https://orcid.org/0000-0001-9092-7923
Abstract
Dorsal preservation surgeries in which the subperichondral and subperiosteal planes are used to elevate the soft tissue envelope of the nose have become increasingly widespread because they can reduce postoperative edema and promote faster healing. However, the effects of surgical dissection planes on the viability of cartilage grafts are not known.
The aim of this study was to determine, in a rabbit model, the viability of diced cartilage grafts in different rhinoplasty dissection planes (sub–superficial musculoaponeurotic system [SMAS], subperichondral, subperiosteal).
Diced cartilage samples were placed in the sub-SMAS, subperichondrial, and subperiosteal planes, and after 90 days, histopathologic analysis was performed. Cartilage graft viability was evaluated based on the loss of chondrocyte nuclei in the lacuna, the presence of peripheral chondrocyte proliferation, and the loss of matrix metachromasia in the chondroid matrix.
The median [interquartile range] percentages of live chondrocyte nucleus viability in the sub-SMAS, subperichondrial, and subperiosteal groups were 67.5% [18.75%] (range, 60%-80%), 35% [17.5%] (range, 20%-45%), and 20% [30.0%] (range, 10%-45%), respectively; and the percentages of peripheral chondrocyte proliferation were 80.0% [22.5%] (range, 60%-90%), 30% [28.75%] (range, 15%-60%), and 20% [28.75%] (range, 5%-60%), respectively. There was strong statistical significance in both parameters (P = .001). Intergroup examination revealed a difference between the sub-SMAS and the other surgical planes (P = .001 for both parameters). A smaller loss of chondrocyte matrix was observed in the sub-SMAS group compared with the other 2 groups, which supports the findings of cartilage viability (P = .006).
Elevating the soft tissue envelope of the nose in the sub-SMAS surgical plane preserves the viability of cartilage grafts better than subperichondrial and subperiosteal elevation.
It is critical in rhinoplasty surgery to have an understanding of the layers of the superficial anatomy of the nose because these play a vital role in shaping the nose and achieving the desired aesthetic outcome. As Saban et al have demonstrated, the anatomy of the nose shares the same layers as the rest of the face, including the skin, superficial areolar layer, superficial musculoaponeurotic system (SMAS), deep areolar layer, and perichondral/periosteal layer.1 In rhinoplasty surgery, regardless of whether open or closed techniques are used, the first surgical step is to elevate the soft tissue layer from the underlying cartilage and bone structures. The surgical dissection planes that can be utilized include the subcutaneous, sub-SMAS, subperichondrial or subperiosteal planes. In classic conventional rhinoplasty, sub-SMAS (supraperichondrial) dissection to the nasal bone followed by subperiosteal dissection is the commonly preferred surgical plan.2 Although this plane is considered more tissue-friendly and avascular than the subcutaneous plane, it has disadvantages such as postoperative edema, numbness, prolonged scar remodeling, and thinning of the soft tissue layer in the long term.3 To overcome these disadvantages, Cakir et al introduced a complete subperichondrial and subperiosteal elevation, which they claim leads to relatively less postoperative edema and faster healing.4 The use of the subperichondrial plane has become more widespread in recent years, particularly in combination with dorsal preservation rhinoplasty surgery.3 Ultimately, the choice of dissection planes at different levels of the nose will depend on the surgeon’s preference and the specific goals of the surgery. Factors such as the manipulation of soft tissue layers and nasal ligaments will also play a crucial role in determining the most appropriate surgical plan.5
Autologous cartilage grafting is a very useful approach immunologically and biomechanically. In primary and revision rhinoplasties, autologous septal, auricular, and costal cartilages are frequently used to achieve perfection in both aesthetic and functional results.6 However, a major limitation of these grafts is their tendency to resorb over time and lose long-term viability, leading to unpredictable aesthetic outcomes and diminished patient satisfaction. Surgical approaches, mechanical and thermal traumas, the form of the cartilage graft, and additional interventions applied to the cartilage grafts affect the viability of the cartilage in the long term. Therefore, various techniques have been developed to reduce cartilage graft resorption, including manipulating the graft's form, applying additional interventions, or wrapping the grafts in Surgicel (Ethicon, Raritan, NJ), fascia, or perichondrium. The use of perichondrium-preserved cartilage, as well as the application of platelet-rich plasma or sildenafil, have also been studied to improve graft viability.7-12 Diced cartilage has been shown to have greater viability than block cartilage in previous studies, making it the preferred choice for our study.9 However, no research has yet been conducted on the impact of dissection planes (sub-SMAS, subperichondrial, and subperiosteal) on the viability of cartilage grafts. Therefore, this study aimed to investigate whether rhinoplasty dissection planes have different effects on the viability of diced cartilage in a rabbit model, making it the first study of its kind in the literature.
