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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 Nasal Osteotomies 255
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Double-Level Osteotomies
A double-level osteotomy is typically used when there is excessive lateral wall
convexity. is procedure essentially combines a low-to-low osteotomy with a
parallel, but more medially located, lateral osteotomy, which approximates the
nasal maxillary suture. is parallel osteotomy should be performed rst so as to
preserve stable bone on which to perform the low-to-low osteotomy.
At the top of the lateral osteotomy it is common to have a few millimeters of unfractured bone. In patients with normal bony thickness, digital pressure may be
applied to produce a transverse greenstick fracture in the medial segment. is
maneuver will produce the desired narrowing by tilting the bones medially. In
patients with thicker nasal bones, increased risk of airway compromise, and risk
of bone collapse, a superior oblique osteotomy is performed to complete the osteotomy or to narrow the gap enough so that digital pressure can complete mobilization of the bones.
Regardless of how the osteotomies are performed, however, preservation of Webster’s triangle, a triangular area of the caudal aspect of the frontal process of the
maxilla abutting the piriform aperture, is mandatory to prevent collapse of the
internal nasal valve with subsequent nasal airway obstruction.
Webster’s
triangle
Furthermore, step-o deformities are prevented by staying low along the bony
vault, keeping the most cephalic margin of the osteotomy below the intercanthal
line/medial canthal ligament. Complications, such as iatrogenic lacrimal system
disruption with resultant epiphora, are likely if osteotomies are continued more
cephalad to this boundary into the thicker nasal bones.
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Approach
Although the literature describes various methods of performing nasal osteotomies, the optimal surgical technique remains controversial.
the bony pyramid using alar, buccal,
,
vestibular, or external incisions have
been described. Various instruments including osteotomes, cutting forceps,
saws, and electrical instruments have been used to perform osteotomies.
Currently two dierent techniques are most frequently used for lateral osteotomies: the internal continuous lateral osteotomy and the percutaneous (external)
perforated (discontinuous) lateral osteotomy. ey should be executed with care
and control to preserve as much so tissue and as many periosteal attachments as
possible, avoiding large subperiosteal tunnels and any unnecessary undermining.
Additionally, to mm osteotomes are frequently used to minimize bleeding,
so tissue disruption, and scarring.
,,,
e two most frequently used techniques are the internal continuous lateral osteotomy and the percutaneous perforated lateral osteotomy, both of which should
be executed with care and control, preserving so tissue and periosteal attachments, and avoiding large subperiosteal tunnels and unnecessary undermining.
,-,-,
Access to
,
Internal Continuous Lateral Osteotomy
Internal continuous lateral osteotomies are most frequently performed through
the vestibular approach.
Operative Technique An opening is made through the vestibular skin anterior to the end of the inferior turbinate using Iris scissors. e scissors are inserted down to the periosteum lateral to the piriform aperture rim, and spread
just enough to accommodate a curved or straight osteotome with a small guard
on the lateral edge.
e edge of the piriform aperture is felt using the blade of the osteotome. By
pressing the guard against the lateral surface and palpating it with the index nger of the free hand, the blade is moved to the desired starting position on the
rim. is position is usually at the level of the attachment of the anterior end of
the inferior turbinate. It is slightly more anterosuperior than the most posterior
point of the piriform aperture edge to preserve Webster’s triangle, which is a triangular area of intact maxillary frontal process near the internal valve region.
eoretically, if the osteotomy is started low (at the most posterior point of the
piriform aperture), infracture could move the anterior end of the inferior turbinate medially and compromise the airway at the level of the internal nasal valve.
Chapter Nasal Osteotomies 257
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erefore the osteotomy is started more superiorly on the rim and is angled
slightly toward the maxilla. is position allows the osteotome to get to the nasal
cheek junction, where it continues superiorly along the base of the bony vault and
curves toward the nasal root. It stops at the level of the medial canthus, where
it should be a few millimeters from the lateral end of the medial osteotomy. e
osteotomy does not separate the nasal-maxillary suture unless a double osteotomy is performed. Rather, the osteotomy should course toward the point of
maximal width, as determined on examination. If a medial osteotomy was not
performed, the infracture is accomplished by rotating the guard of the osteotome
toward the dorsum while gently moving the free end of the osteotome medially.
is will result in a greenstick fracture from the superior end of the osteotomy
site through the weakest line of the nasal bone. If a medial osteotomy was performed, gentle digital pressure is generally sucient to infracture the segment.
Under ordinary circumstances a greenstick fracture is preferred, because a complete fracture is unstable and more dicult to control.
Percutaneous Perforated Lateral Osteotomy
Percutaneous perforated lateral osteotomies are our preferred technique; they
have proved to be predictable and reliable in the correction of the aforementioned deformities. is procedure involves discontinuous perforations made
by a sharp osteotome along the lateral aspect of the bony pyramid, followed by
greenstick infracturing performed using digital manipulation. It is associated
with minimal morbidity and can be executed at any time during the rhinoplasty
operative sequence.
Operative Technique Percutaneous perforated lateral nasal osteotomies confer
specic advantages based on the preservation of so tissue attachments along
with the periosteum, including:
■
Greater stability aer repositioning
■
Decreased dead space
■
Reduced bony malposition with resultant overnarrowing of the bony vault
and/or airway compromise
■
Prevention of ail segment of fractured bone
We generally perform lateral osteotomies during the nal stages of the operation, aer the dorsal-nasal height, septum, and tip have been addressed, although
technically they can be performed at any time during the operative sequence.
