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PRS Resident Chronicles
Friday, August 15, 2014
The Caudal Septum Made Ridiculously Simple
by Jacob Unger, MD

After a rather spirited discussion in our teaching conference last week, and an impromptu learning session that resulted after the end of conference, my mind began turning this rather simple, yet somewhat confusing topic.  The caudal nasal septum and how various actions upon it have completely different actions on the shape and structure of the nose.

One of our exceedingly bright junior residents was presenting a rhinoplasty in photo conference, where we are required to present our week’s cases with pre, intra, and post op photos on the first Thursday of each month.  She was deftly describing the maneuvers used in this case to both create a positive effect on the airway, as well as the aesthetic techniques utilized to create a better nasal shape. The confusion began when the line of questioning from our senior faculty turned towards the action taken at the caudal septum. A conversation on straightening of the septum and up-rotation of the tip and shortening the nose all became intertwined that, without the appropriate nomenclature, left the discussion participants and much of the audience confused.

The crux of the matter is the nasal spine, as we all talked about after the session ended. Anterior to the nasal spine, resection of the caudal septum has no effect on deflection of the cartilaginous septum or L-strut, which is all posterior to the nasal spine, but instead can have marked effect on the aesthetics of the nose.  Resection of the anterior caudal septum, when placed parallel to the natural angle of the septum here will result in shortening of the length of the nose as well as the creation of space for a columellar strut. A small amount of up-rotation of the tip will also occur with this maneuver. Conversely, an angled resection of this anterior caudal septum will result in primarily tip rotation and thus an increase in the columellar-labial angle, with a secondary change of decreased nasal length.

Importantly, none of the aforementioned resections will have an effect on an excessively deviated cartilaginous septum. However, if you perform a resection of the caudal septum POSTERIOR to the anterior nasal spine along the maxillary crest (sometimes referred to as the inferior septum to avoid exactly the confusion that occurred in conference), this will allow for resection of bowed or deviated excess cartilage which can allow for straightening of the septum and therefore an improved airway. It should also be noted that if this inferior septum is resected, parallel to the maxillary crest, but no action is taken on the anterior caudal septum or at the point of the anterior septal angle, there will not be any change to the aesthetic position of the nasal tip structure.

The final teaching point we discussed was that if you perform an inferior septal resection (or posterior caudal septum) to improve septal shape and airway flow, you must reattach the new inferior margin of the septum to the periosteum of the maxillary crest to restabilize the septum. Without this important step, often done with 5-0 PDS in a figure –of-8 fashion, you can have compression and collapse of your midvault with the healing process resulting in what appears to be a residual dorsal hump deformity at the keystone area, as well as an excessive supratip break.

As we held this spontaneous residents-only teaching session we not only developed a deeper and more comprehensive understanding of this topic, but also had the opportunity to bond as a group and make yet another small memory of our training experience that enriched not only our clinical knowledge, but our lives.

About the Blog

Plastic and Reconstructive Surgery

PRS Resident Chronicles” is the official Resident blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit this blog to follow the unique journeys of several young doctors as they go through residency in their respective Plastic Surgery Programs across the country.

We want to hear from Plastic Surgery Residents across the globe as well: how do you use PRS in your residency? What are some of the challenges you’ve faced and successes you’ve had? Join the on-going conversation by commenting, and if you think you have a potentially interesting-enough entry to be a unique blog post, email us at

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Keep in mind that the views and recommendations presented in this blog do not necessarily indicate official endorsements or opinions of the Publisher, PRS, or the ASPS. All views are those of the authors and the authors alone.

Rod J Rohrich, MD


Andre Alcon is a fourth-year medical student at Yale University where he is starting a one year research fellowship in tissue engineering with the department of plastic and reconstructive surgery.

Ashley Amalfi is currently a fifth year Plastic Surgery Resident at Southern Illinois University School of Medicine. She attended the George Washington University and received dual degrees in Fine Arts and Art History. She returned home to attend The University of Rochester School of Medicine and Dentistry in Rochester, NY. Ashley met her husband, a urologist, during her training at SIU. She enjoys yoga, reading, travel and cooking in her free time.

Jordan Ireton is in her first of six years at the University of Texas Southwestern Plastic Surgery residency program.


 Anup Patel, MD, MBA, is a resident in the Yale Plastic and Reconstructive Surgery Program. He co-founded Cents of Relief, a 501(c)3 nonprofit, that empowers victims of human trafficking through health and educational initiatives including those related to reconstructive surgery. Along those lines, he has interest in surgical burden of disease and healthcare policy. He has been selected to serve on the American Society of Plastic Surgeons Board of Directors as resident representative.


Justin Perez is a fourth-year medical student at Weill Cornell Medical College. Born and raised in Reading, Pennsylvania, Justin moved to New York City to attend Fordham University, where he graduated summa cum laude with degrees in Biology and Spanish Literature. His academic interests include tissue engineering and wound healing, the topics of his current research. His hobbies include theater and biking.


Raj Sawh-Martinez, MD is a current resident at the Yale Plastic and Reconstructive Surgery program.  He grew up in Yonkers, NY and completed his undergraduate work in Neural Science at New York University.  He graduated from the Yale School of Medicine in 2011.

Ajul Shah, MD is a graduate of University of Texas Southwestern Medical School and is now a resident in his second of six years at the Yale Plastic Surgery residency program.

Jacob Unger, MD was raised in New Jersey on the shore. He attended Tulane University for his undergraduate work where he rowed on the Tulane Crew Team and majored in Philosophy. He graduated Phi Beta Kappa, Summa cum Laude with honors and then attended New York University School of Medicine. When not working, he enjoys traveling with his wife, surfing, and skiing.

Former Resident Chronicle contributors

Eamon O’Reilly, MD LCDR USN is an active duty US Navy full-time outservice resident in his second of three years at the University of Texas Southwestern Plastic Surgery residency program in Dallas, TX.