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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 235
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If spreader gras are required, septal cartilage is harvested and the gras are fashioned from the posterior inferior portion of the septal cartilage, which has the
most consistent width ( to mm) and appropriate length ( to mm). e
dimensions of the spreader gras are typically to mm high and to mm
long. Spreader gras can be placed unilaterally or bilaterally, parallel to the septum, depending on the deformity being addressed.
Spreader grafts
Spreader gras may be positioned at or above the plane of the dorsal septum to be
visible for aesthetic indications or below it as invisible gras for purely functional
indications.
,
Horizontal mattress sutures of - PDS are used to secure the
gras to the septum. e upper lateral cartilages are reattached to the spreader
gra−septal complex. Resection of the upper lateral cartilages is not performed
unless they produce a contour irregularity on clinical examination.
Preservation of the transverse portions of the upper lateral cartilages and proper
reconstitution of the dorsum are necessary to maintain patency of the internal
nasal valve and the shape of the dorsal aesthetic lines.
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8. Medial/Lateral Osteotomies
Nasal osteotomies are used primarily to correct widened nasal bones, to reposition asymmetrical nasal bones, or to close an open-roof deformity, if present,
aer dorsal reduction.
e percutaneous perforated lateral nasal osteotomy technique
,
aords excellent control, stable long-term results, and shorter postoperative recovery time
than internal nasal osteotomies do. Signicantly decreased trauma to the nasal
mucosa has been noted in cadaver studies using the percutaneous technique.
Percutaneous perforated lateral nasal osteotomies are performed toward the end
of the procedure at the same point in the surgical sequence as any other type of
osteotomy. We inject % lidocaine with epinephrine along the proposed osteotomy site at least minutes before the osteotomy. A sharp mm osteotome is
used to perforate the skin along the nasofacial junction, parallel to the face of the
maxilla at the level of the inferior orbital rim. Once introduced, the osteotome is
tracked subperiosteally up onto the midportion of the nasal pyramid and then
swept laterally down to the proposed site of the osteotomy along the nasofacial
junction. is maneuver displaces the angular artery laterally away from the osteotomy path to prevent bleeding at the osteotomy site.
Chapter Component Dorsal Hump Reduction and Dorsal Reconstitution 237
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Webster’s
triangle
e surgeon carefully directs the osteotome along the proposed osteotomy path
while an assistant uses a mallet to create mm osteotomies, skipping mm each
time from caudal at the piriform aperture to cephalad at the level of the medial
canthi. Care is taken to preserve Webster’s triangle to provide support for the
internal nasal valve. We prefer to start with a low-to-low lateral osteotomy that
continues into a superior oblique osteotomy at the level of the medial canthi; the
junction of the osteotomies typically creates a -degree angle. e osteotome
is tapped gently until a change in the sound and feel of the osteotome indicates
complete perforation of the bone in each location.
is technique results in multiple mm osteotomies with mm of normal bone
between each perforation. Once the perforated osteotomy has been completed
along the entire course of the nasal bone, a similar procedure is performed on the
contralateral side. Using gentle pressure applied with the thumb and forenger,
the surgeon then creates a greenstick fracture along each osteotomy site and positions the nasal bones in their desired location. Aer the osteotomized segments
have been appropriately positioned, the dorsum should be reevaluated to ensure
that no dorsal irregularities have been created. is is particularly important at
the keystone area where the upper lateral cartilages can be pushed posteriorly
deep to the nasal bones or become more prominent on the dorsum as a result of
compression from the repositioned osteotomized segments of bone.
Aer the osteotomized segments have been appropriately positioned, the dorsum
should be reevaluated to ensure that no dorsal irregularities have been created.
is is particularly important at the keystone area.
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Closure of the two percutaneous osteotomy sites is not performed because bleeding is infrequent. Postoperatively, the osteotomy sites are covered by Steri-Strips
aer skin preparation. A esh-colored metal splint is applied aer it is contoured
to t the nasal dorsum. is splint is removed days postoperatively. e percutaneous perforated lateral nasal osteotomy technique minimizes mucosal damage, postoperative intranasal bleeding, edema, and ecchymosis.
