Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
.pdf
Chapter Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 315
https://t.me/medicina_free
did Iswitch from the syringe injection technique to the construct technique?” e
injection technique works surprisingly well when a uniform gra is required to
create a straight prole, and the patient has a tight skin envelope. However, it does
not work well in most secondary cases, in which the dorsal defect is more distal
and a tapered augmentation is needed. Based on experience and unsatisfactory
results, Ino longer inject gra in situ and strongly favor building a construct on
the back table.
POSTOPERATIVE CARE
Aer completion of the operation, all incisions are closed and the dorsum is gently taped with Steri-Strips. Iprefer to use a Denver splint rather than an acrylic
splint. e foam is positioned along the dorsum, and the previously bent splint
is gently placed on top. e pressure from the splint further ensures a smooth
dorsum. When the cast is removed days postoperatively, the nose is inspected
and gentle molding can be carried out as needed. If required, the patient is seen
every days for gra molding for up to days. Patients are informed not to wear
sunglasses for weeks. If asymmetry is present year postoperatively, it can be
easily shaped by beveling with a blade. Alternatively, the now-solid gra can
be removed, shaped, and reinserted.
COMPLICATIONS
Aer a decade of experience with DC-F gras, Ihave seen no evidence of absorption and no warping. To date, the problems with diced cartilage gras have
been more technical rather than intrinsic to the gra itself. A correlate from traditional rhinoplasty surgery is the visibility of the cephalic end of a spreader gra,
which is not the fault of the gra. My problems with diced cartilage gras have
been relatively minor and easily corrected. ey include visibility of DC-F gras
placed in the radix area, especially in patients with very active eyebrow elevation
(more than mm). It is easily corrected under local anesthesia either by reduction with a pituitary rongeur or excision and replacement with fascia alone. For
dorsal gras, edge show occasionally occurs in the rhinion area, whereas caudally,
inadequate graing of the supratip region is sometimes seen. e former is probably caused by poor technique and the very thin skin in the rhinion area. It is
easily corrected under local anesthesia in the oce using a pituitary rongeur. In
one patient, who had a very thin skin envelope, Iplaced a layer of fascia between
the skin and the intact DC-F gra in a revision. In the rhinion area of the gra, a
greater prominence than desired can be present. is can be prevented by making a very tapered construct with minimal ll at the midpoint and laying the gra
into the defect rather than stung it in and molding it. Occasionally a minor
depression develops in the supratip area, the result of an initial undercorrection
in an attempt to create an immediate supratip break. Over time, Ihave learned
Part ree e Dorsum316
https://t.me/medicina_free
to maintain the full gra length and not shorten it to achieve tip seto. If a depression occurs, Icorrect it with a small fascia gra; other surgeons might prefer
AlloDerm. Also, Iam now more compulsive about checking for gra widening in
the supratip area. is can occur aer manual molding of the gra, which forces
cartilage from cephalad to caudal. us far patients have not complained about
it. is experience is in marked contrast to more rigid dorsal gras that can have
serious problems, including warping, malalignment, K-wire extrusion, and total
visibility from skin shrink-wrapping around the gra.
Complications with diced cartilage gras tend to be relatively minor and conned to shape and visibility problems, not absorption.
CONCLUSION
DC-F gras have dramatically revolutionized dorsal gras in rhinoplasty surgery. In my personal experience, they have replaced layered by mm septal
gras, stacked conchal gras, and carved costal cartilage gras. DC-F is technically straightforward, simpler, quicker, and oen aesthetically superior to solid
cartilage gras, without the risk of warping, malalignment, and K-wire extrusion.
In over patients with follow-up exceeding years, Ihave seen no evidence
of gra absorption.
KEY POINTS
■
DC-F gras have several distinct advantages over other techniques in rhinoplasty surgery for dorsal augmentation.
■
It is critical to create a symmetrical dorsal platform on which to place the DC-F
gra. e gra acts as a capstone to a pyramid; if the pyramid is crooked, the
DC-F gra will appear to be displaced.
■
e length, width, thickness, and shape of the construct must be carefully designed.
■
e shape of the gra can be either uniform or tapered. Tapered gra is thicker
cephalically or caudally. e shape should be as accurate as possible before
insertion. Surgeons should not expect to create the ideal shape with molding.
■
Diced cartilage gras are not new. ey have been used ever since modern
plastic surgery began. For the past decade, Ihave used DC-F rather than solid
dorsal gras for dorsal augmentation.
■
A DC-F construct is carefully placed in the nose using percutaneous sutures.
e skin is redraped and the contour checked. Pieces of cartilage can be removed from the open caudal end to achieve nal shape.
Chapter Dorsal Augmentation: Temporal Fascia–Wrapped Diced Cartilage 317
https://t.me/medicina_free
■
When the shape of the dorsum is satisfactory, a Denver splint is applied with
the foam pad, helping to ensure a smooth dorsum. When the cast is removed,
the patient is instructed not to massage the nose or wear glasses for to
weeks.
