Septoplasty at time of Rhinoplasty
Article by Roy A. David, MD
San Diego Facial Plastic Surgeon
Septoplasty at the time of Rhinoplasty
Many patients who present for primary rhinoplasty surgery have concurrent nasal obstruction due to deviated nasal septum. The nasal septum is comprised of a boney and cartilaginous "partition" that divides the nasal passage into two halves. The nasal septum can be felt by placing the thumb and index finger of one hand into either nostril and pinching the fingers together. The front part of the septum is comprised of cartilage, and this is why you can usually move the tip of your nose from side to side. The back or posterior part of the septum is bone.
If either the cartilage or bone part of the septum is off the midline or more on one side of the nasal passage than the other it can block the airflow through that passage way.
The septoplasty procedure is designed to remove or reposition this offending portion of the septum that is causing the obstruction. This procedure, if indicated, not only can but should be performed at the time of a cosmetic rhinoplasty. Ignoring a deviated septum may lead to an attractive nose that doesn't work well, which is never an optimal outcome.
Sometimes it is difficult to determine if nasal obstruction is due to a fixed obstruction such as a deviated septum or due to temporary conditions such as nasal congestion from a cold or allergy. The patient can often differentiate these types of obstruction by keeping notes over a several month period and recording how often one passage is open versus the other. This is helped by alternately occluding one nostril at a time by pressing it inward with your index finger. Ultimately, only a trained surgeon can determine if a deviated septum is the source of the problem by taking a thorough history and identifying the obstruction on physical exam with a headlight and nasal speculum.
A septoplasty can usually be seamlessly integrated into the rhinoplasty procedure. In most cosmetic rhinoplasties it is useful to expose the nasal septum in order to obtain cartilage for grafting. Cartilage grafting at the time of rhinoplasty allows the surgeon to replace and strengthen support mechanisms of the nose that must otherwise be disrupted to make the nose more attractive. At the time of exposing the septum to harvest cartilage, the surgeon should identify and correct any underlying deviation and obstruction caused by the septum.
The septoplasty may involve simply removing a crooked portion of cartilage or bone. This is done with forceps or with an osteotome (a delicate mallet and chisel). In other cases the crooked portion of septum can easily be bent back or softened and replaced into a straight position. In general, the more cartilage that is preserved, the better the total support and strength of the nose. In any case, the surgeon must take care to leave the mucoperichondrium or epithelial (skin) lining of the septum intact. Large tears in this lining can lead to a septal perforation or hole in the septum. While small perforations may be asymptomatic, large tears can cause problems with nasal airflow, crusting, or occasional nosebleeds. Fortunately, this is a rare occurrence in skilled hands.
Once the septum is straightened several dissolvable sutures are placed to close any incisions as well as to close the space left behind by any removed cartilage.
Usually two firm silastic splints are tied alongside the septum in each nasal passage to hold the tissues straight while they heal. These splints are left in for one week and cannot generally be felt by the patient. They usually do not obstruct airflow in the nose.
Septoplasty generally adds zero recovery time to the rhinoplasty procedure and is very well tolerated. Upon removal of the external splint from the rhinoplasty at one week, any internal splints for the septum are also removed, is breathing is generally good immediately.