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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 5  |  Page : 17-20

Sphenoidal process of septal cartilage: Useful autologous graft option in revision rhinoplasty


1 Department of Plastic, Reconstructive, and Aesthetic Surgery, Denizli Government Hospital, Denizli, Turkey
2 Department of Radiology, Denizli Government Hospital, Denizli, Turkey

Date of Submission19-Jul-2020
Date of Acceptance07-Oct-2020
Date of Web Publication17-Mar-2021

Correspondence Address:
Dr. Oguzhan Demirel
Department of Plastic, Reconstructive, and Aesthetic Surgery, Denizli Devlet Hastanesi Changed to Denizli Government Hospital, Sırakapılar, Selcuk Caddesi, 20100 Merkezefendi, Denizli
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_83_20

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  Abstract 


Background: One of the main difficulties of revision rhinoplasty is the lack of sufficient septal cartilage. To overcome this problem, additional cartilage sources such as costal or conchal cartilages are widely used among surgeons. However, these methods can cause some complications. The sphenoidal process of septal cartilage (SPSC) is a unique part of septal cartilage located between the vomer bone and the perpendicular plate of the ethmoid bone and generally untouched during the surgery. As an autologous graft option, the SPSC may be an important cartilage source for revision rhinoplasty cases, especially in patients requiring minor surgical intervention. Methods: Between February 2019 and February 2020, a total of 50 patients who underwent paranasal computed tomography were enrolled in this retrospective study. The length, height, and surface area of the SPSC and surface area of total septal cartilage were calculated. Results: The mean total septal area was 886.2 mm2, ranging from 554.7 mm2 to 1277.5 mm2. The mean total SPSC area was 67.39 mm2. The mean length of SPSC was 12.8 mm in all populations. The highest sphenoidal process length measurement was 27.32 mm, and the lowest was 4.82. Mean sphenoidal process height values were similar in female and male groups (4.99 mm and 5.2 mm, respectively). Conclusion: The sphenoid process of septal cartilage may be an important autologous cartilage option for revision surgeries in terms of sufficient length and height dimensions.

Keywords: Posterior prolongation, revision, rhinoplasty, septal cartilage, sphenoidal process


How to cite this article:
Demirel O, Atesci MS. Sphenoidal process of septal cartilage: Useful autologous graft option in revision rhinoplasty. Turk J Plast Surg 2021;29, Suppl S1:17-20

How to cite this URL:
Demirel O, Atesci MS. Sphenoidal process of septal cartilage: Useful autologous graft option in revision rhinoplasty. Turk J Plast Surg [serial online] 2021 [cited 2022 Jun 29];29, Suppl S1:17-20. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/5/17/311439




  Introduction Top


Rhinoplasty is one of the top surgical procedures worldwide.[1] The complex anatomy of nasal structures, varying range of tissue healing and patient expectations can lead to minor or major complications. Therefore, revision surgery may be required.[2],[3],[4] However, one of the challenging aspects of revision surgery is the lack of septal cartilage for reshaping of the nasal units. In the literature, despite numerous well-known techniques and cartilage sources (costal cartilage or conchal cartilage), limitations and complications are also present.[5],[6],[7],[8],[9] According to these findings, septal cartilage seems to be the best option for reconstruction.

In primary rhinoplasty, the majority of septal cartilage is harvested for esthetic and reconstructive reshaping. However, posteriorly located cartilage segments are commonly untouched in primary rhinoplasty and can be harvested in revision cases.

In the literature, the most posterior part of septal cartilage, which is located between the vomer bone and perpendicular plate of the ethmoid bone (PPE), is defined as the “sphenoidal process of septal cartilage (SPSC),” or “posterior prolongation of septal cartilage.”[10],[11],[12] The fact that it is mostly untouched in primary cases and of considerable size makes it an important cartilage source for revision rhinoplasty, especially in patients requiring minor surgical intervention.

Based on this, the investigation of the dimensions of the SPSC and its relation with the cartilaginous septum on computed tomography (CT) images constitutes the main objectives of this study.


