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.

Histological and molecular characterization of the growing nasal septum in mice.

The nasal septum is a cartilaginous structure that serves as a pacemaker for the development of the midface. The septum is a hyaline cartilage which is surrounded by a perichondrium and epithelium. It remains cartilaginous anteriorly, but posteriorly it undergoes endochondral ossification to form the perpendicular plate of the ethmoid. Understanding of hyaline cartilage differentiation stems predominantly from investigations of growth plate cartilage. It is currently unclear if the morphological and molecular properties of the differentiating nasal septum align with what is known from the growth plate. In this study, we describe growth, molecular, and cellular characteristics of the nasal septum with reference to hyaline cartilage differentiation. The nasal septum grows asynchronous across its length with phases of rapid growth interrupted by more stagnant growth. Growth appears to be driven predominantly by acquisition of chondrocyte hypertrophy. Similarly, cellular differentiation is asynchronous, and differentiation observed in the anterior part precedes posterior differentiation. Overall, the nasal septum is structurally and molecularly heterogeneous. Early and extensive chondrocyte hypertrophy but no ossification is observed in the anterior septum. Onset of hypertrophic chondrocyte differentiation coincided with collagen fiber deposition along the perichondrium. Sox9, Col2, Col10, Mmp13, Sp7, and Runx2 expression was heterogeneous and did not always follow the expected pattern established from chondrocyte differentiation in the growth plate. The presence of hypertrophic chondrocytes expressing bone-related proteins early on in regions where the nasal septum does not ossify displays incongruities with current understanding of hyaline cartilage differentiation. Runx2, Collagen II, Collagen X, and Sp7 commonly used to mark distinct stages of chondrocyte maturation and early bone formation show wider expression than expected and do not align with expected cellular characteristics. Thus, the hyaline cartilage of the nasal septum is quite distinct from growth plate hyaline cartilage, and caution should be taken before assigning cartilage properties to less well-defined cartilage structures using these commonly used markers. Beyond the structural description of the nasal cartilage, this study also provides important information for cartilage tissue engineering when using nasal septal cartilage for tissue regeneration.

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.

Variation in the Developmental and Morphological Interaction Between the Nasal Septum and Facial Skeleton.

While the nasal septum exerts a morphogenetic influence on the facial skeleton, there is evidence that this relationship is highly variable. To better appreciate the precise role of the septum, it is important understand the variable interaction between the septum and surrounding skeleton during ontogeny. Here we analyzed nasal septal and facial skeletal postnatal phenotypic variation using cross-sectional samples of C3H/HeJ and C57BL/6J mice. Initial observations indicated between-strain variation in the magnitude of septal deviation, suggesting differences in septal and facial skeletal interaction. We examined whether variation in septal deviation is due to ontogenetic differences in septal size, or whether variation in facial skeletal growth imposes spatial constraints on the septum. Using microCT we quantified septal size and deviation, and collected coordinate landmark data, which we analyzed using geometric morphometrics. C3H/HeJ mice were significantly more deviated than C57BL/6J during development. We found no differences in septal size between the two strains. However, while both strains exhibited an ontogenetic increase in snout length, C3H/HeJ mice exhibited a non-allometric reduction in nasal bone length. This appears to be influenced by between-strain variation in the spatial relationship between the nasal septum and nasofrontal suture. Unlike C57BL/6J mice, the C3H/HeJ nasal septum is positioned anterior to the nasofrontal suture potentially limiting an early direct influence of septal growth (e.g., through interstitial expansion) on sutural growth. Ultimately, our results underscore that while the septum is a key facial growth center, its precise influence on facial growth varies even in narrow morphological and taxonomic ranges. Anat Rec, 299:730-740, 2016. © 2016 Wiley Periodicals, Inc.

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.

[The growing nose]. / Le nez en croissance.

Children noses have special anatomical and functional characteristics. Early interventions performed before the end of the child's growth have been a main topic as they may cause adverse effects on the subsequent development and the function. This chapter describes the characteristics of the nasal pyramid and the septum at different stages of growth. Should one's approach be very cautious in children surgical indications, one should not hesitate opting for the treatment of congenital malposition or acquired when they jeopardize the nasal function. Considering possible procedures and specific conditions within pediatric field are discussed in this chapter.

