A number of maneuvers are at the surgeon's disposal in the treatment of a caudal septal deviation (4,5). Traditional approaches include scoring the septal cartilage on the concave side, thereby relaxing the "spring" of the cartilage. This may be done as a solitary maneu­ ver, or in conjunction with a so-called "swinging door maneuver." As illustrated in Fig. 3, a wedge of cartilage excised along the maxillary crest releases the caudal septal attach­ ments and allows the septum to swing to the midline. The midline position may be secured with a 4-0 PDS attached to the periosteum adjacent to the opposite side of the nasal spine.

Ethmoid bone splinting grafts or sandwich grafts also may be of benefit in this situation (6). A straight piece of bone is harvested; a large straight Keith needle may be used as a del ­ icate hand-held drill to make holes in the bone graft. The deviated portion of cartilaginous septum may be addressed by scoring on the concave side, and the bone graft or grafts may then be used to splint the septum in a straighter orientation. However, use of the ethmoidbone graft in this location thickens the caudal septum and can contribute to nasal obstruc­tion. The ethmoid bone sandwich grafts may be used to address a deviation of the dorsal septum, where the additional septal thickness caused by this graft is well tolerated (Fig. 4).

In cases of a severely deviated caudal and dorsal septum, the offending portion may be excised and replaced with a straight piece of cartilage, typically harvested from the septum more posteriorly (Fig. 5) (4). Suture fixation to a stable segment of cartilage attached at the osseocartilaginous junction and nasal spine will allow reconstruction of an intact L-strut to support the lower third of the nose. The reconstructed caudal segments can be sutured be­tween the medial crura to set nasal length, projection, rotation, and the alar/columellar re­lation.

Figure 3. Deviated caudal septum, "swinging door" maneuver.

Figure 4. A splinting graft of ethmoid bone may help main­tain the septum in a straighter orientation.

Figure 5. Septal replacement for severe cases of deviated caudal and dorsal septum. In the first case example, a segment of caudal sep­tum is removed and replaced with a straight piece of septal cartilage harvested pos­teriorly. As illustrated, the replacement cartilage is extended caudally and se-cured between the medial crura as well. In this case, a tip graft also was applied. Preoperative and postoperative comparison. This series of intraoperative photographs illustrates total replacement of the severely deviated caudal septum. The severely deviated component is removed, along with pos­terior septum. The deviated septum is replaced with straight septal cartilage harvested posteriorly. A tip graft also was applied.

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