Discussion A Practical Classification of Septonasal Deviation and an Effective Guide to Septal Surgery by Bahman Guyuron, M.D., Cheryl D. Uzzo, R.P.A-C., and Heather Scull Discussion by Rod J. Rohrich, M.D. As the septum goes, so goes the nose—Anonymous Dr. Guyuron and his co-authors are to be commended for presenting their critical anal- ysis and observation of their large experience made during 1224 septoplasties. The authors concisely studied 93 consecutive rhinoplasty patients who had septonasal deviations and de- veloped a classification of six deviation sub- types to optimize surgical correction, In an analysis of their study, the authors delineated six categories of septonasal deformities with individuated management, which will in turn lead to a higher success rate. Dr. Guyuron is a talented surgeon with significant expertise and experience in rhinoplasty. He is concise and critical of his own results; therefore, we must review his rationale for this complex classifica- tion for treatment of septonasal deviation in rhinoplasty. Plastic surgeons can be grouped into wo different general categories, lumpers and split- ters. The authors are in the splitter category; your discussant is in the lumper category. I prefer to break things out into their simples component—easy to teach, reproducible, and practical. I have always viewed septonasal devi- ations simplistically as three descriptive clinical subtypes based on their external, bony, and dorsal septal appearance on frontal view. [have found the internal septal and inferior turbi- nate examination to be variably independent of the external examination. A clinical classifi cation in surgery is only useful if it can be applied easily and effectively for reproducible operative success. The first and most common ype is a straight septal tilt off the vomer with Received for publication August 30, 1909, 2210 no dorsal septal curvature, but often exhibiting as a caudal septal deviation with the nasal tip off the midline vertical meridian with no devi- ation of the nasal pyramid. The second most ‘common type is the C-shaped deformity, which includes the reverse C-shaped deformity as well. Both C-shaped deformities frequently in- clude a nasal pyramid deviation. The third type is most difficult to correct and manifests as an Sshaped external nasal deformity with bony pyramid deviation, One of the major contributions of this article to the management of the deviated nose in thinoplasty is the reemphasis of an accurate preoperative diagnosis of the septal nasal de- formity, both externally and by a comprehen- sive internal examination of the nose, with and without, shrinking the nasal mucosa. Septona- sal deviations are a normal variant in human nasal anatomy. Most do not cause airway prob- lems unless they obliterate at least 50 to 60 percent of the anterior inferior part of the airway, which subsequently leads to compensa tory contralateral inferior turbinate hypertro- phy. All septonasal deviations are different The authors prudently expound on the fact that their study patients’ treatment plans were based primarily upon the preoperative diag- noses of the septal deformity. Lagree with the authors that scoring only is unpredictable in correcting septal deviation and should primarily be used to help straighten the deviated septal area. In our ex- perience, sequential inferior full-thickness cuts in the dorsal septal cartilage (Figs. 1 and 2) up through 50 percent of the remaining dorsalVol. 104, No. 7 DISCUSSION Fic. 1, Inferior full-thickness cuts extending through 50 percent of the dorsal septal strut beginning at the deviated point with distal progression until total septal deviation cor rection is achieved. L-strut will straighten, and at the same time weaken, the dorsal septum. This should be used, in combination with spreader grafts either uni- laterally or bilaterally to reconstruct the deviated nose, especially if it is dorsally deviated as in the Cshaped or Sshaped deformity. The following six principles of straightening a deviated nose have served us well and have been updated from Gunter and Rohrich in 1988! 1. Wide exposure of the deviated structures through the open rhinoplasty approach. 2. Wide release of all mucopericondral attach- ment to the septum, especially the devi- ated portion 3. A goal of straightening the deviated septum in all segments preferentially by retaining an 8- to 10-mm caudal and dorsal strut, but weakening the L-strut with full-thickness inferior cuts (Fig. 2). The weakened L- strut is straightened but must be but- tressed with spreader grafts (Fig. 3) 2211 Fic, 2, Placement of spreader grafts to restore dorsal sep. tal support, straighten the nose, and reconstruct the dorsal aesthetic lines, 4. Restore long-term septal support with buttress- ing batten grafts of the dorsal caudal sep- tum and/or spreader grafts (unilateral or bilateral). It is important to have a per- fectly straight nose intraoperatively before completion of the rhinoplasty Submucosal reduction of anterior/inferior tur- dinate and mucosal retention with resec- tion of the hypertrophied bone is critical to maintaining a straight septum and a good nasal airway 6. Precise planning and execution of nasal os teotomies using external percutaneous os- teotomies based on the preoperative ex- amination of the bony pyramid. CONCLUSIONS This classification is practical and simple. It is based upon the anatomic diagnosis and the key elements of the above mentioned princi- ples. The most important advance in the man-2212 of bilateral spreader grafts delineating the placement of at least two horizontal mattress sutures (5.0 polydioxanone suture) to secure the grafts to the straight ened septal strut. agement of the deviated nose is the use of spreader grafts as described by Sheen"! and refined by others." The use of spreader grafts in the correction of dorsal nasal deviations, whether they are Gshaped or S-shaped, has revolutionized the PLASTIC AND RECONSTRUCTIVE SURGERY, December 1999) management of the deviated nose.**° Spreader grafts maintain and restore the patients’ inter nal nasal valves as well as restore the integrity of the L-strut. Furthermore, by varying the width of the graft or placing the graft unilaterally, residual deviations can be camouflaged. This corrects the dorsal septal deviation by placing unilateral bilateral spreader grafts in the weak- ened L-strutarea. A straight dorsal alignment is maintained, and the dorsal aesthetic lines are restored. I commend Dr. Guyuron and his co-authors in presenting their innovative work, critical analysis, and rationale for management of this difficult problem in rhinoplasty. We all benefit when authors such as Dr. Guyuron share their extensive clinical experience in this challeng- ing arena of plastic surgery. Rod J. Rohrich, M.D. Department of Plastic and Reconstructive Surgery 5323 Harry Hines Boulevard Dallas, Texas 75235-9132 rrohri@mednet.swmed.edu REFERENCES 1. Gumter, J. P., and Rohrich, R. J. deviaied nose: The importance of septal reconstruc: tion, Clin, Plast, Surg. 15: 43, 1988. 2 Rohrich, R.J.,and Sheen,.J.P, Secondary Rhinoplasty. In J. C. Grouting (Ed.), Reoperative Plastic Surgery. St Louis: Quality Medical Publishers, 1994. 3, Sheen, J. H.,and Sheen, A. (Eds.). Aesthetic Rhinoplasty St Louis: Mosby, 1987. Sheen, J. H. Spreader grafts: A method of reconstruct. Wg the roof of the middle nasal vault following rhi- noplasty. Plast. Reconstr. Surg. 73: 230, 1984, Rohrich, Rf, and Holler, L. H. Use of spreader grafts in the extemal approach to thinoplasty. Clin. Plast Surg. 23: 255, 1996, 6, Byrd, H.S., Salomon, J. crooked nose. Plast Management of the ind Flood, J. Correction of the Siurg, 102: 2148, 1998.