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_4442_Библиотеки_им_академика_М_И_Перельмана.pdf
14
Fig. 1.16 Intraoperative
view of nasal cartilages
during primary unilateral
cleft rhinoplasty. 1. Alar
cartilage (cleft side). 2.
Alar cartilage (noncleft
side). 3. Dorsum. 4.
Septum
Fig. 1.17 Lower lateral
cartilage displacement in
bilateral cleft lip patient.
A.Alar cartilages. B.Alae
C.Columella.
D.Prolabium E.Lateral lip
segment. F.Premaxilla
P. Rossell-Perry
nasal tip skin may also affect the outcome after primary cleft rhinoplasty and should
be considered during surgical planning. The soft tissue characteristics of each subunit of the nasal tip are different, for example, the skin of the alar lobule forms a
semirigid unit that maintains the graceful curve of the alar rim.
The Nasal Columella
The nasal columella is dened as the most anterior portion of the nasal septum and
located between the two nostrils linking the nasal tip to the nasal base. It is a single
midline structure composed of cartilage and skin and includes six components: the
caudal septum, medial crura, columellar skin, membranous septum, anterior nasal
spine, and depressor septi nasi muscle (Fig.1.19).
esor nasi
1 Anatomy andPhysiology
Fig. 1.18 Intraoperative
view of nasal cartilages
during primary bilateral
cleft rhinoplasty. 1. Alar
cartilages. 2. Dorsum. 3.
Septum
15
Nasal septum
Lateral crus
Middle crura
Depr
septi
Fig. 1.19 Nasal columella structural framework diagram
This structure in combination with the caudal septum provides support and projection to the nasal tip playing a functional role in nostril patency and breathing.
The nasal columella is composed of the following main structures:
Cartilaginous Framework
It is represented by the medial crus of the alar cartilage and the caudal septum.
Structural support works in combination with ligamentous structures between the
medial crura and caudal septum through the membranous septum and attachments
between both medial crura and caudal septum.
16
P. Rossell-Perry
The medial crus is the inner portion of the alar cartilage and is situated perpendicularly to the septal nasal cartilage. The lower segment, 5mm in length, courses
laterally and often posteriorly and is called the footplate.
The caudal septum is attached through ligaments with the medial crura forming
the central support of the nasal columella. Its most anterior section is membranous.
This structural support of the nasal tip frequently deviates and displaces off the
nasal spine in unilateral cleft lips, and its correction is an essential component of the
primary and secondary cleft rhinoplasty.
Overlaying Soft Tissues
The soft tissue components of the nasal columella include the skin, muscles, nerves,
and vascular tissues.
The skin of the lateral side of the columella is xed, thinner, less sebaceous, and
tightly attached to medial crura connecting with the vestibular skin internally.
The anterior side of the medial crus is covered by mobile skin and subcutaneous
tissue. There is an important muscular component in this area: the depressor septi
nasi. This muscle is located between the caudal end of the cartilaginous septum and
the medial crura.
It connects the incisive fossa of the maxilla to the nasal septum of the nose. This
muscle draws the ala of the nose downward, reducing the size of the nostrils
(Fig.1.19).
The columella follows the direction of the caudal septum and explains its position in patient with unilateral cleft lip in whom the columella deviates toward the
cleft side. Another important application is related to the bilateral cleft lips in which
the columella is hidden into the nasal tip because of the malposition of the alar cartilages; in fact, the columella is not short and is only displaced. Reposition of these
structures using an adequate surgical technique may allow us to repair the columella.
The Nasal Vestibule
The nasal vestibule represents the most anterior section of the nasal cavity and represents an important functional area. It is located between the two nasal valves:
external (nostrils) and internal (limited medially by the caudal septum, laterally by
the limen nasi and inferiorly by the head of the lower turbinate and nasal sill) [11]
(Fig.1.20).
The nasal vestibule is the narrowest portion of the nasal cavities, and any alteration that reduces the lumen (such as scar contractures) is bound to have a great
impact on airow. It is a specialized respiratory organ limited laterally by the ala,
medially by the caudal septum and columella, and superiorly by the limen nasi (or
limen vestibuli), and its inferior limitation is the nostril.
