Extracorporal septal reconstruction with ...

Extracorporal septal reconstruction with polydioxanone foil Gerlinger, I.,* Ka´ra´sz, T.,* Somogyva´ri, K.,* Szanyi, I.,*Ra´th, G.,* Mo´ricz, P.,* & Boenish, M.† *Department of Otorhinolaryngology, University of Pećs, Pećs, Hungary, and Diakonissen Klinik, Linz, Austria Accepted for publication 7 September 2007

Key points

• Conventional septoplasty cannot be the answer to all types of septal deviation. • Indications of extracorporal septal reconstruction with polydioxanone (PDS) foil: (i) selected cases of very high septal deviations, (ii) post-traumatic and (iii) extremely pronounced congenital septal deviations and ⁄ or aesthetic deformities. • Polydioxanone foil facilitates the incorporation of a newly implanted septal graft without significant postoperative complications and is absorbed within 25 weeks.

• The surgical technique is described in detail, and the early postoperative functional and aesthetic results (mean follow-up: 11 months) on 16 patients (mean age: 42 years) are reported. Overall, 88% of the patients responded positively to the question of whether they would choose to undergo the same procedure again, knowing the postoperative result. • The procedure is easy to learn and has already proved to be an excellent combination of modern functional and aesthetic nasal surgery.

During modern septoplasty, the mucoperichondrium is elevated ipsi- or bilaterally, a 2-mm-wide piece of cartilage above the maxillary crest is resected and the cartilaginous septum is mobilised. The mobilisation is greatly facilitated by posterior chondrotomy.1 The posterior–inferior part of the septum is usually removed and any other strongly deviated areas too are resected. The removed pieces of septal cartilage are comminuted, thinned, reshaped or scored, and then reimplanted and fixed in the middle of the space between the inferior turbinates (not always in the sagittal plane) with an adequate suturing technique.2 Extreme septal deviations, post-traumatic significantly deviated nasal septa and congenital nasal deformities resulting in severe septal deviations can be particularly difficult to correct. In these cases, remodelling of the dorsal edge of the septum is obligatory to achieve a satisfactory functional and aesthetic result. The idea of total removal, extracorporal modelling and reimplantation of an extremely deviated nasal septum was first put forward by King and Ashley in 1952.3 In 1995, Gubish4 reported his experience on 1012 extracorporal septoplasties. He used a closed

rhinoplasty technique, sutured together the excised and chopped pieces of the septum, and then reimplanted them between the mucoperichondrial layers. Senyuva et al. removed the whole bony and cartilaginous septum during an open rhinoplasty procedure and reconstructed the dorsal and caudal septal edges with an L-shaped piece of cartilage cut from the quadrangular cartilage.5 It must be emphasised that reimplantation of a newly created septal cartilage, independently of the method used, leads to a decreased stability of the nasal septum, and hence of the nasal pyramid. Boenisch et al.6 recently presented promising experience acquired from animal experimental studies and clinical practice; following complete removal of the septal cartilage, the straight pieces of the septum were sutured very precisely onto a polydioxanone (PDS) foil. After reimplantation, the reshaved cartilage–PDS foil complex was incorporated without difficulty, creating the new framework of the septum, and the PDS foil itself disappeared within 25 weeks.6–8 In our own practice in recent years, in cases with severe septal deviations and ⁄ or aesthetic deformities, the preferred treatment of choice has become extracorporal septoplasty with the use of PDS foil. The aim of this paper was to report our experience with this surgical technique, the complications encountered during shortterm observation, and the degree of satisfaction of the patients with the functional and aesthetic results.

Correspondence: Dr Imre Gerlinger, Department of Otorhinolaryngology & Head and Neck Surgery, University of Pećs, H-7621 Pećs, Munkaćsy M. u. 2., Hungary, Tel.: +36 20 956 3601; fax: +36 72 325745; e-mail: [email protected], [email protected]

2007 The Authors Journal compilation 2007 Blackwell Publishing Ltd • Clinical Otolaryngology 32, 1–7

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Journal: COA CE: Bharathy

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No. of pages: 7 PE: Shyamala

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Correspondence

Patients and methods Participants

Between 1st January 2004 and 31st December 2006, 16 patients (11 females, five males) with an average age of 42 years (26–66 years) were admitted to the Department of Otolaryngology and Head and Neck Surgery at the University of Pećs, with nasal obstruction caused by an extreme septal deviation and ⁄ or an external nasal deformity (saddle nose, or a markedly deviated nasal pyramid). The most frequent reason for the nasal deformity was trauma. Prior to the surgical procedures, detailed anamnestic data were recorded and three-view photodocumentation was prepared in each case after anterior rhinoscopy and nasal endoscopy (30 endoscope). Depending on the degree of deformity of the nasal pyramid, every patient underwent either septo- and ⁄ or rhinoplasty via an external approach. The operations were performed under intratracheal narcosis following the local administration of lignocaine 1% and 1 ⁄ 80 000 adrenaline injection.