METHODS
Eight male New Zealand rabbits, 12 to 18 months old and weighing 3000 to 3850 g, were used in this study. The study received approval from the Necmettin Erbakan University Animal Experiments Ethics Committee (approval no. 2020-034), and the entire study process was carried out in accordance with the National Institutes of Health Guidelines for the Care and Use of Laboratory Animals.13 These animals were selected due to their suitability as a model for human nasal anatomy, as well as their established use in previous studies on rhinoplasty techniques and materials. We aimed to use this animal model to evaluate the viability of diced autologous cartilage grafts under different dissection planes, which could provide valuable information for the development of improved surgical techniques and outcomes in human rhinoplasty.
Prior to surgery, all rabbits were anesthetized with 50 mg/kg ketamine hydrochloride and 5 mg/kg xylazine hydrochloride via intramuscular injection. Additionally, 30 mg/kg of cefazolin was administered as antibiotic prophylaxis. The nasal dorsum was prepared for standard surgical procedures, and a 3-cm longitudinal skin incision was made in the middle of it. Sub-SMAS pocket dissection was performed on the right side by elevating the sub-SMAS layer, whereas on the left side, subperiosteal elevation was performed by exposing the bone after periosteum incision (Figure 1A, B). To create a subperichondrial pocket, a 2-cm skin and perichondrium incision was made in the proximal part of the left auricle, followed by elevation in the subperichondrial dissection plane. Throughout the surgical procedure, care was taken to ensure aseptic conditions and to avoid any mechanical trauma.
Stages of animal experimentation. (A) Sub-SMAS pocket on the right, subperiosteal pocket on the left after a 3-cm longitudinal skin incision on the midline of the nasal dorsum. (B) Subperichondrial pocket formation on the left ear auricle. (C) Preparation of diced cartilage graft; peeling off the skin and perichondrium of the ear auricle. (D) Preparing an equal amount of 3 diced cartilage grafts with a precision scale. (E) Loading the graft material into insulin syringes. (F) Placement of diced cartilage samples into the sub-SMAS on the right nasal dorsum. (G) Subperichondrial placement of diced cartilage samples on the left ear. (H) Subperiosteal placement of diced cartilage samples on the left nasal dorsum. Images before excision for histopathological examination of sub-SMAS graft on the (I) right nasal dorsum (white arrow) and subperiosteal graft on the left nasal dorsum (white triangle), and (J) subperichondrial graft on the left ear after 3 months. SMAS, superficial musculoaponeurotic system.
The right ear auricle of rabbits was amputated. The skin and perichondrium of the amputated auricle were completely peeled. The auricular cartilage was then diced into 2-mm fragments. Each diced cartilage was weighed on a precision laboratory scale with 0.001-g accuracy, and divided into 3 equal parts. These parts were loaded onto 3 separate insulin injectors (as shown in Figure 1C-E).
The diced cartilage samples, prepared as described earlier, were implanted into the sub-SMAS pocket (Group 1) of the right nasal dorsum, the subperichondrial pocket (Group 2) of the left ear, and the subperiosteal pocket (Group 3) of the left nasal dorsum (as shown in Figure 1F-H). The periosteum, perichondrium, subcutaneous tissue, and skin incisions were closed with 4.0 Vicryl suture (Ethicon). All rabbits were fed under appropriate conditions for a period of 90 days. At the end of the 3-month period, rabbits were killed with intraperitoneal sodium thiopental (150 mg/kg), and cartilages in the nose planes (Figure 1I, J) were surgically excised and placed in 10% formaldehyde solution for subsequent histopathological examination.
