In functional reconstructive nasal surgery, incisions are almost always closed. The only exceptions are minor stab incisions. By closing the incisions, the tissues are adjusted and fixed in their new position; postoperative bleeding is prevented as well as scarring and stenosis.

Endonasal mucosal and skin incisions are generally closed with resorbable materials such as Vicryl Rapide (4–0, or 5–0) or PDS (Polydioxanone). This applies to the common endonasal skin incisions used for approaches—such as the caudal septal incision (CSI), intercartilaginous (IC) incision, and vestibular incision—as well as all incisions of the septal and buccal mucosa. A great advantage of using resorbable sutures endonasally is that no sutures have to be removed from the inside of the nose during the first postoperative days.

External skin incisions are closed with nonresorbable monofilament synthetic materials such as Ethilon or Prolene (5–0 or 6–0). These are also used to close special incisions in the nasal vestibule, such as infracartilaginous incisons.

Fixation of plates or grafts of cartilage to rebuild the septum or other structures is usually done with slowly resorbable materials such as Vicryl or Dexon (2–0, 3–0, 4–0).

• Ethilon 5–0 (No. EH7804H) or Prolene 6–0 atraumatic with cutting needle (No. 8695H) to close external skin incisions, such as midcolumellar and infracartilaginous incisions (external approach), alarfacial incisions, and stab incisions.

Notes

The numbers of the suture materials mentioned above are those used by the company Ethicon.

In most countries, suture material made from animal tissue, such as catgut, is no longer used. It is forbidden because it is potentially hazardous for transmitting prion diseases.

Fig. 10.2b A repositioned pyramid is fixed in the midline by a bilateral sling.

There is no consensus on the need for internal dressings. Many surgeons, like ourselves, prefer to apply them in almost all cases of septal, pyramid, and lobular surgery. Internal dressings serve three purposes: 1) to keep the septum in the midline and prevent septal hematoma; 2) to support the nasal bones, cartilaginous pyramid, and lobular cartilages in their new position; and 3) to limit risk of postoperative bleeding.

• Gauze strips 2 cm in width soaked in isotonic saline or with ointment (e.g. with Terracortil).
  
• Adaptic nonadhering dressing (Johnson & Johnson). Available in squares of 7.6 × 7.6 cm from which strips 1–2 cm in width are cut as required.
  
• HydroCell (hydrophylic polyurethane) (Smith & Nephew); various sizes with drawstring.
  
• PVAc sponges (hydroxylated polyvinyl acetate), Merocel, Ivalon, various forms and sizes with drawstring.
  
• Foam (Spiggle & Theis).

Postoperative taping of the external nose is essential in all cases of pyramid and lobular surgery. Tapes are applied: 1) to adjust and keep the various soft tissues in their new position; 2) to diminish postoperative edema and the risk of hematomas and ecchymoses; and 3) to protect the surgical field.

Depending on our surgical goals, we usually start by applying one or two specific tapes, such as:

• Leukoplast (Beiersdorf), white 1 cm.
  
• Steristrip (3M), 12mm (No. R154J)

Note

Tapes are removed with cotton-wool applicators soaked in benzine.

Fig. 10.2d A tip-lift tape fixes the tissues in their new position after upward rotation of the tip.

Fig. 10.2e Pressure tapes on the dorsum fix a rib graft or other transplant material and prevent hematoma.

Fig. 10.2f The external nose and the cranial half of the upper lip are completely taped for fixation and protection and to prevent edema.

Internal dressing vs nasal packing We suggest using the term “internal nasal dressing” when gauzes are applied endonasally to adjust the repositioned nasal structures and keep them in their new position.

The term “nasal packing” is only used when gauzes are more or less forcefully brought into the nasal cavity to stop nasal bleeding.

Fig. 10.3b A stent of thermoplastic material (e.g. Hexcelite) offers less protection but can be remolded easily.

Fig. 10.3c The stent is fixed with tapes to the forehead and cheeks.

Plaster of Paris allows a very good fit but also has certain disadvantages. Making the stent is rather time consuming (it takes about 5 minutes to harden) and somewhat messy. A second drawback is that a stent of plaster cannot be remolded. Thus, if the postoperative swelling subsides after some days and the stent no longer fits, a new one has to be made.

