What is the step-by-step procedure for septorhinoplasty and post-operative care?

Septorhinoplasty: Step-by-Step Procedure and Post-Operative Care

Septorhinoplasty is a complex surgical procedure that addresses both functional nasal obstruction and aesthetic concerns through septal correction and nasal reshaping, requiring a systematic approach with careful attention to anatomical structures to optimize both breathing function and cosmetic outcomes. 1

Preoperative Assessment

• Evaluate nasal airway obstruction and aesthetic concerns
• Document septal deviation patterns and turbinate hypertrophy
• Assess facial symmetry as it affects surgical planning
• Consider a minimum 4-week trial of medical therapy for patients with chronic rhinitis before surgical intervention 2

Surgical Approach Selection

External (Open) Approach

• Preferred for complex deformities and severe septal deviation
• Provides better access to the caudal septum
• Allows direct visualization of nasal structures

Endonasal (Closed) Approach

• Less external scarring
• Shorter operative time
• Limited exposure of nasal structures

Step-by-Step Septorhinoplasty Procedure

1. Anesthesia and Preparation

• General anesthesia or local anesthesia with sedation
• Infiltration with local anesthetic containing epinephrine
• Nasal packing with decongestant-soaked pledgets

2. Incisions and Exposure

• External approach: Transcolumellar incision connected to marginal incisions
• Endonasal approach: Hemitransfixion (Killian) incision preferred over transfixion (Freer) incision, especially for caudal septal deviations 2
• Elevation of mucoperiosteal and mucoperichondrial flaps bilaterally

3. Septal Correction

• Identify and preserve 1-1.5 cm dorsal and caudal L-strut for nasal support
• Remove deviated portions of cartilage and bone
• Straighten remaining septum using scoring, suturing, or batten grafts
• Harvest cartilage for potential grafting needs

4. Bony Pyramid Correction

• Address bony deviations through osteotomies
• For deviated bony pyramid:
  • Resect half the plateau on the deviated side
  • Perform unilateral vertical osteotomy to allow lateral nasal wall movement toward midline 1
• Perform lateral osteotomies to close open roof deformity
• Consider intermediate osteotomies only when necessary (risk of visible irregularities)

5. Middle Third Correction

• Address the dorsal septal edge and upper lateral cartilages
• Separate upper lateral cartilages from septum if needed
• Use spreader grafts for functional and aesthetic improvement of the middle vault
• Consider onlay grafts for unilateral concavity when airway is adequate 1

6. Nasal Tip Modification

• Place columellar strut between medial crura for support and realignment
• Reshape alar cartilages through conservative reduction, suture techniques, and grafting
• Consider domal onlay grafts and shield grafts for tip refinement
• Address asymmetries with strategic grafting and suturing 1

7. Inferior Turbinate Reduction (if indicated)

• Perform submucous resection rather than total turbinectomy to avoid empty nose syndrome 2
• Consider outfracture, radiofrequency reduction, or partial resection based on the degree of hypertrophy

8. Final Adjustments and Closure

• Ensure midline position of septum and nasal structures
• Suture septal flaps with absorbable sutures
• Close external incisions with fine non-absorbable sutures
• Apply external nasal splint and internal nasal packing if needed

Post-Operative Care

Immediate Post-Op (0-7 days)

• Head elevation to reduce swelling and bleeding
• Cold compresses for the first 48 hours
• Pain management with prescribed analgesics
• Intranasal saline irrigation to keep nasal passages moist 2
• Intranasal corticosteroids to reduce inflammation 2
• Avoid strenuous activities, nose blowing, and sneezing

Short-Term Follow-Up (1-4 weeks)

• Remove external splint and sutures at 5-7 days
• Continue saline irrigation and intranasal corticosteroids
• Begin gentle digital massage of nasal dorsum after splint removal
• Gradually return to normal activities over 2-3 weeks
• Avoid contact sports for at least 6 weeks

Long-Term Follow-Up

• Regular endoscopic evaluation to monitor healing 2
• Address any synechiae formation between turbinate and lateral nasal wall or septum
• Monitor for rare complications such as septal perforation or saddle nose deformity 3
• Final aesthetic and functional results typically evident after 6-12 months

Potential Complications and Management

Common Complications

• Bleeding: Apply pressure, topical vasoconstrictors, or nasal packing
• Infection: Prescribe appropriate antibiotics
• Synechiae: Perform lysis and place silastic sheets between surfaces 2

Serious Complications

• Septal perforation: May require repair with tissue grafts
• Saddle nose deformity: May need dorsal augmentation
• CSF leak: Requires immediate surgical repair
• Atrophic rhinitis ("empty nose syndrome"): Avoid total turbinectomy 2

Key Considerations for Optimal Outcomes

• Maintain adequate septal support with L-strut preservation
• Balance aesthetic goals with functional requirements
• Consider facial asymmetry in surgical planning 1
• Use autogenous cartilage grafts for repositioning, reinforcement, and reconstruction 1
• Combine traditional realignment techniques with camouflage methods for optimal correction of asymmetric deviated nose 1

By following this systematic approach to septorhinoplasty, surgeons can address both the functional and aesthetic aspects of nasal deformities while minimizing complications and optimizing patient outcomes.