Septal Graft Research Articles

Septal Perforation Repair Without Intraoperative Mucosal Closure in a Patient With Graft Versus Host Disease

We report a technique used to achieve successful repair of 2 large septal perforations in a patient with graft versus host disease, chronic use of corticosteroids, and chronic use of immunosuppressive medications. A multilayered interposition graft was constructed out of temporal fascia and flexible polydioxanone plates and placed between the mucoperichondrial flaps. Due to large size of the perforations and poor tissue quality, no attempt at mucosal closure of the perforations was made. Instead, silicone sheets were placed for 52 days to facilitate healing. Complete healing of both perforations sites was obtained along with resolution of the patient’s symptoms. The described technique provided an optimal surgical outcome in the setting of multiple large septal perforations, graft versus host disease, chronic corticosteroids, and chronic immunosuppressive medications.

Tip-Oriented Closed Rhinoplasty Built on Septocolumellar Suture and a New Caudal Septal Graft Technique.

A beautiful and appealing nose receives the greatest contribution from the nasal tip subunit, which should be regarded as the primary center of attention during a rhinoplasty procedure. In achieving the desired shape and position of the nasal tip during closed rhinoplasty, the septocolumellar suture functions as the major determinant together with the caudal portion of the septal cartilage, which has a significant influence on the versatility of the septocolumellar suture. The purpose of this study was to present the analysis of the indications, the technical steps, and the advantages of caudal septal graft and septocolumellar suture utilization in closed rhinoplasty. The septocolumellar suture with or without the caudal septal graft combination procedure has been performed in 2286 patients via a closed rhinoplasty approach. Intraoperatively, the septal cartilage at hand was thoroughly evaluated and one of the 5 types of caudal septal grafts was used when necessary. After the establishment of a strong and straight septal cartilage with sufficient height and length, 4 different septocolumellar sutures in a specific order were used to modify the relationship between the lower lateral cartilages and the nasal septum. Of the 2286 cases, 1837 (80.3%) were primary and 449 (19.7%) secondary rhinoplasties, which have been followed up for 9 to 48 months. The caudal septal graft was combined to the septocolumellar suture in 621 (27.1%) patients. Of the caudal septal grafts, 69.7% were used for primary rhinoplasty cases, and 30.3% for secondary rhinoplasties. At the 18th month postoperatively, tip projection was found to be satisfactory for 98% of the patients. The septocolumellar suture combined with caudal septal graft in closed rhinoplasty substantially facilitates the achievement of a cosmetically and functionally pleasing end result, bringing the solution for a wide array of problems such as short nose, supratip deformity, nasolabial angle change, or columellar bowing. Nevertheless, the technique has a steep learning curve; therefore, a meticulous preoperative evaluation should be exerted, a precise surgical planning should be prosecuted, and an excessive reduction of the nasal tip or exaggerated columellar retraction should be avoided.

Effects of Different Cartilage Sculpting Techniques on Cellular Integrity of Nasal Septal Cartilage

Study background: Several techniques exist to sculpt nasal septal cartilage grafts for use in functional and cosmetic rhinoplasty, including the use of cold steel, Bovie electrosection and the Sonopet ultrasonic bone aspirator. This is the first investigation on the effects of these disparate tools on gross cellular integrity of sculpted cartilage. Methods: After IRB approval, extraneous nasal septal cartilage harvested during routine septoplasty and/or rhinoplasty procedures was collected from three patients treated within our institution for use in this study. Cartilage specimens from each patient were divided into four equal segments and a partial thickness trough was sculpted in the center of each piece with one of the three techniques described above. One segment remained free of any additional manipulation and served as a comparative control. Gross cellular architecture and number of viable chondrocytes were assessed with optical microscopy. Results: Minimal disruption of the cellular integrity of nasal septal cartilage samples sculpted with each of the three techniques was noted compared to control. Average cell counts revealed 96%, 97%, 97% and 97% viable nuclei in the scalpel, electrocautery, ultrasonic bone aspirator and control groups, respectively. Conclusion: Cartilage sculpting using cold steel, Bovie electrosection and the ultrasonic bone aspirator appear to have minimal effects on cellular integrity of cartilage grafts. This portends a favorable outlook on long term durability of these cartilage grafts and suggests that these three techniques can be used interchangeably for cartilage sculpting needs.

