The bony cartilaginous unit: the missing graft in septorhinoplasty

Abstract

To achieve the desired nasoseptal refinements in septorhinoplasty, sufficient septal cartilage is needed. There are many cases in which septal cartilage is insufficient, especially in revision surgery. To obtain an optimal outcome, a bony cartilaginous unit is proposed as a versatile graft for various parts of the nose. This bony cartilaginous unit is extracted using the open septorhinoplasty approach in which the bilateral septal flaps are elevated over the entire cartilaginous and bony part; however, the cartilaginous septum and posterior bony part are not separated and are removed as an integrated unit. These bony cartilaginous units can be used as various types of grafts at different sites in the nose. In the present study, the bony cartilaginous units were used as caudal extension grafts, spreader grafts, lateral crural strut grafts, and for the closure of septal perforations. This research has shown the advantage of using septal bone in conjunction with cartilage as an integrated unit to correct external nose and septal deformities, especially in cartilage-depleted patients.

During septoplasty, the cartilaginous and bony septum is usually exposed by complete elevation of a mucosal flap on one side only. The dissection is continued past the bony cartilaginous junction to gain access to any posterior bony deflection or spur. A Cottle elevator may be used at this time to separate the bony and cartilaginous septal segments to allow bilateral posterior septal membrane elevation and access to the posterior septal deviation. At this point, any deviated bony and cartilaginous septum is removed separately while attempting to preserve the L-strut as much as possible. These are the classic steps of septorhinoplasty surgery which have been published even in recent textbooks.

However, cases in which the amount of cartilage for harvesting is very limited often arise, especially in revision surgery. Furthermore, in particular cases, the surgeon may need a hard piece of bone for use as an internal splint. The most challenging scenario is the case in which the surgeon requires the rigidity and firmness of bone and the ease of use of cartilage simultaneously. Examples of this scenario include C-shaped deviations of the caudal and/or dorsal part of the septum in secondary septorhinoplasty and septal perforation. Unfortunately, the separation of the bony parts from the cartilaginous parts of the nasal septum as a very common step in septorhinoplasty deprives the surgeon of the ability to use the bony cartilaginous unit as an integrated piece. The use of the bony cartilaginous unit in septorhinoplasty is introduced in this study, and it is emphasized that certain common manoeuvres, such as bony cartilaginous separation, should be reconsidered.

Materials and methods

This study was conducted in both the university and private practice setting. The surgical protocol was approved by the institutional review board and each patient gave informed consent for the procedure.

All rhinoplasties were performed under general anaesthesia via an open approach. The caudal septum was exposed and bilateral septal mucoperichondrial flaps were raised. Separation of the cartilaginous septum from the posterior bony part was not performed and the bilateral septal flaps were elevated over the entire bony part. The septal cartilage was incised using a No. 10 scalpel blade, leaving an L-shaped cartilage where possible. The cartilage was not resected as usual. The subdorsal cartilaginous incision was continued on the perpendicular plate using Cottle septum scissors ( Fig. 1 ). Great care was taken not to rock the bone during cutting to prevent possible damage to the cribriform plate. Next, the perpendicular plate and vomer were incised posteriorly and inferiorly. The cartilage was then separated from the maxillary crest inferiorly and the bone and septal cartilage were removed as an integrated unit ( Fig. 1 ).

Fig. 1
Steps involved in harvesting the bony cartilaginous unit. (a) Various parts of the septum in a patient with a history of previous septoplasty are shown: septal cartilage ‘c’, perpendicular plate of the ethmoid ‘p’, vomer ‘v’, and the part of the septum removed ‘*’. (b) The use of an 8-mm curved chisel to connect the two bony cuts and complete the harvesting.

The bony cartilaginous units were used as various types of grafts at different sites in the nose, including caudal extension grafts ( Fig. 2 ), spreader grafts ( Fig. 3 ), and lateral crural strut grafts, as well as for the closure of septal perforations.

Fig. 2
Schematic intraoperative cross-sections of the nose, as viewed through the caudal part of the septum. Note the C-shaped deviation of the caudal part of the nasal septum that was straightened with the bony cartilaginous unit.

Fig. 3
(a) A resected bony cartilaginous graft; the thick sections of bone were smoothed and thinned to 1–2-mm thickness using a 9-mm-diameter drill. A small and insufficient part of cartilage is shown (*). (b) Three bony cartilaginous units were cut from the original graft (two spreaders and one septal extension graft); small holes were created in the bony parts using a rotating bur.

Jan 16, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on The bony cartilaginous unit: the missing graft in septorhinoplasty
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