Perpendicular Plate Of The Ethmoid Research Articles

The Blocking Points: The Keys to Consistent Success in Preservation Rhinoplasty.

Preservation rhinoplasty is a growing area of interest among rhinoplasty surgeons. Dorsal preservation-a tenet of preservation rhinoplasty-is predicated on maintaining the integrity of the nasal midvault and effecting aesthetic change through alterations to the bony nasal pyramid and underlying septum. A challenge that is unique to dorsal preservation is the phenomenon of hump recurrence, because of the existence of anatomical blocking points. Blocking points are resistant tensile forces that either impede dorsal lowering intraoperatively or push the dorsum back to its native convexity over time. Five anatomical blocking points have previously been described, which the authors expand on and include an additional two. The seven anatomical blocking points are as follows: the cartilaginous septum, the perpendicular plate of the ethmoid, the lateral osteotomy site, the Webster triangle, the internal mucoperiosteum of the maxillary bone, the medial canthal ligament, and the lateral keystone area. It is critical that the surgeon be aware of the particular blocking points relevant to his or her chosen technique, and to appropriately and methodically address them to ensure consistent long-term results.

Effects of mini-implant assisted rapid palatal expansion on the deviated nasal septum and inferior nasal meatus: A CBCT study

Objective: The purpose of this study was to evaluate the effects of the mini-implant assisted rapid palatal expansion on the nasal septum and the inferior nasal meatus (INM) in the patients with nasal septal deviation. Methods: The CBCT images were taken before (T0), after (T1), and more than 5 months after (T2) MARPE in 17 patients who had NSD. According to the direction of the NSD, the concave side was set as group 1 and the convex side was set as group 2 by patient. The volume of the INM, nasal septal tortuosity ratio were calculated. Also, to evaluate 3-dimensional changes of the nasal septum, distance between C point (The junction of perpendicular plate of ethmoid bone and vomer) and three vertical planes were calculated. And distance between C point and lateral wall of nasal cavity was measured. Results: The total volume of the INM increased significantly after MARPE (p < 0.001). The distance from the C point to the vertical plane increased significantly after MARPE (p < 0.01). Also, there was a significant difference between the groups in the distance between the C point and the lateral wall of nasal cavity (p < 0.001) before and after treatment. But there was no significant difference in the increase ratio. Conclusion: After MARPE, the volume of INM was significantly increased. The nasal septum was more displaced to the deviated side without a significant morphological change. But the increase ratio of both group was similar.

Use of nasal septal bone to straighten septal L-Strut in correction of east Asian short nose: A retrospective study.

The perpendicular plate of ethmoid (PPE) was used to correct short noses in rhinoplasty in Asians, but the safe harvest of the plate and the assessment of its clinical application has been perplexing to plastic surgeons. To explore how to safely cut the perpendicular plate of ethmoid bone and evaluate its application effect. A finite element model was established to guide the clinical operation. A total of 30 patients with short noses were selected. Among them, 15 patients used autologous septal cartilage to lengthen the nasal tip, and 15 patients used the PPE to strengthen the L-shape nasal septum. The differences in the esthetic parameters of the nose, complications, and patients' satisfaction were compared between the two groups. Significant differences were noted in the nasal dorsal length (p=0.001), Goode's ratio (p=0.001), and nasofrontal angle (p=0.003) after rhinoplasty, and no significant differences were noted in any of the esthetic parameters between the two groups. The symptoms of nasal obstruction in the experimental group were significantly lighter than those in the control group (p=0.04). There was no statistically significant difference in the doctors' assessment of outcomes between the two groups (p=0.48). The safest region to harvest the PPE is in the middle and lower third. Rhinoplasty improves the esthetics of the patient's nose. The PPE used to strengthen the L-shape nasal septum structure has a smaller probability of nasal septal deviation with the time in Asian short noses.

