Caudal and Dorsal Septal Reconstruction: An Algorithm for Graft Choices

David A. Sherris, M.D.

ABSTRACT

The objective of this study is to present an algorithm .for choosing graft materials for the reconstruction of severe caudal and/or dorsal septa/ cartilage abnormalities and to examine the long-term results obtained with these techniques. Ret­rospective review of 21 consecutive cases of caudal and/or dorsal septa/ reconstruction via the external approach using the algorithms is presented. The techniques used are carefully described. Patient survey at least 1 year after the initial pro­cedure, rhinologic examination before and after the procedure, and photographic analysis of preoperative and postoperative views are presented. The graft choice algorithm presented helps the surgeon to consider appropriate graft choice alter-natives before surgery. (American Journal of Rhinology 11, 457-466, 1997)

Submucou resection and standard swinging door septo­plasty techniques demand the preservation of an L-shaped strut along the dorsal and caudal septum. Because of this demand, these techniques do not adequately treat caudal and dorsal septal deformities. if the L-shaped septal strut is violated, a variety of postoperative abnormalities can ensue including saddle nose deformity, nasal valve collapse, loss of tip projection, and columellar retraction. Multiple au­thors have presented endonasal caudal end transplantation with septal cartilage or ethmoid hone. 1-6 Other authors have described the external approach using septal cartilage grafts.7-10 Some authors have presented septal or dorsal reconstruction with rib grafts or bone gratis through an endonasal or external approach.11-14

In this study, an algorithm for graft material choices for the reconstruction of the caudal and dorsal septum is presented. The algorithm is especially important so that the surgeon can prepare the patient preoperatively for possible graft sites, as well as associated graft harvest morbidity. The structural grafting materials presented in this article and the treatment algorithm are all autogenous materials secondary to their superiority over all other materials presently avail-able for implantation in these sites. In nonstructural sites, and especially as dorsal only grafts, a variety of autogenous, homografts, and alloplastic alternatives are presented.

SUBJECTS AND METHODS

Between 9/1/94 and 2/1/96, 21 of the 165 patients (13%) undergoing nasal and septa/ reconstruction by the author required caudal and/or dorsal nasal septal reconstruc­tion through the external approach. Of the 21 studied cases, 1 I patients underwent primary nasal septal reconstruction, 7 patients underwent revision nasal septal reconstruction hav­ing received the primary surgery at another institution, and 3 patients had reconstruction of the caudal septum after nasal cancer excision. Nine of 18 patients (50%) had a history of previous nasal fracture (excluding the 3 nasal cancer reconstruction patients). The grafting materials used for septal reconstruction were septal cartilage graft alone in 7 of 21 patients; autogenous rib graft in 6 patients; septal cartilage graft plus stenting spreader grafts of ethmoid bone in 4 patients; stenting spreader grafts of ethmoid hone alone in 2 patients; ethmoid bone replacement grafts in one pa­tient; and calvarial bone graft in one patient. A columellar strut was placed in all patients and 14 of 21 patients re­ceived suture-fixated tip grafts. Six of the tip grafts were septal cartilage, four were ear cartilage, and four were costal cartilage. Nine patients received nonstructural dorsal onlay grafts: three of expanded polytetrafluoroethylene, three of temporalis fascia, two of crushed septa] cartilage, and one of conchal cartilage. The graft materials were chosen by using the treatment algorithm devised over the past 2 years (Fig. 1, A-C).

SURGICAL TECHNIQUES

A right hemitransfixion incision and bilateral mucoperi­chondrial flaps were elevated as far posteriorly on the septum as possible. Care is taken to preserve meticulously the mucosa of the nasal septum bilaterally. The nasal dor­sum is exposed with bilateral marginal incisions and a transcolumellar incision. The upper lateral cartilage is then carefully divided off the dorsal septum in the submucosal plane. If a rent is made in the flaps, it is repaired immedi­ately with 5-0 chromic suture. Further mucoperichondrial flap dissection is done through the dorsum of the nose in cases when dissection posterior to the septal deflection cannot he accomplished through the hemitransfixion inci­sion. The deformed portions of the septum are then resected. In all cases the dorsal septum under the nasal bone and projecting caudally at least 5 mm is preserved as a strut to fixate replacement grafts. In cases where ethmoid hone stenting spreader grafts alone are used, the septal cartilage is weakened by morselization or scoring, but is not divided.

Material for septal reconstruction is next harvested. If the perpendicular plate of the ethmoid and/or vomer bone is used as stenting spreader grafts, small pieces of straight hone are harvested (Fig. 2, A-H). If ethmoid or vomer bone is used as a septa replacement graft, a large, straight piece must he harvested (Fig. 3, A-E). In cases of a mild saddle nose deformity, various autogenous, homograft, or synthetic materials can be used as a dorsal onlay graft (Fig. 1B). Ear cartilage is harvested through an anterior conchal bowl incision using the shadow of the lateral conchal bowl to hide the scar. The radix helicus is left intact so as not to change the contour of the ear. The incision is closed with running 5-0 fast absorbing gut and a cotton tie through bolster.

