Abstract: To explore the method of septoplasty, rhinoplasty nasal function and external nasal shape to achieve the best state. METHODS: ① Using nasal endoscopic septoplasty, rhinoplasty, only the mucous cartilage membrane and mucoperiosteum on the deviated side were peeled off during surgery, the misaligned connection between cartilage and bone was separated, the vertical plate of the sieve bone and the nasal crest of the maxilla were fractured and the cartilage strips were fractured or wedged and resected, and the septal cartilage and bone were realigned so that the three-layer anatomical structure of mucosa-(cartilage-bone)-mucosa was preserved and was in the middle of the lateral wall of the bilateral nasal cavity to ensure that the bilateral The nasal cavity has an appropriate and equal volume and width. The posterior inferior edge of the square cartilage was taken as the material for nasal column and rhinoplasty, and the anterior inferior edge of the square cartilage was retained, thus ensuring the support of the square cartilage to the tip of the nose. RESULTS: This group of cases achieved satisfactory results in both function and appearance after surgery, and no complications occurred. Compared with the conventional submucosal correction of the nasal septum, the efficacy was improved and the operative time and bleeding were significantly reduced, with statistically significant differences (P<0.01). Conclusion: ①In endoscopic septoplasty, it is not necessary to remove the deviated cartilage and bone, but only to separate the misaligned connection of cartilage and bone, fracture the deviated vertical plate of the sieve bone and the nasal crest of the maxilla, fracture or wedge excise the cartilage strips, and realign the cartilage and bone of the septum so that it retains the three-layer anatomy of mucosa-(cartilage-bone)-mucosa to make it straight, and to ensure the proper and equal volume and width of the bilateral nasal cavity, it The maximum improvement of nasal function can be obtained after surgery. The septoplasty not only ensures the three-layer anatomy, but also has significantly lower operative time and bleeding than conventional surgery. ②The anterior lower edge of the square cartilage of the nasal septum has an important supporting role for the tip of the nose. The anterior lower edge of the square cartilage should be avoided as the material in rhinoplasty, and the posterior lower edge should be taken instead. Keywords: septoplasty, rhinoplasty, nasal resistance, nasal endoscopy. Current septal correction procedures include traditional submucosal correction of the septum under headlamp illumination, submucosal resection of the septum, and endoscopic septal correction or submucosal resection of the septum. Both types of submucosal correction of the nasal septum have either separated the mucous cartilage membrane on the opposite side of the incision or not. Compared with submucosal resection of the nasal septum, both preserve part of the square cartilage and remove the deviated part of the vertical plate of the sieve bone, the plough bone and the nasal crest of the maxilla in order to pursue absolute straightness of the nasal septum, leaving part of the nasal septum as a two-layer mucosal structure, which still has the risk of septal perforation. The cartilaginous part of the septum has an important influence on the shape of the nasal bridge and the tip of the nose, and has an important supporting role for the external nose. Deviated septum is often combined with crooked nose and tip deformity, therefore, septal correction involves not only the improvement of nasal function but also an important part of rhinoplasty. In current apical rhinoplasty, the anterior inferior edge of the septal cartilage is routinely used as the best material to support the nasal columella, neglecting its own important role in supporting the nasal tip and nasal bridge morphology. The authors refer to this group of cases as septoplasty in order to distinguish it from the aforementioned submucosal correction of the nasal septum. In this paper, we present 58 cases of endoscopic septoplasty and 3 cases of combined apical deformity with simultaneous apical rhinoplasty. In our septoplasty, only the mucous cartilage and mucous periosteum of the deviated side were peeled off, the square cartilage of the septum was separated from the surrounding bone, and according to the deviation of the vertical plate of the sieve bone, the pear bone, and the nasal crest of the maxilla, the deviated part was fractured but not separated, and adjusted to the middle of the lateral wall of the nasal cavity bilaterally, and then the square cartilage was tensioned and pushed to the middle and the surrounding bone in one plane, so that the septum was centered and straightened, that is, the distance of the septum from The distance between the lateral walls of the nasal cavity, especially the distance between the medial inferior turbinates, is equal, so that the volume of the nasal cavity is equal, and at the same time, the three-layer anatomical structure of each part of the septum is maintained. 