ArticleLiterature Review

Closed Microfracture Technique for Surgical Correction of Inferior Turbinate Hypertrophy in Rhinoplasty: Safety and Technical Considerations

If you want to read the PDF, try requesting it from the authors.

Abstract

An abundance of surgical procedures are in use for the management of inferior turbinate hypertrophy in rhinoplasty patients. An ideal treatment approach is elusive, given the variability of patient presentation regarding obstructive nasal airway, significant complications associated with techniques that cause mucosal trauma, and the high recurrence rates associated with more conservative techniques. In an effort to improve patient safety, the authors describe a conservative technique-the closed microfracture-that provides an effective functional airway improvement and minimal to no complications. The authors propose a treatment approach for enlarged inferior turbinates based on turbinate subtype.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... 3,6,13,17 Interestingly, following their previous work on submucosal turbinoplasty, 7 Rohrich et al later described closed microfracture of the turbinate bone inside an intact mucosal sac as the preferred method for treating ITH. 16 Microfracturing and the related comminution was the key element they identified in reducing the risk of recurrence of the lateralized turbinates in the original position. ...
... Keeping Doyle splints for one week, as customary in rhinoseptoplasty, may help in further preventing any remedialization. 2,16 Piezo technology, by definition, will spare soft tissue and vessels and has gained considerable momentum and widespread acceptance in rhinoplasty over the last few years especially for osteotomy and osteoplasty maneuvers. 29 In the senior author's experience, piezo is used in multiple steps of rhinoplasty in every case, primary or secondary. ...
Article
Consensus is still lacking on the ideal treatment of turbinate hypertrophy concurrent with rhinoseptoplasty. A novel technique of turbinoplasty consisting of incision-bone fracturing by the use of piezoelectric technique—intramucosal microcauterization—lateralization is described in detail. A series of 157 consecutive patients is reviewed with a maximum follow-up of one year. The technique is fast and easy and allows predictability in avoiding postoperative bleeding and preventing remedialization of the lateralized turbinates. Due to the technology required, its use is suggested especially when piezo is employed during other steps of rhinoseptoplasty.
... The best surgical technique for inferior turbinate hypertrophy is debatable. A lot of surgical procedures exist; each of them has its own limitations [6]. ...
Article
Full-text available
Objectives The aim of this study was to compare the outcome of submucous resection and combined submucous diathermy with outfracture technique in treatment of nasal obstruction caused by inferior turbinate hypertrophy.Methods This study is a prospective randomized clinical trial involving 90 patients with hypertrophied inferior turbinate not responding to medical treatment. All patients were selected with equal or near equal mucosal and bony turbinate components using computed tomography (CT) and then randomly allocated into two groups; group A (n = 45): underwent submucous resection in both sides and group B (n = 45): underwent combined submucous diathermy and outfracture in both sides. Subjective (NOSE score) and objective (4-grades endoscopic classification system and PNIF evaluation) measures of nasal airflow were done preoperatively and postoperatively.ResultsSubjective assessment using NOSE scale proved that both techniques were effective in relieving nasal obstruction as it improved in both groups postoperatively compared to the preoperative data. However, resection technique was better than diathermy technique with a statistically significant difference (p < 0.05), while objective assessment of nasal obstruction showed better results in resection group than diathermy group, but with no statistically significant difference.Conclusion Both techniques are effective in relief of nasal obstruction due to inferior turbinate hypertrophy. However, submucous resection showed marked improvement compared to diathermy technique especially at long-term follow-up.
... Using a long heavy Vienna nasal speculum, the inferior turbinate is microfractured through a closed approach. The turbinate is out-fractured in a juddering motion, proceeding from posterior to anterior while pushing the Vienna speculum laterally on the turbinate [11]. ...
Article
Full-text available
Nasal septoplasty is often required to correct a cosmetic deformity, which is a common reason for patients to present to a plastic surgeon. If nasal septoplasty is insufficient, a residual deformity or nasal obstruction may remain after surgery. Even if the nasal septum is corrected to an appropriate position, nasal congestion could be exacerbated if the turbinate on the other side is not also corrected. Therefore, appropriate treatment is required based on the condition of the turbinates. Herein, we survey recent trends in treatment and review previous research papers on turbinoplasty procedures that can be performed alongside nasal septoplasty.
