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Reply: Simplifying the Management of Caudal Septal Deviation in Rhinoplasty

Constantine, Fadi C. M.D.; Ahmad, Jamil M.D.; Geissler, Palmyra M.D.; Rohrich, Rod J. M.D.

Plastic and Reconstructive Surgery: May 2015 - Volume 135 - Issue 5 - p 923e–924e
doi: 10.1097/PRS.0000000000001246
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Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

The Plastic Surgery Clinic, ississauga, Ontario, Canada

Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Correspondence to Dr. Rohrich, Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, Texas 75390-9132, rod.rohrich@utsouthwestern.edu

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Sir:

We appreciate the input from Dr. Aksam and colleagues regarding our article, “Simplifying the Management of Caudal Septal Deviation in Rhinoplasty.” They describe their method of addressing caudal septal deviation by excising a portion of the caudal septum and then using a sheet of polydioxanone foil (PDS plate; Ethicon, Inc., Johnson & Johnson, Inc., New Brunswick, N.J.) to span a gap between the L-strut and the anterior nasal spine and fixate these two structures. However, one major difference must be pointed out between our methods; in our description addressing caudal septal deviation, we only excise the portion of the caudal septum that is redundant in the vertical dimension. Once this redundancy is excised, there should not be a gap between the caudal aspect of the L-strut and the anterior nasal spine. They should lie flush with each other, allowing for a polydioxanone suture to be used to fixate the caudal aspect of the L-strut to the anterior nasal spine.

In their description, Dr. Aksam and colleagues report, “a gap will usually occur between the L-strut and nasal spine after excision,” thus necessitating the use of the spanning polydioxanone plate for support. It should be noted that there are few published data reporting outcomes when using a polydioxanone plate during rhinoplasty. Most descriptions involve using a polydioxanone plate as an absorbable scaffold adapted to cartilage to provide support during healing; when the polydioxanone plate resorbs, the cartilage is still present in the area to provide long-term support.1 Achieving appropriate tip projection and rotation during rhinoplasty is a complex and dynamic process dependent on a variety of structures including the dorsal and caudal septum, lower lateral cartilages, soft-tissue attachments, and additional support in the form of grafts. We wonder what effect allowing a gap between the caudal septum and anterior nasal spine will have at long-term follow-up—will this allow for loss of tip projection and/or rotation? The 47-year-old woman shown in Figures 1 and 2 underwent quaternary rhinoplasty and is shown preoperatively. There is a significant deficiency of tip projection and rotation. At surgery, it was noted that the caudal septum had been excised during a previous operation, and this undoubtedly contributed to the poor tip projection and rotation noted preoperatively. We applaud the authors for their contribution and sharing their techniques to address this challenging problem in rhinoplasty.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

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DISCLOSURE

Dr. Ahmad receives book royalties from CRC Press. Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Quality Medical Publishing and Taylor and Francis Publishing. No funding was received for this article. The other authors have no financial interest to declare in relation to the content of this communication.

Fadi C. Constantine, M.D.

Department of Plastic Surgery

University of Texas Southwestern Medical Center

Dallas, Texas

Jamil Ahmad, M.D.

The Plastic Surgery Clinic

ississauga, Ontario, Canada

Palmyra Geissler, M.D.

Rod J. Rohrich, M.D.

Department of Plastic Surgery

University of Texas Southwestern Medical Center

Dallas, Texas

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REFERENCE

1. Rimmer J, Ferguson LM, Saleh HA.. Versatile applications of the polydioxanone plate in rhinoplasty and septal surgery. Arch Facial Plast Surg. 2012;14:323–330
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