Modified Inferior Turbinoplasty

Modified Inferior Turbinoplasty
Paolo Gottarelli
Modified Inferior
Turbinoplasty
A New Surgical Approach
123
Paolo Gottarelli
Rhinoplasty Surgeon
Bologna, Italy
This is the English version of the Italian edition published under the title La turbinoplastica inferiore
modificata, by Paolo Gottarelli
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Preface
Since the beginning of my medicine studies I have always been fascinated

by the possibility of changing facial features and, with this concern, rhino-
plasty has always attracted me, until it has become the main goal of my pro-
fessional career. After my military service as an Alpine Troops officer at the
Italian frontier, at the age of 27 I became physician assistant at the Plastic
Surgery Department ruled by Dr Carlo Cavina, who initiated me into prac-
tice of nose surgery through the first essential surgical concepts. Nine years
later, as plastic surgery head physician assistant, I started to go and visit the
most important nasal surgeons in the world, trying to widen the concepts
and the techniques learned initially.
I still remember Fernando Ortiz Monasterio (1923) who, after a tennis
match, explained to me the advantages of percutaneous greenstick osteotomy.
It was May 19, 1986, and since that date I have only been using that method
to draw the nasal bones nearer after nasal hump reduction or simply to correct
a post-traumatic asymmetry – and always using a 2 mm straight osteotome.
I remember fundamental meetings with Ralph Millard (1919) and his 33
principles that even nowadays I consider an indispensable guide for any (not
necessarily plastic) surgeon. In 1988 I was impressed by the technically
over-careful rhinoplasty intervention performed by John B. Tebbetts in
Dallas, Texas. Ruled by a strict logic, this young surgeon was able to stand
up to the most famous nasal surgeons such as Jack Sheen. This convincing
logic led him to write, in 1988, a beautiful book about the reasons why pri-
mary rhinoplasty should always be dealt with using open approach, with the
help of a very sophisticated method. And it was in Dallas, Texas, that a group
of excellent surgeons was created, led by Jack Gunter and followed by Steve
H. Byrd, Rod J. Röhrich, John B. Tebbetts, and many others. With their lec-
tures and guidelines collected in two volumes entitled Dallas Rhinoplasty,
v
vi Preface
they transformed the open approach into the best method to treat every part
of the nose, not only in secondary cases, but even more in primary rhinoplas-
ty cases: thanks to improved performance accuracy, primary cases did not
evolve to secondary cases prompted by frequent relapse.
Back 1989, I started presenting the results obtained with Tebbetts’s tech-
nique at the major conferences. In April 1994 I won the first prize at the
Congresso Italiano di videochirurgia plastica (Italian Congress of Videoplastic
Surgery), three months before Tebbetts published his work about Force Vector
Tip Rhinoplasty (FVTR) (Shaping and positioning the nasal tip without struc-
tural disruption, a new, systematic approach. Plast Reconstr Surg 94:61–77).
The awarded video at that congress presented, with a two year follow-up, the
solution to a serious problem of idiopathic unilateral valve insufficiency, only
using Tebbetts’ technique with cartilage grafts and peculiar stitches.
In 1997, with Tebbetts’s authorization, I organized and led in Bologna the
first multimedia live videolecture on nasal surgery, using this method. In the
same year I had the idea to treat turbinate hypertrophy as a plastic surgeon
would do with breast hypertrophy, by harmoniously reducing all three anatom-
ic compartments of the turbinate itself, and then rebuilding it with accurate
sutures so as to avoid the development of cicatricial synechiae, bleeding and,
most of all, without the use of swabs. This method proved to be fundamental
for patient well-being, because it provided a faster and, above all, definite
recovery.
Since then I performed modified inferior turbinoplasty (MIT) on patients
with functional diseases and when aesthetic surgery was required. All this
with the aim to re-balance the loss of space inside the choanae caused by
reduction rhinoplastic surgery that unavoidably affects their function.
Later, in 2003, I introduced the MIT technique at the Teknon Clinic in
Barcelona, to an authoritative group of nasal surgeons headed by Eugene M.
Tardy, Jr., who used and wrote words of admiration for this technique, that
was actually derived from one of his teachers, Dr. Howard P. House.
One year later, in 2004, I was invited by Jaime Planas to hold three lec-
tures and a live surgery at the homonymous clinic in Barcelona during the
two-year course organized there. I remember the exact words that Planas told
me: “Dear Gottarelli, I know many surgeons who do beautiful noses, but very
few also know how to make them breathe. If it is true that your technique
works, you’ve brought up a sore point, and this is why I’ve invited you to our
course”.
In the following years, I made the new concept of nasal surgery more and
more real, and defined it the “Global Rhinoplasty”. Global Rhinoplasty is based
not only on MIT, but also on the so-called “Structural Rhinoplasty” introduced
by Dean Toriumi and on the above-mentioned FVTR by John B. Tebbets.
Preface vii
This is what the most modern and up-to-date methodology can offer in
this field, overcoming not only the controversies between open and closed
rhinoplasty, but also the distinction between pure functional surgery and
pure cosmetic surgery. In these interventions, elements belonging to either
approach may be recognized. For this reason, considering the dichotomy
between functional and cosmetic surgery as outdated, it is more correct to
speak about nasal job or Global Rhinoplasty. This innovative approach of
thinking and performing nasal surgery has not failed to meet the approval
by hundreds of patients, who this year established a nonprofit association
(Io Respiro Onlus, meaning “I Breathe”), committed to spread, among other
goals, information on this new method. Moreover, a new training school for
nose surgery has been created too; its goal is to train a new generation of
nasal surgeons with experience in plastic surgery, otolaryngology, maxillo-
facial surgery, endoscopic surgery and microsurgery.
Paolo Gottarelli
With sincere gratitude I would like to dedicate this book to
those who followed me along my professional and medical
career, namely: all my colleagues, the operating room person-
nel, as well as my staff who supported me with enthusiasm. In
particular, I have to thank the gift of life and the strength my
parents gave me, to whom I will eternally be grateful.
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 The History of Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 Well-Being and Respiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3 Nasal Anatomy and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4 The Inferior Turbinates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
6 How We Attained Modified Inferior Turbinoplasty . . . . . . . . . . . . 21
7 The New Modified Inferior Turbinoplasty . . . . . . . . . . . . . . . . . . . 25
8 Post-traumatic Hump Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
9 MIT, Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
10 The Concept of “Respiratory Symmetry” . . . . . . . . . . . . . . . . . . . . 77
11 The Control of Relapses in Septal Deviations . . . . . . . . . . . . . . . . 79
12 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
xi
Introduction
What is described in this volume about the new method for hypertrophic
inferior turbinate treatment is nothing but the logic consequence of a series
of innovations that come from very far. One by one, these innovations have
allowed for treatment of the nose in all of its parts and functions with
greater precision and result predictability. In order to get through this jour-
ney easily, it is necessary, as usual, to follow the historical steps of this slow
but inexorable evolution.
None of the expert surgeons who wish to give a real meaning to their
work can ignore this. In 1921, Aurel Rethi (1884-1976) paved the way with
his columellar incision. However, this first “open” rhinoplasty followed the
same stages as traditional rhinoplasty, suggested by Jacques Joseph (1865-
1934). This meant that the actual benefits that the open approach allowed
for could not be appreciated, with an additional scar on the columella that
made, at that point, the real advantages fruitless.
This argumentation, opposed to the open approach, has been supported
for many years by those who did not want to consider what happened from
Rethi’s method onwards, a revolutionary event, from all viewpoints.
Following this sterile and obstinate controversy, many opposers prevented
two generations of surgeons from taking a new road so full of satisfaction
and success.
It is thanks to Ante Sercer (1896-1968), a Croatian professor, that the
new technique with the open approach, which he called “decortication”,
was filled with anatomical and functional meanings for the first time.
Actually, this naming was not very suitable, because it contributed to rais-
ing fears and suspicion in surgeons. In fact, the term “decortication” sounds
a bit frightful and reminds us of the treatment for rhinophyma, that is the
complete ablation of the thickened skin layers of the nose.
1
2 Modified Inferior Turbinoplasty
Besides this unfortunate definition, a second issue that prevented the dif-
fusion of this method was the simultaneous work by another great teacher
and surgeon, Maurice H. Cottle (1898-1981), who was much more diplo-
matically able to become popular with his appreciated method. Sercer’s
activity was so prolific that his most promising student, Ivo Padovan (1922-
2010), was responsible for the continuation of this procedure, spreading this
method overseas, in the USA. However, for twenty years, the diffidence
among most American surgeons prevailed, with the exception of Jack R.
Anderson (1917-1992) and Wilfred S. Goodman, who not only began to
appreciate this new technique, but also presented their cases in several med-
ical conferences. Anderson subsequently published the first article on this
new approach and defined this method “Open Rhinoplasty”: this new termi-
nology, instead of Sercer’s “decortication”, was not frightening, and raised
the curiosity of nasal surgeons.
From 1980 onwards, an increasing number of surgeons became active in
this new field and, since the mid-nineties, “Open Rhinoplasty” was taught
in all schools of specialization in Nasal Surgery overseas.
A new generation of surgeons was being formed, and thanks to them the
possible interventions on aesthetic and functional diseases widened enor-
mously. Today an overwhelming majority of surgeons experience the Open
Approach with their patients’ total approval and satisfaction.
From 1997 till now the number of patients operated on using this approach
has reached 5,000.
The History of Rhinoplasty
1
The history of nasal surgery dates back to the mists of time. In the so-called
“Edwin Smith ancient Egypt papyrus”, purchased by the American anti-
quarian Edwin Smith (1822-1906) in Luxor in 1862, there are descriptions
of the diagnosis and treatment of nasal deformities dating back to about
3,000 years ago.
In 800 BC the Indian physician Sushruta described in his Ayurvedic
medicine book Sushruta Samhita surgical interventions conducted on more
than 300 patients performed on the banks of the Ganges, as well a technique
for nasal reconstruction. In the sixteenth century, the Bolognese physician
Gaspare Tagliacozzi (1545-1599) used surgical reconstruction techniques to
correct disfigured noses. In the following centuries, the science and art of
rhinoplasty remained substantially stagnant until the nineteenth century,
when the first plastic surgery pioneers appeared, such as doctor Johann
Friedrich Dieffenbach (1792-1847) from Berlin who, in 1840, used a skin
flap to cover the nasal back.
The first report of a modern endonasal rhinoplasty – published on
Medical Record, 1887, June 4, The Deformity Termed ‘Pug Nose’ and Its
Correction by a Simple Operation – was written by the American physician
John Orlando Roe (1848-1915). In 1892 another American surgeon, Robert
F. Weir (1838-1927), described step-by-step the rhinoplasty techniques for
correction of misshapen noses.
In 1898, the orthopedic surgeon Jacques Joseph (1865-1934) presented
his revolutionary concepts of nasal surgery at the Medical Society of Berlin.
Many rhinoplasty surgery applicants traveled to Germany to learn his inno-
vative techniques, to the point that he is considered the father of rhinoplas-
ty. Many of the basic maneuvers of modern rhinoplasty are essentially the
same as those described by Joseph two centuries ago.
Thanks to the work of surgeons such as Gustave Aufricht (1894-1980),
Joseph Safian (1886-1983) and Samuel Fomon (1889-1971), these techniques
Paolo Gottarelli, Modified Inferior Turbinoplasty © Springer-Verlag Italia 2012 3
have further spread, in particular in the US. Fomon was the one who held the
lectures and rhinoplasty courses that contributed to training many of the mod-
ern rhinoplasty surgeons, such as Maurice H. Cottle (1898-1981) from
Chicago and Irving B. Goldman (1898-1975) from New York.
In the relatively short history of modern rhinoplasty, many experts have
contributed to progress in this field through the development and refinement
of new techniques. The continuing sharing and divulgation of rhinoplasty
techniques have helped to improve the results on patient faces. Many
patients who undergo nasal surgery are often only motivated by aesthetic
reasons, but also frequently for concurrent respiratory disorders. And here
comes the need for simple and multifaceted surgical techniques, where MIT
will prove to have the utmost importance.
Well-Being and Respiration
2
Today, well-being and fitness are well-known topics, but minor attention is
still paid to two of the most vital functions of our health: feeding and
breathing.
It is now recognized that a whole series of diseases having a highly
social impact, cancer included, depends on lifestyle, food and atmospheric
environmental conditions. The reason is due to the fact that our phenotype,
the mutant and variable part of our DNA, represents the larger fraction of
DNA and is strongly conditioned by our living habits. The most recent
progress in cancer treatment comes exactly from the possibility of correct-
ing DNA changes, by repairing the altered protein chains. The concept of
reversibility is therefore predominating even in case of neoplastic diseases.
If we can live 40 days without eating and four days without drinking, we
can survive four minutes at longest without breathing: this clearly accounts
for the power and importance of respiration. Correct respiration slows
down, filters, heats and humidifies the air breathed in through by the nose.
Later on we will see the mechanisms through which all these important
processes occur, but we must also underline the importance and the neces-
sity of nasal respiration in order not to expose bronchi and pulmonary alve-
oli to a sudden and excessive air loading, as occurs any time one breathes
through open mouth.
It is known that those who breathe through their mouth only, develop not
only upper airway inflammatory diseases, but also severe bronchial, lung and
even heart diseases more frequently. We know how many sleep disorders
affect a huge amount of people, from ordinary roncopathy (snoring) to much
more severe sleep apneas, and to the regular use (or even “abuse”) of nasal
vasoconstrictors that represent the only way to decongest the inferior hyper-
trophic turbinates for these patients, with the risk of developing consequent
alterations of the nasal mucosa leading to the onset, in some cases, of hyper-
tension. For these patients, MIT is able to solve the problem definitively.
Another important item regards child health; sometimes these patients