had been divided, the caudal edge of the septum was freed (Fig. 1). The mucosa of the septum was elevated subperichondrially on both sides, and the quadrangular cartilage was then separated from both the maxillary crest and the vomer. Following posterior chondrotomy, the dorsal edge of the nasal septum was separated from the attachment of the upper lateral cartilages, and the cartilaginous nasal septum was removed in one piece. The cartilaginous septum was placed onto a PDS foil (Ethicon Ltd., Budapest, Hungary), its contours were drawn, and the final shape of the graft for reimplantation was planned. On this basis, the PDS foil was cut with scissors and the septal cartilage was also cut into several straight pieces. When necessary, certain parts of the cartilage were made thinner, reshaped or scored. In an optimum case, the PDS foil was completely covered by the pieces of septal cartilage which were resutured (4 ⁄ 0 Vicril; Ethicon) to the foil. Attention was paid to achieving an appropriate height of the caudal

(a)

Outcome measures

The validated septorhinoplasty outcome questionnaire by Alsarraf 9 was completed by the patients. In this questionnaire, the patients were asked to provide information about their situation before the procedure in comparison with their present nasal state (six questions). Each question was scored on a scale from 0 to 4, with 0 and 4 reflecting the worst and best scores respectively. The scores for the six parameters were added together, divided by 24, and multiplied by 100, resulting in a satisfaction score on a scale of 100. In addition to the questionnaire, the patients were asked if they would choose to undergo the procedure again, knowing the final result.

(b)

Statistical analysis

Statistical analysis was performed with the non-parametric, paired t-test, values of P < .05 being taken to be statistically significant. Surgical technique

An inverted V-shaped incision was made in the middle of the columella, which was extended laterally in both nasal vestibula. The skin of the nasal dorsum was gently elevated subperichondrially from the lower lateral cartilages, the upper lateral cartilages and the cartilaginous edge of the nasal septum. After the soft tissue attachment connecting the medial crura of the lower lateral cartilages

1 Fig. 1. (a) Extreme deviation of the caudal end of the nasal septum. (b) The nasal septum is exposed with an open rhinoplasty approach.


LOW RESOLUTION COLOUR

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Correspondence

edge of the new nasal septum, with the new dorsal edge completely straight (Fig. 2). The graft, consisting of the PDS foil with the straight pieces of septal cartilage sutured onto it, was reimplanted between the mucoperichondrium sheets. The anteroinferior part of the graft was sutured to the nasal spine, while the dorsal edge of the graft was sutured to the upper lateral cartilages with two U-shaped stiches (4 ⁄ 0 nylon; Ethicon). To prevent the postoperative development of haematoma, the septal mucoperichondrium was anchored to the implanted graft with further trans-septal mattress sutures. In cases involving significant external nasal deformities, we removed the osseocartilaginous dorsal hump and performed lateral and medial-oblique osteotomies with a 2.0-mm osteotome. When required, deformities of the nasal tip were corrected by the resection of an appropriate amount of cartilage and suturing techniques. The


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(a)

(b)

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operations were completed with bilateral application of a loose-gauze tamponade, and an external splint was also placed on the dorsum. The tamponade was removed on the second, and the external splint on the fifth postoperative day. Neither septal splints nor postoperative antibiotics were applied routinely. Ethical consideration

The patients’ data were collected retrospectively. The study plan was reviewed and approved by our institutional ethical committee. Results Overall complication rates

None of the patients developed septal haematoma, rhinitis, sinusitis, abscess or necrosis of either the skin or the cartilage in the early postoperative period. During the first three postoperative weeks, an evenly widened septum was found in three patients, though this finding disappeared within a further fortnight. In one patient, a mild anterior epistaxis was observed in the second postoperative week, which resolved in response to conservative treatment. The mean of the periods during which these patients have been followed up is 11 months (4– 18 months). During the follow-up period, minimal roughness of the dorsum was observed in two cases. Neither subluxation nor septal perforation has developed in any of the patients. The intensity of crust formation was not higher in these patients than in those who had undergone traditional septoplasty before. Each patient reported a considerable improvement of the nasal breathing. Questionnaire study

Fig. 2. (a) The quadrangular cartilage is removed and cut into several straight pieces. Occasionally, thinning, reshaping and scoring were applied. (b) The final shape of the polydioxanone (PDS) foil and the straight cartilage pieces sutured onto it.