The excised cartilage tissues were subjected to histopathological examination to evaluate the viability of the cartilage grafts. First, the tissues were fixed in 10% formaldehyde, dehydrated in ethanol solution, and cleared with xylene. Subsequently, they were embedded in paraffin blocks after being held in a hot paraffin bath for 2 hours. Tissue sections 5 μm thick were prepared and then stained with hematoxylin-eosin and toluidine blue dyes, following which they were examined under a light microscope. The hematoxylin-eosin–stained sections were analyzed to evaluate the presence of chondroid tissue, whereas toluidine blue–stained sections were used to assess the chondroid tissue matrix, as illustrated in Figure 2. The viability of the cartilage grafts was determined by examining the loss of chondrocyte nucleus in the lacuna, the presence of peripheral chondrocyte proliferation, and the end state of the chondroid matrix, especially the loss of matrix metachromasia, as shown in Figure 3.
Histopathologic examination, stained with toluidine blue at ×40 magnification to assess chondroid tissue matrix.
Three different samples stained with hematoxylin-eosin for cartilage viability. (A-C) Good viability graft; the red arrow in (B) and the black lines in (C) indicate peripheral chondrocyte proliferation and living nucleated chondrocytes. (D-F) Decreased viability; the area in (E) indicated by the red arrow shows no peripheral proliferation. The green arrows in (F) indicate empty and nonliving lacunae; the yellow arrows show living nucleated chondrocytes. (G-I) Chondrocyte viability greatly reduced. Empty lacunae can be seen in (H) and (I).
Diced cartilage samples were blindly evaluated by a pathologist for peripheral chondrocyte proliferation, graft viability, fibrosis substituting for cartilage, vascularization, inflammation, cartilage bone metaplasia, and calcification. Live chondrocytes, the presence of chondrocyte nucleus, and peripheral chondrocyte proliferation, which indicated cartilage viability, were calculated as percentages in our study. Other parameters were scored from 0 to 3 based on their severity: 0, absent; 1, mild; 2, moderate; and 3, severe. Scoring for the presence of chondroid matrix was also done from 0 to 3 as seen in Figure 4: 0, normal; 1, mild loss; 2, moderate loss; 3, severe loss. Scores for all samples were recorded and compared among grafts in the 3 groups.
Examination of chondroid tissue matrix losses with toluidine blue staining: (A) ×400, no loss; (B) ×200, slight loss; and (C) ×200, significant loss.
SPSS v. 22.0 software (SSPS, Inc., Chicago, IL) was used for statistical analysis. The Kolmogorov-Smirnov goodness-of-fit test was used to check data distribution, and according to the results, nonparametric tests were used. Continuous variables are presented as median [interquartile range] (range) and discrete variables as frequencies and percentages. Kruskal-Wallis one-way analysis of variance was applied to compare peripheral chondrocyte proliferation and the presence of live chondrocytes between groups, and the post hoc Tukey test was applied to detect differences between groups. Pearson’s χ2 test was used to compare categoric parameters such as fibrosis, vascularization, inflammation, cartilage bone metaplasia, calcification, and the presence of the chondroid matrix between groups. A P-value of <.05 was considered statistically significant in all statistical analyses.
RESULTS
All statistical analyses of histopathological data are summarized in Table 1. The percentages of live chondrocyte nucleus viability in the sub-SMAS, subperichondrial, and subperiosteal groups were 67.5% [18.75%] (range, 60%-80%), 35% [17.5%] (range, 20%-45%), and 20% [30.0%] (range, 10%-45%), respectively, with statistically significant differences observed between the groups (P = .001). Similar findings were obtained for peripheral chondrocyte proliferation, with the percentage values determined as 80.0% [22.5%] (range, 60%-90%), 30% [28.75%] (range, 15%-60%), and 20% [28.75%] (range, 5%-60%) in the sub-SMAS, subperichondrial, and subperiosteal groups, respectively (P = .001). The sub-SMAS group had the highest viability for both parameters, with statistically significant differences observed between this group and the other 2 groups (P = .001). In contrast, the subperichondrial and subperiosteal groups were similar in terms of chondrocyte nucleus viability (P = .446) and peripheral chondrocyte proliferation (P = .349).