... In the vast majority of cases requiring inferior turbinate reduction, we prefer the closed microfracture technique as described by Rohrich et al. 8 The oxymetazoline soaked pledgets are removed from the vestibules bilaterally and a long heavy Vienna nasal speculum is used to microfracture the inferior turbinates through a closed approach from posterior to anterior while pushing the speculum laterally onto the inferior turbinate. This technique maintains a mucosal sac over the comminuted inferior turbinate, avoiding a greenstick-type fracture that could migrate back into an obstructive position. ...
Article
Full-text available
This invited Special Topic article outlines the authors' evolution and technique to optimize consistent results in rhinoplasty.
... The largest study evaluated 500 patients. 49 No objective outcomes were reported. ...
Article
Background: Inferior turbinate hypertrophy is often encountered by plastic surgeons who perform rhinoplasty. Many treatment options are available to treat the inferior turbinate. The objective of this study was to systematically review outcomes of available techniques and provide guidance to surgical turbinate management. Methods: A MEDLINE search was performed for means of treating inferior turbinate hypertrophy. Studies selected focused on treatment of the inferior turbinate in isolation and excluding patients with refractory allergic rhinitis, vasomotor rhinitis, or hypertrophic rhinitis. Results: Fifty-eight articles were identified, collectively including the following surgical treatments of inferior turbinate hypertrophy: total turbinectomy, partial turbinectomy, submucosal resection, laser surgery, cryotherapy, electrocautery, radiofrequency ablation, and turbinate outfracture. Outcomes and complications were collected from all studies. Procedures such as turbinectomy (partial/total) and submucosal resection showed crusting and epistaxis at comparatively higher rates, whereas more conservative treatments such as cryotherapy and submucous diathermy failed to provide long-term results. Submucosal resection and radiofrequency ablation were shown to decrease nasal resistance and preserve mucosal function. No literature exists to support the belief that turbinate outfracture alone is an effective treatment for turbinate hypertrophy. Conclusions: Treatment of inferior turbinate hypertrophy is best accomplished with modalities that provide long-lasting results, preservation of turbinate function, and low complication rates. Submucosal resection and radiofrequency ablation appear to best fulfill these criteria. Turbinate outfracture should only be considered in combination with tissue-reduction procedures.
Article
Learning objectives: After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective. Summary: The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.
Article
Nasal obstruction is a common complaint, one of the most frequent causes being inferior turbinate hypertrophy, which can be managed with surgery when medical treatment fails. In the last decades, multiple surgical techniques and associated technology have been developed, however, there is no established consensus on what is the best option for the management of this pathology. Literature review, the available surgical methods are stated, taking into account benefits, probable complications and results of each technique. The surgery of inferior turbinate has favorable results in patients with hypertrophic turbinates that do not respond to medical management. To date, microdebrider turbinoplasty has shown superiority in terms of long-term results and lower complication rates. The evidence available to date lacks homogeneity in terms of patient selection methods, measurement of results and follow-up time, so prospective controlled studies are needed in the future to reassess the described methods.
Article
Background: There is a significant variation in the assessment, treatment, and outcomes of nasal airway obstruction and management in the published literature. This study aimed to: (1) define key components of the nasal airway, (2) identify frequent causes of nasal obstruction, and (3) review existing treatment methods. Methods: A systematic review of the literature was performed, and 135 studies were included via the following criteria: English, human subjects, and a primary endpoint of nasal airway improvement. Exclusion criteria were: abstract only, no airway data, pediatric patients, cleft rhinoplasty, sleep apnea, isolated traumatic nasal reconstruction, and cadaveric-only or animal studies. Results: The relevant obstructive sites include the ENV, septum, inferior turbinates, INV, and nasal bones. Addressing the alar rim alone may be insufficient, and inspection of the lateral wall and crura may be indicated. Correction of septal deviation involves attention to the bony base. Mucosal sparing treatment of inferior turbinates improves outcomes. INVs are a major source of nasal obstruction, and treatment includes spreader grafts. The bony nasal vault can contribute to nasal obstruction, including due to surgical osteotomies. Conclusions: Anatomic causes of airway obstruction include the alar rims and lateral nasal walls, deviated nasal septum, inferior turbinate hypertrophy, decreased INV angle, and narrowed nasal bones. Treatments include graft placement; septoplasty; mucosal sparing turbinectomy; and lateral wall support. Pitfalls include failing to address the bony septum, over-resection of inferior turbinates, and narrowing of the nasal vault. Appreciation of airway management during rhinoplasty will improve functional outcomes. Level of evidence v: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Article
Pollybeak deformity represents one of the most common complications of rhinoplasty that require revision rhinoplasty for correction. This article helps to understand the basis behind the deformity, which helps us to prevent and to treat this deformity. This article and video also reiterate that systematic facial analysis is important to look for imperfections and asymmetries in other parts of the face and show how a chin augmentation is performed to correct microgenia.
