Surgical correction of the nose and midface in maxillonasal dysplasia (Binder's syndrome)

In 48 patients with maxillonasal dysplasia the retruded nasal base was corrected with onlay cancellous bone grafts after subperiosteal dissection using an oral vestibular approach. Support for the nasal dorsum was achieved in 39 patients with an L-shaped bone graft from the iliac crest introduced through the same approach. The advancement of the nose was found stable on lateral cephalograms; i.e., resorption did not occur. However, the grafts showed considerable remodeling. Half the patients found the stiffness of the nose to be disturbing. In nine patients, the cartilaginous septum was used instead as a support for the nasal dorsum and tip. At operation, the entire cartilaginous septum was mobilized after subperichondrial dissection and rotated forward either pedicled at the nasal dorsum or completely released. Cartilage regenerated in the periochondrial pocket left behind the advanced septum. The anterior transfer of the nose was 6 to 10 mm. The use of septal advancement is preferred over bone implants in the correction of maxillonasal dysplasia in patients in whom the bony nasal dorsum is of adequate height because it results in a soft and flexible nose and the risk of traumatic fracture and resorption is eliminated. The technique has been used in adolescents with promising results.     

Surgical correction of the severely deviated nose by extramucosal excision of the osseocartilaginous septum and replacement as a free graft

Twenty-five patients with severe internal and external deviation of the nose characterized by deviation of the septum in several planes and almost total obstruction of the airway on one or both sides were operated on. The entire bony and cartilaginous septum was removed in each of these patients, preserving the mucoperichondrial and mucoperiosteal flaps. The extramucosal technique of septal dissection was used. A support graft was fashioned from cartilaginous remnants of the septal cartilage and placed between the mucoperichondrial flaps as a free graft. All patients were followed for a minimum of 1 year. The longest follow-up is 15 years. Aesthetic improvement of the nose was obtained in all patients. All patients experienced varying degrees of improvement in nasal blockade.     

Closure of septal perforation in Osler-Weber-Rendu's disease by bilateral labial-buccal flaps. Case report

We present a case of septal perforation in Osler-Weber-Rendu's disease, treated by rotating bilateral labial-buccal flaps up into the nose to close the perforation and resurface the adjacent areas on the septum.     

The deviated nose: optimizing results using a simplified classification and algorithmic approach

The deviated nose presents a particular challenge to the rhinoplasty surgeon because, frequently, both a functional problem (airway obstruction) and an aesthetic problem must be addressed. An approach to the deviated nose is presented that relies on accurate preoperative planning and precise intraoperative execution of corrective measures to return the nasal dorsum to midline, restore dorsal aesthetic lines, and maintain airway patency. The principles of correction include wide exposure through the open approach, release of all deforming forces to the septum, straightening of the septum while maintaining an adequate dorsal and caudal strut, restoring long-term support, reducing the hypertrophied turbinates, and performing controlled stable percutaneous osteotomies. An operative algorithm is described that emphasizes simplicity and reproducibility, and case studies demonstrate the results that can be achieved with this approach.     

Lengthening the nose with a tongue-and-groove technique

Lengthening the short nose is often a major task. The ability to maintain proper alignment between the nasal base and dorsum may prove difficult without sacrificing the suppleness of the former. In this article, the authors introduce a technique of nose lengthening that ensures alignment of the tip with the rest of the nose yet avoids tip rigidity, unless a significant increase in tip projection is also planned. Two spreader grafts are placed, one on either side of the septum, and are extended beyond the caudal septal angle proportional to the planned nasal lengthening. A columella strut, with the cephalocaudal dimension equaling the combination of the width of the existing medial crura plus the amount of planned nasal lengthening, is placed between the medial crura in continuity with the caudal septum and is fixed to the medial crura using 5-0 clear nylon or polydioxanone suture. If additional projection beyond what is achievable by mere placement of a columella strut is required, the strut is fixed to the spreader grafts in a more projected position. Otherwise, the columella strut is simply positioned between the extensions of the spreader grafts. It is necessary to mobilize the lower lateral cartilages to prevent excessive columella show. This procedure has been performed on 23 patients over the past 12.5 years, with 20 patients enjoying good-to-excellent results. The advantages of this technique include its predictability and reproducibility, and the ability to elongate the nose with a mobile nasal base that is in line with the rest of the nose. If suture fixation is used to gain more projection, the technique proves dependable but the nose will become more rigid than is optimal. The requirement of three pieces of properly shaped septal cartilage, which might not be available when a secondary rhinoplasty is performed, is the major disadvantage of this operation. Furthermore, the procedure is, to some degree, labor-intensive.     

