Reconstruction of caudal end of septum. A case for transplantation

Morphological Patterns and Variations of the Nasal Septum Components and Their Clinical Implications

The aim of this study was to clarify the morphological patterns and proportions of the components of the nasal septum. Anatomical examinations were performed on 70 nasal septums of embalmed Korean adult cadavers. The septal deviation was checked before cutting the nasal cavity midsagittally with the aid of a laryngoscope. The shape of each component of the nasal septum was identified, and photographs were taken from a midline sagittal view. A line was drawn on each photograph between the septal components, and then the area of each septal component was measured using software. The mean area proportions of the septal cartilage (SC), the perpendicular plate of the ethmoid bone (PPE), the vomer, and the nasal crest of the maxilla relative to the total area of the nasal septum were 25.6%, 43.0%, 25.8%, and 5.6%, respectively. The morphology of the nasal septum was classified into 3 main patterns according to the proportion of each septal component. The proportions of the SC, the PPE, the vomer, and the nasal crest of the maxilla were similar to the mean values of the present study in 45.7%. The proportions of the SC, the PPE, and the vomer were similar to each other (with a difference of <15%) in 24.3%. The proportion of the PPE exceeded 50% of the total area of the nasal septum in 22.9%. The results reported herein provide detailed anatomical knowledge that can be used as a valuable reference for rhinoplasty procedures.

Bone grafts as a recyclable material in nasal surgeries

OBJECTIVE

To evaluate long-term results of septal bone grafting and to show sustainable viability of bone grafts with objective parameters such as computed tomography.

METHODS

Nasal septal bones were used as splinting grafts during septo/rhinoplasty operations in 27 patients (Male=16; Female=11) between 2009 and 2013. Of these, only the 21 patients who were monitored long-term and who had computed tomography (CT) records were included in this investigation. The average duration of monitoring for the patients reported here was 17 (12-37 months) months. Patients were excluded for the following reasons: pregnancy; morbid obesity; uncontrolled diabetes; long-term oral steroid or chemotherapeutic agent use; inflammatory, systemic or immunodeficiency disease or acute local infections at the operative site. Bone graft positions, lengths and respective resorption were evaluated and compared pre-postoperatively for each patient.

RESULTS

Bone grafts retained 90% of their lengths in 14 of the 21 (66.6%) patients. In other cases, control computed sinus tomography showed four bone grafts at 80%, two grafts with 70%, and one graft retained 60% of the original lengths. None of the grafts showed resorption less than 50%.

CONCLUSION

Bone grafts are reliable grafts and can be used as an alternative to cartilage grafts.

The impact of Metzembaum septoplasty on nasal and facial growth in children

Several studies have investigated the effects of septoplasty on facial growth in children, with conflicting results. However, just handful of those employed objective measures or evaluated patients after facial growth completion.

Objective

This study assesses the effects of the Metzenbaum septoplasty, which preserves the perichondrium and growth-related areas on nasal and facial growth in children.

Method

We included those children submitted to surgery before the age of 14 and who had 16 years or years of follow up. Sixteen patients were selected. We evaluated the following parameters: clinical satisfaction (nasal patency and aesthetics), anthropometric measurements and cephalometry. Scientific design: cross-sectional historical cohort.

Results

The mean age at surgery was 13 years, children were assessed on average 4.3 years after surgery. Only one patient had anthropometric and cephalometric values below normal, but no aesthetics or patency complaints. Four other patients complained about their nasal aesthetics and three had patency complaints.

Conclusion

The Metzenbaum septoplasty appears to be a safe technique to correct caudal septum deviations. This technique had no significant impact on facial growth of the patients assessed.

The caudal septum replacement graft

OBJECTIVE

To describe a technique for reconstructing the lost tip support in cases involving caudal septal and premaxillary deficiencies.

METHODS

The study included 120 patients with aesthetic and functional nasal problems resulting from the loss of caudal septal and premaxillary support. An external rhinoplasty approach was performed to reconstruct the lost support using a cartilaginous caudal septum replacement graft and premaxillary augmentation with Mersilene mesh.

RESULTS

The majority of cases (75%) involved revisions in patients who had previously undergone 1 or more nasal surgical procedures. A caudal septum replacement graft was combined with premaxillary augmentation in 93 patients (77.5%). The mean follow-up period was 3 years (range, 1-12 years). The technique succeeded in correcting the external nasal deformities in all patients and resulted in a significant improvement in breathing in 74 patients (86%) with preoperative nasal obstruction. There were no cases of infection, displacement, or extrusion.