The area of the internal nasal valve should be preserved during primary cleft
rhinoplasty in order to prevent functional disorders.
The limen nasi is an important structure of the nasal vestibule and represents the
junction between the upper and lower lateral cartilages (scroll region). It is the place
where the intercartilaginous incision is made to access the nasal dorsum and also
performed during the rotational composite ap and VYZ techniques of primary cleft
1 Anatomy andPhysiology
Fig. 1.20 The vestibule of
the nose diagram. 1. Alar
margin. 2. Nasal columella.
3. Caudal septum. 4. Nasal
tip. 5. Intercartilaginous
border. 6. Alar cartilage
(sky blue area). 7. Nostril
sill. 8. Internal nasal valve
angle. 9. Nostril
17
rhinoplasty. This structure separates the vestibule from the nasal cavity and represents the change from the vestibular skin to the respiratory epithelium of the
nasal cavity.
This area between the upper lateral and lower lateral cartilages is a cul-de-sac,
known as the infundibulum or diverticulum. It has a distortion in cleft lip patients
and requires reposition of the lower cartilage over the upper cartilage (mucocutaneous junction). The nasal vestibule is enclosed by the nasal cartilages and lined by
skin (hair-bearing, sebaceous, and sweat glands) until reaching the marginal line
(caudal border of the lower lateral cartilage). This is a keratinized stratied squamous epithelium.
Above the marginal line until the limen nasi, the lower lateral cartilage is covered
by a transitional epithelium which is a thinning of the stratied epithelium. The difference between these two linings is easily identied because they have different colors.
Below the marginal border (caudal border of lower lateral cartilage), the color is
the same as the color of the skin of the face and above the marginal border until the
limen nasi the area is reddish because of the transition of the epithelium (Fig.1.21).
This anatomical reference is very important to locate the place of marginal incision used for the nasal approach during rhinoplasty and the surgical techniques used
for primary cleft rhinoplasty used by the author.
Due to functional nature, the nasal vestibule area is severely affected by scar
contractures and synechia which can cause breathing disorders.
Recurrence of the nasal deformity after primary cleft rhinoplasty may be
explained by scar contracture of the nasal vestibule lining and support the success
of the surgical techniques based on vestibular lengthening, such as Potter.
The author developed a vestibular lengthening method using a combination of
V-Y advancement ap (Potter) with a lateral Z plasty (Berkeley) in a similar form
as the presurgical orthopedic (NAM) that temporarily expands the nasal vestibule
and named it as “the surgical nasoalveolar molding” [12–14].
18
Fig. 1.21 Characteristics
of the nasal vestibule,
marginal, and
intercartilaginous borders.
1. Nasal vestibule 2.
Marginal border 3. Area
below the marginal border
that covers the alar
cartilage. 4. Columella. 5.
Alae. 6. Nasal tip
P. Rossell-Perry
The development of scars in this functional area may increase the risk of scar
contractures; therefore, postoperative use of nasal conformers is mandatory for at
least 6months.
The Nasal Septum
This bony and cartilaginous structure is covered by nasal mucosa located in the
midline separating the right and left nostrils, extending from the nares to the
choanae.
It provides support to the columella, nasal tip, vault, and mucosa inuencing
nasal airow.
Bony-Cartilaginous Framework (Fig.1.22)
The framework of the nasal septum is composed of four parts: septal cartilage, perpendicular plate of the ethmoid bone, vomer, and maxillary crest. Minor contributions are made by palatine, nasal, and frontal bones [15].
The septal cartilage (“quadrangular cartilage”) is a hyaline type and articulated
with bones and cartilaginous structures of the nose, posteriorly with the perpendicular
plate of the ethmoid bone (posterosuperiorly) and the vomer (posteroinferiorly).
Its inferior margin joins the nasal crest and the anterior nasal spine of the maxilla. The maxillary crest has a maxilla component (anteriorly) and a palatal component (posteriorly). The anterosuperior border of the septal cartilage is articulated
with the two triangular upper lateral cartilages. This articulation forms an angle
between 10° and 15° which represents anteriorly the angle of the internal nasal
valve, an important functional structure of the nose [16].