Of the 16 patients included in this study, 13 completed the questionnaire, and the remaining three patients were interviewed by phone. There was generally a significant improvement in the satisfaction score following the extracorporal septal reconstruction from a mean score of 38.4 ± 3.2 preoperatively to one of 66.8 ± 2.9 on average 11 months postoperatively (Fig. 3), with an improvement in the absolute score in 14 (88%) of the patients, and an unchanged level of satisfaction in two (12%). No worsening of the nasal condition was reported. Overall, 14 patients (88%) responded positively to the question of whether they would choose to undergo the same procedure again (Figs 4 and 5). The septorhinoplasty outcome may therefore be assessed as highly satisfactory.


4

Rhinoplasty outcome evaluation score (%)

100

Statistical analysis

90

Preoperative and postoperative satisfaction scores of the questionnaire on a scale of 100 for 16 patients revealed significant improvement as a result of extracorporal septal reconstruction: P < .001 (Fig. 3).

80 66.8 70 60

Discussion

PRE

50 38.4

POST

40

Problems with Killian’s submucosal septal resection

30

The surgical correction of septal deviations underwent a significant transformation during the past century. Killian reported on the technique of submucous septal resection in 1905, and that procedure predominated in septal surgery for decades.10 Then, from the 1960s, septoplasty, first suggested by Cottle et al. became increasingly popular.11 A number of clinical studies proved, that following Killian’s septal resection, septal perforation and an aesthetic deviation (saddle nose or

20 10 0

Fig 3. Preoperative (PRE) and postoperative (POST) scores of the questionnaire on a scale of 100 for 16 patients who had undergone extracorporal septal reconstruction. P < .001


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Correspondence

(a)

(b)

(c)

(d)

Fig. 4. Post-traumatic marked deformity of the nasal pyramid with significant septal deviation. (a) Preoperative front view; (b) preoperative inferior view; (c) postoperative front view; (d) postoperative inferior view. 2007 The Authors Journal compilation 2007 Blackwell Publishing Ltd • Clinical Otolaryngology 32, 1–7

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Correspondence

(a)

(b)

(c)

(d)

5

Fig. 5. Saddle nose and columellar retraction. (a) Preoperative side view; (b) preoperative inferior view; (c) postoperative side view; (d) postoperative inferior view.

columella retraction) develop relatively frequently. The nasal mucous membranes rather often become atrophic and the signs of metaplasia also occur quite frequently. Trembling of the frameless septum results in chronic obstructions in 10% of the cases.12,13 Disorders of the mucociliary transport, hypertrophy of the inferior turbinates and a constant watery nasal discharge (‘old man’s drip’) may occur with some frequency following Killian’s technique.12,13 A further disadvantage of this technique is that it cannot be carried out in childhood. Moreover, it is not an appropriate solution in cases of caudal or high septal deformities, or severe congenital and post-traumatic septal deviations.12,13 Problems with conventional septoplasty

It was recently pointed out by Mlynski that the long-term results of traditional septoplasty are not always satisfactory either.2 The causes may involve the following: (i) incorrect preoperative analysis of the nasal obstruction in the

absence of rhinomanometry, acoustic rhinometry and rhinoresistometry, when the real reason for an obstruction caused by mucosal swelling (e.g. an allergy) or other causes (e.g. undiagnosed chronic ethmoiditis) is not recognized; (ii) shaping of the new septum in the sagittal plane is a false approach; (iii) the septum should rather be located in the space between the inferior turbinates (which is not always the sagittal plane) so that the nasal cycle should remain undisturbed and (iv) surgical failures (neglect of two-point fixation of the septum, the absence of eight-shaped sutures, or an unsatisfactory columellar suture technique).1,2 Alternative techniques in septal surgery

During the past decade, although several clinical studies have been published on endoscopic, shaver-assisted and laser-assisted septoplasties, these methods have not gained wide popularity and, because their indication is rather limited, they can be applied only in cases of isolated deviations.14–16


6

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Correspondence

Strengths of the study

Acknowledgements

At our Department, the indication of extracorporal septal reconstruction is an extreme degree of congenital (Sshaped or V-shaped) or post-traumatic deviation, causing significant nasal obstruction. This technique can also be applied in the management of high-septal deviations, when the traditional methods can not guarantee a satisfactory result, or in cases of narrow nasal valves, when the procedure can be combined with spreader grafts.7,17 PDS foil is available in different sizes and in three different thicknesses (0.15, 0.25 and 0.50 mm). It is totally absorbed in the human organism after 25 weeks, as a consequence of the slow process of hydrolysis and later a complete metabolisation.7,17 Similarly to the nasal cartilage, the foil is flexible, though it can preserve its shape, and it can easily be sutured and fixed to nasal cartilage pieces. The use of autologous human cartilage would be a closer to ideal solution, but this material is not available in the required sizes. The application of allogenic grafts is not possible either, due to the transmission of blood-borne infections (hepatitis B and C, AIDS and Kreutzfeld-Jacob disease).6–8

The authors would like to thank Dr Sa´ra Jeges, Department of Bioanalytics, Medical School, Pećs University, Hungary for the statistical analysis.

