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The ethmoid bone is the ideal graft to strengthen nasal septum L-strut among different grafts: An evaluation based on finite element analysis

Published:August 23, 2022DOI:https://doi.org/10.1016/j.bjps.2022.08.046

      Summary

      Background

      In the rhinoplasty of Asian short nose deformity, the surgeon cuts a portion of septal cartilage and retains the nasal septum L-strut, but a deviated nasal septum is formed after the surgery under forces of soft tissue contracture. Although various autologous grafts are used to reinforce the L-strut, there is a lack of objective “mechanical theory” to support the clinical findings in other studies at the present time.

      Methods

      A simplified and geometrical finite element model of L-strut reinforced with clinically common materials, including auricular cartilage, nasal septal cartilage, and perpendicular plate of ethmoid, was established. Simulating the mechanical environment of nasal tip in reality, when the force was loaded, the von Mises stress and directional deformation of the L-strut were observed under different widths. Kruskal–Wallis test was used to examine the significance of intergroup differences of L-strut, and P < 0.05 indicated statistical significance.

      Results

      All autologous grafts decreased the maximum directional deformation of L-strut, and the variance of nasal tip displacement was reduced; the perpendicular plate of ethmoid showed a distinct effect. The increasing width of the L-strut reduced the maximum displacement of the nasal tip, but the influence of using grafts as a reinforcement to the L-strut was much greater than the residual width (p = 0.003).

      Conclusion

      The graft reinforcement significantly increased the stability of the L-strut, which enhanced the resistance to deformation in the long-term action of tension, and the effect of the perpendicular plate of ethmoid to reinforce was significantly better than that of auricular and nasal septal cartilage.

