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 A Predictable and Algorithmic Approach to Tip Renement and Projection 455
https://t.me/medicina_free
Medial Crural Septal Suture
Medial crural septal sutures can be placed aer all other tip-suturing techniques
are performed, or concomitant with medial crural suturing when signicant tip
rotation and repositioning is anticipated preoperatively. Medial crural septal sutures secure the middle crura to the caudal septum and can be used to reduce or
increase nasal tip projection, depending on the placement. If the medial crura
are anchored to a more anterior position on the caudal septum, the tip will rotate
in a cephalad direction and tip projection will increase.
Conversely, if the medial crura are xed to the more posterior portion of the
caudal septum, tip projection will decrease. is can also result in tip derotation
and reduction of the columellar-labial angle as well as the nasolabial angle. If undue tension is placed on the medial crura at the anterocaudal septum position,
columellar retraction may occur. As with the medial crural suture, preliminary
needle xation will help facilitate proper suture placement.
e medial crural septal suture is oen indicated in the aging and drooping tip
for its eects on tip rotation and projection.
Similar eects can be achieved by suturing the medial crura to a xed columellar strut gra or a septal extension gra.
is may be indicated when the cau
dal septum is resected to rotate the tip, and suturing the medial crura to the new
septal position will cause a retracted columella.
-
Part Four e Tip456
https://t.me/medicina_free
Invisible Tip Gras
Invisible tip gras are preferred over visible tip gras because visible gras can
reabsorb, develop asymmetry, and/or become sharply angulated over the long
term, necessitating revision.
Invisible tip gras, including the anatomic cap gra and morselized cartilage on
lay gras, are used if a small degree of tip contouring or volume augmentation is
desired aer tip suturing is completed. Cartilage resulting from the cephalic trim
of the lower lateral cartilage can be used to fashion an anatomic cap gra. is
cartilage gra is typically thin and pliable so it contours over the tip very well
and it does not have any distinct edges, so palpability and/or visibility of the gra
is not a problem. If the tip requires minimal augmentation or improvement of
mild irregularities, morselized cartilage onlay gras can be placed. e cartilage
is morselized in a cartilage crusher and can range from being slightly bruised (to
make it less rigid and more conforming without sharp edges) to crushed into a
thin sheet (which can act as scaolding for tissue ingrowth). Morselized cartilage onlay gras can be used anywhere for augmentation or correction of mild
irregularities.
Depressor Septi Nasi Muscle Surgery
In some patients, the depressor septi nasi muscle may decrease tip projection by
pulling the tip caudally and posteriorly. Transnasal release or transoral dissection
and transposition of the muscle is indicated when hyperdynamic nasal tip ptosis
and underprojection are noted preoperatively. It is important to realize that in-
-
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 457
https://t.me/medicina_free
traoperative evaluation of the depressor septi nasi muscle is unreliable, because
animated views are required.
,
Intraoperative evaluation of the depressor septi nasi muscle is unreliable, because
animated views are required.
Lateral Crural Malposition
e lower lateral cartilage is the structural cornerstone for the alar rim and overall tip support. However, it is the strength, anatomic positioning, and orientation
of the lateral crus that are paramount to the location, contour, and stability of
the ala. External valve collapse, notching, and retraction can all become apparent
when the lateral crus is unable to provide proper support for nasal so tissues
that become further stressed with inspiratory eort. If excessive lateral crural
convexities or concavities are present but tip projection and balance have been
achieved, alar contour gras or lateral crural strut gras can be used to provide
support and to prevent future loss of alar rim integrity.
,
Alar Contour Gras
e alar contour gra provides a foundation for reestablishing a normally functioning external nasal valve and an aesthetically pleasing nasal tip and alar contours. e use of alar contour gras decreases the risk of alar deformities including alar notching or retraction, as well as excessive concavity or convexity of the
alar rim.
