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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 265
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e patient is shown years aer surgery. Clinical analysis at this time revealed
a normal radix, narrowed dorsal aesthetic lines, improved nasofacial balance,
increased tip projection, increased nasal length, and a rened nasal tip.
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is -year-old woman desired aesthetic correction to her nose and did not
complain of nasal airway obstruction. She had a past medical history signicant
for basal cell cancer of the dorsum of her nose and had undergone Mohs micro
graphic surgery with subsequent skin gra reconstruction at an outside facility.
On the frontal view, a wide bony base, poorly dened tip, and nostril asymmetry were noted. On the lateral view, a dorsal hump was easily discerned, with a
stepo near the radix.
e operative goals included the following:
■
Straighten the dorsum.
■
Re-create symmetrical dorsal aesthetic lines.
■
Narrow the bony base.
■
Reduce dorsal hump.
■
Rene tip.
■
Correct nostril asymmetry.
-
Dorsal reduction
Tip sutures:
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Interdomal
Transdomal
Intercrural
Chapter Nasal Osteotomies 267
Surgical Plan
1. Use an open approach with transcolumellar stair-step incision connected to
bilateral infracartilaginous incisions.
2. Perform component reduction of the dorsum (mm).
3. Harvest septal cartilage, leaving an L-strut.
4. Perform cephalic trim, leaving a mm alar rim strip.
5. Place a columellar strut with medial crural strut sutures to unify the tip complex.
6. Perform intercrural, interdomal, and transdomal suturing to rene the tip.
7. Perform percutaneous perforated lateral low-to-low and superior oblique osteotomies.
8. Resect the alar base.
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e patient is seen months postoperatively showing narrowing of her dorsum,
correction of the dorsal hump, renement of the tip, and improvement of nostril symmetry.
Chapter Nasal Osteotomies 269
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POSTOPERATIVE CARE
Although postoperative care is individualized, we recommend head-of-bed elevation, perioperative antibiotic therapy (cephalexin mg by mouth every hours
for hours), a steroid dose-pack (Medrol), activity restriction, and narcotic pain
control (hydrocodone/acetaminophen).
We strongly encourage the use of nasal saline solution, and in some cases, a nasal decongestant such as oxymetolazone nasal spray for postoperative nasal congestion and ask patients to avoid nose blowing, straining, or performing heavy
or strenuous activity for weeks. We also caution against eating any foods that
require excessive lip movements or transmission of compression through the
nasomaxillary buttress (such as apples and corn on the cob).
Patient management is individualized and depends on the extent of functional
or aesthetic renement; however, perioperative antibiotics, a steroid dose-pack,
and activity restriction are important considerations.
Cool compresses are applied periorbitally for the rst hours. e patient
should not allow anything to rest on the nose for at least weeks, including eyeglasses. Aer this time, the patient should only resume wearing glasses if there
is no discomfort felt along the bony vault. If needed, glasses can be taped to the
forehead, or contact lenses can be worn as soon as the edema has diminished
suciently to allow easy insertion.
Osteotomy can be the most traumatic and least controlled with the potential for
a variety of serious complications. e surgeon should therefore develop and feel
comfortable with a technique oering reproducibility, consistency, and minimal
morbidity.
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COMPLICATIONS
Complications of Lateral Nasal Osteotomies
Infections Operative Trauma Cosmetic Problems
Local
Abscess
Cellulitis
Granuloma
Systemic Edema Insucient mobilization of lateral
Intracranial
Hemorrhage (hematoma,
ecchymosis)
Nasal cyst formation
Anosmia
Arteriovenous stula
Epiphora
Canalicular bleeding
Neuromuscular injury
Intracranial injury
Excessive narrowing or convexity
bony walls
U
ns
table bony pyramid
Rocker formation
Redundant so tissue
Stair-step deformity
Nasal bone asymmetry
Complications may arise, regardless of the technique used. Familiarity with the
diagnosis and treatment of these is critical to the complete care of the patient.
e percutaneous perforated lateral osteotomy technique using a sharp 2mm
osteotome provides excellent control of the bony pyramid and is associated with
a reduction in intranasal trauma.
CONCLUSION
Osteotomies are an extremely useful technique that can be performed in both
cosmetic and functional nasal surgery. ey are generally used to narrow the
lateral nasal walls, to close open roof deformities, and to create symmetry by allowing for straightening of the nasal bony pyramid. Although they can be performed in a variety of ways, the rhinoplasty surgeon must understand the indications, advantages, disadvantages, and potential complications of each approach.
We have found the percutaneous perforated lateral osteotomy technique to be
reliable, reproducible, and predictable. If performed correctly, there is minimal
morbidity to the patient with almost imperceptible scarring and negligible damage to the nasal mucosa.
Chapter Nasal Osteotomies 271
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KEY POINTS
■
A complete understanding of nasal anatomy and its inherent variations is essential for optimizing outcomes of nasal osteotomies.
■
e purpose of lateral nasal osteotomy is to narrow a widened lateral nasal wall,
close an open roof deformity, and mobilize a deviated nasal pyramid.
■
Medial osteotomies may be performed when the bony dorsum is excessively
wide, the nasal bones are deviated, or the bony dorsum is excessively narrow
and needs to be widened with spreader gras.
■
e nasal bony vault varies in thickness regionally, making controlled narrowing challenging; thus aesthetically pleasing and reliable results remain dicult
to obtain with medial osteotomies.
■
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.
■
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.
■
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 (mm preferred). Visible scarring can be reduced by cleansing the chisel before use.
■
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.
■
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.
■
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.
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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.
■
Patient management is individualized and depends on the extent of functional
or aesthetic renement; however, perioperative antibiotics, a steroid dose-pack,
and activity restriction are important considerations.
■
Osteotomy can be the most traumatic and least controlled with the potential
for a variety of serious complications. e surgeon should therefore develop
and feel comfortable with a technique oering reproducibility, consistency,
and minimal morbidity.
■
e percutaneous perforated lateral osteotomy technique using a sharp mm,
osteotome provides excellent control of the bony pyramid and is associated
with a reduction in intranasal trauma.
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Chapter Nasal Osteotomies 273
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