See how septoplasty surgery is performed in this video shot from the surgeon's perspective.
Using a novel, high definition point-of-view camera, Seattle Facial Plastic Surgeon, Dr. Thomas Lamperti, narrates an intra-operative video showing an overview of how closed septoplasty surgery is performed. The typical incisions and techniques used are discussed as are the methods of suturing the incisions. You will also see how Dr. Lamperti is able to avoid needing to use any post-operative nasal packing.
"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."