Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
.pdf
Chapter Getting Rhinoplasty Right the First Time 175
https://t.me/medicina_free
CONCLUSION
e best chance to get the result is during the primary rhinoplasty. Accurate initial assessment and proper execution of primary rhinoplasty based on the anatomic deformity and using a graduated surgical approach is critical.
Over the past years, several key concepts and strategies for success have
emerged and play a critical role in getting rhinoplasty right the rst time. e
open approach provides great exposure and opportunity to more accurately assess and manipulate the structural elements of the nose. When manipulating
the dorsum, a component dorsal approach is used. is allows a graduated approach with preservation and proper reconstitution of upper lateral cartilages
when reducing a dorsal hump to ensure an aesthetically pleasing lateral prole
and smooth and symmetrical dorsal aesthetic lines on the frontal view. Although
gras are frequently required during rhinoplasty, the surgeon should make an
eort to use invisible gras. ese gras provide additional structural support
as well as improve contour; however, invisible gras decrease the long-term consequences associated with visible gras due to changes in the gra itself or the
overlying so tissues. Finally, it is critical to follow patients long term. Expertise
and experience are gleaned from critical analysis of one’s own results.
KEY POINTS
■
e open rhinoplasty technique provides unparalleled exposure for accurate
anatomic diagnosis and systematic technical execution.
■
We have evolved a component approach to the dorsum that uses incremental
manipulation to establish well dened and smooth dorsal aesthetic lines while
preventing undesirable dorsal deformities or internal valve collapse.
■
Although gras are frequently required during rhinoplasty, the surgeon should
make an eort to use invisible gras.
■
Primary rhinoplasty oers the surgeon a unique opportunity to manipulate
undisturbed tissue planes and native anatomy to produce a result that meets
both aesthetic and functional goals. It is during this rst nasal surgery that the
opportunity to achieve the best result exists.
■
Expertise and experience are gleaned from critical analysis of one’s own results.
We learn through analyzing factors that play a role in a successful rhinoplasty;
what is more important, we learn even more so from shortcomings or failures
to achieve the desired goals of surgery.
Part Two Basic Surgical Concepts176
https://t.me/medicina_free
REFERENCES
1. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg :-,
.
2. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an anatomic study validating the
safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg :-; discussion
-, .
3. Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review
of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg :ee, .
4. Rohrich RJ, Muzaar AR, Janis JE. Component dorsal hump reduction: the importance of main-
taining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg :-; discussion -,
.
5. Roostaeian J, Unger J, Lee MR, Rohrich RJ. Reconstitution of the nasal dorsum following compo-
nent dorsal reduction in primary rhinoplasty. Plast Reconstr Surg (in press).
6. Gruber RP, Park E, Newman J, et al. e spreader ap in primary rhinoplasty. Plast Reconstr Surg
:-, .
7. Byrd HS, Meade RA, Gonyon DL Jr. Using the autospreader ap in primary rhinoplasty. Plast Re-
constr Surg :-, .
8. Geissler PJ, Roostaeian J, Lee MR, et al. Role of upper lateral cartilage tension spanning suture in
restoring the dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg (in press).
9. Rohrich RJ, Minoli JJ, Adams WP Jr, et al. e lateral nasal osteotomy in rhinoplasty: an anatomic
endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg : ; discussion , .
10. Rohrich RJ, Janis JE. Osteotomies in rhinoplasty: an updated technique. Aesthetic Surg J :-,
.
11. Rohrich RJ, Janis JE, Adams WP Jr, et al. An update on the lateral nasal osteotomy in rhinoplasty:
an anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr
Surg :-; discussion , .
12. Rohrich RJ, Kurkjian TJ, Hoxworth RE, et al. e eect of the columellar strut gra on nasal tip
position in primary rhinoplasty. Plast Reconstr Surg :-, . Erratum in Plast Reconstr
Surg :, .
13. Rohrich RJ, Hoxworth RE, Kurkjian TJ. e role of the columellar strut in rhinoplasty: indications
and rationale. Plast Reconstr Surg :e-e, .
14. Unger JG, Lee MR, Kwon RK, Rohrich RJ. A multivariate analysis of nasal tip deprojection. Plast
Reconstr Surg :-, .
15. Adams WP Jr, Rohrich RJ, Hollier LH, et al. Anatomic basis and clinical implications for nasal tip
support in open versus closed rhinoplasty. Plast Reconstr Surg :-, .
16. Rohrich RJ, Raniere J Jr, Ha RY. e alar contour gra: correction and prevention of alar rim de-
formities in rhinoplasty. Plast Reconstr Surg :-; discussion -, .
17. Rohrich RJ, Liu JH. Dening the infratip lobule in rhinoplasty: anatomy, pathogenesis of abnor-
malities, and correction using an algorithmic approach. Plast Reconstr Surg :-, .
18. Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: an algorithmic ap-
proach. Plast Reconstr Surg :-, .