Article
Male rhinoplasty is unique in that it requires precise pre-operative planning to achieve a successful result. Better communication and clarity is paramount with male rhinoplasty patients because the patients may be less attentive. It is important for the surgeon to screen the patients for any psychosocial disorders. Through a series of cases, male rhinoplasty techniques are highlighted. Masculine features should be preserved and the nose should not be feminized or over-sculpted. Another key component in any rhinoplasty case is proper skin care especially during the post-operative period.
Article
Background: The sheer number of accepted inferior turbinoplasty techniques emphasizes the fact that there is no general agreement on which approach yields optimal results, nor are there data available that describes prevalent techniques in turbinate surgery among plastic surgeons. Objective: The aim of this study was to identify practice patterns among plastic surgeons who perform inferior turbinoplasty during rhinoplasty. Methods: Members of the American Society of Plastic Surgeons were invited to participate in an anonymous, Internet-based survey containing questions related to personal preferences and outcomes in inferior turbinate surgery. Results: A total of 534 members of the American Society of Plastic Surgeons participated in the survey. Most (71.7%) trained in an independent plastic surgery program with prerequisite training in general surgery. More than half (50.6%) had more than 20 years of operative experience; only 15.2% reported performing greater than 40 rhinoplasties per year. The 5 most preferred inferior turbinate reduction techniques were outfracture of the turbinates (49.1%), partial turbinectomy (33.3%), submucous reduction via electrocautery (25.3%), submucous resection (23.6%), and electrocautery (22.5%). Fewer than 10% of the respondents reported the use of newer techniques such as radiofrequency thermal ablation (5.6%), use of the microdebrider (2.2%), laser cautery (1.1%), or cryosurgery (0.6%). Mucosal crusting and desiccation were the most frequently reported complications. Conclusions: The results of this survey provide insights into the current preferences in inferior turbinate reduction surgery. Plastic surgeons are performing more conventional methods of turbinate reduction rather than taking advantage of the many of the more novel technology-driven methods.
Article
Learning objectives: After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty. Summary: Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.
Article
Nasal airway obstruction is a frequently-encountered problem, often secondary to inferior turbinate hypertrophy. Medical treatment can be beneficial but is inadequate for many individuals. For these refractory cases, surgical intervention plays a key role in management. The authors evaluate the current trends in surgical management of inferior turbinate hypertrophy and review the senior author's (SS) preferred technique. A questionnaire was devised and sent to members of the American Society for Aesthetic Plastic Surgery (ASAPS) to determine their preferred methods for assessment and treatment of inferior turbinate hypertrophy. One hundred and twenty-seven physicians responded to the survey, with 85% of surveys completed fully. Of the responses, 117 (92%) respondents were trained solely in plastic surgery and 108 (86.4%) were in private practice. Roughly 81.6% of respondents employ a clinical exam alone to evaluate for airway issues. The most commonly-preferred techniques to treat inferior turbinate hypertrophy were a limited turbinate excision (61.9%) and turbinate outfracture (35.2%). Based on the results of this study, it appears that limited turbinate excision and turbinate outfracture are the most commonly-used techniques in private practice by plastic surgeons. Newer techniques such as radiofrequency coblation have yet to become prevalent in terms of application, despite their current prevalence within the medical literature. The optimal method of management for inferior turbinate reduction should take into consideration the surgeon's skill and preference, access to surgical instruments, mode of anesthesia, and the current literature.
