traction suture modification to tongue-in-groove caudal ... · from 2003 to 2016, 148 patients...

YIJOM-3721; No of Pages 4

Clinical Paper

Cosmetic Surgery

Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxxhttp://dx.doi.org/10.1016/j.ijom.2017.06.007, available online at http://www.sciencedirect.com

Traction suture modification totongue-in-groove caudalseptoplastyY. A. Indeyeva, T. S. Lee, E. Gordin, D. Chan, Y. Ducic: Traction suture modificationto tongue-in-groove caudal septoplasty. Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx. ã 2017 International Association of Oral and Maxillofacial Surgeons. Publishedby Elsevier Ltd. All rights reserved.

Abstract. Caudal septal deviation leads to unfavorable esthetic as well as functionaleffects on the nasal airway. A modification to the tongue-in-groove (TIG) techniqueto correct these caudal septal deformities is described. With placement of atemporary suspension suture to the caudal septum, manual traction is applied,assuring that the caudal septum remains in the midline position while it is beingsecured with multiple through-and-through, trans-columellar and trans-septalsutures. From 2003 to 2016, 148 patients underwent endonasal septoplasty usingthis modified technique, with excellent functional and cosmetic outcomes and arevision rate of 1.4%. This modified TIG technique replaces the periosteal suturethat secures the caudal septum to the midline nasal crest in the original TIGtechnique. This simplifies the procedure and minimizes the risk of securing thecaudal septum off-midline when used in endonasal septoplasty.

Please cite this article in press as: Indeyeva YA, et al. Traction suture modification to tongu

Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.06.007

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Y. A. Indeyeva1, T. S. Lee1,E. Gordin2, D. Chan3, Y. Ducic4

1Department of Otolaryngology — Head andNeck Surgery, Virginia CommonwealthUniversity School of Medicine, Richmond,Virginia, USA; 2Department of Otolaryngology— Head and Neck Surgery, The StateUniversity of New York Downstate, Brooklyn,New York, USA; 3Department ofOtolaryngology — Head and Neck Surgery,Indiana University School of Medicine,Indianapolis, Indiana, USA; 4Otolaryngologyand Facial Plastic Surgery Associates, FortWorth, Texas, USA

Key words: caudal septal deviation; tongue-in-groove; endonasal septorhinoplasty; septo-plasty.

Accepted for publication

The nasal septum serves as a major con-tributor to the internal nasal valve1. Asidefrom its functional importance, the caudalseptum holds esthetic implications. Itsrelationship to the nasal lobule and thecolumella makes caudal septal deviationnoticeable on both frontal and lateral fa-cial views1. Unrepaired caudal septal de-formities may result in distortion of thelower third of the nose, imparting a twistedappearance, tip ptosis, columellar widen-ing, excessive columellar show, or persis-tent nasal obstruction2.A number of surgical techniques have

been proposed for correcting caudal septal

deformities, including the swinging door,the doorstop, the tongue-in-groove (TIG),and the extracorporeal septoplasty1,3. In1999, Kridel and colleagues described themost recent adaptation to the midline fix-ation method, coining it ‘the tongue-in-groove technique’4. One of the challengesof the original TIG technique involvessecuring the caudal septum to the nasalcrest soft tissue or periosteum. Adequateplacement in the midline position can bedifficult while working in a relativelysmall space with limited exposure, ascommonly seen in endonasal septoplasty.Misplacement of this suture will result in

persistent caudal septal deviation. A sim-plified, traction suturing technique thatprovides stabilization to the mobile, cau-dal septum until it is properly secured intomidline is proposed.

Materials and methods

Patients who had undergone caudal septumrepositioning during endonasal septorhino-plasty were identified and their clinicaloutcomes were analyzed in a retrospectivefashion. Patients who had undergoneopen septorhinoplasty or concurrent septal

e-in-groove caudal septoplasty, Int J Oral

ons. Published by Elsevier Ltd. All rights reserved.

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2 Indeyeva et al.


