The Caucasian Nasal Septum: An In Vivo Computed Tomography Study

The Caucasian Nasal Septum: An In Vivo Computed Tomography Study Abstract Background The nasal septum is composed of cartilaginous and bony components and an understanding of each component volume is essential in both functional and cosmetic surgery. Objectives We sought to radiographically measure septal dimensions on cross sectional computer tomography (CT) images, establishing average parameters for normal anatomy among a single, Caucasian population group. Methods One hundred and fifty consecutive sinus CT scan images were examined and 100 cases with appropriate sagittal views were included in the study. On each septum, the sagittal CT images were assessed and 14 points were identified and 23 lengths measured and tabulated. Trigonometric formulae were used to accurately calculate surface areas of 11 resulting triangles which constituted the components of the nasal septum. Results Measurements from 100 patients were included, with a mean age of 50.2 years, constituting 47 males and 53 females. Our surface area mapping established the following areas for both males and females respectively (mm2): quadrangular cartilage 1148 and 981; vomer 894 and 741; perpendicular plate of ethmoid bone 1244 and 1006; and total surface area 3287 and 2728. Our only statistically significant comparison in the series was found in the female series when age and reducing quadrilateral cartilage size were compared, highlighting reducing size with age (P = 0.04). Conclusions The study presents the largest published data series representing nasal septal measurements on CT images in a living Caucasian population. Our data demonstrates that septal size remains constant after adolescence, throughout our age-varied series (18-79 years), except in the female population where the quadrilateral cartilage reduces in size with age. Level of Evidence: 4 The nasal septum is composed of septal cartilage and its bony articulations. These cartilage articulations include the nasal bones, perpendicular plate of the ethmoid (PPE), vomer, and the maxillary crest, creating a mosaic pattern septum.1,2 Anatomical variation and abnormalities are commonly seen in the ear, nose and throat patients presenting with breathing difficulty and as a general rule septoplasty is performed to correct such deformity or obstruction. The septal cartilage and bones are also pivotal in rhinoplastic surgery as the cartilage and bone are often used as a graft for reconstruction and support.3 Preoperative radiological imaging is rarely undertaken in patients undergoing septal and rhinoplastic surgery and knowledge of septal dimensions have previously been based on autopsy studies.4-6 Radiological imaging such as computed tomography (CT) of the paranasal sinuses, including the sagittal images,7 allows more accurate measurements and assessment in the living subjects. The literature is sparse in accurate septal surface area data when comparing anatomical parameters between populations and on this basis we aimed to radiographically measure septal dimensions, along with constituent component surface areas, on cross sectional CT images. The study would allow us to establish average, set measured parameters for normal septal anatomy among a single population group, aiding in surgical planning during septoplasty and rhinoplasty surgery. METHODS Study Design and Setting A retrospective review of CT scans of the paranasal sinuses at Heartlands Hospital in Birmingham (United Kingdom) was undertaken. Data Sources CT scans were viewed using IMPAX software (Agfa HealthCare NV, Mortsel, Belgium). Sagittal reformats were reviewed at 1 mm slices in a bony window. Ethics Adhering to the guiding principles of the Declaration of Helsinki this was an anonymous, retrospective analysis of case notes and investigations and as such no ethical approval was sought or required. Study Participants This study intended to collect data on sinus CT scans of 100 Caucasian nasal septa retrospectively who were operated on from June 27, 2013 to March 31, 2014. Cases were only eligible for inclusion if an adequate view of the bony and cartilaginous nasal septum could be viewed in one image. The following exclusion criteria were then applied: age less than 18 years, non-Caucasian (identified via British National Health Service Trust database-held demographics and ethnicity), previous septal surgery, significant septal deformity, and movement/amalgam artefact, which may preclude accurate measurements Data Collection Scans were assessed for eligibility by the first two authors (C.D. and J.H.). Each data point was agreed on as a consensus between both authors, ensuring interassessor concordance, as such a single value was recorded for each measurement. The incorporated ruler feature in the IMPAX radiology system was used to obtain lengths to one tenth of a millimeter. For each septum, 14 points were identified and 23 resulting lengths measured and tabulated (Figure 1) represents an example 54-year-old male case and the measurement points and lengths highlighted). Trigonometric formulae were used to accurately calculate surface areas of 11 resulting triangles displayed in Figure 1, which constituted the three components of the nasal septum. Figure 1. View largeDownload slide Graphical representation of the data points and subsequent triangles used to measure surface area of nasal septum, on a representative sagittal reformat. The featured representative case is a 54-year-old man. Figure 1. View largeDownload slide Graphical representation of the data points and subsequent triangles used to measure surface area of nasal septum, on a representative sagittal reformat. The featured representative case is a 54-year-old man. Data Synthesis Basic statistical analyses were performed using Microsoft Excel for Mac 2011 Version 14 (Microsoft Corp., WA). Unpaired t tests were used to compare surface areas of constituent nasal septal components with respect to sex. Linear regression analysis was used to relate surface areas to age. These analyses were performed using the GraphPad QuickCalcs website: http://graphpad.com/quickcalcs/ (accessed 7th December 2014; GraphPad Software Inc., CA). RESULTS Demographics The authors reviewed the CT scans of 151 cases. Fifty one of these were excluded as they failed to meet our highlighted criteria. Measurements