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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4450_Библиотеки_им_академика_М_И_Перельмана
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cavity. At the chondropremaxillary– and perpendicular–
vomeral junction, a pronounced cartilaginous and bony
crest and spur are present. Due to these skeletal
distortions, the inferior part of the vomer is part of the
nasal floor on the NCS (▶ Fig. 2.30 and ▶ Fig. 2.31).
Fig. 2.30Cleft lip- and cleft palate-nose on the left side. Septal deformity at the level of
the premaxilla. The premaxilla deviates to the CS at a 45° angle. The cartilaginous
septum and vomer are deviating to the left. A huge crest is present at the
chondropremaxillary and chondrovomeral junction. The inferior turbinate is located
lower and is somewhat compressed.
Fig. 2.31Cleft lip- and cleft palate-nose on the left side. Deformity of the septum and
turbinates at the level of the vomer. The perpendicular plate and vomer deviate to the
CS. A pronounced crest and spur are usually present at the chondrovomeral and the
perpendicular–vomeral junction. The inferior turbinate on the CS is compressed and
positioned lower. The inferior turbinate on the NCS usually demonstrates compensatory
hypertrophy.
The depressed ala usually contributes to stenosis of the
valve area. The inferior turbinate on the CS is lower and
compressed in a lateral direction. Its bony lamella is lower
than normal. On the NCS, the inferior turbinate is usually
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compensatory hypertrophied. The middle turbinate on the
CS is generally somewhat more slender than on the NCS.
2.1.12Congenital Nasal Hypoplasia
(Nasomaxillary Dysplasia, Binder
Syndrome)
This syndrome is characterized by congenital
underdevelopment of all nasal structures in combination
with maxillary hypoplasia or retrusion. It is relatively rare
and sporadic. In most cases, the cause is unclear. The bony
and cartilaginous pyramids are low, wide, and
underprojected. The lobule is flat and wide. The nostrils
vary greatly in shape from round to square, and have a
transverse axis. The tip is broad and sometimes bifid, the
columella is short and broad, and the alae are abnormally
convex (▶ Fig. 2.32 and ▶ Fig. 2.33). The septum is
underdeveloped in an anterior and caudal direction and
may be partially missing. The maxillary bones are
hypoplastic and the midface is retruded (▶ Fig. 2.34). The
anterior nasal spine is usually missing. This syndrome is
sometimes called Binder syndrome ([15]).
Fig. 2.32Congenital nasal hypoplasia. The bony pyramid, cartilaginous pyramid, and
lobule are low, wide, and short.
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Fig. 2.33Congenital nasal hypoplasia. The nostrils are square; the tip is broad and
sometimes bifid; the columella is short and broad; the alae are round and abnormally
convex.
Fig. 2.34Congenital nasal hypoplasia. The midface is underdeveloped and retruded.
2.1.13Facial Syndromes
Facial Asymmetries
The following facial asymmetries may be distinguished: the
long-face syndrome, the short-face syndrome, maxillary
protrusion, maxillary retrusion (midface hypoplasia),
mandibular prognathism, and mandibular retrognathism. In
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this section, we restrict ourselves to a discussion of the
syndromes that significantly affect the analysis and surgical
correction of nasal deformities.
Left–Right Facial Asymmetry
Various elements of the skull and face are asymmetrical
between the right and the left. Two examples are presented
in ▶ Fig. 2.35 and ▶ Fig. 2.36, where the middle and lower
part of the face is concave on the right. The external ear
canal and auricle on the right are located lower than on the
left side. The maxillary bones are asymmetrical, with a
relative retroposition on the right. The mouth is displaced
to the right, the left corner being somewhat lower than the
right. The mandible is asymmetrical. The chin is displaced
to the right. Because of the severe facial asymmetry, it is
difficult to determine whether the nose is in the midline or
deviated. For instance, when the trichion–nasion–stomion–
gnathion line is drawn, the nose seems to be deviating to
the left. When the trichion–nasion–tip line is drawn, the
external pyramid appears straight. Both cases stress the
importance of careful facial analysis. It is crucial to
determine the position of the external pyramid in relation
to the other facial structures.
Fig. 2.35Facial asymmetry. Asymmetry of the middle and lower thirds of the face,
suggesting a severely deviating external nasal pyramid. In reality, there is only a limited
septal and pyramidal deviation.
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Fig. 2.36Facial asymmetry. A similar case to ▶ Fig. 2.35, showing a combination of a
deviation of the nose to the left and a concavity of the face to the right.
Maxillary and Mandibular Retrusion
Maxillary Retrusion (Retroposition)
The maxilla is bilaterally or unilaterally retropositioned
with respect to the frontal bones and the nasal pyramid.
Bilateral retroposition of the maxilla and cheek accentuates
the degree of prominence (projection) of the nose in
relation to the face. Unilateral retropositioning may give
(or accentuate) the impression that the external nose is
leaning to that side. Retroposition of the maxilla may be
examined clinically by studying the face from above with a
flat object on both cheeks (▶ Fig. 2.37). Exact measurements
may be made by X-ray cephalometry.
Fig. 2.37Retroposition of the maxilla.
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