are hurriedly defined as “allergic”, instead of being visited by a specialist
able to detect the presence of abnormalities or defects of the upper airways,
like a septum deviation or an inferior turbinate hypertrophy. Hence, it
should be stressed that even in these cases surgical intervention could be
taken into consideration. Subjects should have to be selected in advance,
with the utmost respect for their still-growing functional structures.
Moreover, we should not underestimate the occurrence of nasal and
breathing symptoms in subjects who practice sports, both at amateur and
professional level, which can limit their competitive performances by
exposing them to frequent episodes of colds or inflammation of the respira-
tory tree (pharyngitis, bronchitis, etc.) and real sports performance handi-
caps such as the difficulty for divers in performing the Valsalva maneuver
for compensation.
Poor blood oxygenation caused by alterations in the upper respiratory
tract (particularly in the nose) is inevitably associated with social relation-
ship disorders characterized by difficulties in concentration and perform-
ance, as well as sleep disorders followed by drowsiness during the day. But
there are even negative effects on automatic mechanisms such as swallow-
ing, conditioned by the presence of congenital or secondary nasal malfor-
mations, such as post-traumatic nasal septum deviations.
Nasal Anatomy and Function
3
3.1 Embryological Development
At the fourth week of gestational growth, the cells of the neural crest (where
the nose will be formed) begin to migrate caudally towards the midface.
Two symmetrical nasal placoderms (rudiments of the olfactory epithelium)
develop; afterwards, they will be divided by the nasal pits into medial and
lateral processes (rudiments of the superior lip and nose). The medial
processes will form the septum, filter and nasal premaxilla; the lateral ones,
instead, will form the lateral nose
structure; finally, the stomodeum
Frontonasal process
(the anterior ectodermal portion of
the intestinal tract) will develop to
form the mouth below the nasal
structure. A nasobuccal membrane
separates the mouth (lower oral cav- Nasal
ity) from the nose (upper nasal cav- placodes
ity). When the olfactory pits deepen,
Stomodeum
the choanae develop, putting in
communication the nasal cavity
Mandibular
with the nasopharinx (Fig. 3.1). arch Maxillary
promi
At the tenth week, the cells dif-
II arch
ferentiate into muscular, cartilagi-
nous and bone tissue. Any change
occurring during this early stage of III arch
facial embryogenesis will consider-
ably affect the fetus with palatoschi- Cardiac bulge
sis, cleft lip, choanal atresia, sinus Fig. 3.1 Embryological development at the
aplasia, polyrhinia etc. fourth week

3.2 Anatomical Structures
With the perspective of performing a corrective plastic surgery, the follow-

ing anatomical components should be taken into consideration.
3.2.1 Soft Tissues of the Nose
Skin
The skin surface of the nose can be divided into three anatomic units:
• upper third: the skin of the upper portion of the nose, thin and relatively
extendible (flexibility and mobility), closely adheres to the underlying
osteocartilaginous structure;
• middle third: the skin of the nasal dorsum is the thinnest and least dis-
tensible, because it is closely adherent to the underlying anatomical
structures;
• lower third: in addition to being particularly rich in sebaceous glands, the
skin of the lower portion of the nose is similar to that of the upper third.
Mucosa
The vestibule is characterized by a mucous lining of squamous epithelium
that, penetrating towards the inside, turns into transitional epithelium and
then into cylindrical respiratory epithelium. It is a tissue rich in seromucous
glands capable of maintaining upper airway humidification and protecting
the airways from the pathogens in the atmosphere.
Muscles
Nose movements are controlled by four groups of facial and neck muscles
deeply located beneath the subcutaneous layer and connected with the
superficial muscolo-aponeurotic system (SMAS):
• the elevator muscle group;
• the depressor muscle group;
• the compressor muscle group;
• the dilator muscle group.
3.2.2 Aesthetic Nose Structure
Before planning, preparing and executing any nasal surgery, it is necessary

to divide the external structure of the nose into subunits and aesthetic seg-
ments in order to help the plastic surgeon to determine exactly the size,
extension and topographic location of defects or deformities to be correct-
ed (Fig. 3.2):
3 Nasal Anatomy and Function 9
• aesthetic nasal subunits:

Dorsal
- lobule or tip of the nose
- columella
- right alar base Sidewall
- right alar wall
- left alar wall
Tip
- left alar base
- dorsum of the nose
Ala nasi
- right dorsal wall
- left dorsal wall
• aesthetic nasal segments:
- dorsum of the nose Soft triangle
- sidewalls
Columella
- tip
- soft triangle
- ala nasi Fig. 3.2 External structure of the nose divided
into aesthetic segments
- columella.
3.2.3 Nose Bone Structure
In the antero-superior part of the splanchnocranium lies the nasal bone,

formed by a thin, quadrilateral symmetric bone lamina. It varies in size and
shape from individual to individual, closing the nasal cavities upwards and
frontwards. Along with major, minor and accessory alar cartilages, it forms
the external nose structure.
It is connected superiorly with the frontal bone, laterally with the maxil-
la and medially with its contralateral homologous through harmonic sutures.
It is also connected with the ethmoid perpendicular lamina, and from their
union, inferiorly and frontally on the median plane, the antero-superior nasal
spine develops. The latter has two surfaces and four edges: the lower edge
helps to define, at the upper level, the piriform orifice of the nose.
The nasal septum is a flat wall, pentagonal in shape, theoretically
equidistant from the side wall in all its endonasal areas. It divides the
inner nose into two compartments, forming the medial wall with an area
of 30-35 cm2.
The septum is made of a patchwork of structures (membrane, cartilage,
bone) covered with cutaneous and mucous elements. Proceeding in the
antero-posterior direction, the septum is composed by the columella (semi-
rigid), membranous septum (flexible), septal cartilage (semi-flexible) and
by the osteoseptum (rigid, albeit with some flexibility at the osteocartilagi-
nous joints).
In addition to the basic components (cartilage, quadrangular, vomer, eth-