The use of thermoplastic material has the advantages of simplicity and cleanliness, while remolding is easy. The fit is not as good as with plaster of Paris, however. There are also soft aluminum splints on the market.

• Biplatrix plaster of Paris (Beiersdorf).
  Usually six layers are used. They are cut to the required size and shape with heavy scissors.
  
• Hexcelite orthopedic tape (Hexcel Medical Products, Welkenraedt, Belgium).
  
• Thermoplastic external splints (NasofixTM Thermo, Atos; AccuformTM external splint, Smith & Nephew; SoftFormTM, Spiggle & Theis).
  
• Soft aluminum external splints (Smith & Nephew; SoftFormTM, Spiggle & Theis); various sizes and custom-cut.

Fig. 10.5 A prosthesis (“septal button”) is cut to measure for closing a septal perforation.

• Bivalve septal splint (Reuter; Atos; Invotec; Smith & Nephew; Spiggle & Theis; Micromedics), Silicone or polyethylene. Available in two or three different sizes with a thickness of 0.25mm and 0.5 mm.
  
• Custom-cut splints (Invotec), fluoroplastic; 0.25 mm, 0.5 mm, 1.0 mm, and 1.5mm thickness.
  
• Septal splints with airway. Some surgeons prefer to use septal splints with airway. We do not use them. The advantages for the patient are usually less than expected and these rather massive splints may interfere with a careful application of the internal dressings.

Sheets of medical grade silicone or fluorplastic may be used to prevent synechiae and to keep a reconstructed nasal valve or vestibule open.

• Silastic sheet (Invotec, Smith & Nephew; Spiggle & Theis); 0.5 mm, 1 mm, 1.5 mm thickness.

• Silicone septal button (Atos, Invotec, Smith & Nephew, Micromedics, Spiggle & Theis); medical grade silicone, available in two sizes.

The quality and success of a surgical intervention depends mainly on the following factors: analysis of the pathological condition; surgical concept; skill of the surgeon, anesthesiologist, and surgical assistants; and quality of the instruments.

Since the beginning of modern surgery in the 1880s, hundreds of instruments for nasal surgery have been designed. More than 50 authors have contributed to their development. Often, their names are still linked to the instruments they have introduced or popularized. However, most of the tools currently in use are no longer identical to their original designs. Generally, major and minor changes have been made by other surgeons and instrument makers. Nonetheless, in many cases the name of the originator is still linked to the instrument, largely for practical reasons. During surgery, for example, it is simpler to ask for a “Graig” than for a “heavy, biting septum forceps.” A side effect of this custom is that younger generations become familiar with the names of some of the pioneers in nasal surgery.

The discussion and illustrations in this chapter only deal with the instruments used in the departments in Utrecht (the Netherlands) and Ulm (Germany). The authors are fully aware of the fact that many other valuable and effective instruments are available.

• Six cotton-wool applicators.
  
• Small cup with 200 mg crystalline cocaine.
  
• Small cup with 10–15 drops of adrenaline 0.1%.
  
• 10–20 ml lidocaine 1% with adrenaline 1:100 000.
  
• 3-ml syringe.
  
• 16-mm/0.5-mm and 40-mm/0.8-mm needles.
  
• Short nasal speculum.

• Small cup with 10 ml cocaine 3% with adrenaline 1:20 000.
  
• Small gauzes.
  
• 3-ml syringe.
  
• 16-mm/0.5-mm, 40-mm/0.8-mm, and 50-mm/1.1-mm needles.

Fig. 10.7 Instruments for local anesthesia and vasoconstriction. a Six cotton-wool applicators. b Cotton wool. c Small cup with 200 mg crystalline cocaine. d Small cup with 15 drops of adrenaline 0.1%.

Fig. 10.8a Short, broad speculum (Hartmann–Vienna type). b Narrow, medium-long speculum (Cottle).

Fig. 10.8c Medium-long speculum (Killian). d Long speculum (Killian).

Fig. 10.10 Disposable blades

Fig. 10.12a-c Retractors: a alar retractor (alar protector); b short, angulated retractor (Aufricht); c long, angulated retractor (Aufricht).

Fig. 10.12d–f Retractors: d uneven, four-pronged, blunt retractor (Cottle); e double retractor (Neivert); f double retractor (Aiach).