Secondary Rhinoplasty for Unilateral Cleft Nasal Deformity.

BACKGROUND: Secondary cleft rhinoplasty presents some of the most challenging cases of both cosmetic and functional nasal deformities. Understanding the anatomy and growth abnormality seen with the cleft nasal deformity helps to tailor surgical management. This article seeks to expand on the application of current concepts in secondary rhinoplasty for unilateral cleft lip nasal deformity. METHODS: The authors review nasal analysis in the cleft rhinoplasty patient and provide the surgical management for each aspect in the secondary cleft rhinoplasty. RESULTS: The secondary rhinoplasty was divided into seven areas: piriform hypoplasia, septal reconstruction, dorsal reshaping, tip reshaping, tip projection, alar reshaping, and alar repositioning. Surgical management for each is provided. CONCLUSION: Secondary cleft rhinoplasty requires an understanding of the structural dysmorphology, and the use of cosmetic, functional, and secondary rhinoplasty techniques for its successful management.

Rostro-caudal maturation of glial cells in the accessory olfactory system during development: involvement in outgrowth of GnRH neurites.

During mammalian embryonic development, GnRH neurones differentiate from the nasal placode and migrate through the nasal septum towards the forebrain. We previously showed that a category of glial cells, the olfactory ensheathing cells (OEC), forms the microenvironment of migrating GnRH neurones. Here, to characterize the quantitative and qualitative importance of this glial, we investigated the spatiotemporal maturation of glial cells in situ and the role of maturing glia in GnRH neurones development ex vivo. More than 90% of migrating GnRH neurones were found to be associated with glial cells. There was no change in the cellular microenvironment of GnRH neurones in the regions crossed during embryonic development as glial cells formed the main microenvironment of these neurones (53.4%). However, the phenotype of OEC associated with GnRH neurones changed across regions. The OEC progenitors immunoreactive to brain lipid binding protein formed the microenvironment of migrating GnRH neurones from the vomeronasal organ to the telencephalon and were also present in the diencephalon. However, during GnRH neurone migration, maturation of OEC to [GFAP+] state (glial fibrillary acid protein) was only observed in the nasal septum. Inducing depletion of OEC in maturation, using transgenic mice expressing herpes simplex virus thymidine kinase driven by the GFAP promoter, had no impact on neurogenesis or on triggering GnRH neurones migration in nasal explant culture. Nevertheless, depletion of [GFAP+] cells decreased GnRH neurites outgrowth by 57.4%. This study suggests that specific maturation of OEC in the nasal septum plays a role in morphological differentiation of GnRH neurones.

Septorhinoplasty in the Pediatric Patient.

Pediatric septorhinoplasty has been an area of controversy because early surgical intervention can prevent normal growth. There are certain conditions where early correction of the nose is indicated, such as in cleft lip nasal deformities, severe traumatic deformities, and congenital nasal lesions. Animal and clinical studies have been helpful in elucidating certain areas of the nose that are potential growth zones that should be left undisturbed when performing nasal surgeries on pediatric patients. We discuss the timing, indications, and surgical technique in pediatric septorhinoplasty.

Septoplasty in children.

OBJECTIVES: Physicians have long had concerns about the potential harmful effects of pediatric septoplasties on the nasoseptal growth process because septal cartilage is important for the growth and development of the face. METHODS: In this review article, pediatric septoplasty and its indications are discussed, together with a literature survey. In addition, overviews of development of the nasal skeleton from neonate to adult, nasal growth, and cartilaginous septum are presented. Important issues and comments on pediatric septoplasties are provided. RESULTS: During septoplasty procedures, elevation of the mucoperichondrium unilaterally or bilaterally does not negatively affect growth of the face. Stabilization of the septum may be easier when mucosal elevation is performed unilaterally. The nasal floor mucosa should not be elevated so to avoid damage to the incisive nerves. Corrections and limited excisions may be done from the cartilaginous septum. Separation of the septal cartilage from the perpendicular plate, especially at the dorsal part, should not be performed because this area is important for the length and height of the nasal septum and nasal dorsum. Incisions or excisions should not be performed through the growing and supporting zones, especially at the sphenoethmoid dorsal zone. CONCLUSION: If there are severe breathing problems related to the septal deviation, septoplasty should be performed. In the majority of cases, septal surgery may be conducted in 6-year-old children. However, if necessary, septal surgery may be performed in younger children and even at birth.