Clinical efficacy of lengthening the short nose with X- septal extended spreader graft

Objective To investigate a safe and effective method of lengthening the short nose. Methods 29 females (17-37 years) with short nose were corrected with septal extended spreader grafts using autologous cartilage and combined with expanded polytetrafluoroethylene (e-PTFE) to reconstruct the supporting structures underneath to improve the upward and forward strength of the nasal tip in order to increase the nasal length and to correct the over rotation of nasal tip. The shield and cap grafts were also used for the patients whose nasal tip were too low with verticaI dome division technique. Results All the patients showed preserved nasal length after surgery with well-proportioned nasal features and the nasal lip angles were normal. There was no evidence of postoperative nasal shortening. No operative or postoperative complications (infection, deviation, extrusion, and delayed inflammation, perforation of nasal septum and dorsal depression) were detected by follow-up from 6 to 12 months, except 2 patients felt tip extended defects. All the patients were pleased with the surgical results achieved. Conclusions It is necessary to provide powerful forward and upward strength to lengthen nose and correct the over rotation of nasal tip effectively and safely. The use of septal extended spreader grafts by autologous cartilage and combined with expanded polytetrafluoroethylene (e-PTFE) represents a valuable tool for the short nose and proper cartilage grafts can improve the height of the nasal tip and correct the over rotation of the nasal tip further. Key words: Short nose; Septal cartilage; Grafts; Expanded polytetrafluoroethylene (e-PTFE)

The Multi-Lock System for Rhinoplasty.

Among the greatest challenges in rhinoplasty are setting the nasal tip contour and projection, and avoiding excessive upward rotation of the nose. Many suture and graft fixation techniques have attempted to achieve this result but may still produce results lacking in refinement. This study aims to describe in detail a new approach to stabilize the nasal tip for a durable and more predictable result. Twenty-eight surgeries were performed by the author, following a standardized technique which included: a modified distal onlay dorsal graft, a modified columella strut, and bilateral caudal septal sliver grafts. Follow-ups were conducted with all patients for at least 365 days. Twelve patients had follow-ups ranging from 456 to 619 days. At the nasal tip there was no loss of projection or rotation. One patient had a traumatic nasal fracture and left the study. Two patients had unilateral alar retraction not related to the technique described. One patient with thin nasal skin was submitted to a surgical revision to thin the caudal septal extension grafts and improve the nasal airflow. The Multi-Lock System for rhinoplasty is a good option to assure nasal length as well as projection and rotation of the tip. Also, it seemed to decrease the dead space of the supra-tip area which avoided pollybeak deformity. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Laryngeal clefts

Laryngeal clefts

A novel technique for spreader graft placement without dorsum resection during septoplasty.

This paper presents a novel method for spreader graft placement without dorsum resection in patients who have a deviated septum with a narrow internal nasal valve angle. A Killian incision was used for the endonasal septoplasty, and all spreader grafts were harvested from excised deviated septal cartilages. Procedures were conducted under general anaesthesia at the same centre by the same surgical team that performed the endonasal procedure. Successful placement of spreader grafts was achieved endonasally. Although the endonasal placement of spreader grafts seems to be more difficult than placement conducted by an open approach technique, an endonasal procedure has many advantages. Our technique provides surgeons with the opportunity to shorten operation time, obtain autologous septal graft material and secure the columellar architecture. Surgeons familiar with the classical (endonasal) septoplasty procedure can easily apply this technique to widen a narrow internal nasal valve angle, without corrupting nasal integrity.

Endoscopic Septoplasty: A Retrospective Analysis of 415 Cases.

