The Clinical Analysis of the Nasal Septal Cartilage by Measurement Using Computed Tomography

The Quadrangular Cartilage in Rhinoplasty: A Surgically Focused CT Dimensional Analysis of Black African and Caucasian Populations

The apparent lack of quadrangular cartilage in Black African noses is commonly observed both from a radiological and clinical point of view. To the best of our knowledge, only a few research papers have been conducted on the facial proportions and structural anatomy of black people of Southern and Eastern Africa. The aim of this retrospective comparative study is a radiological assessment of the total amount of septal quadrangular cartilage by measuring its area in sagittal CT views, in two selected Black South African and Caucasian (CA) samples and the comparison with the literature in our hands. Statistical analysis was conducted, categorical variables are shown as frequencies and percentages, while continuous variables as means and standard deviations. Normal distribution of variables was verified using the Shapiro-Wilk test or by means of skewness and kurtosis values. Differences among unpaired groups were evaluated using the independent Student's t-test for normally distributed data (complemented by the Cohen's d to show the effect size with the following cutoff: d = 0.2, "small" effect size; d = 0.5, "medium" effect size; d = 0.8, "large" effect size) and Mann-Whitney U test in case of non-normal distribution. Statistical significance was defined as p < 0.05 setting the α-error probability at 5%. This study shows that, on average, there is 30% more cartilage available in CA compared with Black African noses and confirms the apparent lack of quadrangular cartilage and in Black African noses which is commonly observed in surgery. The need for an adequate amount of autologous septal cartilage makes cartilage availability a major concern before surgery and being able to preoperative accurately measure the amount of septal cartilage that is available to be harvested for other grafts in the surgery is essential.

A Radioanatomical Study of Nasal Septal Cartilage: Influencing Factors and Clinical Implications

BACKGROUND

The septal cartilage is the most common and advantageous donor site for autogenous cartilage grafts in rhinoplasty.

OBJECTIVES

We aimed to examine the parts of nasal septum of Turkish patients and assess the association between the size of these structures and patient characteristics such as age and sex. Through this, we investigated whether some external features of the nose could be useful in predicting the septal cartilage area (SCA).

METHODS

Paranasal sinus computerized tomography (PNCT) images of 174 patients were examined with Radiant Dicom Viewer 2024.1. The "multiplanar reconstructions" feature was used, and the coronal and transverse planes were adjusted to show the largest part of the septum in the sagittal plane. SCA, perpendicular plate of ethmoid (PPE) and Vomer areas were measured with the closed polygon area measurement feature.

RESULTS

The mean SCA, PPE, Vomer, and total septal area (TSA) were 9.76 ± 1.89, 11.21 ± 2.23, 6.73 ± 1.26, and 27.72 ± 3.47 cm2 in overall, 10.26 ± 1.94, 12.33 ± 1.86, 7.26 ± 1.31, and 29.86 ± 2.88 cm2 in males, and 9.29 ± 1.74, 10.11 ± 1.98, 6.24 ± 1.01, and 25.15 ± 2.65 cm2 in females, respectively (p = 0.001, 0.000, 0.000, 0.000, respectively). SCA was negatively correlated with age and positively correlated with nasal bone length, nose projection, nose length, and TSA.

CONCLUSIONS

Greater age, female sex and small nasal pyramid are associated with smaller septal cartilage. CT is a reliable and useful method for evaluating the preoperative septal cartilage area.

LEVEL OF EVIDENCE IV

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 .

Predictive Evaluation of Septal Cartilage-bone Complex for Rhinoplasty Using Cone Beam Computed Tomography

Background

Septal extension grafting (SEG) is commonly used for correcting Asian short noses. When septal cartilage is limited, septal bone can be included. This study evaluates the outcomes of SEG using a septal cartilage-septal bone complex (SCBC) and assesses preoperative cone beam computed tomography (CBCT) for predicting septal bone suitability.