■
DC-F gras can be used in the entire range of rhinoplasty cases, from primary
cases requiring augmentation to unexpected defects encountered in secondary cases to composite reconstruction for a collapsed nose, and for burned out
cases requiring an aesthetic reconstructive rhinoplasty.
■
Preoperative planning can include photographic analysis using angles and
lengths, CT scans, and a review of previous operative reports.
■
A gra will solidify within a matter of months and can be easily trimmed or
removed in its entirety, shaped, and reinserted as necessary.
■
Deep temporal fascia should be harvested in as large a piece as possible, oen
measuring to cm vertically by to cm transversely. Fascia contracts dramatically!
■
e cartilage cannot be diced too ne. It is compressed until it is virtually a
solid paste and can be passed through the hub of a tuberculin syringe.
■
e fascial sleeve is made to measure to t the defect. e fascia is pinned to
a Silastic block under slight tension and folded to a width of to mm. e
length is determined by the size of the dorsal defect.
■
e goal is to create a dorsal gra with ideal dimensions and contour. e volume of cartilage will determine the height, whereas the curved, natural contour is achieved with the nondominant hand at the time of lling. e dorsum
should not be overgraed, because the gra will not be absorbed!
■
Time is taken to create the ideal-shaped construct while it is on the back table.
Surgeons should not expect to make major changes by molding the gra once
it is in the nose.
■
Postoperatively DC-F gras provide a smooth dorsum with signicant augmentation, a natural contour, and well-dened dorsal lines.
■
Complications with diced cartilage gras tend to be relatively minor and conned to shape and visibility problems, not absorption.
REFERENCES
1. Daniel, RK, Calvert JC. Diced cartilage in rhinoplasty surgery. Plast Reconstr Surg :-,
.
2. Daniel RK. Diced cartilage gras in rhinoplasty surgery: current techniques and applications. Plast
Reconstr Surg :-, .
3. Daniel RK. Mastering Rhinoplasty. New York: Springer, .
4. Calvert JW, Brenner KB, DaCosta-Iyer M, et al. Histological analysis of human diced cartilage
gras. Plast Reconstr Surg :-, .
5. Peer LA. Diced cartilage gras. Arch Otolaryngol :-, .
6. Burian F. e Plastic Surgery Atlas. New York: Macmillan, .
7. Guerrerosantos J. Temporoparietal free fascial gras to the nose. Plast Reconstr Surg :-,
.
Part ree e Dorsum318
https://t.me/medicina_free
8. Willingseder P. Cranioplasties by means of diced cartilage and split rib gras. Minerva Chir :-
, .
9. Daniel RK, Sajjadain A. Secondary rhinoplasty: management of the over resected dorsum. Facial
Plast Surg :-, .
10. Welling DB, Maves MD, Schuller DE, et al. Irradiated homologous cartilage gras: long-term re-
sults. Arch Otolaryngol Head neck Surg :-, .
11. Erol OO. e Turkish delight: a pliable gra for rhinoplasty. Plast Reconstr Surg :-,
.
12. Kim EK, Daniel RK. Operative techniques in Asian rhinoplasty. Aesthet Surg J :-, .
13. Daniel RK. Middle Eastern rhinoplasty: anatomy, aesthetics, and surgical planning. Facial Plast
Surg :-, .
14. Daniel RK. Rhinoplasty: septal saddle nose deformity and composite reconstruction. Plast Recon-
str Surg :-, .
15. Daniel RK, Brenner KA. Saddle nose deformity: a new classication and treatment. Facial Plast
Surg Clin North Am :-, .
16. Daniel RK. Aesthetic Plastic Surgery: Rhinoplasty. Boston: Little Brown, .
■ ■ ■ ■ ■ ■
https://t.me/medicina_free
PART FOUR
e Tip
This page intentionally left blankThis page intentionally left blank
https://t.me/medicina_free
■ ■ ■ ■ ■ ■
https://t.me/medicina_free
17
Basic Nasal Tip Surgery:
Anatomy and Technique
Jack P. Gunter Michael R. Lee Jamil Ahmad Rod J. Rohrich
T
o provide proper treatment of the nasal tip, the surgeon must have a comprehensive knowledge of relevant anatomy. Such anatomy provides the framework
ultimately responsible for tip position and shape. Furthermore, understanding
the role that dierent structures contribute to tip characteristics facilitates optimal diagnosis and treatment planning.
Pivotal to success in rhinoplasty is thorough analysis of both the face and nose.