  Methods Top


A total of 50 patients who applied to our clinic between February 2019 and February 2020 were enrolled in this retrospective study. All patients underwent paranasal CT and measurement points were marked. The total septal cartilage surface area (TSA) and the total surface area of the sphenoidal process of septal cartilage (SPA) were calculated through paransal CT. The height of the SPSC (SPH) and length of the SPSC (SPL) were measured. Patients with severe septal deviation and a history of surgery were excluded. The study was conducted according to the declaration of Helsinki for human participants and approved by the Pamukkale University Hospital Local Ethical Committee.

Measurement landmarks

All measurements were performed on medial sagittal paranasal CT images. The width of the SPSC was calculated at the maximum point. To assess the length of the SPSC, the mean values of the superior and inferior lengths of the SPSC were calculated. Measurement landmarks and their descriptions are given in [Table 1]. The calculated distances and surface area of the SPSC are defined in [Table 2]. Landmarks of the SPSC: sphenoidal process of septal cartilage on paranasal CT imaging are illustrated in [Figure 1]. In addition, landmarks of the SPSC as viewed on the dry skull of a human cadaver are illustrated in [Figure 2].
Table 1: Landmarks and descriptions

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Table 2: Measurements between landmarks and their definitions

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Figure 1: Landmarks of SPSC on paranasal computed tomography imaging

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Figure 2: Landmarks of SPSC on the dry skull of human cadaver

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Statistical analysis

The data were analyzed using the SPSS software version 25.0 (IBM, NY, USA) statistical program. All parameters were subjected to graphical and analytical normality tests. Independent sample t-tests and bivariate correlation analyses were used to determine the relationships among parameters. The results were considered statistically significant for P < 0.05.


  Results Top


The landmark distances measured in 50 patients, including 25 females and 25 males, were analyzed. The mean age of all patients was 26.88 years. In addition, the mean age was similar in both sexes, at 26.8 years in females and 26.9 years in males. The mean distances in all patients are summarized in [Table 3]. Descriptive data regarding the association of distance with sex are detailed in [Table 4]. The Kolmogorov–Smirnov normality test was applied to all following parameters: Total septal cartilage surface area (TSA), Sphenoidal process of septal cartilage surface area (SPA), Sphenoidal process of septal cartilage height (SPH), Sphenoidal process of septal cartilage length (SPL), and age. A normal distribution was observed for all parameters.
Table 3: Descriptive statistics of general population

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Table 4: Descriptive statistics based on gender

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Based on the descriptive analysis results, the mean total septal area was 886.2 mm2, ranging from 554.7 mm2 to 1277.5 mm2. However, the mean TSA was higher in males (960.9 mm2) than in females (811.6 mm2). The mean total SPSC area was also higher in the male population (76.6 mm2 vs. 58.1 mm2). The mean length of the SPSC was 12.8 mm in all patients. The highest sphenoidal process length measurement was 27.32 mm, and the lowest was 4.82. The mean sphenoidal process height values were similar in females and males (4.99 mm and 5.2 mm, respectively).

To assess significant differences in the TSA, SPA, SP, and SL by sex, the independent sample t-test was applied. According to the results, statistically significant differences were observed in the TSA (P = 0.009), SPA (P = 0.043), and SPL (P = 0.030) by sex. However, no significant difference was observed in the SPH by sex (P = 0.455).

According to the Pearson's correlation test, no statistically significant correlation was observed between the TSA and SPA measurements (P = 0.111). In addition, no statistically significant correlation was found between age and the TSA (P = 0.381) or SPA (P = 0.249).


  Discussion Top


The nasal septum basically consists of two main structures: the septal cartilage and the perpendicular plate of the ethmoidal bone. After birth, the cartilaginous nasal septum grows remarkably in the first 2 years of life. The total nasal septum is cartilaginous in the neonatal period, and after the middle of the 1st year, PPE occurs with endochondral ossification of the cartilaginous septum. Afterward, the area of PPE merges with vomer bone posteriorly by ossification. Because of differences in the degree of ossification, the posterior edge of the septal cartilage may exist between the area of PPE and vomer bone in the sphenoidal direction, but not in all patients. Therefore, this specialized area of septal cartilage is termed the “sphenoidal process of the septal cartilage.”[13],[14]

In the literature, there have been few studies on the sphenoidal process of the septal cartilage. In 2003, Phillips et al. assessed posterior prolongation of the septal cartilage. Their results showed that the mean posterior prolongation length was 24.3 mm and that the mean height was 4.33 mm. In addition, the mean area was 102.8 mm2.[11]