Methods

A retrospective review was conducted of Korean women planned for SEG with SCBC from July 2021 to June 2022. Preoperative CBCT scans measured Hounsfield Unit (HU) values for septal cartilage, perpendicular plate of the ethmoid (PPE), and vomer. Of 27 patients, 19 underwent SEG with SCBC, whereas 8 did not due to unsuitable septal bone. Clinical outcomes and satisfaction were assessed through surveys and photographs.

Results

For the 19 patients using SCBC, the average HU for PPE was 286.5 ± 126.6 (ratio 6.8 ± 2.1), and for vomer, HU was 230.3 ± 95.2 (ratio 5.7 ± 1.8). SEG significantly improved nasal length and tip projection, although tip softness was less favorable. Among the 8 patients not using SCBC, 5 had bones that were too thick and stiff (PPE: 667.8 ± 102.2, ratio 15.5 ± 2.7; vomer: 342.8 ± 55.1, ratio 8.1 ± 2.3), and 3 had fragile bones (PPE: 148.7 ± 45.4, ratio 3.1 ± 0.7; vomer: 199.0 ± 68.6, ratio 4.1 ± 0.9).

Conclusions

SEG using SCBC effectively corrects short noses in Asian patients. Preoperative HU ratios from CBCT can help predict septal bone quality and guide surgical planning. Further research with larger cohorts is needed to confirm these findings.

In-House Virtual Planning and 3D-Printed Surgical Guides for Reconstructive Rhinoplasty

BACKGROUND

Performing rhinoplasty in patients with craniofacial malformations remains a challenge, even for experienced surgeons. Advances in 3-dimensional technology and their application in surgical planning and printing of cutting guides and splints have become important tools for improving aesthetic and functional results.

OBJECTIVES

The aim of this preliminary report was to describe an in-house workflow for surgical planning and printing of cutting guides and splints for complex rhinoplasty cases.

METHODS

An in-house workflow for complex rhinoplasty was described, as applied in the maxillofacial department of a children's hospital specializing in the treatment of cleft and craniofacial malformations.

RESULTS

Customized surgical guides helped the surgeon harvest and mold potential septal and costochondral grafts more accurately, reduced surgical time, and verified the dimensions of the sculpted nasal shape following surgical planning templates. Patient satisfaction according to the Rhinoplasty Outcome Evaluation questionnaire was 18/24.

CONCLUSIONS

The presented workflow represents a potential asset for obtaining more accurate and satisfactory results in complex rhinoplasties.

LEVEL OF EVIDENCE: 5 (DIAGNOSTIC)

Impact of posterior septectomy on olfaction in endoscopic endonasal transsphenoidal surgery

BACKGROUND

Endoscopic endonasal transsphenoidal surgery is widely used to resect pituitary adenomas, yet its impact on olfactory function after resection of the posterosuperior nasal septum remains a concern. To optimize surgical techniques to preserve olfactory function, it is essential to understand the relationship between the extent of septal resection and olfactory outcomes.

METHODS

This retrospective study analyzed 295 patients who underwent pituitary adenoma surgery. The extent of nasal septum resection was quantified and its impact on olfactory function was assessed using the Cross-Cultural Smell Identification Test (CCSIT), Sino-Nasal Outcome Test-22 (SNOT-22), and a Visual Analog Scale (VAS) for olfactory loss. Preoperative and 6-month postoperative scores were compared to evaluate changes in olfactory function.

RESULTS

There was a significant correlation between larger septal resections and greater reductions in CCSIT scores, indicating a decline in olfactory function. Furthermore, patients with more extensive septal resections reported increased discomfort and olfactory loss, as evidenced by higher SNOT-22 and VAS scores. These findings highlight the importance of the nasal septum in maintaining laminar airflow and its role in olfactory function.

CONCLUSION

Study underscores the adverse effects of extensive posterior septectomy on olfactory outcomes. Minimizing the extent of septal resection may help preserve olfactory function, suggesting a need for surgical strategies that maintain septum integrity to reduce the risk of postoperative olfactory impairment.