The incidence of maxillary sinus carcinoma in nasal mass

The external nose is pyramidal in shape with its root above and base directed downwards. The framework is composed of bones and cartilages. The bones are the two nasal bones articulating medially. Laterally they articulate with the frontal process of maxilla, superiorly to the medial part of nasal notch of frontal bone and inferiorly to the lateral cartilage of nose and posteriorly with the perpendicular plate of ethmoid bone. Considering the malignant conditions of nose & PNS, the most common issq. cell carcinoma of maxillary sinus (37.S°lc>), followed by S. q cell carcinoma of nose (25%), and then Adenocarcinoma of maxillary sinus (1 2.5%), Sq. cell carcinoma of Ethmoid sinus (12.5%) & adenoid cystic carcinoma of maxillary sinus (12.5°/o) These findings are comparable with reports of Cheesman (1957) , who had noted that Sq. cell carcinoma comprised of 80% of cases & Bahadur et al (1984), who reported that most common was Sq. cell carcinoma (65%).Followed by adenocysticcarcinoma (12%), Adinocarcinoma (12%) Meliginate lanoma (2%) olfactory neuroblastoma(2%).

Indications for Preservation Rhinoplasty: Avoiding Complications.

Nasal dorsal preservation surgery was described more than 100 years ago, but recently has gained prominence. Our objective is to show the surgical technique, the main indications and counterindications, and the complications. It is a technique that does not cause the detachment of the upper lateral cartilage (ULC) from the nasal septum, and has the main following sequence: preparation of the septum and its resection can be at different levels (high or low, i.e., SPAR [septum pyramidal adjustment and repositioning] A or B); preparation of the pyramid; transversal osteotomy; lateral osteotomy(s); and septopyramidal adjustment. The result is a nose with a lower radix than the original, a deprojection of the nasal dorsum tending to maintain its original shape; an increase in the interalar distance (IAD) and enlargement of the nasal middle ⅓; and loss of projection of the nasal tip and roundness of the nostrils. Thus, the ideal candidate is the one who benefits from such side effects, that is: tension nose, that is, high radix with projected dorsum, projected anterior nasal septal angle (ANSA), narrow middle ⅓, narrow IAD, thin nostrils and straight perpendicular plate of the ethmoid (PPE), and, depending on the characteristics, the deviated nose. The counterindications are low radix, irregularities in the nasal dorsum, ANSA lower than rhinion, and a wide middle ⅓. And the main stigmas are: a nose with a very low radix, middle ⅓ enlarged, residual hump, and saddling of the supratip area. Other issues of this technique are: the shape of the radix; the need or not to remove PPE; wide dorsum; irregular dorsum; ANSA lower than rhinion; weak cartilages; long nasal bone; deviated PPE; and obsessive patient. We conclude that this is a great technique for noses with characteristics suitable to it; care must be taken with the stigmas it can cause.

Inferior Meatus Mucosal Flap for Septal Reconstruction and Resurfacing After Nasoseptal Flap Harvest.

View Video S1

The Use of Bony Septum as an Extended Spreader Graft in Primary and Secondary Rhinoplasty

Objective: To describe a surgical technique using bony septum, specifically vomer or perpendicular plate of the ethmoid (PPE), as an extended spreader graft (ESG) for securing septal extension graft (SEG) and for correcting internal nasal valve dysfunction.
 Methods:
 Design: Descriptive Case Series
 Setting: Tertiary Private Hospital
 Participants: Thirty-two (32) patients who underwent aesthetic rhinoplasty from May 2016 to October 2017 were evaluated, and ten (10) patients presenting with symptomatic obstruction were considered for inclusion. The surgical technique was applied in patients with weak SEG for control of nasal length and tip projection who had inadequate septal cartilage for SEG and ESG intraoperatively. Results were evaluated grossly under direct vision intra-operatively and post-operatively to check the patency of the internal valve.
 Results: Bony septum was used as an ESG in five (5) patients (1 male, 4 females, ages 35 to 50-years-old) with inadequate septal cartilage. Intraoperative evaluation under direct vision showed anterior caudal septal deviation in all 5 patients in whom correction was confirmed after placement of SEG and ESG. Immediate post-operative evaluation confirmed bilaterally patent nasal valve in all 5, who reported subjectively improved breathing at 2 and 4 weeks post-operatively. Post-operative photographs showed improvement of nasal length and tip.
 Conclusion: The use of the bony septum (vomer and PPE) as an ESG for primary or secondary rhinoplasty is a potentially effective means of supporting and securing the SEG for control of nasal length, preventing tip deviation or rotation and for improving internal valve function. Further trials are needed to establish its reliability and long-term effectivity.
 Keywords: rhinoplasty; vomer; perpendicular plate of the ethmoid (PPE)