      Keywords

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      References

        • Han S.K.
        • Lee D.G.
        • Kim J.B.
        • Kim W.K.
        An anatomic study of nasal tip supporting structures.
        Ann Plast Surg. 2004; 52: 134-139
        • Park J.H.
        • Jin H.R.
        Use of autologous costal cartilage in Asian rhinoplasty.
        Plast Reconstr Surg. 2012; 130: 1338-1348
        • Gunter J.P.
        • Rohrich R.J.
        Lengthening the aesthetically short nose.
        Plast Reconstr Surg. 1989; 83: 793-800
        • Lee S.H.
        • Koo M.G.
        • Kang E.T.
        Septal cartilage/ethmoid bone composite graft: a new and improved method for the correction underdeveloped nasal septum in patients with short noses.
        Aesthetic Plast Surg. 2017; 41: 388-394
        • Jang Y.J.
        • Alfanta E.M.
        Rhinoplasty in the Asian nose.
        Facial Plast Surg Clin N Am. 2014; 22: 357-377
        • Cone Jr, J.D.
        • Hobar P.C.
        The short nose.
        Clin Plast Surg. 2016; 43: 169-176
        • Cervelli V.
        • Bottini D.J.
        • Gentile P.
        • et al.
        Reconstruction of the nasal dorsum with autologous rib cartilage.
        Ann Plast Surg. 2006; 56: 256-262
        • Sen C.
        • Iscen D.
        Caudal septal advancement for nasal tip projection and support in rhinoplasty.
        Aesthetic Plast Surg. 2006; 30: 135-140
        • An Y.
        • Yang X.
        • Xue H.
        • et al.
        Inferior portion of the perpendicular plate of the ethmoid as a suitable grafting material in rhinoplasty and septoplasty procedures.
        J Plast Reconstr Aesthet Surg. 2018; 71: 1664-1678
        • An Y.
        • Feng N.
        • Chen L.
        • et al.
        A novel technique for short nose correction in Asians: M-shaped conchal cartilage combining with septal extension graft.
        J Craniofac Surg. 2019; 30: 1560-1562
        • Lee S.J.
        • Liong K.
        • Tse K.M.
        • Lee H.P.
        Biomechanics of the deformity of septal L-Struts.
        Laryngoscope. 2010; 120: 1508-1515
        • Mau T.
        • Mau S.T.
        • Kim D.W.
        Cadaveric and engineering analysis of the septal L-strut.
        Laryngoscope. 2007; 117: 1902-1906
        • Lee J.S.
        • Lee D.C.
        • Ha D.H.
        • Kim S.W.
        • Cho D.W.
        Redefining the septal L-strut in septal surgery.
        PLoS One. 2015; 10e0119996
        • Yang X.
        • Li D.
        • Xue H.
        • et al.
        Anatomical characteristics of the perpendicular plate of the ethmoid: an analysis of paranasal sinus computed tomography via three-dimensional reconstruction.
        J. Craniofac. Surg. 2019; 30: 604-606
        • An Y.
        • Xie L.
        • Chen L.
        • et al.
        Short nose correction: septal cartilage combined with ethmoid bone graft.
        J. Craniofac. Surg. 2019; 30
        • Asgharpour Z.
        • Baumgartner D.
        • Willinger R.
        • Graw M.
        • Peldschus S.
        The validation and application of a finite element human head model for frontal skull fracture analysis.
        J Mech Behav Biomed Mater. 2014; 33: 16-23
        • An Y.
        • Xie L.
        • Chen L.
        • et al.
        Short nose correction: septal cartilage combined with ethmoid bone graft.
        J. Craniofac. Surg. 2019; 30: 1898-1901
        • Meirson D.H.
        Nasal anatomy and reconstruction.
        Dermatol Clin. 1998; 16: 91-108
        • Patel R.G.
        Nasal anatomy and function.
        Facial Plast Surg. 2017; 33 (Facial plastic surgery): 3-8
        • Lan M.Y.
        • Jang Y.J.
        Revision rhinoplasty for short noses in the Asian population.
        JAMA Facial Plast Surg. 2015; 17: 325-332
        • Jung D.H.
        • Moon H.J.
        • Choi S.H.
        • Lam S.M.
        Secondary rhinoplasty of the Asian nose: correction of the contracted nose.
        Aesthetic Plast Surg. 2004; 28: 1-7
        • Toriumi D.M.
        • Patel A.B.
        • DeRosa J.
        Correcting the short nose in revision rhinoplasty.
        Facial Plast Surg Clin N Am. 2006; 14 (vi): 343-355
        • Dini G.M.
        • Iurk L.K.
        • Ferreira M.C.C.
        • Ferreira L.M.
        Grafts for straightening deviated noses.
        Plast Reconstr Surg. 2011; 128 (529e–537e)
        • Kayabasoglu G.
        • Yilmaz M.S.
        • Altundag A.
        • Cayonu M.
        • Varlı A.F.
        • Guven M.
        Bone grafts as a recyclable material in nasal surgeries.
        Auris Nasus Larynx. 2015; 42: 24-28
        • Apaydin F.
        Bone recycling in nasal septal reconstruction.
        Facial Plast Surg. 2013; 29: 473-478
        • Westreich R.W.
        • Courtland H.W.
        • Nasser P.
        • Jepsen K.
        • Lawson W.
        Defining nasal cartilage elasticity: biomechanical testing of the tripod theory based on a cantilevered model.
        Arch Facial Plast Surg. 2007; 9: 264-270
        • Menapace D.C.
        • Carlson K.D.
        • Dragomir-Daescu D.
        • Matsumoto J.
        • Hamilton G.S.
        Finite element analysis of the septal cartilage L-strut.
        Facial Plast Surg Aesthetic Med. 2021; 23: 90-97
        • Woo J.S.
        • Dung N.P.
        • Suh M.K.
        A novel technique for short nose correction: hybrid septal extension graft.
        J Craniofac Surg. 2016; 27: e44-e48
        • Kim D.W.
        • Egan K.K.
        • O'Grady K.
        • Toriumi D.M.
        Biomechanical strength of human nasal septal lining: comparison of the constituent layers.
        Laryngoscope. 2005; 115: 1451-1453
        • Tekke N.S.
        • Alkan Z.
        • Yigit O.
        • et al.
        Importance of nasal septal cartilage perichondrium for septum strength mechanics: a cadaveric study.
        Rhinology. 2014; 52: 167-171
        • Mowlavi A.
        • Masouem S.
        • Kalkanis J.
        • Guyuron B.
        Septal cartilage defined: implications for nasal dynamics and rhinoplasty.
        Plast Reconstr Surg. 2006; 117: 2171-2174
        • Jang Y.J.
        • Yeo N.K.
        • Wang J.H.
        Cutting and suture technique of the caudal septal cartilage for the management of caudal septal deviation.
        Arch Otolaryngol Head Neck Surg. 2009; 135: 1256-1260