Correction of caudal deviation

1. Caudal spetal
devation
Under suprivision of prof Dr:
Ayman Madany

2. Introduction
Caudal septal deviation is defined as deviation of the
anterior most portion of the nasal septum. In addition
to functional symptoms, caudal septal deviation can
cause significant cosmetic deformities, including
lobule deviation, tip ptosis, and deformity of the
middle one-third of the nose. Caudal septal deviation
differs from traditional septal deviation in that it
involves a portion of the septum that contributes to
the nasal valve area and the support of the nasal tip

3. Anantomy
The nasal septum divides the left and right nasal
cavities. It is lined by mucoperichondrium anteriorly
(covering the quadrangular cartilage) and
mucoperiosteum posteriorly (covering the bony
septum), and superiorly becomes continuous with
the cribriform plate mucosa, and inferiorly with the
nasal floor mucosa.
the posterior aspect of the quadrangular cartilage
articulates neatly with the bony septum at the bony-
cartilaginous junction.
The bony septum consists of the perpendicular plate
of the ethmoid bone superiorly, extending to the
cribriform plate, and the vomer inferiorly, which
borders the choana.
The most inferior aspect of the nasal septum is the
bony maxillary crest, which consists of the maxillary
bone anteriorly and the palatine bone posteriorly.

4. CLASSIFICATIONS
One common classification for caudal devation :
Type A> Dislocation of caudal length with excess length coming out of one of
the nostrils or excess length bending on itself, causing visible external
deformity.
Type B >“C- shaped” deviation of the caudal end because of excess anterior
posterior length causing bending of the septum in one or both nostrils.
Type C >Swing door caudal septal deviation, where the internal septum is in
midline or mild deviation and the caudal septum is angulated causing
deformity and obstruction.
Type D >Complex caudal septal deviations including “S-Shaped” deviation.

5. Surgical Techniques:
• The deviated caudal septum has a significant impact on nasal base specially the Tip position and symmetry.
• Treatment of caudal septum can be the most significant element in treatment of many crocked noses.
• The caudal septal deviation is classified into mild, moderate, and severe. No single method of correction
showed efficacy in all cases.
• In the time of Freer and Killian, a caudal and dorsal strip was always left. Frequently the most obvious portion
of septal deformity, the caudal end was undisturbed and deformity persisted.
• The earliest attempts to correct caudal septal deflections involved resection of the deformed segment which
resulted in columellar retraction and ptosis of the nasal tip. By resecting caudal segment and implanting it
separately in the columellar pocket, surgeons have attempted to eliminate the effects of mucosal scar
contracture on membranous septum.

6. 1) Swinging Door
• Method Metzenbaum was one of the first to describe a
procedure for correction of the caudal septum. The caudal
septum is dislocated from the attachment of the anterior
nasal spine by wedge resection of the excessive vertical
cartilage along the maxillary crest and fixed with an
absorbable suture to the periosteum on the opposite side of
the nasal spine using a figure-of-eight suture.
• This method has been modifed by Pastorek and Becker,
who introduced the “doorstop” technique. It involves the
transposition of the deviated caudal septum over the anterior
nasal spine to the opposite n asal cavity without further
cartilage resection. However, the septum may slip from the
midline of the maxillary crest when the suture loosens or
when the soft tissue stretches out, which can lead to
undercorrection of the caudal septum. Furthermore, there is
a possibility of saddle nose deformity when excessive
resection is made.

7. 2) Cross-hatching Incision
• The cross-hatching incision based on
the theory of interlocked stress was
demonstrated by Gibson and Davis in
1957 and by Fry in 1966.
• Multiple crossing incisions are
performed on the concave side of the
septal cartilage preserving intact
contralateral cartilage alignment.
• Although incisional technique is more
conservative than cartilage wedge
resection or cutting, it could be inefective
and induce cartilage weakness or
overcorrection. Furthermore, it is difcult
to predict the efect of this technique
because the eventual straightening of the
septum is completed by a secondary
healing process.
3) Scoring Incision
• A partial-thickness scoring incision is made on the
concave cartilage surface, which afects the
interlocked cartilaginous stress and bends the tissue
to the opposite side.
• Because the scoring incision alone does not provide
sufcient correction and the cartilage returns to its
original deviation, applying 2-octylcyanoacrylate (2-
OCA) tissue adhesive onto scoring incision may
increase efcacy and prevent concavity recurrence.
The percentage of straight septum by postoperative
anterior rhinoscopy and postoperative symptom
score for nasal obstruction were signifcantly better in
the scoring+OCA group than scoring alone group.
However, a temporary foreign body reaction
characterized by septal swelling occurred in 12.5%
of the scoring+OCA group.

