Braz J Otorhinolaryngol. 2016;82(4):403---407

www.bjorl.org

Brazilian Journal of

OTORHINOLARYNGOLOGY

ORIGINAL ARTICLE

Two-level septocolumellar suture technique forcorrection of septal caudal dislocation�

Nevzat Demirbileka, Cenk Evrena,∗, Mustafa Suphi Elbistanlıb, Uzay Altuna,Selda Sarikaya Günayc

a Department of Otolaryngology, Head and Neck Surgery, Medilife Beylikduzu Hospital, Istanbul, Turkeyb Department of Otolaryngology, Head and Neck Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkeyc Department of Otolaryngology, Head and Neck Surgery, Kemer Government Hospital, Antalya, Turkey

Received 13 May 2015; accepted 22 June 2015Available online 5 November 2015

KEYWORDSSeptal caudaldislocation;Septum fixation;New suture technique

AbstractIntroduction: Caudal septal dislocation is a respiratory and cosmetic problem. The correctionof caudal septal dislocation is a challenging issue. Although different modalities have beendescribed for the treatment, it is still controversial.Objectives: This study aims to describe a two-level suture technique which can be used tocorrect and stabilize the septum in the columellar pocket.Methods: The caudal septum was fixed to the nasal spine with suturing, and an anterior col-umellar pocket was formed. Two septocolumellar sutures including superior and inferior wereperformed to correct the dislocated caudal septum and to increase the stability of caudalseptum in the columellar pocket.Results: Anterior rhinoscopy showed no recurrent deviation or dislocation in our patients.Conclusion: Our suture technique is an effective and easy-to-use method to correct the cau-dal septal dislocation. It can also be used to increase the stability of corrected septum byother techniques. A two-level suture technique increases the success of correction and reducesthe risk of postoperative septal caudal luxation, stabilizing the superior portion of the caudalseptum, in particular. Therefore, it would reduce the rate of redo surgeries.

© 2015 Associacao Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial. Publishedby Elsevier Editora Ltda. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

� Please cite this article as: Demirbilek N, Evren C, Elbistanlı MS, Altun U, Günay SS. Two-level septocolumellar suture technique forcorrection of septal caudal dislocation. Braz J Otorhinolaryngol. 2016;82:403---7.

∗ Corresponding author.E-mail: drcenkevren@yahoo.com (C. Evren).

http://dx.doi.org/10.1016/j.bjorl.2015.06.0091808-8694/© 2015 Associacao Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial. Published by Elsevier Editora Ltda. This is an openaccess article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

404 Demirbilek N et al.

PALAVRAS-CHAVEDesvio septal caudal;Fixacão de septo;Nova técnica desutura

Técnica de sutura septocolumelar em dois níveis para correcão de desvio septalcaudal

ResumoIntroducão: O desvio septal caudal é um problema respiratório e estético, e a sua correcão étarefa desafiadora. Embora tenham sido descritas diferentes modalidades para o tratamento,esse é ainda um tópico controverso.Objetivos: O presente estudo objetivou descrever uma técnica de sutura em dois níveis, quepode ser empregada na correcão e estabilizacão do septo na bolsa columelar.Método: O septo caudal foi fixado à espinha nasal com suturas, após a realizacão de uma bolsacolumelar anterior. Duas suturas septocolumelares, superior e inferior, foram aplicadas para acorrecão do desvio septal caudal e, também, para maior estabilidade do septo caudal na bolsacolumelar.Resultados: Rinoscopia anterior não resultou em recorrência do desvio ou luxacão em nossospacientes.Conclusão: Nossa técnica de sutura é um método efetivo e de fácil uso para a correcão dodesvio septal caudal. A técnica também pode ser utilizada para aumentar a estabilidade deseptos corrigidos por outras técnicas. A técnica de sutura em dois níveis aumenta o sucessoda correcão e diminui o risco de luxacão septal caudal, estabilizando, em particular, a partesuperior do septo caudal. Portanto, nossa técnica diminui o percentual de reoperacões.© 2015 Associacao Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial. Publicadopor Elsevier Editora Ltda. Este e um artigo Open Access sob uma licenca CC BY (http://creativecommons.org/licenses/by/4.0/).

