by Jacob G. Unger, MD
After a rather spirited discussion in our teaching conference last week, and an impromptu learning session that resulted after the end of conference, my mind began turning this rather simple, yet somewhat confusing topic. The caudal nasal septum and how various actions upon it have completely different actions on the shape and structure of the nose.
One of our exceedingly bright junior residents was presenting a rhinoplasty in photo conference, where we are required to present our week’s cases with pre, intra, and post op photos on the first Thursday of each month. She was deftly describing the maneuvers used in this case to both create a positive effect on the airway, as well as the aesthetic techniques utilized to create a better nasal shape. The confusion began when the line of questioning from our senior faculty turned towards the action taken at the caudal septum. A conversation on straightening of the septum and up-rotation of the tip and shortening the nose all became intertwined that, without the appropriate nomenclature, left the discussion participants and much of the audience confused.
The crux of the matter is the nasal spine, as we all talked about after the session ended. Anterior to the nasal spine, resection of the caudal septum has no effect on deflection of the cartilaginous septum or L-strut, which is all posterior to the nasal spine, but instead can have marked effect on the aesthetics of the nose. Resection of the anterior caudal septum, when placed parallel to the natural angle of the septum here will result in shortening of the length of the nose as well as the creation of space for a columellar strut. A small amount of up-rotation of the tip will also occur with this maneuver. Conversely, an angled resection of this anterior caudal septum will result in primarily tip rotation and thus an increase in the columellar-labial angle, with a secondary change of decreased nasal length.
Importantly, none of the aforementioned resections will have an effect on an excessively deviated cartilaginous septum. However, if you perform a resection of the caudal septum POSTERIOR to the anterior nasal spine along the maxillary crest (sometimes referred to as the inferior septum to avoid exactly the confusion that occurred in conference), this will allow for resection of bowed or deviated excess cartilage which can allow for straightening of the septum and therefore an improved airway. It should also be noted that if this inferior septum is resected, parallel to the maxillary crest, but no action is taken on the anterior caudal septum or at the point of the anterior septal angle, there will not be any change to the aesthetic position of the nasal tip structure.
The final teaching point we discussed was that if you perform an inferior septal resection (or posterior caudal septum) to improve septal shape and airway flow, you must reattach the new inferior margin of the septum to the periosteum of the maxillary crest to restabilize the septum. Without this important step, often done with 5-0 PDS in a figure –of-8 fashion, you can have compression and collapse of your midvault with the healing process resulting in what appears to be a residual dorsal hump deformity at the keystone area, as well as an excessive supratip break.
As we held this spontaneous residents-only teaching session we not only developed a deeper and more comprehensive understanding of this topic, but also had the opportunity to bond as a group and make yet another small memory of our training experience that enriched not only our clinical knowledge, but our lives.