Part Four e Tip458
https://t.me/medicina_free
e extended alar contour gra can inuence the rotational orientation of the
lateral crus so that the caudal and cephalic borders are rotated into the same horizontal plane further inuencing the tip and alar contours. Alar contour gras are
almost always placed at the end of the operation.
Lateral Crural Strut Gras
Lateral crural strut gras are commonly placed before tip modications, and
before a columellar strut gra, to reorient and/or stabilize the alar arch. Added
support to the nasal tip and alar arch is provided by lateral crura that lie in
the same rotational plane with respect to their caudal and cephalic margins.
When the caudal margin of the lateral crura is oriented below the cephalic margin (lower lateral cartilage malposition), a parenthesis tip can result, which fre
quently requires lateral crural repositioning with the use of a lateral crural strut
gra (frequently with transection at the accessory chain) in addition to other
tip-shaping techniques.
-
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 459
https://t.me/medicina_free
Final Assessment and Renement
e shape and projection of the nasal tip are critically assessed before and aer
redraping the skin envelope. e balance between the nasal dorsum and the tipdening points is scrutinized to control the supratip break and prevent a future
pollybeak deformity. e tip-dening points should project approximately to
mm over the nasal dorsum in female patients. Asymmetry and/or contour
deformities (visible and/or palpable) are corrected using incremental suture and
gra adjustments. Large dorsum-tip discrepancies can oen result from an inadequate columellar strut gra and/or a poorly positioned medial crural septal
suture. Smaller discrepancies can result from poorly executed transdomal sutures
and/or interdomal sutures. It is important to alter one suture at a time, so that
the result is not inuenced by multiple variables.
e skin envelope should be redraped aer each suture is placed to determine
whether modications in position or degree of tightness are needed.
Visible Tip Gras
If the nal tip projection is inadequate
despite the incremental application
of the previously described suturing
and graing techniques, meticulously
placed visible grafts are used, such
as infratip, onlay, and combined tip
gras. ese can be applied using septal or conchal cartilage.
Part Four e Tip460
https://t.me/medicina_free
e dimensions of these gras are critical, because supratip, infratip, and domal
landmarks can become blunted if these gras are not accurately curved at anatomic breakpoints. In addition, gras that may initially appear hidden may become visible with time as the skin envelope becomes less edematous.
If the desired tip projection and renement are not achieved using available
invisible/nonpalpable tip suturing and cartilage graing techniques, then visible/
palpable cartilage gras may be used. ese include an assortment of infratip,
onlay, and combined tip gras.
Nostril-Lobule Imbalance
Nostril-tip balance should also be reassessed and corrected, when indicated, with
appropriate nostril-shaping techniques and other nal tip adjustments. When
preoperative nostril-tip disproportion is recognized, the surgeon should observe
the dynamic changes that have been made to this imbalance intraoperatively. For
a patient with large nostril−small tip disproportion, excising a complete wedge
of alar tissue reduces both alar aring and the nostril circumference. When the
patient has a short nostril, there is oen lobular excess. In this case, a so triangle
excision is required, with or without transdomal sutures to elongate the nostril
apices. Care must be taken to avoid exaggeration of a short nostril deformity,
which can result from maneuvers that increase tip projection and/or augment
the infratip lobule without concomitant techniques that elongate the nostril.
Nostril-lobule imbalances must be assessed preoperatively and reassessed intraoperatively, because a preexisting disproportion may be exaggerated by augmenting the tip and failing to address the nostril.
D E F
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 461
https://t.me/medicina_free
OPERATIVE TECHNIQUE FOR AN ALGORITHMIC APPROACH
A B C
1. e cartilaginous framework is exposed using the open rhinoplasty approach
with a stair-step transcolumellar incision and bilateral infracartilaginous incisions. e lower lateral cartilages are separated from the upper lateral cartilages at the scroll area.
2. Aer addressing any required dorsal reduction, septal cartilage is harvested
as necessary for later use as gras, taking care to maintain adequate septal/
dorsal support.
