Position. The operation is best done with the patient horizontal on an operating table, with the head and shoulders well raised. His nose is then almost on a level with the eye of the surgeon, who is armed with a frontal search-light or Clar’s mirror (see [p. 571]), although he can also operate successfully with an ordinary forehead reflector.
Fig. 299. Bayonet Knife.
The incision. This can be made with a narrow scalpel, but a much shorter instrument mounted on a bayonet handle cutting all round the point will be found more satisfactory (Fig. 299). The incision is made from the side of the convexity, just anterior to it, and generally about half a centimetre behind the junction of the skin and mucous membrane (Fig. 300). It is started high up in the attic of the nose, and carried downwards to the floor. Sometimes it curves a little backwards below, but it is quite unnecessary to convert it into an L-incision by a second cut backwards. The incision, in its whole extent, divides the mucous membrane and cartilage at one cut, but without puncturing or wounding the mucosa of the opposite (concave) side. In doing this the operator’s forefinger in the opposite nostril serves as a useful guide (Fig. 301). In those cases where the lower free end of the quadrilateral cartilage is displaced from behind the septum cutaneum into one nostril— commonly but erroneously described as ‘dislocation of the septum’—the incision is made directly over the exposed extremity (Fig. 300, b-a).
| Fig. 300. Incision for Submucous Resection of the Septum. The incision is made, on the convex side, from B to A. If the free end of the quadrilateral cartilage is displaced from behind the septum cutaneum, and presents in one nostril, then the incision is made from b to a. | Fig. 301. Making the Incision from the Convex Side in Submucous Resection of the Septum. The forefinger of the left hand acts as a guard in the opposite nostril. |
Raising the convex flap. With a small sharp elevator the muco-perichondrium is raised along the posterior edge of the incision. Great care must be taken not to pass the raspatory between the mucous membrane and the closely adhering perichondrium. The dead white, slightly roughened surface of the bare cartilage should be distinctly visible, and should not be coated with any soft, smooth, or pinkish perichondrium. Once the flap is well started a dull-edged detacher (Fig. 302) will readily undermine it by sweeping movements gradually advancing upwards and backwards. If possible the limits of the convexity should be passed, but it is well not to attempt to go round sharp projections, as it is there that perforations are apt to take place. It is easier at a later stage to strip the flap off crests or spurs.
Fig. 302. Dull-edged Detacher.
Incision through the cartilage. If the cartilage has not already been completely cut through at the first incision it is now divided in the same extent as the cut in the muco-perichondrium, great care being taken not to button-hole the mucosa of the concavity.
Raising the concave flap. The sharp elevator, followed by the dull-edged detacher, is introduced from the incision on the convex side. The muco-perichondrium of the concavity is now raised in the same way and with the same precautions already used on the convexity, the sharp elevator and then the dull-edged detacher being introduced through the incision in the obstructed orifice, and manœuvred between the cartilage and the concave flap without puncturing the latter (Fig. 303).