The anterior portion of the caudal septum articulates with the nasal columella
through the membranous septum.
car
1 Anatomy andPhysiology
Nasal bone
Septal
cartilage
Alar
tilage
Maxilla
19
Ethomid
Vomer
Palatine
Fig. 1.22 The nasal septum bony cartilaginous framework diagram
The area between the nasal bone, septal cartilage, bony septum, and upper lateral
cartilages which is rmly connected by brous tissue is the keystone area, a critical
zone for maintaining the stability of the nasal dorsum.
The vomer is an unpaired bone located in the midline and articulated with the
septal cartilage, maxilla, palatine, ethmoid, and sphenoid bones. It has an important
relation with the premaxilla. This bone is also known as incisive or intermaxillary
bone (Goethe’s bone because of his description in 1784) and represents the primary
palate [17].
The junction between the vomer and premaxilla (vomero-premaxillary suture) is
an important facial growth site, and the surgical procedures involving this area were
found to inhibit of maxillary growth. This area should be preserved, especially during premaxilla setback procedures [17].
Overlying Mucosa
The nasal septum is covered with a mucosal layer that warms air passing through
the nasal cavity.
Nasal septum deviation is a common disorder observed in unilateral cleft lip and
palate and affects the nasal physiology reducing the airow and causing congestion
20
Super
P. Rossell-Perry
and difculty breathing in these patients. This structure often shows convexity
toward the cleft side, and the direction of the deviation is toward the noncleft side.
The nasal columella follows the deviation of the caudal septum portion.
Surgical correction of its caudal portion is performed during the primary cleft
rhinoplasty.
Internal Lateral Wall
The lateral wall of the nasal cavity is composed of curved shelves of bone known as
the turbinates. They are a ngerlike and project into the nasal cavity creating pathways for the air to ow called meatus. There are three pairs of turbinates and four
pairs of meatuses (Figs.1.4 and 1.23).
The function of the turbinate is to increase the surface area of nasal mucosa and
the contact with the inspired air which is heated and humidied.
They also disrupt the laminar ow of the air, making it slow and turbulent.
The three turbinates are superior, middle, and inferior.
The inferior turbinate is the largest and has immune functions because it is the
rst to come in contact with the outside air. Additionally, it is enlarged in unilateral
cleft lip patients [18].
The four meatuses are inferior (between the inferior turbinate and nasal oor),
middle (between the inferior and middle turbinates), superior (between the middle
and superior turbinate), and the sphenoethmoidal recess (located superiorly and
posteriorly to the upper turbinate).
The lateral wall also contains the following openings which drain a variety of
structures as follows: sphenoid sinus, ethmoidal air cells, maxillary sinus, frontal
sinus, and nasolacrimal duct.
ior turbinate
Middle turbinate
Inferior turbinate
Fig. 1.23 Internal lateral wall of the nose diagram
1 Anatomy andPhysiology
21
Bony Framework (Fig.1.4)
The bone structure of the lateral wall of the nasal cavity consists of the frontal process of the maxilla, lacrimal region, the ethmoid bone, perpendicular section of the
palatine bone, and medial pterygoid plate of the sphenoid.
The ethmoid bone is located at the midline of the anterior cranial fossa and forms
also the roof of the nasal cavity and the medial wall of the orbits.
The cribriform plate forms the roof of the nasal cavity and contains small perforations allowing olfactory nerve bers to cross.
Laterally, two small cuboidal bone structures are located between the orbits
and the nasal cavity. These are the ethmoidal labyrinths which include the ethmoidal sinus and cells. The sphenopalatine foramen (a structure between sphenoid and palatine bones) is located at the level of the superior meatus. This
foramen communicates the nasal cavity and the pterygopalatine fossa. The sphenopalatine artery, nasopalatine, and superior nasal nerves passed through
this region.
Overlying Mucosa
The nasal mucosa covering the lateral wall and turbinates contains many blood vessels. This mucosa has respiratory epithelium, which consists of pseudostratied ciliated columnar cells with goblet cells. The inferior turbinate is exclusively covered
with a pseudostratied ciliated and not ciliated columnar epithelium with more goblet cells on its lateral side.
This structure may shrink or swell in response to the quality of the inspired air.