Fig. 1. An absorbable suture is secured to the caudal septum and is then passed through thecolumellar skin between the bilateral medial crura to be used as a traction suture.

Fig. 2. An assistant applies tension with the traction suture to maintain the caudal septum in themidline position while multiple through-and-through, trans-columellar and trans-septal suturesare placed across the hemi-transfixion incision to secure the caudal septum into the midlineposition.

perforation repairs were not included in theanalysis.

Technique

After a standard septoplasty is performedthrough a hemi-transfixion incision, thecaudal septum is released completelyfrom its soft tissue attachments in thesubperichondrial plane bilaterally andalong the maxillary crest to allow forcomplete mobilization. Next, the maxil-lary crest is reduced, if necessary, toprovide a stable flat surface on whichthe caudal septum can rest. Next, con-verse scissors are used to perform a ret-rograde dissection between the medialcrura, and a soft tissue pocket is createdto hold the repositioned caudal septum.The pocket spans the length of the colu-mella, from the area immediately belowthe domes of the lower lateral cartilagesdown to the anterior nasal spine.A temporary traction suture is then

placed using an absorbable suture (i.e.4–0 Vicryl), which is secured to the caudalmargin of the septum at its midpoint(Fig. 1). The traction suture, with theneedle still attached, is then passed be-tween the medial crura and out through thecolumellar skin at the columellar mid-point, and the suture is left long(Fig. 1). By varying the location at whichthe suture passes through the columella,alteration in the nasal tip position ispossible.Manual traction is then applied by an

assistant to pull the caudal septum in the

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midline position. It is important that thevector of traction is directed midline, aspullingthesuture laterallywill tilt thecaudalseptum and the nasal tip, leading to devia-tion. While an assistant maintains constanttension on the traction suture, the caudalseptum is visualized through the hemi-transfixion incision to ensure that it is sitting

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midlineat itsbasealongthenasalcrest. If thecaudal septum demonstrates excess verticalheight, persistent deviation will be noted,and the base of the caudal septum should beappropriately trimmed. If, at this point, theposterior margin of the caudal L-strut isimpinging on the nasal airway due to twist-ing, it can either be trimmed if there issufficient cartilage width to avoidcompromising nasal support, or correctedusing a number of additional septoplastytechniques, such as scoring or grafting.While manual traction is being applied to

the suspension suture, 4–0 chromic gutsuture on a straight Keith needle is usedto place multiple through-and-throughsutures across the hemi-transfixionincision to secure the caudal septum inthe midline within its soft tissue pocket(Fig. 2). Several sutures are placed in mul-tiple locations immediately posterior to themedial crura, in the membranous septum,and through the caudal septum. Contrary tothe original TIG, the authors do not routine-ly suture the medial crura directly to thecaudal septum. The through-and throughsutures described provide adequate struc-tural support in securing the nasal tip to thenewly positioned caudal septum with mini-mal to no physical overlap between themedialcruraand the caudal septum. Incasesof excess columellar show, the medial cruracan be set back and secured directly to thecaudal septum.

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http://dx.doi.org/10.1016/j.ijom.2017.06.007

Modified tongue-in-groove caudal septoplasty 3


Fig. 3. (A) Basal view demonstrating a severe leftward caudal septum deviation that is contacting the left lateral nasal wall. (B) Once the caudalseptum has been exposed and freed from the surrounding mucosa, one can easily see the severe deviation of the caudal septum to the left. (C) Viewat 1-year postoperative with the caudal septum sitting in the midline position behind the columella.

Once multiple through-and-throughsutures have been placed with proper po-sitioning of the caudal septum and thenasal tip, the traction suture is cut flushwith the columellar skin.Similar to the original TIG technique,

increased tip rotation or projection can beachieved by varying the position of themedial crura relative to the caudal septumwhen these through-and-through suturesare being placed. Additionally, any exces-sive columellar width at the columellarbase can be corrected with trans-columel-lar sutures by binding the medial cruralfoot-plates together.Bilateral Doyle splints are covered in

topical mupirocin or bacitracin ointmentand secured with 3–0 Prolene sutures toprevent synechiae formation. It is impor-tant to avoid excessive caudal septummanipulation when the Doyle splintsare being secured as it can misplace thecaudal septum. The splints are left inplace for 7 days.

