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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 Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 305
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is -year-old woman presented years aer a primary closed rhinoplasty.
During the early postoperative period, she had three Kenalog injections to her
supratip region. She was devastated by the result and described her nose as too
long and her tip as that of a “clown nose.” She also related, “My mother won’t look
me in the eye.” Essentially, the patient wanted her old nose back, with a strong
bridge and a small bump. On the anterior view, the dorsal lines were pinched
in the middle third, worse on the le than the right, which made her tip appear
rounder. On the lateral view, the dorsum looked overresected, and the pollybeak
tip was evident. e oblique view showed that the dorsal line was broken at the
midvault, and her tip appeared dependent.
In planning the surgery, two important technical issues had to be determined.
First, from the physical examination, it was evident that the patient’s le nasal
bone was inwardly displaced. If a perfectly straight dorsal gra were placed on
an asymmetrical base, it would appear crooked. e challenge was to change the
orientation of the le bone from vertical to angled, move it outward, and maintain the position.
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Second, what type of dorsal augmentation was needed? On preoperative examination, her septum felt weak and had indeed been partially resected. Would this
augmentation require conchal cartilage or rib? A straight, so prole can be created with a tapered DC-F gra, but the patient wanted a strong prole with the
suggestion of a hump, thus favoring a uniform DC-F gra.
Surgical Plan
1. Harvest a large sheet of deep temporal fascia.
2. Perform an open approach through transcolumellar and infracartilaginous
incisions.
3. Excise .mm of supratip scar tissue (so tissue pollybeak).
4. Explore the septum through a right unilateral transxion incision.
5. Harvest available cartilage, leaving a to mm strut.
6. Harvest the conchal bowl through a retroauricular incision.
7. Perform a medial oblique and low-to-low osteotomy on the le side only.
8. Insert a partial-length (distal) spreader gra on the right and a full-length
spreader gra on the le, extending into the bony vault to maintain the outward position of the le bone.
9. Insert a laminated columellar strut made of conchal cartilage reinforced with
septal cartilage.
10. Reduce the alar cartilages to mm rim strips.
11. Shape the tip with domal creation and interdomal sutures.
12. Apply a shield-shaped tip gra with a posterior boost made from septal cartilage plus a dome-shaped tip renement gra made from excised alar cartilage.
13. Dice scraps of cartilage and pack them into a tuberculin syringe on the back
table.
14. Build a DC-F construct the measures mm long by mm wide by mm
thick.
15. Ensure uniform thickness to create a strong prole and minihump. (In a typical secondary rhinoplasty, a tapered DC-F gra is used to prevent fullness in
the rhinion area.)
16. Insert alar rim gras.
17. Close all incisions and apply a cast.
Almost years postoperatively, the patient’s nose essentially appears as it did
before her rst operation. e patient and her family are pleased with the result.
On the anterior view, her bony pyramid is no longer collapsed on the le side.
On the lateral view, her dorsum has a natural unoperated contour with a small
minihump and a nice seto of the tip. On oblique view the dorsum is strong with
a well-dened dorsal line. e tip is no longer dependent and broad.
Chapter Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 307
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is case illustrates two of the principal advantages of DC-F gras. e gra is
composed of scraps of cartilage rather than a solid piece. is patient’s septum
had been compromised, and mm of augmentation with conchal cartilage was
virtually impossible. e only alternative was a rib gra. is was not needed,
because a DC-F gra was performed. In addition, the exibility of shaping DC-F
allows surgeons to design each construct to t the patient’s goal, including the
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creation of a small hump on top of a major augmentation. Interestingly, the patient stated that further distinct improvement in tip denition occurred to
months postoperatively, thus conrming that the skin envelope continues to thin
without the need for Kenalog injections.
is -year-old woman presented for a secondary rhinoplasty years aer
her original surgery, which was performed elsewhere. She did not like the surgical look of her nose, especially the pinched, droopy tip. On the anterior view,
her dorsum was collapsed in the midvault, whereas the tip has a classic hanging
columella (seagull in ight). On the lateral view, her dorsum appeared overresected and the alar rims retracted. On the oblique view, her tip looked attened
as though pressed against a glass window. Deviation of the caudal septum and
destruction of the le so tissue facet were apparent on the basal view. is patient had a four-view disaster with major deformities in each view of her nose.