In a study conducted by Kim et al., the effect of the sphenoidal process on septal deviation was assessed. According to the results, the mean SPSC length was determined to be 25.9 mm in patients with septal deviation.[10] In another study by the same author, the mean SPSC length was 26.05 mm in patients nose deviation and 11.95 in controls without nose deviation.[14]

Our finding of a mean length of 12.80 mm is compatible to that in the latter study. The exclusion of deviated septa in the present study may explain the differences in the results. In addition, the mean height of the SPSC was similar to that reported in the literature (5.13 mm versus 4.33 mm).[11]

On investigation of the surface area, the mean total cartilaginous septal area measurement was consistent with that reported in the literature. In a study by Daultrey et al., the septal area was measured in CT images. They found that the mean quadrangular cartilage area was 1148 mm2 in males and 981 mm2 in females.[15] In addition, in another study by Miles et al., the mean total cartilaginous septal area was 817.2 mm2.[16] However, the mean SPSC area was lower in our study than in the literature. Phillips et al. proposed 102.8 mm2 as the mean surface area of the SPSC, which was higher than our finding (67.39 mm2).[11] This difference may be due to developmental characteristics of the study population based on the different degrees of ossification.[13]

On the other hand, because the ossification of cartilaginous tissue occurs gradually, the area of the cartilaginous part of the nasal septum tends to decrease with age.[13] In a study by Kim et al., although the total nasal septal size did not change significantly, a decreased proportion of cartilaginous septum and an increased proportion of PPE were observed with increasing age.[17] In the present study, no statistically significant correlation was observed between age and the surface area of the septal cartilage or SPSC. The small patient sample and lack of subgroups for age may contribute to this discordance.

Moreover, the thickness of the graft material is important for structural support. In a study by Mowlavi et al., the septal cartilage thickness was measured, and the highest values were found at the base of the cartilage. They also observed similar results in the SP of the septal cartilage.[18] Similarly, Van Loosen et al. proposed that the thickest regions were located posteriorly.[13] In contrast, in a study conducted by Özkan et al., the posteroinferior part of the septal cartilage was compared with the superior parts of the septal cartilage. According to histological assessments, the proteoglycan content was higher in the posteroinferior part of the septal cartilage. Consequently, the author proposed that excess proteoglycan content may be the cause of the soft structure of the cartilage. In addition, after crushing samples of cartilage, they observed that the posteroinferior part widened more than the superior parts of the septal cartilage. It has been suggested that this enlargement may be due to the soft structure of the tissue.[19]

As mentioned above, even though the thickness of the SPSC is similar to that of other parts of the cartilaginous septum, a softer structure can limit its usage in revision cases. In situations that require large amounts of strong cartilage tissue (saddle nose, recurrent deviation, severe short nose, etc.), the SPSC may not be an appropriate cartilage source. In such cases, the use of costal cartilage or conchal cartilage may be more beneficial.

On the other hand, the use of SPSC as a cartilage graft with its soft structure and sufficient size may allow the correction of small deformities such as contour irregularities and tip deformities. Importantly, this may prevent additional comorbidity for patients.


  Conclusion Top


Nasal tip procedures and minor contour deformities account for the majority of revision cases. To overcome these problems, grafts are essential. Importantly, tip grafts, cap grafts, columellar strut grafts, lateral and medial crural grafts, and alar rim grafts are generally used in revision surgery. In terms of soft structure, thickness, length and sufficient surface area, the SPSC may be an important autologous cartilage option for surgeons.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Internatıonal Survey on Aesthetıc/Cosmetıc Procedures Performed in 2018. Available from: https://www.isaps.org/wp-content/uploads/2019/12/ISAPS-Global-Survey-Results-2018-new.pdf. [Last accessed on 2019 Dec 03].  Back to cited text no. 1
    
2.
Crosara PF, Nunes FB, Rodrigues DN, Figueriredo AR, Becker HM, Becker CG, et al. Rhinoplasty complications and reoperations: Systematic review. Int Arch Otorhinolaryngol 2017:97-101.  Back to cited text no. 2
    
