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Nasal reconstruction need not be complex to be efficacious

Article-Nasal reconstruction need not be complex to be efficacious

Key iconKey Points

  • 'Reverse nutcracker' procedure maintains and improves the airway, surgeon says
  • Reverse nutcracker can be performed in conjunction with other nasal reconstructive procedures
  • Valve problems are often the cause of nasal airway obstruction

In nasal reconstruction, the most complex procedure or diagnostic test isn't necessarily the best, according to one surgeon.

Dr. Lesavoy
The traditional approach to submucosal resection for patients with nasal obstruction is a fairly difficult procedure, says Malcolm A. Lesavoy, M.D., an Encino, Calif., plastic surgeon and clinical professor of plastic, cosmetic and reconstructive surgery and hand surgery at the University of California Los Angeles Medical Center. "It's usually bloody," he says, and it carries risks such as septal perforation. "Sometimes you miss a piece of the vomer, or some cartilage, and postoperatively the patient isn't that much improved."

Conversely, Dr. Lesavoy says that a procedure he calls the "reverse nutcracker" is "an extremely simple way of fixing the airway. It has nothing to do with aesthetics at all. It's all about maintaining and improving the airway."

To perform the procedure, he says, "Take a wide-bladed speculum or a large Pean clamp and place it in the nostril, down to where the obstruction is. Then you basically open up the instrument inside the nostril," and repeat the procedure in the other nostril. "You're basically doing a forceful closed septal osteotomy. When you're doing this, you'll hear a little crack or pop. Essentially, you're making an airway. The whole procedure takes maybe eight seconds. Nothing could be simpler."

SIMILAR EFFORTS According to Ronald P. Gruber, M.D., "Many years ago, Dr. Lesavoy and I realized we were both doing the same thing — he was using a Pean, and I was using a large nasal speculum. When you spread with a nasal speculum, you fracture perpendicular plating and outfracture the turbinates. I'm happy it works in most all cases." In a few cases, "I have to go back and do some bony work on the perpendicular plate if the patient has an unusual piece of bone sticking up that is separate from the cartilaginous septum." Dr. Gruber is an Oakland, Calif., plastic surgeon and an adjunct clinical faculty member of Stanford University School of Medicine.

Dr. Gruber says he performs this maneuver routinely on every nasal reconstruction patient. "Often, we are doing lateral osteotomies, which compromise the airway," he says. "So we should do a prophylactic septoturbinotomy to compensate for what is going to be some partial airway obstruction from the lateral osteotomy."

Surgeons can perform the reverse nutcracker procedure in conjunction with other nasal reconstructive procedures, Dr. Lesavoy says. "If I'm doing it in conjunction with a rhinoplasty, for example, I don't even charge for it. There is essentially no dissection and very little bleeding." In his hands, the procedure works for any patient who complains of inability to breathe through the nose, he says.

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