Usefulness of T2-Weighted Images with Deep-Learning-Based Reconstruction in Nasal Cartilage

OBJECTIVE

This study aims to evaluate the feasibility of visualizing nasal cartilage using deep-learning-based reconstruction (DLR) fast spin-echo (FSE) imaging in comparison to three-dimensional fast spoiled gradient-echo (3D FSPGR) images.

MATERIALS AND METHODS

This retrospective study included 190 set images of 38 participants, including axial T1- and T2-weighted FSE images using DLR (T1WIDL and T2WIDL, belong to FSEDL) and without using DLR (T1WIO and T2WIO, belong to FSEO) and 3D FSPGR images. Subjective evaluation (overall image quality, noise, contrast, artifacts, and identification of anatomical structures) was independently conducted by two radiologists. Objective evaluation including signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) was conducted using manual region-of-interest (ROI)-based analysis. Coefficient of variation (CV) and Bland-Altman plots were used to demonstrate the intra-rater repeatability of measurements for cartilage thickness on five different images.

RESULTS

Both qualitative and quantitative results confirmed superior FSEDL to 3D FSPGR images (both p < 0.05), improving the diagnosis confidence of the observers. Lower lateral cartilage (LLC), upper lateral cartilage (ULC), and septal cartilage (SP) were relatively well delineated on the T2WIDL, while 3D FSPGR showed poorly on the septal cartilage. For the repeatability of cartilage thickness measurements, T2WIDL showed the highest intra-observer (%CV = 8.7% for SP, 9.5% for ULC, and 9.7% for LLC) agreements. In addition, the acquisition time for T1WIDL and T2WIDL was respectively reduced by 14.2% to 29% compared to 3D FSPGR (both p < 0.05).

CONCLUSIONS

Two-dimensional equivalent-thin-slice T1- and T2-weighted images using DLR showed better image quality and shorter scan time than 3D FSPGR and conventional construction images in nasal cartilages. The anatomical details were preserved without losing clinical performance on diagnosis and prognosis, especially for pre-rhinoplasty planning.

Long-Term Outcomes of Secondary Nasal Tip Plasty After Degradation of a Polycaprolactone (PCL) Mesh

BACKGROUND

In secondary nasal tip plasty, it is often difficult to harvest appropriate septal extension grafts for sufficient tip projection. Therefore, studies using numerous alloplastic materials in rhinoplasty have been reported. This study aimed to evaluate the nasal tip change over time after tip plasty using a PCL mesh.

METHODS

We conducted a retrospective study of 86 Asian patients who received secondary tip plasty by septal extension grafting with a PCL mesh as a batten graft. Patient demographics and surgical outcomes were examined. The outcome variables were nasolabial angle, nasofrontal angle and Goode ratio. Measurements were performed with photographs obtained at short-term (postoperative 4-6 months) and long-term (more than postoperative 24 months) follow-ups. Aesthetic outcomes and safety were assessed using the Global Aesthetic Improvement Scale.

RESULTS

Among 86 patients, 56 had a long-term follow-up. The mean age was 33.33 years, and the male-to-female ratio was 17.44:82.56. The nasolabial and nasofrontal angles did not change significantly between the short-term and long-term follow-ups. The Goode ratio, which is a useful tool to evaluate nasal projection, was decreased by 5.00%. Nevertheless, all patients were satisfied, and the long-term aesthetic outcomes were improved in 54 (96.4%) patients. There were two cases (2.33%) of complications, including one infection and one case of PCL-mesh protrusion.

CONCLUSIONS

The present study demonstrated the usefulness and safety of PCL meshes when used in septal extension grafts as batten grafts. Although biodegradation seems to affect the nasal projection, PCL is still useful in secondary tip plasty along with other alloplastic materials.

LEVEL OF EVIDENCE IV

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 .

