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Research Article Journal of Otolaryngology and Reconstructive Surgery
Nasal Valve Stabilization in Extracorporeal Septoplasty
Ignazio Tasca1, Ceroni Compadretti Giacomo1, Tomas Losano1*, Carlos Boccio2 and Yesica Lijdens2
1
Department of Otorhinolaryngology, Imola Hospital, Imola (BO), Italy
2
Department of Otorhinolaryngology, Italian Hospital of Buenos Aires, Argentina
Received Date: January 18, 2016, Accepted Date: February 12, 2016, Published Date: February 22, 2016.
*Corresponding author: Tomas Losano, Department of Otorhinolaryngology, Imola Hospital, Via Montericco 4, 40026 Imola (BO), Italy, Tel: 393-356-663-460;
Fax: 3905-4266-228; E-mail: losano.tomas.ignacio@gmail.com
Abstract
Background: Among the different operations for septoplasty, the
extracorporeal septoplasty technique basically consists in the removal
of all the nasal septum, the correction of bone and cartilage deformities,
and their replacement with a particular suture technique to correct the
markedly deviated nasal septum especially in the internal nasal valve
area. The drawbacks of this surgery technique are as follows: swelling of
the mucosa in the valve area and restenosis, the development of saddle
nose and septal hematoma. The aim of this study is to describe our results
with a modified suture technique of the extracorporeal septoplasty (ECS),
taking into account the operative time and functional results.
Patients and Methods: A retrospective chart review of 133 adult
patients treated with extracorporeal septoplasty from January 2011
to December 2013 was performed in a primary care centre in Imola
city, Italy. Preoperative and postoperative evaluations were done using
rhinomanometry and acoustic rhinometry. Statistical Analysis was
performed with commercially available software (IBM SPSS Statistics
for Windows, Version 21.0. Armonk, NY: IBM Corp.).
Results: We followed up a total of 133 cases in our centre. Three
patients (2.25%) had to be re-operated on due to impaired nasal patency.
A statistically significant improvement was evident after surgery based
on the rhinomanometric and acoustic rhinometric outcomes.
Conclusions: Nasal valve stabilization in extracorporeal septoplasty
is a successful surgical technique for anterior deviations of the septum,
with an optimal surgery time and a reproductible surgical technique.
Keywords: Extracorporeal Septoplasty; Suture Technique; Rhinoma-
nometry; Acoustic Rhinometry; Deviated Septum; Nasal Valve Area
Introduction
The nasal septal deviation is a common disorder in otolaryngology
and one of the major causes of nasal obstruction. In some cases, septal
deviation is non-symptomatic, but in a high number of patients it
causes functional disturbance. The degree of septal deviation affects
the severity of symptoms so as severe nasal obstruction strongly
affects patients’ quality of life [1]. Ever since Killian and Freer
introduced the concept of the submucous resection, the technique
has been gradually developed by many operators sustainably and
scientifically. In the last century, there have been significant advances
regarding surgical septal procedures [2,3].
In patients with a mild or moderate deviation of the septum,
traditional techniques of septoplasty are effective to improve nasal
breathing. On the other hand, in severe anterior deformities, usually
associated with stenosis of the nasal valve, these methods have
unsatisfying results and sometimes can cause functional problems
due to over resection or over weakening of the cartilage [4].
In case of severe anterior deformities of the septum, with
compromise of the valve area, the removal of the whole septum,
followed by extracorporeal reconstruction and reinsertion is
recommended [5]. In cases of severe septal deviation, Gubisch
advised total quadrangular cartilage extraction, external
reconstruction of the septal framework, and reinsertion in the
J Oto Rec Surg ISSN: 2470-1041
Copyright: © 2016 Tasca I, et al.
Open Access
mucopericon- drial pocket. Fixation of the reconstructed septum to
the anterior nasal spine and to the upper lateral cartilages avoided
saddling and relapse of the deviation.
The main drawback of extracorporeal septoplasty is the
destabilization of the junction of the quadrilateral cartilage and
nasal bones with the subsequent alteration of the dorsal contour. In
this study, we aim to define a personal modified suture technique.
The philosophy of which, is to support the quadrangular cartilage
inserted and stabilized the valve area in order to minimize the risk
of alteration of the dorsal contour and prevent the restenosis in the
valve area.
Patients and Methods
Between January 2011 and December 2013, we retrospectively
reviewed the medical records of all patients treated by an
extracorporeal septoplasty in Imola Hospital, Italy. The Institutional
Review Board of the Hospital approved this retrospective study.
We included patients that were followed up in our centre and
had a middle to sever anterior (Cottle’s areas I and II principally)
structural nasal patency impairment, with nasal valve affectation,
based on the rhinomanometric results and anterior rhinoscopy.
The information regarding perioperative data including
patient demographics, preoperative data, side of the nasal patency
impairment, diagnostic studies, operative details, postoperative
outcomes and complications was obtained. The side of the nasal
obstruction was determined by anterior rhinoscopy. The nasal
patency was assessed using Anterior Active Rhinomanometry (AAR)
with Rhinopocket® rhinomanometer and acoustic rhinometry (AR)
[6-7]. We performed both examinations, before and after surgery
during the follow-up period, based on the Consensus report on
acoustic rhinometry and rhinomanometry [8].
According to our clinic normative, we considered a range
of 0.25-0.50 Pa/cm3/s as normal rhinomanometric result. The
resistance is determined at a pressure of 150 Pa. Data was acquired
at a flow/pressure display. The AR software provides minimal
cross-sectional areas in two separate points: the first minimal
cross-sectional area (MCA 1) from 10 mm to 32 mm of the nostril,
and the second minimal cross-sectional area (MCA 2) which is
located from 32 mm to 64 mm of the nostril. A median MCA1 value
of 0.73 cm2 (range 0.57–1.45 cm2) was considered a normal result.
Preoperatively, AAR and AR were performed in basal condition,
after decongestion and after dilatation.
The surgery outcome was evaluated by comparing pre
and postoperative baseline investigation results taking into
consideration the average results of the follow up done 3, 6 and 12
months after the surgical intervention. All examinations were done
by the same operator after a 15-minute period of acclimatization.
Surgical Technique
All the procedures are performed by an endonasal approach
with general anesthesia and orotracheal intubation. The surgical
Page 1 of 5
J Oto Rec Surg ISSN: 2470-1041 Vol. 2. Issue. 1. 31000112