Chapter Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 309
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e operative goals included the following:
■
Harvest a sheet of deep temporal resection.
■
Expose the nose using an open approach.
■
Analyze the tip. (is revealed a prior resection of % of the lateral
crura.)
■
Excise the supratip scar tissue. (is revealed a cartilaginous pollybeak.)
■
Excise a tapered .mm section of cartilaginous dorsum.
■
Expose the septum.
■
Resect a mm wide bowed section of the caudal septum.
■
Harvest the cartilaginous body of the septum.
■
Harvest a portion of the conchal bowl (to be diced by the circulating
nurse).
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■
Insert bilateral spreader gras and suture them into place with multiple
sutures of - PDS.
■
Mobilize the alar cartilages from the underlying mucosa.
■
Suture the lateral crural strut gras to the remnants of each lateral crus.
■
Insert a columellar strut.
■
Shape the tip with the following sutures: columellar, domal creation, and
domal equalization.
■
Construct a dorsal DC-F gra on the back table with thickness tapered
from .mm cephalically to .mm at the midpoint to .mm caudally.
■
Insert the DC-F construct using percutaneous guide sutures at the nasion and x/close the gra caudally at the anterior septal angle using -
plain catgut.
■
Provide additional tip projection with a two-layer onlay tip renement
gra covered with a piece of fascia.
■
Make marginal incisions along each alar rim, fully transpose the lateral
crura, and suture the lateral crural strut gras to the alar rims.
■
Insert Doyle splints and apply a Denver splint.
Postoperatively DC-F gras provide a smooth dorsum with signicant augmentation, a natural contour, and well-dened dorsal lines.
Chapter Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 311
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e patient is pleased with her result year months postoperatively. On the anterior view, her nose appears shorter and the hanging columella is corrected. Her
collapsed midvault with its disrupted dorsal lines is replaced with very visible
parallel dorsal lines. On the oblique view, her long verticalized tip is compressed
into a very well-dened domal-tip complex. Her dorsum is smooth and blends
into the radix. On static and smiling lateral views, her dorsum is straight and tip
dependency is eliminated.
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is -year-old woman had a rhinoplasty at age and was disappointed with
the result immediately. A revision year later did not make a signicant improvement. Her respiration was signicantly impaired. On internal examination the
vestibular and internal valves were collapsed. On the anterior view, her nasal tip
was extremely pointy with a very sharp bossa. Midvault collapse was evident on
the oblique view. On the lateral view, her dorsum looked overresected and had
a characteristic ski-slope curvature. e basal view showed a pointy tip and dis
torted nostrils. is was one of my rst DC-F gra surgeries, performed over
years ago.
-
Chapter Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 313
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Surgical Plan
1. Assess the septum via a right unilateral transxion incision. (is conrmed
a prior submucous resection of a portion of the septum.)
2. Perform an open approach, which requires meticulous dissection and multiple reinjections of the tip to allow safe skin elevation.
3. Assess the tip. (is revealed a prior Goldman tip procedure; that is, transection of the lateral crura, followed by midline suturing to create a central
“tent pole” or pointy tip.)
4. Slightly reduce the distal cartilaginous pollybeak.
5. Harvest all available septal cartilage.
6. Harvest the cartilaginous portion of the h rib.
7. Insert a columellar strut.
8. Reverse the medial transposition of the lateral crura by repairing the divided
alae at the dome.
9. Suture lateral crural strut gras to the distal lateral crura, and then rotate
them into the alar bases.
10. Place an additional alar rim structure gra on the le.
11. Place a concealer gra over the tip in the infralobular position.
12. Dice cartilage and place it in a tuberculin syringe.
13. Suture a fascial sleeve around the syringe.
14. Insert diced cartilage under the dorsum, and expand it to the desired augmentation.
15. Close the gra caudally.
16. Make mm nostril sill excisions.
17. Suture footplate gras to the columellar base.
18. Close all incisions and apply a cast.
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Almost years postoperatively, and without revisions, the patient’s dorsum looks
natural with its dorsal lines. She has maintained to mm of augmentation
from day , without absorption. Intraoperatively every secondary rhinoplasty is
a surprise and requires exibility. Reversal of the Goldman tip and coverage of
the suture repair with a concealer gra was devised out of necessity. Because this
was one of the rst DC-F gras that Iperformed, it raises the question, “Why
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