Pediatric septorhinoplasty.

In the appropriately selected patient, septorhinoplasty can benefit a pediatric patient presenting with significant nasal trauma, abscess, or mass that will likely result in a progressive deformity in the growing nose or with negative functional or psychosocial effect. Clinical and experimental observations support a conservative approach to cartilage scoring and resection in pediatric patients in which septorhinoplasty is deemed necessary.

Are gender differences in external noses caused by differences in nasal septal growth?

BACKGROUND: The nasal septum plays an important role in nasal growth, but there have been few reports on the relationship between the septum and nasal growth. The authors investigated the relationship between septa and external noses using computed tomography during the growth period. METHODS: One hundred and ninety-eight patients under the age of 21 were enrolled in this study between 2008 and 2012. The authors evaluated a total of 9 measurement items (five for nasal bones and septa, and four for external noses). RESULTS: In the final age group, most measurement items were significantly larger in males than in females. However, there was no remarkable difference between male and female growth processes. Nasal bridge length and nasal height were significantly correlated with the nasal bone or septum in almost all age groups. The relative proportion of the cartilaginous septum decreased significantly with age, and was negatively correlated with the perpendicular plate in all age groups. CONCLUSIONS: Nasal septa and external noses were both larger in males than in females at the beginning of the study period, although not significantly. The differences became significant throughout the study due to differential increases between the sexes during the monitored growth spurts.

Secondary cleft nasoplasty at primary school age: quantitative evaluation of the efficacy of resorbable plates.

BACKGROUND: Secondary cleft nasal deformity in children of primary school age can result in permanent impact to a child's self-esteem. The ideal technique and timing of addressing the deformity remain controversial, as harvest of septal cartilage affects nasal growth and limits future options. METHODS: Fifty-three patients underwent secondary cleft nasoplasty with resorbable plate placement as a columellar strut. All patients had standardized preoperative and postoperative photographs. Basilar photographs were analyzed for height and width of each nostril, height and width of the nose, and deviation of the nasal tip from midline. RESULTS: In unilateral clefts, improvements in nostril width, nostril height, tip height, and tip deviation were found to be statistically significant in early postoperative photographs; improvements in nostril height, tip height, and tip deviation remained statistically significant in late photographs. In patients with bilateral clefts, improvements in nostril height and tip height were found to be significant in early postoperative photographs, with improvement in nostril height remaining significant in the long term. Partial plate exposure limited to the columellar base occurred in five patients (9.4 percent), successfully treated in the clinic setting with no loss of nasal tip support. CONCLUSIONS: The authors provide quantitative data regarding nasal outcomes following secondary cleft nasoplasty using resorbable plates for tip support. Significant long-term improvements in nasal appearance are possible using this technique with minimal complications. In those patients presenting with cleft nasal deformity at primary school age, the use of resorbable plates can improve nasal symmetry and spare native cartilage and thereby reduce the potential for nasal growth disturbance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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

UNLABELLED: 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.

O impacto da septoplastia Metzembaum sobre o crescimento nasal e facial em crianças / The impact of Metzembaum septoplasty on nasal and facial growth in children

Há vários estudos que investigaram os efeitos da septoplastia no crescimento facial em crianças, com resultados conflitantes. No entanto, poucos empregaram medidas objetivas ou avaliaram os pacientes após o término do crescimento facial. OBJETIVO: Este estudo avalia os efeitos da septoplastia Metzenbaum, que preserva o pericôndrio e áreas relacionadas com o crescimento, sobre o crescimento nasal e facial em crianças. MÉTODO: Crianças que foram operadas antes dos 14 anos e que apresentavam 16 anos ou mais na avaliação foram incluídas. Dezesseis pacientes foram selecionados. Os seguintes parâmetros foram avaliados: satisfação clínica (patência e estética nasal); medidas antropométricas; cefalometria. Desenho científico: estudo de coorte histórica com corte transversal. RESULTADOS: A idade média na cirurgia foi de 13 anos; as crianças foram avaliadas em média 4,3 anos após a cirurgia. Apenas um paciente apresentou medidas antropométricas e cefalométricas abaixo da normalidade, porém, sem queixas quanto à estética ou à patência. Outros quatro pacientes apresentaram queixa quanto à estética nasal e três quanto à patência nasal. CONCLUSÃO: A septoplastia Metzenbaum parece ser uma técnica segura na correção de desvios caudais. Esta técnica não apresentou impacto significativo no crescimento facial dos pacientes avaliados.

