Titanium Septum Plate: A novel technique to straighten and to stabilize the Nasal Septum using a Modified Titanium Breathe-Implant

Received: 27 November, 2018 Accepted: 25 June, 2019 Published: 26 June, 2019 *Corresponding author: Daniel F àWengen, MD, ORL Center Binningen, Hauptstrasse 11, 4102 Binningen, Switzerland, Tel: 41614221946; E-mail:


Introduction
A novel surgical technique is presented using a modifi ed Titanium Breathe-Implant as a Titanium Septum Plate (TSP) to duplicate the anterior nasal septum. In 31 patients over a period of 2.3 years no complications arised. The TSP has improved surgical and aesthetical results of septoplasty in all patients.
The use of TSP might provide a reliable addition in septoplasty.
The cartilagineous nasal septum is the main supporting structure of the nasal dorsum. The shape of the nose greatly depends on the septum [1]. Symmetric nasal breathing relies on symmetric airways due to a straight septum. In septoplasty the cartilaginous septum is approached and all efforts are made to straighten the septum [2]. The septal cartilage often presents with anterior defl ections that have proven over time to be diffi cult to correct. Various surgical techniques have been applied to straighten the cartilage among them scoring, scratching, incisions, sutures, cartilagineous duplications, sheething by autologeous bony ethmoidal plate Abstract Importance: The cartilagineous nasal septum remains a diffi cult structure to straighten and to stabilize as it tends to bend. Recurrence of an asymmetric and bent septum is a frequent complain in patients as it may lead to asymmetric nasal breathing and/or aesthetic asymmetries of the shape of the nose.
Objective: To investigate a novel technique: the implantation of a titanium septum plate (TSP) in its use as a septum stabilizer and straightener. To present a clinical study on the experience of a modifi ed titanium Breathe-Implant used as a septum plate.

Design Settings and Participants:
In this retrospective study, medical records as well as preoperative and postoperative functional studies in which a titanium septum plate had been used between February 2014 and May 2016 in a total of 31 consecutive patients subjected to septoplasty with the use of one or two Titanium Septum Plates (TSP) in closed and open surgeries by the same surgeon were reviewed. All (100 %) were eligible and included in the study.
Interventions: Before surgery, a complete rhinological examination was conducted including nasal endoscopy, digital endonasal photography, rhinomanometry, PNIF mask testing, and a SNOT 20 questionnaire.
Results: This is the fi rst report in the literature to use a titanium plate in septoplasty. There were no intra-or postoperative complications in the use of TSP. In all 31 patients all TSP remain in the nose. In the accumulated observational period of 544 months there were no exposures internally or externally, no extrusions, no infections and no explantations. In the usual placement of TSP the implant runs parallel to the axis of the nose. Metal is much stronger than cartilage to straighten the nasal axis. No postoperative infection was observed and no antibiotic prophylaxis or therapy were necessary.

Conclusions and Relevance:
The implantation of TSP has proven over time to be safe and reliable. Titanium is an inert metal suited for septal surgery. Future implants specifi cally designed for septoplasty will facilitate septal surgery and will help to achieve more stable long-term results with hopefully better patient satisfaction than septoplasty alone. or Polydioxanone (PDS) [3][4][5]. Permanent reliable results are diffi cult to achieve. Surgeons need all possible help to achieve a strong septum in the midline of the nose.

Breathe-implant modifi ed as a fl at titanium plate
The Titanium nasal implant « Breathe-Implant » has been surgically implanted since its CE mark in 2003 in thousands of patients worldwide [6,7]. Over a period of more than 15 years Breathe-Implant has stood the test of time. Breathe-Implant is designed to be sutured to the Upper Lateral Cartilage (ULC) to open and to stabilize the internal nasal valve in a reliable and effi cient way. Breathe-Implant has all edges rounded off and it has proven to be safe and reliable. Metal is stronger than any other material. Bone might brake and autologous cartilage is too weak and too thick: it might narrow the endonasal airspace.
Breathe-Implant is only 0.5 mm in thickness: it will not obstruct the airway. Breathe-Implant is available in 6 sizes.
For TSP only the largest size XXL was used. This is an off-label use of Breathe-Implant and the patients were informed about it. However there was no IRB approval obtained in Switzerland.
Breathe-Implant is bent straight by hand and then by hammer.
It must be protected from direct metal contact by the hammer by putting it between layers of surgical gauze before it can be hit by the hammer and used as a straight plate (Figure 1). This results in a boomerang shaped Titanium plate that can be used  [8,9]. Surgical procedures were uneventful. All surgeries were performed by a single surgeon. The decision to use a

Functional results
Pre-and postoperative rhinomanometry [10], measure- The TSP also helped to achieve a straighter external nasal axis. In the usual placement of TSP the implant runs parallel to the axis of the nose. Metal is much stronger than cartilage to straighten the nasal axis. In the future cartilagineous spreader grafts might be needed less often to straighten and to structure the nose [11]. Due to their volume cartilagineous grafts may also cause nasal obstruction. TSP is signifi cantly thiner and will cause less airway obstruction.

Discussion
Previously surgeons depended on various techniques in order to achieve a straight and stable cartilagineous septum.
Postoperative results were often unreliable with uncontrollable deviations of the septal cartilage leading to persistent asymmetric nasal breathing : A major cause for dissatisfaction by the patient. The TSP may help to achieve better straightening of the nasal septum. Potential indications for the use of TSP include among others : weak or deviated anterior septum,

Confl ict of interest disclosures
The author receives a royalty for Breathe-