Histopathological Results of Diced Cartilage
| Group 1, sub-SMAS (n = 8) | Group 2, subperichondrial (n = 8) | Group 3, subperiosteal (n = 8) | P-value | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cartilage viability (%) | |||||||||||||
| Living chondrocyte ratio | 67.5 [18.75] (60-80) | 35 [17.5] (20-45) | 20 [30.0] (10-45) | .001a | |||||||||
| Peripheral proliferation | 80.0 [22.5] (60-90) | 30 [28.75] (15-60) | 20 [28.75] (5-60) | .001a | |||||||||
| n=8 | n=8 | n=8 | |||||||||||
| 0 | 1+ | 2+ | 3+ | 0 | 1+ | 2+ | 3+ | 0 | 1+ | 2+ | 3+ | ||
| Chondroid stromal loss (n) | 7 | 1 | — | — | 3 | 5 | — | — | 2 | 3 | 2 | 1 | .006b |
| Peripheral changes in the tissue (n) | |||||||||||||
| Fibrosis | — | 4 | 4 | — | — | 2 | 5 | 1 | — | 2 | 3 | 3 | .287b |
| Vascularization | — | 5 | 3 | — | — | 4 | 4 | — | — | 3 | 5 | — | .607b |
| Inflammation | — | 6 | 2 | — | — | 5 | 2 | 1 | — | 1 | 5 | 2 | .112b |
| Cartilage ossification | 7 | 1 | — | — | 7 | 1 | — | — | 8 | — | — | — | .580b |
| Calcification | 4 | 4 | — | — | 6 | 2 | — | — | 4 | 1 | — | 3 | .073b |
| Group 1, sub-SMAS (n = 8) | Group 2, subperichondrial (n = 8) | Group 3, subperiosteal (n = 8) | P-value | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cartilage viability (%) | |||||||||||||
| Living chondrocyte ratio | 67.5 [18.75] (60-80) | 35 [17.5] (20-45) | 20 [30.0] (10-45) | .001a | |||||||||
| Peripheral proliferation | 80.0 [22.5] (60-90) | 30 [28.75] (15-60) | 20 [28.75] (5-60) | .001a | |||||||||
| n=8 | n=8 | n=8 | |||||||||||
| 0 | 1+ | 2+ | 3+ | 0 | 1+ | 2+ | 3+ | 0 | 1+ | 2+ | 3+ | ||
| Chondroid stromal loss (n) | 7 | 1 | — | — | 3 | 5 | — | — | 2 | 3 | 2 | 1 | .006b |
| Peripheral changes in the tissue (n) | |||||||||||||
| Fibrosis | — | 4 | 4 | — | — | 2 | 5 | 1 | — | 2 | 3 | 3 | .287b |
| Vascularization | — | 5 | 3 | — | — | 4 | 4 | — | — | 3 | 5 | — | .607b |
| Inflammation | — | 6 | 2 | — | — | 5 | 2 | 1 | — | 1 | 5 | 2 | .112b |
| Cartilage ossification | 7 | 1 | — | — | 7 | 1 | — | — | 8 | — | — | — | .580b |
| Calcification | 4 | 4 | — | — | 6 | 2 | — | — | 4 | 1 | — | 3 | .073b |
Values are median [interquartile range] (range) or number. Parameters of the diced cartilage samples were scored from 0 to 3 based on their severity: 0, absent; 1, mild; 2, moderate; and 3, severe. Scoring for the presence of chondroid matrix was also done from 0 to 3, as seen in Figure 4: 0, normal; 1, mild loss; 2, moderate loss; 3, severe loss. SMAS, superficial musculoaponeurotic system. aKruskal-Wallis one-way analysis. bPearson χ2 test.