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.

Cleft lip, nose, and palate: the nasal septum as the pacemaker for midfacial growth.

The need to be aware of the dynamics of cartilage development and growth is encountered by surgeons whenever they attempt to correct craniofacial defects such as unilateral or bilateral cleft lip/cleft palate or midfacial injuries after trauma. Within the craniofacial region, the nasal septal cartilage and the sphenoethmoidal and sphenooccipital cranial synchondroses are distinguished from other craniofacial cartilages in possessing intrinsic growth potential. Indeed, growth of the nasal septal cartilage outstrips the growth of other skeletal and soft tissues in the midface to such an extent that it is the pacemaker for growth of the face and anterior portion of the skull. We revisit and reinforce the importance of the nasal septum as pacemaker with analysis of 3 classes of evidence: in vivo growth of the nasal septum in nonhuman mammalian models; composition and in vitro growth of nasal septal cartilage or chondrocytes; and experience from the surgical repair of unilateral or bilateral facial clefts.

The Sarnat studies in craniofacial biology.

Dr. Bernard Sarnat is one of plastic surgery's greatest laboratory investigators. His contributions to our understanding of modern craniofacial molecular biology are immense. His landmark studies continue to influence the way we approach and treat patients today. This article outlines his classic investigations of the craniofacial skeleton, with particular interest in lower face, midface, and upper face development; cranial suture and cranial base biology; and tooth and dental development. In this article, a brief summary of Dr. Sarnat's investigations are followed by how these data have had an important clinical impact.

Pediatric nasal injuries and management.

Although serious trauma injuries are uncommon in the pediatric population, nasal injuries are a more common problem. In this population, many physicians are uncomfortable managing these injuries. The evaluation and treatment of nasal trauma differ considerably in children compared with adult nasal fractures. Poor patient cooperation during the physical exam coupled with significant anatomic differences can present the nasal surgeon with a difficult diagnostic dilemma. The surgical management of pediatric nasoseptal injuries is not without controversy, as disturbing the nasal growth centers can have significant effect on future nasal and midfacial development. This article reviews the diagnostic and therapeutic challenges presented by these injuries for children and provides recommendations to successfully manage nasal injuries in this population.

Nasal growth after pediatric septoplasty at long-term follow-up.

BACKGROUND: Septoplasty in children is still a matter of open discussion, because it is thought that a surgical procedure on a developing structure might produce some adverse effects on normal nasal growth. The goal of this retrospective study is to evaluate the effects of pediatric nasal septum surgery in a long-term follow-up by anthropometry. METHODS: Forty-four Italian patients, 25 male patients and 19 female patients, who had undergone septoplasty during childhood using the endonasal approach, were reassessed after a mean follow-up of 12.2 years. Anthropometric recordings were used to identify any growth retardation due to the operation by a comparison with previously published age-specific normative data of North American white subjects. Nasal measurements consisted of five linear parameters, three angular parameters, and three proportional index. RESULTS: There were no significant differences in any of the measures between the sample and controls (p > 0.1) with regard to gender, with the exception of the nasolabial angle measurement. Indeed, the nasolabial angle of the female patients was significantly reduced compared with controls (p = 0.04), whereas that of the male patients was reduced compared with controls (p = 0.08). This measurement seems to be influenced by the type of operation, because it has been noted that the nasolabial angle of patients treated surgically by extracorporeal septoplasty were significantly lower than those of patients treated surgically by conservative septoplasty. CONCLUSION: Pediatric septoplasty may be indicated in selected cases of obstructing nasal septum deformities. The operation, performed via endonasal approach, does not interfere with the normal growing nasal process.