Uncommonly, osteotomies can increase intraoperative edema and ecchymosis
obscuring visual evaluation and making further renements more challenging
to perform. It is important to note that when performing the initial exposure
during rhinoplasty, undermining over the bony vault should be limited to the
central dorsum to preserve so tissue attachments to the nasal bones laterally.
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When performing the initial exposure during rhinoplasty, undermining over the
bony vault should be limited to the central dorsum to preserve so tissue attachments to the nasal bones laterally.
,
Our preferred technique is as follows
:
1. Inject approximately ml of % lidocaine with :, epinephrine,
both intranasally and along the lateral nasal sidewalls. Allow approximately minutes for the hemostatic eect of the epinephrine to take
place.
2. Sharpen a at mm osteotome, rinse with saline solution, wipe with a
clean towel, and rinse again to remove all dust from the surgical whetstone.
Contraindications include elderly patients with thin, fragile nasal bones, patients
who wear heavy eyeglasses, patients with congenitally short nasal bones (where
the caudal border is less than one centimeter below the intercanthal line), or
patients with thick nasal skin and/or a history of hypertrophic scar formation.
Caution should also be exercised in certain nonwhite races with low, broad noses.
Always use a sharp osteotome (2mm preferred). Visible scarring can be reduced
by cleansing the osteotome before use.
3. Introduce the sharpened mm osteotome percutaneously at the midportion of the bony nasal pyramid at the level of the inferior orbital rim and
nasofacial junction parallel to the horizontal surface of the maxilla.
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4. Avoid injury to the angular artery by sweeping the osteotome down the
lateral nasal sidewall in the subperiosteal plane to the halfway point of
the proposed pathway of the osteotomy.
Most efficient
cutting angle
Nasal bone surface
Maximizing osteotome efficiency and precision
5. Orient the osteotome at an angle so that only one corner of the edge is
in direct contact with the bone to precisely focus the force and minimize
trauma. Strike with the mallet until a change in both feel and sound at
that location is achieved.
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6. Perform multiple discontinuous osteotomies spaced mm apart in the
It is imperative to remain within the initial percutaneous puncture site while
extending the osteotomies to prevent increased risk of iatrogenic angular artery
trauma and subsequent ecchymosis.
conguration desired (low-to-low, low-to-high, or other).
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If it is necessary to withdraw the osteotome, it should be replaced in the original
percutaneous access site with the same precautionary downward sweeping motion, as previously described. Perform the same procedure on the contralateral
side.
7. Aer the bilateral osteotomies are completed, perform a greenstick fracture of the nasal bones using gentle pressure between the thumb and
forenger until they are positioned in their desired location. If more than
gentle digital pressure is required, reinsert the osteotome and evaluate the
prior osteotomy line for persistent large gaps between perforations.
Aer the perforated osteotomies are completed, a controlled, bimanual greenstick fracture is made to allow repositioning of the bony pyramid. Osteotomies
can be performed at any point during the procedure. Aer the osteotomized segments have been appropriately positioned, the dorsum should be reevaluated to
ensure no dorsal irregularities have been created. is is particularly important
at the keystone area.
8. Aer the osteotomized segments have been appropriately positioned, the
dorsum should be reevaluated to ensure 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 due to compression from the
repositioned osteotomized segments of bone.
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Aer the osteotomized segments have been appropriately positioned, the dorsum
should be reevaluated to ensure no dorsal irregularities have been created. is
is particularly important at the keystone area.
9. No sutures are required to maintain position of the osteotomized segments. It is helpful to apply gentle sustained pressure to the osteotomy
sites to decrease bleeding and to help prevent postoperative ecchymosis.
e nasal skin is cleansed with alcohol and adhesive is applied followed
by Steri-Strips. A malleable dorsal compression splint (Denver splint) is
contoured and applied to the nasal dorsum for days to minimize postoperative edema.
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e surgeon must avoid overcompression during application of the Denver splint
to prevent malposition of the osteomized segments resulting in overnarrowing
of the bony vault. Care should be taken to avoid iatrogenic injury to the angular artery by sweeping down the lateral nasal sidewall in a subperiosteal plane.
CASE ANALYSES
is -year-old woman expressed dissatisfaction with the appearance of her
nose and complained of nasal airway obstruction. She was otherwise healthy and
had no past medical or surgical history and no history of facial trauma. Clinical
analysis revealed a good facial prole and facial proportions, moderately thick
nasal skin, wide dorsal aesthetic lines with a broad nasal base, a bulbous nasal
tip, a high radix with short nose, and inadequate tip projection.
e operative goals included the following:
■
Lengthen the nose.
■
Increase tip projection.
■
Narrow dorsal aesthetic lines.
■
Rene and correct the bulbous nasal tip.
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Surgical Plan
1. Use an open approach with a transcolumellar stair-step incision connected to
bilateral infracartilaginous incisions.
2. Lower the radix using a burr.
3. Correct the slightly deviated nasal septum and harvest septal cartilage, leaving an L-strut.
4. Use bilateral extended spreader gras to lengthen the nose.
5. Perform wide undermining of the nasal tip skin and release the lower lateral
cartilages from their attachments to the upper lateral cartilages.
6. Perform cephalic trim leaving a mm alar rim strip.
7. Use interdomal and transdomal suturing to rene the tip.
8. Perform percutaneous perforated lateral low-to-low and superior oblique osteotomies.
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