Saturday, April 25, 2015

Vascularity of the nose and it's significance in revision rhinoplasty

  Blood supply and drainage


Like the face, the human nose is well vascularized with arteries and veins, and thus supplied with abundant blood. The principal arterial blood-vessel supply to the nose is two-fold: (i) branches from the internal carotid artery, the branch of the anterior ethmoid artery, the branch of the posterior ethmoid artery, which derive from the ophthalmic artery; (ii) branches from the external carotid artery, the sphenopalatine artery, the greater palatine artery, the superior labial artery, and the angular artery.

The external nose is supplied with blood by the facial artery, which becomes the angular artery that courses over the superomedial aspect of the nose. The sellar region (sella turcica, “Turkish chair”) and the dorsal region of the nose are supplied with blood by branches of the internal maxillary artery (infraorbital) and the ophthalmic arteries that derive from the internal common carotid artery system.

Internally, the lateral nasal wall is supplied with blood by the sphenopalatine artery (from behind and below) and by the anterior ethmoid artery and the posterior ethmoid artery (from above and behind). The nasal septum also is supplied with blood by the sphenopalatine artery, and by the anterior and posterior ethmoid arteries, with the additional circulatory contributions of the superior labial artery and of the greater palatine artery. These three (3) vascular supplies to the internal nose converge in the Kiesselbach plexus (the Little area), which is a region in the anteroinferior-third of the nasal septum, (in front and below).

Furthermore, the nasal vein vascularisation of the nose generally follows the arterial pattern of nasal vascularisation. The nasal veins are biologically significant, because they have no vessel-valves, and because of their direct, circulatory communication to the sinus caverns, which makes possible the potential intracranial spreading of a bacterial infection of the nose. Hence, because of such an abundant nasal blood supply, tobacco smoking does therapeutically compromise post-operative healing.

Lymphatic drainage

The pertinent nasal lymphatic system arises from the superficial mucosa, and drains posteriorly to the retropharyngeal nodes (in back), and anteriorly (in front), either to the upper deep cervical nodes (in the neck), or to the submandibular glands (in the lower jaw), or into both the nodes and the glands of the neck and the jaw.

Epistaxis (Nosebleeds)

Jeffrey D Suh MD, Rohit Garg MD, MBA


The nasal cavity is extremely vascular, meaning it has a large blood supply. Blood is supplied via both the internal and external carotid systems. The major blood arteries in the nasal cavity include the anterior and posterior ethmoid arteries and the sphenopalatine arteries. Over 90% of nose bleeds occur in the anteroinferior (front bottom) nasal septum (wall that divides your nose between left and right sides) in an area known as Kiesselbach’s plexus, named after Wilhelm Kiesselbach, a German otolaryngologist. Keisselbach's plexus is located over the anterior nasal septum and is formed by anastomoses (coming together) of 5 arteries:

  • Anterior ethmoidal artery (from the ophthalmic artery) (Figure 1)
  • Posterior ethmoidal artery (from the ophthalmic artery)
  • Sphenopalatine artery (terminal branch of the maxillary artery) (Figure 2)
  • Greater palatine artery (from the maxillary artery)
  • Septal branch of the superior labial artery (from the facial artery)
Approximately 5% to 10% of epistaxis is estimated to arise from the posterior nasal cavity, in an area known as Woodruff’s plexus. Woodruff's plexus is located over the posterior middle turbinate and is primarily made up of connection of branches of the internal maxillary artery, namely, the posterior nasal, sphenopalatine, and ascending pharyngeal arteries. Posterior bleeds usually originate from the lateral wall and more rarely from the nasal septum.

  Blood supply and viability of nasal grafts

By Dr. Richard Davis
Rebuilding a damaged outer nose has similarities to rebuilding an A-frame house. Both structures have an architectural framework that provides structural support and determines the overall, length, width and shape of the structure. In order to modify the structure's shape, the framework must be exposed and then physically reconfigured. In the nose, the structural framework is the nasal skeleton, consisting of cartilage and bone, whereas the house is typically wood and concrete. However, unlike a house, the nasal framework is composed entirely of living tissue – tissues that must have a constant flow of blood to remain viable. In the nose, nutrients such as oxygen, glucose, minerals, etc, are delivered to the skeletal framework through a network of tiny blood vessels found within the overlying skin and underlying mucous membranes. By necessity, any type of nasal surgery (or nasal injury) causes varying degrees of damage to this circulatory network. While the human body has an incredible capacity to heal from such damage, recovery is never fully complete and some blood vessels are permanently lost.

