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Fig. 35.20 Three female adolescents aged 16years with a drained septal abscess at age 3, 5 and 7.5years, respectively
[55]
W. Pirsig
35.4 Part IV: Remarks onNasal
Reconstruction
35.4.1 Anterior Nose andNasal
Cavities
The nasal cartilages form a complex triangular
framework for a mobile nasal lobule which acts
as the portal to the upper airways. The eyecatching shape of this cartilaginous pyramid may
provoke emotions ranging from delight at rst
sight of a beautiful person to frightful reactions
setting eyes on destroyed nasal remains. The
increase of the nose in size also mirrors the development of Homo sapiens into different populations during mankind’s settling on the whole
earth from Africa. Or, as Desmond Morris
summed it up: ‘the human nose grew taller and
longer as mankind spread out and away from its
hot moist Garden of Eden, keeping its airconditioning function up to scratch’ [1].
The composition of this cartilaginous framework is so unique to each individual and may
concern rhinosurgeons because they cannot predict the outcome of their surgical procedures.
Essential functions for the whole airways are
triggered and controlled in the anterior nose. On
the other hand, the protruding position in the
midface makes the nose more vulnerable to external damage. No wonder the anterior nose is also
the site of most nasal obstructions caused by cartilaginous and bony distortions as mentioned
above. Although prospective studies on the incidence of rhinosurgical mistakes and complications are lacking, the adverse results are most
often associated with the surgery of the nasal cartilages. Cartilages heal following their intrinsic
laws and do not behave the way the surgeons
want. In particular complications of septoplasty
are due to wrong indications as a consequence of
an incorrect or incomplete analysis and interpretation of the anatomical structures and the nasal
functional tests [49].
Therefore, clinical diagnostics should especially focus on the nds of the anterior nose, supported by endoscopy, rhinomanometry, acoustic
rhinometry, rhinoresistometry and long-term
study of the nasal cycle [19, 35]. Cole and coworkers [10, 56], who contributed many basic
data on the functions of the anterior nose, concluded from their studies as to nasal treatments
that it is seldom necessary to extend septal and/or
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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491
turbinate surgery far beyond the piriform aperture in the treatment of nasal obstruction [14].
For many patients, I can fully support this
statement.
To restore the disturbed structures of the anterior nose, our surgical options are septorhinoplasty to form a straight anterior septum and
correction of the nasal valve regions and enlarged
erectile tissues, for instance, by turbinoplasty of
the inferior turbinate. The septal turbinates
should better be preserved. The reconstruction of
the valve region is sometimes more effective for
breathing than a septoplasty alone. If transplants
or implants are used, they should be cartilagelike as to elasticity, thus avoiding the creation of
an immobile and vulnerable anterior nose. This
also means to prefer autogenic tissues. If an autogenic bone is used, it should be a boomerangshaped piece instead of a rigid L-shaped bone.
The aim to reconstruct the nose posteriorly to
the valve regions is to create physiological slitlike nasal cavities providing a proper nasal resistance, turbulence and nasal cycle for breathing,
air-conditioning and olfaction. This cannot be
achieved by performing one schematic surgical
procedure, but only by applying several technical
options tailored for the individual pathological
nasal nds. This means for the septum that need
not be reconstructed as a straight plate in the
middle and posterior nose, but it should be placed
approximately in the middle between the always
asymmetrical lateral nasal walls. It is of utmost
importance to create an adequate distance of the
septum to the erectile tissues of the lateral walls
which enables the achievement of the abovementioned functions [35]. This may also mean to
leave a physiological septal deviation as it is
grown or to transform a crooked septum into a
physiological septal deviation. Figure 35.21
shows an example of this ‘philosophy’. The
crooked and airway obstructing septum to the left
impacted by the medially deformed right-sided
middle turbinate was surgically corrected and is
still slightly deviated to the left. In addition, the
right-sided inferior turbinate was submucously
reduced. After 3months the slitlike nasal cavities
enabled normal breathing with a bilateral nasal
cycle.
35.4.2 One Option toTreat aNasal
Valve Stenosis
Several procedures have been published to treat a
nasal valve problems [57, 58]. The following
technique has successfully been used since 1975
by the author. The indication is valve stenosis
caused by a mostly congenitally too long caudal
end of the triangular cartilage, often without a
returning of the lower margin and a valve angle
less than 10°.
A rhomboid piece of skin (marked red in
Fig. 35.22) is excised from the cul-de-sac.
After elevation of the nasal mucosa from the
posterior aspect of the triangular cartilage, the
cranial surface of the caudal end of the triangular cartilage (here depicted with a tiny
returning) is freed from connective tissue and
excised cranially from the remaining triangular cartilage (marked blue in Fig. 35.22).
Closure of the incision using 5-0 sutures creates a slightly curved new part of the nasal
valve region with an angle larger than 20° that
acts as a bend which transforms inspiratory
laminar airstreams into more turbulent ones.
