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 Structural Graing of the Nasal Tip 435
https://t.me/medicina_free
An extracorporeal septoplasty was performed and a septal-L strut was reconstructed from the septal cartilage. It was secured to the anterior nasal spine caudally and to the nasal bones and upper lateral cartilage remnants cephalically.
e missing right middle crura was reconstructed with a septal cartilage gra. A
columellar strut gra was used to stabilize the medial crura. Bilateral alar contour
gras were placed to reinforce the alar rims. A diced cartilage−fascia gra was
placed to augment the dorsum and camouage the dorsal irregularities.
Part Four e Tip436
https://t.me/medicina_free
e patient is shown years postoperatively. Tip asymmetry and the hanging
columella have been corrected, and a straight septum was achieved, with functional improvement. e nasal dorsum was augmented and the dorsum is straight
and smooth.
Chapter Structural Graing of the Nasal Tip 437
https://t.me/medicina_free
COMPLICATIONS
Tip asymmetries can occur as a result of uneven placement of structural gras.
e surgeon must exercise care in placing the gras symmetrically.
If a columellar strut gra is placed directly against the premaxilla, displacement
from the midline can be seen postoperatively. If the columellar strut gra overlaps the caudal septum, shiing from the midline can be seen. If a so tissue pad
is not protected between the columellar strut gra and the anterior nasal spine,
the patient can experience a clicking sensation while smiling.
Caudal septal extension gras can cause deviation of the nasal tip if stabilized
in an overlapping fashion to the caudal septum. To avoid this, the caudal septal
gra is aligned end to end with the existing caudal septum using splinting gras.
Lateral crural strut gras may displace the vestibular skin medially and compromise the airway if they are not extended to the piriform aperture. Lateral crural
strut gras prepared from rib cartilage must be thinned enough to avoid this
problem. If structural gras for lower lateral cartilage reconstruction are thick,
the thickness of the gras may create bulk around the tip. is is particularly true
for gras prepared from rib cartilage.
CONCLUSION
A stable, well-structured nasal tip is essential for functional and aesthetic purposes. Short and weak medial crura usually present with an underprojected
tip. e columellar strut gra is an eective and commonly used method for
strengthening the medial crura and improving the tip support. If an increase of
tip projection is needed, the medial crura can be advanced on a long and strong
columellar strut gra or caudal septal extension gra. For a further increase in
tip projection and for improvement of tip contour, shield-shaped or onlay tip
gras can be used.
Asymmetries and congenital malformations of the lower lateral cartilages can be
corrected with the use of a variety of structural gras. Lateral crural strut gras
are versatile tools in correcting curvature deformities of lateral crura, malposition of the lateral crura, and reinforcement of weak lateral crura.
In secondary rhinoplasty, reconstruction of the nasal framework to produce an
aesthetic and functional improvement should be the goal. A variety of structural
gras may be required to achieve these goals. Anatomic reconstruction of weak-
Part Four e Tip438
https://t.me/medicina_free
ened 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.
KEY POINTS
■
e lower third of the nose has a tripod-like support structure that is made up
of the conjoined medial crura and lateral crural complex based bilaterally on
the piriform aperture. Reconstructing a stable tripod structure supports the
nasal tip, strengthens the alar sidewalls, and provides an aesthetically pleasing
nasal tip.
■
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.
■
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.
■
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.
■
Lateral crural strut gras are indicated for correction of concave lateral crura,
a boxy tip, cephalic malposition of the lateral crura, alar rim retraction, and
strengthening of weak lateral crura.
■
In secondary cases, 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.
■
In secondary cases with an overresected nasal skeleton, tip projection is usually
lost and has to be reestablished. Tip projection can be achieved with a columellar strut gra, caudal septal extension gra, or tip gras.
■
e columellar strut gra is a very useful tool for stabilizing the columellar base
and correcting medial crural deformities. A long and strong columellar strut
gra can be used to increase tip projection by advancing medial crura on it.
■
Tip gras can be used to increase tip projection and improve tip contour. In
secondary cases, shield-shaped tip gras are preferred to achieve tip denition
and hide tip asymmetries. e sharp edges of the cartilage can be camouaged
using fascia or perichondrial gras.
■
e lateral crural gra is a versatile tool for reshaping, repositioning, or replacing the missing segments of the lateral crura and domes.
■
Long lateral crural gras can be prepared from rib cartilage and thinned, al
lowing the gra to bend and be used to reconstruct the missing domes and
the lateral crura.
-
Chapter Structural Graing of the Nasal Tip 439
https://t.me/medicina_free
REFERENCES
1. Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol :-, .
2. Janeke JB, Wright WK. Studies on the support of nasal tip. Arch Otolaryngol :-, .
3. McCollough EG, Mangat D. Systematic approach to correction of nasal tip in rhinoplasty. Arch
Otolaryngol :-, .
4. Adams WP Jr, Rohrich RJ, Hollier LH, et al. Anatomic bases and clinical implications for nasal tip
support in open versus closed rhinoplasty. Plast Reconstr Surg :-; discussion -,
.
