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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
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Chapter Component Dorsal Hump Reduction and Dorsal Reconstitution 225
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Radix
TDP
Radix
TDP
In women, the new dorsal line on lateral view should lie slightly posterior to a
line connecting the nasofrontal angle with the tip-dening points (TDP). e
dorsum should be slightly higher in men to avoid feminizing the nose.
In women, the dorsum should lie just below a line connecting the nasofrontal
angle with the tip-dening points, whereas the dorsum should be no lower than
this line in men to avoid feminizing the nose.
Any patient with a dorsal hump, dened by excess height above a line from the
radix to the tip-dening points, is an appropriate candidate for component dorsal hump reduction.
OPERATIVE TECHNIQUE
In primary rhinoplasty, the open approach is our preferred technique. A closed,
or endonasal, approach is used on occasion in the case of the isolated dorsal
hump. Guided by a precise preoperative clinical analysis, we perform the initial
modication of the dorsum before addressing the tip correction. is sequence
establishes the balance between the tip and the dorsum that is crucial to an opti-
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mal aesthetic result. Component dorsal hump reduction followed by dorsal reconstitution of the osteocartilaginous hump involves eight essential steps:
1. Dorsal undermining
2. Separation of the upper lateral cartilages from the septum
3. Incremental component dorsal septal reduction
4. Incremental dorsal bony reduction (using a rasp)
5. Incremental reduction of upper lateral cartilages (if indicated)
6. ree-point dorsal palpation test
7. Reconstitution of the dorsum with sutures (most common), spreader
aps, and/or spreader gras (if indicated)
8. Medial/lateral osteotomies (if indicated)
1. Dorsal Undermining
Meticulous skeletonization is used to expose the dorsal osteocartilaginous framework, maintaining the plane of dissection as close to the cartilaginous surfaces as
possible. Dissection is continued subperiosteally over the bony vault. e periosteal layer protects against postoperative so tissue adhesions and camouages
the reconstructed bony vault; care must be taken not to tear the periosteum excessively. Preservation of the lateral so tissue and periosteal attachments to the
bony sidewalls provides signicant support and stability for the nasal pyramid
aer osteotomies have been performed; therefore lateral dissection must be limited to the amount necessary to allow access for bony hump reduction.
Preservation of the lateral so tissue and periosteal attachments to the bony
sidewalls provides signicant support and stability for the nasal pyramid aer
osteotomies have been performed; therefore lateral dissection must be limited to
the amount necessary to allow access for bony hump reduction.
Chapter Component Dorsal Hump Reduction and Dorsal Reconstitution 227
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Extensive undermining is needed only in older patients, patients with thick skin,
and patients with a signicant osteocartilaginous hump (greater than mm).
Care must be taken to avoid dissection under the nasal bones and detachment of
the upper edge of the upper lateral cartilages. At times the surgeon must gently
push the upper lateral cartilages down and out of the way to avoid inadvertent
transection when reducing the septum and/or the bony dorsum.
2. Separation of the Upper Lateral Cartilages From the Septum
Creating bilateral superior submucoperichondrial tunnels is essential before
beginning the component reduction of the dorsal hump. e mucoperichondrium of the dorsal septum is elevated, from caudal to cephalad, until the elevator reaches the nasal bones. e upper lateral cartilages can be sharply separated
from their junction with the septum without damaging the mucosa. is maneuver also allows removal of the bony and cartilaginous hump while sparing the
mucosa. Extramucosal resection of the bony and cartilaginous components is a
critical concept; preservation of the mucosa reduces the potential for late cicatricial narrowing of the internal nasal valve and webbing of the vestibule. Furthermore, spreader gras can then be placed in a closed space and dorsal gras
separated from the nasal cavity. Preservation of mucosal integrity also aords
greater overall stability aer septal reconstruction.
Creation of bilateral submucoperichondrial tunnels before component reduction
of the dorsal hump prevents cicatricial narrowing of the internal nasal valve and
webbing of the vestibule.
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3. Incremental Component Dorsal Septal Reduction
Once the subperichondrial tunnels have been made and the transverse portions of the upper lateral cartilages have been separated from the septum using
a No.scalpel, a cartilaginous hump in three pieces results—the septum centrally and the transverse portions of the upper lateral cartilages laterally. Dorsal
hump reduction begins with the isolated central septum, using serial incremental
resections of the septal cartilage with angled septal scissors under direct vision.