The efficiency of correcting a disturbed nasal
valve region can be increased by adding the
anterior turbinoplasty in case of an enlargement of the anterior inferior turbinate as
shown by acoustic rhinometry [59]. Especially
in the case of the physiological septal deviation, both methods may be sufficient to solve
the functional breathing problem without
touching the septum.
35.4.3 Back-to-Back Technique
toReconstruct theAnterior
Septum
The severe destruction of the anterior nasal septum from trauma, including septal abscess and
perforation, frequently produces saddling of the
cartilaginous nasal dorsum with enlarged angles
of the nasal valve. Functional and aesthetically
acceptable long-term results of anterior septal
and nasal valve reconstruction could be achieved
in 26 patients after a mean follow-up of 36months
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W. Pirsig
Fig. 35.21 X-ray images of a patient with septal deviation. Left: preoperatively. Right: 3 months after septoplasty and correction of the right-sided middle and inferior
using a straight and balanced back-to-back autogenic ear cartilage introduced by the author in
1986 [60].
Ear cartilage grafts from the cymba-cavum
concha complex were harvested through an
anterolateral approach (Fig. 35.23). A special
incision was used to divide the concave ear cartilage into two halves while preserving the posterior perichondrium. The graft was folded and
xed with guide sutures in its nal position
between the hypoplastic anterior nasal spine and
the caudal end of the cranial septodorsal cartilage
remnant. Thus, a viable, stable, balanced backto- back graft of 2.5–3 cm length was created,
long enough to reconstruct the anterior septum
and the nasal valve and to correct part of the saddle nose deformity. The rest of the ear cartilage
turbinates resulting in a physiological septal deviation and
bilateral slitlike cavities (Pirsig 1972, unpublished)
was used to ll the remaining cartilaginous saddle. At follow-up, the back-to-back grafts showed
no macroscopic signs of resorption. Graft position and shape had remained intact, and all noses
were adequately projected and mobile. All
patients but one felt satised with the functional
and aesthetic result. The saddle completely disappeared in two-thirds of the patients. Nasal
breathing considerably improved in 21 patients,
remained the same in 4 patients, and worsened in
1 patient.
Our long-term study also showed that even
42% of the patients with a large septal perforation—which was not closed—reported improved
nasal breathing and marked reduction of previous
nasal symptoms because the valve region had been
reconstructed by the back-to-back transplant.
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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493
Fig. 35.22 Steps to enlarge the too small valve angle by shortening part of the caudal end of the triangular cartilage
(Pirsig 1975, unpublished)
35.4.4 Closure ofSeptal Perforation
inaChild
The worst sequela of the septal abscess is the septal perforation, especially during growth. We had
to face this relatively rare sequela due to nose
picking in early childhood in a Caucasian 7-yearold boy. He suffered nearly daily epistaxis, crusting and permanent mouth breathing. After
insufcient conservative treatments, we decided
to perform a pilot study on a 9-year-old boy to
close the septal perforation of 1cm in diameter in
the areas II and III according to Cottle
(Fig.35.24). Four bipedicled mucosal advancement aps introduced by Fairbanks [61] and
Schultz-Coulon [62] were used to reconstruct the
mucosal lining. To ll the cartilaginous defect, a
piece of autogenic mainly hyaline cartilage was
taken that had been grown from a composite graft
of demineralised bovine bone matrix (DBBM),
enrolled in a pedicled perichondrial ap of the
boy’s right pinna. The Rotterdam group of
Verwoerd and Verwoerd-Verhoef had shown the
feasibility of this new type of composite graft
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Caudal and graft in place
Caudal end graft
Fig. 35.23 Steps of back-to-back cartilage grafting (3 coloured gures, Pirsig, unpublished; drawing from [60])
35 Physiology oftheNasal Cartilages andTheir Importance toRhinosurgery
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Fig. 35.24 Nine-year-old boy with septal perforation, preoperatively (Pirsig, unpublished)
495
Fig. 35.25 Seventeen-year-old adolescent, 8years after the closure of septal perforation (Pirsig, unpublished)
applied in a two-step procedure for the
reconstruction of defects in the cricoid ring [63]
and anterior laryngeal wall of growing rabbits
[64]. Furthermore, they could show that this neocartilage provided a valuable substitute for the
lost parts of the cartilage and appeared capable of
growth. The operation to close the septal perforation by implanting the transformed xenogenic
DBBM in the septal defect of the boy of 9years
was successful. Details of the surgical procedure
and histological ndings were published 2years
later [65].
I could follow the adolescent over 8 postoperative years (Fig. 35.25). He had no breathing
problems and epistaxis over all the years, but a
dry nose which he treated with saline douches.