Anatomical Characteristics of the Perpendicular Plate of the Ethmoid: An Analysis of Paranasal Sinus Computed Tomography via Three-Dimensional Reconstruction.

In recent years, the perpendicular plate of the ethmoid (PPE) has emerged as a new autogenous grafting material in rhinoplasty and septoplasty of nasal deviation. However, no studies have outlined the precise size, shape, and morphologic features of the PPE. Therefore, this study aimed to provide detailed information on the anatomical and morphologic characteristics of the PPE to assist surgeons in performing surgeries that are more precise. About 104 Chinese patients who underwent paranasal computed tomography were assessed in this study. By analyzing the features of the PPE reconstructed with 3-dimensional models, the characteristics of the PPE at different stages of development and according to sex were observed. The PPE had a flat shape, and its lower part was relatively thin. It usually developed horizontally with age, which contributed to expansion of the PPE area. The dimensions of the PPE were significantly larger in male patients than in female patients. Through the reconstruction and measurement of Chinese patients' PPE, the authors have established precise information about the PPE's anatomical and morphologic features. The flat shape and proper size, which are similar to those of nasal septum cartilage, make the PPE an ideal alternative to conventional autogenous grafting materials. The findings might be useful to surgeons in helping them perform surgeries that are more precise.

Efficacy of endoscopic approach to reconstruct the medial orbital fracture with perpendicular plate of ethmoid

Objective:To study the efficacy of endoscopic sinus approach in the repair of medial orbital fracture with perpendicular plate of ethmoid.Method:Retrospective chart was reviewed in 10 cases receiving endoscopic approach to reconstruct the medial orbital fracture with perpendicular plate of ethmoid.We observed the improvement of the symptom such as diplopia, eye movement,and enophthalmos of the preoperative and postoperative.Result:After postoperative follow-up of 4 months to 23 months, all the patients had no graft loss or displacement, infection and other complications, and except for 1 patient with mild diplopia, other patients recovered completely, including eye movement disorder, diplopia,and enophthalmos.Conclusion:Endoscopic approach is a safe and effective treatment in the repair of medial orbital fracture with perpendicular plate of ethmoid.

The Caucasian Nasal Septum: An In Vivo Computed Tomography Study.

The nasal septum is composed of cartilaginous and bony components and an understanding of each component volume is essential in both functional and cosmetic surgery. We sought to radiographically measure septal dimensions on cross sectional computer tomography (CT) images, establishing average parameters for normal anatomy among a single, Caucasian population group. One hundred and fifty consecutive sinus CT scan images were examined and 100 cases with appropriate sagittal views were included in the study. On each septum, the sagittal CT images were assessed and 14 points were identified and 23 lengths measured and tabulated. Trigonometric formulae were used to accurately calculate surface areas of 11 resulting triangles which constituted the components of the nasal septum. Measurements from 100 patients were included, with a mean age of 50.2 years, constituting 47 males and 53 females. Our surface area mapping established the following areas for both males and females respectively (mm2): quadrangular cartilage 1148 and 981; vomer 894 and 741; perpendicular plate of ethmoid bone 1244 and 1006; and total surface area 3287 and 2728. Our only statistically significant comparison in the series was found in the female series when age and reducing quadrilateral cartilage size were compared, highlighting reducing size with age (P = 0.04). The study presents the largest published data series representing nasal septal measurements on CT images in a living Caucasian population. Our data demonstrates that septal size remains constant after adolescence, throughout our age-varied series (18-79 years), except in the female population where the quadrilateral cartilage reduces in size with age.