It is important to preserve the upper lateral cartilages—equal resection of the
upper lateral cartilages and septum results in rounding of the dorsum, whereas
excessive resection of the dorsal edges of the upper lateral cartilages as compared
with the septum results in an inverted-V deformity or an overly narrow midvault.
Excessive resection of the dorsal edges of the upper lateral cartilages can lead to
an inverted-V deformity or an overly narrow midvault.
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4. Incremental Dorsal Bony Reduction
A sharp, downbiting diamond rasp is used to reduce the osseous hump. Reduction of small and medium humps (mm or less) can usually be accomplished
with incremental rasping. A slightly oblique bias should be maintained while
rasping to minimize the risk of avulsion of the upper lateral cartilages or septum from the bony vault. Rasping should proceed along the le and right dorsal
aesthetic lines and then centrally in a methodical fashion using controlled, short
rasp excursions with the thumb and index nger of the nondominant hand used
to stabilize the bony vault. Infrequently, a guarded mm osteotome may be required to reduce larger bony humps. e osteotomy should proceed from the
caudal edge of the nasal bones to the radix at or slightly above the level of the
planned dorsum in a conservative manner. is is followed with a rasp for nal
bony adjustments. Alternatively, a power oscillating burr with a dorsal skin protector can be used under direct visualization to remove large cranial bony humps.
Reduction of the bony hump is most commonly carried out with a downbiting
rasp; large humps may require a guarded osteotome or a power oscillating burr
with a dorsal skin protector.
5. Incremental Reduction of Upper Lateral Cartilages
Only aer reduction of the cartilaginous septal and bony dorsal components of
the hump is reduction of the upper lateral cartilages considered. However, this
may be unnecessary in some cases, and it is essential to avoid overresection of
the upper lateral cartilages to prevent internal nasal valve collapse and long-term
irregularity of the dorsum.
nasal bones and a high and narrow osteocartilaginous framework are noted preoperatively.
,
It is even more important to avoid this when short
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Incremental reduction of the upper lateral cartilages is typically performed
from either the dorsal edges with large hump reductions (greater than mm) or
from the caudal border of the upper lateral cartilages when one is attempting to
shorten the nose and/or reduce lateral side wall fullness in the scroll area.
6. ree-Point Dorsal Palpation Test
roughout the dorsal reduction procedure, it is crucial to repeat the threepoint dorsal palpation test aer each modication of the dorsum. is test is
performed with the dominant index ngertip, moistened with normal saline solution. e ngertip gently palpates the le and right dorsal aesthetic lines and
then palpates centrally to detect any dorsal irregularities or contour depressions.
Maintaining the appropriate height of the upper lateral cartilages also preserves
the dorsal aesthetic lines, permitting any necessary narrowing or straightening
of the lines. Aer the skin envelope is redraped, the three-point dorsal palpation
test is performed to ensure that a straight and smooth dorsum has been obtained
before septal reconstruction or lateral osteotomies are begun.
Use of the three-point dorsal palpation test aer each maneuver will help to ensure the creation of a smooth, straight dorsum.
It is important to make certain that the upper lateral cartilages are pulled in a
dorsal direction to their correct position, because they have a tendency to fall
away from the dorsum, giving the false impression that they have been appropriately aligned relative to the dorsal septum and bony vault when in fact they
are still excessive.
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It is important to make certain that the upper lateral cartilages are pulled in a
dorsal direction to their correct position, because they have a tendency to fall
away from the dorsum giving the false impression that they have been appropriately aligned relative to the dorsal septum and bony vault when in fact they are
still excessive.
7. Reconstitution of the Dorsum
When they have been appropriately preserved, the dorsal edges of the upper lateral cartilages act as “autospreaders,” maintaining the T-shaped contour of the
dorsum that is critical for balanced dorsal aesthetic lines and preservation of the
internal valves.