Insulin-like growth factor-I and growth differentiation factor-5 promote the formation of tissue-engineered human nasal septal cartilage.

INTRODUCTION: Tissue engineering of human nasal septal chondrocytes offers the potential to create large quantities of autologous material for use in reconstructive surgery of the head and neck. Culture with recombinant human growth factors may improve the biochemical and biomechanical properties of engineered tissue. The objectives of this study were to (1) perform a high-throughput screen to assess multiple combinations of growth factors and (2) perform more detailed testing of candidates identified in part I. METHODS: In part I, human nasal septal chondrocytes from three donors were expanded in monolayer with pooled human serum (HS). Cells were then embedded in alginate beads for 2 weeks of culture in medium supplemented with 2% or 10% HS and 1 of 90 different growth factor combinations. Combinations of insulin-like growth factor-I (IGF-1), bone morphogenetic protein (BMP)-2, BMP-7, BMP-13, growth differentiation factor-5 (GDF-5), transforming growth factor ß (TGFß)-2, insulin, and dexamethasone were evaluated. Glycosaminoglycan (GAG) accumulation was measured. A combination of IGF-1 and GDF-5 was selected for further testing based on the results of part I. Chondrocytes from four donors underwent expansion followed by three-dimensional alginate culture for 2 weeks in medium supplemented with 2% or 10% HS with or without IGF-1 and GDF-5. Chondrocytes and their associated matrix were then recovered and cultured for 4 weeks in 12 mm transwells in medium supplemented with 2% or 10% HS with or without IGF-1 and GDF-5 (the same medium used for alginate culture). Biochemical and biomechanical properties of the neocartilage were measured. RESULTS: In part I, GAG accumulation was highest for growth factor combinations including both IGF-1 and GDF-5. In part II, the addition of IGF-1 and GDF-5 to 2% HS resulted in a 12-fold increase in construct thickness compared with 2% HS alone (p < 0.0001). GAG and type II collagen accumulation was significantly higher with IGF-1 and GDF-5. Confined compression modulus was greatest with 2% HS, IGF-1, and GDF-5. CONCLUSION: Supplementation of medium with IGF-1 and GDF-5 during creation of neocartilage constructs results in increased accumulation of GAG and type II collagen and improved biomechanical properties compared with constructs created without the growth factors.

[The nasal development after one-staged correction of nose deformity and unilateral complete cleft lip in infancy].

OBJECTIVE: To introduce one-staged correction of nasal deformity and unilateral complete cleft lip in infancy and to observe the nasal development after the operation. METHODS: The unilateral complete cleft lip and nasal deformity were corrected in one stage in27 cases. They were followed up for several years. With post-operative photos, the anthropometric method was used to analyze the nasal development. RESULTS: The long-term results were excellent in 10 cases, good in 14 cases, and poor in 3 cases. CONCLUSIONS: Based on the anatomic findings of nasal blood supply, one-staged correction of nasal deformity and unilateral complete cleft lip in infancy can be performed with no obvious interference with nasal development. The secondary nasal deformity before school age can be alleviated or avoided.

Rhinosurgery in children: basic concepts.

In newborns, the main supporting structure of the nose is the dorsoseptal cartilage, a T-bar-formed complex of septum and upper lateral cartilages, which is essentially an external extension of the cartilage of the anterior cranial base. Later the anatomic situation gradually changes -- a potential pitfall for surgeons and radiologists. The vulnerability of various processes underlying postnatal development of the facial skeleton is discussed. The cartilaginous septum is the dominant growth center. Loss of septal cartilage at different ages leads to different facial syndromes involving nose, maxilla, and orbita. The septal cartilage in children demonstrates thinner fracture-prone areas next to thicker growth zones. Septum fractures have a preference for the thinner regions, corresponding with the most frequent septum deviations observed in growing children. The essential problem in pediatric rhinosurgery is not the age-specific anatomy but the poor wound-healing capacity: fractured or transected septum cartilage will not heal, and disconnected ends tend to overlap, resulting in increasing or recurrent deviations. Based on clinical and experimental evidence, indications and "safe" and "unsafe" techniques of rhinosurgery are presented for children of various age groups.