Application of perpendicular plate of ethmoid bone in short nose plasty in Chinese with insufficient septal cartilage

Objective To evaluate the applied value of septal cartilage combined with perpendicular plate of ethmoid bone graft in short nose plasty in Chinese people with insufficient septal cartilage. Methods From February 2015 to March 2017, thirty-five women with short noses underwent septal extension grafting in our institute. We used perpendicular plate of ethmoid bone to enhance the L-strut structure. An L-strut, comprising 0.6 cm segments of the caudal and dorsal cartilaginous septum, was left altered to harvest more cartilages for septal extension. The harvested septal cartilage was grafted on one side of the caudal septum. Then the alar cartilage was fixed at the end of the septal cartilage graft. Nasal lengths and nasolabial angles were measured pre- and postoperatively. Results The average nasal lengthening was (3.37±1.87) mm (P<0.001). There was no infection, cerebral spinal fluid leakage, hemorrhage and other complications postoperatively. The average follow-up was 10 months (6 months to 2 years). After operation, 33 patients were satisfied with the nasal contour, 1 patient complained of high tip projection whereas one patient complained of low tip projection, and the dissatisfactions were corrected by revision surgeries. Conclusions Combining the septal cartilage with perpendicular plate of ethmoid bone graft presents an adequate nose lengthening and a decreased nostril show, even in patients with very little septal cartilage. With minimum complications, this novel technique provides promising clinical outcomes and high patient satisfaction. Key words: Short nose; Perpendicular plate of ethmoid bone; Septal reinforced implant; Rhinoplasty

Vomero-premaxillary joint: A marker of evolution of the species

ObjectiveAccording to evolutionary developmental (evo-devo) theory, the vomers are bones derived from the secondary palate. Growth of the palatine processes of the maxillae, including the precursors of vomer bones, results in midline fusion posteriorly to the primary palate, which forces the ascension of the vomer bones towards the primary nasal septum, formed by septal cartilage and the perpendicular plate of the ethmoid. According to this hypothesis, the anterior border of the vomer articulates with the posterior surface of the premaxilla in the incisive canal (IC). Material and methodThe objective of this retrospective study was to measure the degree of impaction of the anteroinferior angle of the vomer in the IC on CT scans showing a non-deformed nasal septum. Thirty-two out of a series of 506 nasal sinus CT scans were used to obtain measurements on coronal sections of non-deformed septa through the IC. ResultsThirty-one of the 32 vomers were impacted in the IC. In the case of a Y-shaped vomer (n=26), 43% of the length of the vomer was impacted in 41% of the length of the IC. In the case of I-shaped vomers (n=6), 34% of the length of the vomer was impacted in 41% of the length of the IC. The only vomer that did not impact into the IC was Y-shaped. ConclusionImpaction of the vomer in the IC posteriorly to the premaxilla can be explained by the evo-devo concept of the formation of the nasal cavities. In contrast, the classical embryological description of the formation of the nasal septum cannot provide an explanation for impaction of the vomer.

The ethmoid and presphenoid of cetaceans.

