In performing septoplasty, one of the first things we want to do is to identify the anterior septal angle. We call the anterior septal angle the gateway to the nose. Once we've identified it, we can then carry on over the surface of the dorsum. The dorsal perichondrium is undermined and the upper lateral cartilage is initially released from the dorsal aspect of the septum. Then using a 15 blade, we score on the mucoperichondrium carefully so that we can find the correct plane for dissection. A caudal elevator is then used to elevate the mucoperichondrium on the cartilaginous septum. First dorsally, then we sweep caudally, then inferiorly down to the maxillary spine. You can feel with the tip of the instrument where you're on bone or when you're on cartilage. The upper lateral cartilage is then completely released from the dorsal aspect of the septum all the way up to the keystone. When the scissors can no longer close, you've reached bone. On the contralateral side, we'll be releasing the mucoperichondrium again, but only in so much so as to allow us to perform, in this instance, dorsal reduction. We don't always have to do a complete elevation of the mucoperichondrium on both sides unless you have a very severe septal deviation or under such difficult circumstances. Once we have both sides exposed to the extent that we feel that they need to be, we're going to be performing a dorsal hump reduction. In this case, we'll do it with a sharp, bent-back scissors for the quadrangular cartilage. And then a variety of methods can be done to take down the osseous hump as well. A powered instrument can be used, or other things. We'll expose the caudal septum now. So in cases when you have caudal septal excess, you can resect a small portion from the anterior, middle, or posterior septal angles, in this case, mostly middle septal angle. All of these components, all of these reductions, whether it's dorsal or caudal, have to be done before the submucous resection of the septum is performed, and the reason why is that you want to maintain an L-strut of no less than 10 to 12 millimeters, and many surgeons maintain even more than that. You'll notice that along the dorsal and caudal aspects, where they meet, it's not exactly a right angle. A slight curve here will prevent us from having a stress riser that can occur when you have a sharp angle between those cuts. You cut through partially, you can use a 15 blade, and then elevate on the other side. The blunt side of the freer can help you to elevate the mucoparicondrium on the opposite side, and then this is a septal knife that we'll use to complete the excision, and a bent back scissor going up to the perpendicular plate. Completing the elevation of the mucoparicondrium on the contralateral side, and then releasing it inferiorly and caudally and taking a small portion of the perpendicular plate with us. At this point we'll go back and we'll find any osseous spurs or cartilaginous spurs that still exist.

septoplasty

anterior septal angle

mucoperichondrium

L-strut

cartilage removal