Septal Surgery Challenges in Rhinoplasty.

During rhinoplasty, the most stressful areas of the nasal cartilaginous septum are at the key area and anterior nasal spine. A stable fixation of the caudal septum to respond to these stresses is of utmost importance. The prerequisite for a successful fixation is a well-prepared recipient bed for caudal septum and suture fixation. The bed can be opened by using scissors, osteotome, or powered instrumentation. Simple or multiple sutures passing from the bone and/or surrounding soft tissues are used for fixation. At the key area, if a complete separation of the L-strut occurs, it should be sutured to nasal bones and upper lateral cartilages. The septum should be supported by splinting spreader grafts to increase stability. To prevent dorsal irregularities, a dorsal onlay camouflage graft should be used. The best way is to take cautions to prevent such a mishap. That is why a dorsal segment of 12 to 15 mm should be preserved, at least at the key area, and part of the mucoperichondrium should stay attached to the septum.