Anatomical variation of the nasal septum: analysis of 57 cadaver specimens.

OBJECTIVES: The purpose of this study was to examine the anatomical variation of the osseous and cartilaginous components of the nasal septum. STUDY DESIGN: Fifty-seven cadaver specimens were digitally scanned and analyzed utilizing Bersoft Image software. Anatomical data were statistically analyzed utilizing SPSS 13.0. Evaluation of the area of the osseous/cartilaginous nasal septum as well as an estimation of the available cartilage for grafting was performed. RESULTS: Septal specimens revealed males had greater variation in cartilaginous area compared to female specimens. The intranasal/extranasal cartilage contributes about 45%/55% of the total cartilage, respectively. The data indicate that the mean area of cartilage available for grafting is around 420 mm(2). CONCLUSIONS: Significant variability in the cartilaginous elements of the nose is the rule rather than the exception. Key differences exist in the anatomic location of the graft material between males and females. This has important surgical implications given the critical attention required during graft harvesting in order to maintain support of the nose.     

External septorhinoplasty in the cleft lip nose

When the entire septum as well as the cartilaginous vault are exposed to direct vision by degloving the nasal covering, the complete extent of the deformities in cleft lip nose can be clarified. The septal cartilage is hollowed out leaving an L-shaped anterosuperior portion, whereas the intranasal structures are simultaneously altered to ensure the patency of the nasal airway. An adequate-sized piece is cut from the removed cartilage and is fitted to the anterior part of the remaining cartilage to enforce the columella, which acts as a strut to keep both lower lateral cartilages symmetrical and to create a nasal tip. Thus, a new cartilaginous pyramid with symmetrical nostrils is reconstructed. If the anterosuperior portion of the cartilage is deviated, the concave surface is scored to allow it to be straightened before the strut is fitted. Satisfactory cosmetic and functional results were obtained in most patients with adult cleft lip nose, including those associated with deviation, without any major complications.     

Carotid sinus syndrome as the presenting symptom of cystadenolymphoma

Background

The composite graft from the conchal cartilage is a graft that is often used, especially in surgery on the nose, due to its capacity to resolve problems of cover and tissue deficit, arising from the removal of neoplasms or as the result of trauma, burns or following over-aggressive rhinoplasty. We have started to use skin-perichondrium-cartilage graft from the ear to cover large areas of the nose with very satisfying results as well as we describe in the reported clinical case.

Methods

The operation consisted of reconstruction of the cartilaginous nasal septum, which had previously been removed, using two vestibular labial mucosa flaps to reconstruct the mucosa, and cartilage from the ear conch for the cartilaginous septum. After this, the skin edges of the fistula were turned to recreate the inner lining of the nose and form a vascular base of wide area to accept the composite graft. The case concerns a female 74-year old patient who had undergone several oncological surgery for a relapsing basal cell carcinoma on the dorsum of the nose. The operation consisted of reconstruction of the cartilaginous nasal septum using two vestibular labial mucosa flaps to reconstruct the mucosa, and cartilage from the ear conch for the cartilaginous septum.

Results

The perichondrial cutaneous graft has shown in this surgical case very favorable peculiarities that make it usable even in facial plastic surgery.

Conclusions

We believe that the positive experience that we achieved in the use of composite grafts for the reconstruction of large areas of the nose could be interesting for others surgeons.     

Middle-vault narrowing in the wide nasal dorsum: the "Reverse Spreader" technique

The middle vault is a transition zone between the nasal tip and nasal bones and plays an important role in profile, tip projection, tip rotation, and tip support. This report presents an alternative to conventional techniques specific to the middle nasal vault for a patient population with particular nasal features. A narrow middle vault with internal nasal valve collapse is functionally and aesthetically addressed by the insertion of spreader grafts. However, the inverse of this situation is sometimes encountered. A patient with a broad middle vault and without internal nasal valve collapse will benefit from reduction of the horizontal width of the cartilaginous dorsum, which is in effect the reverse of spreader grafts. This effect is achieved by excising a vertical wedge-shaped strip of cartilage that follows the length of the upper lateral cartilage at the junction of the upper lateral cartilage and the dorsal nasal septum.     

