1 State of the Art

The surgical techniques of deviated noses have evolved gradually. Reduction and mobilization techniques causing a weakening of the structural supports have given way to a more conservative surgery involving restructuring and increases.

In 1952, King and Ashley [1] had suggested that the mobilization of the entire nasal septum was necessary to obtain a right frame. Currently, Gubisch [2] is using successfully for over 25 years an “extracorporeal septoplasty” based on this principle. Since 1996, he uses an open approach to detach the bony and the septal cartilage in one piece. He uses cartilaginous incisions associated with cartilaginous or bony spreader graft sometimes using a drill for thinning. He also has ­experience of PDS plates to stabilize the graft, as suggested by Bönisch and Mink [3, 4]. He reported a revision rate of 7% and irregularities of the dorsum complaints of 8–11%.

The stability of the septal cartilage and the irregularities of the dorsum are the reported problems related to this technique. In order to overcome these problems, some authors like Senyuva Guzel [5] and Gubisch [6] have proposed to fix the septum to the upper cartilage by open approach. Finally after the completion of the open roof, he places a cartilaginous onlay graft on the dorsum as suggested by McKinney [7] in order to reduce irregularities.

Currently, in conservative surgery, autogenous cartilage graft is used to replace, reinforce, or rebuild the osteochondreal structure component [8]. The idea is to maintain an L-shaped strut at the septum after releasing alar and triangular cartilage. The association of septal batten graft, spreader graft, scoring incisions, and suturing techniques allows recovery of the septum. Some authors have used camouflage techniques whose goal is to create an illusion of a straight nose by cartilage grafting of the nasal anatomy various components [9]. In the middle third, the challenge is twofold: correction of the deviation and preservation of the internal nasal valve. Repositioning of the triangular cartilages from the septum is the key point. The interest of “extracorporeal rhinoseptoplasty” is to obtain a masterpiece self-­stabilizing and to simultaneously correct the irregularities of the dorsum. This piece acts as a cartilaginous keystone ensuring its stability and that of the nasal arch. The piece is a result of the various procedures conventionally used to correct the septum: the spreader graft, the L-shaped strut graft, and the cartilaginous onlay graft. The replacement of the newly constructed model using an endoscope provides an easy and accurate tool to ensure proper positioning on the bottom of the anterior nasal spine. The upper lateral cartilages build on the spreader grafts laterally, avoiding collapse of the internal valve, and superiorly in the open roof between the nasal bones.

The authors believe that the problem of stability at long term is assured by its threefold support system. Thus, the pattern is biomechanically stable over time.

Using the model of the “extracorporeal rhinoseptoplasty” has the advantage that it can be used in an endonasal approach. The construction of the model is stepwise and therefore repeatable. The best indication of “extracorporeal rhinoseptoplasty” is the reconstruction of the middle third of the nose, deviated noses even more when the overlaying skin is thin requiring a perfect regular structure.

2 Surgical Technique of “Extracorporeal Rhinoseptoplasty”

The principle of this technique is to remove the whole septal cartilage and the cartilaginous dorsum in one piece and then to make a cartilaginous model corresponding to the nose framework. This is performed using a closed approach: First step is the septoplasty by a right-sided interseptocolumellar hemitransfixion incision, bilateral detachment in the subperichondral plane, and exposure of the entire cartilaginous and bony septum, which is required to remove the cartilaginous septum and the cartilaginous dorsum in one piece. By doing so, a significant amount of autologous material can be obtained to extracorporeally built the framework.

Initially in this step, we perform a 180° rotation of the levy so that the edge of the posteroinferior wall becomes the anterosuperior corner. In fact, the posteroinferior septum makes a good support on the anterior nasal spine, between the medial crura of the alar cartilages.

Then the different parts of the framework are drawn: one septal L-shaped strut, two spreader grafts, and one cartilaginous onlay graft (Fig. 20.1):

Fig. 20.1
figure 1

Different parts of the framework: 1 – septal L-shaped strut; 2 – spreader grafts; 3 – cartilaginous onlay graft

Full size image
  1. 1.

    Septal L-shaped strut: The sagittal supporting element on which will be sewn other cartilage grafts. This L-shaped piece will rest on the lower anterior nasal spine and anteriorly between the medial crura like a columellar strut. (Projected size should be 3.5  ×  3.5 cm.)

  2. 2.

    Spreader grafts: They should be attached superiorly and laterally to the septal L-shaped strut to reconstruct the cartilaginous dorsum allowing maintenance of the width of the subunit dorsi-nasal (Sheen lines) and a stable support to the upper cartilage avoiding collapse of the internal valve. On their superior plan, a stair-shaped incision is to be performed in the posterior region with a depth of 1 mm to accommodate cartilaginous onlay graft. (Projected size should be +/− 2.5  ×  0.5 cm.)

  3. 3.

    Cartilaginous onlay graft: It will be sewn on the upper surface of spreader grafts. It will close the bony dorsum. (Projected size should be 2.5  ×  0.5 cm.)

The grafts are secured to them by polyfilament, resorbable sutures, as Vicryl® (Fig. 20.2). Once the framework has made, the osteocartilaginous structure will be corrected. A subperiosteal dissection to the level of the radix of the nose is performed. The authors strive to achieve an extramucosal technique. Resection of the bony hump and lateral osteotomies (in-fracture) can be performed.

Fig. 20.2
figure 2

Real framework

Full size image

Finally the model is replaced; it must be delicately positioned, either under direct vision with a “Aufrich ecarteur” or using a video-assisted endoscopic system. The framework is introduced through the interseptocolumellar way, in a sagittal direction. The anterior angle of the septal L-shaped strut based on the lower anterior nasal spine and cartilaginous onlay graft is directed upward and backward based on the residual bone at the dorsum nasofrontal angle. The body of the model is located between the upper cartilages. When positioning, try to lock the spreader grafts as an interlocking “LEGO®” in the open roof residual (Fig. 20.3). This produces a self-­assembling stable reconstruction in all three special planes, creating a symmetrical and regular dorsum; a transcolumellar traction suture is used when placing the framework; Reuter valves are attached for stabilizing the assembly. The ­projection of the upper cartilages is adjusted to spreader grafts (Figs. 20.4, 20.5, 20.6, and 20.7).

Fig. 20.3
figure 3

Modelization “LEGO®” of the framework, construction, and the positioning between the nasal spine and the bony part of the nose. Yellow: septal L-shaped strut; black: spreader grafts; green: cartilaginous onlay graft; white: nasal bone. (a) Framework without cartilaginous on lay draft after pushing down. (b) Framework with cartilaginous on lay draft after pushing down

Full size image
Fig. 20.4
figure 4

Reconstructed nose on coronal section view, showing the framework positioning (a) at the bony nose and (b) at the cartilaginous nose

Full size image
Fig. 20.5
figure 5

(a, b) Framework in situ

Full size image
Fig. 20.6
figure 6

(a) Preoperative 28-year-old woman with nasal deviation (I-shaped nose), a dorsal hump, and an internal valve collapse. (b) Postoperative after “extracorporeal rhinoseptoplasty”

Full size image
Fig. 20.7
figure 7

(a) Preoperative 21-year-old woman with nasal deviation, airway obstruction, C-shaped nose, a dorsal hump, and retrogenia. (b) Postoperative result with a straight dorsum, the restoration of balance dorsal aesthetic lines, and better chin correction with good labial competence

Full size image