Nasal obstruction is the most common complaint in nasal and sinus disease. Deviated nasal septum is a very frequently encountered and common cause. Surgical correction of a deviated septum- nasal septoplasty- is the definite treatment for septal deviation. Over the last 2 decades, the applications for endoscopy in the field of rhinology have evolved beyond functional endoscopic sinus surgery (FESS). Septoplasty which is among the three most commonly performed procedures in otolaryngology is particularly well suited to endoscopic application. Endoscopic septoplasty as a minimally invasive technique can limit the dissection and minimize trauma to the nasal septal flap under excellent visualization whose primary advantage is to decrease morbidity and post operative swelling in isolated septal deviation by limiting the excision to the area of deviation. This was a retrospective study, conducted in a tertiary care medical college hospital over a period of 5years. The study group comprised 415 patients in and around Nashik District; who visited our tertiary health centre and were subjected to endoscopic septoplasty. Complete data records from 415 patients were available for statistical analysis. Maximum numbers of patients were in age group 20-39. The youngest patient was 7years old and oldest was 75years. Mean age was 32years. The 7years old was operated for DCR for congenital NLD block and septoplasty was adjunct procedure. Even the 75years was operated for DCR. In the present study out of 415 cases, 256 (67.5%) cases were male and 115 (32.5%) cases were female. There is a male preponderance in the overall distribution of cases. In the present study of 415 patients, the most common operative procedure done was septoplasty in 260 (62.6%), FESS with septoplasty in 38 (9.2%) cases, septorhinopolasty in 41 (9.9%) cases and DCR with septoplasty in 78 (18.3%) cases. Endoscopic septoplasty facilitates good access to accomplish endoscopic DCR, FESS, and accurate and adequate septal graft harvest in severely deviated noses for septorhinoplasty. Complications like dental pain, paraestaesia, septal perforation, saddle nose deformity and persistent deviation are a rarity.

Effect of septoplasty with a caudal septal batten graft on changes in nasal shape.

This study aimed to determine frequency of external nasal deformities in patients with deviated septa and the effect of endonasalseptoplasty with batten grafting on the external nasal appearance. The 52 patients who underwent endonasalseptoplasty with a batten graft for the correction of caudal septal deviations were included in the study. The preoperative and postoperative photographs of 52 patients were reviewed retrospectively. Gross changes (nasal deviation, dorsal middle vault height, tip height change, and nostril asymmetry) were assessed. Anthropometric measurements (dorsal height, nasal tip projection, nasolabial angle, nasofrontal angle, and deviation angle) were performed. Preoperative assessment showed that 71% of the 52 patients had deformities, including nasal deviation (n=28), hump nose (n=19), saddle nose (n=3), and nostril asymmetry (n=15). On postoperative analysis, favorable changes in dorsal deviations were seen in 61% of patients. There were no aesthetic changes for hump or saddle nose deformities, whereas nostril asymmetry was corrected in 20% of patients. Anthropometric measurements also showed that dorsal deviation angles were corrected after surgery (P<.05), whereas other parameters showed no significant changes. In selected cases, deviated noses can be corrected to some extent by septoplasty with caudal septal batten grafting.

Giant true inferoposterior left ventricular aneurysm presenting with heart failure: insights from multimodality imaging

A 58-year old male patient who had undergone post-infarction ventricular septal defect closure and venous coronary bypass grafting to the obtuse marginal artery 2 years previously, presented with congestive heart failure. Echocardiography, computed tomography and ventriculography revealed a giant inferoposterior left ventricular aneurysm (Fig. 1A–D, Supplementary Video 1). Surgical left ventricular restoration was performed by a direct linear suture (Fig. 1E and F).

Unusual presentation of an asymptomatic pseudomeningocele within the sphenoid sinus

We report the rare case of a 55-year-old woman with an asymptomatic left sphenoid sinus pseudomeningocele mimicking a mucocele. A 55-year-old woman was found to have an incidental mass in the left sphenoid sinus on computed tomography. Magnetic resonance imaging confirmed the presence of a mucocele. A left endoscopic sphenoidotomy was performed to drain the mucocele. Despite an anatomical puncture through a stenosed sphenoid ostium, alarmingly, the opening leaked cerebrospinal fluid. A dehiscent lateral wall was identified with a dural opening communicating with the sphenoid sinus. This was immediately repaired with a free nasal septal mucosal graft. Six months post-operatively, the patient remained free from cerebrospinal fluid leakage. Pseudomeningoceles are extremely rare in the absence of trauma or iatrogenic injury. Surgeons should be alert to their presence as they can mimic a unilateral mucocele or nasal polyp. Endoscopic management lends itself to a single-stage repair.

