The authors generally use intranasal incisions for a deviated nose but will frequently use the open or external rhinoplasty technique when there are severe asymmetries, deviations, and tissue deficiencies.^2,⁵^–⁷ Some of the indications for use of the external rhinoplasty are as follows: (1) a nasal deformity that is difficult to precisely analyze; (2) one in which there is severe asymmetry of the lateral bony walls and the lower lateral cartilages; (3) when tissue deficiencies exist so that it is necessary to precisely place and suture implants in position⁸; (4) congenital anomalies such as the cleft-lip nose or other deformities in which profound asymmetries exist; (5) an extremely wide bony and cartilaginous dorsum, whether or not a hump is removed; and (6) for teaching purposes. The external approach involves a transverse midcolumella incision in a gull-wing curve rather than one with sharp angle. The authors use the gull-wing incision as opposed to the inverted gull-wing incision to create a single point rather than two points at the distal end of this diffuse random pattern flap. The incision is then extended upward along the caudal edge of the medial crus and laterally along the caudal margin of the lateral crus as an alar cartilage margin incision (Fig. 37-1). The elevation is initiated with sharp knife dissection, with the columella skin being elevated before the elevation is extended laterally over the lateral crura of the lower lateral cartilages. The external incision crossing the columella leaves a barely perceptible scar and offers excellent visualization by means of the “degloving” of the nose.

Figure 37-1. The external (open) approach. A, A gull-wing incision is made, crossing the columella just above the flare of the feet of the medial crura and then extending upward along the caudal edge of the medial crura and into marginal incisions laterally with the surgical knife. The skin is further elevated with the Stevens tenotomy scissors. B, Excellent exposure can be obtained to the root of the nose, which assists in evaluating asymmetry of the dorsum. The caudal septum and anterior nasal spine can be approached through the external approach, or a separate hemitransfixion incision may be made as shown by the dashed line.

Septal and Columella Modifications

It is impossible to discuss correction of the difficult nasal deformity without addressing surgery of the involved septum. The specific techniques required are determined by the amount of cartilage that remains and how angulated or dislocated it is. The septum must be considered as an ideal donor site for cartilage and bone implants. When adequate material is available, it is an excellent implant for the nasal dorsum, a columella strut, a shield implant to the tip, a filler for depressions in the area of the upper lateral cartilages, and for creating spreader and batten grafts. Once the incisions are made, elevation of the mucoperichondrial flaps is frequently difficult because of fibrosis through fracture sites and overlapping or lamination of the cartilage itself. In the previously operated nose, a practical approach involves beginning the elevation of the mucoperichondrium beneath the dorsum, because this area is often previously undisturbed. The elevation then proceeds downward toward the previous operative site, where cartilage and bone may have been removed.

For the severely deviated or previously operated nose, it is usually necessary to elevate the mucoperichondrium on both sides of the septal cartilage, although it is preferable whenever possible to leave it attached on one side as the bone and cartilaginous angulations are corrected. Freeing fibrous contractions and septal angulations is essential in allowing the septal framework to straighten. The extent to which cartilage and bone must be removed or repositioned is dictated by the particular deformity encountered and the direction of the angulations. Generally, scoring or removal of thin strips of cartilage along the existing angulations is required to achieve straightening (Fig. 37-2). Release of all tension vectors allows a buckled septum to straighten. Determination of the final position of the septum may not be possible until osteotomies have been performed, particularly if the nasal bones and upper lateral cartilages are severely deviated from the midline. A final determination of what more, if anything, needs to be done to the septum, therefore, must sometimes await the completion of medial and lateral osteotomies, when the entire nose is positioned in the midline (Fig. 37-3) regarding deviations of the central bony complex).

Figure 37-2. Correcting septal curvature. A, Vertical shave to reduce septal thickening. The shave may also be used to reduce bowing. B, Removal of cartilage wedges to straighten the septum in the midline. C, Scoring to allow the cartilage to open and return to the midline.

Figure 37-3. Correction of central component deviation. For deviations of the entire root of the nose or the remaining central component of the nose, it is necessary to establish a firm fulcrum with the osteotome to fracture this central portion toward the midline. This difficult maneuver requires a complete medial osteotomy paralleling the septum as close as possible, as opposed to the fading medial osteotomy.

Transseptal coaptation sutures, which bring the two mucoperichondrial flaps together and pass between angulations or cartilage pedicles to prevent overlap, are great aids in this surgery (Fig. 37-4). Polyethylene splints have been used for a number of years to stabilize the septum in the early postoperative period and to prevent the development of synechiae, particularly when turbinate surgery has been performed. Two through-and-through sutures are always placed through the polyethylene splints. The sutures are placed so that one arm of the suture goes between cartilage pedicles or beneath the septal cartilage for support. The second arm of the suture goes back through the mucoperichondrium and cartilage. One may splint the septum further at a major angulation with a straight portion of thin perpendicular plate of the ethmoid.

Figure 37-4. Coaptation sutures. Further modifications of the septal reconstruction in which it has been necessary to remove a significant amount of cartilage and bone. Coaptation sutures may be either single sutures through and through the mucoperichondrium or a continuous suture passed back and forth through and through and tied to the original free end.

Caudal Repositioning

When it is necessary to reposition the caudal portion of the septum, it is usually necessary to free the mucoperichondrium on both sides to release all extrinsic tension on the cartilage. The septal cartilage is then detached from the underlying anterior nasal spine and maxillary crest. Intrinsic tension of the septum is relieved by scoring, cross-hatching, and wedging. Once this caudal pedicle is freed of the tension vectors, it may be maintained in the midline by sutures that go around the anterior spine or through a burr hole in the spine (Fig. 37-5). To further prevent dislocation, an additional suture may be passed through the two mucoperichondrial flaps and between the bone of the spine and the cartilage. The cartilage pedicle is attached directly to the spine for alignment, and the two mucoperichondrial flaps when sutured together add further stability. When necessary, the caudal edge of the septum may be held in proper relation to the columella with interrupted sutures or direct through-and-through septocolumellar sutures (Fig. 37-6).