Morphological and histological findings after typical surgical manipulations on growing septal cartilage in rabbits.

One remaining problem of nose surgery is surgical correction of a prepubertal distortion of the septum. Unfortunately, the growing cartilage reacts differently upon a surgical intervention; in most cases this might cause iatrogenic disturbance of the development. Our clinical and histological studies with polydioxanone (PDS) foil in septal reconstruction showed that the PDS foil successfully prevented postoperative sequelae like dislocation of the reimplanted cartilage fragments and recurrent deviation caused by overlapping of the cartilage borders. Furthermore, it seemed to stimulate cartilage regeneration. The question occurs whether the same effect can be expected if growing septal cartilage is supported by the PDS foil. This animal study showed remarkable effects of the resorbable PDS foil in healing and regeneration of the growing septum up to complete resorption of the PDS, which coincidentally paralleled the outgrowth of the septal cartilage in rabbits, such as in cartilage regeneration and in prevention of secondary septal deviations due to bending of the newly formed cartilage or incomplete healing of cut edges.

Open rhinoplasty in children.

Septorhinoplasty in children carries the risk of growth disturbance of the nose and premaxilla. The open or external approach has the advantage that the cartilaginous nasal skeleton remains intact. This open approach enables the surgeon to excise dermoid cysts and to realign lower lateral cartilages (unilateral cleft) without disturbing the integrity of the cartilaginous skeleton. In our experience, absolute indications for open rhinoplasty in children include dermoid cyst, cleft lip nose, and septal abscess. Relative indications include septal deviations causing severe nasal airway obstruction and or progressive distortion of the nose. In this article, we discuss the indications, advantages, disadvantages, and operative technique of open rhinoplasty in children. Our indications for open rhinoplasty in children and some selected cases are illustrated.

Human serum for tissue engineering of human nasal septal cartilage.

OBJECTIVE: To compare the chondrogenic and proliferative effects of pooled human serum (HS) and fetal bovine serum (FBS) on tissue-engineered human nasal septal chondrocytes. STUDY DESIGN AND SETTING: Human chondrocytes were expanded for one passage in monolayer in medium supplemented with 10% FBS, 2% HS, 10% HS, or 20% HS. Cells were then suspended in alginate beads for 3D culture for 2 weeks with 10% FBS, 2% HS, 10% HS, or 20% HS. RESULTS: Monolayer cell yields were greater with HS than FBS. In alginate, cellular proliferation, glycosaminoglycan production per cell, and type II collagen were significantly higher with 10% HS compared to 10% FBS controls. CONCLUSION: HS results in increased proliferation and production of cartilaginous extracellular matrix by tissue-engineered human nasal septal chondrocytes, compared to FBS controls. SIGNIFICANCE: Culture with human serum may facilitate creation of neocartilage constructs that more closely resemble native tissue.

Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood.

The purpose of this article is to review human craniofacial growth and development, especially the growth of the mandible, to clarify the relationship between obstructive sleep apnea (OSA) syndrome and craniofacial abnormality, and finally, to propose the hypothesis that negative pressure produced in the chest of the OSA child inhibits the growth of the mandible. Recently, the development of diagnosis and treatment of OSA syndrome has progressed rapidly; however, the prevention of OSA syndrome was merely seen. Craniofacial abnormality is reported as one of the causes of OSA syndrome. If craniofacial abnormality is determined only by genetics, it is difficult to manage the craniofacial skeleton to prevent OSA syndrome. The role of epigenetic factors on craniofacial growth and development is still controversial. However, if we stand on the functional matrix hypothesis, we can manage not only growth of the mandible but also the craniofacial skeleton as a whole. The author proposes the hypothesis that the negative pressure produced in the chest prohibits the growth of the mandible even if the patients have a capacity for growth and development; therefore, if this negative pressure disappears because of the removal of the tonsil and/or adenoids or by an orthodontic treatment to make a patency of the airway, the mandible may grow normally, and we can prevent or reduce a number of OSA syndromes in the future.