3 cases of combined nasal tip deformity, 2 cases of nasal column deformity and 1 case of nasal wing atrophy syndrome. In this group of 3 cases, the posterior inferior edge of the square cartilage of the nasal septum was taken, and the anterior inferior edge of the nasal septum was preserved to ensure the support of the anterior inferior edge of the square cartilage for the stability of the nasal tip. 1, data and methods 1.1, clinical data Treatment group: a total of 58 cases of nasal endoscopic septoplasty and rhinoplasty. The diagnosis was made on the basis of complaints, anterior rhinoscopy and nasal endoscopy, nasal resistance measurement, and in some cases, coronal CT examination of the sinuses.1 There were 20 cases of S-shaped deviation, 21 cases of C-shaped deviation, 17 cases of bony spine and crest, 7 cases of high deviation, 30 cases of leftward deviation, and 28 cases of rightward deviation. Among them, 25 cases complained of simple nasal obstruction affecting sleep, 8 cases of recurrent rhinorrhea, 10 cases of nasal obstruction with migraine, and 15 cases of nasal obstruction with recurrent sneezing and clear or mucous nasal discharge. Male, 36 cases, female, 22 cases, age 17-56 years old. Control group: 62 cases of nasal septal deviation were treated with traditional submucosal correction of nasal septum. Among them, there were 24 cases of S-shaped deviation, 28 cases of C-shaped deviation, 10 cases of bony spine and crest, including 5 cases with high deviation, 29 cases of leftward deviation and 33 cases of rightward deviation. Among them, 19 cases complained of simple nasal obstruction affecting sleep, 6 cases of recurrent rhinorrhea, 25 cases of nasal obstruction with migraine, and 12 cases of nasal obstruction with recurrent sneezing and clear or mucous nasal discharge. Male, 37 cases, female, 25 cases, age 17-68 years old. 1.2. Methods Nasal resistance measurement method: The anterior nasal active manometry was performed using a German-made ATMOS 300 nasal resistance meter, and the measurement results were expressed as the nasal resistance value corresponding to a differential pressure of 150 Pa. Surgery: Nasal endoscopy group: 31 cases under local anesthesia and 27 cases under general anesthesia. The details were as follows: 1% bupivacaine/epinephrine swabs were used to constrict the nasal cavity bilaterally (saline/epinephrine swabs were used for patients under general anesthesia), the nasal septum was fully exposed, and the procedure was decided according to the deviation of the nasal septum. If the deviation is extensive, S-shaped deviation or C-shaped deviation, subchondral infiltration anesthesia with 1% lidocaine/epinephrine injection at the skin-mucosal junction of the anterior portion of the nasal septum on the side of the incision is performed. A C-shaped incision was made 2 mm anterior to the skin-mucosal junction of the septum on the side of the deviated septal projection, and after separating the mucous cartilage membrane and mucous periosteum at the incision with a mucosal knife under the nasal endoscope, the mucous cartilage membrane and mucous periosteum on the deviated side were separated with a stripper with an aspirator, and the joints between the sieve bone vertical plate and the square cartilage and between the square cartilage and the maxillary nasal crest and plow bone were crossed to fully expose the deviated square cartilage, the maxillary nasal crest, the The square cartilage and the vertical plate of the sieve bone were disconnected, the mucoperiosteum of the contralateral vertical plate of the sieve bone was separated, and the deviated vertical plate of the sieve bone was occluded or fractured by occlusal forceps to straighten it in the middle of the lateral wall of the bilateral nasal cavity. The lower edge of the square cartilage is freed from the upper edge of the maxillary nasal crest and the anterosuperior edge of the plow bone, and the mucoperiosteum on the opposite side of the maxillary nasal crest is separated, and the fractured and deviated maxillary nasal crest and plow