If a rib graft is used for septal reconstruction, it is har­vested at this time. If there is no evidence of significant saddle deformity, then a cartilaginous rib graft is harvested from the confluence of the 7th and 8th rib through a 4-5 cm incision directly over the 8th rib.

The graft is easily carved into wafers with a dermatome blade (Fig. 4). If a significant saddle nose deformity along with intact septal mucoperichondrium and deformed upper lateral cartilages are present concurrently. then the 9th cos­tal cartilage and a 2 cm segment of hone is harvested in continuity (Fig. 5, A-G). In some of the cases the cartilag­inous 10th rib is harvested through the same incision for use as a columellar strut. Dissection around the rib cartilage is done in the subperichondrial plane starting on the external surface of the graft and proceeding down the sides. The harvest site is closed in layers over a small penrose drain.

When calvarial bone is needed, it is harvested from the parietal skull through a hemicoronal incision. Troughs are drilled through the outer table around the bone segment(s) to be harvested. The bone grafts are harvested with an angled blade on a power saw, with care not to violate the inner calvarial bone table. The hemicoronal incision is closed in layers over a suction drain that is left in overnight.

The grafting material of choice is carved appropriately to reconstitute the portion of septal cartilage and dorsum that had been resected or is deficient. Special attention is paid to reconstruct the extremely important 1 to 2 cm caudal and dorsal L-shaped strut. Septal replacement grafting materials are sutured into place with 5-0 polydioxanone sutures. If ethmoid hone stenting spreader grafts are needed, a hand auger is used to drill holes in the hone for through and through suture placement (Fig. 2, A-H). Any other dorsal work including cartilage trimming, rasping, and osteotomies are done. The upper lateral cartilages are trimmed appro­priately and sutured back to the dorsal septal reconstruction with 5-0 polydioxanone sutures. A columellar strut is placed and sutured into place with 4-0 plain mattress su­tures. Any further tip work, including cephalic trim, done division, and suture-fixated tip grafting are done. The mu­coperichondrial flaps are whip-stitched hack to the recon­structed septum with 4-0 plain suture.

In severe saddle nose cases, the nasal hones are rasped down a few millimeters to provide a raw hone bed for the cantilevered bone or bone/cartilage grafts. The dorsal grafts are then carved to appropriate size with power drills and sharp dissection. With costal cartilage, care is taken to carve equally on opposing sides to avoid later graft warping (Fig. 5, A and B). The rib or calvarial bone segment is fixed to the nasal bones with two 1.2 mm diameter lag screws through a central stab incision in the nasion region. If the upper lateral cartilage is severely deformed and obstructing the nasal valve, then it is submucosally divided on either side of the midline and sutured up to the cantilevered dorsal graft. The lower lateral cartilages are placed on top of the canti­levered dorsal graft, and occasionally must be sutured in this position. In severe saddle nose cases, the tip graft is applied after placement of the dorsal graft. The dorsal graft is not fixed to the columellar reconstruction as this results in an unnaturally rigid nasal tip that is prone to fracture.

In patients with minimal saddling, multiple alternative graft choices are available including septal, ear or costal cartilage, temporalis fascia, homografts, or synthetic mate­rials. In patients who have had other sites harvested, leftover material can be used. If no adjunctive graft materials have been harvested, then homograft material or synthetic mate­rial can be considered. Irradiated rib, lypholysed dermis, and expanded polytetrafluoroethylene are good alternatives as small to medium tissue fillers on the dorsum.

The nose is dressed with silastic splints, taping, and plastic casting. Occasionally, nasal packs are placed over-night. If sinus surgery is done before reconstructive septo­rhinoplasty: then the ethmoid cavities are packed for 1 to 3 days with sponge sinus packs.

DATA ACQUISITION AND ANALYSIS

All patients were asked to fill out a postoperative survey at least 12 months after surgery. Patients underwent preoperative and postoperative rhinologic examination by another surgeon with evaluation of nasal tip support, colu­mellar symmetry and retraction, columellar and dorsal sym­metry, evidence of septal deformity, evidence of septal perforation, and overall airway appearance. In addition, preoperative and at least I2-month postoperative photo-graphs were taken and evaluated by another surgeon. Any complications in the postoperative period were documented appropriately.