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ntroduction

orrection of septal caudal dislocation is a challenging prob-em for both the surgeon and the patient. Septal fixationo the nasal spine is a primary method for stabilizing theaudal septum. However, it can be complicated for a sur-eon with limited experience, while it can be unfeasibleor the nasal spine resection, even for an experienced sur-eon. Although it is stabilized, fixation can be inadequateue to damaged septal and nasal spine connections, therebyeading to postoperative luxation-induced re-deviation.1 Inddition, insufficient support or over-resection may cosmet-cally produce loss of tip projection, columellar retraction,nd supratip depression.1

The earliest and most common method for the correc-ion of septal caudal dislocation is Metzenbaum’s ‘‘swingingoor’’ (SD) technique. Using this technique, dislocated cau-al septum is shifted on the midline and fixed to nasalpine. In later years, Noorman published a modification ofhe SD technique which includes using maxillary crest as aoorstop after shifting of dislocated septum to the oppositeide of dislocation.2 Another method was described by Gold-an, in which cartilage scoring, resection and suturing stepsere defined. Furthermore, the modified Goldman tech-ique, which includes triangular cartilage resection fromislocated caudal septal cartilage and suturing steps wasescribed by Lawson.3

Two different suture techniques, which can be used botho correct the caudal septal dislocation and as a complemento previous fixation of cartilage to nasal spine techniquesy increasing the stability of caudal septum were published

n the literature. Batioglu et al.4 described a caudal septaluture technique that can be used single or complemen-ary to previous techniques, in which the caudal septum

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s sutured to the soft tissue between the medial cruraf the lower lateral cartilages by incising the midpoint ofhe columella skin from outside with non-absorbable sutureaterial. Kenyon et al.5 also described a technique that

ncludes fixation of the dislocated caudal septum in the col-mellar pocket with midpoint mattress suture.

In this study, we aimed to describe an easy way to cor-ect and increase the stability of the caudal septum inolumellar pocket by suturing it in two-level, thus preven-ing re-dislocation of the caudal septum.

ethods

his technique was performed between August 2010 anduly 2014. Our suture technique was used in patients under-oing septoplasty due to mild to moderate septal caudalislocation with or without nasal septal deviation of otherarts of the nasal septum. A total of 71 patients who under-ent septoplasty using the combined septocolumellar suture

echnique were enrolled. The study was approved by thethics in Research Committee of the institution, under pro-ocol 2014/246.

Patients with septal caudal dislocation have beenrouped as mild, moderate and severe depending on theegree of narrowing of the nares by dislocated caudal end ofasal septum. Dislocations narrowing the nares medially upo 25% were accepted as mild, from 25% to 50% as moderate,nd over 50% as severe.

Routine preoperative and pre-anesthesia examinations

single surgeon on all patients. Following 0.05% of oxymeta-oline hydrochloride administration to the nasal mucosa,idocaine and 1/100,000 of adrenaline were infiltrated.

Two-level septocolumellar suture technique for correcting septal caudal dislocation 405

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A unilateral hemi-transfixion incision to the anterior portionof the nasal septum was performed. The incision was per-formed through the dislocated side of the septum and2---3 mm posterior to the cauda. Both mucoperichondrialflaps were elevated and an appropriate technique for septalpathology was applied. L-strut was preserved to maintainthe structural function of the septum. The anterior sep-tum was freed from all mucosal connections. Deviationsof maxillary crest were corrected by excision or medialreplacement. Of note, excess cartilage in the caudal septalbase is resected. Other techniques including scoring, trian-gular cartilage resection or shifting the caudal septum tothe opposite side of dislocation were carried out. A tunnelbetween the medial crus of the alar cartilages was createdwith angled converse scissors or curved iris scissors. The sep-tum was initially re-attached to the maxillary spine througha 4.0 absorbable monofilament suture (Vicryl®, Ethicon Inc.,USA).