19. Rohrich RJ, Deuber MA. Nasal tip renement in primary rhinoplasty: the cephalic trim cap gra.
Aesthet Surg J :-, .
■ ■ ■ ■ ■ ■
https://t.me/medicina_free
11
Frequently Used Gras in Rhinoplasty:
Nomenclature and Analysis
Jack P. Gunter Alan Landecker C. Spencer Cochran
O
ver the past few decades, numerous graing techniques have been devel
oped to sculpt the nasal framework in primary and secondary rhinoplasty. ese
techniques have originated from the basic principle that maintenance of the major supporting structures of the nose is fundamental for aesthetic and functional
purposes. Failure to maintain or furnish needed support results in suboptimal
results with deformities that are challenging to correct.
-
Maintenance of the major supporting structures of the nose is fundamental for
aesthetic and functional purposes.
Failure to maintain or furnish needed support results in suboptimal results, with
deformities that are challenging to correct.
BACKGROUND
Discussion of these graing techniques at meetings and in the plastic surgery
literature has greatly improved our results in modern rhinoplasty. However, surgeons have been confused by the signicant variability in the nomenclature,
anatomic position, and clinical indications for each gra. In this chapter we will
analyze these aspects of the most commonly used gras in modern rhinoplasty
to provide a simple and easy-to-reference rhinoplasty graing guide for surgeons
at all levels. Gras described in the guide are listed according to their intended
location on the nose, and in alphabetical order within each group. With the help
of the Gunter Rhinoplasty Diagrams (Caneld Scientic, Inc., Faireld, NJ), each
177
Part Two Basic Surgical Concepts178
https://t.me/medicina_free
gra is didactically presented and analyzed for its nomenclature, anatomic location, and clinical indications. is graing guide was evaluated by numerous
expert surgeons before its completion to include their experience, preferred nomenclature, and technical modications. ey are acknowledged at the end of
the chapter.
Overview of Rhinoplasty Gras by Region
Dorsum Autospreader ap
Dorsal onlay gra
Dorsal sidewall onlay gra (lateral nasal wall gra)
Radix gra
Spreader gras
Septal extension gra
Ti
p Anc
A
la
r region Alar batten gra
B
ase A
hor gra
Cap gra
Columellar strut gra (xed)
Columellar strut gra (oating/xed oating)
Extended columellar strut–tip gra (extended shield gra)
Onlay tip gra
Shield gra (Sheen or infralobular gra)
Subdomal gra
Umbrella gra
Alar contour gra (alar rim gra)
Alar spreader gra (lateral crural spanning gra)
Composite alar rim gra
Lateral crural onlay gra
Lateral crural strut gra
Lateral crural turnover ap
lar base gra
Columellar plumping gras
Premaxillary gra
is is a generalized description of the gras, and sometimes the shape, position,
and usage vary depending on the situation and desires of the surgeon. However,
we hope that this information will improve the understanding and teaching of
this fascinating operation.
e shapes, position, and usage of gras vary depending on the situation and
the desires of the surgeon.
Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 179
https://t.me/medicina_free
Gunter Diagram System
e Gunter Rhinoplasty Diagrams were introduced in to graphically document the intraoperative maneuvers in rhinoplasty. ey serve as valuable tools
for postoperative evaluation of the patient and eective teaching instruments for
surgeons learning the technical steps performed in rhinoplasty.
An individualized Gunter diagram is included to depict the anatomic position of
each gra described. e color key for interpretation of the diagrams is as follows:
Green 5 Autologous gras
Black
Red
Orange
Blue
Pink 5 Homogras (for example, irradiated cartilage or dermal homo-
5 Sutures and outline of anatomic structures
5 Incisions and excisions
5 Previous incisions or excisions
5 Implants
gra)
For more information on Gunter diagrams, see “Interpreting the Gunter Rhinoplasty Diagrams” in the front of this book.
GRAFTS OF THE NASAL DORSUM
Autospreader Flap
An autospreader ap is used to control the width of the midvault while maintaining the integrity of the internal nasal valve.
lateral cartilages from the dorsal septum, the excess portion of the upper lateral
cartilages is used as an autospreader ap. It is fashioned by rotating the transverse
portion of the upper lateral cartilage internally, followed by suture xation to the
dorsal septum. e sutures can be tightened to adjust the width of the midvault.
-
Aer separation of the upper
Part Two Basic Surgical Concepts180
https://t.me/medicina_free
Dorsal Onlay Gra
A dorsal onlay gra is a longitudinal gra
used to augment the nasal dorsum. e
gra best spans the entire length of the
dorsum from the radix to the septal angle.
However, to prevent visible step-o deformities, it can be used for shorter distances
to correct localized depressions, asymmetries, or irregularities.
Septal cartilage is the preferred source for minimal to moderate augmentation
with a dorsal onlay gra, but costal cartilage usually is required for large augmentations.
Internal stabilization of costal cartilage gras is recommended to prevent warping. Auricular cartilage is used occasionally but has the disadvantage of being
dicult to shape so that it has a smooth surface. To prevent displacement, dorsal onlay gras should be xed to the underlying framework with sutures or a
percutaneous K-wire.