Maxilla-premaxilla approach to septal surgery in the cosmetic patient

The maxillary-premaxillary approach to septal deformity developed by Cottle and Loring in 1958 is presented. The method is examined in terms of not only its role in repairing nasal function but also its advantages in controlling the septum for better cosmetic results. Excellent results were achieved using this approach in 350 patients with concomitant functional and cosmetic complaints. The method allows step-by-step diagnosis and treatment for all septal deformities and preserves excellent blood supply to the mucoperichondrial flaps, allowing a water-tight closure for repositioning as grafts, septal bone, and cartilage. It was discovered in most patients that curvature of the septum anteriorly and at the nasal dorsum was due to deformities at more posterior locations. As a result of scarring and overgrowth of the septum after trauma, stresses developed that caused the septum to assume a curved position. Once the stresses were relieved, the cartilaginous septum returned to the midline without further manipulation. The practice of removing curved portions of anterior cartilaginous septum, as with most forms of submucous operations, is unnecessary.     

Correction of the Asian deviated nose with no hump using unilateral bony mobilisation and dorsal septal suture fixation.

A deviated nose is corrected by straight realignment and long-term maintenance of the bony and cartilaginous structure. Traditional rhinoplasty usually involves complete separation of both upper lateral cartilages from the septum and bilateral bony mobilisation after osteotomy. In the Asian deviated nose with no hump, these procedures are intrinsically destabilising and may weaken the supporting bony and cartilaginous structure. To avoid these problems, I performed unilateral bony mobilisation with anterior wedge resection and suture fixation of the dorsal septum to the nasal bone without separation of the upper lateral cartilage. This manoeuvre is simple and reproducible and produces satisfactory straightening and maintenance of the nasal dorsum while maximally preserving the structural support. Here, I describe the surgical techniques including the choice of the site of unilateral osteotomy and wedge resection, a new classification of bony deviation, two surgical modifications applied to different types of deviation and rationale of dorsal septal suture fixation. Also, clinical cases of nasal deviation are presented.     

Nasal tip refinement in primary rhinoplasty: The cephalic trim cap graft

Background: Commonly used techniques for achieving nasal tip projection and refinement are adequate for most primary rhinoplasty patients, but they may result in undesirable tip bifidity and visible lower lateral cartilage angularity, especially in patients with thin skin. Objective: We report the use of “like” local tissues, cephalic trim cartilage remnants of the lower lateral cartilages, as invisible tip grafts to soften any angular cartilage edges or tip bifidity. Methods: The cartilaginous framework was exposed by using the open rhinoplasty approach. Lower lateral cartilages were separated from upper lateral cartilages, the caudal septum at the anterior septal angle, and from each other. A cephalic trim was performed as necessary, with the cartilaginous segments preserved for use as a cap graft. Interdomal sutures and transdermal sutures were used either alone or in combination to set the desired tip projection. If tip bifidity was visible through thin nasal tip skin, a cephalic trim cap graft was placed. Results: The procedure can achieve a well-unified nasal tip with no evidence of bifidity, angularity, or cartilage graft visibility. Conclusion: Use of this technique to improve nasal tip projection can avoid undesirable tip bifidity and visible lower lateral cartilage angularity in patients with thin nasal skin. (Aesthetic Surg J 2002;22:39-45.)     