Comparisons with other studies

The results of rabbit experiments have proved that, after the absorption of PDS foil, neither inflammation of the cartilage nor a foreign body reaction is observed and the incorporation of the cartilage proceeds undisturbed.6–8 When PDS foil is used, there is little chance of the cartilage pieces sliding on each other or of subluxation of the new septum. A further advantage of this method is that creation of the new septum follows the process during which the tension of the cartilage is eliminated and, with the pieces of septal cartilage sutured upon the PDS foil, a straight nasal dorsum can be shaped.17,18 During reimplantation, an ideal nasolabial angle can be formed. Further, in the event of a rare reoperation, the surgical preparation is easier. Certainly, the operation can also be performed by using the closed rhinoplasty technique, but we decided on the external approach to achieve better visibility and better aesthetic results, especially when operating on the bony pyramid. It should be highlighted that extracorporal septoplasty with the use of PDS foil nicely combines both the functional and the aesthetic approaches, which is a pre-requisite for the achievement of an excellent result.

References 1 Jones N.S. (1999) Principles for correcting the septum in septorhinoplasty: two-point fixation. J. Laryngol. Otol. 113, 405–412 2 Mlynski G. (2006) Surgery of the nasal septum. Facial Plast. Surg. 22, 223–229 3 King E.D. & Ashley F.L. (1952) The correction of the internally and externally deviated nose. Plast. Reconstr. Surg. 10, 116 4 Gubish W. (1995) The extracorporal septum plasty: A technique to correct difficult nasal deformities. Plast. Reconstr. Surg. 95, 672–676 5 Senyuva C., Yu¨cel A., Aydin Y. et al. (1997) Extracorporal septoplasty combined with open rhinoplasty. Aesth. Plast. Surg. 21, 233–239 6 Boenisch M., Hajas T. & Trenite N. (2003) Influence of polydioxanone foil on growing septal cartilage after surgery in an animal model. Arch. Facial Plast. Surg. 5, 316–319 7 Boenisch M. & Mink A. (2000) Clinical and histological results of septoplasty with a resorbable implant. Arch. Otolaryngol. Head Neck Surg. 126, 149–154 8 Boenisch M. & Nolst Trenite G. J. (2006) Reconstructive septal surgery. Facial Plast Surg. 22, 249–255 9 Alsarraf R. (2000) Outcomes research in facial plastic surgery: a review and new directions. Aesthetic Plast. Surg. 24, 192–197 10 Killian G. (1905) The submucosus window resection of the nasal septum. Ann. Otorhinolaryng. 14, 363 11 Cottle M.H., Loring R.M., Fischer G.G. et al. (1958) The maxilla-premaxilla approach to extensive nasal septum surgery. Arch. Otolaryngol. Head Neck Surg. 68, 301 12 Fjemedal O., Saunte C. & Pedersen S. (1988) Septoplasty and ⁄ or submucous resection? 5 years nasal septum operations. J. Laryngol. Otol. 102, 796–798 13 Haraldsson P., Nordemar H. & Anggard A. (1987) Long-term results after septal surgery – submucous resection versus septoplasty? ORL J. Otorhinolaryngol. Relat. Spec. 49, 218–222 14 Hwang P.H., Mclaughlin R.B., Lanza D.C. et al. (1999) Endoscopic septoplasty: indications, technique, and results. Otolaryngol. Head Neck Surg. 120, 678–681 15 Kamami Y.V., Pandraud L. & Bogara A. (2000) Laser assisted outpatient septoplasty: results in 703 patients. Otolaryngol. Head Neck Surg. 122, 445–449 16 Sousa A., Iniciarte L. & Levine H. (2005) Powered endoscopic nasal septal surgery. Acta Med. Port. 18, 249–255 17 Petropoulos I., Nolst Trenite G.J., Boenisch M. et al. (2006) External septal reconstruction with the use of polydioxanone foil: our experience. Eur. Arch. Otorhinolaryngol. 263, 1105–1108 18 Gomulinski L. (2006) The severely deviated septum – the way I solve the problem. Facial Plast Surg. 22, 240–248

Conflict of Interest

None to declare. 2007 The Authors Journal compilation 2007 Blackwell Publishing Ltd • Clinical Otolaryngology 32, 1–7

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