moid perpendicular lamina), the columella, membranous septum, inferior
nasal spine, premaxilla, maxillary nasal ridges, palatine bone nasal ridges,
the sphenoid nasal ridge, frontal nasal ridge and medial processes of the
nasal bones should also be considered as components of the septum. The
core of this patchwork is represented by the premaxilla and its connections
with the quadrangular cartilage and vomer.
The septum has four edges or angles: inferior, caudal, anterior or dorsal,
and posterior. The anterior septal angle is located at the junction of the cau-
dal and dorsal margins. The caudal edge has a curved profile and defines an
angle – the inferior septal angle – at the junction between the middle and
posterior thirds, that measures 45-55° approximately.
At the infero-caudal level, the septum rests on the inferior nasal spine
(maxilla-premaxilla) behind which the premaxillary and alar ridges, maxil-
lary and palatine ridges form the inferior bone septum. At the antero-supe-
rior level lies the quadrangular cartilage, contained within the septal cavity
or area, lined with perichondrium. The cartilage of the septum is subdivid-
ed posteriorly into vomer and perpendicular lamina. This lamina should the-
oretically have a mid-sagittal direction, but it is often distorted by large-
radius curvature. The superior portion of the perpendicular lamina is rarely
pneumatized by the frontal septum. At the superior level, the frontal spine
and the nasal bone processes form the cephalic septum, which completed
the nasal dorsum.
The nasal septum represents the common element between cavities and
nasal pyramid. Anatomically, it plays an essential role in the architecture of
the external pyramid: the bone portion supports the nasal bones, while the
cartilaginous septum represents the cartilaginous nasal dorsum. The osteo-
cartilaginous components of the anterior septum significanty contribute to
the architecture of the nasal valve area. An oblique deviation of the inferior
nasal spine, premaxilla or anterior vomer can alter the shape of each nasal
valve area. A reduction in the caudal edge height of the septal cartilage, at
the level of the supporting area extending from the premaxilla to the dor-
sum, leads to a reduction in the os internum diameter, therefore causing a
lowering of the septum-triangular junction.
The sidewalls of the nose contain three pairs of shell-shaped small bones:
the curled bones (nasal conchae) or superior, medium and inferior
turbinates. The inferior nasal turbinate defines, in the inner portion of the
nasal choanae, the superior meatus (together with the medium nasal concha)
and the inferior meatus, i.e. the area between the concha itself, the horizon-
tal jaw portion (palatine process) and the horizontal palatal plate, extension
of the process itself.
3.3 Functional Anatomy
The normal airway pattern is basically determined by the shape and size of the
nasal cavities. Therefore, any difference in shape and size in the internal nose,
both isolated or associated, causes an aerodynamic nasal discomfort, which is
mainly characterized by obstructive disorders. The endonasal volume is a
three-dimensional dynamic space constantly changing as it is influenced by
environmental, hormonal, nervous and age-related factors. Therefore, the nose
acts as a variable airflow resistor, whose resistance is made up of a constant
and some variable components. The constant component is represented by the
osteo-cartilaginous structure of the nasal cavities. The variable ones are vascu-
lar (degree of submucosal vascular plexus filling) and muscular (dilator mus-
cle activity).
The volume can be divided into six parts:
• vestibular volume (or Cottle’s area n. 1);
• valvular volume (or Cottle’s area n. 2);
• attic (or Cottle’s area n. 3);
• volume of the anterior turbinate (or Cottle’s area n. 4);
• volume of the rear of the turbinates (or Cottle’s area n. 5);
• choanal opening and nasopharynx.
The nasal septum represents the medial wall of endonasal volumes.
These volumes can be modified through surgical procedures carried out for
functional and/or aesthetic purposes. The major nasal resistive segments are
located in the first 3.5 cm of nasal airway, as they are the vestibular and
valvular segments of the nasal cavity. They are represented by the columel-
la footplate, the rounded vestibule on the latero-caudal edge of the lateral
crus, the superior cul-de-sac, the triangular cartilage-septum structure, the
piriform opening floor and the head of the inferior turbinate.
3.4 Histology
From a histological viewpoint, the walls of the nasal cavities are made of 14
different kinds of tissue, each of them with a different healing capacity:
• cutaneous;
• subcutaneous;
• adipose tissue;
• connective tissue;
• nerves;
• arteries and veins;
• hyaline cartilage of the septum. Its biomechanical behavior depends on
the properties and distribution of major components such as collagen
fibers, elastic fibers, chondrocytes, proteoglycan units, hyaluronic acid

and water. These components have a complex interaction, which is the
basis of a balanced system of forces (internal interlocked stress system),
whose resultant is equal to zero: the outer layers maintain the inner lay-
ers under pressure and this condition provides the cartilage with its pecu-
liar resilience;
• perichondrium;
• submucosa;
• bone;
• periosteum;
• respiratory mucosa (ciliated epithelium and related glands);
• mucocutaneous junction at the nostrils (subject to potential concentric
stenosis-related contraction);
• chondro-osseous joint girdle of the septum.
The process of tissue healing depends on trauma dimension and severi-
ty. The tissues with fast recovery skills (skin, subcutaneous, connective,
muscle and mucosa) heal forming a variable amount of cicatricial connec-
tive tissue, which exerts an unequal but constant traction twisting tissues
with slow recovery skills (cartilage and bone).
3.5 Nasal Function
We have seen how important the nasal function is, which is reduced only
because of an altered nasal anatomy. In particular, a correct nasal respirato-
ry function depends on the morphology of at least three anatomical struc-
tures of the nose:
• nasal septum;
• nasal valve;
• inferior turbinates.
To these three anatomical structures we have to add a fourth one, which
comes into play more infrequently and affects the health of the cavities in
proximity and continuity to the nose:
• the paranasal sinuses.
When the mucosa lining these cavities gets sore, sinusitis (maxillary,
frontal, etc.) arises; in order to avoid this disease, it is important that the sep-
tum cartilage (the most prominent) and the bone cartilage (posterior) are
lined up as much as possible. Nasal septum deviations, besides causing a
stenosis in one of the two nasal fossae (choanae), leads to the so-called com-
pensatory hypertrophy of the inferior turbinate on the side opposite to the
deviated fossa (Fig. 3.3).
The purpose of this compensation mechanism is to slow down the air
Fig. 3.3 Imaging of the facial skeleton and paranasal sinuses: compensatory hypertrophy of the bone
coming in too fast, which becomes too cold for this larger portion. As a
result, quite paradoxically, the quality of breathing worsens, especially at
night when the hypertrophic inferior turbinate is filled with more blood,
thus occluding the choana concerned.
The nasal valve is, however, a delicate anatomical component that, in
case of nasal plaster, is opened by lifting the skin at the level of the lateral
or triangular cartilages of the nose that represent the middle part of the nose.
For surgical purposes, therefore, the nose can be briefly divided into
three parts: the upper part, represented by the nasal bones, the intermediate
part, with lateral or triangular cartilages, and the lower part, represented by
alar cartilages that shape and support the tip of the nose.
The Inferior Turbinates
4
The nasal cavities are completely covered with mucus, firmly adherent to
the periosteum and perichondrium of the underlying osteocartilaginous
skeleton.
There are two distinguishable kinds of mucosa:
• the respiratory mucosa, pink and moist, that covers most of the surface.
It is a pseudostratified columnar epithelium with cilia that move the air-
flow towards the rhinopharynx; mingled within are the caliciform muci-
parous glands, which produces the mucus that drapes the nasal mucosa
for protective purposes; in the lamina there are glands with mixed
serous-mucous secretion. Into the deeper layer, a cavernous tissue of the
nasal mucosa is located, made of large, grossly dilated veins;
• the olfactory mucosa, smooth and yellowish, that covers the olfactory
region, surrounded by the superior turbinate, superior meatus and part of
the olfactory cleft, between the septum and the free edge of the middle
turbinate. The epithelium of this mucosa is made of three different cells:
- Schultze’s olfactory cells, which are actual neurons with a proximal
neuritic extension afferent to the first cranial nerve, and a distal den-
dritic extension, from where small branches on the mucosal surface
depart;
- supporting cells, cylindrical and very tall, each in close contact with
the other;
- basal cells, in contact with the basilemma; they can substitute the yel-
low-colored supporting cells.
In the tunica propria lie Bowman’s olfactory glands, which produce
serous secretions.
In this context we find the inferior turbinates, dynamic structures that are
entitled to divert the nasal airflow and create a first resistance barrier in
order to allow the supplying vascular system to “condition” the external air-
flow before entering the lungs (Fig. 4.1a,b).
a b
Fig. 4.1 Trajectory of inspiratory airflow inside the nasal conchae in sagittal (a) and frontal (b)
projections
These structures are rather bulky (4-7 cm long, 2 cm large), located in

the critical area of the nasal valve near the intermediate septum; they are
made of trabecular bone, supplied by a thick net of capillaries and lined
with mucocavernous tissue.
Examination of the nose by anterior rhinoscopy is capable of depicting
the size, morphology and color of the inferior turbinates, as well as the
pathophysiologic features of the nasal mucosa and the mucosal secretion.
Administration of a vasoconstrictor (e.g., oxymetazoline hydrochloride)
and an anaesthetic spray (tetracaine), may help to understand if the obstruc-
tion is caused by a simple mucosal congestion or, conversely, by anatomi-
cal changes such as an underlying trabecular hypertrophy.
All this considered, the indication for surgical treatment of the inferior
turbinates is recommended both in patients with unilateral compensatory
hypertrophy related to nasal septum deviation, and in those with chronic
bilateral hypertrophy.
Diagnosis
5
The most important step in medicine and surgery is the diagnosis: in this
concern, the diagnosis has to be functional and aesthetic.
Computed tomography (CT) of the paranasal sinuses has to be consid-
ered as an essential step before taking the decision of a possible nasal sur-
gery (Box 5.1 and Fig. 5.1).
Even when the reasons for surgery are merely aesthetic, CT scanning is
necessary for the following reasons:
• of the 80% of the population suffering from respiratory diseases, 30%
Box 5.1 What CT scans show

1. The septum in all of its parts
2. The inferior turbinate with possible hypertrophy
3. The middle turbinate with possible polypoid alterations or bullous conchae
4. The maxillary sinuses with mucosal alterations, sinusitis and polyposis
5. The meatal orifices, communication foramens between nose and sinuses. Serious sinusitis or
polyposis may obstruct the orifices, thus triggering increasingly critical diseases
6. The ethmoid and sphenoid sinuses, often affected by inflammatory processes
7. Congenital malformations and abnormalities
8. Expanding tumoral processes
1
2
3
5
4
Fig. 5.1 CT scan of the sinuses, frontal section. 1 Nasal septum; 2 inferior turbinates; 3 middle
turbinates; 4 maxillary sinuses; 5 meatal ostia

have no consciousness of the matter and are asymptomatic, as the inner

anatomical alterations are present from infancy and the respiratory mem-
ory has not perceived any worsening;
• after reductive rhinoplasty for aesthetic purposes, some previously hid-
den problems may become evident. The surgeon must therefore feel
compelled to avoid such unexpected events;
• a normal skull imaging does not provide satisfactory information
because it simultaneously shows an enormous amount of anatomical
structures at the caudocranial level, between the nose tip and the ears,
which is the actual extension of nose and paranasal sinuses. It should be
remembered that the nose communicates with the ears (Eustachian
tubes), with the eyes (nasolacrimal duct) and the maxillary, frontal, eth-
moidal and sphenoidal sinuses. For these reasons, CT scans are funda-
mental as they are able to distinguish in subsequent sections all the
anatomical structures.
Beyond the detailed assessment of disease extension, some other struc-
go
tm s
m
ti
Fig. 5.2 Coronal CT of the paranasal sinuses, which highlights, on the right, the bullous concha;
deformation of the right mid-turbinate associated with septal deviation, moved by the abnormal
development of the contralateral turbinates towards the opposite side. go, ocular bulb; m, maxil-
lary sinus; s, nasal septum; tm, mid-turbinate; ti, inferior turbinate
5 Diagnosis 19
tures accurately detected by a duly performed CT scan are of primary