The reconstruction of thyroid cartilage defect due to penetrating laryngeal trauma using a autogenous septal cartilage graft

The reconstruction of thyroid cartilage defect due to penetrating laryngeal trauma using a autogenous septal cartilage graft

Assessment of the 18-month permanence of onlay tip cartilage grafts following rhinoplasty

Augmentation rhinoplasty requires addition of materials of various natures to reshape the nasal pyramid. Onlay tip grafts are single or multilayered grafts placed horizontally over the alar domes. The aim of the present study was to assess the 18-month permanence of onlay septal cartilage grafts. Twenty-eight patients underwent rhinoplasty with onlay tip cartilage graft, between June 2008 and November 2008 at the Campus Bio-Medico University in Rome, Italy. They were reviewed and photographed 6 months and 18 months postoperatively. Comparison of 6-month and 18-month postoperative pictures was performed with Adobe Photoshop CS. Measurements on pictures were taken with AutoCAD. Comparison of photographs showed no visible difference in nasal tip projection. Comparison of the measurements of tip projection showed a mean reduction of 0.06 mm (0.19%). Considerable stability of nasal tip projection after rhinoplasty with onlay tip grafts was observed postoperatively. Comparison of standardised digital photographs is a valid procedure to assess contour alterations of various anatomical structures after plastic surgery.

Lengthening the short nose with bilateral septal spreader graft and columellar strut

Objective To investigate a safe and effective method of lengthening the short nose.Methods Thirty-nine cases of short nose were corrected by the bilateral septal spreader graft and columellar strut using autologous cartilage,combined with expanded polytetrafluoroethylene (e-PTFE)to reconstruct the supporting structures to improve the forward and upward strength of the nasal tip in order to increase the nasal length and to correct the over rotation of nasal tip.The shield and cap grafts were also used for the patients whose nasal tip were too low with vertical dome division technique.Results All the patients showed preserved nasal length after surgery with well-proportioned nasal features and the nasal lip angles were normal.There was no evidence of postoperative nasal shortening.No operative or postoperative complications were observed by follow-up for 6 months to 1 year,except for 2 cases with graft cartilage being apparent on nasal tip.All the patients were satisfied with the surgical results achieved.Conclusions It is necessary to provide powerful forward and upward strength to lengthen nose and correct the over rotation of nasal tip effectively and safely.The application of bilateral septal spreader graft and columellar strut using autologous cartilage and combined with e-PTFE represents a valuable tool for the short nose and proper cartilage grafts of nasal tip can improve the height of the nasal tip and further correct the over rotation of the nasal tip. Key words: Short nose; Septal spreader graft; Rhinoplasty

The short nose: Preoperative evaluation and management

Lengthening the short nose is considered the most difficult operation in rhinoplasty Several techniques have been described ranging from a mere tip graft up to paranasal osteotomies. After preoperative evaluation and measurements, the author suggests a method of lengthening by cartilage grafting using either costal or septal grafts. The type of cartilage grafting depends on the preoperative condition of the nasal septum and the availability of the adequate septal graft. If deemed inappropriate, a costal cartilage graft is harvested and shaped to give the desired effect. By applying the technique in 8 patients, adequate lengthening was achieved in 5 cases. The main obstacle to reach the desired length is the inadequate stretchability of the skin envelope especially after a previous trauma or an operation.

Modified technique to increase nostril cross-sectional area after using rib and septal cartilage graft over alar nasal cartilages

Describe a modified technique to increase nostril cross-sectional area using rib and septal cartilage graft over alar nasal cartilages. A modified surgical technique was used to obtain, carve and insert cartilage grafts over alar nasal cartilages. This study used standardized pictures and measured 90 cadaveric nostril cross-sectional area using Autocad(®); 30 were taken before any procedure and 60 were taken after grafts over lateral crura (30 using costal cartilage and 30 using septal cartilage). Statistical analysis were assessed using a model for repeated measures and ANOVA (Analysis of Variance) for the variable "area". There's statistical evidence that rib cartilage graft is more effective than septal cartilage graft. The mean area after the insertion of septal cartilage graft is smaller than the mean area under rib graft treatment (no confidence interval for mean difference contains the zero value and all P-values are below the significance level of 5%). The technique presented is applicable to increase nostril cross section area in cadavers. This modified technique revealed to enhance more nostril cross section area with costal cartilage graft over lateral crura rather than by septal graft.