Comparison of tracheal and nasal chondrocytes for tissue engineering of the trachea

BACKGROUND: This study was undertaken to evaluate the feasibility of creating engineered tracheal equivalents grown in the shape of cylindrical cartilaginous structures using sheep nasal cartilage-derived chondrocytes. We also tested sheep tracheal and nasal septum for cell yield and quality of the engineered cartilage each produced. METHODS: Nasal septum and tracheal tissue were harvested from sheep. Chondrocytes from each were separately isolated from the tissues and suspended in culture media. Tracheal and nasal chondrocytes were seeded onto separate polyglycolic acid matrices. Cell-polymer constructs were cultured for 1 week and then wrapped around a 7-mm diameter x 30-mm length silicon tube and implanted subcutaneously on the back of nude mice for 8 weeks (each, n = 6). Both of the tissue-engineered tracheas (TET) were harvested and analyzed for histological, biochemical, and biomechanical properties. These values were compared with native sheep trachea. RESULTS: The morphology and histology of both tracheal-chondrocyte TET and nasal-chondrocyte TET closely resembled that of native sheep trachea. Safranin-O staining showed that tissue-engineered cartilage was organized into lobules with round, angular lacunae, each containing a single chondrocyte. Chondrocytes from the trachea or nasal septum produced tissue with similar mechanical properties and had similar glycosaminoglycan and hydroxyproline content. CONCLUSIONS: This study demonstrates that the property of TET using nasal chondrocytes is similar to that obtained using tracheal chondrocytes. This has the potential benefit of facilitating an autologous approach for repair of segmental tracheal defects using an easily obtained chondrocyte population.     

Mini-forum: rhinoplasty by external approach. Collumello-trans-alar approach of open rhinoplasty: advantages]

For several years, the authors have been using a columellar transalar incision through the medial crus along the nasal septum, reaching the vault and continued laterally by a transalar cartilaginous incision. The nasal tip is thus opened like a car-hood, leaving the alar cartilage attached to the skin and exposing the triangular cartilage and the nasal septum. This approach allows septoplasty to be performed with excellent exposure. The tip is easily revised backwards allowing anomalies to be viewed directly. The advantages of this external approach compared with the classical external Rethi's approach are multiple: simplicity and rapidity of the technique, excellent access to triangular cartilages and the triangular-septum junction; possibility of always going from an endonasal approach to an external one and excellent access to the tip. Moreover, there is no long term swelling of the tip. The indications of this external approach are asymmetry of the tip, excessive tip projection, saddle nose deformities and secondary rhinoplasties. No complication has been observed in a series of 32 patients with a follow-up of 6 to 48 months. There is no disturbance of the tip position and the skin scar is imperceptible.     

Treatment of septal hematomas and abscesses in children

The cartilaginous part of the nasal septum of a child with a septal hematoma or abscess is at risk of destruction. Consequently, the noses of these children can collapse, causing a saddle nose deformity, and in time, the normal outgrowth of both the nose and maxilla will be disturbed. In adulthood, they will have an underdeveloped saddle nose deformity with too much upward rotation of the nasal tip and a retroposition of the midface. Sequelae like these should be prevented by prompt diagnosis and surgical intervention. In this article, the management of septal hematomas and abscesses is discussed with special focus on reconstruction of destructed septal cartilage with the use of autologous cartilage grafts fixed to a polydioxanon plate.     

The crooked nose: principles of treatment

Correction of the crooked nose is one of the most challenging procedures in rhinoplasty. The goals of the surgery are creation of a rigid and straight cartilaginous L-strut, correction of the deviated bony structures, and improvement of the nasal airway. Curvatures of the dorsal septum can be corrected with several techniques. Spreader grafts, cartilage batten grafts, or ethmoid bone grafts can be utilized for internal stenting to straighten the dorsal deviations. The surgical treatment for a deformed caudal septum with the most predictable and successful outcome is resection and replacement with a straight septal cartilage graft. In severe deviations of septum cartilage involving both dorsal and caudal portions of the L-strut, extracorporeal reconstruction of the septal cartilage may be the required method. For correction of the deviated bony pyramid, several osteotomy methods can be employed. Medial osteotomy, low-to-low or low-to -high internal lateral osteotomy, double-level lateral osteotomies, and external lateral osteotomy are the options, depending on the deformity. Dorsal onlay grafts can provide camouflage for any residual asymmetries after septal reconstruction or can be applied for dorsal augmentation.     

