Recommended Plane for Septoplasty
The correct surgical plane for septoplasty is the subperichondrial/subperiosteal plane, which involves meticulous dissection between the mucoperichondrium and the underlying septal cartilage and bone. 1, 2, 3
Technical Approach to the Subperichondrial Plane
The fundamental principle of modern septoplasty is painstaking subperichondrial dissection without injuring the septal cartilage, which is critical for preventing postoperative complications including redeviation, pseudo-hump nose, and nasoseptal defects. 3
Key Technical Steps:
Bilateral mucoperichondrial elevation is performed to access the deviated septal structures, with the extent of dissection tailored to the severity and location of the deviation 1, 2
Preservation of intact mucoperichondrial flaps on both sides of the septum is essential—the mucoperichondrium must remain uninjured during dissection to maintain blood supply and prevent perforation 3
Use of "Cottle tunnels" (limited dissection pockets) allows targeted correction of specific deviations while minimizing unnecessary tissue trauma 3
Optimal visualization using either binocular operating microscope or endoscopic technique is emphasized to maintain the correct plane and avoid cartilage injury 3, 4
Advantages of Proper Plane Dissection
Staying in the correct subperichondrial plane provides several critical benefits:
Maintains structural integrity by preserving the cartilage framework and its blood supply 2, 3
Reduces complication rates including septal perforation (which occurs more frequently with improper technique) 1, 3
Enables cartilage preservation techniques such as suture fixation, locking, and shaving rather than extensive resection 1, 2
Allows for stable reconstruction with the ability to reposition and anchor cartilage segments using permanent sutures to the anterior nasal spine 5, 2
Endoscopic vs. Traditional Approach
Endoscopic septoplasty is increasingly replacing traditional headlight septoplasty because it provides superior visualization while maintaining the same subperichondrial plane. 1, 4
The endoscopic approach allows limited dissection to only the area of deviation, reducing morbidity and postoperative swelling 4, 6
This is particularly valuable for posterior septal deformities where visualization with traditional techniques is challenging 4, 6
The fundamental plane of dissection remains subperichondrial regardless of whether endoscopic or open technique is used 4, 6
Critical Pitfalls to Avoid
Violation of the mucoperichondrial plane leads to the most common complications:
Tearing or perforating the mucoperichondrium during dissection increases risk of septal perforation and should be primarily sutured if recognized intraoperatively 3
Inadequate mobilization of the anterior septum with remaining cartilage tension leads to redeviation—the septum must be completely freed from its attachments 3
Excessive cartilage removal (as in older submucosal resection techniques) is less tissue-sparing and has higher perforation rates compared to preservation techniques 1, 2
Failure to re-fixate mobilized cartilage to the periosteum of the anterior nasal spine after repositioning can result in postoperative displacement 3