3. A conservative cephalic trim is performed, as necessary.
4. Nonpalpable/invisible methods are initially used to address the nasal tip. A
columellar strut gra is rst placed to maintain or enhance tip projection. If
the preoperative analysis calls for to mm of additional projection, we generally prefer to use a oating columellar strut gra fashioned from the harvested septum. Care is taken to dissect the so tissue pocket for the gra to a
point to mm anterior to the anterior nasal spine (A). e xed columellar
strut gra fashioned from rib cartilage is used only when a signicant amount
of increased projection is required. is gra is placed in a so tissue pocket
dissected down to the anterior nasal spine and straddles the spine.
Part Four e Tip462
https://t.me/medicina_free
5. The majority of tip refinement and incremental enhanced projection is
achieved with tip-suturing techniques. Medial crural sutures are rst placed
to stabilize the medial crura to each other or to the columellar strut gra. is
maneuver allows the surgeon to precisely estimate the desired tip projection
and to unify the tip.
6. Interdomal sutures are placed between the domal segments of the middle
crura of the lower lateral cartilages (B and C), primarily to increase infratipcolumellar projection and/or renement. In cases of domal asymmetry, individual unilateral or bilateral transdomal sutures are placed between the domal
and lobular segments of the middle crura (D and E). As this suture is tightened, the domes are brought into symmetry. Care must be taken not to overtighten this suture to avoid alar pinching or collapse.
7. During the placement of individual tip sutures the nasal skin should be re
draped frequently to assess the adequacy of tip projection and renement after each alteration. If the eect of a suture is undesirable, the suture is simply
removed and/or replaced. It is important to remember that with the open approach, to mm of tip projection will be lost before the nal postoperative
form has been achieved.
8. In approximately % to % of primary patients these techniques will result
in the desired tip alteration. If tip projection/renement is still inadequate,
then tip graing techniques are used. We frequently use remnants from cephalic trim, which may have been performed as a combination tip gra, especially in thin-skinned patients. It may be secured to the columellar strut gras
or medial crura and anterior septal angle with - PDS (F). ese gras will
soen the appearance of the domes and will be invisible, even through a thin
skin envelope. In the very thick-skinned individual who requires increased
projection, onlay gras are used, beveling the edges as necessary. Infratip gras
may be necessary primarily to enhance infratip lobular renement, or combined gras may be used to enhance both projection and infratip lobular denition.
9. Once the nal desired tip renement and projection have been achieved, the
remainder of the operative procedure is performed, including osteotomies (as
necessary), meticulous incision closure, and standard splinting.
As much as 1 to 2mm of tip projection will be lost before the nal postoperative
tip projection has been achieved using the open approach.
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 463
https://t.me/medicina_free
CASE ANALYSES
is -year-old woman presented for treatment of nasal obstruction, greater
on the le than on the right; she also had a dorsal hump and a wide, amorphous
nasal tip.
Nasal analysis revealed the following:
■
A narrow midvault and slight dorsal hump (mm)
■
An underprojected and boxy nasal tip with moderately asymmetrical
lower lateral cartilages
■
Large nostril to small tip−lobule imbalance
■
A hyperactive depressor septi nasi muscle
■
Anterior septal deviation
■
Bilateral inferior turbinate hypertrophy
Part Four e Tip464
https://t.me/medicina_free
Tip sutures:
Interdomal
Transdomal
Medial crural
Surgical Plan
1. Use an open approach with transcolumellar incision and infracartilaginous
extensions.
2. Perform septal reconstruction and harvest cartilage gra material.
3. Reduce the dorsal hump (mm) in component fashion.
4. Perform a cephalic trim, leaving symmetrical alar cartilages and a mm alar
rim strip.
5. Place a oating columellar strut gra.
6. Use medial crural, interdomal, and transdomal sutures.
7. Place bilateral invisible spreader gras to widen the midvault and to stent the
internal nasal valve.
8. Perform bilateral anterior-inferior turbinate resection.
9. Perform depressor septi muscle release and transposition.
Соседние файлы в папке Библиотека им академика М.И. Перельмана