Management of the middle nasal third in revision rhinoplasty

The middle nasal third is often the source of both aesthetic and functional problems with primary rhinoplasty. Weakness of the middle nasal vault can occur from overresection of the upper lateral cartilages or cartilaginous nasal septum, malposition of the upper lateral cartilages, or from secondary scarring from the primary rhinoplasty. These functional and aesthetic problems can be avoided by maintaining an adequate infrastructure to the middle nasal vault. If secondary problems occur in the middle nasal third, precise anatomic reconstruction can be performed in the form of cartilage grafting and/or suture reconstitution. This reconstruction requires an in-depth knowledge of the functional nasal anatomy and the ability to re-create the infrastructure so that it withstands the forces of scarring and wound contraction. This article outlines the anatomy of the middle third of the nose, the conditions that cause secondary middle-third problems, and the surgical management of these deformities.     

鼻中隔前端、中隔前颌韧带和鼻前棘复合体切除对兔面中部生长发育的影响

为探讨手术切除兔鼻中隔软骨前端、中隔前颌韧带和鼻前棘复合体后对面中部生长发育的影响,用20只2周龄日本大耳白兔,分为实验组,手术切除上述复合体;对照组,只切开不切除。术后2,8,14,20,28周时摄头颅侧位片,分别测量上颌骨长度和高度,鼻骨长度和面角变化情况。结果经统计学处理差异均无显著意义。提示胚胎期鼻中隔软骨通过中隔前颌韧带的传导作用,对面中部生长发育起重要作用,但出生后,这种作用即不明显,仅起机械性支持作用。因此早期矫正唇裂鼻畸形不致影响面中部正常发育。     

鼻中隔前端、中隔前颌韧带和鼻前棘复合体切除对兔面中部生长发育的影响

为探讨手术切除兔鼻中隔软骨前端、中隔前颌韧带和鼻前棘复合体后对面中部生长发育的影响，用２０只２周龄日本大耳白兔，分为实验组，手术切除上述复合体；对照组，只切开不切除。术后２，８，１４，２０，２８周时摄头颅侧位片，分别测量上颌骨长度和高度，鼻骨长度和面角变化情况。结果经统计学处理差异均无显著意义。提示胚胎期鼻中隔软骨通过中隔前颌韧带的传导作用，对面中部生长发育起重要作用，但出生后，这种作用即不明显，仅起机械性支持作用。因此早期矫正唇裂鼻畸形不致影响面中部正常发育。     

鼻中隔软骨支撑植入体行短鼻延长的临床应用探讨

目的：探讨鼻中隔软骨支撑植入体行短鼻延长的应用效果。方法：取鼻中隔软骨设计支撑植入体,在鼻中隔与鼻翼软骨之间,增加鼻背长度,伴低鼻者同时行植入体植入。结果：本组136例患者131例效果满意,2例认为鼻延长程度未达到自己的要求,4例认为过长稍翘一点更好,经再次手术后满意。结论：此方法可获得理想的鼻背长度,并保持鼻尖位置的长期固定不变,形态自然。     

同期鼻中隔和鼻整形术

目的：探讨同期鼻中隔和鼻整形术治疗伴有鼻中隔偏曲的歪鼻、驼峰鼻、鹰嘴鼻等外鼻畸形的手术方法和效果。方法：采用鼻侧软骨与大翼软骨间切口，单面一边骨膜蒂骨瓣截骨法处理骨锥畸形，联合“转门法”矫正鼻中隔偏曲。结果：36例均获满意效果，随访32例受术者1～15年，无复发和并发症。结论：本手术方法既避免了鼻骨及鼻中隔软骨的游离移位和鼻黏膜损伤，又保证了鼻骨和鼻中隔软骨的血供，在矫正了外鼻畸形的同时，又矫正了偏曲的鼻中隔，收到外鼻美容与恢复鼻腔通气功能的双重功效。     