5. Sheen JH. Spreader gra: a method of reconstructing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg :-, .
6. Toriumi DM. Management of the middle nasal vault in rhinoplasty. Oper Tech Plast Reconstr Surg
:-, .
7. Rohrich RJ, Potter JK, Landecker A. Preoperative concepts for rhinoplasty. In Gunter JP, Rohrich
RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis: Quality Medical
Publishing, .
8. Gunter JP, Freidman RM. Lateral crural strut gra: technique and clinical applications in rhinoplasty. Plast Reconstr Surg :-; discussion -, .
9. Toriumi DM. Structure approach in rhinoplasty. Facial Plast Surg Clin North Am :-, .
10. DeRosa J, Watson D, Toriumi DM. Structural graing in secondary rhinoplasty. In Gunter JP,
Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis: Quality Medical Publishing, .
11. Gunter JP, Cochran CS. e tripod concept for correcting severely deformed nasal tip cartilages.
In Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St
Louis: Quality Medical Publishing, .
12. Rohrich RJ, Raniere J Jr, Ha RY. Alar contour gra: Correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg :-; discussion -, .
13. Rohrich RJ, Ha RY, Raniere J Jr. Correction of alar rim deformities: alar contour gras. In Gunter JP,
Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis: Quality
Medical Publishing, .
14. Cerkes N. Concurrent elevation of upper lateral cartilage perichondrium and nasal bone periosteum: the perichondro-periosteal ap. Aesthetic Surg J :-, .
15. Gunter JP, Rohrich RJ, Hackney FL. Open approach in secondary rhinoplasty. In Gunter JP, Rohrich
RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis: Quality Medical
Publishing, .
16. McCollough EG, Fedok FC. e lateral crural turnover gra: correction of the concave lateral crus.
Laryngoscope :-, .
17. Apaydin F. Lateral crural turn-in ap in functional rhinoplasty. Arch Facial Plast Surg :-,
.
18. Gunter JP, Freidman RM, Hackney FL. Correction of alar rim deformities: lateral crural strut gras.
In Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St
Louis: Quality Medical Publishing, .
19. Rohrich RJ, Adams WP Jr. e boxy nasal tip: classication and management based on alar cartilage suturing techniques. Plast Reconstr Surg :-; discussion -, .
20. Gruber RP, Freidman GD. Suture algorithm for broad or bulbous nasal tip. Plast Reconstr Surg
:-; discussion -, .
21. Gruber RP, Nahai F, Bogdan MA, et al. Changing the convexity and concavity of nasal cartilages
and cartilage gras with horizontal mattress sutures. Part II: Clinical results. Plast Reconstr Surg
:-; discussion -, .
22. Sheen JH. Malposition of the alar cartilages. Presented at the Annual Meeting of the American
Society of Aesthetic Plastic Surgery, Los Angeles, May .
23. Petro MA, McCollough EG, Hom D, et al. Nasal tip projection. Arch Otolaryngol Head Neck Surg
:-, .
Part Four e Tip440
https://t.me/medicina_free
24. Gunter JP, Clark CP, Freidman RM. Internal stabilization of autologous rib cartilage gras in rhinoplasty: a barrier to cartilage warping. Plast Reconstr Surg :-, .
25. Rohrich RJ, Adams WP Jr, Deuber MA. Graduated approach to tip renement and projection. In
Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St
Louis: Quality Medical Publishing, .
26. Kridel RW, Konior RJ, Shumrick KA, et al. Advances in nasal tip surgery: the lateral crural steal.
Arch Otolaryngol Head Neck Surg :-, .
27. Foda H, Kridel RW. Lateral crural steal and lateral crural overlay: an objective evaluation. Arch
Otolaryngol Head Neck Surg :-, .
28. Gibson T, Davis WB. e distortion of autogenous cartilage gras: its causes and prevention. Br J
Plas Surg :-, .
29. Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal
cartilage gra. A preliminary report. Plast Reconstr Surg :-, .
30. Byrd S, Andodochick S, Copit S, et al. Septal extension gras: a method of controlling tip projection, rotation and shape. Plast Reconstr Surg :-, .
31. Cerkes N. e crooked nose: principles of treatment. Aesthetic Surg J :-, .
32. Guyuron B, Poggi JT, Michelow BJ. e subdomal gra. Plast Reconstr Surg :-; discus
sion -, .
-
■ ■ ■ ■ ■ ■
https://t.me/medicina_free
21
A Predictable and Algorithmic Approach
to Tip Renement and Projection
Rod J. Rohrich Jerey E. Janis Ashkan Ghavami Jamil Ahmad
Attaining a well-dened and properly projecting nasal tip is vital to success in
rhinoplasty. A thorough understanding of the anatomic structures that provide
nasal tip support and their inuences on tip projection and shape is critical for
the proper diagnosis and treatment of intricate nasal tip deformities.