bone are bitten off with an occlusal forceps, so that they are straightened and placed in the middle of the lateral wall of the bilateral nasal cavity. At this point, if the square cartilage is flat, push it to the middle to dock with the surrounding bone and straighten the nasal septum, removing excess bone or cartilage if necessary to ensure a flat docking of the septal cartilage with the bone. If the square cartilage is severely deviated, the upper edge of the square cartilage projection must be excised 2mm wide cartilage strip parallel to the nasal base, and 1-2mm after the incision 1mm wide cartilage strip perpendicular to the nasal base, so that the deviated part of the square cartilage is free from the anterior, posterior, superior and inferior, the mucosal tension is further reduced, it is pushed to the middle and the nasal septum is straightened. If the square cartilage is centrally convex, the square cartilage can be straightened by removing the square cartilage at the most convex point in the shape of a "cross". If the square cartilage is severely deviated and cannot be corrected by the above method, the lower edge of the square cartilage will be separated from the mucous cartilage membrane on the opposite side, and the deviated part of the cartilage will be removed in one piece, and then put back into the mucous cartilage membrane capsule after fracturing and trimming to make it flat, so that it will be in one plane with the surrounding cartilage and bone, and the whole septum will be in the middle of the lateral wall of the nasal cavity on both sides, so that the volume of the nasal cavity will be equal. The incision is sutured with one to two stitches so that the mucosa is well aligned. It is crucial to reshape the nasal septum after surgery by placing a ventilation tube and filling the nasal cavity bilaterally from the bottom to the top of the nasal cavity with an equal amount of stuffing for 48 hours to ensure that the width and volume of the nasal cavity are equal after surgery to facilitate the improvement of nasal function after surgery. If the deviation is not large and is only localized to the bone spine and crest, the incision is made as close as possible to the deviation, the anterior edge of the crest or spine, and the surgical incision is located on the side of the protrusion of the crest or spine. After separating and peeling the mucous cartilage and mucous periosteum at the crest or spine with a mucosal knife under the nasal endoscope, the cartilage and bone of the deviation are removed by biting forceps and the nasal septum is straightened. This method takes only a few minutes to complete the operation, and there is almost no pain during the operation and minimal postoperative reaction. In this group of cases, three patients had a deviated septum with an apical deformity, and we used it to reshape three patients with an apical deformity by removing the posterior lower edge of the square cartilage of the nasal septum while correcting the septum endoscopically. In two cases, the nasal column was short and one side of the nostril was oblate. A V-shaped incision was made on the nasal column and the medial anterior edge of the bilateral anterior nostrils, and the subcutaneous tissue was separated to expose the medial pedicle of the greater pterygoid cartilage and the anterior edge of the square cartilage bilaterally, and the mucous cartilage and mucous periosteum of the nasal septum were dissected from the deviated side. In one case, the nasal septum was bilaterally atrophied, the anterior nostril was narrowed, and the left side of the nasal septum was deviated in a reverse C-shape, after the septum was corrected endoscopically as described above, the posterior lower part of the deviated square cartilage was removed and divided into After the septum was corrected endoscopically by the aforementioned method, the lower posterior part of the deviated square cartilage was excised and divided into two halves (Figure 1a-1b), which were implanted into the prepared subcutaneous tunnel of the nasal wing, with the inner end against the upper anterior part of the square cartilage and the outer part reaching the subcutaneous part of the nasal wing, and the nasal wing was propped outward with the force of the elastic spreading of the square cartilage, thus enlarging the anterior nostril. Conventional surgery group: all of them used C- or L-shaped incisions in the anterior part of the left septum. The mucous cartilage membrane and mucoperiosteum were fully stripped bilaterally, the square cartilage and the vertical plate of the