8. 4) Septal Batten Graft
• Batten graft has been introduced for correction caudal deviation due to the weakening of the caudal
septal support. T
• he graft is inserted submucosally on the concave side of the nasal septum and fxed to the septum to
correct the curvature.
• Caudal septal batten grafting using septal cartilage or bone has been reported to straighten and
strengthen the deviated caudal septum. Furthermore, several alloplastic implants have been
introduced to replace autologous implants. Silicone, Gore-Tex, Medpor, and polycaprolactone are
currently available and have been used with variable success rates.
• Bony batten grafting improved subjective nasal obstruction evaluated by the Nasal Obstruction
Symptom Evaluation (NOSE) scale in all patients.
• the use of the cartilage or bone on the caudal septum can make the caudal septum and nose too
thick and stif, which can be anatomically unnatural and lead to nasal obstruction

9. 5) Tongue in groove
• Kridel described the “tongue in
groove” technique for the
management of caudal deviations.
The procedure involves placement
of the caudal septum into the
groove between the medial crura
to hold it in place, the tongue in
groove is a useful technique in a
limited number of cases, specially
hanging columella, but it causes
stiffness of the nose and may
shorten the nose.

10. • Steps
• A full transfixion incision is created and the
mucoperichondrium is elevated from the septum
bilaterally in a posterior direction for at least 4 mm to
expose both sides of the caudal end of the cartilaginous
septum.
• Caudal septal deviations often require partial separation of
the posterior junction of the cartilaginous septum and the
bony vomer; or a minimal resection of cartilage along the
nasal floor at the maxillary crest to allow the septum to
swing back to a midline position.
• retrograde dissection is performed between the medial
crura using fine forceps and tenotomy scissors to create a
pocket. The medial crura are then advanced
cephaloposteriorly, placing the denuded caudal septum
into the potential space created between them. If there
was excessive width to the columella preoperatively, soft
tissue from the dissected pocket may be removed to help
in the narrowing. The results of the initial trial placement
will determine if any caudal septal cartilage excision is
necessary

11. • Once any required cartilage trimming is completed, the caudal septum
is again placed into the groove between the medial crura, and the nose
is examined while the columella is gently held in place .
• Once the precise desired relationship of the medial crura to the
septum is obtained, these structures are fixed with a series of sutures
between the medial crura and the caudal septum.
• Typically 3 or 4 chromic sutures are placed in a through-and-through
fashion using a straight needle. Alternatively, permanent (Prolene
polypropylene; Ethicon Inc, Somerville, NJ) or semipermanent (PDS
polydioxanone; Ethicon Inc) sutures may be placed in a buried fashion
prior to membranous closure.
• An external approach with dissection between the caudal aspect of the
medial crura offers more complete exposure to facilitate buried suture
placement

12. 6) marionette septoplasty
• For cases of severe caudal septal
deviation, Kayabasoglu developed a
modified closed technique for
extracorporeal septoplasty and called
this type of endonasal caudal septal
replacement grafting a “marionette
septoplasty” because of the
appearance of the sutures when the
graft is fixed and the procedure’s
resemblance to marionette art.

13. • Steps
• a hemitransfixation incision is made on the side of the
deviation, and submucoperichondrial flaps are elevated
bilaterally
• A 1-cm vertical chondrotomy is made 1 to 2 mm from the
cephalic point of the dorsal aspect of the deviation. A
horizontal chondrotomy is made from this point posteriorly,
approximately 8 mm below and parallel to the dorsum. All
septal structures in front of and below these incisions are
removed.
• A dorsal strut of cartilage is retained to facilitate
stabilization of the cartilage grafts used to reconstruct the
caudal septum. The harvested septum is used to create a
straight L-shaped strut.
• The dimensions of the L strut are such that the length of
the nose is not shortened. The L strut is then sutured with 4-0
Vicryl Rapide at three points: the point corresponding to the K
point, the point corresponding to the middle of the medial
crura, and the point corresponding to the anterior nasal spine.
These three temporary fixation points aid in positioning and
stabilizing the graft during surgery.

