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Hello and welcome Doctor Stephen Mulholland in Toronto, Canada, plastic surgery talk, and welcome to another installment of our podcast series. If you find these engaging, entertaining, educational, please share, subscribe and comment.
Today’s podcast is on Septoplasty, or the management of airway surgery. The management of airflow, in conjunction with cosmetic Rhinoplasty. So what is a Septoplasty, or what is airway surgery? Airway surgery is the operative intervention on anatomic, or functional obstacles to air passing back and forth through the nose, without obstruction. There are a number of anatomical components that can get in the way, or block the free flow of air and give the sense of inability to breathe through one of your nostril openings and passages. One of the principle anatomical structures is called the septum, or the partition. It’s that partition in the middle of your nose that divides your nose into a right and a left half, and the partition can be straight in which case the air will often flow in a laminar pattern and you’ll have nice air exchange. However, if your septum tends to be deviated, or deflected, on one side or the other it can cause turbulent flow. One side if flowing well and the other is turbulent, and you perceive you can’t breathe through one side or the other. So the septum, or the middle partition, can sometimes block one side or the other, and that will often require correction.
The correction of that septum, where it’s straightening or removal of the crooked part, is called a Septoplasty.
So what do you get out of a Septoplasty, why is a Septoplasty a procedure, and when is it offered? In general, you can get a Septoplasty as a stand alone procedure, with no cosmetic Rhinoplasty or nose job. That kind of airway breathing surgery is generally covered by the manage care and health care plans of most provinces and states, and private insurers. In my practice, as a busy cosmetic nose job or Rhinoplasty surgeon, I don’t offer Septoplastys alone. I offer a cosmetic reduction Rhinoplasty, or a nose job, and if you have airway issues, concerns or blockages, then we offer a Septoplasty as part of the Rhinoplasty procedure.
So a Septoplasty then corrects air flow, and if we make a nose smaller, so particularly during reduction Rhinoplasty making the nose narrower, taking the bridge down, we want to make sure that the four lane highway, which is the air passages, doesn’t become a two lane highway and obstruct airflow. So you can have a straight septum, reduce the nose and still sometimes end up with relative airway constriction. So we take a look at other anatomical structures too, so the word Septoplasty refers to the septum, but often a nasal surgeon like myself will look at other structures like the turbinance, which can encroach from the side wall whereas the septum is in the middle. We may do partial Turbinectomy, or sub terbinectomy which is reduction of your turbinants.
We may look at other internal structures, such as what’s called the internal valve, because your breathing can close off when we do procedures such as Spirographs to open the internal valve. So when I say I’m going to be doing a reduction Rhinoplasty, which includes Septoplasty, it really means airway management surgery, which can be Septoplasty or management of straightening the septum, a Turbinectomy for side wall obstruction, and internal valve surgery and external valve surgery to make sure there’s no functional collapse. So a good nose surgeon, a good cosmetic Rhinoplasty surgeon, is always gonna be very cognoscente and serving your airway as well, and providing airway surgery at the same time. Septoplasty and airway surgery are to ensure after your cosmetic reduction Rhinoplasty, you still breathe well.
So who is a good Septoplasty candidate? Well someone who is undergoing cosmetic Rhinoplasty procedure, that has a deviated septum that either has compromised breathing going into the surgery, or may have compromised breathing if we don’t do the Septoplasty surgery is usually the most common candidate in my practice. So a patient undergoing cosmetic Rhinoplasty that needs reduction of the Septoplasty to ensure, or minimize the risk, of compromised breathing after.
Often the Septoplasty is also done to harvest graft material, so we take the cartilage, the stiff cartilage of the septum, and we make tip grafts, and support grafts, structural support for the cosmetic Rhinoplasty to ensure a long-term, stable outcome and result. So you can be a candidate for Septoplasty for breathing, and breathing surgery, and also harvest of graft material that’s used to structurally support your cosmetic Rhinoplasty patient.
Patients who have airway obstruction, before their Rhinoplasty who are having reduction Rhinoplasty, or clearly indicated for Septoplasty procedure, and usually we’re good at getting about 90% of patients breathing the same or better after cosmetic Rhinoplasty. About 8% of patients, despite the best Septoplasty and airway surgery that a surgeon can do, management of all anatomic structures and functional valves that might lead to constricted airway and compromised breathing, can sometimes, in 8% of cases, still love their nose job and feel that one or the other side is slightly compromised. So there’s about an 8% risk, despite Septoplasty and other functional airway surgery, that your nose looks great but your airway is slightly compromised, and that’s one of the risks of going into a reduction Rhinoplasty that patients need to be accepting of.