Fortunately, the nasal circulation has excess capacity, so the overall circulatory impact of a well-executed surgical intervention is usually negligible. However, repeated surgeries, especially when combined with poor surgical technique, can eventually impair circulatory function. Moreover, the surgery itself causes additional temporary circulatory impairment as a consequence of swelling and inflammation. When the total circulatory impairment exceeds the threshold for minimal tissue perfusion, tissues become oxygen-deprived, or ischemic, and complications such as cell death, infection and tissue resorption soon develop.

Because revision rhinoplasty relies almost entirely upon the transplantation of cartilage into the nose, a healthy recipient blood supply is a key element in ensuring survival of grafted tissues. A robust circulation not only ensures prompt re-vascularization of the transplanted cartilage grafts, it also lowers the risk of infection and graft resorption. Gentle surgical technique, avoidance of tobacco or nicotine, and good supportive care can help to optimize circulatory support to the vulnerable grafted tissues. 

However, in noses with severely damaged circulation, such as those subjected to multiple previous rhinoplasty procedures, the likelihood of graft resorption, infection, and even skin necrosis (death) are increased, especially when coupled with smoking, infection, cocaine abuse, excessive swelling, diabetes or other conditions, medications or supplements that impair circulation. In this patient population, good surgical technique is often negated by poor circulation and the results of surgery are usually disappointing.

Vascular Anatomy of the Nose and the External Rhinoplasty Approach
Dean M. Toriumi, MD; Royce A. Mueller, MD; Thomas Grosch, MD; Tapan K. Bhattacharyya, PhD; Wayne F. Larrabee Jr, MD
Arch Otolaryngol Head Neck Surg. 1996;122(1):24-34. doi:10.1001/archotol.1996.01890130020003. 

 Conclusions:  The major arterial, venous, and lymphatic vasculature courses in or above the musculoaponeurotic layer of the nose. In the external rhinoplasty approach, dissection in the areolar tissue plane below the musculoaponeurotic layer will minimize tip edema and protect against skin necrosis by preserving the major vascular supply to the nasal tip.(Arch Otolaryngol Head Neck Surg. 1996;122:24-34)
Nasal tip blood supply: an anatomic study validating the safety of the transcolumellar incision in rhinoplasty.
 Rohrich RJ, Gunter JP, Friedman RM.

The nasal tip blood supply was studied through anatomic dissections and microangiography in 31 fresh cadaver specimens. The lateral nasal artery was present in all specimens, bilaterally in 30 (97 percent) and unilaterally in one (3 percent) and was located in the subdermal plexus 2 to 3 mm superior to the alar groove. The columellar branch of the superior labial artery was visualized bilaterally in 3 specimens (9 percent) and unilaterally in 21 (68 percent), and was absent in 7 (23 percent). Transcolumellar (external rhinoplasty) incisions were performed in 11 of these cadavers prior to dye injection. A consistent crossover flow (100 percent) was seen from the lateral nasal artery arcades to the distal aspect of the transected columellar branches. We conclude that nasal tip blood supply is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. Collateral flow to the nasal tip may be provided by branches of the ophthalmic artery. The external rhinoplasty transcolumellar incision does not compromise nasal tip blood supply unless extensive tip defatting or extended alar base resections (above the alar groove) are performed.

Blogger N.B.  It is my personal belief that repetitive reopening of the same external incision can increase the possibility of developing necrosis &/or serious cutaneous nerve damage ie.Neuroma's.  Of course there are other factors to consider as mentioned above and consideration as to the location of where the original external incision was made is of utmost importance.

The question of  "How many times can a nose take an open rhinoplasty w/o damaging the skin" was posed on the realself website. There's differing opinions from rhinoplasty surgeons.

Good vascularity is not only important in viability of bone/cartilage, synthetic implant grafts but equally important in viability of skin grafts and flaps. Injectable fillers can cause vascular occlusion. I would speculate that over cauterization of a specific area may also be a concern as to compromising vascularity.