The cartilage was then prepared for superior septocol-umellar suture with a 4.0 absorbable monofilament suture(Vicryl®, Ethicon Inc., USA). First suture was placed supe-riorly. The needle first passed through the alar cartilageof incision side from lateral to medial 3 mm anterior tothe mucoperichondrial incision (Fig. 1A). The needle wasadvanced through the septal cartilage (Fig. 1B). The needlepassed through non-deviated, non-incised side mucoperi-chondrium from medial to lateral (Fig. 1C). Full-thicknesswas reinforced 2 mm posterior of the mucoperichondrialincision, the needle was removed at the contra mucoperi-chondrium and it was, then, tied (Fig. 1D).

Inferior septocolumellar suturing was performed with a

4.0 absorbable monofilament suture (Vicryl®, Ethicon Inc.,USA). The needle first passed through the alar cartilageof incision side from lateral to medial 3 mm anterior tothe mucoperichondrial incision (Fig. 2A). The needle was

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perior septocolumellar suture.

dvanced through the septal cartilage (Fig. 2B). The needleassed through non-deviated, non-incised side mucoperi-hondrium from medial to lateral (Fig. 2C). Full-thicknessas reinforced 2 mm posterior of the mucoperichondrial

ncision, the needle was removed at the contra mucoperi-hondrium and it was, then, tied (Fig. 2D and E).

Internal Doyle silicon splints were left in place for 2 daysn all cases.

esults

e performed this suturing technique on 71 septoplastyases during four years. Among them, 44 (62%) were malesnd 27 (38%) were females. Total follow-up period rangedetween 6 and 18 months. One patient (1.4%) had surgery-elated bleeding. Anterior packing was replaced in thisatient. Two patients (2.8%) had columellar indurationsithin the first week following surgery, resolved with antibi-tic pomade. Anterior rhinoscopy showed no recurrenteviation or dislocation. Total follow-up duration was 6onths in 29 patients, one year in 23 patients, and 18onths in 19 patients. Preoperative (Fig. 3A) and sixthonth postoperative (Fig. 3B) pictures of a patient oper-

ted with two level septocolumellar suture technique areeen.

iscussion

he nose, at the top of the respiratory system, is theost outwardly protruding and vulnerable part of the face.

herefore, it is the major organ which can be affected byaxillofacial injuries. Nearly 75---80% of the individuals had

ertain anatomical nasal deformities. Septoplasty is one ofhe major surgeries in the ear, nose, and throat practice.

406 Demirbilek N et al.

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s the most involved area is the anterior part of the nose,eptum should be robustly fixed during suturing at the endf surgery. Anterior septal deformity repair, in particular,s effective in preventing several complications includingupratip depression, columellar retraction, and expansionf the nasal base.1 Although a successful surgery can beerformed, insufficient fixation may yield undesirable out-omes. Our suture technique describes a way to fix caudaleptum between two columellar cruras. It can be used addi-ionally to SD or modified SD techniques.

In Metzenbaum’s popular SD technique, dislocated caudaleptum is shifted on the midline and fixed to nasal spine. Inater years, Noorman modified SD technique by using maxil-ary crest as a doorstop after shifting of dislocated septum tohe opposite side of dislocation.2 Both techniques are effec-ive to correct caudal dislocations; however, they may be

nadequate for selected cases or in cases in which maxillarypine must be removed and caudal septal fixation may not bedequate or sometimes impossible. Also, upper part of cau-al septum tends to dislocate following the procedure due

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ferior septocolumellar suture.

o insufficient support to this portion. In the present tech-ique with a two-level fixation, stability increased and theisk for dislocation decreased. In the modified SD technique,n the other hand, caudal septum part removed from thether side of maxillary spine may narrow the airway passage.hen combined with the SD technique, our suturing tech-

ique may yield to midway position of the caudal septumnd equal airway passages.

The Goldman technique includes scoring, resection anduturing components, while the modified Goldman tech-ique requires triangle shaped cartilage excision from theislocated portion of caudal septum and suturing the sep-um to maxillary spine.3 These techniques may help toeduce nasal tip support and columellar retraction due toartilage excision. In a study including 68 patients withaudal septal deviation, Batioglu et al.4 performed a point

ncision into the columellar midpoint following septoplastynd formed a columellar pocket. The incision was ceasedsing inside-to-outside suturing technique and carried oututside-to-inside suturing onto the midpoint incision site.