importance for a surgeon (Fig. 5.2).
They consist in:
• the presence of anatomical abnormalities, as the bullous concha, of the
middle turbinate or the paradoxical turbinate;
• the uncinate process, a passage leading to the maxillary hiatus below,
and the frontal sinus infundibulum above;
• the position of the anterior ethmoidal artery crossing the ethmoidal
roof with a large number of anatomic variations; this artery must be pre-
served to prevent orbital bleeding or hematomas;
• the presence of abnormal cells such as Haller cells and Onodi cells;
• the medial wall of the orbit, the lamina papyracea; because of its deli-
cacy, it may be pathologically worn away, thus exposing the fibrous cap-
sule that should remain safeguarded;
• the thickness and position of the ethmoidal roof;
• the anatomy of the sphenoid and its relation between internal carotid
artery and optic nerve.
How We Attained Modified Inferior
Turbinoplasty
6
The inferior turbinates, main organ for respiration and the entire health, are
often still treated as if they were anatomic parts not related with the others
and almost always with caustic procedures such as laser, electrocautery or
even with more advanced radiofrequency therapies: this is a nonsense as
well as a deontological issue.
Back in 1951, Howard P. House published on the Laryngoscope journal
a fundamental trial about the need to evaluate, at any time, not only the
external size of the inferior turbinates, but also the possible hypertrophy of
the inferior curled bone.
During the 14th International Course of Plastic Surgery at the Clinica
Planas in Barcelona, held in June 2004, I had the opportunity of describing
once again how the bone portion can become hypertrophic for several rea-
sons. First of all, because of the peculiar conformation of the inferior curled
bone, which can be extremely trabeculate so as to make room for the vascu-
lar lacunae. Under the centrifugal traction produced by the ingravescent
hypertrophy of the soft mucocavernous tissues, the bone increases in volume.
It is essentially an osteogenic mechanical pressure induced by osteodis-
traction and supported by an increased vascularization. This leads not only
to better oxygenation but also to the influx of a greater number of nutrients
that enlarge the curled bone size until sometimes it reaches the septum
(turbinate-septum clash). The simple dislocation (out fracture) of the curled
bone cannot guarantee sufficient results, as it does not contribute to achiev-
ing a reduction in bone volume, but – as a result of strain trauma – it may
lead to further osteofibrous proliferation, capable of nullifying the treatment.
Hence the need to always treat the bone component of the inferior
turbinate.
This is the first reason why all the techniques defined as “hot” (laser,
electrocautery and radiofrequency) are to be proscribed at all cost. The
absurdity of using such techniques is even more evident if we refer to the
experiences of dentists and periodontal specialists, proctologists and oph-

thalmologists.
As a matter of fact, for over two decades, mucogingival hypertrophies
have no longer been treated with those hot techniques, which are responsi-
ble for relapses in 100% of cases. The same happens in ophthalmology
when it is necessary to cut the conjunctival mucosa.
Such obvious considerations prompted the need to treat inferior turbinate
hypertrophy using a more scientific and consistent method. The correct
approach to cope with the hypertrophy of all of these three anatomical com-
partments (lower curled bone, cavernous erectile tissue and mucosal lining)
should be the balanced and uniform dimensional reduction of all three com-
partments, thus restoring the physiologic ratio.
On this behalf, let us consider the modern approach of surgery towards
hypertrophic breast reduction (gigantomastia). As happens with the inferior
turbinates, breasts are also made of three anatomical compartments: the
gland, the adipose tissue and the skin envelope. Plastic surgeons would never
dream of introducing a needle connected to an acusector into the breast tis-
sue and electrocuting, or to use laser to obtain volume reduction.
In such a case, it has always been clear that the approach must be differ-
CURLED BONE GLAND
CAVERNOUS
FAT TISSUE
TISSUE
MUCOSA SKIN
Fig. 6.1 Anatomical structure of the nasal turbinates and the breast
6 How We Attained Modified Inferior Turbinoplasty 23
ent. Therefore, why should the intervention on turbinates be different?

The reasons are manifold. The first and most obvious one concerns the
anatomical position of the inferior turbinates and the difficulty of being able
to correct them completely.
The second reason is represented by common practice and by the fact
that the industry has made available to surgeons technical equipments that
are very easy to use. But the most critical reason is, as a matter of fact, the
lack of a stimulus towards innovation and the well-being of patients.
Another key aspect is the performance of medical and surgical treatments
carried out without a correct diagnosis. Too often do we examine patients
who have undergone surgical intervention with hot techniques, who unfortu-
nately witness the unavoidable relapses, and present with severe deviations
of the nasal septum, sinusitis, reduction of ostium-meatal complex volume,
etc., which, as we know very well, are the leading cause of inferior turbinate
hypertrophy.
Prior to any intervention, a CT scan is essential to correctly assess all the
anatomical structures that define adequate respiration. Lower turbinates
showing unmistakable signs of hypertrophy are no accident, but depend on
an alteration in uni- or bilateral airflow. In this case, septal deviations rep-
resent the main cause of the so-called “compensatory hypertrophy” of one
or both inferior turbinates. This is the initial mechanism through which
nature tries to limit the overflow of cold air passing through the choana
enlarged by the septal deviation (concave portion).
There are also conditions of uni- or bilateral valvular insufficiency, gen-
erally caused by trauma or incorrect surgery, that may also change the air-
flow, thus causing a compensatory hypertrophy through the same patho-
physiologic mechanism. A thorough diagnosis should prevent any mistake
in surgical treatment choice. These considerations have not only led to the
introduction of the modified inferior turbinoplasty (MIT) technique, but
also to “Global Rhinoplasty”, which represents a rational method to face
complex situations and disorders that affect the nose and limit its function
by triggering new diseases throughout the respiratory (throat, bronchi and
lungs) as well as the myocardial regions.
To sum up, a CT scan of the paranasal sinuses without contrast enhance-
ment should always be performed before surgery, so as to select a surgical
approach capable of reshaping the lower turbinates, as happens with hyper-
trophic breasts. To gain a correct access, it is necessary to use an “open
approach”, which is the most appropriate method not only to perform MIT,
but also to meticulously and predictably perform septoplasty to enlarge the
meatal ostia and to restore any anatomical part of a deviated nose.
The New Modified Inferior Turbinoplasty
7
Hypertrophy of the inferior turbinates has always represented a serious prob-

lem for those involved in nasal surgery.
Back in 1952, the American surgeon Howard P. House drew attention to
the fact that hypertrophy of the inferior turbinate was almost always related
to the increase in size of the inferior curled bone. Gottarelli later explained
this increase in size as caused by two factors: the increased metabolic
processes at the expense of the hypertrophic soft tissues caused by hyper-
vascularity and related angiogenesis, and the mechanical factors typical of
osteodistraction: since the inferior curled bone is very elastic, trabeculate
and also naturally vascularized, the “migration” of the soft parts towards the
septal wall creates a kind of traction at the expense of the bone, which starts
to stretch and grow.
As a consequence, in order to obtain a correct restoration of the hyper-
trophic inferior turbinates, it is necessary to also intervene on the curled
bone.
In fact, all surgeons recognize the superiority of turbinoplasty compared
to simple turbinectomies and to all easier procedures aimed at reducing the
soft tissues alone through direct heat application or laser photothermolysis.
All these simple and rapid methods show their weak points very soon, with-
in six to twelve months, and sometimes even earlier! This happens because
a tissue either resected or treated by thermal stimulation, responds in the
medium period by developing secondary hyperplasia. Periodontology, a
branch of dentistry that deals with the tooth-supporting apparatus and, in par-
ticular, with gum health, has given up many years ago to the use of radiofre-
quencies and electrocautery for gingival remodeling. This occurred because
the recurrence of gingival overgrowth was the rule. Periodontologists have
therefore gone back to corrective interventions using cold-cutting scalpels.
The first surgeon who reconciled these needs was Dr. Cottle, who pro-
posed a sort of decompression of the inferior turbinate in its bony and cav-
ernous portion (the tissue lying between the mucosa and the external bone)
through a vertical incision at the head of the turbinate.
In 1997, the potential of this technique was further improved, suggesting
a longitudinal incision from head to tail of the inferior turbinate, followed by
osteocavernous decompression with the reduction of the expanded mucosa.
The new method, named modified inferior turbinoplasty (MIT), achieves a
total reconstruction through suture flaps made of absorbable material.
This procedure consists of seven distinct surgical steps lasting approxi-
mately seven minutes. The big turning point is that, thanks to the precision
of the intervention, the onset of cicatricial synechiae (cicatricial tissue
between septal wall and turbinate) obstructing the choanae is prevented and
the risk of bleeding, in spite of the elimination of endonasal swabs, is virtu-
ally abolished.
In the creation of MIT, a crucial role was played by Tebbetts’ “open
approach”, first introduced in Italy by Gottarelli himself.
Among many opportunities offered by the “open approach”, there is the
careful control of the deep anatomical structures, such as the inferior
turbinate.
However, MIT is also feasible with the “closed” surgical approach,
although it is not an advisable practice.
7 The New Modified Inferior Turbinoplasty 27
Box 7.1 Anatomy of the intervention

The inferior turbinate is made of three parts, like a fruit:
• curled bone stone

• cavernous tissue pulp
• mucosa peel
For this reason, all anatomical components must be reduced, as happens with MIT.
MIT: 7 steps in 7 minutes
• Infiltration
Using a Carpules® syringe, anaesthetic drugs are locally infused (like dentists do before
extraction).
Duration: 15 seconds.
• Incision
The surgeon incides the turbinate longitudinally.
Duration: 15 to 30 seconds.
• Limb lifting
The turbinate is “opened” by lifting the cut edges. The bony tissue is therefore exposed.
Duration: 2 minutes.
• Reduction of bone hypertrophy

The bony portion of the turbinate is sharpened: the size is reduced and the hypertrophy cor-
rected.
• Reduction of cavernous tissue hypertrophy

