PROCEDURE IN DETAIL: 
The patient was brought to the operating room, and consent and identity were verified.  General anesthesia was induced, and the patient was intubated by the Anesthesia team.  Afrin-soaked cotton pledgets were inserted into each nasal cavity.  The bed was spun 90 degrees.  Operative time-out was performed to confirm the correct patient, procedure, and laterality.  The nasal septum was injected with 1% lidocaine containing 1:100,000 epinephrine.  The patient was prepped with betadine and toweled out in a sterile fashion.

The pledgets were removed and the nasal cavities were inspected.  The septum was noted to be deviated as described above, and the turbinates were noted to be hypertrophic.  A hemitransfixion incision was made on the left in the membranous septum and a small pocket was developed over the caudal septal cartilage.  The perichondrium was incised sharply and elevated with a Woodson in a subperichondrial plane.  The plane was elevated superiorly and posteriorly using a 0-degree endoscope and suction Freer until the bony septum was reached.  The elevation was carried inferiorly until the maxillary crest was reached.  An incision was made in the quadrangular cartilage parallel to the caudal margin preserving a 15 mm caudal strut.  The right-sided mucoperichondrial flap was elevated using the 0-degree endoscope and suction Freer.  The bony cartilaginous junction was disarticulated with a Cottle and a dorsal cut was made preserving a generous dorsal strut.  The deviated portion of the quadrangular cartilage was then separated from the maxillary crest and removed.  Additional deviation in the bony septum was addressed: a cut was made with the Mayo scissors superiorly to detach the deviated bony septum from the skull base and then the bone was removed using a Takahashi.  Additional maxillary crest was resected where it narrowed the nasal cavity.  Once the septum was well-reduced, the pocket was irrigated and any remnant pieces of bone and cartilage were removed.  The nasal cavity was inspected on both sides to ensure an adequate septoplasty had been performed.

The head of the inferior turbinate on each side was injected with additional 1% lidocaine with 1:100,000 epinephrine.  Beginning on the left, a stab incision was made in the head of the inferior turbinate and the soft tissue was dissected off the turbinate bone using a Cottle elevator.  Submucous resection was performed using a 2.9 mm turbinate blade and then the turbinate bone was outfractured.  On the right-hand side, a stab incision was made in the head of the inferior turbinate and the soft tissues elevated off the bone using a Cottle elevator.  Submucous resection was performed using a 2.9 mm turbinate blade and the turbinate bone was outfractured.

The nose was then cleaned and inspected on both sides.  The septum was now midline and the inferior turbinates were well-reduced.  The middle meatus and nasal choana were easily visible on each side using a nasal speculum and anterior rhinoscopy.

The left hemitransfixion incision was closed with 5-0 fast gut in an interrupted fashion.  A 4-0 plain gut on an SC-1 needle was used to perform a quilting suture beginning at the posterior septal angle and carrying this up towards the anterior septal angle and then posteriorly along the dorsum.  This then zigzagged back anteriorly and was tied off at the posterior septal angle.  Doyle splints were inserted into each nasal cavity and sutured in place anteriorly with a single 3-0 Prolene suture.  The knot was tied on the left-hand side.  The oropharynx was suctioned out.  The patient was turned back over to anesthesia, awakened, extubated, and taken to the recovery room in good condition.

COMPLICATIONS:  None.

SPECIMENS:  None.

BLOOD LOSS:  50 mL.

DISPOSITION:  PACU and home.