PREOPERATIVE DIAGNOSES:
1. Nasal airway obstruction.
2. Hypertrophic nasal turbinates.
3. Nasal fracture.
POSTOPERATIVE DIAGNOSES:
1. Nasal airway obstruction.
2. Hypertrophic nasal turbinates.
3. Nasal fracture.
OPERATIONS PERFORMED:
1. Radiofrequency reduction of the bilateral infranasal turbinates.
2. Nasal airway reconstruction.
3. Open reduction of nasal fracture with columellar graft and dorsal grafts.
SURGEON: John Doe, MD
ESTIMATED BLOOD LOSS: 100 mL.
COMPLICATIONS: None.
ANESTHESIA: General endotracheal.
OPERATIVE FINDINGS:
1. Severely convoluted nasal septum and asymmetric nasal dorsal hump.
2. Hypertrophic nasal turbinates.
3. Poor tip and dorsal support.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. After successful general endotracheal anesthesia was established, an oropharyngeal pack was placed. Cocaine and 1% Xylocaine with 1:100,000 epinephrine were placed in the usual fashion for nasal surgery. The patient was draped. We injected 3 mL of saline into the hypertrophic left inferior turbinate and we placed 300 joules of radiofrequency energy posteriorly and 300 joules anteriorly in the contralateral hypertrophic turbinate.
We injected 3 mL of saline and placed 300 joules of radiofrequency energy posteriorly and 300 joules anteriorly. We then made a standard left Killian incision. The mucoperichondrium and mucoperiosteal flaps were elevated. The quadrangular cartilage was disarticulated from the bone and septum posteriorly, and the obstructive portion of the bony septum was conservatively resected. A thin strip of inferior quadrangular cartilage was resected. The obstructing portion of the maxillary crest was cleared of its mucoperiosteum and then conservatively resected. Both inferior turbinates were laterally outfractured. These maneuvers greatly served to improve the airway. Plain suture on the Keith needle was used circumferentially to reapproximate the mucoperichondrial flaps; two of these sutures were placed.
With a fresh #15 blade, we made a left intercartilaginous incision. Soft tissue was elevated off of the cartilaginous and bony dorsum, and we then incrementally lowered the asymmetric cartilaginous nasal dorsum with a #15 blade under direct vision with an Aufricht. We then freshly sharpened osteotomes and removed the asymmetric nasal dorsal hump. When doing this, there was minimal tip support and dorsal support was insufficient. We then formed a precise pocket in the columella with retrograde dissection and shaped and sized a columellar graft, which was placed into the columella and sewn into place with 4-0 chromic in an interrupted fashion. We then, with great care, requiring extra time and dissection, fashioned a dorsal graft from the cartilage.
Two pieces were sewn into place with 4-0 clear nylon, knot was buried, the edges were beveled, and this graft was placed overlying the inadequate nasal dorsum. We then removed the graft. Medial and lateral osteotomies were performed, serving to narrow the asymmetric nasal dorsal hump. We then replaced the nasal dorsal graft, requiring extra time and some manipulation, the dorsal graft was placed into excellent position, providing excellent support of the nasal dorsum. Tip support was excellent.
The incision was closed with 3-0 chromic in running and interrupted fashion. Cosmesis was excellent. Profile alignment was excellent. The nasal dorsum was narrowed from its widened asymmetric preoperative position and the profile alignment was excellent. Telfa and bacitracin were placed bilaterally intranasally. A mustache dressing was placed externally. A Denver splint was placed very carefully over the nose after careful taping. The previously placed oropharyngeal pack was removed. Estimated blood loss was 100 mL. There were no surgical complications.
