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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 415
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Minimal dorsal hump reduction, radix augmentation, and alar base reduction
were also performed.
e patient is shown months postoperatively. e nasal tip is rened, tip projection is increased, a straight dorsum has been achieved, and the alar base width
is reduced.
Part Four e Tip416
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is -year-old patient presented with a mild form of maxillonasal dysplasia
(Binder’s syndrome). She had low tip projection and underdeveloped, infantile
lower lateral cartilages and septal cartilage.
e operative goals included the following:
■
Reconstruct the septal L-strut.
■
Reconstruct a structured nasal tip.
Chapter Structural Graing of the Nasal Tip 417
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Cartilage from the sixth rib was harvested. Five cartilage strip gras were prepared for septal L-strut reconstruction and lower lateral cartilage reconstruction.
First, septal L-strut reconstruction was performed with placement of two struts
dorsally and one strut caudally. e caudal strut was placed more caudally as a
septal extension gra. Two long cartilage gras were prepared for lower lateral
cartilage reconstruction. ese gras were thinned to less than a millimeter of
thickness to make them pliable. Medially the cartilage gras were sutured to the
caudal septal extension gra reconstructing the medial crura. e gras were
bent with spanning sutures using - nylon and new domes were created. e
lateral segments of the gras were kept long and were extended to the piriform
aperture. e vestibular skin is then secured to the lateral crural gras with -
gut suture. A dome equalization suture was placed to approximate the gras and
to create dome-dening points.
Part Four e Tip418
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e patient is shown months aer surgery. A structured approach allowed
anatomic reconstruction of the nasal tip and the septum. Tip projection was increased signicantly and the alar rims are well supported.
Chapter Structural Graing of the Nasal Tip 419
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is -year-old patient presented with a dorsal hump, inadequate tip projection,
short medial crura, weak alar rims, and a short infratip lobule. She had airway
problems caused by her caudal septal deviation.
e operative goals included the following:
■
Correct the septal deviation.
■
Reduce the dorsal hump.
■
Increase tip projection and lengthen the short infratip lobule.
■
Support the weak domes and lateral crura.
Using the open rhinoplasty approach, septoplasty was performed with caudal
septal relocation. e bony and cartilaginous hump were reduced and spreader
aps were used to restore the cartilaginous dorsum. e footplates were sutured
the caudal septum. A long columellar strut gra was prepared from the harvested
septum and the medial crura were advanced on the columellar strut gra with
sutures. A shield-type tip gra was placed to increase tip projection and lengthen
the infratip lobule. An onlay tip gra was placed at the cephalic aspect of the
shield gra. Alar contour gras were placed bilaterally to support the alar rims.
Part Four e Tip420
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e patient is shown years postoperatively. e dorsal hump was removed, the
caudal septal deviation has been corrected, tip projection is increased, the infratip
lobule is elongated, and the alar rims are well supported.
SHORT LOWER LATERAL CARTILAGES
Short lower lateral cartilages usually present with inadequate tip projection and
ill-dened nasal tip contours. If the medial crura are short and lateral crura are
long, the lateral crural steal procedure (advancing the lateral crura medially with
spanning suture) can elongate the medial crura and increase tip projection. is
technique is eective and useful in increasing tip projection and usually combined with the placement of a columellar strut gra for stability. e lateral crural
steal technique rotates the nasal tip upward, augments the infratip lobule, and
changes the columellar-lobular angle.
Chapter Structural Graing of the Nasal Tip 421
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If the overall length of the lower lateral cartilages is short, the lateral crural steal
technique will shorten the lateral crura further. In this case, the lateral crura can
be divided from accessory cartilages to advance medially, and a lateral crural
strut gra is placed between the lateral crura and the accessory cartilages to reconstitute a stable nasal tip tripod.
Case Analysis
is -year-old patient presented with a dorsal hump, inadequate tip projection, and an ill-dened nasal tip. Her medial crura were short and the footplates
did not extend down to the nasal base. e lateral crura were weak, the alar rims
were not well supported, and she had weak dome support.
e operative goals included the following:
■
Reduce the dorsal hump.
■
Increase tip projection and improve the nasolabial angle.
■
Support the weak alar sidewalls.
Part Four e Tip422
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Using the open rhinoplasty approach, the nasal dorsum and nasal tip were exposed. Aer harvesting the septal cartilage, the bony and cartilaginous hump was
removed. Spreader aps were used to establish the cartilaginous dorsal width.
e medial crura were separated and the caudal septum was exposed down to the
anterior nasal spine. e anterior nasal spine was reduced. A transxing suture
was placed to set back the medial crura on the caudal septum. e lateral crura
were divided from the accessory cartilage junctions. e lateral crura were advanced mm medially with spanning sutures (lateral crural steal). A long columellar strut gra was placed between the medial crura to increase tip projection.
Lateral crural strut gras were placed on both sides between the lateral crura and
the accessory cartilage to reconstitute a stable nasal tip tripod.
Chapter Structural Graing of the Nasal Tip 423
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e patient is shown year postoperatively. e dorsal hump is gone, tip projection is increased, the medial crura are set back to the nasal base, the short medial
crura are lengthened, the nasal tip is well supported, and the alar rim retraction
has been corrected.
Part Four e Tip424
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CONGENITAL DEFORMITIES OF THE LOWER
LATERAL CARTILAGES
Congenital asymmetries or the absence of lower lateral cartilages can be corrected with structural graing principles. Lateral crural strut gras can be used to
correct lateral crural asymmetries. In the absence of lateral crura, a lateral crural
gra can be placed to replace the missing segment. If available, septal cartilage is
the gra material of choice in these cases.
SECONDARY DEFORMITIES OF THE LOWER
LATERAL CARTILAGES
If the principles of structural rhinoplasty are not taken into consideration at the
time of primary rhinoplasty, there usually is a loss of the tip-supporting mecha
nisms. Excessive removal of the tip cartilages and inadvertent use of sutures further accentuates the problem. e septal integrity may be lost, and this increases
tip-support problems. ere may be asymmetries, and functional issues may accompany these deformities.
In secondary rhinoplasty, reconstruction of the nasal framework to produce an
aesthetic and functional improvement should be the goal. Following structural
rhinoplasty principles, functional deformities are treated to give a more normal
and balanced nasal shape, reestablish nasal support, restore tip projection, and
treat the nasal airway problems. A variety of structural gras may be required to
achieve these goals. A stable and straight septal cartilage is essential for tip support, and septal reconstruction should precede any tip reconstruction.
Anatomic reconstruction of the weakened or interrupted lower lateral cartilages
and reconstitution of a stable nasal tip tripod must be performed for a predictable outcome. e newly reconstructed cartilaginous framework should be strong
enough to withstand the even greater forces of scar contraction during the healing period.
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