Sunday, January 4, 2015

New(er) Treatments for Empty Nose Syndrome

Empty Nose Syndrome (ENS) has unfortunately been a controversial diagnose amongst Otolaryngologists (ENT physicians).  Many ENT physicians in the past refused to seriously acknowledge the patients moderate to debilitating and paradoxical symptoms which developed after re-sectioning of the inferior turbinates (I.T's) in particular the anterior portion or whole I.T. and/or part of the middle turbinates. Victims of ENS had suffered double victimization because their  surgeons would defensively and reflexively write them off simply as unhappy patients who must of coincidentally developed a latent mental health problem after their turbinectomies.  There are still some obstinate ENT physicians that still reject the diagnoses outright but many are finally waking up largely due to the ease of information available on internet where publications have scientifically explained the victims host of complaints.

The person most responsible for shedding light on this topic was retired surgeon Dr. Eugene Kerns of Mayo Clinic in Rochester Minnesota. He is credited for coining the term Empty Nose Syndrome.
It was after two of his ENS patients committed suicide that he decided to devote more time to this unknown misunderstood condition. Both patients led normal active lives prior to their turbinate surgeries with no history of mental illness. In 2000 Dr. Kerns gave a taped lecture on Empty Nose Syndrome to fellow rhinologists, Dr. Kern tells his audience that the nasal mucosa “is the organ of the nose.” He outlines the four main function of this organ: “Olfaction, defense, respiration, and cosmesis.” ‘Please think of it as an organ system, just as you think of the lungs, the liver…the kidneys, as organ systems.” He points out that his Empty Nose Syndrome patients lack cilia, lack functioning mucosa. “When we remove functioning tissue what happens?” he asks. “When we destroy mucosa…these respiratory functions and defensive functions can be significantly compromised. When we convert a nose to a mouth….it’s not aerodynamically efficient…wide open noses do not function…” “How much tissue can you remove and still have normal function? We know you can remove probably eighty to ninety percent of a liver and still have normal liver function. You can remove a kidney…and have the second kidney and still have normal function. How much nose can be removed? I don’t think we know that.”
He says it took about six years, on average, following surgery, for the residual tissue of the nose to fail, in his Empty Nose Syndrome patients.

In past decade Dr. Steven Houser has been recognized as a pioneer in the field offering surgical acellular dermal implant (alloderm)  and injectable liquid alloderm (cymetra) for ENS. Alloderm implants have already been implanted successfully for a few years now in a small but growing number of ENS patients. At four years follow-up, results seem stable and encouraging. It seems that Alloderm implants can't fully cure ENS but can help alleviate the symptoms with various degrees of success, depending on the individual condition of each patient. It is difficult or virtually impossible to use Cymetra on its own to achieve a large volume implant, but it can be used successfully to further augment prior Alloderm implants, thus perfecting the initial result achieved with regular Alloderm.

Does the Method of Inferior Turbinate Surgery Affect the
Development of Empty Nose Syndrome?
Steven M. Houser
Pub date:Feb 10, 2014
ENS, fortunately, is extremely rare. The degree of mucosal damage
relates more directly to the development of ENS than the volume of
excised tissue. Most surgical patients will never develop ENS.
Turbinate surgery should only be considered if medical management
(e.g., allergy medications in the face of allergic rhinitis) has failed.
Using the least invasive process to effect airway improvement in the
face of turbinate enlargement is then wise. Turbinate outfracture
appears safe, as do conservative submucosal reduction procedures.
Turbinate excision should be restricted to disease processes that
prohibit lesser approaches (e.g., cerebrospinal fluid leak repair may
necessitate middle turbinate sacrifice). Turbinate reduction
approached via mucosal damaging procedures (i.e., surface cautery
and laser reduction) should be abandoned in favor of safer techniques.
Poster nose1 on ENS forums has stated even a smaller amount of tissue being removed in such a way that leaves the mucosa damaged can lead to severe ENS symptoms. For example, turbinates that have been cauterized can result in quite severe ENS symptoms.

The term Empty Nose Syndrome fits descriptively well with those who have a structural turbinate deficit. But for those with nasal mucosa dysfunction and little to no structural deficit perhaps a more fitting term would be Nasal Mucosa Dysfunctional Syndrome (NMDS), if I may be so bold to coin a condition. Some who have had their turbinates excised will more likely have a combination of the two. The degree of how much mucosa is damaged/removed will likely coincide with the severity of one's symptoms. In regards to the Inferior Turbinate there's another factor at play. In partial resectioning of the I.T.  resectioning of the anterior portion is much more likely to result in ENS  then resectioning of the posterior portion of the I.T.  I myself can testify to this because my first turbinate surgery consisted of lateral and posterior excision of the I.T's. This did not cause me any ENS. However after my anterior portion was removed in another surgery years later i started to develop some of the symptoms associated with ENS. However I should point out a caveat here is that almost all my left I.T. is now missing. I don't have all the symptoms likely b/c my anterior portion was excised submucosally.  However inbetween those two surgeries I had underwent a cauterization procedure.  Note: I also did not experience ENS symptoms after my cautery of the I.T's where I then had partial lateral anterior I.T's and medial flap of the mucosa which was rolled up to form a smaller medial turbinate performed by the surgeon who performed my first turbinectomy.

