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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4442_Библиотеки_им_академика_М_И_Перельмана.pdf
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6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.9 Diagram of caudal septum reposition during Mc Comb modied cleft rhinoplasty. A. Caudal septum. B. Maxilla C. Anterior nasal spine
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repair of the soft tissue platform which ignores the abnormal skeletal base. Skeletal base is nally repaired using the alveolar bone graft later during mixed dentition period (Figs.6.11 and 6.12).
As I mentioned initially, these methods represent an alternative for conservative surgeons who may have a concern regarding the scar contracture of nasal vestibular incisions.
Cases (Figs.6.13, 6.14, 6.15, 6.16, 6.17, 6.18, 6.19, 6.20, and6.21)
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Alar cartilage
Alar cartilage
C
anscutaneous
P. Rossell-Perry
olumella
(non cleft side)
Nasal tip
(cleft side)
Tr stitches
Fig. 6.10 Diagram of nasal tip reconstruction during Mc Comb modied cleft rhinoplasty
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
AB
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B
A
Fig. 6.11 Vestibular nasal oor reconstruction during Mc Comb modied technique. A: Alar ap. B: Columellar base ap
ab
Fig. 6.12 Vestibular nasal oor reconstruction during Mc Comb modied technique. Vestibular segment of the nasal oor is repaired in a patient with unilateral cleft lip and palate. (a) Preoperative view. (b) Postoperative view
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Fig. 6.13 Case 1. Preoperative view of a 3-month-old infant with complete unilateral cleft lip
Fig. 6.14 Case 1. Immediate postoperative view of the infant shown in Fig.6.13 after undergoing nasal repair using the Mc Comb modied technique
P. Rossell-Perry
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.15 Case 1. Long-term (10years) postoperative view of the infant shown in Fig.6.13 after undergoing nasal repair using the Mc Comb modied technique
159
Fig. 6.16 Case 2. Preoperative view of a 3-month-old infant with complete unilateral cleft lip
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Fig. 6.17 Case 2. Immediate postoperative view of the infant shown in Fig.6.16 after undergoing nasal repair using the Mc Comb modied technique
Fig. 6.18 Case 2. Long-term (9years) postoperative view of the infant shown in Fig.6.16 after undergoing nasal repair using the Mc Comb modied technique
P. Rossell-Perry
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.19 Case 3. Preoperative view of a 3-month-old infant with complete unilateral cleft lip
Fig. 6.20 Case 3. Immediate postoperative view of the infant shown in Fig.6.19 after undergoing nasal repair using the Mc Comb modied technique
161
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Fig. 6.21 Case 3. Long-term (10years) postoperative view of the infant shown in Fig.6.19 after undergoing nasal repair using the Mc Comb modied technique
P. Rossell-Perry

The Composite Rotational Flap Rhinoplasty

This is a limited incision method for primary cleft rhinoplasty designed to be used in mild unilateral cleft lip nose forms (microform and incomplete forms). The method has been developed by the author and uses a composite ap (vestibular skin and cartilage) medially displaced in a rotational form; it is indicated for mild forms because they allow us preserve the lateral wall of the nasal vestibule preventing the development of lateral webs since the vestibular incision is not connected with lip incisions [11] (Figs.6.22 and
6.23). In complete unilateral cleft lips, the release of the ala from its attachment to the
pyriform aperture is mandatory; therefore, the lip and nose incisions are continuous, and the development of lateral web and intranasal scar contractures is more common in these cases. Its indication for microforms may be debatable because some associated nasal deformities are very mild and require only nasal base shortening.

Surgical Technique

Markings
The nose surgery starts performing the vestibular markings. The rotational com­posite ap design is composed by two lines: the marginal one which follows the lower border of the alar cartilage of the nose and a short intercartilaginous line
6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.22 Preoperative marking diagram for rotational composite ap cleft rhinoplasty in a patient with unilateral incomplete cleft lip
Fig. 6.23 Postoperative view for rotational composite ap cleft rhinoplasty in a patient with incomplete cleft lip
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placed at the level of the limen nassi (intercartilaginous border) between the upper and lower lateral cartilages of the nose. The marginal line is an inferior curve which can be easily identied pushing the nasal tip from outside using the nger­tip, and then the border is more relevant. Another parameter to identify location of
164
side)
Mar
P. Rossell-Perry
this line is the change of color of the vestibular skin; below the marginal border, the color of the skin is the same as the nasal skin, but above that line, there is a transitional epithelium (from skin to the nasal mucosa) and the color is red; there­fore it is easy to locate the border of the alar cartilage following the line between these areas with different colors (Fig. 1.21). This line starts from the intercarti­laginous border and nishes before the medial wall of the nasal vestibule at the level of cleft side nasal dome (Figs.6.24 and 6.25). The intercartilaginous line is designed in continuity with the lateral end of the marginal marking and follows the intercartilaginous border (limen nassi) which is clearly identied. The extent of this marking is about 3–5mm in order to release the lateral border of the alar cartilage and allow the rotation of the composite ap (Figs.6.26, 6.27, and 6.28). Both lines are surrounding the alar cartilage to create the composite ap (com­posed by the vestibular skin and alar cartilage). The lateral wall of the nasal ves­tibule is preserved and prevents the development of lateral webs or scar contractures. The use of postoperative nasal conformers is optional using this technique because of the used limited incision.
Nasal tip
ginal incisión
Nasal vestibule
Lateral lip
Fig. 6.24 Diagram of marginal incision during rotational composite ap cleft rhinoplasty
Alar cartilage (cleft side)
Alar cartilage (non cleft
Columella
Medial Lip