CONCLUSIONS

The caudal septum replacement graft proved to be very effective in restoring the lost tip support in patients with caudal septal deficiency. Combining the graft with premaxillary augmentation using Mersilene mesh helped increase support and stability over long-term follow-up.

Reconstruction of anterior nasal septum: back-to-back autogenous ear cartilage graft

OBJECTIVES/HYPOTHESIS

The ideal material for reconstructing the nasal septum in the deficient nose has not been found. Since 1986, the authors have used autogenous cartilage from the cavum conchae to successfully correct the anterior septum and the associated cartilaginous saddle. The long-term results in 26 patients with a destroyed septum and a saddle nose are reported.

STUDY DESIGN

Retrospective study.

METHODS

The mean age of the patients at surgery was 40.2 years, and the mean number of previous nasal procedures was 1.6. Because 11 patients had septal perforations and insufficient septal cartilage or bone, ear cartilage grafts from the cavum conchae were harvested through an anterolateral approach. A special incision was used to divide the concave ear cartilage while preserving the posterior perichondrium. This produced a stable, balanced back-to-back graft. The graft was 2.5 to 3 cm long, long enough to allow reconstruction of the anterior septum and to correct part of the saddle nose deformity. The rest of the conchal cartilage was used to fill the remaining cartilaginous saddle. Follow-up investigations included photographs and visual analogue scales of the patients' symptoms and satisfaction.

RESULTS

After a mean interval of 36.7 +/- 22.3 months, the back-to-back grafts showed no macroscopic signs of resorption. Graft position and shape remained intact after transplantation. All noses were adequately projected and mobile. All patients but one were satisfied with the functional and esthetic result. With a score of 4 representing the level of satisfaction as "very good," the mean score of the patients was 3.2 +/- 0.79. The saddle of the nose completely disappeared in 65.4% of patients, was minimally visible in 23.1%, and was slightly present in 11.5%. Nasal breathing improved considerably in 21 patients, remained the same in 4 patients, and worsened in 1 patient. The mean score of all patients for nasal breathing was 7.3 +/- 1.87 on a visual analogue scale of 0 to 10, with 10 representing satisfaction as "very good".

CONCLUSION

The back-to-back autogenous ear cartilage graft is a viable, stable, and balanced graft for functional and aesthetic reconstruction of the anterior nasal septum and cartilaginous saddle deformity in patients with a severely traumatized and deficient septum.

Bone and temporal fascia graft for the closure of septal perforation

OBJECTIVES

To assess the reliability of temporal fascia and bone graft for the closure of septal perforation.

STUDY DESIGN

Prospective longitudinal non-randomized.

METHODS

The repair of septal perforation was performed using endonasal dissection; suture of the borders of the perforation on at least one side, and interposition of a graft of temporal fascia with bone, either a perpendicular plate of ethmoid (six) if available or mastoid cortex (three) if not.

RESULTS

All patients had closure without re-perforation. Eight out of nine patients had complete closure of the perforation (88.8 per cent). These patients had perforations of less than 3 cm in diameter. The ninth patient had a perforation of more than 3 cm diameter (3.5 x 2.5 cm), and obtained a closure of about 80 per cent of the original perforation. The remaining perforation was in the posterior part of the nose. The patient was relieved of his symptoms (crusting and bleeding). This incomplete closure was most probably due to migration of the graft immediately after surgery. There was no morbidity of the donor site or the ear in the mastoid cortex graft group of patients. This is to our knowledge the first report of the use of the mastoid cortex as a graft in septal perforation.

CONCLUSIONS

We consider that the graft of temporal fascia with bone is very reliable, and the use of bone ensures closure while avoiding the complications of a lax septum in large perforations. The technique is suitable for perforations up to 2.5 cm diameter. Perforations larger than 3 cm in diameter are more difficult to close, but closure of the anterior part of the perforation will relieve the patient from the most annoying symptoms.

Caudal and dorsal septal reconstruction: an algorithm for graft choices

The objective of this study is to present an algorithm for choosing graft materials for the reconstruction of severe caudal and/or dorsal septal cartilage abnormalities and to examine the long-term results obtained with these techniques. Retrospective review of 21 consecutive cases of caudal and/or dorsal septal reconstruction via the external approach using the algorithms is presented. The techniques used are carefully described. Patient survey at least 1 year after the initial procedure, rhinologic examination before and after the procedure, and photographic analysis of preoperative and postoperative views are presented. The graft choice algorithm presented helps the surgeon to consider appropriate graft choice alternatives before surgery.