**7. Septal deformities**

In most cases basic techniques will result in a straight functional nasal airway though in complicated cases more aggressive approaches may be necessary.

#### **7.1. Complicated septal deformities**

Sometimes the nasal septum is deviated in several different planes, and insisting on basic septoplasty techniques does not solve the problem and may lead to septal perforation and many other complications. Extracorporeal septoplasty is a known modality that may be applied by experienced surgeons. In this technique, after an open approach skeletonization, the upper lateral cartilages are completely stripped off from nasal septum and then septal cartilage is precisely detached from all its anatomic connections and is taken out completely. The deformed nasal septum, which is now on the surgical table, is completely re-evaluated. Broken and deformed parts are excised and omitted in a way that a heavy strong L strut remains or is reconstructed. This newly formed septum is placed back inside the nose and tightly fixed to the bony vault and upper lateral cartilages [44-47]

### **7.2. Inadequate osteotomy**

the main advantage of this technique is its reversibility and when an ideal result is not obtained intra-operatively, the sutures can be removed. Upper lateral cartilages are conservatively trimmed and other standard valve reconstruction techniques such as

**3. Docile splay graft**: The docile splay graft is a piece of septal cartilage that is gently crushed and is placed over the nasal septum in a way that it covers the nasal septum and the two upper lateral cartilages are located laterally to the graft. It is believed that this simple graft will prevent upper lateral cartilages from functional movements and collapse [43]

**1.** Spreader grafts may be indicated to straighten a curved nasal dorsum that is not corrected

**2.** Internal nasal valve reconstruction prevents and corrects inverted V deformities and plays

In most cases basic techniques will result in a straight functional nasal airway though in

Sometimes the nasal septum is deviated in several different planes, and insisting on basic septoplasty techniques does not solve the problem and may lead to septal perforation and

spreader grafts may be applied (Figure 8).[40-42]

778 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 8.** Autospreader

**6.5. Important points**

**7. Septal deformities**

**7.1. Complicated septal deformities**

in normal septoplasty techniques [39]

a substantial role in providing aesthetic brow lines.

complicated cases more aggressive approaches may be necessary.

Sometimes intraoperative evaluations show that in spite of clear lateral osteotomy lines, medialization of bony segments is not achieved; in these cases medial osteotomy (in internal continuous osteotomy) and lateral oblique osteotomy (in external perforating osteotomy) may be indicated.

#### **7.3. Medial osteotomy**

In most rhinoplasty cases, lateral osteotomy will fulfill all the aims of osteotomy and there are limited indications for medial osteotomy; in indicated cases medial osteotomy may resolve some potential complications and will complete the bony vault surgery such as:


#### **7.4. Rocker deformity**

Rocker deformity is a relatively common sequel of lateral osteotomy. In this complication a large bony spicule is seen and palpated after lateral osteotomy over nasal radix. Like many other complications the best is to avoid this deformity by limiting osteotomy line maximum up to lateral canthus and not to extend it in thicker bony compartments. In case rocker deformity is seen, sharp bony spicules may be gently trimmed and sometime crushed cartilages or fascia can be used to camouflage the deformity. [51]

#### **7.5. Crooked bony vault**

In some post-traumatic nasal deformities a conventional lateral osteotomy does not result in an ideal symmetric bony vault; a double layer osteotomy may solve the problem in most cases. In this technique a deep low or low lateral osteotomy is performed in the traditional way; the second line of osteotomy is started in a higher plane and then with light finger pressure the bony vault is molded. In case adequate results are not achieved a third line may be designed on one side or both sides of the nose. [52]

#### **7.6. Important points**

