Nasal septum incision selection

A Killian incision is not a rare selection for initial surgery. All parts of the nasal septum, except for the caudal septal cartilage, are fully exposed using this method. Revision surgery using this type of incision is difficult and easily leads to septal perforation. In China, Xiao et al. applied a U-shaped incision at the front end of the nasal septum to correct the deviation of the anterior nasal septum and obtained satisfactory outcomes.^{Reference Xiao, Kong, Wang, Yang and Le12} However, a U-shaped incision requires the mucosa to be incised at the anterior superior part of the nasal septum, the front end of the nasal septum and the base of the cavum nasi, which will create a large incision, leading to suturing difficulties and prolonged recovery time.

Sillers et al. found that semi-penetrating incisions, penetrating incisions, Killian incisions and extranasal approaches were applicable for revision surgery, but they did not present any further descriptions.^{Reference Sillers, Cox and Kulbersh13} In our study, a semi-penetrating straight incision was made at the front of the caudal nasal septum, and the caudal nasal septum and nasal crest of the maxilla were fully exposed. Then, the malformation at the caudal end could be easily corrected. At the same time, this incision location avoided the incision used in the previous surgery and facilitated dissection of the mucoperichondrium and mucoperiosteal flaps. Collapse of the nasal tip and septal perforation could also be avoided due to the lowered columellar strength.

Anterior nasal septum deviation treatment

The nasal valve area, including the caudal nasal septum, lower margin of the lamina dorsi nasi (upper lateral cartilage), front end of the inferior turbinate and base of the apertura piriformis, is the narrowest part of the upper airway. Dislocation of the caudal nasal septum is the most common reason for stenosis in the nasal valve area.

Dinis et al. showed that after receiving initial surgery, 42 per cent of patients were extremely satisfied, 35 per cent were satisfied and 23 per cent were unsatisfied.^{Reference Dinis and Haider5} These authors also pointed out that the post-operative degree of satisfaction was closely associated with post-operative stenosis in the nasal valve area. Becker et al. found that the main reasons for revision surgery after the failure of septoplasty were the incomplete correction of stenosis in the nasal valve area and deviation of the nasal septum.^{Reference Becker, Dobratz, Stowell, Barker and Park14} These authors also compared the interval between the revision surgery and the initial operation and found that the average interval for patients with stenosis of the nasal valve area was 7.5 years, whereas it was 3.2 years for those without stenosis of the nasal valve area. This indicated that stenosis of the nasal valve area was often ignored by rhinologists. Grymer et al. showed that partial correction of a caudal nasal deviation was prone to present better efficacy compared with complete correction of a posterior nasal deviation because the nasal valve area is the narrowest part of the upper airway.^{Reference Grymer, Hilberg, Elbrønd and Pedersen15}

Correction of a caudal nasal deviation is key to the revision of a deflected septum. In 1929, Metzenbaum first described the method for surgery of the causal nasal septum and pointed out that deviation of the posterior septum tended to have a smaller effect on the ventilation of the nasal cavity compared with deviation of the anterior septum.^{Reference Metzenbaum16} He also believed that retaining the caudal end was extremely important for supporting the nasal tip. He then applied the swinging door method and resected the caudal convex in a wedge shape to restore the caudal septum to the median line. However, while correcting the caudal septum, this method tended to weaken its strength, which was not conducive to maintaining the supporting structure of the nasal tip.

Various improvements in Metzenbaum's method have been reported, such as suturing the caudal septum to the nasal spine of the maxilla or suturing autograft materials, including nasal septum cartilage or bone, to support the caudal nasal septum cartilage.^{Reference Harrison and Jones7,Reference Pastorek and Becker17–Reference Giacomini, Lanciani, Di Girolamo, Ferraro and Ottaviani19} However, fixing the nasal septum at the caudal end may lead to stenosis of the nasal valve area and aggravate nasal obstruction because the nasal septum cartilage is relatively thick.^{Reference Constantine, Ahmad, Geissler and Rohrich20} Although the bony nasal septum, as a graft, is thinner and harder than cartilage, it often requires suturing via an open approach. This causes substantial nasal trauma and may lead to stiffness of the nasal tip. The intranasal method employed in this approach could prevent the redislocation of the caudal septum, strengthen the columella and prevent post-operative deformity of the nasal tip.