from 100 patients were included. The mean age of all participants was 50.2 years (SD ± 15.9; range, 18-79). This constituted 47 males with a mean age of 51.5 (SD ± 17.8; range, 18-79) and 53 females with a mean age of 49.0 (SD ± 14.0; range, 19-78) (Tables 1 and 2). Table 1. Comparison of Components of the Nasal Septum by Sex Area Sex Mean (mm2) SD (range) (mm2) t (95% CIs) P-value Quadrangular cartilage Male 1148 183 (771-1617) 168 (99-236) <0.001 Female 981 162 (698-1572) Vomer Male 894 142 (573-1164) 153 (100-207) <0.001 Female 741 127 (390-1045) Perpendicular plate of ethmoid Male 1244 182 (790-1695) 238 (168-308) <0.001 Female 1006 172 (693-1511) Total Male 3287 315 (2414-3972) 559 (440-678) <0.001 Female 2728 284 (2082-3610) Area Sex Mean (mm2) SD (range) (mm2) t (95% CIs) P-value Quadrangular cartilage Male 1148 183 (771-1617) 168 (99-236) <0.001 Female 981 162 (698-1572) Vomer Male 894 142 (573-1164) 153 (100-207) <0.001 Female 741 127 (390-1045) Perpendicular plate of ethmoid Male 1244 182 (790-1695) 238 (168-308) <0.001 Female 1006 172 (693-1511) Total Male 3287 315 (2414-3972) 559 (440-678) <0.001 Female 2728 284 (2082-3610) View Large Table 1. Comparison of Components of the Nasal Septum by Sex Area Sex Mean (mm2) SD (range) (mm2) t (95% CIs) P-value Quadrangular cartilage Male 1148 183 (771-1617) 168 (99-236) <0.001 Female 981 162 (698-1572) Vomer Male 894 142 (573-1164) 153 (100-207) <0.001 Female 741 127 (390-1045) Perpendicular plate of ethmoid Male 1244 182 (790-1695) 238 (168-308) <0.001 Female 1006 172 (693-1511) Total Male 3287 315 (2414-3972) 559 (440-678) <0.001 Female 2728 284 (2082-3610) Area Sex Mean (mm2) SD (range) (mm2) t (95% CIs) P-value Quadrangular cartilage Male 1148 183 (771-1617) 168 (99-236) <0.001 Female 981 162 (698-1572) Vomer Male 894 142 (573-1164) 153 (100-207) <0.001 Female 741 127 (390-1045) Perpendicular plate of ethmoid Male 1244 182 (790-1695) 238 (168-308) <0.001 Female 1006 172 (693-1511) Total Male 3287 315 (2414-3972) 559 (440-678) <0.001 Female 2728 284 (2082-3610) View Large Table 2. Linear Regression Analysis of Surface Area With Respect to Age Area Sex Slope 95% CIs P-value Quadrangular cartilage Male −0.05 −3.14, 3.05 0.976 Female −3.21 −6.33, −0.09 0.044 Vomer Male 0.41 −1.99, 2.80 0.734 Female 0.19 −2.37, 2.75 0.881 Perpendicular plate of ethmoid Male 0.04 −3.05, 3.12 0.980 Female 1.11 −2.33, 4.55 0.519 Total Male 0.40 −4.93, 5.73 0.880 Female −1.91 −7.57, 3.76 0.503 Area Sex Slope 95% CIs P-value Quadrangular cartilage Male −0.05 −3.14, 3.05 0.976 Female −3.21 −6.33, −0.09 0.044 Vomer Male 0.41 −1.99, 2.80 0.734 Female 0.19 −2.37, 2.75 0.881 Perpendicular plate of ethmoid Male 0.04 −3.05, 3.12 0.980 Female 1.11 −2.33, 4.55 0.519 Total Male 0.40 −4.93, 5.73 0.880 Female −1.91 −7.57, 3.76 0.503 View Large Table 2. Linear Regression Analysis of Surface Area With Respect to Age Area Sex Slope 95% CIs P-value Quadrangular cartilage Male −0.05 −3.14, 3.05 0.976 Female −3.21 −6.33, −0.09 0.044 Vomer Male 0.41 −1.99, 2.80 0.734 Female 0.19 −2.37, 2.75 0.881 Perpendicular plate of ethmoid Male 0.04 −3.05, 3.12 0.980 Female 1.11 −2.33, 4.55 0.519 Total Male 0.40 −4.93, 5.73 0.880 Female −1.91 −7.57, 3.76 0.503 Area Sex Slope 95% CIs P-value Quadrangular cartilage Male −0.05 −3.14, 3.05 0.976 Female −3.21 −6.33, −0.09 0.044 Vomer Male 0.41 −1.99, 2.80 0.734 Female 0.19 −2.37, 2.75 0.881 Perpendicular plate of ethmoid Male 0.04 −3.05, 3.12 0.980 Female 1.11 −2.33, 4.55 0.519 Total Male 0.40 −4.93, 5.73 0.880 Female −1.91 −7.57, 3.76 0.503 View Large Septal Areas Data tabulation and analysis revealed our septal surface area broken into constituent components, along with confidence intervals for each sex (Table 1). Comparison with an unpaired t test revealed statistically significant larger surface areas for all septal components in the male data set. This translates to 981 mm2 (1.52 square inches, range 698-1572) of quadrangular cartilage in the female septum vs 1148 mm2 (1.78 square inches, range 771-1617 mm2). We also performed linear regression of septal component surface areas with respect to age for both sexes, identifying reducing quadrangular cartilage surface area with increasing age in the female population (P = 0.044). Whilst a subtly negative trend was found in male data, this was not found to be statistically significant (Table 2). DISCUSSION There is paucity of literature defining dimensions of the nasal septum. Much of the data are anecdotal and relate to surgical techniques as opposed to defining the dimensions of the septal anatomy. Aside from Kim et al’s8 and Kim et al’s9 CT image measured series, a large portion of the literature published takes measurement from cadaveric specimens. In these cadaveric studies, the series numbers have been relatively small, the largest being 57 reported by Miles et al.5 Another two studies published by Prabhu et al6 and de Pouchat et al10 contained only 16 and 14 subjects respectively. Miles et al5 analyzed 57 cadaveric specimens, digitally scanning the septa and analyzing the data using image software. Their results comprised 30 male and 27 female cases with the average age of 77 (32-97yrs). Their series reported an average cartilaginous septum area of 817.2 mm2; this difference compared with our 1059.32 mm2. Miles’s further septal components recorded PPE, and the vomer as 1093 ± 198.4 mm2 and 668.5 ± 131.9 mm2 respectively, vs our larger results; 1244.172 ± 53.5 mm2 and 894.432 ± 41.6 mm2. The disparity in results may be due to the smaller relative sample size and obvious use of cadaveric specimens. Understandably cadaveric sample measurements may be subject to inaccuracies secondary to specimen dehydration after death and damage during harvest and resection, where our series takes measurements in living subjects. De Pouchat’s10 14 case cadaveric series also compares with our study, with an average septal area of 933.11 mm2 (range, 594.44-1431.87 mm2). The septal cartilage was excised and measurements taken from digital photography, however bony septal components were not included. Exclusion of bony septum may have led to inaccurate readings as small cartilage volumes may have been lost during excision and samples may have been subject to postmortem degradation. It is also worth noting the sample size was both small and included a racially different population (South American subjects) which may also explain the skewed data when compared to our results. Perhaps the most comparable data is produced in Kim et al’s11 paper which studied 168 postnasal space (PNS) CT scans, similarly assessing sagittal films. Their subjects were all Korean, comprising 113 men and 55 women, with average age of 32.5 years. Average total septal area and cartilaginous area were 2731.66 mm2 and 752.76 mm2 respectively; this compared with our readings of 2990.49 mm2 and 1059.32 mm2. Larger readings in the Caucasian population may be explained by the obvious race contrast. A further group of Korean researchers used magnetic resonance imaging (MRI) to assess sagittal section in 280 cases (Kim et al),12 with measurements taken, as in our series, using the IMPAX system inbuilt ruler feature. The paper reported the area of nasal septal cartilage relative to the total nasal septum decreased with age reaching a maximum when an individual is in his or her 20s, with significant change thereafter. Unlike our series, they found no significant differences between the sexes though the study included subjects as young as 1 year old. The study established total septal area in adults to be 2323.5 ± 243.3 mm2 and septal cartilage alone 889.4 ± 151.6 mm2, smaller readings than our series perhaps explained by the use of MRI and the difference in the Korean population series. The study was limited in comparable data with ours as bony septal components were not included in the data collection. Kim et al9 compared the nasal septum and its components in Koreans and whites using sagittal reconstructed CT scan data. 27 patients of white origin and 64 patients of Korean origin older than 20 years were enrolled in this study. Their study included an exclusive “white” population albeit with smaller numbers to ours (n = 27, M = 16, F = 11) and allowed closest comparison with our data as the established total septal dimensions surface area of 2828.7 mm2 and 2390.09 mm2 for males and females respectively. These figures, compared with our series, reveal marked differences in results. Although the study’s series was limited and only delineated “white” as a separate category, this did not separate an exclusively “Caucasian” predominately European population, as in our data set, perhaps further explaining the difference (Table 3). Table 3. Comparison of Relevant Septal Constituent Surface Areas in Current Literature Studies Current study (n = 100) Miles et al5 (n = 168) Kim JS et al11 (n = 168) Kim NG et al9 (n = 27) Kim IS et al12 (n = 280) de Pouchat10 (n = 14) Study cases/method In vivo CT Cadaveric In vivo CT In vivo CT In vivo MRI Cadaveric Ethnic population British Caucasian Ethnicity not specified Korean White and Korean Korean South American Area Sex Quadrangular cartilage (mm2) Male 1148 767.62 997.88 844.35 692 933.11** Female 981 713.72 861.30 790.14 * Vomer (mm2) Male 894 964.32 701.66 705.25 * * Female 741 822.08 582.95 631.90 * * PPE (mm2) Male 1244 1083.92 1129.2 1199.0 * * Female 1006 974.56 945.8 988.1 * * Total (mm2) Male 3287 2815.87 2828.7 2748.6 2127** * Female 2728 2510.36 2390.09 2410.1 Studies Current study (n = 100) Miles et al5 (n = 168) Kim JS et al11 (n = 168) Kim NG et al9 (n = 27) Kim IS et al12 (n = 280) de Pouchat10 (n = 14) Study cases/method In vivo CT Cadaveric In vivo CT In vivo CT In vivo MRI Cadaveric Ethnic population British Caucasian Ethnicity not specified Korean White and Korean Korean South American Area Sex Quadrangular cartilage (mm2) Male 1148 767.62 997.88 844.35 692 933.11** Female 981 713.72 861.30 790.14 * Vomer (mm2) Male 894 964.32 701.66 705.25 * * Female 741 822.08 582.95 631.90 * * PPE (mm2) Male 1244 1083.92 1129.2 1199.0 * * Female 1006 974.56 945.8 988.1 * * Total (mm2) Male 3287 2815.87 2828.7 2748.6 2127** * Female 2728 2510.36 2390.09 2410.1 CT, computer tomography; MRI, magnetic resonance imaging; PPE, perpendicular plate of the ethmoid. * Data not available. **The study does not provide separate values for different sexes. View Large Table 3. Comparison of Relevant Septal Constituent Surface Areas in Current Literature Studies Current study (n = 100) Miles et al5 (n = 168) Kim JS et al11 (n = 168) Kim NG et al9 (n = 27) Kim IS et al12 (n = 280) de Pouchat10 (n = 14) Study cases/method In vivo CT Cadaveric In vivo CT In vivo CT In vivo MRI Cadaveric Ethnic population British Caucasian Ethnicity not specified Korean White and Korean Korean South American Area Sex Quadrangular cartilage (mm2) Male 1148 767.62 997.88 844.35 692 933.11** Female 981 713.72 861.30 790.14 * Vomer (mm2) Male 894 964.32 701.66 705.25 * * Female 741 822.08 582.95 631.90 * * PPE (mm2) Male 1244 1083.92 1129.2 1199.0 * * Female 1006 974.56 945.8 988.1 * * Total (mm2) Male 3287 2815.87 2828.7 2748.6 2127** * Female 2728 2510.36 2390.09 2410.1 Studies Current study (n = 100) Miles et al5 (n = 168) Kim JS et al11 (n = 168) Kim NG et al9 (n = 27) Kim IS et al12 (n = 280) de Pouchat10 (n = 14) Study cases/method In vivo CT Cadaveric In vivo CT In vivo CT In vivo MRI Cadaveric Ethnic population British Caucasian Ethnicity not specified Korean White and Korean Korean South American Area Sex Quadrangular cartilage (mm2) Male 1148 767.62 997.88 844.35 692 933.11** Female 981 713.72 861.30 790.14 * Vomer (mm2) Male 894 964.32 701.66 705.25 * * Female 741 822.08 582.95 631.90 * * PPE (mm2) Male 1244 1083.92 1129.2 1199.0 * * Female 1006 974.56 945.8 988.1 * * Total (mm2) Male 3287 2815.87 2828.7 2748.6 2127** * Female 2728 2510.36 2390.09 2410.1 CT, computer tomography; MRI, magnetic resonance imaging; PPE, perpendicular plate of the ethmoid. * Data not available. **The study does not provide separate values for different sexes. View Large We sought to compare our study results with the current, relevant studies with accurate septal component constituent surface area measurement (Table 3). Comparing our data with the current literature shows our series produced the largest surface areas for each septal constituent. This is perhaps explained partly by the racial differences between our Caucasian population and the East Asian population groups in other studies, and it is partly explained by the differences in measurement on CT images on live cases in our studies and the cadaveric specimen measurements in other studies. In establishing a correlation between age and septal size, we also performed linear regression analysis (Figures 2 and 3), comparing both sexes, modelling age against all constituent septal components (quadrilateral cartilage, vomer, perpendicular plate of ethmoid, and total septal surface area). Our Caucasian series suggested a negative correlation between age and quadrangular cartilage surface area. Kim et al’s series also revealed area of the cartilaginous septum decreased with age (P < 0.05) though they did report the surface area of total nasal septum remained constant, confirmed in our data set as bony septal component size also remained static. Figure 2. View largeDownload slide Linear regression analysis of surface area with respect to age in Caucasian females. Figure 2. View largeDownload slide Linear regression analysis of surface area with respect to age in Caucasian females. Figure 3. View largeDownload slide Linear regression analysis of surface area with respect to age in Caucasian males. Figure 3. View largeDownload slide Linear regression analysis of surface area with respect to age in Caucasian males. Interestingly our only statistically significant comparison in the series was found in the female series when age and reducing quadrilateral cartilage size were correlated (Figure 2) this was however not seen when male data were assessed whether alone or in combination with the female data (Figure 3). Study Limitations Our study is not without its limitations. We used straight lines between defined points to create triangles whereas the border between different parts of septum is not a straight line and this might have caused minor inaccuracies in measurement of the surface area for each septal segment. The septal cartilage sits 1 to 2 mm within the groove of the maxillary crest and it is possible that the small sliver of the cartilage may have not been measured as the cartilage was covered by the maxillary crest. Finally the caudal antero-posterior border of the septum on our measurement was based on a line drawn from the anterior nasal spine to the anterior septal angle which may have missed some septal cartilaginous area around the middle septal angle. We will modify our measurement technique in future studies to take these elements into account. Though the limitations above exist, our confidence intervals included in the data set, make allowance for such variations and give a close and “usable” representation of the available septal cartilage measurements in the adult Caucasian population. Developing the study in future, we would hope to compare potential race-dependent anatomical variation, whilst increasing case numbers, allowing more accurate population assessment. Adding further data points for measurement during data collection would improve accuracy and ultimately give a refined septal surface area. Further work may include a separate study of the pediatric population and whilst CT imaging in such a population is very limited, measurements may be established through MRI allowing mapping of septal growth through childhood and a clearer indication as to when septal anatomy reaches its full adult dimensions. CONCLUSIONS Our study presents the largest published data series on surface area of the septal components in a living Caucasian population, assessed using computed tomography imaging. Our data demonstrate that septal size remains constant after adolescence. Our only statistically significant comparison in the series was found in the females when age and quadrilateral cartilage size were compared, indicating a reduction in this component surface area with increasing age, contrary to current reported understanding that the total cartilage volume decreases with age, we found consistent cartilage size with age increase although bony septal size remained constant. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Mladina R . The role of maxillar morphology in the development of pathological septal deformities . Rhinology . 1987 ; 25 ( 3 ): 199 - 205 . Google Scholar PubMed 2. Russell WH , Paul EK , Allison RM . The nasal septum . In: Cummings CW , Fredrickson JM , Jarker LA , Krause CJ , Schuller DE , eds. Otolaryngology-head and neck surgery . 4th ed . St. Louis, MO : Mosby Inc ; 2005 . 3. Parrilla C , Artuso A , Gallus R , Galli J , Paludetti G . The role of septal surgery in cosmetic rhinoplasty . Acta Otorhinolaryngol Ital . 2013 ; 33 ( 3 ): 146 - 153 . Google Scholar PubMed 4. Godley FA . Nasal septal anatomy and its importance in septal reconstruction . Ear Nose Throat J . 1997 ; 76 ( 8 ): 498 - 501 , 504-506. Google Scholar PubMed 5. Miles BA , Petrisor D , Kao H , Finn RA , Throckmorton GS . Anatomical variation of the nasal septum: analysis of 57 cadaver specimens . Otolaryngol Head Neck Surg . 2007 ; 136 ( 3 ): 362 - 368 . Google Scholar CrossRef Search ADS PubMed 6. Prabhu LV , Ranade AV , Rai R , et al. The nasal septum: an osteometric study of 16 cadaver specimens . Ear Nose Throat J . 2009 ; 88 ( 8 ): 1052 - 1056 . Google Scholar PubMed 7. Adeel M , Rajput MS , Akhter S , Ikram M , Arain A , Khattak YJ . Anatomical variations of nose and para-nasal sinuses; CT scan review . J Pak Med Assoc . 2013 ; 63 ( 3 ): 317 - 319 . Google Scholar PubMed 8. Kim J , Cho JH , Kim SW , Kim BG , Lee DC , Kim SW . Anatomical variation of the nasal septum: correlation among septal components . Clin Anat . 2010 ; 23 ( 8 ): 945 - 949 . Google Scholar CrossRef Search ADS PubMed 9. Kim NG , Park SW , Park HO , Choi TH , Kim J , Choi J . Are differences in external noses between whites and Koreans caused by differences in the nasal septum ? J Craniofac Surg . 2015 ; 26 ( 3 ): 922 - 926 . Google Scholar CrossRef Search ADS PubMed 10. de Pochat VD , Alonso N , Figueredo A , Ribeiro EB , Mendes RR , Meneses JV . The role of septal cartilage in rhinoplasty: cadaveric analysis and assessment of graft selection . Aesthet Surg J . 2011 ; 31 ( 8 ): 891 - 896 . Google Scholar CrossRef Search ADS PubMed 11. Kim JS , Khan NA , Song HM , Jang YJ . Intraoperative measurements of harvestable septal cartilage in rhinoplasty . Ann Plast Surg . 2010 ; 65 ( 6 ): 519 - 523 . Google Scholar CrossRef Search ADS PubMed 12. Kim IS , Lee MY , Lee KI , Kim HY , Chung YJ . Analysis of the development of the nasal septum according to age and gender using MRI . Clin Exp Otorhinolaryngol . 2008 ; 1 ( 1 ): 29 - 34 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. 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The Caucasian Nasal Septum: An In Vivo Computed Tomography Study

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Abstract

Abstract Background The nasal septum is composed of cartilaginous and bony components and an understanding of each component volume is essential in both functional and cosmetic surgery. Objectives We sought to radiographically measure septal dimensions on cross sectional computer tomography (CT) images, establishing average parameters for normal anatomy among a single, Caucasian population group. Methods One hundred and fifty consecutive sinus CT scan images were examined and 100 cases with appropriate sagittal views were included in the study. On each septum, the sagittal CT images were assessed and 14 points were identified and 23 lengths measured and tabulated. Trigonometric formulae were used to accurately calculate surface areas of 11 resulting triangles which constituted the components of the nasal septum. Results Measurements from 100 patients were included, with a mean age of 50.2 years, constituting 47 males and 53 females. Our surface area mapping established the following areas for both males and females respectively (mm2): quadrangular cartilage 1148 and 981; vomer 894 and 741; perpendicular plate of ethmoid bone 1244 and 1006; and total surface area 3287 and 2728. Our only statistically significant comparison in the series was found in the female series when age and reducing quadrilateral cartilage size were compared, highlighting reducing size with age (P = 0.04). Conclusions The study presents the largest published data series representing nasal septal measurements on CT images in a living Caucasian population. Our data demonstrates that septal size remains constant after adolescence, throughout our age-varied series (18-79 years), except in the female population where the quadrilateral cartilage reduces in size with age. Level of Evidence: 4 The nasal septum is composed of septal cartilage and its bony articulations. These cartilage articulations include the nasal bones, perpendicular plate of the ethmoid (PPE), vomer, and the maxillary crest, creating a mosaic pattern septum.1,2 Anatomical variation and abnormalities are commonly seen in the ear, nose and throat patients presenting with breathing difficulty and as a general rule septoplasty is performed to correct such deformity or obstruction. The septal cartilage and bones are also pivotal in rhinoplastic surgery as the cartilage and bone are often used as a graft for reconstruction and support.3 Preoperative radiological imaging is rarely undertaken in patients undergoing septal and rhinoplastic surgery and knowledge of septal dimensions have previously been based on autopsy studies.4-6 Radiological imaging such as computed tomography (CT) of the paranasal sinuses, including the sagittal images,7 allows more accurate measurements and assessment in the living subjects. The literature is sparse in accurate septal surface area data when comparing anatomical parameters between populations and on this basis we aimed to radiographically measure septal dimensions, along with constituent component surface areas, on cross sectional CT images. The study would allow us to establish average, set measured parameters for normal septal anatomy among a single population group, aiding in surgical planning during septoplasty and rhinoplasty surgery. METHODS Study Design and Setting A retrospective review of CT scans of the paranasal sinuses at Heartlands Hospital in Birmingham (United Kingdom) was undertaken. Data Sources CT scans were viewed using IMPAX software (Agfa HealthCare NV, Mortsel, Belgium). Sagittal reformats were reviewed at 1 mm slices in a bony window. Ethics Adhering to the guiding principles of the Declaration of Helsinki this was an anonymous, retrospective analysis of case notes and investigations and as such no ethical approval was sought or required. Study Participants This study intended to collect data on sinus CT scans of 100 Caucasian nasal septa retrospectively who were operated on from June 27, 2013 to March 31, 2014. Cases were only eligible for inclusion if an adequate view of the bony and cartilaginous nasal septum could be viewed in one image. The following exclusion criteria were then applied: age less than 18 years, non-Caucasian (identified via British National Health Service Trust database-held demographics and ethnicity), previous septal surgery, significant septal deformity, and movement/amalgam artefact, which may preclude accurate measurements Data Collection Scans were assessed for eligibility by the first two authors (C.D. and J.H.). Each data point was agreed on as a consensus between both authors, ensuring interassessor concordance, as such a single value was recorded for each measurement. The incorporated ruler feature in the IMPAX radiology system was used to obtain lengths to one tenth of a millimeter. For each septum, 14 points were identified and 23 resulting lengths measured and tabulated (Figure 1) represents an example 54-year-old male case and the measurement points and lengths highlighted). Trigonometric formulae were used to accurately calculate surface areas of 11 resulting triangles displayed in Figure 1, which constituted the three components of the nasal septum. Figure 1. View largeDownload slide Graphical representation of the data points and subsequent triangles used to measure surface area of nasal septum, on a representative sagittal reformat. The featured representative case is a 54-year-old man. Figure 1. View largeDownload slide Graphical representation of the data points and subsequent triangles used to measure surface area of nasal septum, on a representative sagittal reformat. The featured representative case is a 54-year-old man. Data Synthesis Basic statistical analyses were performed using Microsoft Excel for Mac 2011 Version 14 (Microsoft Corp., WA). Unpaired t tests were used to compare surface areas of constituent nasal septal components with respect to sex. Linear regression analysis was used to relate surface areas to age. These analyses were performed using the GraphPad QuickCalcs website: http://graphpad.com/quickcalcs/ (accessed 7th December 2014; GraphPad Software Inc., CA). RESULTS Demographics The authors reviewed the CT scans of 151 cases. Fifty one of these were excluded as they failed to meet our highlighted criteria. Measurements from 100 patients were included. The mean age of all participants was 50.2 years (SD ± 15.9; range, 18-79). This constituted 47 males with a mean age of 51.5 (SD ± 17.8; range, 18-79) and 53 females with a mean age of 49.0 (SD ± 14.0; range, 19-78) (Tables 1 and 2). Table 1. Comparison of Components of the Nasal Septum by Sex Area Sex Mean (mm2) SD (range) (mm2) t (95% CIs) P-value Quadrangular cartilage Male 1148 183 (771-1617) 168 (99-236) <0.001 Female 981 162 (698-1572) Vomer Male 894 142 (573-1164) 153 (100-207) <0.001 Female 741 127 (390-1045) Perpendicular plate of ethmoid Male 1244 182 (790-1695) 238 (168-308) <0.001 Female 1006 172 (693-1511) Total Male 3287 315 (2414-3972) 559 (440-678) <0.001 Female 2728 284 (2082-3610) Area Sex Mean (mm2) SD (range) (mm2) t (95% CIs) P-value Quadrangular cartilage Male 1148 183 (771-1617) 168 (99-236) <0.001 Female 981 162 (698-1572) Vomer Male 894 142 (573-1164) 153 (100-207) <0.001 Female 741 127 (390-1045) Perpendicular plate of ethmoid Male 1244 182 (790-1695) 238 (168-308) <0.001 Female 1006 172 (693-1511) Total Male 3287 315 (2414-3972) 559 (440-678) <0.001 Female 2728 284 (2082-3610) View Large Table 1. Comparison of Components of the Nasal Septum by Sex Area Sex Mean (mm2) SD (range) (mm2) t (95% CIs) P-value Quadrangular cartilage Male 1148 183 (771-1617) 168 (99-236) <0.001 Female 981 162 (698-1572) Vomer Male 894 142 (573-1164) 153 (100-207) <0.001 Female 741 127 (390-1045) Perpendicular plate of ethmoid Male 1244 182 (790-1695) 238 (168-308) <0.001 Female 1006 172 (693-1511) Total Male 3287 315 (2414-3972) 559 (440-678) <0.001 Female 2728 284 (2082-3610) Area Sex Mean (mm2) SD (range) (mm2) t (95% CIs) P-value Quadrangular cartilage Male 1148 183 (771-1617) 168 (99-236) <0.001 Female 981 162 (698-1572) Vomer Male 894 142 (573-1164) 153 (100-207) <0.001 Female 741 127 (390-1045) Perpendicular plate of ethmoid Male 1244 182 (790-1695) 238 (168-308) <0.001 Female 1006 172 (693-1511) Total Male 3287 315 (2414-3972) 559 (440-678) <0.001 Female 2728 284 (2082-3610) View Large Table 2. Linear Regression Analysis of Surface Area With Respect to Age Area Sex Slope 95% CIs P-value Quadrangular cartilage Male −0.05 −3.14, 3.05 0.976 Female −3.21 −6.33, −0.09 0.044 Vomer Male 0.41 −1.99, 2.80 0.734 Female 0.19 −2.37, 2.75 0.881 Perpendicular plate of ethmoid Male 0.04 −3.05, 3.12 0.980 Female 1.11 −2.33, 4.55 0.519 Total Male 0.40 −4.93, 5.73 0.880 Female −1.91 −7.57, 3.76 0.503 Area Sex Slope 95% CIs P-value Quadrangular cartilage Male −0.05 −3.14, 3.05 0.976 Female −3.21 −6.33, −0.09 0.044 Vomer Male 0.41 −1.99, 2.80 0.734 Female 0.19 −2.37, 2.75 0.881 Perpendicular plate of ethmoid Male 0.04 −3.05, 3.12 0.980 Female 1.11 −2.33, 4.55 0.519 Total Male 0.40 −4.93, 5.73 0.880 Female −1.91 −7.57, 3.76 0.503 View Large Table 2. Linear Regression Analysis of Surface Area With Respect to Age Area Sex Slope 95% CIs P-value Quadrangular cartilage Male −0.05 −3.14, 3.05 0.976 Female −3.21 −6.33, −0.09 0.044 Vomer Male 0.41 −1.99, 2.80 0.734 Female 0.19 −2.37, 2.75 0.881 Perpendicular plate of ethmoid Male 0.04 −3.05, 3.12 0.980 Female 1.11 −2.33, 4.55 0.519 Total Male 0.40 −4.93, 5.73 0.880 Female −1.91 −7.57, 3.76 0.503 Area Sex Slope 95% CIs P-value Quadrangular cartilage Male −0.05 −3.14, 3.05 0.976 Female −3.21 −6.33, −0.09 0.044 Vomer Male 0.41 −1.99, 2.80 0.734 Female 0.19 −2.37, 2.75 0.881 Perpendicular plate of ethmoid Male 0.04 −3.05, 3.12 0.980 Female 1.11 −2.33, 4.55 0.519 Total Male 0.40 −4.93, 5.73 0.880 Female −1.91 −7.57, 3.76 0.503 View Large Septal Areas Data tabulation and analysis revealed our septal surface area broken into constituent components, along with confidence intervals for each sex (Table 1). Comparison with an unpaired t test revealed statistically significant larger surface areas for all septal components in the male data set. This translates to 981 mm2 (1.52 square inches, range 698-1572) of quadrangular cartilage in the female septum vs 1148 mm2 (1.78 square inches, range 771-1617 mm2). We also performed linear regression of septal component surface areas with respect to age for both sexes, identifying reducing quadrangular cartilage surface area with increasing age in the female population (P = 0.044). Whilst a subtly negative trend was found in male data, this was not found to be statistically significant (Table 2). DISCUSSION There is paucity of literature defining dimensions of the nasal septum. Much of the data are anecdotal and relate to surgical techniques as opposed to defining the dimensions of the septal anatomy. Aside from Kim et al’s8 and Kim et al’s9 CT image measured series, a large portion of the literature published takes measurement from cadaveric specimens. In these cadaveric studies, the series numbers have been relatively small, the largest being 57 reported by Miles et al.5 Another two studies published by Prabhu et al6 and de Pouchat et al10 contained only 16 and 14 subjects respectively. Miles et al5 analyzed 57 cadaveric specimens, digitally scanning the septa and analyzing the data using image software. Their results comprised 30 male and 27 female cases with the average age of 77 (32-97yrs). Their series reported an average cartilaginous septum area of 817.2 mm2; this difference compared with our 1059.32 mm2. Miles’s further septal components recorded PPE, and the vomer as 1093 ± 198.4 mm2 and 668.5 ± 131.9 mm2 respectively, vs our larger results; 1244.172 ± 53.5 mm2 and 894.432 ± 41.6 mm2. The disparity in results may be due to the smaller relative sample size and obvious use of cadaveric specimens. Understandably cadaveric sample measurements may be subject to inaccuracies secondary to specimen dehydration after death and damage during harvest and resection, where our series takes measurements in living subjects. De Pouchat’s10 14 case cadaveric series also compares with our study, with an average septal area of 933.11 mm2 (range, 594.44-1431.87 mm2). The septal cartilage was excised and measurements taken from digital photography, however bony septal components were not included. Exclusion of bony septum may have led to inaccurate readings as small cartilage volumes may have been lost during excision and samples may have been subject to postmortem degradation. It is also worth noting the sample size was both small and included a racially different population (South American subjects) which may also explain the skewed data when compared to our results. Perhaps the most comparable data is produced in Kim et al’s11 paper which studied 168 postnasal space (PNS) CT scans, similarly assessing sagittal films. Their subjects were all Korean, comprising 113 men and 55 women, with average age of 32.5 years. Average total septal area and cartilaginous area were 2731.66 mm2 and 752.76 mm2 respectively; this compared with our readings of 2990.49 mm2 and 1059.32 mm2. Larger readings in the Caucasian population may be explained by the obvious race contrast. A further group of Korean researchers used magnetic resonance imaging (MRI) to assess sagittal section in 280 cases (Kim et al),12 with measurements taken, as in our series, using the IMPAX system inbuilt ruler feature. The paper reported the area of nasal septal cartilage relative to the total nasal septum decreased with age reaching a maximum when an individual is in his or her 20s, with significant change thereafter. Unlike our series, they found no significant differences between the sexes though the study included subjects as young as 1 year old. The study established total septal area in adults to be 2323.5 ± 243.3 mm2 and septal cartilage alone 889.4 ± 151.6 mm2, smaller readings than our series perhaps explained by the use of MRI and the difference in the Korean population series. The study was limited in comparable data with ours as bony septal components were not included in the data collection. Kim et al9 compared the nasal septum and its components in Koreans and whites using sagittal reconstructed CT scan data. 27 patients of white origin and 64 patients of Korean origin older than 20 years were enrolled in this study. Their study included an exclusive “white” population albeit with smaller numbers to ours (n = 27, M = 16, F = 11) and allowed closest comparison with our data as the established total septal dimensions surface area of 2828.7 mm2 and 2390.09 mm2 for males and females respectively. These figures, compared with our series, reveal marked differences in results. Although the study’s series was limited and only delineated “white” as a separate category, this did not separate an exclusively “Caucasian” predominately European population, as in our data set, perhaps further explaining the difference (Table 3). Table 3. Comparison of Relevant Septal Constituent Surface Areas in Current Literature Studies Current study (n = 100) Miles et al5 (n = 168) Kim JS et al11 (n = 168) Kim NG et al9 (n = 27) Kim IS et al12 (n = 280) de Pouchat10 (n = 14) Study cases/method In vivo CT Cadaveric In vivo CT In vivo CT In vivo MRI Cadaveric Ethnic population British Caucasian Ethnicity not specified Korean White and Korean Korean South American Area Sex Quadrangular cartilage (mm2) Male 1148 767.62 997.88 844.35 692 933.11** Female 981 713.72 861.30 790.14 * Vomer (mm2) Male 894 964.32 701.66 705.25 * * Female 741 822.08 582.95 631.90 * * PPE (mm2) Male 1244 1083.92 1129.2 1199.0 * * Female 1006 974.56 945.8 988.1 * * Total (mm2) Male 3287 2815.87 2828.7 2748.6 2127** * Female 2728 2510.36 2390.09 2410.1 Studies Current study (n = 100) Miles et al5 (n = 168) Kim JS et al11 (n = 168) Kim NG et al9 (n = 27) Kim IS et al12 (n = 280) de Pouchat10 (n = 14) Study cases/method In vivo CT Cadaveric In vivo CT In vivo CT In vivo MRI Cadaveric Ethnic population British Caucasian Ethnicity not specified Korean White and Korean Korean South American Area Sex Quadrangular cartilage (mm2) Male 1148 767.62 997.88 844.35 692 933.11** Female 981 713.72 861.30 790.14 * Vomer (mm2) Male 894 964.32 701.66 705.25 * * Female 741 822.08 582.95 631.90 * * PPE (mm2) Male 1244 1083.92 1129.2 1199.0 * * Female 1006 974.56 945.8 988.1 * * Total (mm2) Male 3287 2815.87 2828.7 2748.6 2127** * Female 2728 2510.36 2390.09 2410.1 CT, computer tomography; MRI, magnetic resonance imaging; PPE, perpendicular plate of the ethmoid. * Data not available. **The study does not provide separate values for different sexes. View Large Table 3. Comparison of Relevant Septal Constituent Surface Areas in Current Literature Studies Current study (n = 100) Miles et al5 (n = 168) Kim JS et al11 (n = 168) Kim NG et al9 (n = 27) Kim IS et al12 (n = 280) de Pouchat10 (n = 14) Study cases/method In vivo CT Cadaveric In vivo CT In vivo CT In vivo MRI Cadaveric Ethnic population British Caucasian Ethnicity not specified Korean White and Korean Korean South American Area Sex Quadrangular cartilage (mm2) Male 1148 767.62 997.88 844.35 692 933.11** Female 981 713.72 861.30 790.14 * Vomer (mm2) Male 894 964.32 701.66 705.25 * * Female 741 822.08 582.95 631.90 * * PPE (mm2) Male 1244 1083.92 1129.2 1199.0 * * Female 1006 974.56 945.8 988.1 * * Total (mm2) Male 3287 2815.87 2828.7 2748.6 2127** * Female 2728 2510.36 2390.09 2410.1 Studies Current study (n = 100) Miles et al5 (n = 168) Kim JS et al11 (n = 168) Kim NG et al9 (n = 27) Kim IS et al12 (n = 280) de Pouchat10 (n = 14) Study cases/method In vivo CT Cadaveric In vivo CT In vivo CT In vivo MRI Cadaveric Ethnic population British Caucasian Ethnicity not specified Korean White and Korean Korean South American Area Sex Quadrangular cartilage (mm2) Male 1148 767.62 997.88 844.35 692 933.11** Female 981 713.72 861.30 790.14 * Vomer (mm2) Male 894 964.32 701.66 705.25 * * Female 741 822.08 582.95 631.90 * * PPE (mm2) Male 1244 1083.92 1129.2 1199.0 * * Female 1006 974.56 945.8 988.1 * * Total (mm2) Male 3287 2815.87 2828.7 2748.6 2127** * Female 2728 2510.36 2390.09 2410.1 CT, computer tomography; MRI, magnetic resonance imaging; PPE, perpendicular plate of the ethmoid. * Data not available. **The study does not provide separate values for different sexes. View Large We sought to compare our study results with the current, relevant studies with accurate septal component constituent surface area measurement (Table 3). Comparing our data with the current literature shows our series produced the largest surface areas for each septal constituent. This is perhaps explained partly by the racial differences between our Caucasian population and the East Asian population groups in other studies, and it is partly explained by the differences in measurement on CT images on live cases in our studies and the cadaveric specimen measurements in other studies. In establishing a correlation between age and septal size, we also performed linear regression analysis (Figures 2 and 3), comparing both sexes, modelling age against all constituent septal components (quadrilateral cartilage, vomer, perpendicular plate of ethmoid, and total septal surface area). Our Caucasian series suggested a negative correlation between age and quadrangular cartilage surface area. Kim et al’s series also revealed area of the cartilaginous septum decreased with age (P < 0.05) though they did report the surface area of total nasal septum remained constant, confirmed in our data set as bony septal component size also remained static. Figure 2. View largeDownload slide Linear regression analysis of surface area with respect to age in Caucasian females. Figure 2. View largeDownload slide Linear regression analysis of surface area with respect to age in Caucasian females. Figure 3. View largeDownload slide Linear regression analysis of surface area with respect to age in Caucasian males. Figure 3. View largeDownload slide Linear regression analysis of surface area with respect to age in Caucasian males. Interestingly our only statistically significant comparison in the series was found in the female series when age and reducing quadrilateral cartilage size were correlated (Figure 2) this was however not seen when male data were assessed whether alone or in combination with the female data (Figure 3). Study Limitations Our study is not without its limitations. We used straight lines between defined points to create triangles whereas the border between different parts of septum is not a straight line and this might have caused minor inaccuracies in measurement of the surface area for each septal segment. The septal cartilage sits 1 to 2 mm within the groove of the maxillary crest and it is possible that the small sliver of the cartilage may have not been measured as the cartilage was covered by the maxillary crest. Finally the caudal antero-posterior border of the septum on our measurement was based on a line drawn from the anterior nasal spine to the anterior septal angle which may have missed some septal cartilaginous area around the middle septal angle. We will modify our measurement technique in future studies to take these elements into account. Though the limitations above exist, our confidence intervals included in the data set, make allowance for such variations and give a close and “usable” representation of the available septal cartilage measurements in the adult Caucasian population. Developing the study in future, we would hope to compare potential race-dependent anatomical variation, whilst increasing case numbers, allowing more accurate population assessment. Adding further data points for measurement during data collection would improve accuracy and ultimately give a refined septal surface area. Further work may include a separate study of the pediatric population and whilst CT imaging in such a population is very limited, measurements may be established through MRI allowing mapping of septal growth through childhood and a clearer indication as to when septal anatomy reaches its full adult dimensions. CONCLUSIONS Our study presents the largest published data series on surface area of the septal components in a living Caucasian population, assessed using computed tomography imaging. Our data demonstrate that septal size remains constant after adolescence. Our only statistically significant comparison in the series was found in the females when age and quadrilateral cartilage size were compared, indicating a reduction in this component surface area with increasing age, contrary to current reported understanding that the total cartilage volume decreases with age, we found consistent cartilage size with age increase although bony septal size remained constant. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Mladina R . The role of maxillar morphology in the development of pathological septal deformities . Rhinology . 1987 ; 25 ( 3 ): 199 - 205 . Google Scholar PubMed 2. Russell WH , Paul EK , Allison RM . The nasal septum . In: Cummings CW , Fredrickson JM , Jarker LA , Krause CJ , Schuller DE , eds. Otolaryngology-head and neck surgery . 4th ed . St. Louis, MO : Mosby Inc ; 2005 . 3. Parrilla C , Artuso A , Gallus R , Galli J , Paludetti G . The role of septal surgery in cosmetic rhinoplasty . Acta Otorhinolaryngol Ital . 2013 ; 33 ( 3 ): 146 - 153 . Google Scholar PubMed 4. Godley FA . Nasal septal anatomy and its importance in septal reconstruction . Ear Nose Throat J . 1997 ; 76 ( 8 ): 498 - 501 , 504-506. Google Scholar PubMed 5. Miles BA , Petrisor D , Kao H , Finn RA , Throckmorton GS . Anatomical variation of the nasal septum: analysis of 57 cadaver specimens . Otolaryngol Head Neck Surg . 2007 ; 136 ( 3 ): 362 - 368 . Google Scholar CrossRef Search ADS PubMed 6. Prabhu LV , Ranade AV , Rai R , et al. The nasal septum: an osteometric study of 16 cadaver specimens . Ear Nose Throat J . 2009 ; 88 ( 8 ): 1052 - 1056 . Google Scholar PubMed 7. Adeel M , Rajput MS , Akhter S , Ikram M , Arain A , Khattak YJ . Anatomical variations of nose and para-nasal sinuses; CT scan review . J Pak Med Assoc . 2013 ; 63 ( 3 ): 317 - 319 . Google Scholar PubMed 8. Kim J , Cho JH , Kim SW , Kim BG , Lee DC , Kim SW . Anatomical variation of the nasal septum: correlation among septal components . Clin Anat . 2010 ; 23 ( 8 ): 945 - 949 . Google Scholar CrossRef Search ADS PubMed 9. Kim NG , Park SW , Park HO , Choi TH , Kim J , Choi J . Are differences in external noses between whites and Koreans caused by differences in the nasal septum ? J Craniofac Surg . 2015 ; 26 ( 3 ): 922 - 926 . Google Scholar CrossRef Search ADS PubMed 10. de Pochat VD , Alonso N , Figueredo A , Ribeiro EB , Mendes RR , Meneses JV . The role of septal cartilage in rhinoplasty: cadaveric analysis and assessment of graft selection . Aesthet Surg J . 2011 ; 31 ( 8 ): 891 - 896 . Google Scholar CrossRef Search ADS PubMed 11. Kim JS , Khan NA , Song HM , Jang YJ . Intraoperative measurements of harvestable septal cartilage in rhinoplasty . Ann Plast Surg . 2010 ; 65 ( 6 ): 519 - 523 . Google Scholar CrossRef Search ADS PubMed 12. Kim IS , Lee MY , Lee KI , Kim HY , Chung YJ . Analysis of the development of the nasal septum according to age and gender using MRI . Clin Exp Otorhinolaryngol . 2008 ; 1 ( 1 ): 29 - 34 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: Feb 19, 2018

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