The nasal length was adequate, but the lobule
showed growth inhibition, minimal cartilaginous
sagging which was not visible preoperatively and
a retracted columella. The septum was straight
with ciliary activity on the sites of the former perforation. The maxillary retrusion was marked but
already visible at the age of 9years when signs of
septal growth inhibition due to the perforation
were already obvious. In a nal step under local
anaesthesia, I tried to improve the nasal appearance using pieces of ear cartilage. During this
surgery, I elevated the right mucoperichondrium
from the septal cartilage to get a look at the
implant. There was a complete connection of the
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transformed cartilage with the original septal
remnant. The surface of the implant was slightly
tuberous and solid. Unfortunately, I could not
evaluate whether the implant had grown.
35.5 Conclusions
Nasal cartilages function together in a complex
anatomical framework connected by a web of
connective tissues and partly covered by a layer
of ne muscles. Their protruding position in the
centre of the face may act as an eye-catcher, and
their mobility may serve as a crumpled zone protecting the head against external frontal stress.
The anterior nose with its two parallel tubes is
the ideal portal to the respiratory system. In the
valve regions, we nd the narrowest cross-sectional areas of the nose, where two-thirds of the
total respiratory resistance are generated. In
these regions, the laminar airstreams are transformed into turbulent ones. Thus, together with
the erectile lining of the nasal cavities, the anterior nose provides the tools for the air-conditioning of the respiratory system and for the acting
of the nasal cycle.
No wonder such a complex and exposed construction like the anterior nose is very vulnerable
to all types of damaging inuences and especially to mechanical injuries. The septodorsal
cartilage is the dominating structure for nasal
shape and midfacial growth. Particularly, its
anterior part is most often involved in nasal injuries and its reconstruction mainly inuences the
surgical long-term outcome. Thus, rhinosurgeons should predominantly focus on the rehabilitation of this anterior nose with its complex
cartilaginous framework and erectile lining.
Diagnostic methods like endoscopy, acoustic
rhinometry, rhinoresistometry and imaging
allow a better insight into the structural and
functional characteristics of the damaged softand hardware of the nose. Too mechanistic
thinking for nasal reconstruction should be
replaced by a concept of applying several technical options tailored for the individual pathological nasal nds and the requirements of nasal
physiology. In this chapter, I presented some of
my personal experiences and how I got an insight
into the complexity of the nasal cartilages
through long-term follow-up of the patients. One
example is the acceptance of a physiological
septal deviation which acts in harmony with the
lateral walls instead of creating a straight anteroposterior septal plate just for optical beauty.
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Physiology andPathophysiology
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oftheGrowing Nasal Skeleton
H.L.Verwoerd-Verhoef, G.J.V.M.van Osch,
andC.D.A.Verwoerd
36
Core Messages
• The outcome of surgical interventions in the
midfacial region is largely dependent on the
quality of wound healing of the tissues.
However, in children, the second aspect of
paramount importance is the impact on further
growth.
• The knowledge of the anatomy of the nasal
skeleton from birth to adolescence and current
data concerning the ‘normal’ development of
the midfacial prole is mandatory for physicians working in this eld.
• Surgery of the nasal skeleton in children of
different ages should reinstate form and function, optimise further growth and minimise
the risks for abnormal development. As to
restoring normal growth, clinical observations
have still insufciently produced convincing
evidence.
• Results of animal experiments have largely
contributed to understanding developmental
mechanisms of the midface, the way they are
inuenced by various surgical interventions
like partial resections and fractures of the cartilaginous and bony skeleton, and nally the
feasibility to restore growth by surgery.
• Key issues are (1) the dominant role of specic growth zones in the cartilaginous nasal
H. L. Verwoerd-Verhoef (*) · G. J. V. M. van Osch
C. D. A. Verwoerd
Erasmus MC Rotterdam, Rotterdam, The Netherlands
septum, the shift of its support from the sphenoid to the anterior rim of the perpendicular
plate, the connection with the premaxilla (via
the anterior nasal spine) and the connection of
the upper lateral cartilages with the nasal
bones; (2) the poor wound healing capacity of
growing and maturing nasal cartilage and its
deformation due to the release of interlocked
stresses in the tissue.
• The clinical long-term results as far as nasal
growth is concerned after nasal surgery (like
septoplasty) should be studied more extensively at different ages up till after puberty.
• The process of cartilage tissue engineering is
making progress when autologous cells from
the septum or auricle are seeded together with
stem cells in a biodegradable scaffold.
• The emerging technology of 3D and 4D printing offers the opportunity to design personalised implants for nasal reconstruction.
36.1 Physiology oftheGrowing
Nasal Skeleton
36.1.1 Introduction
Rhinosurgical procedures are common in the adult
patient group, and techniques have been developed
and improved based on the experience with large
numbers of patients. Most common is the septoplasty which is performed to correct a symptomatic
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Ö. Ö. Celebi, T. M. Önerci (eds.), Nasal Physiology and Pathophysiology of Nasal Disorders,
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