Histopathological Results of Diced Cartilage
| Group 1, sub-SMAS (n = 8) | Group 2, subperichondrial (n = 8) | Group 3, subperiosteal (n = 8) | P-value | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cartilage viability (%) | |||||||||||||
| Living chondrocyte ratio | 67.5 [18.75] (60-80) | 35 [17.5] (20-45) | 20 [30.0] (10-45) | .001a | |||||||||
| Peripheral proliferation | 80.0 [22.5] (60-90) | 30 [28.75] (15-60) | 20 [28.75] (5-60) | .001a | |||||||||
| n=8 | n=8 | n=8 | |||||||||||
| 0 | 1+ | 2+ | 3+ | 0 | 1+ | 2+ | 3+ | 0 | 1+ | 2+ | 3+ | ||
| Chondroid stromal loss (n) | 7 | 1 | — | — | 3 | 5 | — | — | 2 | 3 | 2 | 1 | .006b |
| Peripheral changes in the tissue (n) | |||||||||||||
| Fibrosis | — | 4 | 4 | — | — | 2 | 5 | 1 | — | 2 | 3 | 3 | .287b |
| Vascularization | — | 5 | 3 | — | — | 4 | 4 | — | — | 3 | 5 | — | .607b |
| Inflammation | — | 6 | 2 | — | — | 5 | 2 | 1 | — | 1 | 5 | 2 | .112b |
| Cartilage ossification | 7 | 1 | — | — | 7 | 1 | — | — | 8 | — | — | — | .580b |
| Calcification | 4 | 4 | — | — | 6 | 2 | — | — | 4 | 1 | — | 3 | .073b |
| Group 1, sub-SMAS (n = 8) | Group 2, subperichondrial (n = 8) | Group 3, subperiosteal (n = 8) | P-value | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cartilage viability (%) | |||||||||||||
| Living chondrocyte ratio | 67.5 [18.75] (60-80) | 35 [17.5] (20-45) | 20 [30.0] (10-45) | .001a | |||||||||
| Peripheral proliferation | 80.0 [22.5] (60-90) | 30 [28.75] (15-60) | 20 [28.75] (5-60) | .001a | |||||||||
| n=8 | n=8 | n=8 | |||||||||||
| 0 | 1+ | 2+ | 3+ | 0 | 1+ | 2+ | 3+ | 0 | 1+ | 2+ | 3+ | ||
| Chondroid stromal loss (n) | 7 | 1 | — | — | 3 | 5 | — | — | 2 | 3 | 2 | 1 | .006b |
| Peripheral changes in the tissue (n) | |||||||||||||
| Fibrosis | — | 4 | 4 | — | — | 2 | 5 | 1 | — | 2 | 3 | 3 | .287b |
| Vascularization | — | 5 | 3 | — | — | 4 | 4 | — | — | 3 | 5 | — | .607b |
| Inflammation | — | 6 | 2 | — | — | 5 | 2 | 1 | — | 1 | 5 | 2 | .112b |
| Cartilage ossification | 7 | 1 | — | — | 7 | 1 | — | — | 8 | — | — | — | .580b |
| Calcification | 4 | 4 | — | — | 6 | 2 | — | — | 4 | 1 | — | 3 | .073b |
Values are median [interquartile range] (range) or number. Parameters of the diced cartilage samples were scored from 0 to 3 based on their severity: 0, absent; 1, mild; 2, moderate; and 3, severe. Scoring for the presence of chondroid matrix was also done from 0 to 3, as seen in Figure 4: 0, normal; 1, mild loss; 2, moderate loss; 3, severe loss. SMAS, superficial musculoaponeurotic system. aKruskal-Wallis one-way analysis. bPearson χ2 test.
The results of the examination of chondrocyte matrix loss also showed statistically significant differences between the groups (P = .006). The sub-SMAS group had a lower loss of chondrocyte matrix than the other 2 groups, which further supports the findings of better cartilage viability observed in this group. However, no statistically significant differences were detected in the categoric parameters of fibrosis, vascularization, inflammation, cartilage bone metaplasia, calcification, and the presence of the chondroid matrix among the groups (the P-values obtained for the comparison of each parameter were .287, .607, .112, .580, and .073, respectively). Figure 5 shows the distribution of the data in the box-plot graph for the percentage of live chondrocyte nucleus viability among the 3 groups.
Box-plot graph demonstrating (A) better viability (presence of chondrocyte nucleus) and (B) peripheral proliferation of diced cartilage grafts placed in sub-SMAS compared to those placed in subperichondrial and subperiosteal locations. SMAS, superficial musculoaponeurotic system.
DISCUSSION
The subperichondrial and subperiosteal elevations, initially introduced in 2013 by Cakir et al as a part of dorsal preservation rhinoplasty, have gained popularity in recent years.4 This dissection technique creates an avascular plane that preserves the nasal ligaments, resulting in reduced bleeding during surgery and a more tissue-friendly procedure. The benefits of this approach include decreased postoperative edema, limited scar formation, minimal skin thinning in the long run, and faster healing. This study was carried out to investigate the effect of these dissection planes, along with the sub-SMAS plane, on the viability of cartilage grafts. Despite the aforementioned advantages of subperichondrial and subperiosteal elevations, our results have revealed that the sub-SMAS surgical plane provides better support for the viability of autologous cartilage grafts in rhinoplasty.