In addition to preservation of the upper lateral cartilages, proper reconstitution
of the upper lateral cartilages with sutures (most common), spreader aps, and/or
spreader gras (if indicated) is also essential.
of dorsal reconstitution techniques that rely solely on appropriate suture placement. is approach has largely obviated the need for spreader gras.
,
We typically employ three types
Type 1: Midvault Restoration Using the Upper Lateral Cartilage
Tension-Spanning Suture
2-4 mm
A - PDS suture is placed from the dorsal edges of both upper lateral cartilages
to the distal septum, advancing both upper lateral cartilages mm distally along
the septum.
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A second suture can be placed proximally along the
upper lateral cartilages and septum as needed to give
extra support and improve contour at any points of
irregularity or bulging if a symmetrical upper lateral
cartilage position was not achieved with placement
of the previous suture.
e upper lateral tension-spanning suture stabilizes the upper lateral cartilages to
the septum on slight tension, thereby providing a straighter and more anatomic
contour. Use of the upper lateral tension-spanning suture is particularly benecial in thin-skinned patients because of increased visibility of contour irregularities, and in patients requiring larger (mm or greater) dorsal hump reduction in
which the dierential between the septum and upper lateral cartilages is more
pronounced, leading to a greater propensity for midvault irregularity.
Type 2: Midvault Restoration Without Using the Upper Lateral Cartilage
Tension-Spanning Suture
e - PDS suture is placed without advancing the edge of both upper lateral
cartilages distally along the dorsal septum. is is indicated in patients with
upper lateral cartilages that can maintain a straight contour aer release from
the septum. is is oen the case for patients with strong cartilage who require
minimal dorsal hump reduction. is is also indicated in patients where narrowing at the distal end of the midvault must be avoided. e upper lateral tension-
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spanning suture oen re-creates and enhances the natural taper seen with the
upper lateral cartilages as they reach the supratip region in their distalmost dorsal attachment. By not placing the upper lateral cartilages on tension when reapproximating them to the septum, the surgeon is able to diminish the narrowing
eect of this suture.
Type 3: Midvault Restoration With Spreader Flap Modication
Type 3A
Type 3B
e - PDS sutures are placed caudal to the upper edge of the upper lateral
cartilages, thereby infolding the superior edge of the upper lateral cartilages.
is serves a spreader-type function. is technique should be employed when
attempting to widen the midvault. It can be used with (see type A, above) or
without (see type B, below) advancement of the upper lateral cartilages along
the dorsal septum acting as an upper lateral cartilage tension-spanning suture.
e decision to perform the spreader ap with an upper lateral cartilage tensionspanning suture is based on the particular anatomic goals for the patient as described earlier with the type and techniques.
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Reconstitution of the upper lateral cartilages following component reduction
with sutures, such as the upper lateral cartilage tension-spanning suture, is an
important component to achieving smooth and symmetric dorsal aesthetic lines.
Since the introduction of spreader gras in , surgeons have used them extensively in both primary and secondary rhinoplasty.
,,
Many rhinoplasty surgeons have embraced the concept, leading several authors to describe variants of
the spreader gra and/or spreader aps with dierent indications.
-
However,
the enthusiasm behind spreader gras and/or aps may have extended their application beyond their utility, resulting in their application when not indicated.
Patients undergoing primary rhinoplasty with no existing nasal obstruction are
unlikely to need spreader gra placement when the midvault is properly restored. Avoiding spreader gra placement may obviate the need for cartilage
gra harvest and prevents dorsal widening when this is not desired. Use of the
aforementioned approach for reconstituting the dorsum has proved reliable and
reproducible while avoiding the use of spreader gras in a majority of cases.
Situations in which spreader gra and/or ap use is more likely to be required
include secondary rhinoplasty midvault reconstruction, existing internal nasal
valve dysfunction, and narrow nose syndrome in primary cases.
Criteria for Using Spreader Gras and/or Flaps
in Primary Rhinoplasty
1. Inverted-V deformity
2.
Existing nasal obstruction secondary to internal valve insuciency
Asymmetrical dorsal aesthetic lines despite the use of upper lateral tension-
3.
spanning sutures
4.
Correction of dorsal septal deviation
Dorsal reduction greater than mm
5.
6.
Ethnic nose with weak cartilaginous support
Males with a narrow nose
7.
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