Article
The improved exposure afforded by the external rhinoplasty approach has allowed for more precise surgical maneuvers and makes more consistent results possible. This study examines the frequency and array of surgical maneuvers during primary aesthetic rhinoplasty in a single surgeon's practice. A retrospective review of 100 consecutive primary external cosmetic rhinoplasty patients with a minimum follow-up of approximately 1 year was conducted. Surgical maneuvers were reviewed and tabulated. Special attention was devoted to the number of cartilage grafts and suturing techniques used. Operative times and incidence of revision surgery were investigated. The mean duration of surgery was 1 hour 50 minutes. The majority of rhinoplasties involved concomitant septal surgery for deviation and airway occlusion or cartilage harvesting. Osteotomies were performed on over 95 percent of patients. The dorsal hump was removed on 84 percent of the patients. The most common grafts used included alar rim grafts in 88 percent, subdomal grafts in 77 percent, and spreader grafts in 74 percent. Sutures used to contour the cartilage included transdomal sutures in 62 percent, followed by footplate approximation sutures in 32 percent. Seventy-seven patients had interdomal sutures placed as a component of subdomal grafting. The senior surgeon has found that common incorporation of certain maneuvers offers more consistent, aesthetically pleasing, and superior functional outcomes. Careful review of this article may guide the reader to consider the more frequent use of some maneuvers or reduction of other maneuvers to reflect that of a streamlined and higher-volume rhinoplasty practice.
Article
The evidence-based medicine (EBM) schema advocates critical appraisal of the scientific literature for treatment of diseases. The objective of this review was to analyze the role of surgery for symptomatic adult inferior turbinate hypertrophy (ITH) by focusing on the following question: In adults with nasal airway obstruction (NAO) from documented ITH having failed medical therapy, does inferior turbinate surgery improve disease-specific quality of life, symptoms, and/or objective parameters with minimum 6-month follow-up?. Evidence-based review. Articles for inclusion were identified by query of appropriate search terms in the PubMed database. The articles were reviewed independently by two authors and assigned an evidence level based on standard EBM guidelines. The search yielded 514 abstracts for review, retrieved 143 abstracts for full review, and included 96 articles in the report. The majority of the articles were assigned level 4 (75) or level 5 (18) evidence. One report was assigned level 1 and two reports were assigned level 2. Median number of patients reported was 50 (range, 1-533). Subjective assessment parameters were reported in 80 studies. Objective parameters were evaluated in 36 studies, including acoustic rhinometry or rhinomanometry (26) and mucociliary function (8). Overwhelming data supported efficacy of surgery for NAO from ITH with positive results reported in 93 studies. The literature provides considerable level 4 and 5 evidence for efficacy of surgery for adult symptomatic ITH. Given the paucity of level 1 and 2 data, future studies should focus on prospective studies with matched control groups for comparison.
Article
When conservative medical management of symptomatically enlarged inferior turbinates is ineffective, the obstructing tissue may be reduced by an intramucosal or extramucosal destructive procedure (such as electrocautery, cryotherapy, or laser vaporization), or by conservative surgical resection. In the latter instance, enlarged conchal bones may be removed by the technique of turbinate submucous resection, while diffuse stromal hypertrophy necessitates partial resection of the inferior turbinates. A number of techniques of inferior turbinate surgery have been described. I have used the procedure of "inferior turbinoplasty" with increasing frequency for more than 9 years. Three to five years after such surgery, a detailed followup of 40 patients revealed none of the once-feared sequelae of turbinate resection, such as bleeding, crusting, foul nasal discharge, or bothersome postnasal drainage. Histologic examination of turbinates almost 5 years after turbinoplasty revealed fibrosis and scarring, with a marked decrease in mucous gland population, and normal mucosa. To obtain the best possible functional result inferior turbinate surgery is a necessary adjunct to most septal surgery. If conservatively done, it does not impair normal turbinate function. It must be stressed, however, that if the underlying cause of the turbinate hypertrophy is not addressed, recurrent obstruction can and probably will occur.
Article
The key to the correction of severely deviated noses is straightening the nasal septum. An emphasis is placed on conservative management of the external nasal framework while being prepared to perform extensive surgery on the deviated septum. If the septum can be modified and repositioned in the midline without losing support to the nose, consistently good functional and aesthetic results are obtained. Several techniques that we have found to be of value in achieving this goal have been discussed and illustrated and three representative cases have been presented.