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.

Real-time monitoring of the growth of the nasal septal cartilage and the nasofrontal suture.

INTRODUCTION: The nasal septum is thought to be a primary growth cartilage for the midface and, as such, has been implicated in syndromes involving midfacial hypoplasia. However, this internal structure is difficult to study directly. The aims of this study were to provide direct, continuous measurements of the growth of the nasal septal cartilage and to compare these with similar measurements of the nasofrontal suture to test whether the growth of the cartilage precedes the growth of the suture and whether the growth of the septal cartilage is constant or episodic. METHODS: Ten Hanford minipigs were used. Linear displacement transducers were implanted surgically in the septal cartilage and across the nasofrontal suture. Length measurements of the cartilage and suture were recorded telemetrically each minute for several days. RESULTS: The growth rate of the nasal septal cartilage (0.07% ± 0.03% length/h) was significantly higher than that of the suture (0.03% ± 0.02% length/h) (P = 0.004). The growth of both structures was episodic with alternating periods of growth (5-6 per day) and periods of stasis or shrinkage. No diurnal variation in growth of the cartilage was detected. CONCLUSIONS: These results are consistent with the notion that growth of the septal cartilage might drive growth of the nasofrontal suture. Growth of the midface is episodic rather than constant.

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.

Nasal septal and craniofacial form in European- and African-derived populations.

As a component of the chondrocranium, the nasal septum influences the anteroposterior dimensions of the facial skeleton. The role of the septum as a facial growth center, however, has been studied primarily in long-snouted mammals, and its precise influence on human facial growth is not as well understood. Whereas the nasal septum may be important in the anterior growth of the human facial skeleton early in ontogeny, the high incidence of nasal septal deviation in humans suggests the septum's influence on human facial length is limited to the early phases of facial growth. Nevertheless, the nasal septum follows a growth trajectory similar to the facial skeleton and, as such, its prolonged period of growth may influence other aspects of facial development. Using computed tomography scans of living human subjects (n = 70), the goal of the present study is to assess the morphological relationship between the nasal septum and facial skeleton in European- and African-derived populations, which have been shown to exhibit early developmental differences in the nasal septal-premaxillary complex. First we assessed whether there is population variation in the size of the nasal septum in European- and African-derived samples. This included an evaluation of septal deviation and the spatial constraints that influence variation in this condition. Next, we assessed the relationship between nasal septal size and craniofacial shape using multivariate regression techniques. Our results indicate that there is significant population variation in septal size and magnitude of septal deviation, both of which are greater in the European-derived sample. While septal deviation suggests a disjunction between the nasal septum and other components of the facial skeleton, we nevertheless found a significant relationship between the size of the nasal septum and craniofacial shape, which appears to largely be a response to the need to accommodate variation in nasal septal size.

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.

Nasal septal and premaxillary developmental integration: implications for facial reduction in Homo.

The influence of the chondrocranium in craniofacial development and its role in the reduction of facial size and projection in the genus Homo is incompletely understood. As one component of the chondrocranium, the nasal septum has been argued to play a significant role in human midfacial growth, particularly with respect to its interaction with the premaxilla during prenatal and early postnatal development. Thus, understanding the precise role of nasal septal growth on the facial skeleton is potentially informative with respect to the evolutionary change in craniofacial form. In this study, we assessed the integrative effects of the nasal septum and premaxilla by experimentally reducing facial length in Sus scrofa via circummaxillary suture fixation. Following from the nasal septal-traction model, we tested the following hypotheses: (1) facial growth restriction produces no change in nasal septum length; and (2) restriction of facial length produces compensatory premaxillary growth due to continued nasal septal growth. With respect to hypothesis 1, we found no significant differences in septum length (using the vomer as a proxy) in our experimental (n = 10), control (n = 9) and surgical sham (n = 9) trial groups. With respect to hypothesis 2, the experimental group exhibited a significant increase in premaxilla length. Our hypotheses were further supported by multivariate geometric morphometric analysis and support an integrative relationship between the nasal septum and premaxilla. Thus, continued assessment of the growth and integration of the nasal septum and premaxilla is potentially informative regarding the complex developmental mechanisms that underlie facial reduction in genus Homo evolution.

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.