CASE ANALYSES
is healthy -year-old woman presented with a dorsal hump and bulbous tip.
e frontal view demonstrates poorly dened dorsal aesthetic lines and a large,
wide nasal tip. e lateral view demonstrates a moderate dorsal hump with supratip fullness and an underrotated tip.
e operative goals included the following:
■
Reduce the dorsal hump.
■
Create symmetrical and harmonious dorsal aesthetic lines.
■
Increase tip rotation.
■
Improve tip denition.
Chapter Component Dorsal Hump Reduction and Dorsal Reconstitution 239
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Type 1 dorsal
reconstitution
6 mm
Surgical Plan
1. Use an open approach with a stair-step transcolumellar incision and bilateral
infracartilaginous extensions.
2. Perform component dorsal hump reduction (mm).
3. Perform septal reconstruction.
4. Reconstitute the dorsum with upper lateral cartilage tension-spanning suture
(type ).
5. Perform cephalic trim leaving a mm alar rim strip.
6. Place a columellar strut.
7. Use intercrural, interdomal, and transdomal sutures (- PDS).
8. Perform low-to-low percutaneous perforated lateral osteotomies.
9. Place alar contour gras.
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Comparison views of preoperative and -month appearance demonstrate correction of the dorsal hump with harmonious dorsal aesthetic lines, a supratip
break, an increased nasolabial angle, and a well-dened tip.
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is woman had a history of nasal airway obstruction, septal deviation, a dorsal
hump, and an active depressor septi nasi muscle. e frontal view demonstrates
obvious dorsal-to-caudal rightward septal deviation, with deviated dorsal aesthetic lines and tip-dening points and a slightly widened bony base. She appeared to have an active depressor septi muscle on dynamic examination. e
lateral view demonstrates a moderate dorsal hump and the appearance of an
elongated nose because of the anterior radix position. Internal nasal examination revealed a septal tilt, with le dorsal septal deviation and right caudal septal
deviation, as well as compensatory le inferior turbinate hypertrophy.
e operative goals included the following:
■
Straighten the dorsum.
■
Re-create symmetrical dorsal aesthetic lines.
■
Correct/preserve the internal nasal valve.
■
Reduce the dorsal hump.
■
Increase tip projection to overcome the appearance of an elongated nose.
■
Release active depressor septi nasi muscle.
■
Correct inferior turbinate hypertrophy.
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Tip sutures:
Intracrural
Intradomal
Transdomal
Surgical Plan
1. Use an open approach with a stair-step transcolumellar incision and bilateral
infracartilaginous extensions.
2. Perform component dorsal hump reduction (mm).
3. Harvest septal cartilage leaving an L-strut.
4. Reposition the caudal septum onto the anterior nasal spine.
5. Perform cephalic trim leaving a mm alar rim strip.
6. Place a columellar strut.
7. Use intercrural, interdomal, and transdomal suturing.
8. Perform submucous resection and outfracturing of inferior turbinates.
9. Perform low-to-low percutaneous perforated lateral osteotomies.
10. Perform depressor septi nasi muscle release.
11. Place alar contour gras.
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Comparison views of preoperative and -month postoperative appearance demonstrate correction of the deviation with redenition of symmetrical dorsal aesthetic lines, correction of the dorsal hump, narrowing of the bony base, and
renement of the tip.
plunging tip, and the patient’s subjective complaints of nasal airway obstruction
resolved.
Of note, dynamic examination did not demonstrate a
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is -year-old woman desired aesthetic improvement of her nose. She also
complained of nasal airway obstruction. On the frontal view, she has an ill-dened dorsal aesthetic line, a wide bony vault, and obscure tip-dening points.
On the lateral view, she has a prominent dorsal hump and a subtle decrease in
her nasolabial angle.
e operative goals included the following:
■
Re-create symmetrical and harmonious dorsal aesthetic lines.
■
Reduce the dorsal hump.
■
Increase tip rotation slightly.
■
Rene the tip and dene tip-dening points.
■
Narrow the bony base.
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