sieve bone, the nasal crest of the maxilla and the plow bone were exposed, the square cartilage was excised, the upper edge was preserved for 8 mm, 2 mm after the incision was made, the mucous cartilage capsule was reinserted after trimming, and the lower part of the anterior part of the vertical plate of the sieve bone, the nasal crest of the maxilla and the plow bone were removed from the deviation. Five of the cases with high deviation of the nasal septum were not adequately corrected. In both groups, the relationship between the inferior turbinate and the nasal septum was repeatedly evaluated before and after nasal contraction. In cases where the inferior turbinate was significantly enlarged due to bony hyperplasia, terminal inward displacement or mucosal hypertrophy on the spacious side of the nasal cavity, intraoperative low-temperature plasma ablation of the hypertrophied inferior turbinate mucosa was performed before contraction of the nasal cavity by adrenaline swabs, or the inferior turbinate bone fracture was externally displaced to shape the inferior turbinate to reduce its volume so that the septum could be corrected with The septum can be reshaped with reference to the position of the inferior turbinate. To avoid artificial effects of operator proficiency on operative time and bleeding, all cases reported here were performed by the first author as the operator. Analysis of results: The results of operative time, intraoperative bleeding, and nasal resistance were expressed as x±s and analyzed by one-dimensional ANOVA with SPSS 13.0 for windows, with 95% confidence interval and P< 0.05 as statistically significant. 2. Results All nasal endoscopic septoplasties were completed within 10-50 minutes, with a mean of 24.6±8.8 minutes, and intraoperative bleeding was 2-10 ml, with a mean of 5.1±1.78 ml. The nasal septum was corrected to the maximum extent, and all high deviations were corrected, and the septum maintained its three-layer anatomical structure of mucosa-(bone-chondral)-mucosa. In the six-month postoperative follow-up, there was no case of nasal septal perforation, nasal flap, nasal obstruction or dryness, etc. All postoperative symptoms of nasal obstruction or nasal obstruction with headache and nasal bleeding disappeared, and in 15 cases of nasal obstruction with sneezing and clear nasal discharge, the symptoms were significantly reduced in 8 cases and disappeared in 7 cases. The clinical symptoms basically disappeared, and one of the patients with nasal atrophy syndrome had satisfactory results at 9-month postoperative follow-up (Figure 2a-2b). In contrast, the conventional submucosal correction of the nasal septum required 28-60 minutes, with an average of 38.5 ± 6.5 minutes, which was significantly higher than that of the nasal endoscopy group (P < 0.01); intraoperative bleeding ranged from 10 to 32 ml, with an average of 20.0 ± 4.58 ml, which was significantly higher than that of the nasal endoscopy group (P < 0.01). At the six-month postoperative follow-up, five patients with high deviation still felt local discomfort and nasal obstruction on the deviated side, but it was less than that before surgery. In the remaining cases, all the symptoms of nasal obstruction or nasal obstruction with headache and rhinorrhea disappeared after surgery. 7 of the 12 cases of nasal obstruction with sneezing and clear nasal discharge had significantly reduced symptoms and 5 cases had disappeared. In one case, a nasal septal perforation with a diameter of about 2 mm appeared six months later, but there were no obvious discomfort symptoms. The total bilateral nasal resistance of the cases in the nasal endoscopy group before surgery was 0.32 Pa/cm2.S-1~1.29 Pa/cm2.S-1, with a mean of 0.57±0.20 Pa/cm2.S-1, and the total bilateral nasal resistance 1 month after surgery was 0.09 Pa/cm2.S-1~0.28 Pa/cm2.S-1, with a mean of 0.21±0.05 Pa/cm2.S S-1, with statistically significant differences in the preoperative and postoperative comparisons (P < 0.01). In the control group, the total bilateral nasal resistance was 0.35 Pa/cm2.S-1 to 1.26 Pa/cm2.S-1 before surgery, with a mean of 0.59±0.23 Pa/cm2.S-1, and the total bilateral nasal resistance was 0.10 Pa/cm2.S-1 to 0.29 Pa/cm2.S-1 1 month after surgery, with a mean of 0.23±0.06 Pa/cm2.S-1. S-1, and the difference was statistically significant in the preoperative and postoperative comparisons (P < 0.01). There was no statistically significant difference between the preoperative nasal resistance and postoperative nasal resistance of the nasal endoscopy group and the control group compared with each other (P > 0.05). 