Extracorporeal septoplasty

What repeats

Five findings that hold across the literature.

It is reserved for the septum that will not straighten in place

Slight deviations, single vomer spurs, maxillary crests and simple C-shaped deformities are managed endonasally. S-shaped and severe wavelike deviations, the cleft nose, the multiply fractured septum and most revision cases are the ones the open approach with extracorporeal reconstruction is used for. The systematic reviews frame it the same way: the technique addresses severe deviation where in situ septoplasty is insufficient.

Rests on: Heppt and Gubisch, septal surgery in rhinoplasty · Lazzeroni et al., systematic review · and septoplasty.

The pooled functional result is a fall of about 55 NOSE points

Seventeen studies covering 1418 patients were pooled. The mean NOSE score fell from 75 before surgery to 19.5 afterwards, a mean difference of 55 points with a confidence interval of 49.5 to 60. Objective nasal flow measured by rhinometry improved by 70% to 71% across studies at six months. I-shaped deviations improved by 2.7 degrees and C-shaped deviations by 11.9 degrees. Complication rates across the same studies ranged from 0 to 18%. A single-centre series of 55 patients collected over 28 months recorded a median NOSE score of 14.5 before surgery and 3.0 afterwards.

Rests on: Bresler et al., meta-analysis · Lazzeroni et al. · Ross Mobley and Long, 55 patients.

It matches in situ correction on appearance and beats it on breathing

Of 169 rhinoplasty patients, eighty-four had extracorporeal correction and the remaining 85 in situ correction. Deviation angle, nasofrontal and nasolabial angles and tip projection improved significantly in both groups. Operating times were 135 and 128 minutes. Complication rates were similar. No patient in the extracorporeal group had persistent nasal obstruction, against five of 78 in the in situ group, 6.4%, who needed revision septoplasty. A randomised comparison in 46 patients with anterocaudal deviation put the extracorporeal arm ahead on every objective and subjective outcome except tip deviation angle, with no difference in complications.

Rests on: Lee and Jang, comparative outcomes · Tian et al., randomised comparison.

The keystone area is what the modifications are built to protect

Disrupting the junction where the septum meets the nasal bones risks a saddle nose. Anterior septal reconstruction avoids the commonest complication of standard extracorporeal septoplasty by preserving the dorsal strut of septal cartilage and its attachment to the nasal bones at the keystone. The shark-tooth modification retains a small triangular segment of cartilage on the bony septum as a marker for repositioning, so septal height and the dorsal profile are preserved.

Rests on: Most, anterior septal reconstruction · Nieuwman et al., shark-tooth technique · and saddle nose.

The partial version reports the same size of gain as the total

Anterior septal reconstruction in 12 consecutive patients took NOSE from 76.6 to 12.9 with no complications. In 77 patients the same technique took NOSE from 68.2 to 21.1 in the first three months and to 15.8 after three months, moving patients from the severe to the mild band. In 103 Korean patients the obstructive score fell from 64.02 to 19.31, the cosmetic score from 60.61 to 14.25, and minimal cross-sectional area rose from 0.30 to 0.56 cm2.

Rests on: Most · Surowitz et al., 77 patients · Suk and Lee, Asian series.

By how much of the septum comes out

Total, partial, and the versions that keep the dorsum attached.

Total removal and a rebuilt neoseptum

The whole plate is explanted, straightened and replanted. The 1999 refinements describe a milling cutter to flatten the explanted plate, microplates to stabilise the medialised nasal spine, and a rein stitch, transosseous sutures and quilting stitches to fix the replanted septum. Of 436 rhinoseptoplasties in one year, 108 had severe deviations and were treated this way.

Rests on: Gubisch and Constantinescu, refinements · Heppt and Gubisch.

Modified fixation, keeping the operation shorter

A modified fixation series of 27 patients reported significant correction of the external deviation angle, 24 patients, 89%, satisfied with appearance, and all 23 patients with moderate to severe pre-operative obstruction satisfied with their breathing. A series of 64 Asian patients recorded a mean operative time of 89.3 minutes, obstruction falling from 7.9 to 3.1 on a visual analogue scale, and no recurrent deviation, no tip deprojection and no revisions over a mean follow-up of 13.3 months.

Rests on: Jang and Kwon, modified fixation · Mun et al., Asian series.

Partial removal, keeping part of the plate in place

In 30 crooked noses, 28 had partial and two had total extracorporeal septoplasty. The neoseptum was rebuilt from septal cartilage in 27 cases, 90%, from costal cartilage in one and from conchal cartilage in two. All patients had good functional and aesthetic outcomes at 12 months with no major complications.

Rests on: Pradhan et al., partial extracorporeal septoplasty · and rib cartilage grafts.

