Extracorporal septal reconstruction with polydioxanone foil
Gerlinger, I.,* Kárász, T.,* Somogyvári, K.,* Szanyi, I.,*Ráth, G.,* Móricz, P.,* &
Boenish, M.†
*Department of Otorhinolaryngology, University of Pécs, Pécs, 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 Pécs, H-7621 Pécs, Munkácsy
M. u. 2., Hungary, Tel.: +36 20 956 3601; fax: +36 72 325745; e-mail:
i.gerlinger@freemail.hu, gerlingerimre@hotmail.com
2007 The Authors
Journal compilation 2007 Blackwell Publishing Ltd • Clinical Otolaryngology 32, 1–7
C O A
Journal Name
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Manuscript No.
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Dispatch: 30.9.07
Journal: COA CE: Bharathy
Author Received:
No. of pages: 7 PE: Shyamala
C O R R E S P O N D E N C E: H O W W E D O I T
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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 Pécs, 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.
2007 The Authors
Journal compilation 2007 Blackwell Publishing Ltd • Clinical Otolaryngology 32, 1–7
LOW RESOLUTION COLOUR
2
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
LOW RESOLUTION COLOUR
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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.
2007 The Authors
Journal compilation 2007 Blackwell Publishing Ltd • Clinical Otolaryngology 32, 1–7
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
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Discussion
PRE
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38.4
POST
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Problems with Killian’s submucosal septal resection
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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
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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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LOW RESOLUTION COLOUR
Correspondence
(a)
(b)
(c)
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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
2007 The Authors
Journal compilation 2007 Blackwell Publishing Ltd • Clinical Otolaryngology 32, 1–7
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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 Sára Jeges, Department of Bioanalytics, Medical School, Pécs 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., Yücel 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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