以鼻中隔软骨为鼻小柱支撑移植物在鼻尖整形中的应用

目的:探讨以鼻中隔软骨为鼻小柱支撑移植物在东方人鼻尖整形中的应用。方法:在50例鼻尖整形患者中,均以鼻中隔软骨为鼻小柱支撑移植物,使用固定悬浮型移植27例,延伸型移植13例,鼻中隔延伸型移植10例。结果:除1例因术后鼻尖突出度不足,经二次手术纠正外,余49例鼻尖成形良好,患者对手术效果满意。结论:根据不同情况,以鼻中隔软骨的不同植入形式进行鼻小柱支撑移植是鼻尖整形中一项良好的手术技术。     

利用鼻中隔粘骨膜复合瓣修复半侧鼻下部衬里缺损的临床研究

目的:探讨一种半侧鼻下部全层缺损衬里修复的手术方法.方法:根据衬里缺损的面积,设计对侧相应大小鼻中隔粘膜软骨膜复合组织瓣,通过鼻中隔背部跨越鼻中隔软骨,将血运良好的复合组织瓣固定在缺损周边的骨膜上.对8例半侧鼻下部全层缺损患者采用此方法修复衬里,其中3例男性,5例女性,并同时运用局部皮瓣或额部皮瓣修复外层,耳软骨或肋软骨重建支架,随访6～12个月,了解鼻衬里恢复情况.结果:本组8例患者再造鼻衬里均血运良好,鼻腔大小及通气正常,鼻中隔形态正常,供区呼吸性上皮覆盖,无穿孔、感染或偏曲.结论:在半侧鼻下部全层缺损的衬里再造中,应用此方法进行衬里修复,组织性质最接近,血运好且薄,柔软且挛缩程度小,同时为软骨支架提供良好血供,保持了鼻部组织的完整及自然形态,是一种良好的鼻部衬里修复方式.     

A surgical approach to the bifid nose

Summary A bifid nose is a rare congenital deformity due to failure of the paired nasal processes to fuse to a single midline organ during early gestation.Mild forms can be dealt with along the principles of corrective rhinoplasty.In the correction of moderate to severe forms of a bifid nose a new approach is presented.Through an external skin incision an extramucous resection of a scaphoid segment of cartilage and bone consisting of the 2 widely spread laminae of the cartilaginous and osseous septum bifidum is performed and a monolaminar septum is reconstructed fusing the two septal portions together with the mucosal lining with mattress sutures in the midline. Narrowing of the wide nasal base is achieved by lateral and transverse osteotomy with consequent medial shift of the side walls.The scaphoid shaped segment is then replanted to form the new natural hyphen looking triangular and elevated nasal roof. The alar cartilages are united in the midline and shaped to form a single tip.In one patient with a bifid nose associated with a congenital median nasal dermoid cyst the sinus tract and the cyst were extirpated and the nose reconstructed simultaneously using this technique.     

鼻中隔软骨及耳软骨在鼻尖整形中的联合应用

目的：探讨鼻中隔软骨及耳软骨在鼻尖整形手术中的联合应用的方法和优点。方法：对56例就医者施行了此项手术,应用自体鼻中隔软骨做鼻中隔延伸移植物,耳软骨做鼻尖移植物,结合各种鼻翼软骨缝合技术进行鼻尖整形。结果：所有鼻外形获得显著改善,鼻尖形态自然、圆润而俊俏,同时无皮肤或粘膜破损、假体外露、感染等并发症的发生,随访3个月～1年,鼻尖形态稳定,效果满意。结论：联合应用鼻中隔软骨及耳软骨进行鼻尖整形的方式,更接近正常鼻解剖结构,更好控制鼻尖形态,更容易获得预期的效果。