RESULTS

Average follow up for patients was 19.8 months postop­erative with a range of 12 to 29 months. Patients' survey results demonstrated that 19 of the 21 patients (90%) say they have much improved (normal) breathing postop­eratively, while 2 (10%) say that they have improved breathing (mild residual obstruction) (Table I). No patients have unchanged or worse breathing than before surgery. Eleven of the patients (52%) reached their peak on breath­ing improvement 0-1 month after surgery; seven (33%) more reached it within 3 months: and the remaining three (15%) reached the peak breathing within 6 months. Eigh­teen of the patients (85%) say the appearance of their nose is much improved, while the remaining three (15%) of patients say the appearance is improved. No patients com­plained of worsening of appearance, and no patients are unchanged after surgery; 100% of patients say they would undergo the procedure again if they were in the same situation.

Figure 2 A-H. Ethmoid bone scenting spreader grafts are drilled with a hand auger. The gratis can be either unilateral or bilateral depending on the desired effect. The patient appears preoperatively and / year postoperatively after bilateral ethmoid bone stenting spreader grafts, a free septal cartilage replacement graft, a septal cartilage tip graft, lateral osteotomies, donne division, and minimal cephalic trim.

Results of photographic analysis and rhinologic exami­nation by another surgeon demonstrate that 16 patients (76%) have a much improved, normal, and straight caudal and dorsal septum postoperatively, while 5 patients (24%) have improved caudal and/or dorsal septum with a mild residual defect (Table ii). No patients were judged un­changed or worse in appearance intranasally or externally after surgery. The only perioperative complication was a patient who experienced partial graft exposure through a small mucosal defect for 2 weeks postoperatively. This closed spontaneously without any sequelae. Two years post-operatively there was evidence of graft resorption in the supratip region of the patient who received a calvarial bone graft. There was no evidence of hematoma or infection in the postoperative period in any patient. No grafts extruded.

COMMENT

Reconstruction of the caudal and dorsal septum via the external approach is not necessary to repair the bulk of septal deformities. In fact, only 13% of all the patients undergoing nasal septal reconstruction during the study period required the external approach with cartilage and/or bone grafting to the caudal and/or dorsal septum. All cases were first approached through an endonasal approach with a hemitransfixion incision. The mildest of defects were reconstructed with standard septoplasty techniques plus car­tilage scoring or suture techniques to reconstitute caudal end deformities (Fig. IA). This study addresses the more severe deformities that required the external septorhinoplasty ap­proach.

A key maneuver in using the external approach for com­plex septal reconstruction is to divide the upper lateral cartilage from the dorsal septum. This maneuver improves exposure, allows precise graft placement, and makes suture fixation of the grafting material much more simple. in addition, the exposure makes septal flap dissection easier, allows repair of dorsal and tip asymmetries, and is useful in revision cases when the amount of cartilage present within the mucoperichondrial space is unclear. in the graft choice algorithm, ethmoid hone stenting spreader grafts along with cartilaginous morselizaiton are represented as the first ap­proach to moderate dorsal and caudal septal deflections that could not be handled endonasally (Fig. IB). Unfortunately, one of the two patients who underwent ethmoid bone stent­ing spreader grafts alone had a residual defect postopera­tively. The threshold to cutting the septal cartilage at the bend and using a free septal cartilage graft combined with ethmoid stenting spreader grafts has subsequently been lowBred.

 

Figure 3 A-E. An etlmuoid bone septa/ replacement graft sutured in place before trimming. Preoperative and 9 month postoperative views are shown. The patient also received an ear cartilage tip graft, a temporalis.fascia dorsal onlav graft, dome division and reconstitution, and lateral osteotomiec.

Figure 4. Rib cartilage for septal replacement is carved with a dermatome blade.

The stenting spreader grafts of ethmoid bone are useful to prevent graft and dorsal strut overlap. In cases of unilateral upper lateral cartilage collapse, a single spreader graft that is moderately thick (1-2 mm) is fashioned to both stabilize the septal cartilage graft and to even the lateral cartilages (Fig. 2B). In cases of a narrow nasal dorsum, outfracturing and medial osteotomies combined with bilat­eral thick stenting spreader grafts of ethmoid bone are used to broaden the dorsum and fixate the graft (Fig. 2, A-H). In patients with symmetric, proportionally correct upper lateral cartilages, a very thin wafer of ethmoid bone may be used to help fixate the septal replacement graft and prevent overlap, while doing little to affect dorsal width.