Dorsal Sidewall Onlay Gra (Lateral Nasal Wall Gra)
Dorsal sidewall onlay gras are placed along the lateral side of the nose and have
dierent shapes and sizes depending on the indications. ey are used to combat localized lateral depressions or asymmetries of the body of the nose and especially to camouage collapse of the upper lateral cartilages. e gra may be
crushed to help hide sidewall irregularities. If placed over bone, the gra is more
likely to be palpable or visible, because the bony base is unyielding.
Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 181
https://t.me/medicina_free
Radix Gra
A radix gra is a single or layered dorsal gra placed in a tight pocket that is
created over the radix. If the pocket is larger than the gra, the gra is xed in
place with percutaneous sutures or K-wires. Radix gras are used to augment an
inadequate nasofrontal angle or to redene the radix breakpoint further cephalad, which causes an apparent lengthening of the nose.
e sh
ape and thickness of a radix gra will depend on the amount of augmen-
tation desired.
e e
es of a radix gra should be crushed or carefully beveled to prevent vis-
dg
ibility.
Spreader Gras
Spreader gras are usually paired, longitudinal gras placed between the dorsal
septum and the upper lateral cartilages in a submucoperichondrial pocket.
Part Two Basic Surgical Concepts182
https://t.me/medicina_free
Spreader gras are used to restore or maintain the internal nasal valve, straighten
a deviated dorsal septum, improve the dorsal aesthetic lines, and reconstruct an
open roof deformity.
Septal cartilage is the preferred source of spreader gras. e length and shape
can vary depending on the indication. e gras may extend above the level of
the dorsal septum to slightly augment the dorsum (pistol gras) or caudally beyond the septal angle to lengthen the nose or increase tip projection. ey are
suture-xated to the septum before reapproximation of the upper lateral cartilages to the septum–spreader gra complex.
Spreader gras are used to restore or maintain the internal nasal valve, straighten
a deviated dorsal septum, improve the dorsal aesthetic lines, and reconstruct an
open roof deformity.
Septal Extension Gras
Septal extension gras are used to control the projection, support, shape, and
rotation of the tip and are dependent on the presence of a stable caudal septum.
ey also help to create a supratip break. e gras are divided into three types.
TypeI gras function as paired dorsal spreader gras that extend beyond the
anterior septal angle into the interdomal space. TypeII gras are paired batten
gras that extend diagonally across the caudodorsal junction of the septal L-strut
into the tip-lobule complex. TypeIII gras function as direct extension gras afxed to the anterior septal angle. Although septal cartilage is the preferred source,
both auricular and rib cartilage have been used.
Chapter Frequently Used Gras in Rhinoplasty: Nomenclature and Analysis 183
https://t.me/medicina_free
GRAFTS OF THE NASAL TIP
Anchor Gra
Anchor grafts can be used to improve tip
support and/or projection and collapse or
deformation of the lateral crura.
anchor-shaped gras whose sha is sutured
to the caudal margin of the medial crura. e
transverse components (wings) may replace
the lateral crura or lie over their remnants and
are sutured to them.
Anchor gras may be used to improve tip support and/or projection and collapse
or deformation of the lateral crura.
ese are
e gra is harvested from the auricular concha and is then designed according
to the patient’s needs. Symmetrical carving of the wings can be dicult because
of the asymmetries of the conchal bowl.
Cap Gra
A cap gra is a small gra placed in the space between the tip-dening points
and the middle crura. e gra is used to rene, soen, and ll in cles of the
nasal tip in patients who have thin skin to minimally enhance tip projection and
occasionally rene the infratip lobule area.
is remnants obtained from the cephalic trim of the lower lateral cartilages, but
septal or auricular cartilage may also be used.
,
e preferred source of cartilage
Part Two Basic Surgical Concepts184
https://t.me/medicina_free
Columellar Strut Gra (Floating/Fixed Floating)
A oating columellar strut is a gra placed in a tight pocket that is dissected between the medial crura through a small incision caudal to the feet of the medial
crura (endonasal approach). A xed-oating columellar strut (open approach)
is sutured to the medial crura for stabilization. A to mm pad of so tissue is
usually maintained between the gra and the nasal spine to prevent movement of
the gra back and forth over the spine with lip movements. A columellar strut
helps to maintain tip support and increase tip projection and aids in shaping the
columellar-lobular angle. Septal cartilage is preferred, but costal cartilage is used
when a stronger strut and more enhanced projection are desired. Auricular cartilage may be used, but a double layer is required if strength is needed.
Columellar Strut Gra (Fixed)
Columellar struts may be xed to the nasal spine or premaxilla to provide more
stable support to the nasal tip. A xed columellar strut is the most eective way
to increase tip projection with a strut and can also aid in lengthening the nose.
When rib cartilage is used, stabilization and control are enhanced with a .-
Соседние файлы в папке Библиотека им академика М.И. Перельмана