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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 Structural Graing of the Nasal Tip 395
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Preservation or reconstitution of a stable, well-dened nasal tip framework is
indispensable for a successful rhinoplasty operation. e structural approach to
the nasal tip enables the surgeon to strengthen the tip framework, reinforce the
disrupted support mechanisms and control the position of the nasal tip to resist
the forces imparted by scar over the long term.
Preserving or reconstituting the structural nasal framework is essential for consistent and successful long-term results.
e open rhinoplasty approach provides better visualization without distortion
of cartilages, leading to accurate diagnosis and treatment.
e open rhinoplasty approach provides better visualization without distortion
of cartilages, leading to accurate diagnosis and treatment.
In modern rhinoplasty, lower lateral cartilage graing has been frequently used
to strengthen and reshape the lower lateral cartilages. Autologous cartilage is the
best material for structural graing of the nasal tip.
Various lower lateral cartilage deformities require cartilage graing for more predictable and consistent outcomes. ese deformities can be grouped as follows:
1. Curvature deformities of the lateral crura
2. Cephalic malposition of the lateral crura
3. Weak lower lateral cartilages
4. Short lower lateral cartilages
5. Congenital deformities of the lower lateral cartilages
6. Secondary deformities of the lower lateral cartilages
CARTILAGE GRAFTS FOR STRUCTURAL GRAFTING OF THE
LOWER LATERAL CARTILAGE COMPLEX
Autologous cartilage graing is the preferred treatment, when structural graing
of the tip cartilages is needed. If available, septal cartilage is the gra of choice
for autologous cartilage graing because it is rigid, relatively straight and in the
same operative eld. It can be used as a columellar strut to support the nasal
tip or replace parts of the lower lateral cartilage complex and spreader gras as
needed. However, septal cartilage is oen insucient in secondary operations.
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Autologous cartilage graing is the preferred treatment, if structural graing of
the tip cartilages is considered. If available, septal cartilage is the gra of choice
for autologous cartilage graing.
Auricular cartilage can be used to replace lateral crural defects. Onlay tip gras
and shield-type tip gras can be prepared from concha. However, accidity and
convolutions inherent in its structure limit the use of auricular cartilage in structural graing.
If signicant support is required, autologous rib cartilage is the gra of choice.
Rib oers an unlimited amount of cartilage for structural graing. Long, straight
struts can be prepared from the rib cartilage for reinforcement or reconstruction of the lower lateral cartilage complex. Rib cartilage is less calcied and more
elastic in young individuals, and this allows the preparation of ultrathin gras
for lower lateral cartilage reconstruction.
If signicant support is required, autologous rib cartilage is the gra of choice.
Long, straight struts can be prepared from rib cartilage for reinforcement or reconstruction of the lateral crural complex.
Operative Technique for Rib Cartilage Harvest
A to cm incision is made along the inframammary fold in female patients.
In male patients the incision is kept shorter, usually around . to cm and is
placed exactly on the rib cartilage to be harvested. e straightest portions of the
sixth and seventh ribs are ideal to obtain cartilage gras for structural graing.
Chapter Structural Graing of the Nasal Tip 397
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Aer elevation of the perichondrium, a longitudinal incision is performed on the
rib using a No. or blade. Another parallel incision about to .mm apart
is performed.
Using a semisharp, ne and straight-tip elevator (to avoid injury to the pleura)
the incisions are completed to full cut and a straight rectangular cartilage gra
is harvested.
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Aer the rst gra is taken, it is much easier to harvest a second, third, or fourth
piece using the same technique. is technique facilitates the gra harvest, reduces postoperative morbidity, and shortens the operating time.
CURVATURE DEFORMITIES OF THE LATERAL CRURA
Curvature deformities of the lateral crura cause an unpleasant appearance of the
lower third of the nose and sometimes compromise nasal function. e most
common curvature deformities are excessively convex lateral crura, presenting as
a bulbous or boxy nasal tip and excessively concave lateral crura. Some unusual
and asymmetrical curvature deformities of lateral crura can be seen.
Concave Lateral Crura
Concave lateral crura are cosmetically displeasing and may cause dysfunction of
the external nasal valve, resulting in vestibular airway obstruction.