There are very few prior indications to a limited sub-total Septoplasty. The indications are: harvest the graft material for your structural Rhinoplasty procedure, or correction of airway. There are some patients, however, who have very limited septum following college emasculate diseases, and we may need to leave that septum in tact. Patients with bleeding disorders, or platelet scarcity may not be a good candidate for Septoplasty. Patients who have undergone some transnasal abuse of drugs at a younger age, such as cocaine, often have large septo-perpetration, or septo-compromise, and they’re not good candidates. So we sort out anatomic, metabolic and functional reasons why you may not be a Septoplasty candidate. But for primary reduction Rhinoplasty, or making your nose job to form a nasal facial contour that’s smaller, virtually every candidate who is healthy is a good candidate for a Septoplasty. Either for graft material for your nose job, or for preventative or therapeutic intervention on airway obstruction.
So how is Septoplasty performed? There are a couple different techniques. There is Endonasal, or internal Septoplasty, where all the surgery is done through one of the arrays. The lining of the septum is lifted off, and the septum is exposed, and the small piece or the deflected/obstructed part of the septum is removed. Then the flaps over the septum are re-sutured with dissolvable sutures. That’s a Peer Septoplasty.
In general, with reduction Rhinoplasty, the septum is operated on during the Rhinoplasty, so the skin is lifted up if it’s an external approach, the septum is exposed. Enough support is left behind to structurally support the nose after the surgery, but a relatively large segment of the septum is often removed during reduction Rhinoplasty; both to facilitate breathing after, and also to have enough graft material for tip support, structural support of the middle third of the vault, tip grafting, other internal valve structural support. So a lot of ways that we use the septum to support the cosmetic Rhinoplasty, so we take the septum during a nose job, both for form and breathing, and structure of the Rhinoplasty itself. When the nose is closed, the flaps are put back up to the residual septum internal dissolving sutures are used, and you never see any scars from the Septoplasty, they’re all internal.
In general, if you’re undergoing a reduction Rhinoplasty and you’re taking the bridge down, and the side walls in, and you’ve done a preventative Septoplasty for airway flow, you will notice that you’ve had a successful Septoplasty when your reduction Rhinoplasty looks great and your breathing the same, or better. That was only achieved by your surgeon doing an excellent job at airway management surgery, looking at all the relative obstructive legions, turbinants, internal/external valve and septum, and addressing them while making your nose smaller. So you have a smaller nose that you breathe the same through, that’s a great result, and you know your Septoplasty was successful.
You know you’re successful with your Septoplasty if you had airway obstruction that you can’t breathe through one side or the other; you had your nose operated on, and you had your septum operated on as well and you have a nice nose job, and you’re obstruction becomes clear or improved airflow, in the face of a smaller nose. That’s, again, airway flow improved, successful indication that you’re Septoplasty went well.
What’s an indication that it didn’t go as well as anticipated? You have airway obstruction after your reduction Rhinoplasty, there’s one side of the nose or the other that doesn’t breathe as well. That may be due to a variety of factors, septum being one of them, and you’d revisit with your nasal surgeon after about 6 months, because it takes about 6 months for the internal environment to settle and to truly manifest the kind of airflow you’re gonna have after a cosmetic Rhinoplasty.
What’s the recover from a Septoplasty? Well, the recovery period can be measured in short term recovery, and then long term recovery. Short term recovery is the healing of the risk of the septum oozing or bleeding after. So invariably, after a Septoplasty where the linings are quite fragile and we restitch the linings, some type of packing control is performed by your surgeon. Some surgeons use little hollow tubes that they put down each nostril, and suture those to the septum so you can breathe through your nose while compression is placed against the lining of the septum, for five to seven days. Then those are removed, and then the risk of having a post-septoplasty nose bleed is very low, because they can still occur but it’s very low.
Other surgeons still will use more of a traditional technique, where the nose is packed on either side with a soft, vastly impregnated, packing gauze. That gauze is removed on day three, to five. By removing the gauze, you can then breathe again, but you haven’t been able to breathe during that three to five day period, and you’ve been a mouth breather. That would be the typical packing, the traditional packing technique versus the insertion of the compression, open airway nasal tubes. Either way, your surgeon is gonna select with you one of those two techniques to minimize bleeding. So the short term recovery is the removal of the packing technique. Once the packing technique is removed, you still may have a little obstruction because there’s a lot of swelling and edema inside the nasal mucosal; the lining of the nose.