3.
Layliev J, Gupta V, Kaoutzanis C, Ganesh Kumar N, Winocour J, Grotting JC, et al. incidence and preoperative risk factors for major complications in aesthetic rhinoplasty: Analysis of 4978 patients. Aesthet Surg J 2017;37:757-67.  Back to cited text no. 3
    
4.
Loghmani S, Loghmani A, Maraki F. Secondary rhinoplasty: Aesthetic and Functional concerns. Plast Surg (Oakv) 2019;27:217-22.  Back to cited text no. 4
    
5.
Mohan R, Shanmuga Krishnan RR, Rohrich RJ. Role of fresh frozen cartilage in revision rhinoplasty. Plast Reconstr Surg 2019;144:614-22.  Back to cited text no. 5
    
6.
Yi JS, Jin HR. Use of mastoid periosteum graft in primary and revision rhinoplasty. Aesthetic Plast Surg 2019;43:1295-300.  Back to cited text no. 6
    
7.
Oh GJ, Choi J, Kim TK, Jeong JY, Kim JH, Kim S, et al. Feasibility of a polydioxanone plate as an adjuvant material in rhinoplasty in Asians. Arch Plast Surg 2019;46:152-9.  Back to cited text no. 7
    
8.
Robotti E, Penna WB. Current practical concepts for using rib in secondary rhinoplasty. Facial Plast Surg 2019;35:31-46.  Back to cited text no. 8
    
9.
Elfeki B, Park SH, Eun S. Caterpillar graft for secondary rhinoplasty. J Craniofac Surg 2019;30:1552-5.  Back to cited text no. 9
    
10.
Kim J, Kim SW, Kim SW, Cho JH, Park YJ. Role of the sphenoidal process of the septal cartilage in the development of septal deviation. Otolaryngol Head Neck Surg 2012;146:151-5.  Back to cited text no. 10
    
11.
Phillips PS, Harvey RJ, Sacks R, Chin D, Marcells GN. Posterior prolongation of the cartilaginous nasal septum: An under-utilised source of autologous graft material. J Laryngol Otol 2013;127 Suppl 1:S21-5.  Back to cited text no. 11
    
12.
Kim JH, Jung DJ, Kim HS, Kim CH, Kim TY. Analysis of the development of the nasal septum and measurement of the harvestable septal cartilage in Koreans using three-dimensional facial bone computed tomography scanning. Arch Plast Surg 2014;41:163-70.  Back to cited text no. 12
    
13.
Van Loosen J, Van Zanten GA, Howard CV, Verwoerd-Verhoef HL, Van Velzen D, Verwoerd CD. Growth characteristics of the human nasal septum. Rhinology 1996;34:78-82.  Back to cited text no. 13
    
14.
Kim J, Han SH, Kim SW, Cho JH, Park YJ, Kim SW. Clinical significance of the sphenoidal process of the cartilaginous nasal septum: A preliminary morphological evaluation. Clin Anat 2010;23:265-9.  Back to cited text no. 14
    
15.
Daultrey C, Hardman J, Anari S. The Caucasian nasal septum: An in vivo computed tomography study. Aesthet Surg J 2018;38:717-22.  Back to cited text no. 15
    
16.
Miles BA, Petrisor D, Kao H, Finn RA, Throckmorton GS. Anatomical variation of the nasal septum: Analysis of 57 cadaver specimens. Otolaryngol Head Neck Surg 2007;136:362-8.  Back to cited text no. 16
    
17.
Kim J, Cho JH, Kim SW, Kim BG, Lee DC, Kim SW. Anatomical variation of the nasal septum: Correlation among septal components. Clin Anat 2010;23:945-9.  Back to cited text no. 17
    
18.
Mowlavi A, Masouem S, Kalkanis J, Guyuron B. Septal cartilage defined: implications for nasal dynamics and rhinoplasty. Plast Reconstr Surg 2006;117:2171-4.  Back to cited text no. 18
    
19.
Özkan AÇ, Kozanoğlu E, Bilgili AM, Öngüt C, Agbulut O. Advantageous Donor Site Alternative for Preparing Crushed Cartilage Graft: The Postero-inferior Part of the Septal Cartilage. Indian J Otolaryngol Head Neck Surg. 2020.doi: https://doi.org/10.1007/s12070-020-01897-8.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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