sides are infiltrated using 1 % lidocaine with epinephrine 1:100,000 2. Midline suture: as the main point of fixation it gives support
before the operation. to the middle nasal vault so as to avoid nasal dorsal collapse.
The septum is approached through a caudal septal incision on 3. L-inverted suture: approximates the nasal mucosa in the
the right side, with Cottle hemitransfixion incision, 1-2 mm from valve area in order to prevent from dead space (risk of
the caudal margin, cutting the pericondrium completely. The caudal haematoma) and to further stabilize the replanted septum
margin of the septal cartilage should be completely exposed using (Figure 4).
suction dissector with careful movements. Once the caudal margin
is exposed, the surgeon starts to create the anterior tunnels along The hemitransfixion incision is closed, suturing the septum and
the subperichondral avascular plane. columella with mattress sutures. Closure of the hemitransfixion
incision is performed using 3-0 Vicryl suture with a 6 cm straight
Then, the creation of the magic plane is made with the needle.
Knapp scissors introduced through the hemitransfixion incision
immediately under the membranous septum and into the crural
connective tissue, with small spreading movements. That is how
a small anterior pocket to the anterior nasal spine is created. The
pre-spinal connective fibers are then incised along the axis running
from the cartilaginous septum to the spine, thus exposing the nasal
spine, the anterior-inferior septal angle, and the medial portion of
the inferior margin of the pyriform aperture.
Subperiosteal inferior tunnels are then created along the floor
of the nasal cavities. After joining these tunnels the septal space
is exposed, allowing a general view of the whole septum and Figure 2: Graft tethered to the muco-pericondral flap
its bony framework. With the aid of a nasal speculum, the entire
anterior septum can be visualized from vault to floor. The entire
quadrangular cartilage was surgically removed leaving only a small
3 mm strip of cartilage close to the keystone area (Figure 1).
Once the septal bony structures have been removed, nasal
packing is inserted. We use Lyofoam® in 2-3 × 10 cm strips. These
have been placed in the nasal cavities and pushed posteriorly
toward the nasopharynx and into the nasal cavity up to the attic.
Packing keeps the crushed bone and/or cartilage fragments
repositioned during posterior reconstruction.
Reconstruction prevents from dystrophic sequelae which
may in turn lead to a flaccid septum and even to a possible septal
perforation or prolapse of the turbinates.
The most regular, defect-free area of the quadrangular cartilage
(which has been previously removed) is trimmed and shaped into a Figure 3: Suture should be under the quadrangular cartilage inserted
rectangle; in some cases this may include part of the perpendicular
plate. The graft is tethered to the mucopericondrial flap with
polyglactin 910 suture 3/0 (Vycril®) (Figure 2).
Cartilage graft fixation is accomplished by a 3-point suture
using 3-0 Vicryl suture:
1. Inferior: mucosa-to-mucosa suture prevents the neoseptum
from slipping out of the midline to the nasal floor, it goes
under the quadrangular cartilage (Figure 3).

