Septoplasty - Surgical Steps

Pre-operative Setup

• Anesthesia: General or local with sedation. Topical vasoconstrictor is applied first - 4% cocaine solution or oxymetazoline on cotton pledgets. This is followed by infiltration with lidocaine + epinephrine along the septum, columella, and anterior nasal floor for vasoconstriction and hydrodissection.
• Pre-treatment with IV fentanyl and midazolam by anaesthesia team counters the cardiovascular effects of cocaine/vasoconstrictors.
• Patient positioned supine with head-ring support, slight head elevation (~15-20°) to reduce venous congestion.

Step 1 - Incision

Step 2 - Mucoperichondrial Flap Elevation

• A Cottle elevator (or similar) is inserted into the subperichondrial plane - this is the critical avascular plane that, when correctly entered, gives minimal bleeding and protects the mucosa.
• Caudally, the perichondrium adheres tightly to cartilage - scoring the area helps identify the correct dissection plane.
• Usually only the concave side flap is raised - this preserves the opposite mucosa and reduces perforation risk.
• Both flaps are raised when: surgeon wants to place through-and-through sutures, for S-shaped deformities (scoring needed on both sides), or for bilateral access.
• Extent of elevation depends on the surgical plan - can be raised as far cephalically as needed to access the perpendicular plate of ethmoid for graft harvesting.

• Back-to-front (cephalad to caudal): Flap raised anteriorly at caudal septum then directed cephalically, then sweeping back caudally posteriorly. Maintains correct subperiosteal plane.
• Front-to-back (tunnel technique): Anterior tunnel raised over quadrilateral cartilage, then a separate posterior tunnel raised behind the spur. The mucosa over the spur tip is released last by sharp dissection, avoiding tearing under tension.

Step 3 - Addressing the Deformity

A. Cutting Techniques

• Scoring: Parallel incisions/grooves made on the concave side of deviated cartilage - releases intrinsic tension and allows the septum to spring to the midline. The resulting scar tissue locks it in position. Unreliable alone; best combined with a splinting graft.
• Swinging door technique (caudal dislocation): A strip of excess cartilage is excised from the caudal L-strut, allowing the septum to swing back to midline like a door. The septum is then sutured back to the anterior nasal spine (ANS) with 4-0 PDS through a drill hole in the ANS.
• Osseocartilaginous junction disarticulation: When the dorsal L-strut deviation is due to deviation at its bony attachment to the perpendicular plate of ethmoid, the junction is fully disarticulated (sometimes including 1-1.5 mm of the last attachment to upper lateral cartilages).
• Bony septum: The perpendicular plate of ethmoid and vomer are addressed with a Jansen-Middleton forceps, Kerrison rongeur, or powered microdebrider - they are removed or reshaped. Spurs at the vomerine groove are similarly removed.

B. Grafting Techniques

• A deviated segment can be kept straight by splinting it against a batten graft.
• Graft materials: harvested septal cartilage, perpendicular plate of ethmoid (stronger and thinner than cartilage - thinned with a 5 mm diamond burr, then perforated with a Fissure burr before placement), or vomer.
• The graft is sutured on the concave side a few mm from the septal edge (to avoid palpability and avoid blocking future spreader graft placement).

C. Suturing Techniques

• Through-and-through mattress sutures placed across the septum to reshape and hold cartilage in the midline.
• Used for caudal fixation to ANS (4-0 PDS), to fix relocated segments, and to quilt the mucosal flaps at closure.
• Transcartilaginous fixation sutures can be used in the extracorporeal technique after reimplantation.

D. Relocating Techniques

• Extracorporeal septoplasty: The entire deviated cartilaginous septum is removed from the nose, reshaped/carved on the back table, and reimplanted. Used for the most complex deformities. Requires meticulous reimplantation with fixation sutures.
• Allows three-dimensional correction not possible with in situ techniques.

Step 4 - Closure

• The mucoperichondrial flap(s) are repositioned over the corrected septum.
• Bilateral quilting sutures (continuous locking or mattress, 3-0 or 4-0 absorbable - e.g. chromic gut or Vicryl) are placed through both sides of the septum to re-appose the mucosal layers, obliterate dead space, and prevent haematoma.
• Alternatively, nasal splints/packs can be used to hold flaps in position.
• The original mucosal incision is closed with interrupted or continuous absorbable sutures (4-0 Vicryl or chromic).

Step 5 - Packing / Splinting

• Internal nasal splints (silicone Doyle splints) and/or nasal packing (BIPP, merocel, or dissolvable haemostatic agents) are placed to:
  • Maintain septal position
  • Control bleeding
  • Prevent synechia formation
• Splints are usually removed at 1-2 weeks post-op.

Endoscopic Septoplasty (Variation)

Intraoperative Endoscopic Photographs

Summary Mnemonic - "I FRAME C"

• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 1 - Chapter 103 (Septoplasty), pp. 1186-1188
• Cummings Otolaryngology Head and Neck Surgery - Chapter 29 (Septoplasty Technique and Evolution), pp. 571-572