Abstract
The most serious form of nasal dorsum pathologies is saddle nose deformity. Vary of nasal dorsal augmentation grafts were reported in the literature but inferior bone graft (ITBG) alone has not attracted attention. The ITBG has advantages such as easy and fast harvesting, easy to shape due to cancellous bone tissue. The graft technique is similar to the inferior turbinoplasty with the medial mucosal flap technique and can be performed without bioabsorbable hemostatic material (e.g. Turkish Delight), suture fixation, or without tissue adhesives. Major complications of the ITBG technique are injury of the posterior lateral nasal branch of the sphenopalatine artery and subdermal mucous cyst that developing on nasal dorsum. Since easy application, fast harvesting, and similar permanence to cartilage grafts as augmentation material, ITBG can also been used successfully in minor dorsal deficits in addition to saddle nose deformities.
Keywords: Inferior turbinate bone graft, Conchal bone, Turkish Delight graft, Saddle nose
Background
The nasal dorsum is an important aesthetical unit that can be damaged due to trauma, granulomatous diseases, or previous surgeries and difficult to manage in reconstruction [1]. The most serious form of nasal dorsum pathologies is saddle nose deformity [2]. Graft materials are almost required to regain the deficient nasal dorsal height. Nasal dorsum augmentation grafts reported in the literature are septal cartilage, auricle or costal cartilage, calvarial, iliac, or conchal bone, and synthetic implants [3]. The most ideal graft material should be easily obtainable, adaptable to the nasal dorsum tissue and shape, and low cost. Nasal septum cartilage is the most ideal material with these features, but due to trauma, granulomatous diseases, and previous nasal septal surgeries, sufficient septal cartilage may not be obtained [4]. Auricular and costal cartilage grafts cause additional surgical procedures, thus increasing the rate of complications [3]. Bone grafts are difficult to harvest and shape, also bone material is not suitable for the nasal dorsum structure except for the inferior turbinate bone graft (ITBG) [5]. Synthetic materials are less preferred due to the cost and the risk of extrusion, displacement, and infection. The ITBG has advantages such as easy and fast harvesting, easy to shape due to cancellous bone tissue, but there is only one limited report in the literature [5]. Inferior turbinoplasty (IT) is an effective surgery for nasal obstruction alone or with septoplasty or functional septorhinoplasty. ITBG can be created with the bone removed during IT surgery. Even if the IT is not planned in the main surgery, harvesting of ITBG does not cause additional morbidities, such as to obtain of the auricle or costal cartilage. The ITBG can be performed without bioabsorbable hemostatic material (e.g. Turkish Delight), suture fixation, or without tissue adhesives and this report is designed to emphasize the importance of this graft.
Material and Surgical Technique
The lower turbinates are erectile structures in the lateral wall of the nose. It consists of the spongy bone in the middle and the nasal mucosa lined with the surrounding multi-layer squamous epithelium. To harvest ITBG, a turbinoplasty with a medial flap is planned and excessive resection of the inferior turbinate is avoided. After decongestion is achieved, lidocaine and adrenaline solution is infiltrated through the inferior turbinate. A mucosal incision is made along the anterior and inferior margins of the inferior turbinate. The medial mucosa is elevated from the beginning to the horizontal part of the lower turbinate. With Heymann nasal scissors, excision of the lower turbinate and lateral mucosa is started. Before reaching the posterior attachment point of the lower turbinate, the excision is completed by directing the direction of the scissors inferiorly. The lateral mucosa over the inferior turbinate is peeled extracorporeally from the periosteum. The desired shape is given by crushing the inferior concha bone with a straight Kelly Clamp. The necessary corrections can be made again with scissors (Fig. 1). The prepared ITBG is placed in the planned area after the other procedures regarding the septum and dorsum are completed (Fig. 2).
Fig. 1.
Preparation of inferior turbinate bone graft (ITBG)
Fig. 2.
Cartilage and bone saddle nose deformity. Frontal and lateral view of preoperative and postoperative in operation room
Conclusion
Inferior Turbinate Bone Graft was designed primarily for the reconstruction of saddle nose deformity in trauma and granulomatous diseases where septum cartilage is insufficient. In addition, the indications for nasal dorsal augmentation can be expanded similarly to the septal cartilage graft. This technique has also been used successfully in minor dorsal deficits. One of the most important complications of the ITBG technique is intraoperative or postoperative epistaxis due to injury of the posterior lateral nasal branch of the sphenopalatine artery which very close to the posterior attachment of the turbinate. To avoid injury to this branch, it is recommended to advance the insertion inferiorly when approaching the posterior attachment of the turbinate during IT. Generally, it can be detected and controlled intraoperatively, in some cases, postoperative nasal packing or cauterization may be required. Another major complication is mucous cyst that develops in the nasal dorsum due to leaving mucosa on the turbinate bone. In case of mucous cysts deveoped, total excision is required. No special care or precaution or dressing is recommended for patients undergoing ITBG except for general septorhinoplasty postoperative care and applications. No evidence of resorption of the graft was observed during the four-year follow-up period of experience (Fig. 3).
Fig. 3.
Cartilage saddle nose deformity in a revision case. Frontal and lateral view of preoperative and at 4th year postoperative
Key Points
Saddle nose deformity is a serious pathology of nasal dorsum.
Augmentation materials are necesserary with insufficient septal cartilage remnant.
ITBG can be performed easily and fastly.
Graft preparation time is less than 10 min.
Major complications are epistaxis and subdermal mucous cyst.
ITBG has similar permanence to cartilage grafts
This tecnique is suitable for minor dorsal deficits in addition to saddle nose deformities.
Acknowledgements
None.
Authors Contributions
All authors contributed equally to the design of study, data collection, writing, review of the references, critical review, and final approved version of the manuscript.
Funding
This research did not receive any specific fund.
Compliance with Ethical Standards
Conflict of interest
The authors declare no conflict of interest.
Ethical Approval
The institutional review board was approved by the Ethics Committee of the Affiliated University for the study (560-25/12/2018).
Footnotes
Publisher's Note
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