Dean Toriumi: Replacing the Nasal Septum

Does Dr. Toriumi take out and replace the nasal septum, and, if so, under what circumstances ? 

Dean Toriumi:

Rarely do I remove the nasal septum and replace it. The vast majority of patients will undergo a conventional septoplasty to straighten their septal deviation. In the conventional septoplasty operation, deviated portions of the septal cartilage are removed leaving an intact L-shaped septal strut (see figures 1 and 2). It is important to preserve this L-shaped septal strut to avoid loss of support and possible collapse of the nose. 

Perhaps some of the confusion arises from the name of a graft that I commonly use, called a caudal septal extension graft. In many cases I will place a caudal septal extension graft, which is a cartilage graft that is positioned end to end or may overlap the existing caudal nasal septum (see figure 3). 

A caudal septal extension graft is similar to a columellar strut except it is more stable, as it is connected to the existing caudal septum. This graft provides excellent support to the nasal tip without changing the existing septum. The caudal septal extension graft prevents postoperative loss of tip projection and sets nasal length as well as other parameters. I find this graft very helpful to avoid common rhinoplasty complications, such as postoperative loss of tip projection (resulting in a polybeak deformity), short nose deformity, overrotated nose ("turned up nose"), etc. However, use of this graft is clearly not equivalent to replacing the nasal septum, as it is a cartilage graft that is added to the existing nasal septum to provide support. 

Patient A.S. underwent a primary rhinoplasty after suffering trauma to her nose leaving her with a deviated nose, nasal obstruction and nasal deformity. She requested that her nose be straightened, her nasal tip shape be improved, and her airway corrected. She also requested to keep her nose on the shorter side. Her surgery required straightening the nasal septum, and a caudal septal extension graft was used to stabilize and straighten her nasal tip. Her caudal septum was not replaced, but, rather, the extension graft was added to provide tip support and move her tip back to the midline. This is the method used in the majority of primary cases. Rarely do I remove and replace the septum. Postoperatively, her nose is noted to be straight, and her airway is dramatically improved. 

Patient J.F. underwent a primary rhinoplasty to correct an overprojected nose and large dorsal hump. In her operation her nasal septum was straightened. Only the deviated portion of the nasal septum was removed, leaving an L-shaped septal strut behind. This is typical and does not require replacing the nasal septum. Postoperatively, her nose is noted to be straighter, and her dorsal hump was reduced. 

This patient underwent a fairly typical primary rhinoplasty using the open rhinoplasty approach, dorsal hump reduction, placement of spreader grafts, and tip work to reshape her tip. She had plenty of her own septal cartilage to perform the necessary grafts and provide her with excellent structure to better insure a long term outcome.

On rare occasions I do replace the caudal portion of the septum. The primary indications include the severely deviated caudal septum, unstable caudal septum, or a previously over-resected caudal septum. In the case of the severely deviated nasal septum, removal and replacement of the deviation is the best method in my hands to create a straight nose with a good airway. Many surgeons will leave the deviated septum or try to manipulate it, which can be successful but also has a high incidence of failure or partial correction. Failure to straighten the septum may leave the patient with a deviated nasal septum and nasal obstruction. Many surgeons try to resect the deviated portions of the deviated caudal septum without replacing it, leaving the patient with a potential loss of tip support. These patients will frequently be left with a residual septal deviation, inadequate tip projection, turned up short nose, retraction of the columella, etc. To prevent these deformities I prefer to replace the deviated septal cartilage that is removed in order to reestablish appropriate tip support and prevent complications.

Patient S.L. had a crooked nose deformity and severely deviated caudal septum that was blocking her airway on the right side. Correction required removal of the existing caudal septum and replacing it with another piece of her own cartilage to recreate a stable nasal septal structure. Using this technique her nose could be reconstructed around this new midline caudal septum. The postoperative result shows correction of the deviation of her nose, excellent symmetry to the base of the nose with an open nasal airway. 

This patient is very happy with her outcome and has excellent nasal function with no consequences of replacing her deviated caudal septum.The patients who undergo this type of operation do well, and what is accomplished is the reconstruction of the caudal septum to a state that would be considered normal instead of deviated. In my opinion it is better to reconstruct a new straight caudal septum that will support the tip and create an excellent airway instead of doing a less stable operation potentially leaving deviation and obstruction. Over the past 20 years, I have had great success with this approach to correct severe septal deviations. I published this technique in 1994 in an article entitled, "Subtotal septal reconstruction of the nasal septum," (Toriumi DM, Laryngoscope Vol. 104, 7, July 2004). Since then many other surgeons have adopted this technique for correction of the deviated caudal septum, overresection of the septum, lengthening the nose, etc.

One of the most common steps in a typical reductive rhinoplasty is to trim the existing caudal septum to shorten the nose or rotate the nasal tip. This frequently leaves patients with a severely deficient caudal septum. When these patients come to me for revision, I often find that the caudal septum is essentially gone or severely damaged. I prefer to place a new caudal septum in these cases to replace the normal anatomy and regain tip support. Patient C.F. underwent a previous rhinoplasty in which an excessive amount of caudal septum was resected in a previous operation. This resulted in a severe loss of tip support, loss of tip projection, and drooping of the nasal tip. Replacement of the deficient caudal septum allowed replacement of support and improved tip contour 

This is the type of patient that requires structural grafting to insure a good outcome. To overview, surgical management of the nasal base involves either placement of a columellar strut, caudal extension graft, or rarely replacement of the caudal septum. Patients undergo placement of a caudal septal extension graft that does not involve replacement of the caudal septum. The caudal septal extension graft actually involves placement of a graft that acts as an extension off of the existing caudal septum. This is a very powerful graft, enables stabilization of the base of the nose, and helps prevent postoperative loss of tip projection, drooping of the tip and shortening of the nose. The caudal septal extension graft or caudal septal replacement can result in stiffness of the nasal tip or change in upper lip feel and position.. We discuss these potential sequellae with patients if such grafting maneuvers may be used. Over the past 20 years, I have noted that the vast majority of patients have no negative consequences from such grafts and do well with a good, long-lasting outcome.