-
e following factors help to determine tip projection
■
Length and strength of the lower lateral cartilages
■
Length and stability of the medial crura and middle crura
■
Suspensory ligament that spans the crura over the anterior septal angle of
the upper and lower lateral cartilages
■
Fibrous connections between the upper and lower lateral cartilages
■
Abutment with the piriform aperture
■
Anterior septal angle
■
Skin and so tissue thickness and availability
e length, strength, shape, and position of the lower lateral cartilages as well as
the brous/ligamentous attachments between these paired structures play a central role in supporting the nasal tip.
nasal base, and piriform aperture provide additional stability and support to the
nasal tip through their so tissue attachments.
-
e upper lateral cartilages, nasal septum,
-
:
441
Part Four e Tip442
https://t.me/medicina_free
Ultimately, tip projection and denition are determined by the dynamic interplay between the aforementioned tip-supporting structures and the overlying
skin and so tissue envelope. Since the relative contribution of each structure in
tip projection varies from one patient to another, all tip-supporting components
should be critically assessed and the treatment plan individualized.
Preoperatively, an underprojecting nasal tip may be diagnosed as the primary
nasal deformity or may accompany other nasofacial imbalances. Iatrogenic loss
of tip support may result from purposeful or unintended violation of critical
tip-supporting structures.
,
Maneuvers such as cephalic trim of the lower lateral cartilages, caudal septal resection, dorsal reduction, transxion incisions,
and alar base resections aect tip support and can cause a substantial reduction
in tip projection.
projection through disruption of skin and so tissue supports.
,,
e open approach can also lead to a small reduction in tip
Over the past two decades, conventional destructive and irreversible tip modication techniques such as cartilaginous resection, transection, morselization, and
scoring have been replaced by nondestructive, reversible, incremental, and dynamic tip-suturing techniques.* e popularity of visible/palpable cartilage gras
placed in a subcutaneous pocket underneath nasal skin has declined in recent
years in favor of invisible/nonpalpable gras placed within or underneath the
cartilaginous framework.†
PREOPERATIVE ASSESSMENT AND PLANNING
Accurate diagnosis of the nasal deformity and understanding the patient’s expectations are the initial essential steps to a successful outcome. Patients may
desire simple tip renement but may not understand the dynamic relationships
between the upper, middle, and lower nasal thirds and the resultant eects of
these relationships on overall nasal shape and balance. erefore patient edu
cation plays an important role. Performing a comprehensive nasofacial analysis
will allow the detection of both prominent and subtle factors that contribute to
the nasal tip deformity and will assist the surgeon in developing a treatment plan
directed at each specic component. In addition, meticulous surgical technique,
frequent intraoperative reassessment, and proper postoperative management all
contribute to a successful outcome.
*References , , , , -.
†References , , , , , .
-
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 443
https://t.me/medicina_free
Natural horizontal
facial plane
Comprehensive nasofacial analysis should include evaluation of the lip-chin complex. Byrd and Hobar suggested establishing a nose-lip-chin plane (NLCP),
with ideal chin projection (in females) dened as mm posterior to a plumb line
drawn perpendicular to the natural horizontal Frankfort plane. e appearance
of ideal tip projection depends on this relationship, because an underprojected
chin will make the nasal tip seem overprojected, and vice versa.
e appearance of ideal tip projection is dependent on the relationship of the
nose-lip-chin complex, because an underprojected chin will make the nasal tip
seem overprojected, and vice versa.
e thickness and sebaceous character of the nasal skin should also be evaluated. Males and certain ethnic subgroups such as those of black, Mediterranean,
Hispanic, and Middle Eastern descent tend to have thicker, more sebaceous
-
skin.
e thicker skin envelope may camouage the results of tip modication, so more aggressive maneuvers in these patients may be necessary to achieve
the desired result.
-
However, the need for more aggressive techniques to obtain
an increase in tip projection, denition, or nasal length must be balanced with the
limitations of stretching the skin envelope, because an iatrogenic tension tip may
be produced that can lead to vascular compromise and skin loss in severe cases.
In a patient with thick, sebaceous skin, alterations to the cartilaginous framework may need to be more aggressive to produce adequate tip denition and
projection.
Part Four e Tip444
https://t.me/medicina_free
Next, attention is turned toward proportional nasal analysis, which has been
thoroughly described previously.
and basal views.
,
e presence of domal asymmetry, tip morphology (boxy or
,
Tip denition is best assessed on the frontal
bulbous tip), the degree of nostril show, columellar excess, caudal septal deviation, and a hanging (static) or hyperdynamic (animated) tip are noted. Animated
views should be obtained to diagnose depressor septi nasi muscle hyperactivity
resulting in hyperdynamic tip ptosis.
Tip projection is best assessed on the lateral view; it is evaluated by determining the
proportion of the tip that lies anterior to a
vertical line drawn adjacent to the most projecting part of the upper lip. Fiy percent
A
B
to % of the tip should lie anterior to this
vertical line. If less than % of the tip projects anterior to this reference line, the tip is
A 50%-60%
of AB
underprojected.
1. 0
Adequate tip projection is dened as the presence of 50% to 60% of the tip lying
anterior to the most projecting point of the upper lip.
0.67
Tip projection can also be measured as .
times the ideal nasal length.
Соседние файлы в папке Библиотека им академика М.И. Перельмана