Reconstructing the nasal septum in rhinoplasty surgery

Nasal septum reconstruction is an essential component of a successful rhinoplasty for both nasal cosmesis and function. In this review, we provide both historical strategies and contemporary updates in nasal septum surgery. Conventional septoplasty involves removal of deformed septal cartilage, with care taken to maintain the integrity of the dorsal and caudal cartilaginous L-strut and avoid opposing mucoperichondrial flap perforations that can cause septal perforations after the healing period. When these conditions cannot be met, advanced septal reconstruction techniques may be required to address caudal septal deviation, dorsal septal deviation, and septal perforations, including extracorporeal structural reconstruction in particularly severe cases. Recent refinements of these more extensive techniques also include subtotal and anterior modifications to total septal reconstruction to better preserve the keystone area and dorsal preservation techniques to minimize disruption of aesthetically desirable aspects of the native nose. We conclude with an algorithmic pathway containing major considerations that highlight advantages of each technique described in this review to guide the rhinoplasty surgeon toward appropriate maneuvers to achieve the desired cosmetic and functional result in septal reconstruction.