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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 Advanced Suture Techniques 355
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Interdomal Suture
Opening the nose, splitting the tip cartilages slightly to gain access to the anterior
septal angle of the septum (to elevate mucoperichondrium and release upper lateral cartilages) are all necessary maneuvers but do result in some splaying of the
domes and loss of strength and symmetry. e interdomal suture restores symmetry and corrects splaying. A - PDS suture is approximate the middle crura
(on the cephalic side) at a level that is approximately to mm below (posterior
to) the domes. e domes themselves are not sutured together because there is
normally a small separation of a few mm between the cephalic end of the domes.
If a columellar strut is planned, this suture is usually placed aer the strut is put
in place because strut placement can oen be disrupting.
e interdomal suture restores tip strength and symmetry.
Lateral Crus Suture
Any convexity of the lateral crus can be improved or reversed with a horizontal mattress
suture of - PDS. While holding the most convex portion of the convex lateral crus, the suture needle is placed on one side of the forceps,
perpendicular to the direction of the lateral crus
trying to take as small a bite as possible. e second bite is taken on the other side of the forceps
so that the distance between should be approximately mm.
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e knot is only tied tightly enough to atten the convexity. Oen a second or
third lateral crus suture at dierent locations along the lateral crus is necessary
to atten out the entire length of the lateral crus. One should look at the very
posterior (lateral) aspect of the lateral crus to see whether it curls in and becomes
very convex. If so, that is a good location for a lateral crus suture too.
e lateral crus suture removes convexity of the lateral crus.
Columellar-Septal Suture
Occasionally a small adjustment of the tip complex with respect to the caudal
septum is necessary. It may be desirable to secure the entire cartilaginous tip
complex to the caudal septum, either projecting it or, if necessary, deprojecting
it a little bit. e columellar-septal suture will do that but only to a small extent.
It is not a substitute for serious projecting, such as can be achieved by a columellar strut, or serious deprojecting techniques such as resection of a portion of the
posterior lateral crus or a section of the middle crus.
Chapter Advanced Suture Techniques 357
https://t.me/medicina_free
Beginning just caudal to the columella, a large needle - PDS suture is passed
between the leaves of the middle crura, which contains strong bers for a good
purchase. e needle then picks up the anterior septal angle of the septum in two
bites (because sutures tend to pull through if only one bite is used), and then the
needle is passed back between the leaves of the middle crura, where the knot is
tied. When the columellar part of the skin ap is reapplied, it will rest on and
cover the knot. Care is taken not to overtighten the knot, which otherwise would
cause columellar retraction.
Intercrural Suture
On occasion the caudal aspect of the middle crura tends to are causing what
would be a wide columella. At the anterior end of the middle crura such aring
can actually cause an unwanted broad infratip lobule. An intercrural suture narrows the width of the middle crura in this region. It is simply a - horizontal
mattress suture not tightened too much but just enough to give the proper width
to the columella.
e intercrural suture narrows the medial crura (columella).
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CASE ANALYSES
is -year-old women had a bulbous nasal tip, dorsal hump, long nose, hanging columella, and broad nose.
e operative goals included the following:
■
Use an open approach.
■
Perform cephalic resection of the lateral crus.
■
Employ suture techniques:
Transdomal
Interdomal
Lateral crus
Columellar-septal
■
Perform a humpectomy.
■
Place spreader aps.
■
Shorten the septum.
Chapter Advanced Suture Techniques 359
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Twelve months aer surgery, improvement in the size of her nasal tip and its proportions are evident. e nasal length and width are improved as well. However,
the general width of the nose is still slightly large.
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is -year-old woman presented with a broad round nasal tip and dorsal hump.
e operative goals included the following:
■
Use an open approach.
■
Perform cephalic resection of the lateral crus.
■
Employ suture techniques:
■
Perform a humpectomy.
■
Place spreader aps.
Transdomal
Interdomal
Lateral crus
Chapter Advanced Suture Techniques 361
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Fieen months aer surgery there is improvement in her round, ill-dened
tip. e basal view shows much better triangulation, although the columella is
slightly broad. e prole is also improved.
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is -year-old woman had a broad tip, medium-thick skin, and a radix deciency.
e operative goals included the following:
■
Use a closed approach.
■
Deliver the tips through a marginal incision and an intercartilaginous incision.
■
Employ suture techniques:
■
Perform cephalic excision of the lateral crus.
■
Augment the radix.
Hemitransdomal
Interdomal
Lateral crus
Chapter Advanced Suture Techniques 363
https://t.me/medicina_free
Twelve months aer surgery, the nasal tip is narrower and the radix deciency
is somewhat improved, though not completely. Overall, the nostrils are more
equilateral on basal view.
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is -year-old woman presented with a broad tip, and a broad nose in the
upper half; the tip was slightly overprojected, with a nasofacial angle that was
somewhat obtuse.
e operative goals included the following:
■
Employ suture techniques:
■
Perform medial oblique and lateral osteotomies.
■
Reduce the dorsum more at the caudal end.
■
Place spreader aps.
■
Perform deprojection by releasing tip structures from the caudal septum.
■
Slightly augment the radix.
Lateral crus
Interdomal
Columellar-septal
Hemitransdomal
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