In minor concavity deformities with wide lateral crura, a lower lateral crural
turnover ap or lateral crural turn-in ap can be used to correct the deformity. In
the lateral crural turn-in ap technique an incision is made longitudinally on the
lateral crura, leaving a to mm intact alar rim strip, similar to when cephalic
trim is performed. e cephalic portion of the lateral crus is turned into a pocket
created under the remaining lateral crus and xed with two or three sutures. e
Chapter Structural Graing of the Nasal Tip 399
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lateral crural turn-in ap reshapes and supports the lateral crura and internal
nasal valve. is is also a useful technique for patients with weak lateral crura.
Excessively concave lateral crura cause a pinched deformity on the nasal tip and
a nasal airway compromise. In cases of severe concavity of the lateral crus, the
most predictable method of correction is placement of a lateral crural strut gra
into a pocket underneath the lateral crus. Aer cephalic resection of lateral crus
leaving at least a to mm intact alar rim strip, the gra is placed on the undersurface of lateral crus and secured to the lateral crus with two or three sutures.
e lateral crural strut gra corrects concavity of the lateral crura and improves
external nasal valve patency.
Case Analysis
is -year-old primary rhinoplasty patient presented with nasal airway obstruction and a pinched nasal tip caused by severely concave lateral crura and a
narrow middle vault. Internal nasal examination revealed a narrow internal nasal
valve angle with a straight septum.
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e operative goals included the following:
■
Correct the middle vault collapse.
■
Correct the concave lateral crura and external valve collapse.
Using an open rhinoplasty approach, the nasal dorsum and the nasal tip was exposed, and septal cartilage was harvested. Spreader gras were placed into the
submucosal pockets between dorsal septum and upper lateral cartilages bilaterally. Lateral crural strut gras approximately by mm were prepared from the
thicker portion of the septum. Cephalic portions of lateral crura were resected
leaving a mm alar rim strip. e lateral crural strut gras were placed on the
undersurface of lateral crura and xated to the lateral crura with three nonabsorbable sutures.
Chapter Structural Graing of the Nasal Tip 401
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e patient is shown year postoperatively. e narrow middle vault is widened,
and internal nasal valve insuciency has been improved. e pinched nasal tip
and external nasal valve collapse have been corrected with the use of the lateral
crural strut gras. e nasal airway is improved signicantly.
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Convex Lateral Crura
Most boxy tip deformities can be corrected by placing horizontal mattress sutures
from medial crus to lateral crus. e lateral crural mattress suture is also a useful technique in correcting the convexity of the lateral crura in the bulbous and
boxy tip. However, these sutures may create a secondary deformity by displacing
the lateral crus−accessory cartilage junction medially, compromising the nasal
airway. Lateral crural strut gras straighten the excessively convex lateral crura
and are useful in preventing or correcting this potential problem.
Case Analysis
is -year-old patient presented with an asymmetrical narrow dorsum and
boxy nasal tip. Her lateral crura were convex with a medial angulation at their
junction with the accessory cartilages, creating a supraalar notching deformity.
She had a mild degree of cephalic malposition. Internal nasal examination revealed a narrow internal nasal valve with a deviated septum obstructing the airway.
Chapter Structural Graing of the Nasal Tip 403
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e operative goals included the following:
■
Correct septal deviation.
■
Reduce the dorsal hump.
■
Widen the narrow bony vault and narrow middle vault.
■
Correct the boxy nasal tip and supraalar notching deformity.
Using the open rhinoplasty approach, septoplasty and septal cartilage harvest
were performed. Aer mm of dorsal reduction, medial oblique osteotomies with
outfracturing were performed to create room for spreader gras. Bilateral superiorly extended spreader gras were placed to widen the dorsum and improve
internal nasal valve function. Lateral osteotomies were not performed. Cephalic
portions of lateral crura were resected, leaving a mm alar rim strip and transdomal sutures were placed to correct the tip bulbosity.
e modied lateral crural strut gras along the undersurface of the lateral crura
were placed bilaterally. e gras were prepared wider laterally, to support alar
rim and correct supraalar notching. e lateral end of the gra was placed caudal
to the alar groove. A thin radix gra prepared from cephalic remnants of lateral
crura was placed to augment radix.
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e patient is shown year postoperatively. e narrow bony vault and midvault
are widened and internal nasal valve collapse has been corrected. A smooth,
straight dorsum is achieved. e boxy nasal tip and supraalar notching is corrected with the use of modied lateral crural strut gras.
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