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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4442_Библиотеки_им_академика_М_И_Перельмана.pdf
226
Alar cartilages
a
Lateral lip
Nasal tip
C
anscutaneous
Intranasal alar
base incisión
Prolabium
Fig. 8.3 Nasal tip dissection during bilateral Mc Comb cleft rhinoplasty
P. Rossell-Perry
Nasal tip
Columell
Fig. 8.4 Nasal structure
reposition during Mc
Comb modied technique
Alar cartilage
Tr
stitches
olumella
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
Cases (Figs.8.5, 8.6, 8.7, 8.8, 8.9 and8.10)
Fig. 8.5 Case 1.
Preoperative view of a
3-month-old infant with
complete bilateral cleft lip
Fig. 8.6 Case 1. A
3-year-old postoperative
view of the infant shown in
Fig.8.5 after undergoing
nasal repair using the Mc
Comb modied technique
227
Fig. 8.7 Case 1. A 7-year
postoperative view of the
infant shown in Fig.8.5
after undergoing nasal
repair using the Mc Comb
modied technique
228
Fig. 8.8 Case 2.
Preoperative view of a
3-month-old infant with
severe complete bilateral
cleft lip
Fig. 8.9 Case 2. A
3-year-old postoperative
view of the infant shown in
Fig.8.5 after undergoing
nasal repair using the Mc
Comb modied technique
P. Rossell-Perry
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
Fig. 8.10 Case 2. A
8-year-old postoperative
view of the infant shown in
Fig.8.8 after undergoing
nasal repair using the Mc
Comb modied technique
229
The Composite Rotational Flap Rhinoplasty forMicroforms
andIncomplete Bilateral Cleft Lip Nose
This surgical technique developed by the author is a limited incision method for
primary cleft rhinoplasty and designed initially to be used in mild unilateral cleft lip
nose forms (microform and incomplete forms). The advantage of this method is that
it allows 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.
A composite ap (vestibular skin and cartilage) is designed and medially displaced
in a rotational form (Figs.8.11 and 8.12). It is indicated for bilateral incomplete
cleft lips or incomplete side in combined forms of bilateral cleft lips.
Surgical Technique
Markings
Surgery starts performing markings. They are composed by two lines, the inferior
curved line following all the lower border of the alar cartilage (marginal incision)
and the upper one at the level of the intercartilaginous border. The marginal border
(produced by the lower border of the alar cartilage) represents a change in the epithelium of the vestibule of the nose. This line can be easily identied because of the
change of the color; above the line is red and below is the same color as the nasal
skin. The nasal lining of the vestibule consists of squamous epithelium and changes
to a different one, the pseudostratied ciliated columnar respiratory epithelium. The
marginal line starts from the intercartilaginous border laterally and nishes before
the medial wall of the nasal vestibule medially (Figs.8.13 and 8.14). The second
marking is performed in continuity with the lateral side of the marginal marking and
230
P. Rossell-Perry
Fig. 8.11 The rotational
composite ap cleft
rhinoplasty. Surgical
marking diagram. 1.
Composite ap. 2.
Marginal incision. 3.
Intercartilaginous incision
(small triangular area for
resection)
a
b
Fig. 8.12 The rotational
composite ap cleft
rhinoplasty. Medial
rotation and lateral
advancement donor site
closure using
transcutaneous stitches. 1.
Composite ap. 2.
Marginal incision. 3.
Intercartilaginous incision.
4. Columella. 5. Alae. 6.
Lateral crus. 7. Domes. 8.
Medial crus. Green arrow:
rotational medial
displacement
tilaginous
Int
ab
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
231
Alar
cartilages
ercartilaginous
border
Columella
Lateral lip
Prolabium
Nasal
tip
Nasal vestibuleNasal vestibule
Intercar
border
Lateral lip
Fig. 8.13 Diagram of marginal marking during rotational composite ap technique for bilateral
cleft lip nose repair
Fig. 8.14 Right marginal incision during rotational composite ap technique for bilateral cleft lip
nose repair. (a) and (b) Right marginal incision
232
tilaginous
Int
ab
P. Rossell-Perry
follows the intercartilaginous border (limit between the upper and lower lateral cartilages of the nose) (Figs.8.15 and 8.16). The upper line is designed in continuity
with the lateral end of the marginal marking and follows the intercartilaginous border (limen nassi), and its extension is around 3–5mm. This short marking let the
surgeon to release the lateral border of the alar cartilage and allow the rotation of the
Alar
cartilages
ercartilaginous
border
Columella
Lateral lip
Prolabium
Fig. 8.15 Diagram of intercartilaginous marking during rotational composite ap technique for
bilateral cleft lip nose repair
Nasal
tip
Nasal vestibuleNasal vestibule
Intercar
border
Lateral lip
Fig. 8.16 Left marginal and intercartilaginous incision during rotational composite ap technique
for bilateral cleft lip nose repair. (a) Left marginal incision (b) Left intercartilaginous incision
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
Fig. 8.17 Position
incisions of the rotational
composite ap cleft
rhinoplasty for bilateral
cleft lip
233
composite ap. Both lines are surrounding the alar cartilage to create the composite
ap (composed by the vestibular skin and alar cartilage). Main benet of this method
is the preservation of the lateral wall of the nasal vestibule which prevents the development of scar contractures inside the nose. These markings are performed in both
sides in bilateral incomplete cleft lips (Fig.8.17).
Incisions After local anesthetic inltration and supercial lip incisions following lip markings using 11 blade scalpel, the nasal repair is performed. Nasal
incisions are performed following vestibular markings (marginal and intercartilaginous) around the alar cartilage of the cleft side using a 15-blade scalpel to
create the composite ap (Figure). It is recommended the excision of a small
triangle from the lateral corner of the ap to avoid redundancy of tissue after
closure. These incisions are performed in both sides in incomplete bilateral
cleft lips.
Rotational Composite Flap andNasal Tip Dissection
After identication of the alar cartilage and using a semiopen approach through the
marginal incision and using ne scissors, the composite ap (vestibular skin and
alar cartilage) is dissected on the supracartilaginous plane and elevated from lateral
to medial side including alar cartilage and vestibular skin in both sides. A small
triangle is resected at the lateral end of the composite ap to facilitate its closure
after medial rotation. Interdomal fatty tissue is preserved and the dissection continues over the upper lateral cartilages. Then, the nose dissection continues with the
nasal tip including both sides through the vestibular incision and on the supracartilaginous plane separating the nasal skin from the cartilaginous structure of the nose
(alar cartilages, domes, and lower dorsum). Both alar domes should be separated
from the overlaying skin in order to facilitate the reposition of the structures from
the cleft side (Figs.8.18 and 8.19).
234
ilaginous
Int
P. Rossell-Perry
a
Composite flap
Nasal vestibule
ercartilaginous
border
Lateral lip
b
Alar
cartilages
Prolabium
Nasal
tip
Composite flap
Nasal vestibule
Intercart
border
Columella
Lateral lip
Fig. 8.18 (a) Diagram of nasal tip dissection during rotational composite ap technique for bilat-
eral cleft lip nose repair. (b) Nasal tip dissection during rotational composite ap technique for
bilateral cleft lip nose repair
8 Surgical Techniques forBilateral Cleft Lip Nose Repair
a
b
235
Fig. 8.19 (a) Diagram of bilateral composite ap elevation after nasal tip dissection. (b) Rotational
composite ap elevation left side