Through the incision, the size of the cavernous and spongy tissues covering the bony portion
of the turbinate are reduced; lastly, the turbinate size is reduced.
Duration: 1 minute.
• Washing
The operated area has to be cleaned.
Duration: 15 seconds.
• Suture
The incision is stitched up using a surgical “hair-sized” thread; the suture is hermetic and
continuous, the thread is made of polylactic acid (made of carbohydrates) and therefore
absorbable.
After surgery
The nose should not be blown for 5-7 days following intervention. Conversely, accurate wash-
ings with seawater or saline thermal water (3-4 times a day) should be performed. Within a
month the patient’s conditions will normalize.
Post-traumatic Hump Nose
8
Treatment of the post-traumatic nose is extremely delicate and requires high-

ly professional technical equipment. The first rumor to be debunked is that
functional surgery is separated from aesthetic surgery. Nothing could be far-
ther from the truth. Functional surgery can never be separated from aesthet-
ic surgery and speaking of aesthetics is not as appropriate as speaking of
shaping or, better, of “eumorphy”, which means normal and natural shape.
Surgical treatment is difficult because we face the alteration and dis-
placement of most of the anatomical structures that make up the external
and internal nose. The nasal pyramid is often diverted to one side and the
tip to the other side, the dorsal line has a scoliotic pattern, the lateral carti-
lages are partially collapsed, as well as the nose tip cartilage. The disloca-
tion and luxation of the most prominent part of the cartilaginous septum
(candle septum) lead to collapse of the tip with an opening in one nostril
much wider than the other one. Inside the choana, through an anterior
rhinoscopy or a deeper endoscopic examination, we may see the cartilagi-
nous septum and the osteoseptum deviated in one or more points; hypertro-
phy of a turbinate in case of recent trauma or of both turbinates in chronic
cases, will therefore be unavoidable. Many of these patients become slaves
and addicted to vasoconstrictor sprays, the only weapon to “deflate” the
turbinates stuffed with blood and to receive a little airflow.
Using modified inferior turbinoplasty, this intervention, albeit difficult, has
reached levels of high result predictability with no postoperative pain, with-
out the application of swabs and with a short and totally safe hospitalization.
The versatility of Global Rhinoplasty and the strength represented by the
widespread use of cartilage autografts, capable of supporting and reinforcing
the deflected and weakened nose, is the utmost that can be done today to treat
the nose. The postoperative dressing with small plasters on the dorsum of the
nose, covered by a plastic and stiff material, has to be worn for seven days,
the same period as with ordinary rhinoplasty, and this again thanks to small
cartilaginous supporting and correcting devices that prevent the cartilage from
returning to the previous deviation (elastic memory of the septum).
Subsequently, MIT will be performed, as well as the regularization and
the centralization of the pyramid. This last maneuver will also be carried out
in the least traumatic and most conservative way and in respect of the anato-
my: if the nasal bones are off-axis, they should be mobilized to be straight-
ened, but not too much, so as to avoid the risk of excessively narrowing the
back of the nose. All this can be obtained using the method introduced in
1986 by Fernando Ortiz Monasterio.
This is the percutaneous greenstick fracture technique; by using 2 mm
micro-osteotomes we can reach our goal without producing the scars and
trauma typical of the ordinary 4 mm osteotome. The complete fractures of the
nasal bones are less precise and less controllable because of an over-mobiliza-
tion of the bone. The micro-greenstick-osteotomies are, in fact, incomplete
micro-fractures that limit the trauma, providing immediate stability.
We will see at this point how the different stages of MIT follow one
another, with the support of clear pictorial images.
MIT, Step by Step
9
Anatomy 32
Pathology 44
MIT Goals 52
Corrective Surgery 54
Step 1: Infiltration 56
Step 2: Incision 58
Step 3: Detachment 60
Step 4: Bone Decompression 62
Step 5: Mucocavernous Decompression 68
Step 6: Washing 72
Step 7: Suture 74
In this section, the images on the right side are commen-

ted in the text.

ANATOMY
The nose is made of two nasal cavities separated on the sagittal plane by the
septum, with an osteocartilaginous skeleton covered with periosteum and
perichondrium.
Structurally, four walls are identified:
• upper wall or vault, formed by nasal bones, frontal bone and ethmoid;
through the ethmoid cribrate lamina, the olfactory bundles originating
from the olfactory bulb enter into the nose;
• lower wall or floor, formed by the horizontal plate of palatine bone and
by the palatine process of the maxillary bone, which separates the nose
from the mouth;
• medial wall, or septum, formed (in the antero-posterior direction) by the
septal quadrangular cartilage, ethmoid perpendicular lamina, vomer and,
below, by the nasal crest of the maxilla and palatine process;
• side wall, which consists in the superior and medial turbinates, ethmoid
portions, inferior turbinate; moreover, the wall is also formed by the
frontal process of the maxilla and by the vertical plate of the palatine.
Sometimes there is also the supreme turbinate of Santorini, above the
superior turbinate.
The bony protrusions of the turbinates run parallel between them and form
many meati communicating with the nasal fossae, where the ways out of the
paranasal sinuses are: in the upper meatus, the narrowest one, the posterior
ethmoid cells drain; in the middle meatus, the largest one, the anterior eth-
moid cells, the frontal and the maxillary sinuses drain. These orifices are
located in the semilunar hiatus, a groove in the dorsal concavity limited
anteriorly by the uncinate process and posteriorly by the ethmoidal bulla; in
the inferior meatus drains the nasolacrimal duct.
The nose can be divided into an outer and an inner structure. The balance
between these two structures is essential for good respiration. For this rea-
son, the inferior turbinates must always be evaluated in advance even in
case of possible aesthetic surgery.
9 MIT, Step by Step 33
ANATOMY
1. Superior turbinate.
The medial expansion of the ethmoid has a rudimental development in human
beings, barely detected under the mucosal lining. It shows a nearly horizontal
development and the tail reaches the superior edge of the choana. On its medi-
al surface lies a portion of the olfactory area, which has a peculiar yellow-
brownish appearance (locus luteus).
ANATOMY
2. Middle turbinate.
It is an ethmoidal, triangular-shaped apophysis, with an anterior basis and a
posterior vertex. In the antero-posterior direction, it initially takes an oblique
direction, then a horizontal one.
The medial face is convex, while the lateral face is concave and hides the
middle meatal structure.
The medial lamina, anteriorly inserted at the basicranium, is covered by the
olfactory mucosa and crossed by olfactory nerve fibers. On the rear, instead,
the turbinate is loosely anchored to the ethmoid, and only its posterior end
is attached to the lateral wall of the nose.
With its lateral edge it is attached to the upright branch of the superior maxilla.
The inferior edge is thick and twisted, and gives rise to the concal sinus
(Zuckerkandl), sometimes divided into compartments by thin vertical humps.
The anterior end is a rounded bulge (operculum), separated from the nose
wall by a narrow cleft. A small hump (agger nasi) starts from the anterior
end and extends downwards and frontwards. The head can be pneumatized
to varying degrees in 5-10% of individuals (concha bullosa), a finding first
described by Santorinus (1724) and reported with evidences by Zuckerkandl
(1893). Often unilateral, it may sometimes reach a considerable size (28
mm), spreading to touch the septum or the inferior turbinate, or grazing the
floor of the nasal fossa. In the middle turbinate, the presence has been proved
of cystic forms, admirably described by Radoievitch et al. (1959). Already
present in the embryo (Kikuchi, 1903), and noticed at all ages, they are lined
up with the same mucosa as the ethmoidal cells (Kikuchi, 1903; Harmer,
1903). In very rare cases, meningocele has been reported (O’Brien, 1931).
The back end (tail) reaches the supero-lateral corner of the choana, approx-
imately 12-14 mm from the tubal ostium.
The concha bullosa is an abnormality in middle turbinate development:
instead of being a flat bone that limits the middle meatus, i.e. the area where
the paranasal sinuses open, favoring the entrance of inhaled air, it takes on
a globular shape and blocks the meatus, producing nasal respiratory
obstruction, which patients report as “high”. Owing to the malfunction of
the paranasal sinus orifices, recurrent episodes of sinusitis are frequently
reported.
ANATOMY
3. Inferior turbinate.
This is an independent, paired, symmetrical and thin bone, folded on itself,
sagittally elongated, triangular in shape. In the anterior portion it is slightly
oblique downwards and frontwards, and procedes almost horizontally near
the floor of the nasal fossa. The rear end, instead, is very sharp.
The inferior turbinate has two free faces, two joint edges, a free edge and
two ends.
• Internal or nasal face. An oblique ridge divides downwards and back-
wards this convex face into two sides, superior and inferior. The shape
of the curled bone and the amplitude of the meatus depends on the direc-
tion (horizontal or oblique) of the superior side. Conversely, the inferior
side always has a sagittal trend and shows a surface plagued by irregular
bony ridges.
• External or meatic face, concave and less bumpy than the nasal face.
The shape of the superior (free) margin influences its depth: when it is
folded on itself some grooves are formed, becoming areas of stagnant
secretions.
• Joint (anterior and postero-superior) margins. The superior edge is
connected with the upright branch of the superior maxilla. The postero-
superior edge has an oblique direction downwards and backwards. It is
anteriorly connected with the posterior lip of the lacrimal dacryocyst and
posteriorly with the posterior turbinal crest of the palatine bone. The
apophyseal system of the superior turbinate is originated from the superi-
or margin and it consists, in the antero-posterior direction, of the lacrimal
process (the external face forms, together with the lacrimal dacryocyst of
the superior maxilla, the naso-lacrimal duct; the inner face corresponds to
the anterior segment of the middle meatus), in the maxillary or auricular
process, so called for its peculiar shape resembling a dog’s ear, and in the
ethmoid process, trait d’union with the uncinate process.
• Free margin. Considerably thick, it is close (4-5 mm) to the nasal cav-
ity floor.
• Anterior end (head). Next to the piriform ridge (2-3 mm), it is attached
with its anterior edge to the upright branch of the maxilla.
• Posterior end (tail). It is located approximately 1 cm from the tubal open-
ing, whose function can be seriously damaged by disorders of the tail.
ANATOMY
Superior meatus. Poorly developed, it is to be taken into consideration