Figure 1: Quadrangular cartilage with ethmoid bone Figure 4: L- inverted suture to stabilize valve area

Citation: Tasca I, Compadretti GC, Losano T, Boccio C, Lijdens Y (2016) Nasal Valve Stabilization in Extracorporeal Septo- Page 2 of 5
plasty. J Oto Rec Surg 2(1): 112.
J Oto Rec Surg ISSN: 2470-1041 Vol. 2. Issue. 1. 31000112

Synthetic packing is left in the nasal fossae for two days to ensure (2.25%) had to be reoperated on due to impaired nasal patency.
the flap adheres, prevent septal hematoma and displacement of the Neither saddling of the dorsum nor irregular contour of it
inserted fragments. was observed in the postoperative period. Follow-up ranged
from 3 to 18 months (mean, 12 months). All patients stayed,
Statistical Analysis
hospitalized for 48 hours. The nasal photographs of patients in
In the descriptive analysis, quantitative variables with normal the base view, before and at least six months after surgery were
distribution were expressed with means and standard deviation evaluated (Figure 5,6).
and the ones with abnormal distribution with medians and range;
whereas qualitative categorical variables were summarized as An average of the postoperative results obtained at month 3, 6
frequency and percentage. Preoperative nasal resistance obtained and 12 was made (Table 2). A statistically significant improvement
by AAR and nasal cross sectional areas obtained by AR were was evident after surgery based on the rhinomanometric and
compared with postoperative results using the non-parametric acoustic rhinometric outcomes.
Wilcoxon Sign Rank test. Differences were considered significant
at a p value of <0.05. Statistical Analysis was performed with Discussion
commercially available software (IBM SPSS Statistics for Windows, Severe deviations of the nasal septum, especially when the
Version 21.0. Armonk, NY: IBM Corp.). anterior and/or superior parts of the quadrangular cartilage are
involved, represent one of the most difficult challenges for nasal
Results
surgeons. Removal of the deviated segments, as prescribed in
A total of 133 adult patients treated with extracorporeal
septoplasty were enrolled in this study. Patient characteristics
are summarized in table 1. Surgeries were done by five different
surgeons of the ENT department with a median operating time of
42 minutes (range, 20-58min).
No intraoperative complications were reported. Early
complications included septal hematoma in one patient (0.75%)
which requires drainage in the outpatient clinic. Three patients

Variable N = 133
Male, n(%) 109 (82)
Age, mean (SD), years 41.76 (15)
Previously treated, n (%) 27 (20.3)
Side affected, n(%)
Right nostril 37 (27.8)
Left nostril 46 (34.6)
Bilateral 50 (37.6)
Kind of rhinomanometric impairment n(%)
Structural 41 (30.82)
Mixed 92 (69.7)
Figure 5: Preoperative Images
Table 1: Patient characteristics

Variable Preoperative Postoperative p

AAR Pa/cm3/s median (range)
Baseline right nostril
Inspiration 0.74 (0.00-61.00) 0.27 (0.00-1.77) 0.0001
Expiration 0.61 (0.00-28.40) 0.00 (0.00-1.29) 0.0001
Baseline left nostril
Inspiration 1.14 (0.00-240.00) 0.26 (0.00-2.44) 0.0001
Expiration 1.00 (0.00-553.0) 0.00 (0.00-1.75) 0.0001
AR cm2 median (range)
Baseline right nostril
MCA 1 0.32 (0.08-0.96) 0.44 (0.16-2.08) 0.0001
MCA 2 0.31 (0.03-1.11) 0.50 (0.14-1.13) 0.0001
Baseline left nostril
MCA 1 0.32 (0.05-0.87) 0.38 (0.09-1.94) 0.002
MCA 2 0.28 (0.04-0.96) 0.41 (0.13-0.93) 0.0001

Table 2: Comparative preoperative and postoperative baseline investiga-

tion results
AAR indicates Active Anterior Rhinomanometry; AR- Acoustic Rhinometry;
MCA 1- the first Minimal Cross-sectional Area; MCA 2- the Second Minimal Figure 6: postoperative - six months later
Cross-sectional Area