Another treatment option now being explored for reducing ENS symptoms is PRP or PRL injections into the nasal cavity. 
PRP (Platelet-Rich Plasma)

Blood is taken from your body and put in a centrifuge. In the centrifuge the blood platelets will be separated. These platelets have great healing abilities which also work in natural wound healing. The out-coming concentrate can be injected to the damaged tissue.  The platelets collected in PRP are activated by the addition of thrombin and calcium chloride, which induces the release of these factors from alpha granules.. The growth factors and other cytokines present in PRP include:[1][2]
PRP has been applied for a some time in different applications (for e.g. nerve injury, bone repair and oral surgery), but only for a relatively short time for the nose.

The PRP might bring the nasal mucosa to a healthier level.

PRL (Platelet-Rich Lipotransfer)

PRL is combining PRP with a lipotransfer.
A lipotransfer is taking your own fat and placing it to another part of your body. The fat contains adult stem cells, which showed good regenerative effects. The stem cells in the fat can be enriched.
Lipotransfers are used for example in breast augmentation/ reconstruction, smoothening wrinkes and other tissue defects.

The therapy consists in the matching between platelet growth factors  and mesenchymal stem cells from adipose tissue taken from the abdomen / buttocks / hip of the patient, through a small liposuction under local anesthesia.

The adipose tissue is centrifuged and purified and subsequently combined with PRP: is thus obtained a compound called PRL (Platelet Rich Lipotransfer), which will be injected in the nasal mucosa in order to stimulate the regeneration of the turbinates and of other atrophic areas in nasal cavity. 

 Doctors, who treat ENS with PRP/ PRL

Prof. Valerio Cervelli, Italy

Dr. Enrico Donde, Italy

Dr. Lino di Rienzo Businco, Italy

Dr. Robert Bodlaj, Germany

PRP & ACell Implants now available at US Institute for Advanced Sinus Care & Research
 The newly created US Institute for Advanced Sinus Care & Research is now offering platelet-rich plasma injections combined with acellular dermis implants for patients with Empty Nose Syndrome. The Institute is physically located in Columbus Ohio.  Dr. Subinoy Das, former Director of Sinus Surgery at The Ohio State University, Audit Chair and Fellow of the American Rhinologic Society, and winner of the 2013 Fowler Award for the Top Basic Science Research Project in Otolaryngology is the new Medical Director.  The Institute collaborates with leading otolaryngologists throughout the
world in an effort to provide patients with advanced and rare sinus diseases with cutting edge therapies.

Hyaluronic acid gel in the treatment of empty nose syndrome. 
Marek ModrzyƄski

Because of its simplicity, safety, and fairly good, but impermanent clinical effects, HA injections appear to be worth considering in less severe forms of ENS. 


Acellular dermal (alloderm) grafts versus silastic sheets implants for management of empty nose syndrome.
 The objective of the study is to conduct a prospective randomized blind clinical study comparing the efficacy and safety of use of acellular dermal (alloderm) grafts versus silastic sheets submucosal implants for management of empty nose syndrome (ENS). . Both graft materials are well suited to this procedure with no statistical evidence for a significant difference between them. The silastic implant is inert and yet incorporated into the surrounding tissue because of the fashioned macropores. It is available and inexpensive. Acellular dermis graft is reliable, predictable, and readily shaped. Patients of both groups showed marked subjective and objective improvements. The surgical procedure is safe and relatively simple to perform. 

Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome.

CONCLUSION: The reconstruction of inferior turbinate with Medpor is a new promising approach to treat patients with empty nose syndrome. 

N.B. My understanding is that medpor is difficult to remove if need be since it incorporates itself with other surrounding tissue's. Therefore one should be skeptical to this approach using medpor, silastic sheets (silicone) or any unnatural products inside the nose.

More Info on Empty Nose Syndrome: