Growth of the Deviated Septum
and Its Influence on Midfacial
Development
Wolfgang Pirsig, M . D.
The influence of the healthy or deviated human
nasal septum on the growth of the nasomaxillary
complex is controversial and has been discussed for
more than 100 years. Knowledge of the effects of
surgical interventions on the growing septum is of
practical value to find out the proper time for rhino-
surgery without adding more damage to the cranio-
facial skeleton. Even from more recent reviews,2,3no
definitive information can be gained concerning the
role of the septal cartilage as a primary growth center
of major importance for midface development.
In order to draw any meaningful conclusion re-
garding midfacial growth, prospective well-controlled
studies are required. These studies have to include
otorhinolaryngologic and orthodontic data, obtained
by endoscopy, longitudinal series of lateral cephalo-
metric radiographs, dental casts, photographs un-
der standard conditions, and documents about fam-
ily members. These data have only just become
available for any group of these patients.
Furthermore, there are principal limitations to
drawing conclusions from the patients' data, which
is explained by the following observation: When we
examine, for instance, 17-year-old adolescents who
underwent septoplasty at the age of 8, we investigate
a nasomaxillary complex that has been influenced by
a series of intrinsic and extrinsic factors, the modes
of action of which are poorly understood. Thus, we
are investigating not only the long-term effect of
surgery, but also the late effects of the early trauma
and infection, racial and hereditary influences, hor-
HNO-Klinik, University of Ulm, Ulm, Germany
Reprint Requests: Prof. Dr. W. Pirsig, HNO-Klinik, University of Ulm, Prittwitzstrasse 43,
D-7900 Ulm, Germany
Copyright 01992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved
Downloaded by: National University of Singapore. Copyrighted material.
monal and nutritive conditions, to name only a few.
It is impossible to separate the effects of these var-
ious factors when analyzing the nasal structures at
follow-up. Since we usually do not know the exact
history of midfacial trauma, especially whether the
injury damaged only the nose, or only the maxilla,
or both, we cannot evaluate the interrelationship of
nasal and maxillary growth in most of our patients
with an injured nasomaxillary complex.
Therefore we have to refer to animal experiments
concerning this problem, although the results are
often contradictory. This short review discusses
some open questions and clinical findings in the
Caucasian race and the corresponding results from
animal studies concerning midfacial development.
For a better understanding of the interrelationship of
nasal and maxillary growth, some basic data about
the septolateral cartilage will be summed up.
DEFINITIONS
Septa1 deviations can be caused by genetic influ-
ences, mechanical injuries, and, rarely, by congeni-
tal malformations, infections, or neoplasia. Thus,
septal deviation can occur in utero, during delivery,
and throughout the whole life-span.
The first controversy arises from defining the crite-
ria for a septal deviation and especially how to quan-
tify the extent. This dilemma of comparable defini-
tions holds true for the neonate's nose, but is also

encountered when examining a nose in later life.
Therefore we find a wide range of incidence of septal
deviation in newborns, from 0.5 to 50% (Fig. 1).
Computed tomography, magnetic resonance imag-
ing, acoustic rhinometry, and oscillometry are valu-
able methods for determining the site or sites and
Figure 1. Female neonate with an irreponible nasal devi-
ation to the left (above). Twelve years later (below), the girl
presented with an inverted C-shaped nasal deviation (septal
deviation in right areas 2 and 5, according to Cottle) and a
maxilla that is shortened and compressed in its left half.
GROWTH OF THE DEVIATED SEPTUM-Pirsig
amount of septal deviation, but only a few patients
have been examined by these newer and partially
loading techniques. Another difficulty is how to de-
fine standards of midfacial normality. This problem
has long been studied by the orthodontists, but is
also far from clarified.
ANATOMIC CONSIDERATIONS
The human nasal septum is the dominating struc-
ture to determine the size and shape of the visible
nose and thus essentially influences the appearance
of the face. The septal cartilage together with its
bilateral triangular cartilages approximately forms a
T-bar-like three-dimensional anatomic entity, termed
"septolateral cartilage," that is cranially partially cov-
ered by the nasal bones. Carl and Henriette Ver-
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woerd with their group at the University of Rotter-
dam pointed to the important fact that this T-bar
shaped cartilaginous structure is under permanent
stress during growth.4 Any kind of mechanical or
surgical trauma, destroying this entity, initiates an
irreversible deviation of the cartilage from its genet-
ically determined direction of growth.
Our knowledge about this growing septolateral
cartilage is still very incomplete. There is, for in-
stance, no series of anatomic specimens depicting
the development of this T-bar structured cartilage
from the newborn to the adult. Poublons from the
Rotterdam group dissected the noses of two still-
borns and found that the triangular cartilage on ei-
ther side of the septum widens laterally in a vault
shape under the nasal dorsum. The triangular car-
tilage extends from the nasal tip to the still car-
tilaginous base of skull in the neonate. During nasal
growth, the cranial parts of the triangular cartilages
beneath the nasal bones are resorbed except a small
remnant of 2 to 10mm underlying the caudal borders
of the nasal bones. Nobody has shown the time-table
for this resorption of the growing triangular car-
tilages. From intraoperative findings of seven chil-
dren with nasal dermal sinuses and cysts, for exam-
ple, we observed complete triangular cartilages, as
in full-term neonates up to the age of 4 years.
In his thesis, Poublons also pointed out the impor-
tance of the septolateral cartilage for midfacial growth
by resection experiments in growing rabbits. He
found the triangular cartilages to be necessary for
the normal development of the nasal bones, the
transverse expansion of the dorsal nasal meatus, and
the normal development of the nasal turbinates. The
cartilaginous septum had also an influence on the
developing nasal bones, on the normal development
of the maxilla, and, to a lesser extent, of other
parts of the facial skull.
At the 12th Congress of the European Rhinologic
FACIAL PLASTIC SURGERY Volume 8, Number 4 October 1992
Figure 2. A 6-year-old boy with a swelling in the left nostril (left). The surgically damaged nose and midface 7
years after resection of left nasal bone and triangular cartilage (right).
Society in Amsterdam in 1988, I reported the case
of a 6-year-old boy (Fig. 2), who underwent resection
of the left nasal bone and triangular cartilage be-
cause of histologically suspected sarcoma. Defini-
tively a circumscribed osteomyelitis was diagnosed.
Following this boy 7 years later, we found a short-
ened left nostril with the bony pyramid deviating to
the left and the nasal tip deviating to the unoperated
side. The piriform aperture was positioned higher
on the left side and the nasal process of the maxilla
was reduced. The left inferior turbinate was smaller
than the right one, the caudal end of the septal
cartilage deviated slightly to the right (Fig. 2). These
findings are similar to Poublon'ss result after uni-
lateral resection of the triangular cartilage in grow-
ing rabbit. Lossen and Verwoerd-Verhoef6of Rotter-
dam demonstrated the complex anatomic structure
of the septal cartilage in the new-born, which is
characterized by various areas of different thickness
of the septal cartilage and by different density of
chondrocytes. Reviewing my histologic material of
about 300 biopsies taken from the human growing
septal cartilage between 1972 and 1979, I concluded
that this complex anatomic struclre of the septal
cartilage is existent at least in the first two decades of
life. Nevertheless, systematic studies of the septal
structures for infants and children are still lacking.
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In addition, there is also no study demonstrating the
normal interrelationship between the growing nasal
septum and maxilla in children.
MICROCOSMOS SEPTUM: SOME
METABOLIC DATA
Corresponding to the complex anatomic structure
of the human septal cartilage, there is a similar com-
plex pattern throughout life concerning the meta-
bolic aspects of the septal cartilage. This cartilage is
unique because it results from sequential inductive
interactions from cephalic mesoderm and neural
tube and neural crest ectoderm. To study the meta-
bolic and proliferative potential of this cartilage, a
group at the University of Ulm investigated biopsies
of the intact septal cartilage of patients aged 5 and 65
years who were operated on because of septal devia-
tion.7-9 Adults with acromegaly were studied as an
example of pathologic septal growth. Cell replication
was measured by in vitro incorporation of labeled
thymidine, and the extent of matrix synthesis was
measured by in vitro incorporation of labeled sulfate
into cartilage. The first finding was that septal car-
tilage can be divided in five areas with different
metabolic capacities.7

In addition, metabolic pathways were assessed by
measuring several intracellular enzymes, related to
biomatrix degradation, as cathepsin B and D, P-hexas-
aminidase, and acid and alkaline phosphatase in the
septal cartilage of healthy individuals and acro-
megalic patients. Again, different areas were found
within the septal cartilage based on activities of these
various enzymes.8
Differences could also be detected concerning the
cell density of the septal cartilage. The highest cell
density was found in the anterior free end, whereas
significantly lower cell densities were determined in
the other areas of healthy persons. In another experi-
ment chondrocytes were isolated from the different
areas of the human septal cartilage to determine the
capacity of isolated chondrocytes for clonal prolifera-
tion (Fig. 3) in response to growth hormone and
some growth factors.9
Contrary to previous suggestions, the posterior
area of the septal cartilage adjacent to the perpen-
dicular plate cannot be considered a growth zone,
but is rather an area in which, until age 40, chondro-
cytes are transformed into bone by enchondral ossi-
fication. Chondrocytes isolated from this posterior
area display the lowest clonal proliferation rate.
These various biochemical studies demonstrate
vcohy
18 - 52y
formation
Figure 3. Proliferative potential of the human septal car-
tilage in three age groups. The numbers in the 5 different
areas of the septal cartilage represent percent of the colony-
forming chondrocytes/100 inserted cells in comparison to
fetal chondrocytes, which form 100% (Reprinted with per-
mission from Vetter et a[.')
GROWTH OF THE DEVIATED SEPTUM-Pirsig
that the human septal cartilage is a very complex
part of the midface and is built up of five areas: the
anterior free or caudal end, the suprapremaxillary
area, the central area, the posterior area, and the
caudal prolongation of the septal cartilage (Fig. 3).
These five areas display partial age dependency,
strict local distribution and predominance of matrix
synthesis, cell replication, intracellular glycogen
content, cell density, and proliferative capacity. For
most of these intracellular parameters, there are sig-
nificant differences between chondrocytes of healthy
individuals and acromegalic patients. Vetter et a1 con-
cluded: "Our studies demonstrate, that metabolism
and growth characteristics of human septal chon-
drocytes are mainly regulated by their location in the
septal cartilage. In addition, hormones and growth
factors may further modulate specific aspects of me-
tabolism and proliferation of septal chondrocytes as
could be shown in the acromegalic patients."
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These metabolic data support the hypothesis of an
active role of the human septal cartilage for midfacial
growth and the genetically determined role of each
chondrocyte within the septal cartilage. A practical
interpretation of these findings for the rhinosurgeon
is, for instance: if growing cartilage from the poste-
rior septum is transposed into the columella pocket
for septal reconstruction, it will preserve the meta-
bolic and proliferative potentials of its former posi-
tion. In the literature, I could not find comparable
studies on the human "microcosmos maxilla."
WOUND HEALING IN THE DEVELOPING
NOSE
If nasal cartilage is damaged by trauma or surgery,
we find incomplete or complete cartilaginous frac-
tures with typical tissue reactions along these frac-
ture lines.10-'2 Small incomplete cartilaginous defects
can heal by cartilaginous regeneration from the peri-
chondrium and to a minor degree by interstitial car-
tilaginous growth. Larger defects are filled by fi-
brous tissue. Thus, a scar is formed within the
cartilage, which counteracts the normally balanced
interlocked stresses within an intact cartilage.12When
this intrinsic cartilaginous balance has been dis-
turbed by injury, a bending or angulation of the
fractured cartilage will result during wound healing.
The direction of the cartilaginous deviation is mostly
not predictable, because it depends on the additional
forces of the surrounding traumatized nasal tissues.
A similar unpredictable cartilaginous bending will
be found in a cartilage in which the surface is broken
by a scarification technique or incomplete cross-cuts
techniques, which are recommended by some rhino-
surgeons to treat septal deviations in children and
adults (Fig. 4). Because the scar is not growing at the
FACIAL PLASTIC SURGERY Volume 8, Number 4 October 1992
1disturb the three-dimensional morphologic organi-
Figure 4. Remnants of the anterior septal cartilage of a
14-year-old boy. This cartilage had been corrected by uni-
lateral incomplete cuts (arrows) 6 years ago, which resulted
in partial resorption and unpredictable bending of the car-
tilage. The maxilla showed a slight sagittal compression.
same pace as the surrounding cartilage, the septal
deviation will increase with development. Thus,
each additional cut in or through the cartilage adds
a slowly growing scar to the cartilaginous damages
due to nasal injury.
In cases of complete cartilage interruption we al-
ways observed an incomplete cartilaginous healing
in our patients. A small fibrous bridge persisted
between the healed borders of the cartilaginous frag-
ments.12In the long-term, these borders of the totally
interrupted cartilage face each other in typical posi-
tions: mostly their end-to-end connection is angu-
lated or we find a side-to-side dislocation of the
separated cartilaginous borders with some new car-
tilage bridging the step.13
Of course, these angulations cause a recurrent
septal deviation, which we could see in following
these children until the end of puberty14 Nolst
Trenitk et all5 demonstrated this side-to-side dis-
location or end-to-end angulation of a resected and
immediately reimplanted septal cartilage in the grow-
ing nasal septum of rabbits. In addition, they mea-
sured a foreshortening and saddling of the animal
nose after operation. Although the maxilla showed
no significant growth disturbances in length, the
authors noticed a change in growth direction in
form of a deflection.
Recently some of these findings of wound healing
of traumatized human nasal cartilage have been sup-
ported and clarified by the Rotterdam group in the
growing rabbit.16." These authors concluded from
their results that elevation of the mucoperichon-
drium (tunneling) does not induce significant histo-
logic reactions in the septal cartilage and the wound
reaction of the cut edges resulted in a stump, encap-
sulated by fibrous tissue. Reimplantation of the re-
sected cartilage in exactly the same position does not
zation of the septal cartilage with-its thinnecand
thicker areas and anteroposterior polarity.
However, Verwoerd et all7 found that reimplanta-
tion of the resected normal cartilage did not lead to
normalization of nasal growth. They demonstrated
by their study that this misdirected nasal growth is
"not caused by extensive necrosis, loss of mor-
phological organisation or decreased growth poten-
tials of the reimplanted cartilage, but due to the fact,
that dislocation (duplication and angulation) pre-
vents the anteroposterior growth of the implant to
contribute fully to the lengthening of the total sep-
tum." This gives a good explanation for some of our
insufficient long-term findings after septoplasty in
childhood.14 Histologically we found an incomplete
regenerative potential of septal chondrocytes at the
surgically created cartilaginous edges after septo-
plasty in childhood.10 This probably corresponds to
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the physiologic growth potential of the growing sep-
tal cartilage that was not damaged by trauma or
surgery. This regenerative potential is more pro-
nounced in the anterior free end of the septum and in
the central area and less in the suprapremaxillary
area. This pattern of different regenerative potential
within the septal cartilage is similar to that demon-
strated with the method of colony formation7 from
isolated human septal chondrocytes (Fig. 3). The
amount of regenerated cartilage, however, can never
replace all lost cartilage. Thus, any surgery will add
slowly growing scars and a partial cartilaginousdefi-
cit to the developing septal cartilage.
In our young patients loss of cartilage was ob-
served in cases of infection, especially after septal
abscess,~2~~s but also in areas of surgically created
defects by means of the Killian technique. This car-
tilaginous defect is replaced by very dense fibrous
tissue with only a few vessels, that is, a scar with
nearly no growth potential. When septal abscess or
Killian's submucous septal resection occurred in the
first decade of our patients, we could always docu-
ment an inhibited midfacial growth in the adults.
The unsatisfying long-term effects of submucous
septal resection during the growth period had ear-
lier been reported by Ombrbdanne19 in 50 patients.
SEPTAL DEVIATION IN IDENTICAL TWINS
Information about nasal growth, gained from twin
studies, could be helpful in recognizing which parts
of the nasal skeleton are more genetically or more
epigenetically influenced. Huizing20 described the
underdevelopment of the nose and surrounding
midfacial bones due to septal abscess in childhood
in one sibling of identical twins of Leiden. In 1968
Masing and Hellmich21reported on a pair of identical
 GROWTH OF THE DEVIATED SEPTUM-Pirsig

twins of Erlangen where one sibling had lost her

septal cartilage in early childhood by an abscess
resulting in an inhibited growth of the cartilaginous
nose and of the premaxillary region. Grymer and
Melsen,zz describing nasal findings in 41 pairs of
identical twins, found 21% septal deformities in the
anterior septum, and 74% of the twins had some
deformity in the posterior (bony) septum. From
their findings, the authors conclude: "The distribu-
tion of the deformities within pairs suggests that
anterior deformities might be of external origin, e.g.
traumatic. Posterior deformities may be considered
as part of a normal developmental process of the
maxillary complex, where both genetic and epige-
netic factors may play a role."
In a second study this group22 made a cephalo-
metric analysis of 11twins in which one sibling had
an anterior septal deformity and the other had not.
In case of an anterior cartilaginous deformity, the

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outer nose (septal cartilage, the tip, and the upper
cartilage region) appeared to be shorter than the
nonaffected sibling. "This may indicate that the ante-
rior cartilaginous septum acts upon the cartilaginous
nose like a forward-impelling force, which is miss-
ing or reduced in cases of anterior septal defor-
mities." In cephalometric analysis, the anteroposte- Figure5. Identical twinsof Ulm at age 17 years. The twin
rior length of the maxilla was found to be smaller in on the right broke her nose at age of 12 years without having
the twin with the anterior septal deformity. This any impact on her maxillary development.
finding is similar to observations from animal exper-
iments in which resections of the cartilaginous sep-
tum induced a shorter anteroposterior maxillary
documented history of untreated midfacial trauma
length.
in ~hildhood.14~24 By means of photographs, the fa-
Important for midfacial growth is the time when
cial development could roughly be followed over the
the damage occurred to the nose. We followed a pair
years of growth. In connection with the preoperative
of identical twins, in which one sibling had a severe
set of data, dental casts, and the intraoperative find-
nasal trauma at age 12 years. We corrected this nose
ings of the damaged nasal tissues, this observation
at age of 17, made dental casts and took radio-
led to the following conclusions: some months after
cephalograms of the twins (Fig. 5). Although there
midfacial injury, the deformity of the nose may look
was a severe damage in the septum and nasal pyra-
unimpressive and is often not recognized by the
mid of the sibling with the history of injury, her
family. Alterations of the bony pyramid and premax-
maxilla was longer in the sagittal direction than the
illary region are rarely visible in the first decade. The
maxilla of the healthy sibling, whose teeth 14 and 24
pathologic features of the injured nose become clearly
had been extracted for orthodontic treatment. Both
visible during pubertal growth spurt. The increasing
siblings presented a mirror-imaged retrusion of
degree of pyramidal deviation, saddling, or hump
teeth 11and 21 (Fig. 6). The severe nasal injury at age
formation can be followed in the successive photo-
12 did not influence the development of the maxilla.
graphs as well as the remarkable growth inhibition
This is different from the findings of the Leiden
of the whole nose and midface, resulting in the
twins20 and Erlangen twins,21 since severe midfacial
pathognomonic "child's nose" (Fig. 7) of the adoles-
sequelae had been reported after septal injury in
cent. Parallel with these changes in the appearance
early childhood.
of the damaged noses, we found complaints about
increasingly impeded nasal breathing. in about 60%
of these patients alterations of the premaxilla and/or
NATURAL HISTORY OF THE UNTREATED maxilla could be diagnosed by the orthodontist. In
INJUREDCROWING NOSE some cases the history of the injury in childhood
included the simultaneous damage of the maxillary
Since 1982 we have studied the natural history of complex, but in most cases this information was
60 adult patients, age 18 to 23 years, with a carefully lacking.
FACIAL PLASTIC SURGERY Volume 8, Number 4 October 1992

From these findings, we conclude that the long-

term effect of a nasal trauma in childhood is not
predictable before the end of pubertal growth spurt.
If such an injured nose is surgically treated during
growth, it is impossible to separate the influences of
the original injury and of the surgical intervention at
follow-up after puberty. Conclusions concerning the
interrelationship of nasal and maxillary growth can-
not be drawn from most cases.
As mentioned before20.21septal abscess during the
first decade of life with destruction of the septal
cartilage usually results in a stunted growth not only
of the septum, but also the triangular cartilages, the
bony pyramid, and the maxilla. We can conclude
from several cases (Fig. 8) that the growth inhibition
of the nasal structures is more pronounced the earlier
the septal abscess had destroyed the septal car-
tilage.'* In the young children the nasal bones are
positioned on top of the not yet resorbed cranial

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parts of the triangular cartilages. Thus, the partial
bones.
L
Figure 6. Identical twins of Ulm at age 17 years. Mirror-
imaged retrusion of teeth 11 and 12 occurred in both siblings;
the figure below is that of the twin with the nasal injury in
Figure 5.
Figure 7. This girl had an untreated frontal nasal injury at
age 6 years. The nose at age 7 shows a slight bony deviation
to the right side, a C-shaped bending of the dorsum, and a
small saddle. The harmony of the midface is not yet disturbed
(left). The underdeveloped nose at age 17 is still a "child's
nose," with the bony deviation and saddling more pro-
nounced (right). The maxilla shows a retrusion.
destruction of the triangular cartilages by abscess
also induces an inhibition of growth of the nasal
Brain and Rock25 used radiocephalometry to study
the natural history of nasal injury in childhood.
They performed a retrospective study on the facial
and nasal development in 29 adult patients who
sustained a serious untreated injury to the nose dur-
ing childhood. Measurements of lateral skull radio-
graphs of these patients indicated reduced down-
ward and forward growth in the maxilla, and altered
angulations for certain planes in the middle and
lower thirds of the face. The angle of the nasal projec-
tion was also reduced in the study group. The author
did not give information about the type of nasal
trauma, especially whether the maxilla was involved
in the injury, and about the location of the septal
deviations.
We could only partially support these radioceph-
alometric findings of Brain and Rock in our group of
178 adult patients with nasal trauma in childhood,
who were also investigated by dental casts and ra-
diocephalograms.24~26Instead, we found different
reactions of maxillary development, ranging from
normal to stunted or misdirected growth, combined
with nasal deformity. In Figure 9 we documented
some data of a woman who had a severe nasal defor-
mity after an untreated fall from a trapeze at age 11
years. Surgery revealed a compressed septal car-
tilage with a block of regenerated cartilage poste-
riorly and a straight perpendicular plate. The sym-
metrical midface is combined with a short, small,
and distorted nose, presenting a combined bony and
cartilaginous saddle. The premaxilla is long, with an
anterior length of 17 mm (normal value, 14 mm),
whereas the maxilla shows normal symmetrical di-
mensions (premaxilla anterior, 49 mm as control;
 GROWTH OF THE DEVIATED SEPTUM-Pirsig

no information on the amount and type of midfacial

injury in childhood was available. From our observa-
tions (unpublished data) in the group of 178 patients
with nasal deformity due to trauma in childhood,
we learned that in many patients midfacial defi-
ciency could also be explained by direct injury to the
m a d a alone and not by a misdirected septal growth.
Many rhinosurgeons now correct septal devia-
tions in children, since more conservative tech-
niques have been introduced. The good and poor
A -- 4 long-term results of these septoplastiesin childhood
Figure 8. Three 16-year-old girls, all with drained septal have only incompletely been documented, that is the
abscesses in childhood and subtotal loss of septal cartilage.
The nasal injury occurred at 3 years (left), 5 years (middle), orthodontic findings are mostly lacking. Even with
and 7.5 years (right). (Reprinted with permission from Pir- documentation methods, described earlier, we can-
sig.18) not overcome the previously mentioned limitations
when evaluating findings from human beings.
Therefore we have to go back to animal experi-
ments. Verwoerd et a127 started an impressive series

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anterior width, 34 mm, normal value 36 mm; poste- of experiments in growing rabbits to find out the
rior width, 45 mm, normal value, 44 mm). Summing influence of partial resections of the nasal septal
up, although the nose is hypoplastic and the dam- cartilage on the development of the upper jaw and
aged septal cartilage is too small, the premaxilla is nose. In the last decade his group has shown, that it
rather long and the maxilla presents with normal depends on the location of the damage within the
dimensions. septal cartilage, whether cartilaginous resection will
In many patients with a combined damage of the interfere with midfacial growth.5,6,1~17,271 think each
nasomaxillary complex, the history of the nasal in- rhinosurgeon should study all the details of this
jury in childhood revealed simultaneous damage to research group of Rotterdam to draw meaningful
both nose and maxilla. In other cases, unfortunately, conclusions for our daily work.

Figure 9. A 41-year-old woman with an untreated severe nasal deformity after a fall from a trapeze at age 11
years. Premaxilla and maxilla developed normally after the nasal injury.
FACIAL PLASTIC SURGERY Volume 8, N u m b e r 4 October 1992
CONCLUSIONS
Our knowledge of anatomy genetic and epigenetic
influences, wound healing, and metabolic pathways
of the growing human nasal tissues is still very in-
complete. When combining the results of animal
experiments with some observations in our young
and adult patients, the following features seem to be
important: One determining structure for nasal
growth is the septolateral cartilage, a T-bar shaped
entity that is under permanent stress during growth.
In addition, there are interlocked stresses within the
cartilage. Interruption of these external and inter-
locked stresses by injury or surgery in special sites
of the septolateral cartilage will result in an often
unpredictable change in nasal growth direction. Al-
though nasal structures and surrounding tissues,
especially the maxilla, may develop independently,
there is some evidence that some regions of the sep-
tolateral cartilage control maxillary growth, espe-
cially in the first decade of life. Thus, defined dam-
ages to this cartilage during growth may induce
inhibition or misdirection of midfacial development.
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