Since Metzenbaum1 presented his caudal septoplasty technique in 1929, known as “swinging door,” many authors have developed different ways to correct deviations of the caudal septum. Most of the techniques described have stressed straightening the caudal septum, which will improve the function and to lesser extent the other deformities that can contribute to asymmetry of the nasal base such as tip deviation, nostril asymmetry, and footplates and medial crural deformities.
Based on the concepts and techniques used to correct posterior septal deviation described by Rohrich et al.2 that have evolved to include the management of the caudally deviated septum, caudal septoplasty in conjunction with the use of forked columellar struts has been applied in 18 consecutive patients (6 male and 12 female) with congenital or posttraumatic caudal septal deviation since 2014.
Caudal septoplasty was performed through an open rhinoplasty approach using the graduated technique for simplifying the management of the caudally deviated septum3 with some differences. After wide dissection and release of the mucoperichondrial attachments were carried out, the free edge of the caudal septum was trimmed first if there was any vertical excess followed by the reconstruction of the posterior septum to precisely determine the amount of the caudal strut.
Release and excision of the caudal septum at its articulation with the anterior nasal spine and maxillary crest were performed after assessing the excess degree to allow the deviated septum to be returned to the midline, then accurately suturing the caudal L-strut back to the anterior nasal spine to recreate its articulation.2 When the anterior nasal spine is located away from the midline, judicious excision is undertaken to allow the caudal septum to come into the midline.
The importance of columellar strut as a vital and unifying component for the support and projection of the tip complex was described.4,5
A forked columellar strut was designed using 3 pieces of cartilage graft, 1 central and 2 lateral pieces 2 cm and 1 cm in length, respectively (Fig. 1). An overlap of about 0.5 cm was created between them; the final length of the strut was about 2.5 cm. The forked strut was now inserted and fixed between the medial crura and footplates and adjusted for proper tip position and rotation.
All patients reported a high degree of satisfaction with the surgical outcome in terms of improved columellar shape, position, symmetry, tip projection, and rotation (see Figures, Supplemental Digital Content 1, http://links.lww.com/PRSGO/A455 and Supplemental Digital Content 2, http://links.lww.com/PRSGO/A456).
The forked strut achieved tip and basal support that resist the cartilage and soft-tissue memory in the area of the anterior nasal spine with improvement of nostril asymmetry, footplates, and medial crural deformities. By this design, all structures such as the medial crura and columellar deformities and deflection of nasal tip that contribute to the nasal base asymmetry and commonly accompany the caudally deviated septum are addressed. Another advantage is that this technique allows to use small pieces of cartilage when there is a deficiency in cartilage grafts to construct a long strut.
The patient provided written consent for the use of his image.
1. Metzenbaum M. Replacement of the lower end of the dislocated septal cartilage versus submucous resection of the dislocated end of the septal cartilage. Arch Otolaryngol. 1929;9:282.
2. Rohrich RJ, Gunter JP, Deuber MA, et al. The deviated nose: optimizing results using a simplified classification and algorithmic approach. Plast Reconstr Surg. 2002;110:1509–1523; discussion 1524–1525.
3. Constantine FC, Ahmad J, Geissler P, et al. Simplifying the management of caudal septal deviation in rhinoplasty. Plast Reconstr Surg. 2014;134:379e–388e.
4. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the columellar strut in rhinoplasty: indications and rationale. Plast Reconstr Surg. 2012;129:118e–125e.
5. Abu El-Wafa AM. Columellar strut: is it an integral step in primary rhinoplasty? Plast Reconstr Surg. 2013;131:119e–121e.