Rhinoplasty and endoscopic surgery for functional and inflammatory nasal/sinus disorders

The rhinoplastic surgeon when faced with nasal sinusitis has traditionally delayed aesthetic treatment of the nose, referring the patient to the ear, nose, and throat consultant until complete resolution of the inflammatory condition. Often, under such a scenario, the patient found the ear, nose, and throat procedure to be a traumatic experience that discouraged further surgery of an aesthetic nature. The advent of functional endoscopic sinus surgery has significantly modified the management of paranasal sinus disorders. This minimally invasive, sophisticated procedure can easily be combined with rhinoplasty. More recently, an endoscopic approach has been advocated for management of the septum and lower/middle turbinates. The authors call this functional endoscopic nasal surgery. Functional endoscopic nasal surgery allows a clearer view of the operative field (septum and turbinates), a more accurate correction of nasal obstruction, and better control of bleeding. Thus, endoscopic techniques permit the treatment of functional and inflammatory nasal disorders in a single stage, along with aesthetic improvement. Only the patient with severe sinusitis is unsuitable for combined therapy. The authors present their experience based on 72 consecutive cases of combined functional endoscopic sinus surgery/functional endoscopic nasal surgery with aesthetic rhinoplasty. Complications were minimal and functional failures were limited to 4 percent, whereas aesthetic outcomes remained uncompromised.     

The role of septal surgery in management of the deviated nose

The deviated nose represents a complex cosmetic and functional problem. Septal surgery plays a central role in the successful management of the externally deviated nose. This study included 260 patients seeking rhinoplasty to correct external nasal deviations; 75 percent of them had various degrees of nasal obstruction. Septal surgery was necessary in 232 patients (89 percent), not only to improve breathing but also to achieve a straight, symmetrical, external nose as well. A graduated surgical approach was adopted to allow correction of the dorsal and caudal deviations of the nasal septum without weakening its structural support to the dorsum or nasal tip. The approach depended on full mobilization of deviated cartilage, followed by straightening of the cartilage and its fixation in the corrected position by using bony splinting grafts through an external rhinoplasty approach.     

On rhinomanometry in rhinoplasty

Changes in nasal obstruction, nasal airway resistance, and postoperative nose appearance were evaluated in 92 rhinoplasty patients. Fifty-six patients had a deviation of their nose from the midline preoperatively. They were improved according to rhinomanometry whether the rhinoplasty was combined with a functional septoplasty or with a submucous resection. Among the other 36 patients who did not have a deviation of the nose from the midline, 23 had a rhinoplasty combined with a functional septoplasty and 13 had no surgery on the septum at all. Rhinomanometrically, only patients operated on with the combined operation were improved; the rest became worse, even in terms of nasal obstruction. Among 58 patients from both groups with preoperative nasal obstruction, there was agreement for 76 percent between the subjective and rhinomanometric changes. The advantages of giving the rhinomanometric results in a polar coordinate system are discussed.     

Various uses of the septum in rhinoplasty

The nasal septum can be used with impunity to assist in cosmetic and reconstructive rhinoplasty if an L-shaped bridge with anterior prow is preserved or constructed to maintain normal support to the nose. The septum can serve, of course, as a reservoir of cartilage grafts. Under special conditions, it can spare mucosal and chondromucosal or even osteochondromucosal flaps to aid in the supply of lining and support in reconstructions. The L-shaped septal chondromucosal flap has been found of value in total distal reconstructions and is now offered as a possible adjunct in the correction of certain intact but congenitally flat and/or short noses.     