Article
The inferior turbinates are responsible for nasal obstruction more often than commonly thought. When there is no other obvious cause or nasal obstruction, and when allergic disorder or other medical condition is not responsible, attention should be given to treatment of the inferior turbinates in many instances of nasal obstruction. Such treatment is usually surgical and may consist of submucous resection of the turbinate bone or excision of redundant hyperplastic turbinate tissue, or a combination of the two. Other treatments consist of electrocautery or cryotherapy. Injection of corticosteroids have produced blindness through embolism and, in general, this treatment is discouraged. The paper discusses in some detail which patients are best suited for submucous resection and which for excision of soft tissue. Techniques, which are simple, are also described.
Article
Nasal obstruction must frequently be addressed during functional rhinoplasty. Even after a properly performed septorhinoplasty correcting septal deflection and/or nasal valve collapse, nasal obstruction may persist due to turbinate hypertrophy. Turbinates have many important functions, including warming and humidification of inspired air, and numerous factors can contribute to pathologic enlargement. Management of inferior turbinate hypertrophy has been actively debated for more than a century. The primary goal of therapy is to maximize the nasal airway for as extended a period as possible while minimizing complications of therapy, such as nasal drying and hemorrhage. This review describes the various medical and surgical therapeutic modalities widely used today, with emphasis placed on surgical management of the inferior turbinates. Advantages, disadvantages, complications, and controversies of each form of treatment are reviewed and discussed. A staged protocol of increasingly invasive interventions is proposed.
Article
In the past 130 years, many surgical procedures for turbinate reduction have been developed. We analyzed the long-term efficacy of 6 of these surgical techniques (turbinectomy, laser cautery, electrocautery, cryotherapy, submucosal resection, and submucosal resection with lateral displacement) over a 6-year follow-up period. We randomly divided 382 patients into 6 therapeutic groups and surgically treated them at the Department of Otorhinolaryngology of the University of Siena. After 6 years, only submucosal resection resulted in optimal long-term normalization of nasal patency and in restoration of mucociliary clearance and local secretory IgA production to a physiological level with few postoperative complications (p < .001). The addition of lateral displacement of the inferior turbinate improved the long-term results. We recommend, in spite of the greater surgical skill required, submucosal resection combined with lateral displacement as the first-choice technique for the treatment of nasal obstruction due to hypertrophy of the inferior turbinates.
Nasal obstruction causing airway resistance is often a result of structural abnormalities. Frequently, turbinate reduction procedures have been used after failure of medical management to address enlarged inferior turbinates, which potentially cause functional narrowing at the nasal valve. Controversy still exists as to the best or most appropriate method for surgical reduction of the inferior turbinate. The multitude of approaches available to the rhinologist is a testament to the lack of a single established method. This paper highlights recently published literature regarding current popular and cutting-edge techniques. There is a trend toward less invasive techniques that can potentially be performed in the clinic setting, rather than in the operating room. In addition, surgical turbinate intervention demonstrates benefit in controlling symptoms of allergic rhinitis other than nasal obstruction. Surgical reduction of the inferior turbinate can be performed using a variety of techniques. When analyzing different methods, emphasis on efficacy, function preservation, and avoidance of complications is paramount.
Article
Septal deviation and inferior turbinate hypertrophy are important contributors to nasal airflow obstruction. In recent years, a closed septoturbinotomy, whereby a speculum is inserted into the nose and the blades are spread, has been shown to centralize the bony septum and outfracture the turbinates in most cases. It is a minimally invasive procedure that frequently corrects bony septal deviation and reduces enlarged inferior turbinates. However, the extent of vault enlargement by that method has not been quantified. The purpose of this study was to demonstrate and quantify the extent to which a closed septoturbinotomy enlarges the maximal diameter of the nasal vault. Measurements and silicone molds of the nasal vault were obtained before and immediately after performing closed septoturbinotomy in nine human cadavers. Measurements were taken with standardized graduated rubber tubing. Molds were obtained with commercially available sealant. All cadaver noses demonstrated enlargement of maximal internal diameter of the obstructed side on both calibrated tubing and silicone mold measurements (p < 0.05). The mean postosteotomy-to-preosteotomy vault diameter ratio was 1.64 (range, 1.25 to 2.3) for the obstructed side and 1.16 (range, 1.0 to 1.4) for the unobstructed side. This 64 percent increase in radius permits a theoretical 7-fold increase in flow by Poiseuille's law. Closed septoturbinotomy is a minimally invasive technique that enlarges the nasal vault in the overwhelming majority of cases. A clinical trial with rhinomanometry is needed to verify the extent of functional improvement.