Shape Prediction of Nasal Bones by Digital 2D-Photogrammetry of the Nose Based on Convolution and Back-Propagation Neural Network

In rhinoplasty, it is necessary to consider the correlation between the anthropometric indicators of the nasal bone, so that it prevents surgical complications and enhances the patient's satisfaction. The penetrating form of high-energy electromagnetic radiation is highly impacted on human health, which has often raised concerns of alternative method for facial analysis. The critical stage to assess nasal morphology is the nasal analysis on its anthropology that is highly reliant on the understanding of the structural features of the nasal radix. For example, the shape and size of nasal bone features, skin thickness, and also body factors aggregated from different facial anthropology values. In medical diagnosis, however, the morphology of the nasal bone is determined manually and significantly relies on the clinician's expertise. Furthermore, the evaluation anthropological keypoint of the nasal bone is nonrepeatable and laborious, also finding widely differ and intralaboratory variability in the results because of facial soft tissue and equipment defects. In order to overcome these problems, we propose specialized convolutional neural network (CNN) architecture to accurately predict nasal measurement based on digital 2D photogrammetry. To boost performance and efficacy, it is deliberately constructed with many layers and different filter sizes, with less filters and optimizing parameters. Through its result, the back-propagation neural network (BPNN) indicated the correlation between differences in human body factors mentioned are height, weight known as body mass index (BMI), age, gender, and the nasal bone dimension of the participant. With full of parameters could the nasal morphology be diagnostic continuously. The model's performance is evaluated on various newest architecture models such as DenseNet, ConvNet, Inception, VGG, and MobileNet. Experiments were directly conducted on different facials. The results show the proposed architecture worked well in terms of nasal properties achieved which utilize four statistical criteria named mean average precision (mAP), mean absolute error (MAE), R-square (R²), and T-test analyzed. Data has also shown that the nasal shape of Southeast Asians, especially Vietnamese, could be divided into different types in two perspective views. From cadavers for bony datasets, nasal bones can be classified into 2 morphological types in the lateral view which “V” shape was presented by 78.8% and the remains were “S” shape evaluated based on Lazovic (2015). With 2 angular dimension averages are 136.41 ± 7.99 and 104.25 ± 5.95 represented by the nasofrontal angle (g-n-prn) and the nasomental angle (n-prn-sn), respectively. For frontal view, classified by Hwang, Tae-Sun, et al. (2005), nasal morphology of Vietnamese participants could be divided into three types: type A was present in 57.6% and type B was present in 30.3% of the noses. In particular, types C, D, and E were not a common form of Vietnamese which includes the remaining number of participants. In conclusion, the proposed model performed the potential hybrid of CNN and BPNN with its application to give expected accuracy in terms of keypoint localization and nasal morphology regression. Nasal analysis can replace MRI imaging diagnostics that are reflected by the risk to human body.

Morphological and Molecular Evaluation of the Tissue Repair following Nasal Septum Biopsy in a Sheep Model

OBJECTIVE

Nasal septal pathologies requiring surgical intervention are common in the population. Additionally, nasal chondrocytes are becoming an important cell source in cartilage tissue engineering strategies for the repair of articular cartilage lesions. These procedures damage the nasal septal cartilage whose healing potential is limited due to its avascular, aneural, and alymphatic nature. Despite the high incidence of various surgical interventions that affect septum cartilage, limited nasal cartilage repair characterizations have been performed to date.

METHODS

To evaluate the healing of the nasal septum cartilage perforation, a septal biopsy was performed in 14 sheep. Two and 6 months later, the tissue formed on the place of perforation was explanted and compared with the native tissue. Tissue morphology, protein and gene expression of explanted tissue was determined using histological, immunohistochemical and real-time quantitative polymerase chain reaction analysis.

RESULTS

Tissue formed on the defect site, 2 and 6 months after the biopsy was characterized as mostly connective tissue with the presence of fibroblastic cells. This newly formed tissue contained no glycosaminoglycans and collagen type II but was positively stained for collagen type I. Cartilage-specific genes COL2, AGG, and COMP were significantly decreased in 2- and 6-month samples compared with the native nasal cartilage. Levels of COL1, COL4, and CRABP1 genes specific for perichondrium and connective tissue were higher in both test group samples in comparison with native cartilage.

