Number 12 Blade Used with Bayonet Forceps for Precise Reduction of Dorsal Septal Cartilage in Rhinoplasty

Goals/Purpose:

I present a technique for dorsal septal cartilage reduction in rhinoplasty that yields consistent and precise results.  Bayonet forceps are used for the dual purpose of stabilizing the cartilage and providing a “track” to guide the blade for straight incision path.  A number 12 blade is used because its unique concave cutting surface permits the cartilage incision using a motion that occurs in the same vector as the long access of the septum. 

Methods/Technique:

This technique is described in the context of open rhinoplasty.  Generally, a rasp is used to incrementally reduce the osseous dorsal component first.  (Figure 1)  The upper lateral cartilages are then separated from the dorsal septum.  The bayonet forceps arms are applied to either side of the septal cartilage in a manner such that the external edge of the arms mark the plane in which the incision will take place.  (Figure 2) A few millimeters of the pointed tip of the 12 blade can be fractured off to remove the sharp tip. (Figure 3)

The number 12 blade is then placed onto the posterior edge of the cartilaginous septum. (Figure 4)  Due to the concave shape of the blade, the handle is held parallel or nearly parallel to the long access of the septum.  Incision of the cartilage is then actuated by pulling the scalpel cephalic to caudal the length of the septum using the grasping arms of the bayonet forceps as a tract.   Minute serial reductions of less than 1 mm are possible and facilitate obtaining the desired result without over reduction.  The remainder of the rhinoplasty proceeds according to the surgeon's preference.

Fig. 1 – After rasping of bony dorsum a notch exists representing the height discrepancy between the reduced nasal bones and the unreduced cartilaginous dorsum.

Fig. 2 – Bayonet forceps are placed on the septum to stabilize if for reduction and to create a track to guide the 12 blade during incision.  The separated dorsal components are also seen.

Fig. 3 – Fracture removal of the tip of the 12 blade.  Photograph also demonstrates the concave/sickle shape of the 12 blade.

Fig. 4 – The 12 blade is placed behind the most cephalad portion of the unreduced septal cartilage.  The cartilage is incised by simple pulling the blade from cephalic to caudal using the bayonet as a guiding track.

Results/Complications:

This technique has been employed consistently over the past four years for primary, secondary, and cleft rhinoplasty with satisfaction and no complications related specifically to the forceps or blade. (Before: Figure 5, Figure 6, After: Figure 7, Figure 8) In order to validate the technique, a previously published avian sternal cartilage model was used to replicate dorsal septal cartilage reduction.⁵  Using this model I confirmed a decreased septal long axis - scalpel handle angle from 45 degrees or greater with 11 or 15 blades (Figure 9) to 10 degrees or less with the 12 blade. (Figure 10) 

Fig. 5 & 6 – Before rhinoplasty

Fig. 7 & 8 – After rhinoplasty

Fig.  9 – Avian model used to evaluate the angle of incidence and hand position when a 15 blade (or 11 blade) is used.  The angle between the long axis of the model septum and the long axis of blade handle is >/= 45 degrees thus placing the cutting hand farther lateral to the septum.

Fig.  9 – Avian model used to evaluate the angle of incidence and hand position when a 12 blade is used.  The angle between the long axis of the model septum and the long axis of blade handle is </= 10 degrees thus positioning the scalpel hand more medial.  The axis of incision motion is nearly parallel to and virtually on the same axis as the long axis of the septum. This facilitates a smooth and controlled incision motion.

Conclusion:

The shape of the bayonet forceps and the 12 blade works synergistically to provide precision and control in septal reduction.  The bayonet forceps provide two benefits.  First, they support the entire length of the septum during incision thus reducing movement and inaccuracies.  Second, the long and straight grasping surface of the bayonet forceps provides a fixed linear surface to guide the scalpel blade. The number 12 blade facilitates the cartilaginous reduction because its sickle shape orients a portion of the cutting surface facing back toward the handle.  Thus the blade makes cutting contact with the cartilaginous septum while the handle is kept parallel or near parallel to that axis.  This orientation combined with the track-like support of the bayonet forceps results in a very smooth incision action as the handle is gently pulled in a caudal/distal direction.  The smoothness of the incision yields precise and straight cartilage cuts in both large and very small septal reductions and thus represents a distinct advantage.