The classic Killian incision

The classic Killian incision extends posterior-inferior­ly. Frequently, as dissection proceeds posteriorly, a tear occurs along the inferior aspect. When the cartilage isincised to allow submucoperichondrial dissection on the opposite side, at this location, the mucoperichondrium is at risk for tearing directly opposite the Killian incision. This puts the patient at high risk for a septal perforation. At this location, septal perforations are frequently symp­tomatic. The modified Killian incision avoids the risks of the classic Killian incision while bypassing the caudal septum (Figure 2). This incision placement also permits extension along the floor, which is useful if a floor tunnel becomes necessary (eg, when the patient has a severe spur along the maxillary crest).

Using a 15 blade, small sharp pointed scissors, or other suitable instrument, I then incise the perichondrium of the septum adjacent to the caudal septum on one side. I perform a submucoperichondrial dissection along the lower half of the septum to allow harvest of septal carti­lage, if needed. If I plan to place a spreader graft by way of an endonasal approach, I am careful not to extend this dissection too high, so that later in the dissection I can make a precise tunnel for the spreader graft.

Next I elevate the mucoperichondrial flap on the opposite side. If I have used a hemitransfixion incision, I begin at the caudal septum. If I have used a modified Killian incision, I gain access to the opposite side by incising the cartilage just anterior to the offending (devi­ated) portion, taking great care to preserve a generous L-strut of at least 15 mm for continued nasal support.

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