SEPTOPLASTY

Dr. John Chaplin – ENT and Head and Neck Surgeon

Auckland NZ

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Overview

Nasal septoplasty is a surgical procedure designed to correct deviation or deformity of the nasal septum the bone and cartilage partition separating the two nasal cavities. The primary goal is to improve nasal airflow, restore structural stability, and facilitate access to adjacent anatomical structures when required. The procedure may be performed as a standalone intervention or in conjunction with other nasal or sinus surgeries, such as turbinate reduction, functional endoscopic sinus surgery (FESS), or rhinoplasty. Insurance will usually cover the fee for septoplasty

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Indications for Septoplasty

Functional Indications

• Nasal airway obstruction due to septal deviation

• Recurrent sinusitis secondary to impaired drainage

• Epistaxis from septal spurs or mucosal trauma

• Sleep-disordered breathing related to nasal obstruction

• Headache or facial pain attributed to septal contact points

• Eustachian tube dysfunction (in selected cases)

Access-Related Indications

Septoplasty is frequently performed to improve surgical access to adjacent structures, including:

• Endoscopic sinus surgery (to improve visualisation and instrument maneuverability)

• Combined with rhinoplasty for functional and cosmetic improvement

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Surgical Approaches

Endonasal (Closed) Approach

The endonasal approach is performed entirely through intranasal incisions, typically via a hemitransfixion or Killian incision.

 

Advantages:

• No external scarring

• Reduced soft tissue dissection

• Faster recovery

• Less postoperative edema

 

Limitations:

• Limited exposure

• Less suitable for severe caudal or dorsal deformities

• More technically demanding for complex deviations

 

Typical Indications:

• Isolated septal deviations

• Posterior or mid-septal deformities

• Functional correction without cosmetic objectives

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Open (External) Approach (Most common in Dr Chaplin's practice)

The open approach involves a transcolumellar incision with elevation of the nasal skin–soft tissue envelope, providing full exposure of the septal cartilage, dorsal septum, and nasal tip structures.

 

Advantages:

• Superior visualisation

• Precise correction of complex deformities

• Better access to the  caudal septum

• Facilitates placement of grafts

 

Limitations:

• External scar (usually minimal)

• Longer operative time

• More postoperative swelling

 

Typical Indications:

• Severe caudal or dorsal deviations

• Revision surgery

• Septoplasty combined with rhinoplasty

• Structural reconstruction

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Techniques for Straightening ​

Bony Septum Mobilisation and Resection

1. Vomer

• The vomer contributes to posterior and inferior septal deviations.

• Deviated segments may be greenstick fractured, repositioned, or partially resected.

• Excessive resection should be avoided to maintain support.

2. Perpendicular Plate of the Ethmoid

• Often involved in high dorsal or posterior deviations.

• Can be mobilised with controlled fractures or selectively excised.

• Care is taken to avoid skull base injury and CSF leak.

3. Maxillary Crest

• Spurs or displacements of the maxillary crest can cause inferior septal deviation.

• Reshaped using guarded osteotomes, rasps, or powered instruments.

• This step is critical for stabilising the caudal septum.

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Cartilage Septum Correction 

Scoring Techniques

• Partial-thickness incisions weaken intrinsic cartilage memory.

• Typically performed on the concave side of the deviation.

• Must be conservative to avoid destabiliaation.

Bracing with cartilage 

• Either autologous septal or allograft cartilage

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Septal Stabilisation and Fixation​

Suturing to the Nasal Spine

• The caudal septum is often repositioned and secured to the anterior nasal spine.

• This restores midline support and prevents postoperative drifting.

• Commonly done with non-absorbable or slowly absorbable sutures.

Bracing Techniques

• Cartilage septal battens (either autologous or allograft)

• Quilting sutures between mucoperichondrial flaps reduce dead space and hematoma

• Mattress sutures may be used to stabilise cartilage

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Graft Materials

Autologous Cartilage

• Septal cartilage (preferred)

• Conchal cartilage

• Costal (rib)cartilage

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Allograft Cartilage

• Cadaveric cartilage processed to reduce antigenicity

• Available as irradiated or fresh-frozen grafts

 

Advantages:

• Avoids donor-site morbidity

• Useful when autologous cartilage is insufficient

• Reduces operative time

 

Disadvantages:

• Potential for resorption

• Higher cost

 

Summary

Septoplasty is a versatile procedure that addresses both functional and structural nasal pathology. Choice of approach – endonasal versus open – depends on the complexity of deformity and the need for visualization or reconstruction. Correction involves a combination of cartilage scoring, selective resection, bony mobilisation (vomer, perpendicular plate, maxillary crest), and stabilisation techniques. Advanced cases may require structural grafting, including spreader grafts and, when necessary, allograft cartilage. Proper execution restores airflow, maintains nasal support, and optimises long-term outcomes.

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