What are the approaches to performing a septoplasty, specifically fixing or removing the deviated cartilage?

Septoplasty Approaches: Cartilage Preservation vs. Removal

The preferred approach to septoplasty is cartilage preservation and reconstruction rather than extensive removal, as this maintains nasal structural support and reduces risk of post-operative complications including saddle nose deformity. 1

Cartilage Preservation Techniques

• Septoplasty with cartilage preservation is currently the preferred procedure over submucosal resection, as it reshapes, repositions, or recontours the cartilage while maintaining structural integrity, with up to 77% of patients achieving subjective improvement 1

• Preservation techniques focus on realignment through:

  • Suture fixation - using permanent 5-0 nylon or PDS 4-0 sutures to reposition the septum to the midline 1
  • Locking techniques - repositioning untrimmed but thinned caudal septum to the contralateral side of the nasal spine/maxillary crest 1
  • Cartilage shaving - conservative thinning of cartilage to reduce deviation while maintaining structure 1

• Weakening techniques may be combined with realignment when necessary:

  • Scoring - partial incisions to use interlocked stress of cartilage (results can be inconsistent) 1
  • Through-and-through incisions - complete incisions to weaken and correct bent septal strut 1
  • Castellation - interdigitating through-and-through incisions that weaken while maintaining integrity 1

Cartilage Removal Techniques

• Submucosal resection (SMR) involves more extensive resection of cartilage and bone, is less tissue-sparing, and has a higher incidence of septal perforation complications 1

• Complete septal resection with extracorporeal correction and replacement (extracorporeal septoplasty) may be necessary in extreme cases but carries significant risks:

  • Can lead to a high percentage of aesthetic profile deformities even in experienced hands 1
  • May result in nasal saddling or recurrent deformity 2
  • Requires meticulous reconnection of cartilage fragments to form a straight, solid plate 3

Reconstruction After Weakening or Removal

• After realignment and weakening procedures, reconstruction is often necessary using:
  • "Figure 8" sutures to stabilize adjacent cartilage segments and prevent overlap 1
  • Batten-type grafts from cartilage or bone to reorient and straighten remaining dorsal and caudal septal struts 1
  • Spreader grafts positioned at the dorsal septal edge between the septum 1, 2

Choosing the Appropriate Approach

• The extent of surgical intervention should be tailored to the type and severity of septal deviation:

  • For slight deviations with minimal cartilage tension, suture fixation may be sufficient 1
  • For moderate deviations, a combination of mobilization, trimming/thinning, and suturing may be appropriate 1
  • For severe deviations, more extensive techniques including cartilage grafting may be required 1, 2

• Endoscopic septoplasty is replacing traditional septoplasty in many clinical settings, offering:

  • Ability to reduce morbidity and postoperative swelling by limiting dissection to the area of deviation 1, 4
  • Improved visualization, particularly for posterior septal deformities 4
  • Particularly valuable in patients who have undergone prior septal cartilage resection 4

Important Considerations and Pitfalls

• While 80% of the general population has an off-center nasal septum, only about 26% have clinically significant deviation causing symptoms 1, 5

• Septoplasty should only be considered after failure of comprehensive medical management including intranasal corticosteroids, saline irrigations, and treatment of any underlying allergic component 5, 6

• Morselization (crushing) of cartilage is generally not favored as it increases surface area with risk of absorption and makes secondary revision extremely difficult 1

• Complete septal resection should be reserved for only the most extreme cases, as preservation techniques with appropriate reconstruction provide better long-term outcomes with fewer complications 1, 3