During the correction of caudal septal deviation, cartilage should be retained at the junction of the basal part of the cartilaginous nasal septum and the nasal crest area of the maxilla. This area is able to prevent the collapse of the cartilaginous nose cone, contraction of the columellar base and other complications.

Posterior nasal septum deviation treatment

During initial surgery for the correction of nasal septum deviation, it is necessary to remove the quadrilateral cartilage and part of the lamina mediana, leaving a square-shaped cartilage–bone defect. Deviation of the posterior nasal septum often occurs as a result of incomplete correction of the upper nasal septum and vomerine ridge. Xiao et al. applied a 0.5 cm longitudinal incision in the anterior deviated area to adjust the middle or upper nasal septum deviation.^{Reference Xiao, Kong, Wang, Yang and Le12} They applied a transverse incision at the labiogingival groove to expose the bone or cartilage in the deviated area and to enable the correction of inferior nasal septum deviation. They also ground the deviated area with an electric drill. However, this kind of incision might lead to a large injury.

In this study, a semi-penetrating circular incision was made at the margin of the septal cartilage–bone defect on the left side of the residual defect from previous surgery, and dissection occurred in various directions along the bilateral cartilage and bone surfaces. The mucoperichondrium and mucoperiosteum within the circular incision were not dissected. The defective osteocartilaginous framework was fully exposed, and the deviated parts could be removed and corrected. As the mucoperichondrium and mucoperiosteal flaps outside the septal cartilage–bone defect were mildly injured during the initial surgery (with light scarring and tissue adhesion), they could be easily dissected from the septal cartilage–bone defect during revision surgery. Thus, this method effectively exposed the deviated osteocartilaginous framework and avoided residual scar tissue and tissue adhesions from the initial surgery. Moreover, this method allowed us to freely select the incision according to the different deviation locations of the nasal septum, resulting in a relatively simple surgical procedure.

Upper nasal septum deviation treatment

Deviation of the upper nasal septum often refers to the upper deviation of the posterior cartilaginous nasal septum and the anterior lamina mediana. This type of deviation is prone to induce local pain and constriction. During surgery, the septal bone and cartilage at the deviated area were exposed fully, retaining a 1–1.5 cm ‘safe region’ at the superior part of the cartilaginous nasal septum. This was necessary in order to remove the deviated bone and cartilage and to maintain the linkage of the cartilaginous nasal septum in the safe region with the posterior bony nasal septum and nose cone. The deviated cartilaginous and bony nasal septum below the safe region could be removed. Thus, this operation was conducted outside the safe region to avoid the collapse of the nose bridge and nasal tip as well as the rotation of the cartilaginous nasal septum.

Limitations

This study has some limitations. First, a small number of cases were included. This study aimed to introduce a new surgical method to determine how to treat residual malformation in the anterior and posterior nasal septum after a previous operation to avoid septal perforation, a saddle nose, a false hump nose, contracture of the nasal columella or post-operative collapse of the nasal tip. After performing 14 such operations, this method was considered safe, feasible, repeatable and effective. Moreover, no control group was used in this study. This study aimed to introduce a surgical technique that was safe, feasible and repeatable for revision septoplasty surgery, rather than to prove its advantages compared with other techniques. Therefore, a self-controlled experiment was conducted instead of including a control group. Furthermore, acoustic rhinometry was not used for evaluating nasal obstruction. The placement of the nasal probe into the nasal cavity led to deformation of the caudal nasal septa with chances of false results. Finally, one patient who suffered from headaches after the operation had to undergo a sinusal CT scan, leading to additional radiation exposure. The cause of headache was acute sinusitis according to the CT scan and routine blood examination. After treatment, the patient recovered from acute sinusitis.