35. Treatment of the post-traumatic deformities of the nasal skeleton
This chapter is divided into three parts. Part 1, includes a diagrammatic description of how the nasal skeleton is corrected surgically. Part 2 shows some important operative steps and Part 3 has some relevant clinical pictures.
Figure 1: Two key diagrams are printed below. A lateral view of the nasal skeleton on the left and an anterio-posterior view on the right which in its lower one third depicts what the surgeon sees through the two nostrils. All these diagrams have been personally drawn by Dr. Uday Bhat, associate professor of plastic surgery at BYL Nair hospital in Mumbai, India after several meetings with the compiler of these notes who is extremely grateful to Dr. Bhat for his contribution.
Figure 2: (Left): Seen from within the nostrils, the everted alar cartilage is seen upside down. Around the lower edge of the lateral cartilage, is the internal valve. The space between the lateral cartilage and alar cartilage is the location of intercartilagenous incision, which when extended medially along the caudal border of the septum, becomes the tansfixion incision (broken red line). Centre and right: The dissection (blue arrow) has begun at the level of the internal valve in the nostril just above the upper edge of the alar cartilage.
Figure 3: Left: The mucosa from the septum has been separated and the arrow shows that the upper lateral cartilage has been cut away from the septum. Right: The nasal bone is now accessible and the arrow shows the direction of the osteotomy (medial) veering a little away from the midline. Medial osteotomy is performed by intranasal approach with a pair of 5mm curved guarded osteotome (one curved to the right, the other to the left).
Figure 4: Left: The lateral osteotomy is shown with a broken line at the junction of nasal plane and facial plane and is in fact on the maxillary bone rather than nasal bone. Although the manoeuvre is possible by intranasal approach, an external percutaneous approach through a small stab incision is preferred for better control. Centre It is performed with a 2 mm unguarded osteotome. The broken line of the pyriform aperture is retained in the diagram to give an idea about the site of the osteotomy. Right: The transverse osteotomy at the root of the nose is completed by an external approach with a 2 mm osteotome.
Figure 5: Left: The upper lateral cartilage on the left side is now cut away from the septum but the osteotomies are not shown but they will be a replica of what was done on the right side. Right: The curved concave cartilage is shown through the nostril and its picture is also drawn outside the main figure. This curvature on the caudal and inferior part of the septum may not reflect as the curvature of the dorsum, but may cause lowering of the nasal profile, needing augmentation. However if symptomatic (airway obstruction), it may be necessary to correct it by septal straightening. Osteotomies are usually not necessary.
Figure 6: Left: A similarly curved septal cartilage in the upper visible, anterior part of the septum is shown here within and outside the nasal cavity. Right: An osteotomy performed on the perpendicular plate of the ethmoid. Only the left side of the nostril is shown here in this figure to avoid confusion. In effect the septum has been broken at the level of the ethmoid and is freed from the attachment to the alar cartilage allowing the surgeon to straighten it. Only sometimes an osteotomy might be required. The septum might need to be dislocated from the vomerine groove and relocated after straightening.
Figure 7: The septal cartilage is being carved to take away the abnormal tension lines caused by the original septal injury which had led to the curvature and has been straightened.
Occasionally the whole of the septum might be removed and then extra-corporeally corrected whether by hand or a crusher. When a crusher is used a biological glue is employed to keep the straightened septum in its new form and then replaced in the nose between the septal mucosa.
N.B. Osteotomies for years were performed intranasally for fear that any incision through the skin will mar the result. While the medial osteotomy continues to be performed intranasally, there is a distinct tendency in the recent past to perform the lateral osteotomy by taking a small incision on the skin. This external or percutaneous approach gives a far better control for the operating surgeon. While the external osteotomy is performed with a 2 mm non-guarded osteotome, in intranasal procedure a pair of 5mm guarded curved osteotomes has been traditionally preferred to safeguard structures in the medial canthal area. The transverse osteotomy is always external and has now replaced a blind out-fracture (a greenstick fracture by outward movement of the osteotome at the end of medial osteotomy). Any uneven breakage is smoothened with a rasp (see below).
Some operative steps are reproduced below.