Two-level septocolumellar suture technique for correcting septa

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Finally, the caudal tip of the septum was knotted in the col-umellar pocket. A 3.0 non-absorbable monofilament suturewas used. They described dimple-shaped shrinkage on thecolumellar skin after the procedure. Although they reportthat this shrinkage disappeared within the first month andcomplete epithelization was achieved, this condition maybecome uncomfortable for the patient. In addition, as thistechnique includes a midpoint skin incision to columella, itmay cause scarring. A non-absorbable suture material usedin this technique may yield to suture material reaction inthe long-term, even. Furthermore, burying the suture to softtissue between medial cruras of the lower lateral cartilagesmay be challenging in unexperienced hands. Unless it is notperformed alone, one-level fixation may not be sufficient toprevent re-deviation. Our technique uses absorbable suturematerials without any skin incisions. Since it is performedlayer by layer, it is very easy to learn and to perform. Two-level fixation may overcome the limitations of one-levelfixation.

In another study, Kenyon et al.5 described mattress suturetechniques in septal dislocation. A mattress suture in theincision site was used to fix the septum to open the full-thickness columellar pocket with a Kenyon suture technique.An absorbable suture such as 3.0 VicrlyRapide® was used.In this technique, septum is fixed in one level and mat-tress suture is performed through all three medial crura,septum, medial crura layers at one prick. However, it maybe difficult to adjust the position of the caudal septum in

the columellar pocket. In addition, it can only stabilize theseptum vertically and when performed alone it may be inad-equate for fixation, as it is a mattress suture and performedat one level. In our technique, backward movement of the

6

l caudal dislocation 407

eedle was started 2 mm posterior to first outward incision,hereby, horizontally stabilizing the septum. Furthermore,wo-level suturing vertically fixates the caudal septum. Weelieve that layered advancing of the needle through theartilages is easier even for inexperienced surgeons.

We did not perform nasal spirometry, acoustic rhinometryr radiological staging of nasal septal deviations to evalu-te the severity of nasal septal deviation of the patients. Its a limitation to this study in objective patient selection.ecause Mladina Classification6 does not give informationbout the severity of the septal caudal dislocation we didot use it in the selection of patients as mild or moder-te. We selected patients as mild or moderate depending onnferior appearance of dislocated caudal septum. We usedhe degree of narrowing of the nares by the caudal endf dislocated septum. Patients accepted as severe caudalislocation thought to be difficult to be evaluated by ourechnique and they were operated as open septoplasty oreptorhinoplasty.

onclusion

n conclusion, we suggest that two-level septocolumellaruturing is an effective and easy-to-use technique in thexation of mild to moderate caudal septal deviations, sup-orting the nasal tip and preserving its symmetry. It doesot require cartilage resection, thus preventing nasal tipupport loss. In combination with the SD, modified SD, Gold-an and modified Goldman techniques offer an advantage.ased on our current experience, it can yield considerableunctional and cosmetic outcomes in the treatment of cau-al septal dislocations. In addition, it is unlikely to lead tony scar or require septal support and it prevents nasal tipomplications.

onflicts of interest

he authors declare no conflicts of interest.

eferences

. Bloom JD, Kaplan SE, Bleier BS, Goldstein SA. Septoplastycomplications: avoidance and management. Otolaryngol ClinNorth Am. 2009;42:463---81.

. Pastorek NJ, Becker DG. Treating the caudal septal deflection.Arch Facial Plast Surg. 2000;2:217---20.

. Lawson WL, Westreich R. Correction of caudal deflections of thenasal septum with a modified Goldman septoplasty technique:how we do it. Ear Nose Throat J. 2007;86:617---20.

. Batioglu-Karaaltin A, Yigit O, Donmez Z. A new persistent suturetechnique for correction of caudal septal dislocation. J CraniofacSurg. 2014;25:2169---71.

. Kenyon GS, Kalan A, Jones NS. Columelloplasty: a new suture

technique to correct caudal septal cartilage dislocation. ClinOtolaryngol Allied Sci. 2002;27:188---91.

. Mladina R. The role of maxillar morphology in the developmentof pathological septal deformities. Rhinology. 1987;25:199---205.