Citation: Tasca I, Compadretti GC, Losano T, Boccio C, Lijdens Y (2016) Nasal Valve Stabilization in Extracorporeal Septo- Page 3 of 5
plasty. J Oto Rec Surg 2(1): 112.
J Oto Rec Surg ISSN: 2470-1041
Cottle’s classic technique, will often lead to total or near-total
cartilage resection resulting in postoperative saddling of the
middle vault, internal valve collapse, and/or posterior relapse of
the septal deviation due to lack of support. Simple replacement of
the cartilage segments between the two mucoperichondral layers,
as suggested by other authors, is a highly imprecise maneuver that
fails to reinforce the anterior and superior part of the septum and
may create postoperative reduplication of the cartilage with nasal
obstruction.
Nowadays there is not a standard treatment for all types of
nasal deformities. Techniques such as suture, swinging door,
septal batten, ethmoid bone sandwich graft, tongue-in-groove, and
extracorporeal septoplasty have been used in managing caudal
septal deviation [5,9-12]. The broad range of approaches illustrates
the difficulty in treating caudal septal deviation and this is the
reason why we consider, there is no doubt regarding the need to
obtain pre and postoperative rhinometric measures if objective
results in septal surgery are to be achieved.
Various techniques have been proposed for the correction of
caudal septal dislocations and deviations. General logic of these
techniques is repositioning and suturing the structures to fix the
caudal septal deformity. The mobilization of the caudal septum to
the midline and anchoring the newly shortened caudal segment
with a figure of eight suture to the nasal spine in a ‘‘swinging
door’’ fashion is defined by, Akduman [13]. Galloway [14], reported
advancing the caudal septal cartilage into columella. The placement
of the caudal septum into the groove between the medial crura to
hold it in place as ‘‘Tongue in Groove’’ technique is defined by Kridel
[10].
In the present study, we showed that the anterior deviation was
corrected successfully and objective improvement was achieved
with our new “3 point suture valve technique”. In our experience,
this technique has several advantages over other corrective
techniques for caudal septal deviation. It preserves a major part
of the cartilage; the conservative remodeling of the quadrangular
cartilage allows the use of septal cartilage grafts in secondary or
revision rhinoplasty and is useful for the simultaneous correction
of caudal deviation of the external nose and nasal obstruction. This
technique completely avoids the cartilage memory from bending
and is a secure technique for the valve area. Therefore, an immediate
intraoperative check-up of the straightening of the caudal septum is
possible, and there is low risk of deviation recurrence, which is a
major issue because the cartilage has a strong tendency to return
to its original shape.
The drawbacks of this procedure are the swelling of the
mucosa, restenosis of the nasal valve area, septal hematoma and
saddle nose development. They can be avoid by a correct suture
technique to straighten the mucosa, especially in the valve area and
give support to the nasal cartilage replaced in order to avoid saddle
nose development.
The operative time that we measure in the study is also a strong
point. Hardy et al.[15], in a cohort of 1753 patients who underwent
a broad range of complex plastic surgical procedures concluded
that surgery duration is an independent predictor of complications,
with a significantly increased risk after three hours. Septoplasty
is usually associated with other surgical procedures such as
functional endoscopic sinus surgery (FESS) and rhinoplasty. That’s
why we considered that it is important to measure surgery time,
to organize the surgical schedule and the operative time when the
intervention is associated with other procedures.
The present study has one limitation. It hasn’t a control group to
compare the surgical method. Despite this limitation, we were able
Citation: Tasca I, Compadretti GC, Losano T, Boccio C, Lijdens Y (2016) Nasal Valve Stabilization in Extracorporeal Septo-
plasty. J Oto Rec Surg 2(1): 112.
Vol. 2. Issue. 1. 31000112
to see that the “3 point suture valve technique” is an effective and
simple technique, which can be used to correct an anterior severe
septal deviation.
Conclusions
Our study presents a drawback that was the use of nasal packing
for 48 hours and admission of the patient for one or two nights at
hospital. The nasal packing could probably be replaced by a septum
mattress suture to stabilize the replaced cartilages, prevent the
septal hematoma and help to heal the valve area.
The extracorporeal septal reconstruction is the advocated
procedure for the correction of the anterior markedly deviated
nasal septum via an endonasal approach. This technique has
demonstrated to be safe and effective to restore nasal patency
and the results remain stable. We describe a new type of simple
suturing technique to correct caudal septal cartilage deviation,
which is quick, easy to perform, free of major complications and
produces excellent cosmetic and functional results.
Acknowledgements
The authors thank Isabel Millicay for her help with the language,
Victoria Ardiles for her help with the statistical analysis and Varinia
Marchi for her help with the instrumental follow-up studies.
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*Corresponding author: Tomas Losano, Department of Otorhinolaryngology, Imola Hospital, Via Montericco 4, 40026 Imola (BO), Italy, Tel: 393-356-663-
460; Fax: 3905-4266-228; E-mail: losano.tomas.ignacio@gmail.com
Received Date: January 18, 2016, Accepted Date: February 12, 2016, Published Date: February 22, 2016.
Copyright: © 2016 Tasca I, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Tasca I, Compadretti GC, Losano T, Boccio C, Lijdens Y (2016) Nasal Valve Stabilization in Extracorporeal Septoplasty. J Oto Rec Surg 2(1): 112.

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Citation: Tasca I, Compadretti GC, Losano T, Boccio C, Lijdens Y (2016) Nasal Valve Stabilization in Extracorporeal Septo- Page 5 of 5
plasty. J Oto Rec Surg 2(1): 112.