Disregarding facial analysis and focusing on the nose alone may lead to overall
disharmony and an untoward result. Once the diagnosis has been established,
the operative goals are determined. Proper execution of a successful treatment
plan requires an understanding of the following:
1. Variations of the so tissues and cartilage framework of the tip and their
contributions to external appearance
2. Factors responsible for tip support and how they are interrelated
3. e result that each surgical maneuver or combination of maneuvers has
on the overall surgical result
Surgery of the nasal tip requires a comprehensive knowledge of nasal anatomy
and support.
In this chapter we will review the relevant anatomy of the nasal tip and operative
strategies used to alter the position and shape of the nasal tip.
321
Part Four e Tip322
https://t.me/medicina_free
Treatment planning should be individualized for each patient. Communication
with the patient is extremely important to identify any unrealistic expectations
and to set more appropriate expectations that are commensurate with what can
be achieved with rhinoplasty. Similar deformities of the nasal tip may require different modications depending on the aesthetic relationship of the tip with the
rest of the nose as well as the face. e use of a graduated approach in modications of the nasal tip allows a safe and predictable approach.
When operating on the nasal tip it is best to follow a graduated approach with
constant reassessment before each maneuver.
ANATOMY OF THE NASAL TIP SUPPORT STRUCTURES
Support for the nasal tip is derived from a combination of bony, cartilaginous,
and so tissue structures. Bone of the midface provides the foundation for nasal
support. Medially, the maxillary crest serves as a buttress for the nasal septum.
e septum in return provides crucial support for the external nose and nasal
tip. So tissue attachments from the dorsal and caudal septum to the lower lateral cartilages have a direct inuence on tip support and location. Laterally, so
tissue attachments connect the lower lateral cartilage complex to the bony piriform aperture.
To rotate the nasal tip, the surgeon must identify and remove anatomic structures
resisting upward rotation.
Nasal bones
Upper lateral
cartilage
Sidewall
Ala
Lower lateral
cartilage
Anatomy Topography
Radix
Dorsum
Tip
Tip location is ultimately dependent on the position of the anterior septum and
lower lateral cartilages.
-
ere are both major and minor tip support structures.
Chapter Basic Nasal Tip Surgery: Anatomy and Technique 323
https://t.me/medicina_free
e paired lower lateral cartilages rely signicantly on the dorsal and caudal
septum for support. Lower lateral cartilage shape, position, and integrity are all
important in terms of nasal tip appearance and functioning of the external nasal
valves. Each lower lateral cartilage comprises a medial crus, a middle crus, and a
lateral crus. e characteristics of these crura, along with so tissue connections
to adjacent structures, dictate the external appearance of the nasal tip.
Major and Minor Tip Support Structures
Major Tip Support Structures
◾
Fibrous connection of lateral crura
to the upper lateral cartilages
◾
Abutment and attachment of the lateral crural complex to the piriform
aperture
◾
Fibrous connection of the medial
Minor Tip Support Structures
◾
Fibrous attachments of the lower lateral cartilages to the dorsal septum
◾
Lower lateral cartilage attachments
to the skin
◾
Membranous septum
crura to the caudal septum and anterior nasal spine
◾
Suspensory ligament of the nasal tip
Lateral Crural Attachments to the Upper Lateral Cartilages
Nasal bones
Upper lateral cartilage
e upper lateral cartilages are secured cephalically by their connection to the
nasal bones. Medially, the upper lateral cartilages abut and connect to the dorsal
septum. Caudally, the upper lateral cartilages exhibit a so tissue attachment to
the cephalic border of the lateral crura at the scroll area. is connection provides support to the lateral crura and nasal tip.
Lower lateral
cartilages:
Lateral crus
Medial crus
Piriform aperture
Accessory cartilages
Septum
Maxillary crest
Anterior nasal spine
Part Four e Tip324
https://t.me/medicina_free
Connective tissue bers that attach the lateral crura to the upper lateral cartilages
allow movement between the two structures while providing tip support. Violating the so tissue connection between these two structures with an incision will
obliterate this support as will cephalic trim of the lower lateral crura.
Lateral Crural Attachments to the Piriform Aperture
Lateral crural complex:
Lateral crus
Accessory cartilages
e lateral crura attach laterally to the piriform aperture by means of accessory
cartilages. e accessory cartilages share continuous perichondrium, allowing
them to function as a unit. Together the lateral crura, accessory cartilages, and
associated so tissue connections to the piriform aperture create the lateral crural complex. e so tissue component of this area has been named the piriform
ligament, underscoring its importance in nasal support. e lateral crural complex provides lateral support and rigidity for the nose.
Fibrous
connections
Suspensory
ligament
of tip
Piriform aperture
abutment
Fibrous
attachments
Support of the lateral crural complex results from the suspensory ligament of
the tip resting on the anterior septal angle, the brous connections to the upper
lateral cartilages, and the abutment with the piriform aperture.
Соседние файлы в папке Библиотека им академика М.И. Перельмана