because its anterior portion leads to the orifices of the posterior ethmoidal
cells. Its anterior portion contains the olfactory cleft, that extends up the
upper part, between septum and mid-turbinate, towards the root of the nose.
Posteriorly, the superior meatus is narrowed by the anterior wall of the
sphenoid.
Middle meatus. Limited superiorly and medially by the internal face of the
middle curled bone and laterally by the nasal wall, it represents a fundamen-
tal cavity from a clinical and surgical viewpoint. It receives the draining ori-
fices of the maxillary sinus, anterior ethmoid and frontal sinus.
Knowledge of the ratio between the lateral wall of the meatic cavity and the
adjacent formations is of primary importance: downwards, the maxillary
sinus; in the remaining portion the medial wall of the orbit and the dacry-
ocyst. This wall is quite regular in the anterior and posterior portion, while
the middle one is crossed by two humps (uncinate process and bulla) and
two grooves (uncinate process groove and bulla groove). The two humps,
backwards and downwards, are considered by some authors as “rudimenta-
ry turbinates” while, according to Mouret’s opinion, they are inversés et
éversés turbinates, i.e. their meatus is located up and backwards instead of
being down and frontwards. From this viewpoint, the uncinate process
groove represents the meatus of the same process, while the groove of the
bulla constitutes the meatus of the bulla itself.
The uncinate process (unciform apophysis) is a thin bony scimitar-shaped
lamella. It adheres to the lateral wall only in correspondence to the antero-
superior (ethmoidal) and postero-inferior (maxillary) ends. The mid-portion
(body) may have a different morphology and direction. The inferior end
crosses the main orifice of the maxillary sinus and sends three extensions:
inferior, towards the inferior turbinate; posterior, to the palatine bone; pos-
tero-superior, to the bulla. The bounded surfaces may lack a bony wall.
ANATOMY
Inferior meatus. It is the area between the concave face (external or meatal)
of the inferior turbinate and the nasal wall. The latter consists of three separate
structures: the inner face of the upright branch of the superior maxilla (anteri-
or third); the inner portion of the maxillary sinus (middle third) and the pala-
tine bone (posterior third). In the anterior third the nasolacrimal duct opens,
while the boundary between the maxillary and the palatine is marked by a hia-
tus, made of a thin bony lamina: the auricular apophysis, locus minoris
resistentiae, of the maxillary sinus wall.
The amplitude of the meatal cavity varies greatly, depending on whether the
inferior turbinate is flattened or rounded.
As a general rule, we will have in the first case a long curled bone, a nar-
rowed nasal concha and a reduced meatus; in the second case, the curled
bone will look short, the nasal concha will be grooved with very marked
humps and the meatus will be large with a reduced-sized maxillary sinus.
The increased vascularity caused by mucocavernous hypertrophy creates a
force (osteodistraction) capable of dragging the curled bone towards the
septum, even thanks to an accelerated osteogenesis, increased by metabolic
processes.
PATHOLOGY
The factors responsible for turbinate disorders are manifold: the most com-
mon pathological conditions are allergic, vasomotor or drug-related disor-
ders, together with the so-called compensatory hypertrophy, which gradual-
ly develops on the opposite side of the septal deviation at the expense of the
bony, vascular and glandular tissues of the nose. The connected causal ele-
ment is chronic “irritative” stimuli of different nature: allergic, nervous,
chemical, thermal, mechanical and pharmacological reasons.
Therefore, from a histopathological viewpoint, hypertrophic-hyperplastic
disorders of increasing severity and decreasing reversibility develop. Actual
hypertrophy is still a physiological response, characterized by glandular
hyperactivity, sinusoid dilatation and stromal cell hypertrophy. This stage is
characterized by the possibility of reducing swelling after local vasocon-
strictor application.
In the next stage (hyperplasia) some structural alterations develop, confirm-
ing the irreversible pathological frame: thickening of the epithelial layer,
cellular infiltration of the real tunica, neoformation of blood vessels, prolif-
eration and myxoid degeneration of connective tissue stroma, hypertrophy
of the curled bone, mostly in the inferior turbinate.
CT imaging (below left) shows hypertrophy of the right inferior curled bone.
PATHOLOGY
Compensatory hypertrophy: CT imaging with evidence of the hypertrophic

curled bone.
These structural changes can be located above all at the rear end of the
turbinate (in particular the inferior curled bone), leading to the so-called
morular degeneration of the turbinate tail. This disease is responsible for
very different symptoms: nasal stenosis, mostly during expiration, sleep dis-
comfort, mucopurulent discharge in the nasopharynx, auditory disorders,
dry throat, pharyngeal tenesmus, as well as symptoms reflected by the near-
by structures.
PATHOLOGY
The inferior turbinate, largely made of erectile tissue, is the most frequently
involved structure. However, there is also evidence of these formations in the
middle turbinate at the rear end of the septum. These changes in turbinate size
modify the volume and shape of the nasal cavities with a lumen reduction
resulting in a significant increase in nasal resistance (law of Blasius).
Compensatory hypertrophy: CT imaging (above and below left) with evi-

dence of hypertrophic curled bone.
PATHOLOGY
The inferior turbinates, whose skeleton is made of an independent little bone,

are the largest and longest nasal turbinates (4-5 cm), with a triangular oblong
shape and an anterior base corresponding to the head of the turbinate, locat-
ed few millimeters away from the nostril; the posterior apex or tail of the
turbinate is located 1 cm away from the opening of the Eustachian tubes.
The respiratory portion of the nasal fossae, along with large sections of the
olfactory structure, is lined with a smooth, pink-colored mucosa, 2 mm thick
at septal level. It becomes thicker, up to 5 mm, at the inferior turbinate level,
rich in cavernous or erectile tissue, especially at the head and tail levels.
The physico-chemical stimulation of the nasal mucosa is expressed in a reflect-
ed way, at the nose level, with circulatory changes, especially in the erectile tis-
sue of the turbinate, accompanied by changes in the lumen of the nasal fossae
and by increase in glandular secretion, mainly serous and mucous. At the same
time, the reflex decreases the amplitude and rhythm of the respiratory system;
the air can remain sufficiently in touch with the surface of the nasal mucosa
and is conditioned in temperature, humidity and purity.
The cavernous tissues are particularly important for the vasomotor reac-
tions. Since this tissue is mainly present at the inferior turbinate level, these
structures are essential for correct breathing.
Temperature and level of humidity of inspired air are emblematic vari-
ables in the characterization of inferior turbinate vasomotor reflex: cold air
causes congestion of the cavernous spaces, as well as excessively hot and
dry air. On the other hand, hot and moist air causes decongestion of the infe-
rior turbinate. The mechanical or chemical stimulation of the nasal mucosa
leads to an increased secretion of serous, particularly fluid material. The
marked vasomotor and secretory reflexes of the nasal mucosa are closely
related and play a very important role in nose defense. This high reactivity
can exceed the limits, going from physiological to pathological, in the so-
called neurodegenerative nasal syndromes, such as hypertrophic inferior
turbinate vasomotor rhinitis.
It is therefore essential to reduce all three anatomical components of the
inferior turbinates as suggested by the MIT method.
Mucosa
Cavernous Tissue
Curled Bone
MIT GOALS
MIT offers the possibility to be free from vasoconstrictor addiction, without

the use of “hot” techniques such as laser, radiofrequency and diathermo-
electrocoagulation (DEC), through a simple, completely painless operation
without the use of swabs.
More than twenty years ago dentists, periodontists, proctologists and oph-
thalmologists have stopped cutting mucous membranes with “hot” tech-
niques, both because of the inevitable relapses and of the tissue alterations
induced by these interventions. Furthermore, “hot” techniques have proved
to be ineffective against bone hypertrophy.
DEC is one of the so-called “hot” techniques that must not be considered as
resolutive in the treatment of osteo-mucocavernous hypertrophy of the infe-
rior turbinate.
CORRECTIVE SURGERY
Open rhinoplasty is performed through a small cut in the middle of the col-
umella that will be almost unrecognizable upon complete recovery. Through
the columellar incision, all structures are exposed: alar and triangular carti-
lages, nasal valve, septum and dorsal bone.
The surgeon is thus able to examine and assess any abnormality in shape,
asymmetry or structural alteration to be corrected with the highest accura-
cy. Any suture and graft can be performed with extreme precision.
In order to avoid any scar, surgeons perform particular cuttings with differ-
ent shapes, according to the surgeons who developed the techniques. The
suture is made with thin wires and after 2-3 weeks the scar is almost imper-
ceptible and becomes virtually invisible upon complete recovery.
STEP 1: INFILTRATION
The first step in MIT is suggested by the need to operate in a bloodless field
as much as possible; since the cavernous tissue is very rich in blood, it is
essential to follow this preliminary step.
• The first reason is to reach an adequate vasoconstriction that allows us
to work in a bloodless field.
• The second reason is the creation of an hydrodissection between the soft
tissues and the inferior curled bone of the turbinate.
• The third reason is that the injected fluid amplifies the turbinate volume
and solidifies it, thus highlighting the exact point for the longitudinal
incision.
Infiltration is performed by using a dental Carpules® syringe with a 27-
gauge, 35-mm needle. A cartridge is inserted into a dental-type syringe,
with a solution of mepivacaine 1:100,000 with epinephrine.
Infusion is carried out by inserting the needle into the head of the turbinate,
first superficially as to blanch the mucosa, then reaching the bony level of
head, body and tail of the turbinate.
A 1.8 mL cartridge is sufficient to achieve the desired result. It is recom-
mended to wait few minutes during which additional washings of cartilagi-
nous septum will be performed, evacuating small hematomas formed
between the two mucosal layers. As a matter of fact, it must be remembered
that inferior turbinoplasty should always be performed after spur and devia-
tion correction. This is necessary to take advantage of the widest working
area inside the choana, always taking into consideration that in order to solve
the patient’s respiratory disease, it is absolutely necessary to remove all the
causes originating turbinate hypertrophy. At this point, after few minutes, a
n. 14 nasogastric probe is inserted, connected to an aspirator that is posi-
tioned in the nasopharynx through the other nasal opening. This simple
maneuver allows to work more easily in an operating area free from blood,
but also from the solution (saline) with which choanae and turbinate are con-
tinuously irrigated.
STEP 2: INCISION
Once the first step of MIT is completed, the incision is performed, using a
Bard-Parker handle blade, size 15, Aesculap Inc.
The incision should be carried out longitudinally from the body towards the
head of the inferior turbinate, taking care to remain along the midline. The
blade must be sunk to the periosteum and then brought up to the head of the
turbinate.
Great attention must be paid when the cut is approaching the head of the
turbinate as there are many anatomical variations and one of the two edges
to be lifted could be completely detached. In this unfortunate case, without
being discouraged, the nasopharynx flap head must be recovered and imme-
diately sutured to the contralateral one. It is advisable to practice at least two
stitches in Vicryl 5/0 to better stabilize the flaps on the head of the turbinate.
Once this stabilization is fulfilled, the intervention can continue regularly.
The incision of the turbinate tail will only be performed after sufficiently
detaching the soft tissues from the bone: in this case, it is better to continue
the separation of the flaps using angled scissors that, where the turbinate
tapers off, allow for a safe incision.
By accurately performing the first and second steps of MIT, as described
above, one can observe the gaping of the arteriola only in 0.5% of the cases.
When this occurs, it is recommended to coagulate the vessel with an acu-
sector using a Colorado tip with 30° angulation.
A new irrigation with saline is then practiced and the next step of detach-
ment and lifting of the two mucocavernous flaps can be performed.
STEP 3: DETACHMENT
This third step is crucial to be able to perform the following reduction of the
underlying hypertrophied curled bone and have a suitable sliding of the
mucocavernous tissue carrying out a correct suture. By using the access way
created through the incision, and using a particularly thin periosteotome, the
soft portion of the bone is gently separated, starting from the head up to the
body of the turbinate. Once the body is detached, even laterally, detachment
continues along the midline, creating a tunnel where the angled scissors will
pass; this will allow for enlargement of the incision along the tail of the
turbinate without risking laceration of the mucosa.
Now the detachment can free the curled bone completely from the soft
parts, thus facilitating the subsequent removal of bony excess. Even in this
step, washings with saline solution should be repeatedly performed.
Instruments used to perform MIT correctly.