Caudal nasal deviation

Caudal nasal deviation, manifested by a "crooked tip," asymmetric nostrils, and a deviated columella, is one of the most challenging deformities encountered in rhinoplasty. This entity is often ignored by rhinoplasty surgeons, on the basis of the assumption that correction of other segments of the deviated nose will improve the caudal nose. Failure to correct this imperfection (or, occasionally, deformity) invariably produces suboptimal results. The nasal structures involved in caudal nasal deviation, namely, the septum, the lower lateral cartilages, and the anterior nasal spine, must be evaluated for identification of the anatomical blocks that have a causative role in caudal nasal deviation. The specific structures with abnormalities related to this deformity are discussed, as are techniques for the correction of the deformities. These techniques significantly augment the surgeon's repertoire of methods for addressing the subtleties of caudal nasal deviation correction and achieving predictable results.     

Dynamics in rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the results revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on frontal view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

Dynamics of rhinoplasty

Nasal dynamics were studied on 87 patients undergoing rhinoplasty of one zone or two distant nasal zones. Statistical analysis of the result revealed that reduction of the nasion area, besides setting the soft tissue back, gave the appearance of increased intercanthal distance and lengthened the nose. Reduction of the nasal bridge resulted in a wider appearance on front view and a cephalically rotated tip on profile. Augmentation of the bridge affected the nose reversely. Tip cephalad rotation was achieved by resecting one of the three areas: the cephalad portion of the lower lateral cartilages (affecting the rims more), the caudal septum (affecting the central portion more), and the caudal portion of the medial crura of the lower lateral cartilages (affecting the central portion only). Resection of the alar base not only narrowed the nostrils but also moved the alar rim caudally. Furthermore, it reduced tip projection when a large alar base reduction was done. Reduction of the nasal spine increased the upper lip length on profile and reduced tip projection when a large reduction took place. Significant reduction in caudal nose projection resulted in widening of the alar base.     

Use of the nasal SMAS to reconstruct defects of the tip, alae, columella, or septum.

Reconstruction using traditional methods for small and medium-sized losses of the soft tissues of the lower third of the nose, including the tip, the columella, alae, or the cartilaginous septum, has meant leaving cicatricial stigmata surrounding the region and has required at least two operational stages. A comprehensive study of the local anatomy was completed, and a specific technique (presented herein) was used to transfer and distribute the well-vascularized layer of superficial muscle and aponeurotic tissue (SMAS) from the dorsum of the nose to the needed site, which provided bulk and a well-nourished surface that could be covered by a distant skin graft, using a one-step flap. The surgical approach to the SMAS was carried out through the scar over the site of tissue loss or through the site of regional ablation or the traumatic wound. Several representative cases are presented.     

CARCINOMA OF THE NASOPHARYNX—Treatment with Radioactive Cobalt

A method of treatment of carcinoma of the nasopharynx is described, using a bead of radioactive cobalt in a Foley catheter placed through the nose and inside the nasopharynx. As an aid in proper placement of the cobalt bead a portion of the nasal septum is removed first. This method of treatment is to supplement rather than replace other methods of treatment such as external x-ray therapy and surgical excision of lymph nodes in the neck.Twenty-two patients were treated with radioactive cobalt beads and the results indicated that it is a useful method for treating carcinoma in the nasopharynx.     

A submicroscopic deletion involving part of the CREBBP gene detected by array-CGH in a patient with Rubinstein-Taybi syndrome

We report a girl with Rubinstein-Taybi syndrome (RSTS) who was found to have copy number loss on 16p13.3 by array-CGH. She has developmental delay and other features of RSTS including downslanting palpebral fissures, a prominent nose with the nasal septum extending below the alae nasi, broad thumbs and big toes, postaxial polydactyly of the right foot and constipation from birth. We report the junction sequence across the breakpoint region for a microdeletion in RSTS. The sequencing results also showed that the deletion was 81.4kb involving three genes DNASE 1, TRAP 1, and CREBBP.     

