For severe dorsal deviation, Dr. Stephan advised that an extra-corporeal septoplasty might be best. A small portion of the dorsal septum is kept intact so that it can be used as an anchor point for the L-strut carved from the resected portion of the cartilage.
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February 2014He also touched on the use of polydioxanone plates when fragments of cartilage can’t be manipulated into the desired outcome: The fragments are placed on the plate, which induces cartilage growth, starts to resorb after 10 days, and is gone after 25 days. “It does align the cartilage that does fuse together better than if you had just sewn those cartilage pieces together alone,” Dr. Stephan said.
The Twisted Nose
Jared Christophel, MD, assistant professor of otolaryngology-head and neck surgery at the University of Virginia in Charlottesville, offered advice on straightening the upper third of the nose. “If the perpendicular plate of the ethmoid in the keystone area is not able to be set straight, it will … set the rest of the nasal dorsum off in that direction,” he said, adding that this can be a particularly tough job using only standard techniques.
Using a fulcrum can help, he advised. He starts with a fading medial osteotomy on the contralateral side and a lateral osteotomy on the contralateral side, then puts the osteotome up into the frontal bone to fulcrum the contralateral side away from the side of the deviation. “This allows that central portion of the perpendicular plate of the ethmoid to be broken over and moved with it.”
Correction of the Collapsed Nasal Dorsum
Edward Farrior, MD, president of the American Academy of Facial Plastic and Reconstructive Surgery and founder of Tampa-based Farrior Facial Plastic Reconstructive and Cosmetic Surgery Center, outlined his approach to the collapsed dorsum:
- He prefers a complete release of the cartilage: “I think it’s important to mobilize the mucoperichondrial flaps so that you can move things and have free movement of the upper lateral cartilages and medial crus.”
- He is not inclined to use unilateral spreader grafts: “My philosophy is I do things pretty much symmetric in the nose … I believe more in freeing things up and putting spread grafts on both sides rather than trying to open the nasal valve by putting a spreader graft on one side.”
- The spreader grafts can be extended above the nasal dorsum for supratip augmentation.
- He cuts a wedge in the top of the spreader grafts, “so that as the spreader graft is sutured beneath the upper lateral cartilage it can extend beneath the bony cartilaginous juncture. And having that wedge on the superior part helps to hold it in place when you do your osteotomies” and perform other tasks.
- Retro-displacing: He preserves all the length in the lateral crus. “When you set it back and suture it to the septum, it will create a little bit of a flare so that you haven’t shortened the distal portion of the lateral crus,” increasing the internal nasal valve. “You do only what is necessary, but be sure to do everything that is necessary.”
Lateral Wall Support
Stephen Park, MD, director of facial plastic and reconstructive surgery at the University of Virginia in Charlottesville, emphasized the importance of precise placement of batten grafts when correcting a dynamic collapse.