Is modified extracorporeal septoplasty (L-strut-preserving or L-strut-reconstruction) a preferable approach to conventional extracorporeal septoplasty for treating nasal septal deviations?

Modified Extracorporeal Septoplasty vs. Conventional Extracorporeal Septoplasty: Functional and Structural Outcomes

Modified extracorporeal septoplasty (L-strut-preserving) is superior to conventional extracorporeal septoplasty for treating nasal septal deviations, as it maintains better structural support while providing comparable functional improvements with fewer aesthetic complications. 1

Understanding Extracorporeal Septoplasty Approaches

• Extracorporeal septoplasty (ECS) is reserved for severe septal deviations where traditional septoplasty techniques are inadequate to address the deformity 2
• Conventional ECS involves complete septal resection with extracorporeal correction and replacement, which carries significant risks including aesthetic profile deformities even in experienced hands 3
• Modified ECS preserves a superocaudal L-strut (approximately 0.5 cm in height), providing better structural support while still allowing for significant correction 1

Functional Outcomes Comparison

• Modified ECS demonstrates statistically significant long-term improvement in respiratory function and obstructive symptoms in patients with moderate to severe septal deviations (4-6 year follow-up) 1
• Conventional ECS has been associated with a high percentage of aesthetic profile deformities despite functional improvement 3
• Extracorporeal septoplasty techniques in general show better functional outcomes than in situ septal correction (ISSC), with ECS patients experiencing no persistent nasal obstruction compared to 6.4% in ISSC patients 4

Structural Outcomes and Complications

• Modified ECS provides structural support without destabilizing the keystone area, a critical advantage over conventional ECS 1
• L-strut preservation in modified ECS reduces the risk of post-operative saddle nose deformity, which is more common with complete cartilage removal 2
• Conservative remodeling of the quadrangular cartilage in modified ECS allows for the use of septal cartilage grafts in secondary or revision rhinoplasty 1

Objective Measurements of Success

• Studies using the validated Nasal Obstruction Symptom Evaluation (NOSE) score show significant improvements following extracorporeal techniques 5, 6
• Active anterior rhinomanometry values confirm objective improvement in inspiratory flow, particularly in moderate and severe deviation cases treated with modified ECS 1
• Anthropometric measurements from preoperative and postoperative photographs demonstrate significant correction of external nose deviation angles with both techniques 7, 4

Surgical Considerations

• Secure fixation of the reimplanted septum is critical for successful long-term aesthetic and functional outcomes following any extracorporeal septoplasty technique 7
• Cartilage preservation techniques are generally preferred over extensive removal, as they maintain nasal structural support and reduce risk of complications 2
• Complete septal resection with extracorporeal correction should be limited to extreme cases where other approaches are inadequate 3

Patient Selection and Approach

• For mild deviations, traditional septoplasty with cartilage preservation is often sufficient 2
• For moderate to severe deviations, particularly those involving the anterocaudal septum, modified ECS shows superior results compared to endonasal septoplasty 6
• The decision between techniques should be based on the severity and location of the septal deviation, with L-strut preservation being particularly important for maintaining nasal tip support 2, 1

Pitfalls and Caveats

• While 80% of the general population has an off-center nasal septum, only about 26% have clinically significant deviation causing symptoms 3
• Morselization (crushing) of cartilage should be avoided as it increases surface area with risk of absorption and makes secondary revision extremely difficult 3, 2
• Conventional ECS requires significant surgical expertise and carries higher risks of aesthetic complications even in experienced hands 3