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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4442_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Foreword 1
- •Foreword 2
- •Preface
- •Contents
- •About the Author
- •Contributors
- •Introduction
- •Nasal Components
- •The Nasal Tip
- •Internal Nose
- •Nasal Aesthetic Subunits
- •The Nasal Columella
- •Cartilaginous Framework
- •Overlaying Soft Tissues
- •The Nasal Vestibule
- •The Nasal Septum
- •Overlying Mucosa
- •Internal Lateral Wall
- •Overlying Mucosa
- •The Nasal Floor
- •Nasal Systems
- •Vascular System
- •Nervous System
- •Musculoaponeurotic System
- •Nasal Superficial Musculo Aponeurotic System (SMAS)
- •Nasal Physiology
- •References
- •Introduction
- •The Unilateral Cleft Lip Nasal Deformity
- •The Bilateral Cleft Lip Nasal Deformity
- •Postoperative Nasal Conformers
- •Recent Advances
- •References
- •3: Classification
- •Introduction
- •Unilateral Complete Cleft Lip Nose
- •Bilateral Complete Cleft Lip Nose
- •The Cleft Code
- •Surgical Timing
- •Primary Cleft Rhinoplasty
- •Intermediate Cleft Rhinoplasty
- •Definitive Rhinoplasty
- •References
- •4: Presurgical Management
- •Introduction
- •Nonsurgical Orthopedics
- •Lip Taping
- •Alveolar Molding Using Plates
- •Surgical Orthopedics
- •Surgical Technique
- •The Nasoalveolar Molding (NAM)
- •The Three-Dimensional CAD-CAM Presurgical Orthopedics
- •Labial Component (Lip Taping)
- •Rhinoplasty Appliance System (RAS) Nasal Component
- •CAD CAM Workflow
- •Alveolar Component (SAAS)
- •Clinical Cases RAS
- •Associated Poor Outcomes and Complications
- •References
- •5: The Unilateral Cleft Lip Nose Deformity
- •Introduction
- •Surgical Protocol
- •References
- •Introduction
- •Presurgical Considerations
- •Preoperative Evaluation
- •Instruments
- •Anesthesia
- •Mc Comb Modified Technique
- •Surgical Technique
- •The Composite Rotational Flap Rhinoplasty
- •Surgical Technique
- •Markings
- •Nasal Septum
- •Nasal Tip Reconstruction
- •Nasal Floor
- •The V-Y-Z Cleft Rhinoplasty (Video 6.1)
- •Surgical Technique
- •Markings
- •Lateral Z Plasty Dissection
- •Nasal Septum
- •Nasal Tip Reconstruction
- •Nasal Floor
- •References
- •7: The Bilateral Cleft Lip Nose Deformity
- •Introduction
- •Surgical Protocol
- •References
- •Introduction
- •Presurgical Considerations
- •Preoperative Evaluation
- •Instruments
- •Anesthesia
- •Mc Comb Modified Technique
- •Surgical Technique
- •Surgical Technique
- •Markings
- •Nasal Floor
- •Nasal Septum
- •Nasal Tip Reconstruction
- •Surgical Technique
- •Markings
- •Lateral Z Plasty Dissection
- •Nasal Septum
- •Nasal Tip Reconstruction
- •Columellar Lateral Z Plasty
- •Nasal Floor
- •References
- •9: Postoperative Management
- •Introduction
- •Immediate Postoperative Care
- •PACU Monitoring
- •Wound Care
- •Feeding
- •Pain Management
- •Agitation Control
- •Short-Term Postoperative Care
- •Postoperative Nasal Conformers
- •Acrylic Custom-Made Nasal Stent
- •Three-Dimensional Printer Rhinoplasty Appliance System (RAS)
- •Orthonostric Appliance
- •Cases
- •References
- •Introduction
- •Nasal Bleeding
- •Associated Infections
- •Children’s Stress
- •Postoperative Bleeding
- •Hypertrophic Scarring
- •Postoperative Wound Infection
- •Granulomas
- •Foreign Body
- •Skin Necrosis
- •Suture Allergic Reaction
- •Dimples
- •Notching (Pinched nose)
- •Lateral Web
- •Nasal Tip
- •Nasal Ala
- •Columella
- •Nasal Sill: Wider Nasal Sill
- •Narrower Nasal Sill
- •Nasal Vestibule
- •Nasal Tip
- •Nasal Ala
- •Nasal Ala Asymmetry
- •Alar Nose Shortening
- •Columella
- •Short Columella
- •Wide Columella
- •Nasal Sill: Wider Nasal Sill
- •Narrower Nasal Sill
- •Nasal Vestibule
- •References
- •Index

6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.9 Diagram of caudal septum reposition during Mc Comb modied cleft rhinoplasty.
A. Caudal septum. B. Maxilla C. Anterior nasal spine
155
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, and6.21)

156
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 modied cleft rhinoplasty

6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
AB
157
B
A
Fig. 6.11 Vestibular nasal oor reconstruction during Mc Comb modied technique. A: Alar ap.
B: Columellar base ap
ab
Fig. 6.12 Vestibular nasal oor reconstruction during Mc Comb modied technique. Vestibular
segment of the nasal oor is repaired in a patient with unilateral cleft lip and palate. (a) Preoperative
view. (b) Postoperative view

158
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 modied technique
P. Rossell-Perry

6 Surgical Techniques forUnilateral Cleft Lip Nose Repair
Fig. 6.15 Case 1.
Long-term (10years)
postoperative view of the
infant shown in Fig.6.13
after undergoing nasal
repair using the Mc Comb
modied technique
159
Fig. 6.16 Case 2.
Preoperative view of a
3-month-old infant with
complete unilateral cleft lip

160
Fig. 6.17 Case 2.
Immediate postoperative
view of the infant shown in
Fig.6.16 after undergoing
nasal repair using the Mc
Comb modied technique
Fig. 6.18 Case 2.
Long-term (9years)
postoperative view of the
infant shown in Fig.6.16
after undergoing nasal
repair using the Mc Comb
modied technique
P. Rossell-Perry

6 Surgical Techniques forUnilateral 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 modied technique
161

162
Fig. 6.21 Case 3.
Long-term (10years)
postoperative view of the
infant shown in Fig.6.19
after undergoing nasal
repair using the Mc Comb
modied 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 forUnilateral 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
163
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 identied 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 identied. The extent
of this marking is about 3–5mm 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
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