Anterior septal reconstruction and anterior septal transplant

Both replace the front of the septum and leave the dorsal attachment alone. The anterior septal transplant resects the caudal septum completely and rebuilds it with extended spreader grafts and a columellar strut, without a separate caudal replacement graft. In 71 patients NOSE fell from 72.25 to 24.00. In a photographic subgroup of 32, frontal deviation went from 2.9 to 1.4 degrees and base view deviation from 4.9 to 1.7 degrees, with tip rotation and projection unchanged and four mild dorsal irregularities.

Rests on: Loyo et al., anterior septal transplant · Most · and the middle vault.

In children

An endonasal dorsum-preserving version was used in fifty-four children aged 6 to 15 with severe anterior deviation and external nasal deformity. Mean follow-up was 24 months, all patients and parents reported functional and aesthetic satisfaction, there were no major complications and none needed revision.

Rests on: Guliyev and Erbek, pediatric technique · and pediatric septoplasty.

What to ask about extracorporeal septoplasty

Questions the evidence supports asking.

Why this rather than straightening the septum in place

The indication is severity. Ask the surgeon which pattern of deviation they are treating, what they would need to see to use the in situ operation instead, and what proportion of their septal cases get the extracorporeal one.

Rests on: Heppt and Gubisch · Lee and Jang.

What happens to the top of my nose

The keystone is where the risk sits, and the named modifications exist to keep the dorsal strut or to mark the septum for exact repositioning. Ask whether the dorsal attachment is being kept, and what the plan is if the profile drops.

Rests on: Most · Nieuwman et al. · and saddle nose.

What is the new septum made of

Usually the patient's own straightened septal cartilage. Where there is not enough, rib or ear cartilage is used. Ask which, and ask about the donor site.

Rests on: Pradhan et al. · Mun et al. · and rib cartilage grafts.

Have I had a septoplasty before

The previously operated septum is a separate problem. Deviation can recur from contractile forces flexing or twisting the L-strut, or the first operation may not have addressed the deviation at all, and repositioning the posterior septal angle on the nasal spine may be needed.

Rests on: Liu et al., previously operated septum · and revision rhinoplasty.

What is the complication rate in this surgeon's hands

The pooled range across studies is 0 to 18%, so the number that matters is the individual surgeon's. Ask for their rate of residual deviation, dorsal irregularity and revision.

Rests on: Bresler et al. · Migliavacca et al., prospective series.

The terms, defined

The words used about this operation.

• Extracorporeal septoplasty: removing the septum, straightening it outside the nose and replacing it. [41078841]
• Neoseptum: the rebuilt septal plate that goes back in. [37605016]
• Keystone area: the junction where the cartilaginous septum meets the nasal bones and the upper lateral cartilages. [16702533]
• L-strut: the dorsal and caudal band of septum that holds the shape of the nose. [42091322]
• In situ septal correction: straightening the septum where it lies, using batten and spreader grafts and caudal cutting and suture. [25079613]
• Anterior septal reconstruction: the modified version that keeps the dorsal strut and its keystone attachment. [16702533]
• Anterior septal transplant: complete resection of the caudal septum with reconstruction by extended spreader grafts and a columellar strut. [28817752]
• Shark-tooth technique: retaining a triangular segment of cartilage on the bony septum as a repositioning mark. [40857704]
• SCHNOS: the Standardized Cosmesis and Health Nasal Outcomes Survey, with separate obstructive and cosmetic scores. [38466953]
• Rhinoplasty Outcome Evaluation: a validated quality-of-life questionnaire for rhinoplasty patients. [38430860]
• Saddle nose: collapse of the dorsum, the complication the modifications are designed to prevent. [40857704]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what the surgeon should assess and record before operating, whichever septal technique is chosen.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries chapters on the twisted nose and on the septal work that straightens it. They are written for surgeons and go further into technique than a patient page should.

• Extracorporeal septorhinoplasty for the twisted nose
• Algorithm for treatment of anterior septal deviations
• Treatment of the Caudal Septum
• The Deviated Nose

The reference summary

Septoplasty in StatPearls and Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, give the anatomy, the indications and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

What is not settled

• The evidence is mostly retrospective. Twenty-two studies met the inclusion criteria in the systematic review, most of them retrospective, with small samples and inconsistent follow-up. [41078841]
• Complication rates run from 0 to 18% between series, which is a surgeon effect rather than a technique effect. [31762301]
• There is one randomised comparison against endonasal septoplasty, in 46 patients. [31996042]
• Follow-up is short. The Asian series reporting no recurrent deviation and no revisions had a mean follow-up of 13.3 months. [32550724]
• The shark-tooth modification is described as a technique without an outcome series behind it. [40857704]
• Residual septal deviation was found in two of 27 patients, 7.4%, in one prospective series, and residual deviation is reported inconsistently elsewhere. [38430860]
• The pediatric technique rests on fifty-four children at one centre. [41145862]
• The reviews call for multicentre randomised trials with long-term follow-up before surgical protocols and outcome measures can be standardised. [41078841]