Elongating Asian nose with autologous septal cartilage

Objective To employ autologous septal cartilage grafting as a new method of elongating the nose and adjusting the nasolabial angle in order to correct the deformities of short nose and bulbous tip.Methods A set of techniques,including,yet not limited to,releasing and sculpturing of the alar cartilages,harvesting of septal cartilages and carving them into L shape and cap-like shape for transplant,moulding the soft tissue envelop with buried through and through sutures etc.were used to lengthen the nose and modify the tip.Results From 2004 to now,the new technique had been applied to 345 patients with short nose and bulbous tip.Follow-up ranged from 6- 48 months,satisfactory outcomes were obtained.Conclusions The new technique adopted by the author in which autologous septal cartilages are settled to the anterior angle of the nasal septum and between the domes of alar cartilages has been proved to be a viable and reliable way to lengthen the nose.Further advantages of this technique include the easiness of harvesting grafts,minimal injury,rare complications of infection and rejection etc. Key words: Short nose; Nasal elongation; Autologous septal cartilage graft; Comprehensive rhinoplasty

Use of Porous High-Density Polyethylene (Medpor) for Spreader or Extended Septal Graft in Rhinoplasty

In this study, 29 patients with porous high-density polyethylene (group A) and 29 patients with septal cartilage (group B) were enrolled for either spreader or extended septal graft. By questionnaire or telephone survey, the authors evaluated patients' cosmetic satisfaction and complications. The authors also used postoperative photographs to evaluate cosmetic results. For the functional analysis, the change of visual analog scale of nasal obstruction and change of minimal cross-sectional area using acoustic rhinometry were compared. Of 29 patients in group A, 27 were totally satisfied with the results. There was no complication except for 2 cases of extrusion during 5.3 ± 1.8 years. The patients in group A showed more decrease of nasal obstruction by visual analog scale and more improvement of minimal cross-sectional area as compared with those in group B. Therefore, porous high-density polyethylene is an ideal alloplastic material for spreader or extended septal graft in rhinoplasty in both cosmetic and functional aspects. And it is also safe and stable over a long-term period.

The Role of Septal Cartilage in Rhinoplasty: Cadaveric Analysis and Assessment of Graft Selection

In addition to providing nearly 50% of total airway resistance via the internal valve, the nasal septum provides support for the cartilaginous portion of the nasal dorsum, and it is responsible for determining the projection of the nasal tip. In modern rhinoplasty, septal cartilage plays an important role as a donor graft material. The authors evaluate the anatomy of nasal septal cartilage, identifying variations according to certain regions of the septum and proposing a correlation between the topography and morphology of septal cartilage and graft choice. An anatomical study was performed on 14 fresh adult cadavers. The excised septal cartilage was placed on grid paper; digital images were taken; all septal cartilage was divided into nine equivalent quadrants; and quantitative measurements for length, height, and area were calculated and compared. Statistical significance was set at P < .05. The average length of the septum was 35.14 mm, while the average height was 32.5 mm. The average septal area was 933.11 mm(2). The septal thickness mean values were analyzed in nine quadrants, ranging from 1.04 to 1.71 mm. Statistically-significant differences in mean values were found in 13 of the 14 cadavers. Specifically, the central and cranial areas were thickest, and the area corresponding to the L-strut was thinnest. Anatomical variations of the thickness of septal cartilage excisions were found to be statistically significant, and these differences play an important role in the proper selection of the septal grafts.

Septumkorrektur in der Septorhinoplastik

In general septoplasty precedes all other procedures in rhinoplasty as a straight, stable septum dictates the aesthetic and functional outcome. The patient's history and expectations, correct preoperative analysis and the surgeon's skills determine the approach in septum correction. As a rule of thumb, slight deviations, e.g. single vomer spurs, maxillary crests, the septal tilt and simple C and S-shaped deformities can be managed endonasally using a hemitransfixion incision and procedures such as the swinging door technique, scoring, batten grafts or caudal septal replacement grafts. In contrast, for severe S-shaped and wave-like deviations, cleft nose deformities, the multiple fractured septum as well as for most revision cases, the open approach with complete septal reconstruction has been found to be the method of choice. After initial general remarks on the basic procedures, the present article focuses on current concepts of septum correction which have to be adapted to the individual pathology.