Don’t be alarmed if you’re still a little obstructed, because it takes about 6 months or more for long term recovery, a long term healing which is the resolution of optimal airflow after Septoplasty, Turbinant and maybe internal valve surgery. By about three months, three to six months, the airflow you’re experiencing then will probably be the terminal airflow you can expect after your internal airway surgery, and that’s the long term recovery. Short term; minimizing the risk of bleeding. Long term; optimizing the recovery of airflow after your septoplasty surgery.
So what are the side effects, or the complications of septoplasty surgery? The number one side effect is you may do a septoplasty, or internal airway surgery with turbinents and valves, and you may still have obstruction. So residual or persistent obstruction. You may have a completely normal airway, with patent airflow, during reduction rhinoplasty and functional airway surgery, and have one side or the other that’s compromised. So new onset airway obstruction can occur after airway surgery, including septoplasty. There may be increased risk of minor nose bleeds during the winter months, because you have dry air and you have scar tissue not he septal lining, and it’s not as, it doesn’t make as much mucus. You may have the odd little nose bleed once or twice during the winter months, so have a humidifier in the room, minimize inhalation of dry air. There may also be some areas of pain or discomfort while you’re healing, and with septo-surgery it may actually have some change in smell, and the persistence of certain smells especially if there’s an area of dryness or crusting. You may have ongoing crusting, and nasal cleaning that you need to perform after septoplasty. That can also occur.
Those are the short and long term side effects, most consistently associated with septoplasty; the most common being some residual or re-occurent airway obstruction despite the septoplasty surgery.
Many surgeries do require some maintenance. Botox requires maintenance, soft tissue fillers require maintenance. Nose surgery, a good reduction nose job, is once ina lifetime. You get a good result, and it lasts. Same with septal surgery. If the septum is reduced, maintained in a stable fashion in the mid line of the nose, and you have good airway exchange, there’s not maintenance required for septal reduction surgery, or septoplasty.
If, however, you undergo a traumatic event; baseball to the nose, you slip and fall on the ice, and you break your nose or injure the septum, you may need secondary septal surgery. So care and intention to avoid trauma, clearly some trauma would be avoiding intra nasal chemicals such as cocaine, or other inhalational agents are very bad for your septal and your colas environment. So a properly performed septoplasty, with good airway outcome, is a lifetime of improvement and requires no specific maintenance.
What are some of the common combination treatments with septoplasty? Well we mentioned some of those. We can divide those into combination intra nasal surgeries, and so a good intra nasal rhinoplasty surgeon will look for your turbinents, side wall blockages, will look for functions valves such as the internal/external valve, the septum and it’s position in the mid line, and even post air nasal issues such as pollups, air cell issues, obstruction into the maxillary sinuses or blocked tear ducts. Other ansillery treatments that improve nasal function may be done at the same time as your airway surgery.
The most common adjunctive surgery is reduction rhinoplasty, or cosmetic rhinoplasty, in conjunction with a septoplasty. Then of course other cosmetic facial procedures such as upper lid, lower lid blepharoplasty, brow lift, mid face, face and neck lift, can be done at the same time as a septo-rhinoplasty, as can any body surgery be done. So adjunctive cosmetic surgery, and adjunctive airway surgery are the most common things that we combine with septoplasty procedures.
So cost in recover. Price of septoplasty varies depending on whether it’s private pay or manage care covered. Manage care coverage septoplasty is covered by a ministry of health in almost all provinces, and most states. If it’s private pay, septoplasty surgery itself can run between five and ten thousand dollars. In general, in most countries where there is manage care coverage of airway obstruction, the cosmetic nose surgeon will not charge the patient for the airway breathing or functional part of the surgery. So you’re paying for the cosmetic rhinoplasty, and you’d get the septoplasty functional valve surgery and turbinent surgery at no additional charge because it’s covered by the manage care plans. In general, five to ten thousand dollars for private pay septoplasty is not uncommon, and it’s done for functional reasons for the improvement of airflow. It can be done for cosmetic reasons, as a source of graft material, and preventative in reducing the nose, insuring open passage way after a smaller passage is created.
So thank you for joining me, Doctor Stephen Mulholland, here in Toronto Canada on plastic surgery talk with our latest podcast installment; septoplasty. How do we do it, and where does it fit in the scope of cosmetic rhinoplasty. Again, if you find these podcasts entertaining, informative, entertaining, please subscribe, share and comment. See yeah next time.