A cribriform plate, a perpendicular plate, and two lateral masses are major components of the ethmoid bone of mammals. Notwithstanding the noticeable bone, virtually sitting in the center of the skull, extensive modifications of the skull of modern cetaceans, especially odontocetes (toothed whales), and the lack of clarity as to what characteristics delimit each element of the ethmoid has made the problem of the nature of the cetacean ethmoid more complicated and elusive than in other, less modified mammals. Furthermore, contention as to whether a perpendicular plate of the ethmoid, or the mesethmoid, exists in all mammals including cetaceans has remained unsettled. In odontocetes, the mesethmoid has been variably identified not only as the osseous nasal septum but also as the mediodorsal region of the posterior wall of the nasal passage below the nasals, as a mass of bone encased by the vomer in front of the osseous nasal cavity at the base of the rostrum, and as a combination of some portions mentioned above. The presence or absence of the mesethmoid in various groups of mammals has attracted the attention of some biologists, and here, I demonstrate that cetaceans have no mesethmoid. The close inspection of the ontogenetic changes of the basicranial elements in cetaceans reveals that a mass of bone ensheathed by the vomer in front, or at the level of the osseous nasal cavity is actually the presphenoid. It is highly likely that in odontocetes the posterior wall of the nasal passages below the nasals consists of the combination of the frontal, the imperforated cribriform plate, the paired ectethmoids, and the vomer, the latter three of which partially concealing the presphenoid dorsally and laterally as the ontogeny proceeds. In contrast, mysticetes clearly display ethmoturbinates and a cribriform plate, which are morphologically similar to those in terrestrial mammals. J. Morphol. 277:1661-1674, 2016. © 2016 Wiley Periodicals, Inc.

The Causes of Persistent and Recurrent Nasal Obstruction After Primary Septoplasty.

Septoplasty is the most frequently performed surgical procedure in patients with nasal obstruction. However, nasal obstruction may persist or recur after septoplasty in some patients. In this study, the authors aimed to determine the causes of nasal obstruction after septoplasty. Fifty consecutive patients who admitted to our clinic with the complaints of persistent or recurrent nasal obstruction after primary septoplasty and had revision surgery between 2011 and 2015 were included in this study. Demographic data and physical examination findings of the patients were recorded. There were 33 men (66%) and 17 women (34%) with a mean age of 37.3 ± 10.5 (range, 21-57) years. Deviation of perpendicular plate of ethmoid bone (44%), inferior turbinate hypertrophy (36%), concha bullosa (26%), caudal septal deviation-nostril asymmetry (20%), and alar collapse (6%) were the pathologies that were unaddressed during primary surgery. The iatrogenic causes of nasal obstruction after septoplasty were collumellar retraction-nasal tip ptosis (46%), nasal synechiae (20%), nasal septal perforation (10%), and saddle-nose/flat nose deformity (10%). Iatrogenic deformities due to surgery and pathologies ignored during primary surgery may cause persistent/recurrent nasal obstruction after primary septoplasty. A detailed physical examination and objective tests showing the site of nasal obstruction, an extensive surgical plan that covers all diagnosed pathologies, and a careful postoperative care must be undertaken to prevent undesired postoperative results.

The olfactory fascia: an evo-devo concept of the fibrocartilaginous nose.

Evo-devo is the science that studies the link between evolution of species and embryological development. This concept helps to understand the complex anatomy of the human nose. The evo-devo theory suggests the persistence in the adult of an anatomical entity, the olfactory fascia, that unites the cartilages of the nose to the olfactory mucosa. We dissected two fresh specimens. After resecting the superficial tissues of the nose, dissection was focused on the disarticulation of the fibrocartilaginous noses from the facial and skull base skeleton. Dissection shows two fibrocartilaginous sacs that were invaginated side-by-side in the midface and attached to the anterior skull base. These membranous sacs were separated in the midline by the perpendicular plate of the ethmoid. Their walls contained the alar cartilages and the lateral expansions of the septolateral cartilage, which we had to separate from the septal cartilage. The olfactory mucosa was located inside their cranial ends. The olfactory fascia is a continuous membrane uniting the nasal cartilages to the olfactory mucosa. Its origin can be found in the invagination and differentiation processes of the olfactory placodes. The fibrous portions of the olfactory fascia may be described as ligaments that unit the different components of the olfactory fascia one to the other and the fibrocartilaginous nose to the facial and skull base skeleton. The basicranial ligaments, fixing the fibrocartilaginous nose to the skull base, represent key elements in the concept of septorhinoplasty by disarticulation.