Rhinoplasty is currently one of the most frequently performed cosmetic surgical procedures, and increasing interest and demand have raised expectations for both patients and physicians. To meet this demand, many new techniques and surgical approaches have been developed, including dorsal preservation surgeries that aim to preserve not only cartilage and bone but also ligaments and subcutaneous tissue to achieve natural-looking noses.3,4 Although these surgeries tend to involve less cartilage grafting, cap and supratip grafting are still often necessary. Additionally, in revision and ethnic rhinoplasty cases, surgical solutions such as utilizing costal cartilage and placing the graft as an onlay subperiosteally are common.14 However, the effect of surgical dissection planes on the viability of cartilage grafting remains an unanswered question in these widespread techniques. Our study aimed to address this untouched issue by evaluating the viability of auricular cartilage placed in different tissue planes (sub-SMAS, subperichondrial, and subperiosteal) in a rabbit experimental model. The question we specifically investigated here is whether the avascularity of the subperichondrial and subperiosteal planes during surgery has a negative effect on the nourishment of the cartilage graft because we know histologically that the sub-SMAS dissection plane conventionally used is a more vascular cleavage area than the subperiosteal and subperichondrial planes.5
Numerous techniques have been developed to preserve the viability of cartilage in rhinoplasty surgery. One of the fundamental studies regarding this issue is the rhinoplasty series performed by Erol and colleagues, which showed that the survival rate of cube-shaped cartilage wrapped in Surgicel (colloquially referred to as “Turkish delight”) is increased.15 However, other studies have found that Surgicel may be insufficient to prevent resorption and that survival rates can be increased when fascia is used instead.16 Yet, the additional incision required for the placement of the fascia graft can increase the risk of complications and prolong operation time.17 In another study, an increase in cartilage survival was observed with cube-shaped diced cartilage covered with perichondrium.7,11 Other methods, such as the application of platelet-rich plasma or sildenafil to cartilage, have also been studied and reported to improve the viability of cartilage grafts.10,12 Despite these additional applications and interventions, this present study aimed to investigate a more basic issue: the effect of the chosen surgical plane on the viability of cartilage. The results of our current study data strongly indicate that cartilage viability is better preserved and cartilage matrix density is closer to normal levels when an elevation is made in the sub-SMAS plane of the nasal soft tissue envelope. In contrast, it was shown that cartilage grafts placed in the subperichondrial and subperiosteal areas did not completely disappear but underwent significant resorption, likely due to the lower vascularity of those surgical planes.5 The findings of this study strongly suggest that utilizing the sub-SMAS plane for cartilage grafting during rhinoplasty is optimal, especially in patients where cartilage grafting is preoperatively planned. This may minimize cartilage resorption in the long term and make it possible to achieve more predictable aesthetic results. Given that aesthetic expectations have become increasingly demanding in recent years, we expect this detail will assist surgeons in their clinical practice in rhinoplasty surgery. However, our study has the inherent limitations of an animal study. Further human studies are needed to objectively evaluate the viability of cartilage grafts in different dissection planes in rhinoplasty surgery.
CONCLUSIONS
The present study demonstrated that elevating the soft tissue envelope of the nose in the sub-SMAS plane during rhinoplasty surgery results in better preservation of cartilage graft viability than achieved with subperichondrial and subperiosteal elevations. These findings suggest that the choice of surgical plane can have a significant impact on the success of cartilage grafting in rhinoplasty and should be carefully considered by surgeons.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
This research was supported by Necmettin Erbakan University, Department of Scientific Research Projects (No. 211218006).
REFERENCES
Author notes
Dr Eravci is an associate professors, Department of Otorhinolaryngology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
Dr Aricigil is an associate professors, Department of Otorhinolaryngology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
Dr Kaplan is an ENT specialist, Department of Otorhinolaryngology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
Dr Arbağ is a professors, Department of Otorhinolaryngology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
Dr Eryilmaz is a professors, Department of Otorhinolaryngology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
Dr Dündar is an assistant professor, Department of Otorhinolaryngology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
Dr Oltulu is an associate professor, Department of Pathology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
Presented at the 16th Turkish Rhinology Congress, May 2022, Ankara, Turkey.
