepancies in rhinoplasty.  Plast Reconstr Surg. 1996;97(3):643-648.PubMedArticle
27.
Paul  N, Messinger  K, Liu  YF, Kwon  DI, Kim  CH, Inman  JC.  A model to estimate L-strut strength with an emphasis on thickness.  JAMA Facial Plast Surg. 2016;18(4):269-276.PubMedArticle
28.
Kim  DW, Egan  KK, O’Grady  K, Toriumi  DM.  Biomechanical strength of human nasal septal lining.  Laryngoscope. 2005;115(8):1451-1453.PubMedArticle
29.
Rhee  JS, Sullivan  CD, Frank  DO, Kimbell  JS, Garcia  GJ.  A systematic review of patient-reported nasal obstruction scores.  JAMA Facial Plast Surg. 2014;16(3):219-225.PubMedArticle
30.
Lipan  MJ, Most  SP.  Development of a severity classification system for subjective nasal obstruction.  JAMA Facial Plast Surg. 2013;15(5):358-361.PubMedArticle
×