Principles of Structural Rhinoplasty in South East Asian Noses

Principles of Structural Rhinoplasty in South East Asian Noses

Identification of varied Sudanese infants ages (at birth, day 4, and 8 weeks) by determination of ossification pattern in the anterior skull base using computed tomography scan (A qualitative postmortem study)

Medico legally this study identify certain Sudanese infants ages (at birth, day 4, and 8 weeks) through description of ossification pattern in the anterior skull base using computed tomography (CT) scan. Also, it is describing the normal anatomical pattern of ossification. So this study will explain and reveals the Sudanese own skull base bony print. Total number of selected cases for study are 12 died children admitted to Mortuary of Khartoum between July\2011 and November\2011, and all cases of known age, sex and nationality (Sudanese) according to police records, confirmed medico legally by evaluation of external signs of live. All cases were examined in Khartoum teaching hospital at January\2012 that explained the skull base development and ossification by direct coronal CT scans, 1 mm and wide window (bone) settings of Para Nasal Sinuses (PNS) protocol. The used CT scan machine is TOSHIBA-Asteion. The observations of day 1, 4 and 8 weeks explained that each determined age has its own skull base bony pattern. Also observations of those ages revealed that the development of the forming parts of skull base which include orbital plates and its extension over lateral ethmoidal air cells, roof of ethmoid complex, cribriform plate, perpendicular plate of ethmoid and ethmoidal air cells was progressively increasing with age except; the perpendicular plate of ethmoid bone which doesn't meet the vomer in the posterior septum at any of these certain ages although vomer was ossified at those varied ages. And the Crista galli neither ossified nor fused with ethmoidal labyrinths at all. Also, the Ethmoidal air cells have never been extended above the plane of the cribriform plate. Observed ages and patterns of ossification was different somewhat from that reported in prior radiologic and anatomic studies in the ethmoidal complex and its extension over the cribriform plate of ethmoid bone also in the crista, galli which was seen ossified as early as 2 months of age in previous study.

Bone Recycling in Nasal Septal Reconstruction

Septal reconstruction alone or together with rhinoplasty can be a very challenging operation. In situations where septal cartilage is used for grafting or is not enough, bony implants taken from the perpendicular plate of the ethmoid and vomer can be used as a filler material between the mucoperichondrial flaps to avoid from unwanted mucosal atrophy, flapping, and septal perforation. These bony implants can also be used for splinting the dorsal and/or caudal segment of the septal cartilage after reshaping by rongeurs. On rare occasions, they can even be used for subtotal reconstruction of the septum.

Septoturbinotomy

The inferior turbinates are a principal cause of nasal airway obstruction. To some extent, the bony septum (the perpendicular plate of the ethmoid) also, on occasion, contributes to that airflow obstruction. There are many excellent methods to resect or ablate the turbinates, including submucous resection and cauterization. However, some have been associated with bleeding, crusting, and the development of synechiae. In this Featured Operative Technique article, we propose 2 mechanical means to expand the nasal vault: (1) the insertion of a large and long speculum that outfractures the turbinates and also centralizes the bony septum when the handles are compressed and (2) the insertion of a large clamp, which is expanded (in reverse "nutcracker" fashion) to achieve a similar result. Mechanical dilation (expansion) of the nasal vault with the speculum or large clamp substantially improves vault diameter such that further work on the turbinates in the form of turbinectomy is seldom necessary. The nasal vault is not necessarily expanded to the maximal diameter that could be achieved with resection procedures but need not be to achieve satisfactory air flow. Septoturbinotomy is a quick and simple way to deal with inferior turbinate hypertrophy. It is a minimally invasive procedure that improves the airway in virtually all cases, such that turbinectomy is seldom employed. It can be used prophylactically on all rhinoplasty cases requiring lateral osteotomy, which potentially shrinks the nasal vault slightly.

The Nasal Keystone Region

The Nasal Keystone Region