14. • In order to place the L strut, limited dissection is
performed between the remnant dorsal septal cartilage
and the caudal part of the upper lateral cartilage to avoid
postoperative dorsal depression. The dissection is then
performed widely between the medial crura. The first point
is fixed at the K point by passing the suture through the
remnant dorsal cartilage and then through the L strut, and
then tying a single knot. The knot is tightened carefully, and
the L strut is moved into place overlying the remnant dorsal
cartilage. Additional knots are tied for fixation
• The sutures from the three points on the L strut are then
placed through the corresponding positions on the nose
and brought out of the skin overlying those points. With
the three sutures attached to the L strut, the graft can now
be positioned and stabilized from all three vectors until a
satisfactory position is attained. Once the ideal position is
found, the cephalic tip of the L strut is fixed to the remnant
cartilage with 4-0 Prolene. It is the overlap of the cartilage
in this step that can shorten the length of the nose, and this
must be considered and avoided when constructing the L
strut. The caudal portion of the L strut is fixed with 4-0
Vicryl Rapide between the medial crura

16. 7) Jang septoplasty
• preserved the naturally strong junction between the
maxillary crest and the septal cartilage and involved cutting
the convex most part of the caudal septum and then
reconnecting it with slight overlapping of the cut ends of the
caudal cartilage strut and called this approach as the cutting
and suture technique of the caudal L-strut
• The surgical procedure includes a division of the deviated
caudal L-strut preserved after resection of the deviated
quadrangular septal cartilage at the central portion. A batten
graft made of septal cartilage or bone is interposed between
the cut ends of the caudal L-strut, the upper part of which
mobilized toward the more concave side of the nasal cavity,
and then sutured.

17. 8) Septal Cartilage Traction Suture Technique
• Technique
• Modified Killian incision was performed using the no. 15 blade at the concave site of the nasal cavity. After elevation
of the mucoperichondrial flap, the deviated septal bone and cartilage were selectively removed, preserving an L-strut of
dorsal and caudal cartilaginous septum at least 1.5 cm long. If the caudal septal deviation was not sufficiently corrected
using that procedure, the vertical caudal cartilage excess was resected at the bottom, without disarticulation
• from the anterior nasal spine, to make a flexible relationship between caudal septum and nasal spine. After removal of
surplus caudal cartilage, the caudal septum was sutured on the modified Killian incision site at two or more points using
5-0 Vicryl (Ethicon, Somerville, NJ). The needle penetrating through the ipsilateral mucosa of incision site was passed
through the most convex part of the caudal cartilage and then sutured through the opposite mucosa of incision site to
pull into the concave side of the nasal cavity. Should the needle not penetrate the septal mucosa fully but not the
opposite septal mucosa. Straightening of the caudal cartilage can be verified immediately after the septal cartilage
traction suture technique.

19. Septal Extension Graft
• The septal extension graft, first introduced by Byrd et
al.
• in 1997, achieved fixing a graft on the caudal or dorsal
septum between both of the lower lateral cartilages
while controlling nasal lengthening and tip projection,
rotation, and shape. Compared to the columellar strut in
patients with weak midvault or lower lateral cartilage,
the septal extension graft has been found to be more
favorable for maintaining tip projection through stronger
support

20. • The pivot locking suture
• Oh et al. demonstrated a pivot locking suture in which, in addition to
the conventional anchoring suture, a figure-of-eight suture is performed on
the cephalic and caudal margin where the graft and L-strut meet. This limits
the up-and-down movement of the graft, and thereby improves the vertical
stability. The vertical figure-of-eight suture
• Unlike the direct extension procedure of Byrd et al., which presents
difficulty in tight fixation, the vertical figure-of-eight suture instead of
horizontal figure-of-eight suture yields more stability. Han et al. measured
the shearing, buckling, and tensile force, after using a butt junction type
through two simple interrupted sutures, two horizontal figure-of-eight
locking sutures, and one vertical figure-of-eight suture. One vertical figure-
of-eight suture was the most powerful method. Compared to the butt
junction type, methods contacting broadly with the cartilage such as the
overlapping type may produce a more powerful fixation, but swallowing of
septal mucosa and wastage of cartilage need to be taken into account.
Thus, the butt junction type with the vertical figure-of-eight suture may be
a good substitution in those who lack available cartilage.

21. Thank you