CONCLUSIONS

Newly formed tissue was not cartilage but rather fibrous tissue suggesting the role of perichondrium and mucosa in tissue repair after nasal septum injury.

The Caucasian Hump: Radiologic Study of the Osteocartilaginous Vault versus Surface Anatomy. Clinical Implications in Structured and Preservation Rhinoplasty

BACKGROUND

The relation between the osteocartilaginous nasal vault and nasal hump characteristics has not been fully investigated.

METHODS

Measurements were collected from computed tomographic nasal scans in the midsagittal plane in adult Caucasian patients seeking rhinoplasty because of nasal hump from January of 2015 to December of 2018. Measurements were compared to those of sex- and age-matched patients not seeking rhinoplasty (control group). Patients with other significant nasal deformities were excluded. The correlations between nasal hump length, height, and osteocartilaginous nasal vault measurements were assessed. Distances from the beginning of the nasal hump to the kyphion and ethmoidal points were measured as well. The location of the nasal hump apex in relation to the keystone area structures was detailed.

RESULTS

The study included 134 Caucasian patients, with 67 presenting nasal hump. The mean patient age was 32.9 years and 69.6 percent were female patients. Nasal hump measured a mean 17 ± 2.7 mm in length and 1.8 mm (range, 1.1 to 3.8 mm) in height. Nasal hump length correlated with nose length and nasal bone length. Nasal hump height correlated with nose length and the angle over the kyphion. In 97 percent of patients, the nasal hump began caudal to the ethmoidal point, and in all patients, the kyphion was underneath the nasal hump. The nasal hump is not a symmetric structure and, in all patients, its apex was situated above the septal cartilage.

CONCLUSIONS

The nasal hump characteristics are mainly attributable to the septal cartilage, and this should be the cornerstone of any dorsal hump reduction strategy. The caudal aspect of the nasal bones contributes to the nasal hump, whereas the posterior ethmoidal plate rarely does.

Folded Cymba Concha: Is It Large and Stable Enough for Caudal Septal Extension Graft in Asian Rhinoplasty?

BACKGROUND

Septal extension grafting (SEG) is used for nasal tip projection and positioning. Often, insufficient quadrangular cartilage is available for grafting in Asians, and in most secondary cases the septum is already harvested. We utilized the folded cymba concha as an alternative for caudal SEG (CSEG) by modifying a tongue-in-groove technique.

OBJECTIVES

The aim of this study was to evaluate the physical suitability of the cymba concha for CSEG and compare its outcomes with those of septal quadrangular cartilage.

METHODS

The mean length and width of 311 harvested consecutive folded cymba conchae were measured from intraoperative photographs. Data from 220 patients with >12 months of follow-up were retrospectively reviewed for clinical outcomes. Clinical demography was determined based on the need for additional spreader grafts. For clinical reliability, anthropometric photographs of patients in whom folded cymba conchae were used were compared with those in whom quadrangular cartilage was used.

RESULTS

Mean [standard deviation] lengths and widths of the folded cymba conchae in men and women were 24.2 [3.9] and 22.4 [3.7] mm, and 7.8 [1.9] and 7.2 [1.9] mm, respectively. Use of the folded cymba concha graft significantly increased nasal tip projection by 28.9% and columellar-labial angle by 9.7%, improving both aspects postoperatively. Anthropometric comparison revealed no significant differences between folded cymba conchae and septal cartilage in terms of nasal tip projection (P = 0.264) and postoperative columellar-labial angle (P = 0.182).

CONCLUSIONS

Folded cymba conchal cartilage can be a primary option for CSEG in Asian septorhinoplasty cases or for individuals with insufficient septal cartilage remnants.