STEP 4: BONE DECOMPRESSION
This fourth step of turbinoplasty is of primary importance: it must be known

that the turbinate bone gets consistently hypertrophic with soft tissue hypertro-
phy; therefore, if a good reduction of the inferior turbinate is to be obtained,
the soft tissues must not be the only ones to be cauterized.
Moreover, some surgeons maintain that dislocation (out-fracture) of the
turbinate may be sufficient, because the air will have more space to get in
simply by moving the turbinate externally. This maneuver is certainly very
useful as a palliative, but the fibrotic repair of the out-fracture will soon
cause a new increase in volume, partially nullifying the result. All this will
be facilitated by the increased residual presence of blood (mucocavernous
hypertrophy) frequently occurring after laser, radiofrequency and electro-
cautery treatment.
This is why, once the curled bone is entirely isolated, partial removal will
be performed using nippers, simply through the careful and gentle use of a
Freer detacher. It is sufficient to leave a moderate amount of bone as soft tis-
sue support, while a complete removal of the inferior curled bone could
cause a soft tissue gaping during respiration. This situation is to be avoided
at all costs.
A simple CT scan confirms how and how much the curled bone is hypertro-
phied, perfectly highlighting what has occurred inside the inferior turbinate.
Back in 1952, the Laryngoscope magazine issued a study by Howard P.
House on the need to reduce the turbinate, bony structure included. Almost 60
years later it is not difficult to notice that the majority of surgeons, instead of
performing turbinoplasty correctly, limit to “scorching” the soft tissues with
different devices. This way, reductions of the soft parts are performed sepa-
rately, without removing the causes that have led to turbinate hypertrophy.
Removal of fragments of the surgically reduced hypertrophic curled bone.
When removing the fragments of the curled bone, it is necessary to leave a

moderate amount of bone as support for the soft parts: the risk of a total abla-
tion of the curled bone could cause a gaping of the soft parts during breathing.
At this point, the inferior turbinate can be compared to the stone of a fruit:
a cherry that has enlarged to the size of an apricot.
STEP 5: MUCOCAVERNOUS DECOMPRESSION
Once the stone is reduced, the pulp and the peel of the fruit should be
reduced too. This is the simile with which MIT can be explained to patients
during their first visit. We can now proceed to reduce the volume of the two
turbinate flaps by using the specific angled scissors.
Reduction and removal of the superior tissue flap of the turbinate.

STEP 5: MUCOCAVERNOUS DECOMPRESSION
Generally, the thicker part is represented by the lower flap and its removal
will obviously turn out to be asymmetric. The removed tissue will have a
lozenge shape, looking like a reddish leech.
During this step, by analyzing the removed structures, the tissue changes
caused, for instance, by a frequent use of vasoconstrictors may be seen. In
this case, a pale and thickened mucosa will be seen, or else the post-treat-
ment degeneration of “hot” techniques may be noticed, as well as the so-
called morular degeneration by the irregular edge of the lining mucosa or
even by real polypoid degenerations.
STEP 6: WASHING
Washings with saline solution are repeatedly performed at each step of

rhinoplasty as well as of turbinoplasty procedures.
Before starting the reconstruction of the inferior turbinate with stitches, it is
advisable to carry out repeated washing to remove small bone fragments
that could lead to complications.
STEP 7: SUTURE
The great advantage of this method, if well executed by suturing the

turbinate flaps, is the perfect anatomic restoration, as plastic surgery does in
a breast reduction intervention.
This is not only satisfying, but also essential to maintain the breathing air-
flow unchanged as much as possible. The suture material used in these cases
is an acid polylactic wire with a P3 curved sharp needle. The use of a
Castroviejo needle held with thin tapered branches is strongly recommend-
ed. When the visibility of the turbinate tail is optimal, a continuous suture
may be performed starting from the deep structure and paying attention to
joining the flaps as much as possible. Sometimes it is advisable to start the
suture with detached stitches, starting from the head of the turbinate. This
will simplify the stitching procedure distally at the tail. The upper attach-
ment of the flaps will subsequently allow for a better vision to join the flaps
at a deeper level. As a general rule, two wires are used for each turbinate, in
order to have a new and sharper needle for the deep suture. The needle may
get blunt by crushing against the residual curled bone.
Once turbinate reconstruction is finished, it may be useful to temporarily

insert a half n. 8 Merocel buffer until the end of the intervention, whose mild
compression will prevent blood storage within the neo-turbinate, facilitating
attachment of the flaps to the periosteum. When the septoplasty or sep-
torhinoplasty operation is done, the buffers will be removed as they are no
longer needed with this method. In the postoperative period, endonasal
washings three times daily will guarantee suture absorption in about four
weeks.
The Concept of “Respiratory Symmetry”
10
In this chapter the reader will find the essence of nasal surgery interpreta-
tion. Inferior turbinate hypertrophy was an unsolved problem before MIT;
instead of being the decisive solvers of these health problems, surgeons had
to take on more modest and unpretentious tones to explain to the patient the
onset of relapse and treatment failure.
Thanks to the logic and common sense that have guided such a new
method (i.e. reduction or re-shaping of all three hypertrofied anatomical
compartments with tissue reconstruction through a precise suture that avoids
buffers and bleeding), MIT has finally solved the essential problem of infe-
rior turbinate hypertrophy. But another, equally important problem remained
pending: how to limit any possible extrinsic cause that could favor inferior
turbinate hypertrophy. Starting from the assumption that the inferior
turbinate always perceives any new uni- or bilateral change in the inspirato-
ry airflow by producing hypertrophy – although with different timings from
patient to patient – we must always seek to reproduce “symmetrical” air-
flows as much as possible.
The reader will now wonder how it may be possible to discuss about “air
symmetries” when, from a physiological viewpoint, the result of the so-
called “nasal cycle” leads, during daytime, to an obvious asymmetry?
One of the possible interpretations of this phenomenon is to be found in
a continuous and alternated automatic control of the functions of these very
important organs, the lower turbinates. When several examinations depict a
permanent anatomical change, an irreversible hypertrophy process (usually
compensatory) has been triggered. The reason for this irreversibility, in
spite of denial by some renown surgeons, lies in the fact that hypertrophy
starts in the soft tissues, then involves the inferior curled bone (metabolic
and bony distraction theory), creating a new anatomic disease that could
only be clearly treated through multi-compartmental reductive surgery. MIT
is exactly the ideal method for the definitive solution to this disease.
Therefore, experienced rhinoplasty surgeons should always make sure,

during the preliminary diagnosis, to check all the anatomical structures that
can affect “symmetric” breathing. We have seen how CT scans of the
paranasal sinuses can be of great help during this stage; an accurate and tar-
geted assessment of the external nose, by also controlling shape and stabil-
ity of the nose tip, the convex or concave form of one or both alar or trian-
gular cartilages, as well as any likely diversion or deviation, could become
more useful.
In post-traumatic noses (the “boxer’s nose” for instance) or in some
failed rhinoplasty outcomes, the height and projection of the nasal bridge
(saddle nose) as well as the stability or instability of the tip, often totally
unsupported with relevant collapse, should be carefully checked.
These alterations in shape create valvular insufficiencies that cannot be
ignored. Palpation of tip consistency will reveal the lack of columellar sup-
port of the caudal septum, typical of the boxer’s nose, but also of many sep-
toplasty outcomes, improperly performed with Cottle’s technique.
As far as septal deviations are concerned, CT findings cannot be com-
pletely reliable. Radiologists should visit their patients before performing a
CT scan. There are, in fact, many caudal septal deviations unrevealed at
imaging (because actually, they are caudal cartilages) that could be clearly
revealed through an external inspection.
Therefore, asymmetric respiration is mainly caused by the following rea-
sons:
• septal deflection;
• valvular insufficiency;
• stenosing neoformations.
The Control of Relapses
in Septal Deviations
11
With regard to the control of septal deviation relapses, an updated system

will be illustrated to fix the caudal to the superior maxillary septum and, in
particular, to the anterior nasal spine.
It is a particular stitch, which safely and strongly joins together a fragile
tissue (the septal cartilage) to another extremely hard and cohesive one (the
bone). Furthermore, a second difficulty frequently occurs, caused by the dis-
tance between the cartilaginous septum and the bone. This distance (ranging
from 1 to 6-7 mm) forms immediately after the removal of the deviated por-
tion at its insertion level in the palatine crest of the superior maxilla. With a
regular suture, the difficulty is focused on the ability to tighten the approach-
ing suture properly without tearing the cartilage. Almost always, the assistant
must hold the knot using the anatomical clamp before final suture tightening.
Gottarelli’s “3GK” stitch has solved these problems once and for all.
11.1 Technical Performance
According to personal experience, a 3/0 braided, non-absorbable wire, with a