光,电镜观察小鼠呼吸道合胞病毒性肺炎的免疫病理改变

Ｂａｌｂ／ｃ小鼠经鼻吸入呼吸道合胞病毒（ＲＳＶ）悬液感染成ＲＳＶ肺炎。于感染第５天后连续隔日取肺,光镜与透射电镜检查。感染第５～７天,肺组织病理改变最严重,多数小鼠表现为间质淋巴细胞（ＬＣ）套状浸润,肺泡隔增宽;少数小鼠出现间质内大量ＬＣ浸润与肺泡内大量单个核细胞渗出的两种病理改变。病毒包涵体出现于肺泡上皮细胞内,细胞受感染后发生肿胀、坏死。Ⅰ型细胞核周胞质内有核衣壳复制,表面病毒芽生形成长短不等的丝状体。第９天,肺泡隔增宽与间质ＬＣ浸润逐渐减轻。第１２天,病毒包涵体明显减少。     

Understanding the nasal airway: principles and practice

LEARNING OBJECTIVES: After studying this article, the reader should be able to: 1. Describe the soft-tissue, cartilaginous, and bony anatomy of the nose. 2. Describe the anatomy and function of the nasal valves. 3. Discuss the governing physiologic principles responsible for airflow dynamics. 4. Discuss the various functions of the nose. 5. Demonstrate an appropriate evaluation of the nasal airway. 6. Discuss the differential diagnosis of nasal obstruction. 7. Discuss appropriate management options for nasal airway obstruction.The nose is a complex, multifunctional organ that requires respect and understanding from the rhinoplasty surgeon. The etiologic and pathologic characteristics of each patient's nasal airway problem determine the treatment of the nasal airway. Frequently, medical management is sufficient without operative intervention. Recent advances have shown that nasal valves in airway patency may play a more important role than the septum. The rhinoplasty surgeon's understanding of the anatomy and physiology of the nasal airway, along with the causes of obstruction, can pave the way for a proper evaluation and appropriate management of nasal airway problems. Lack of understanding can result in misdiagnosis and mismanagement. This article outlines current concepts of medical and surgical management of nasal airway problems and discusses in detail the key concepts and principles in the practical management of the nasal airway.     

The early development of the Jacobson's organ in the cat (Felis silvestris)

The histological study of the nose of an embryo of the cat (Felis silvestris 10 mm) presents a simple cavity which caudally communicates with the oral cavity by a narrow cleft, the primitive choana. This aperture results from the former rupture of the membrana bucconasalis of which the present material still contains remnants. Compared to the simple nasal cavity, the organ of Jacobson, situated at the base of the broad fetal nasal septum, shows a progressive development. From this one might conclude, according to ontogenetical rules, an early functional importance of the accessory olfactory organ. The currently fetal nose under investigation presents the organ as a primary open groove which increases in depth from rostral to caudal. Only caudally, a short section of the organ is already formed into a tube. From the functional point of view, the epithelial lining of this organ is still undifferentiated, but its dorsal part is clearly thickened. It seems that this indicates an early arrangement of the later olfactory epithelium. Beside this it is striking that in early fetal life, the organ of Jacobson extends to a remarkable length within the nasal cavity. Obviously the organ occupies, early in ontogeny, its area inside the little developed nose. Finally, the striking resemblance of the topography of the organ of Jacobson between early embryos of mammals and those of fetal and even some adult reptiles is discussed.     

Acoustic rhinometry: evaluation of nasal cavity geometry by acoustic reflection

To study the geometry of the nasal cavity we applied an acoustic method (J. Appl. Physiol. 43: 523-536, 1977) providing an estimate of cross-sectional area as a function of distance. Acoustic areas in a model constructed from a human nasal cast, in the nasal cavity of a cadaver and in 10 normal subjects and two patients with well-defined afflictions of the nasal cavity, were compared with similar areas obtained by computerized tomography (CT) scans, a specially developed water displacement method, and anterior rhinomanometry. We found a coefficient of variation of the areas of less than 2% by the acoustic method compared with 15% for the rhinomanometric measurements. Acoustic areas correlated highly to similar areas obtained by CT scanning (r = 0.94) and by water displacement (r = 0.96). In two patients the acoustic method accurately outlined, respectively, a tumor in the nose and a septum deviation. It is concluded that this method provides an accurate method for measuring the geometry of the nasal cavity. It is easy to perform and is potentially useful for investigation of physiological and pathological changes in the nose.