Results

The modified technique was used in a totalof 148 endonasal septoplasty patients bythe senior authors (YD n = 51, TL n = 97)from 2003 through 2015 and from 2013through 2016. The majority of them un-derwent concurrent bilateral alar battengraft placement and bilateral inferior tur-binate submucosal reduction and outfrac-ture. All of the patients were followed forat least 6 months, with most individualsbeing followed for a period of at least1 year. One hundred and forty-six patients(98.6%) reported satisfactory functionalimprovement in nasal breathing. Of these,two patients required revision surgery


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using an open technique due to persistentcaudal septal deviation and nasal obstruc-tion, accounting for a 1.4% revision rate(Fig. 3).

Discussion

Caudal septal deviation is a relativelycommon nasal deformity, occurring inup to 44% of patients presenting for rhi-noplasty5. Patients with this deformityreport more severe complaints of nasalobstruction and olfactory problemscompared to control groups, and are likelyto benefit significantly from correctivesurgery2.The tongue-in-groove technique de-

scribed by Kridel et al. allows reposition-ing of the caudal septum to the midlineposition4. Additional modifications to fur-ther simplify the technique are providedherein. Kridel et al. recommend using afull transfixion incision and the placementof a suture securing the caudal septal baseto the soft tissue or periosteum of the nasalcrest in the midline. This maneuver can bedifficult to perform precisely when theTIG technique is being applied for endo-nasal septoplasty, sometimes necessitatingmultiple attempts.The technique presented here uses a

hemi-transfixion incision to minimizethe risk of septal perforation, which cancomplicate a full-transfixion incision.Furthermore, the modified techniquedescribed herein utilizes a traction suture,which holds the caudal septum in themidline position prior to fixation, allowingthe surgeon to visualize the cartilage andperform any further necessary refinementsprior to fixation. In the authors’ experi-ence, this modified TIG technique is


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simpler and quicker to perform than thetraditional method.Lastly, in the modified technique above,

routine overlap of the medial crura withthe caudal septum is not utilized, asopposed to the technique described byKridel et al.4. In the modified TIG thisis only employed in cases of excessivecaudal septal length or for the correctionof excessive columellar show. It is theauthors’ experience that significant over-lap of the caudal septum and the medialcrura may lead to deviation of the nasal tipif there is any persistent deviation of thecaudal septum, however slight. Further-more, patients may complain of an unnat-ural sensation, due to the inability of thenasal tip to move normally when firmlysecured to the caudal septum.The modification described above

significantly increases the ease and effi-ciency of the TIG technique while main-taining the ability to adjust the nasal tipprojection and rotation as described in theoriginal TIG technique.

Funding

None.

Competing interests

None.

Ethical approval

Not applicable.

Patient consent

Not required.

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4 Indeyeva et al.


References

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airway: beyond septoplasty. Am J Rhinol Al-

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2. Liu T, Han D, Wang J, Tan J, Zang H, Wang T,

Yunchuan L, Cui S. Effects of septal deviation

on the airflow characteristics: using computa-

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3. Haack J, Papel ID. Caudal septal deviation.

Otolaryngol Clin North Am 2009;42:427–36.

4. Kridel RW, Scott BA, Foda HM. The tongue-

in-groove technique in septorhinoplasty. Arch

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RJ. Simplifying the management of caudal

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Surg 2014;134:379e–88e.


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Address:Yadranko DucicOtolaryngology and Facial Plastic SurgeryAssociates923 Pennsylvania AvenueSuite 100Fort WorthTX 76104USAE-mail: [email protected]

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Traction suture modification to tongue-in-groove caudal septoplastyMaterials and methodsTechniqueResultsDiscussionFundingCompeting interestsEthical approvalPatient consentReferences

traction suture modification to tongue-in-groove caudal ... · from 2003 to 2016, 148 patients...

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