What is the preferred incision, Freer's (transfixion incision) or Killian's (hemitransfixion incision), for surgical intervention in patients with nasal septal deviation?

Hemitransfixion (Killian) Incision vs Transfixion (Freer) Incision for Nasal Septal Deviation

The hemitransfixion (Killian) incision is generally preferred over the transfixion (Freer) incision for surgical correction of nasal septal deviation, particularly when addressing caudal septal deviations that significantly impact nasal airflow and quality of life. 1, 2

Anatomical Considerations and Incision Selection

Hemitransfixion (Killian) Incision

• Provides better access to the caudal septum
• Facilitates more comprehensive septal manipulation
• Recommended for:
  • Caudal septal deviations
  • Cases requiring extensive septal manipulation
  • When complete bilateral mucoperichondrial elevation is needed 1

Transfixion (Freer) Incision

• More limited access to caudal septum
• May be adequate for:
  • Isolated posterior deviations
  • Simple cases without caudal involvement
  • When minimal septal manipulation is required 3

Evidence-Based Decision Algorithm

1. Assess the location and severity of septal deviation:

   • For caudal septal deviation → Hemitransfixion incision
   • For isolated posterior deviation → Either approach may be suitable

2. Consider the extent of required surgical manipulation:

   • Extensive manipulation needed → Hemitransfixion incision
   • Limited manipulation needed → Either approach may be suitable

3. Evaluate the need for additional procedures:

   • Combined with rhinoplasty → Hemitransfixion or open approach
   • Isolated septoplasty → Either approach based on deviation characteristics

Clinical Outcomes and Considerations

The primary goal of surgical correction is to improve nasal obstruction, which can:

• Improve sleep quality
• Reduce sleep-disordered breathing
• Enhance CPAP compliance in OSA patients 2

Surgical Techniques and Approaches

After appropriate incision selection, the surgical approach may include:

• Mobilization, trimming/thinning, and suturing for isolated caudal septal deflection
• "Contralateral subluxation locking" technique for slightly bowed and unilaterally deviated caudal septum
• Weakening procedures (scoring, castellation) followed by reconstruction with sutures or batten grafts 1

Potential Complications

• Bleeding
• Infection
• Synechiae formation
• Atrophic rhinitis (rare)
• Septal perforation 2, 4

Special Considerations

1. For mild caudal septal deviation: A modified Killian incision approach (J septoplasty) has shown promising results in selected cases 5

2. Post-surgical care is critical:

   • Intranasal corticosteroids
   • Saline irrigation
   • Regular follow-up with endoscopic evaluation 2

Clinical Pearls

• The hemitransfixion approach provides superior access to the caudal septum, which is often the most functionally significant area affecting nasal airflow
• Surgical correction should prioritize functional outcomes (improved breathing) while preserving structural support
• Both conventional and endoscopic septoplasty techniques using Freer's incision have shown similar effectiveness in improving symptoms 3
• Early intervention in significant septal deviation can prevent long-term complications 6