Figure 37-5. Repositioning and suturing of the caudal septum. The dislocated septum is repositioned on the anterior spine and maxillary crest. Reconstruction is augmented by scoring or cross-hatching and proper placement of sutures such that one suture is passed submucosally around the anterior spine. The next fixation suture is passed through one mucoperichondrial flap, between the bone of the anterior spine and the septal cartilage and out through the mucoperichondrium on the other side, and then back through flap, septum, and flap to complete the loop. The other sutures are passed between the mucoperichondrial flaps and between the cartilage pedicles to prevent dislocation.

Figure 37-6. Stabilization of the caudal septum with draw sutures through the center of the columella, reestablishing the septocolumellar relationship. At the end of the procedure, the draw sutures may be removed or may be tied loosely against the columellar skin.

Shortening the Caudal Septum

For the deformed nose with a drooping tip and columella retraction, the entire septocolumellar complex must be critically evaluated. In correcting the drooping tip, the lower lateral cartilages must be rotated cephalically, and strong tip support is needed. Both the caudal septum and the soft tissue may need modification to achieve this (Fig. 37-7). Frequently, there is an associated columella retraction, resulting in an acute nasolabial angle. Correction of the retraction requires straightening the caudal septum and placement of a columellar strut or a plumping graft (Fig. 37-8). Some limited resection of the caudal edge of the septum may be necessary to remove a portion of deformed septum that is dislocated off the anterior spine and projecting into one nostril. When the caudal edge of the septal cartilage is severely dislocated, it often creates distortion and retraction of the columella, even though adequate cartilage is present. Straightening and repositioning of the caudal septum within the columella sometimes corrects the retraction (Fig. 37-9). Rarely is it necessary to shorten the upper lateral cartilages, although reduction of the scroll along their caudal border may be necessary to reduce excessive width in that area.

Figure 37-7. Modifications for shortening the nose. A, Ideal limited shortening and elevation of the tip involving only the outer one third to one half of the caudal septum and limited transfixion incision. B, Shortening of the entire caudal septum with slight angulation extending to the spine. C, Shortening of the entire caudal inferior nose with a deepening of the nasolabial angle. The obtuse nasolabial angle is corrected. A right-angle wedge of bone is removed from the anterior spine, and a suture is passed from the cartilage to the base of the membranous columella, reinforcing the angulation and eliminating the dead space.

Figure 37-8. Correction of acute septolabial angle. A, The columella strut adds columellar fullness. B, When the columella strut is not required, a simple plumping graft serves as a filler and gives support to the feet of the medial crura. An implant may be necessary over the face of the maxilla and beneath the anterior spine to create fullness of the lip portion.

Figure 37-9. Correction of columella retraction. A, Marked columella retraction and drooping tip (preoperative). B, After septal reconstruction with tip rotation and columella filling.

Making the Final Septal Assessment

It is not until all septal reconstructive surgery and the osteotomies are completed that the final analysis of the position of the septum can be made. This position is particularly critical at the junction of the bony and cartilaginous portions of the nose, both internally and externally. At this point, the surgeon can determine whether adequate dorsal support has been maintained. If there is any tendency for the cartilaginous dorsum to sink inward, a draw suture can be passed through the skin to pick up either the septum alone or the upper lateral cartilages and the septum along the dorsum (Fig. 37-10). The suture is passed upward through the skin and held in position while all coapting and supporting sutures are placed and packing is completed. The draw suture can then be removed. In extreme cases, the draw suture can be passed through a thin external splint and tied over a bolus to remain in place for a week until the splint is removed.

Figure 37-10. Dorsal draw suture. If there is loss of support either from injury or surgery at the junction of the septal cartilage with the nasal bones and perpendicular plate of the ethmoid, the remaining caudal septum tilts downward (arrow). A draw suture may be passed through the skin of the dorsum of the nose and then used to pick up either the septum alone or the septum with the upper lateral cartilages. The draw suture is then passed through a soft thin metal nasal splint and tied over a bolus. Dorsal draw sutures may be used simply to maintain the position and support while all intranasal surgery is completed and the nose is packed. The sutures are then removed. When necessary, the sutures may remain in position for one week and are removed with the splint.

The Septocolumellar Complex

The columella and caudal septum must often be addressed in rhinoplasty. There may be columellar retraction caused by retraction of the caudal septum or there may be other abnormalities of the septum and columella that distract from the appearance of the nose. Ptotic lower lateral cartilages with a convex caudal margin can cause increased columellar show. This may be exacerbated by a prominent caudal margin of the septum and/or an excessive membranous septum.

These deformities can be addressed by trimming or sculpturing the medial crura and caudal septum as demonstrated in Fig. 37-11. Other structures that may contribute to the perceived or actual abnormalities of the caudal septum and columella include either ptosis of the lateral crus of the lower lateral cartilage, causing what appears to be a retracted columella, or retraction of the ala, resulting in excessive columella show (Fig. 37-12). These abnormalities must be corrected when addressing the lower lateral cartilages, either through reduction or augmentation (Fig. 37-13). Repositioning of the anterior maxillary spine, division of the depressor nasi musculi, sectioning of the frenulum, and defatting or augmentation of the nasolabial angle may also be necessary when addressing the caudal septum and columella.⁹