bladed needle (Ethibond, Ethicon) is used. After needle passage through the
two sides to be joined, instead of proceeding and knotting the wire, the head of
the wire should be passed at least three times around the other end of the wire
(dormant). This creates a sort of snaky stitch that has a double purpose: wire
locking (keeping it in tension) and creation of a kind of tension-breaker or, bet-
ter, tension-distributor along the axis of the wire with a “coil”, thus preventing
cartilage collapse and breakdown, but maintaining its correct position.
The number of turns around the head of the dormant wire should be at
least three if the gap between septum and bone is between 0 and 2 mm. For
every additional millimeter, an additional turn around the coil should be
added; for example, if the distance between the two different tissues is 5
mm, a coil of at least 6 turns should be created.
Of course, once the coil step is completed, the three regular knots of per-
manent closure will have to be carried out.
With this method there is no possibility to create a relapse for dislocation
of septum quadrangular cartilage. With the aim of “balancing” the airflows,
any obstacle arising from the ridges and spurs of the osteoseptum will obvi-
ously be eliminated. If valvular insufficiency coexists, it will be treated with
cartilaginous grafts, such as Sheen spreader grafts, with cartilaginous battens
if there is a collapse of the lateral crus or with a transversal graft between the
two lateral crura or lateral crural spanning graft (LCSG), as described by
Tebbetts.
If polipoyd neoformation or anything else arises, its removal should be
carried out, as well as the possibility to perform an enlargement of the meatal
ostium, according to the philosophy of Stammberger’s functional endoscop-
ic sinus surgery (FESS), should always be strongly taken into consideration.
Conclusions
12
Several reviews in the literature highlight the success and limitations of the
different surgical techniques used in turbinate hypertrophy treatment.
Passali and colleagues have conducted a trial on 457 patients affected by
nasal obstruction operated with different techniques, excluding patients
with rhinitis and/or infectious sinusitis, nasal septum deviations, polyposis
or those who had previously undergone other surgical treatments. At 4 year
follow-up on 382 patients, the results of the analysis showed short-term res-
piratory permeability (in terms of nasal permeability through the assess-
ment of nasal resistance by rhinomanometry and rhinometric volumes
detection) when techniques such as electrocautery, cryotherapy and laser
therapy were used, that could only be upgraded using turbinectomy.
Another aspect emerging from this study is that the out-patient treatment
is worsened by a higher rate of scars and nasal function changes, while sub-
mucosal decongestion treatments are often complicated by postoperative
bleeding, as well as turbinectomy, even though it stimulates the recovery of
mucociliary transport and local production of humoral defense factors. The
conclusion of the Italian authors is that the technique of choice in inferior
turbinate hypertrophy treatment is the decongestion of the submucosa, bet-
ter still with lateral dislocation, which is able to restore nasal district activ-
ities with the respect of nasal physiology.
Hol et al. reached the same conclusions: turbinoplasty seems to represent
the method of choice. Some time later, Willat reintroduced the concept that
it must not be identified as the only best technique, but as the right method
for all patients with the purpose of obtaining long-term results. This aim has
been pursued in the development of the MIT technique, which undoubtedly
represents at present the most complete approach for reduction of the inferi-
or turbinate. This technique, associated with structural rhinoplasty and
FVTR, has led to a new approach in nose surgery, Global Rhinoplasty (func-
tional and aesthetic), thanks to which a decrease in postoperative bleeding
risk may be attained by completely eliminating the use of the so-dreaded

swabs and by improving the quality of patient’s life after surgery. A method
capable, after all, of combining clinical needs with the patient’s aesthetic
expectations, with compliance levels never obtained before.
Suggested Reading
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About the Author
Academic Activities
Born in Bologna in 1952, Paolo Gottarelli graduated in 1978 in Medicine and Surgery
with honors in the same city. Later on, he specialized in plastic surgery and dentistry.
From 1980 to 1996 he was hospital assistant and primary aid at the Division of Plastic
Surgery at the Rizzoli Orthopedic Institute in Bologna.
Subsequently, he obtained further post-graduate diplomas in biomaterials, cosmetic sur-
gery and nasal surgery.
From 1992 to 2007 he worked with a fixed-term contract as Professor of Aesthetic and
Functional Corrective Surgical Techniques of the nasal pyramid at the University of
Ferrara Department of Otolaryngology directed by Charles Calearo.
From 1992 to 1995 he worked with a fixed-term contract as Professor of Plastic Surgery
principles at the School of Specialization in Physical Medicine and Rehabilitation –
University of Bologna.
From 1992 to 1994 he worked with a fixed-term contract as Professor of Surgery of oral
pre-cancer at the School of Dentistry and specialization in Dental Prosthesis at the
University of Bologna.
From 1992 to 1993 he worked with a fixed-term contract as Professor at the Higher
Institute of Holistic Medicine and Ecology at the University of Urbino.
Professional Activities
In 1989, he introduced for the first time in Italy the innovative Septorhinoplasty tech-
nique by John B. Tebbetts, Dallas.
Since 1991 he was interested in Plastic Surgery computer application, with particular
respect for the informed consent.
From 1992 to 2008, in addition to the ordinary academic activities, he held CME
accredited lectures on Septorhinoplasty, Outpatient Surgery and Lip Surgery.
In 1994 he won the 1st prize for best performance at the National Congress of Videoplasty
Surgery of the Italian Hospital Surgeons Association (ACOI, Associazione Chirurghi
Opedalieri Italiani) with a multimedia video about Tebbetts’ Rhinoplasty technique.
In 1996, at the 45th National Congress of Plastic Surgery, he organized the “Plastic sur-
geon and computer” workshop.
85
In 1997, he was the Chairman of debates about the peculiarities of patients who under-
go plastic surgery at the Informatics Fair “Future Show 2997”. In June, he ran the first
multimedia video lecture on Open Septorhinoplasty according to Tebbetts’ method.
In 1997 he developed the modified inferior turbinoplasty (MIT), an innovative method
of reshaping the inferior turbinates with 4,000 case reports.
In 1998 he was invited to hold a magisterial lesson about Force Vector Tip Rhinoplasty
(FVTR) at the 13th training course of Cosmetic Surgery (monothematic course of
Primary and Secondary Rhinoplasty) in Trieste.
In 2002 he was invited for two lectures at the International Conference of Rhinoplasty,
Dubrovnik.
In 2003 he participated in the 5th Symposium on Aesthetic Plastic Surgery in Barcelona,
where he performed some Rhinoplasty surgeries at the Teknon Medical Center. In this
occasion he showed for the first time his MIT technique.
In 2004 he attended the 14th International Course on Plastic and Aesthetic Surgery,
Barcelona, chaired by Jaime Planas, where he presented four reports on nasal correction
techniques he developed and performed some live interventions at the Clinica Planas.
In 2005 he participated in the 23rd International Annual Symposium of Plastic Surgery-
Aesthetics of Guadalajara in Mexico, chaired by José Guerrero Santos, where he illus-
trated his innovative method on Global Rhinoplasty and modified inferior turbinoplasty.
To date, he is Director and Lecturer of numerous workshops in different Plastic Surgery
fields. In 2010 he also had a video made about MIT. The number of patients operated
with this technique has nowadays reached 5,000.

Modified Inferior Turbinoplasty

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Modified Inferior Turbinoplasty

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Modified Inferior Turbinoplasty

A New Surgical Approach

ISBN 978-88-470-2441-0 ISBN 978-88-470-2442-7 (eBook)

Springer Milan Heidelberg New York Dordrecht London

Library of Congress Control Number: 2011940270

© Springer-Verlag Italia 2012

9 8 7 6 5 4 3 2 1 2012 2013 2014

Cover design: Ikona S.r.l., Milan, Italy

Springer-Verlag Italia S.r.l. – Via Decembrio 28 – I-20137 Milan

Since the beginning of my medicine studies I have always been fascinated

1 The History of Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Well-Being and Respiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3 Nasal Anatomy and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

4 The Inferior Turbinates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

6 How We Attained Modified Inferior Turbinoplasty . . . . . . . . . . . . 21

7 The New Modified Inferior Turbinoplasty . . . . . . . . . . . . . . . . . . . 25

8 Post-traumatic Hump Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

9 MIT, Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

10 The Concept of “Respiratory Symmetry” . . . . . . . . . . . . . . . . . . . . 77

11 The Control of Relapses in Septal Deviations . . . . . . . . . . . . . . . . 79

About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Another important item regards child health; sometimes these patients

3.1 Embryological Development

Paolo Gottarelli, Modified Inferior Turbinoplasty © Springer-Verlag Italia 2012 7

3.2 Anatomical Structures

With the perspective of performing a corrective plastic surgery, the follow-

3.2.1 Soft Tissues of the Nose

3.2.2 Aesthetic Nose Structure

Before planning, preparing and executing any nasal surgery, it is necessary

• aesthetic nasal subunits:

3.2.3 Nose Bone Structure

In the antero-superior part of the splanchnocranium lies the nasal bone,

In addition to the basic components (cartilage, quadrangular, vomer, eth-

3.3 Functional Anatomy

fibers, elastic fibers, chondrocytes, proteoglycan units, hyaluronic acid

3.5 Nasal Function

These structures are rather bulky (4-7 cm long, 2 cm large), located in

Box 5.1 What CT scans show

Paolo Gottarelli, Modified Inferior Turbinoplasty © Springer-Verlag Italia 2012 17

have no consciousness of the matter and are asymptomatic, as the inner

tures accurately detected by a duly performed CT scan are of primary

experiences of dentists and periodontal specialists, proctologists and oph-

CURLED BONE GLAND

ent. Therefore, why should the intervention on turbinates be different?

Hypertrophy of the inferior turbinates has always represented a serious prob-

Box 7.1 Anatomy of the intervention

• curled bone stone

MIT: 7 steps in 7 minutes

• Reduction of bone hypertrophy

• Reduction of cavernous tissue hypertrophy

Treatment of the post-traumatic nose is extremely delicate and requires high-

Step 4: Bone Decompression 62

Step 5: Mucocavernous Decompression 68

In this section, the images on the right side are commen-

Paolo Gottarelli, Modified Inferior Turbinoplasty © Springer-Verlag Italia 2012 31

Superior meatus. Poorly developed, it is to be taken into consideration

Compensatory hypertrophy: CT imaging with evidence of the hypertrophic

Compensatory hypertrophy: CT imaging (above and below left) with evi-

The inferior turbinates, whose skeleton is made of an independent little bone,

MIT offers the possibility to be free from vasoconstrictor addiction, without

Instruments used to perform MIT correctly.

This fourth step of turbinoplasty is of primary importance: it must be known

Removal of fragments of the surgically reduced hypertrophic curled bone.

When removing the fragments of the curled bone, it is necessary to leave a