Septal deviation can be associated with turbinate hyperplasia leading to nasal
obstruction in patients with unilateral cleft lip and palate [18, 19].
The Nasal Floor
The nasal cavity is limited by the following structures (Figs.1.24 and 1.25):
• Roof: It is the olfactory area formed by nasal, frontal, sphenoid, and ethmoid
bones covered by respiratory mucosa.
• Medial wall: It is represented by the nasal septum. It is formed by perpendicular
plate of ethmoid, vomer, and septal cartilage.
• Lateral wall: This is formed by the maxilla, ethmoid, and the palatine bones. It
includes the turbinates and meatuses.
• Floor: The skeletal framework is formed by the maxilla and palatine bones.
Four sections can be clearly identied in the nasal oor.
Anterior (vestibular): This section corresponds to the vestibular nasal oor
(nasal sill).
Primary palate (premaxilla): This is the most anterior portion of the palate and
includes the premaxilla bone which bears the incisor teeth. Close to the junction
with the palatine process of the maxilla is the incisive foramen which transmits
branches of the sphenopalatine artery and the nasopalatine nerve.
Secondary palate (hard palate): The hard palate includes the anterior two-thirds of
the palate, and it is composed by the palatine processes of the maxilla and the
horizontal plates of the palatine bones.
22
nasal spine
ramen
Fig. 1.24 Nasal oor
segment diagram.
A.Nostril sill. B.Primary
palate. C.Secondary
palate. D.Soft palate.
E.Nasal septum
P. Rossell-Perry
Frontal
process
Orbital rim
Infraorbital
foramen
Alveolar
process
Anterior
Zygoma
Nasal bone
Palatine bone
Maxillary sinus
Incisive
fo
Palatal
process
Fig. 1.25 Anatomical diagram of the nasal oor skeletal framework
Soft palate: It represents the posterior third of the palate, and this is the functional
part of the nasal oor and appears during velopharyngeal closure.
The nasal oor is absent in the complete cleft lip and palate (Veau III and IV
types), and it is repaired depending on the surgical protocol used (Table 1.1)
(Figs.1.26 and 1.27).
The author’s protocol is based on cleft lip repair at 3–6months of age and the
whole palate repair at 9–12 months of age. Later the primary palate section is
repaired during alveolar bone grafting during the mixed dentition period [20].
Two-stage hard palate delayed closure (Gothenburg protocol) involves closing
the soft palate section rst and then the hard palate. Primary palate section is closed
Columellar base flap
ular segment)
f
V
f
1 Anatomy andPhysiology
Table 1.1 Nasal oor closure regarding the cleft palate repair protocol
Delayed hard palate Delayed soft closure
Nasal oor One stage
Gothenburg Oslo
LIMA protocol
Segment I 3–6months 3–6months 3–6months 3–6months
Segment II 7–9years 7–9years 3–6months 5years
Segment III 9–12months 3years 3–6months 9–12years
Segment IV 9–12months 6months 9–12months 9–12years
a
The Lima protocol for cleft palate repair considers delayed hard palate closure for severe bilateral
cleft lip and palate
(vestibular segment)
23
a
Mucoperiosteal
flap from premaxilla
(primary palate
segment)
Alar base flap
(vestibular segment)
Muscle
Lateral lip segment
Mucoperiosteal flap
from lateral alveolus
(primary palate
segment)
Nasal Mucoperiosteal
lap (secondary palate
segment)
omer Mucoperiosteal
lap (secondary palate
segment)
Nasal flap from soft
palate (secondary
palate)
Mucoperiosteal
flap from premaxilla
(primary palate
segment)
Alar base flap
(vestib
Muscle
Lateral lip segment
Mucoperiosteal flap
from lateral alveolus
(primary palate
segment)
Prolabium
Premaxilla
Vomer
Hard palate
Soft palate
Velar muscles
Uvula
Fig. 1.26 Bilateral cleft lip and palate nasal oor repair
during alveolar bone grafting [21]. A variant, the Milan protocol, performs the lip
and nose repair at the same time as the soft palate.
The two-stage soft palate delayed closure (Oslo protocol) close rst the primary
and hard palate using the vomer ap and the soft palate later. The cleft lip is repaired
previously at 3months of age during hard palate closure [22].