In this series of patients, autogenous grafting materials were used for all septal reconstruction grafts as well as tip grafts, columellar struts, and cantilevered dorsal grafts. The advantages of autogenous grafts. especially in structural graft sites, include low risk of graft resorption, no risk of graft rejection, and lesser risk of graft infection in compar­ison to any other type of implant. Some authors have used allograft materials for caudal septal reconstruction. "' Al­lograft materials are at a greater risk of resorption, infection, and transmission of infectious diseases, especially in struc­tural graft sites."5 Recently, expanded polytetratluoro­ethylene (ePTFE) has received press as a nasal dorsal onlay implant.'"7 In fact, in this series three patients received ePTFE as a nonstructural dorsal onlay graft. The disadvan­tage of all artificial implant materials in comparison to autogenous materials is higher rate of infection, extrusion, and patient concern over foreign body placement in the nose. In addition, ePTFE cannot be used as a cantilevered, structural implant, but only as a camouflaging onlay im­plant. Yet, the use of alloplasts and homografts is an

TABLE I
Patient Survey Results (n = 21)

	Normal	Improved But	Unchanged	Worse	Much
		Not Normal			Worse
Breathing postoperative (compared to preoperative)	19	2	0	0	0
Appearance postoperative (compared to preoperative)	18	3	0	0	0
Time to peak breathing improved	0-1 Month	1-3 Months	3-6 Months	Greater than
				6 months
	II	7	3	0
Would you undergo the procedure again?	Yes	No

appropriate alternative if the patient is apprehensive about autogenous graft harvest.'5-17 Other alternatives that are acceptable for dorsal onlay grafts include septal cartilage, conchal cartilage, temporalis fascia, and homograft cartilage or dermis. When using synthetic materials, like ePTFE, the risk of infection and extrusion must be well explained.l`',I7 With homografts and autografts, the risk of resorption must be explained.15 Yet, in all cases, the risks are minimized where their uses are limited to nonstructural uses, such as small to medium tissue fillers on the nasal dorsum.

The morbidity of a secondary surgical site associated with autogenous graft harvest and its accompanying difficulties were minimal in this series of patients. The ear cartilage graft harvest is an extremely well-tolerated proce­dure with minimal discomfort after surgery and no evidence of significant deformity from the graft harvest. Unfortu­nately, car cartilage is neither abundant enough to replace severe saddle nose deformities, nor rigid enough to use as a cantilevered graft. In addition. car cartilage is too curved to use as a septa) replacement graft. The rib graft harvest does increase postoperative pain, but this was well-tolerated in the small group of patients who underwent this procedure. Each of these six patients was released within 23 hours of the procedure and none required hospital readmission for postoperative pain control. Within 2 weeks the pain was minimal at this site. Overall, the ear and rib graft donor site morbidity is far outweighed by the advantages of autogenous grafting material over any other implant material avail-able for structural graft sites.

The one patient who underwent dorsal grafting with calvarial bone developed a supratip depression 2 years postoperatively that required camouflaging ear cartilage on-lay grafting. The portion of bone graft over the nasal bones did not resorb in any patient. Although some studies dem­onstrate less resorption of membranous hone grafts than endochondral hone grafts in experimental models, other studies have not substantiated this finding in experimental and clinical models.8,l1-13,15-24 One study comparing mem­branous (calvarial) bone grafts fixed with two lag screws to endochondral (rib) bone grafts fixed with two lag screws showed no statistical difference in resorption.23 Because that study best reflects the technique of lag screw fixation and hone graft structure presented in this article, both rib bone/costal cartilage combination grafts and calvarial bone grafts are reasonable alternatives for cantilevered nose dor­sal grafts.

The rib/cartilage grafts and costal cartilage grafts in this series show no evidence of resorption or warpage over 2-year follow up (Fig. 5). The raw, rasped nasal bones provide an osteoinductive bed to lag screw fixate and feed the short segment of rib bone. The cartilaginous portion of the combination graft is in direct contact with vascular perichondrium and skin and soft tissue envelope. Because of likely to warp.13 The graft itself more closely approximates rigid hone fixation and stability, and the resultant need for the natural nose in that both the graft and the recipient site a shorter cartilaginous segment than if one were to augment have an upper one-third of bone, with a lower two-thirds of the dorsum with costal cartilage alone, the cartilaginous cartilage. The resulting nose feels and looks more natural portion of the combined bone and cartilage graft is less than the rigid, calvarial bone-grafted nose.

Also, the cornbined rib bone and costal cartilage graft is easier to carve and handle than calvarial bone. Taking these conclusions into consideration, the combined rib bone and costal cartilage graft has distinct advantages over calvarial bone grafts with regard to esthetics, texture, and handling characteristics for reconstruction of patients with posttraumatic severe saddle nose deformities (Fig. 6).

Yet, because of the low number of patients in this study that required cantilevered dorsal grafts, no concrete conclusions can be made at this time. Calvarial bone grafting and rib bone and costal cartilage grafts are presented as equivalent alternatives in the severe saddle nose patient in the graft choice algorithm (Fig. IC). Only longer follow-up of all grafts and further study will elucidate the better graft.

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