3, Conclusion Since the joints between cartilage and surrounding bone, the staggered intersection of soft tissues in the joints, and the misaligned connection and deviation of square cartilage and surrounding bone can be clearly seen under nasal endoscopy, and the connection between cartilage and bone can be precisely separated, the excess cartilage or bone can be trimmed off, and the septal cartilage and bone can be reorganized and connected and placed in the middle of the lateral wall of the bilateral nasal cavity, therefore, endoscopic nasal septal Plastic surgery should not only thoroughly correct the septum, but also try to remove the deviated bone and cartilage as little as possible, and rectify the septal cartilage and bone after fracture or strip excision, so that the bone-cartilage scaffold of the septum is basically intact and the three-layer anatomical structure of mucosa-(bone-cartilage)-mucosa of the septum is maintained to avoid complications such as septal perforation and nasal flapping. In order to achieve this purpose, when rectifying and reconstructing the nasal septum, preoperative comparative nasal examination before and after contraction needs to be done repeatedly, including nasal endoscopy and, if possible, preferably coronal CT examination of the sinuses to estimate as accurately as possible the deviation of the nasal septum, the presence of mucosal hypertrophy or osteophytes in the inferior turbinates, the presence of internal displacement of the inferior turbinate ends, the relationship between the nasal septum and the inferior turbinates, their contribution to the patient’s symptoms. In addition to this, nasal resistance testing or nasal acoustic reflex examination is done to objectively evaluate the effect of nasal septal deviation on nasal resistance. On the basis of this information, the surgical plan is designed and decided, and the inferior turbinates are corrected before the septoplasty to ensure that the correct reference is available when the septum is rectified. In both groups of cases reported in this paper, the nasal cavity was adequately evaluated preoperatively as previously described, and special attention was paid during surgery to keep the width and volume of the nasal cavity as equal and appropriate as possible bilaterally; therefore, a good outcome was achieved postoperatively. Since rhinoseptoplasty can correct high deviation, in terms of symptom improvement, the nasal endoscopy group had higher results than the conventional surgery group. As for the operation time and intraoperative bleeding, the nasal endoscopy group was significantly less than the traditional surgery group. Compared with submucosal correction and resection of the septum, some septum after rhinoplasty is not as absolutely flat from the visual effect, but as long as it is ensured that the distance between the bilateral septum and the medial wall of the inferior turbinate is as equal as possible, and the width of the bilateral nasal cavity is equal and the volume is equal, the normal nasal cycle can be established after surgery, thus achieving the purpose of improving the ventilation, heating, moisturizing, and decontamination of the nasal cavity.1-2 Therefore, nasal endoscopic septoplasty achieves both maintaining the three-layer anatomical structure of the septum and achieving satisfactory improvement in function and shape, which is more perfect than submucosal nasal septal correction. The shape of the nasal septum not only affects the function of the nasal cavity, but is often accompanied by a lack of nasal shape, such as a crooked nose and deformity of the tip of the nose. The anterior inferior edge of the square cartilage of the septum plays an important role in supporting the stability of the shape of the nasal tip, the nasal columella, and the anterior nostril. For cases of deviated septum with tip deformity, it is best to perform tip rhinoplasty at the same time as septoplasty. Autologous cartilage is the best material for rhinoplasty, and removing the cartilage from the lower posterior edge of the deviated septum as needed while correcting the septum endoscopically can not only correct the septum, but also ensure the stability of the lower anterior edge of the square cartilage to support the tip of the nose, thus maintaining the interests of the patient to the greatest extent. In this paper, three patients with deviated septum with deformity of the nasal tip were cleverly applied to the deviated part of the septum cartilage for nasal small column reshaping and nasal wing and anterior nostril reshaping.