Explore this issue:February 2014
During the session “Technical Pearls for Functional Rhinoplasty,” panelists offered wisdom gathered from years of experience performing the procedure. Here are a few highlights.
Managing the Inferior Turbinate
Alex Chiu, MD, interim chair of surgery and chief of otolaryngology-head and neck surgery at the University of Arizona in Tucson, offered tips for surgery on the inferior turbinate.
A recent study concluded that submucous resection with outfracture, with microdebrider assistance, is the most effective technique for inferior turbinate reduction, said Dr. Chiu (Laryngoscope. Published online ahead of print on September 19, 2013; doi: 10.1002/lary.24182). He advised that everything in the procedure should be done using the endoscope. “Everything in surgery should be with a focus, even putting in cotton pledgets,” he said. “So use an endoscope, [and] de-congest the area you need to work on as opposed to just kind of shoving those pledgets into the nose.”
For the submucous resection, he prefers a linear incision along the inferior turbinate, which helps with exposure, minimizing the chance of getting into trouble with arterial bleeding from the artery located posteriorly along the inferior turbinate.
He also likes epinephrine-soaked pledgets for hemostasis and as a technique for retracting tissue to free mucosa from the bone.
The trick in septoplasty is creating enough room by modifying the surrounding structures, while preserving enough of the septum itself, said Scott Stephan, MD, assistant professor of otolaryngology at Vanderbilt University in Nashville. “In the modern era there’s more modification of the cartilage in the septum versus in earlier years, [when there was] more of an approach to resect the cartilage,” he said. It’s important to recognize the role of the septum in supporting the middle vault and the tip and to preserve those structural parts of the septum, “much like weight-bearing walls in a house.”
“If you want to modify the septum, you have to know what factors influence it,” he added. Those factors include bone, upper lateral cartilage, and soft tissue. “All of this contributes to a boundary that the septum has to live within, and if you, over time, have too small of a box, then you’re a six-foot man in a five-foot box,” Dr. Stephan said.
Modifying intrinsic features includes resecting bony deviations; modifying the cartilage by scoring the concave side, cross-hatching, and morselizing non-critical areas; and using vertical slats in the dorsum.