Multilayered Costal Cartilage Graft for Nasal Dorsal Augmentation

BACKGROUND

Nasal dorsal augmentation is one of the most commonly performed rhinoplasty procedures in Asia. We describe our experience with multilayered costal cartilage grafting (MCG) for dorsal augmentation in Asian patients. We aimed to evaluate the aesthetic outcomes and complications of MCG in comparison with those of one-block concentric carving costal cartilage graft (OCG) using objective and subjective assessment criteria.

METHODS

Eighty-two consecutive patients who underwent dorsal augmentation with OCG (n = 39) or MCG (n = 43) by a single surgeon between November 2010 and September 2018 with > 12 months of follow-up were included in this retrospective cohort study. The aesthetic outcomes, which were determined by both anthropometric analysis and consensus decision, were compared. Patients' satisfaction and postoperative complications were also analyzed.

RESULTS

Dorsal height ratios and radix height ratios increased significantly by 14.0% and 19.4%, respectively, after the OCG technique (p < 0.001) and by 13.5% and 19.0%, respectively, after the MCG technique (p < 0.001). Anthropometric comparison revealed that OCG did not show any significant differences in dorsal height ratio (p = 0.707) and radix height ratio (p = 0.856) postoperatively when compared with MCG. However, the warping rate was higher in the OCG (15.4%) than in the MCG (4.7%) group, although not significantly. There were no differences in overall patient satisfaction between the two groups.

CONCLUSIONS

Dorsal augmentation with MCG produces similar aesthetic outcomes but a lower warping rate than that with OCG. The MCG technique may minimize graft warping and thus might be an effective alternative for nasal dorsal augmentation, particularly in Asian rhinoplasty.

LEVEL OF EVIDENCE IV

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 .

Dorsal Hump Reduction Based on the New Ethmoidal Point Classification: A Clinical and Radiological Study of the Keystone Area in 138 Patients

BACKGROUND

Hump resection often requires reorganization of the keystone area.

OBJECTIVES

The authors sought to describe the importance of the point where the perpendicular plate of ethmoid joins the septal cartilage (SC) and the nasal bones (NB) (Ethmoidal point [E-point]) for hump resection surgical planning.

METHODS

Measurements from mid-sagittal slices in nasal computed tomography scans taken in adult Caucasian patients between January 2015 and December 2018 were compared between patients seeking primary rhinoplasty due to a nasal hump and patients not seeking rhinoplasty (control group). Patients with previous nasal surgery or trauma, genetic or congenital facial disorders, and high septal deviation were excluded. The length of overlap between NB and SC was compared between the 2 groups. The location of the E-point in relation to the beginning of the nasal hump in the cephalocaudal direction was documented in the patients seeking rhinoplasty.

RESULTS

The study population included 138 patients, 69 seeking and 69 not seeking rhinoplasty (96 females). The mean age was 32.9 years (range, 18-55 years). The length of overlap between NB and SC was similar between both groups (11.7 ± 3.3 vs 10.8 ± 3.3; P = 0.235). The E-point was located before the beginning of the nasal hump in 97% (67/69) of nasal hump patients, and it could be found a mean distance of 2.3 (±2.3) mm cephalic to the latter.

CONCLUSIONS

As a rule, the perpendicular plate of the ethmoid does not contribute to the nasal hump; therefore, only in exceptional cases should this be addressed while performing dorsal reduction.

LEVEL OF EVIDENCE: 3

Septal Extension Graft in Asian Rhinoplasty

A septal extension graft (SEG) can control nasal tip projection, shape, and rotation. SEG and dorsal alloplastic implants have predominated in Asian rhinoplasty, leading to iatrogenic complications such as a foreshortened nose and destruction of remaining septum. The lower nasal two-thirds can be enhanced anteriorly and caudally using the septal L-strut extension graft in Asians with relatively small noses. The septal L-strut extension graft is indicated in primary cases in which the bony dorsum is acceptable but the cartilaginous dorsum is relatively hypoplastic, and in secondary cases with an iatrogenic short-nose deformity due to alloplastic implants.