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>> Dr. Lamperti: This is Seattle Facial Plastic Surgeon, Dr. Thomas Lamperti. Today I'm going
to show you how to perform a closed septoplasty surgery. With the goal of giving you the best
vantage point I've come up with a SurgeonCam which involves a headlight mounted video camera.
To start I'm using a scalpel to make what's called a Killian incision. This is one of
the two common types of septoplasty incisions. The other type is a hemi-transfixion incision
which is very similar but is placed a few millimeters toward the outer edge of the nostril.
Now we're using a Cottle elevator to elevate the skin lining off of the septal cartilage.
There is a nice plane between the cartilage and the skin lining itself that is relatively
bloodless. And this is the plane that we're trying to get into with the sharp end of that
device. We're now switching to a Freer elevator which is a similar device which allows us
to dissect and elect the skin lining off of the cartilage. This is all done bluntly so
there are no cuts other than the initial incision I made in the nose. Of course, we need to
lift the skin lining off of the right side of the septum. Now I'll actually do this through
the same left-sided incision. What I'm doing now is using the Freer elevator's sharp end
to incise the cartilage of the septum about a centimeter and a half back in order to then
enter the right side. And then from that incision in the left side of the nostril and the septal
cartilage I'm able to elevate the mucosa off of the right sided septal wall.
You can see how the nasal speculum in my left hand becomes quite useful in elevating the
skin flaps from each other so that I'm able to see the nasal septum more easily. We're
now using what's called a swivel knife which is used to incise the cartilage of the septum
further. I normally use this to make the dorsal cut meaning the cut that is parallel to the
bridge or dorsum of the nose. We're now freeing up the portion of cartilage where the cartilage
meets the bony part of the septum. We're now using a Takahashi forcep to remove the portion
of deviated cartilage from the septum. Now that we've address the deviated septal cartilage
it's now time to address the deviated bony septum. The septum is made up of thin bone
toward the back of the nose and also along the floor of the nose where it meets the upper
jaw. So we're elevating the mucosa off of these portions of bone and we're using the
Takahashi forcep a large bone spur and in this care right now you can see the large
spur that was jutting off into the left side of the nose. Additional trimming and refinement
of the bony septum will take place using an osteotome. I don't always need to use an osteotome
during a septoplasty but it is a useful tool in certain situations. I do find that addressing
these relatively small deviations along the floor of the nose are quite important in improving
nasal airflow maximally. This is because such a large portion of nasal airflow occurs along
the floor of the nose -- approximately 50 percent. As such, relatively small changes
in the aperture or opening of the nose in this area can affect quite a large subjective
improvement in breathing and nasal airflow.
Now that we've straightened the septum it is now time to close the initial incision
that we made at the beginning of the video. I use a dissolvable suture to do this and
normally I use a 5-0 chromic suture. This will dissolve on its own within a few weeks
typically. I normally just simple interrupted sutures as you can see here. I often tell
people that they'll find that their left nostril will typically be more sore than their right
simply because their is no incision on the right and there is only one of the left. The
reason that I place the incision on the left side is because I am right handed and typically
during surgery the surgeon stands on the right side of the patient. This affords easier access
to the left nostril as a result. In some cases I'll add an incision on the right side if
this is needed to approach a large spur. I'm now placing a quilting stitch in the nose.
This isn't to close an incision but rather is used to re-appose the skin lining on either
side of the septum. In the areas where the bony and cartilaginous were removed where
it was deviated this then allows the skin lining to lay more straight and in the midline.
The needle on the suture is straight and allows me to more easily pass it back and forth repeatedly.
And this is done many times as you can see in order to reattach and reappose the lining
to itself throughout the nasal cavity including toward the back where it was elevated. The
main goal is to avoid allowing any oozing blood or other serous fluid to collect in
the potential space between these skin flaps. The benefit of this type of closure is that
I don't need to use any type of nasal packing after septoplasty surgery. A lot of people
are very concerned and have heard about having the nose packed solid after surgery with strip
gauze and the like. This is typically quite uncomfortable especially to have it removed
and I find that by using this quilting stitch I don't normally need to use any packing at
all. I'll now tie the ends of that sutures to itself. And the sutures will dissolve on
their own after several weeks. Now I'll wipe off the nose of dry blood and betadine which
we used to sterilize the skin. And then the patient will be able to wake up from their
anesthesia.