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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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Bump Ablation (Fig. 3.21–3.25)
䊏
With his or her left hand, the surgeon inserts the retractor underneath
the totally mobilized skin flap on top of the bony and cartilaginous
nasal framework and pulls it upwards. Any remaining cords of connective tissue are removed endoscopically. The bony-cartilaginous bump is
now clearly visible during suctioning.
䊏
Particular care should be taken to cleanly detach the mucosa from both
the anterior septal cartilage and the nasal dome. The surgeon now
begins to ablate the cartilaginous bump. Using a number 11 scalpel, he
or she makes a horizontal incision, starting at the nasal vestibule and
continuing up to the nasal bone, to separate the cartilaginous roof
made up of the medial surfaces of the lateral nasal cartilages and the
upper edge of the septal cartilage.
(Fig. 3.21)
With the retractor still held under tension in an upward position, the
surgeon now places the 11-mm chisel into the incision lines. (Fig. 3.22)
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Fig. 3.21
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Fig. 3.22
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䊏
The retractor can now be removed. The thumb and index finger of the
surgeon‘s left hand now serve simultaneously as guide rails for the
chisel and as protection for the medial canthus. The assisting surgeon
now applies uniform, sensitive hammer blows commensurate with the
thickness and density of the bony structure.
The extent of bump ablation is geared to the lowest point in the region
oftherootofthenose.
The bump should be ablated totally in order to prev ent later irregularities in the region of the dorsum of the nose.
(Fig. 3.23)
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Fig. 3.23
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䊏
The ablat ed bump is now removed with the Blakesley forceps. The surgeon should be careful to remove a piece of bone in the glabella, which
tapers to become the root of the nose in the interests of achieving an
esthetically correct narrowing. (Fig. 3.24)
䊏
The sharp edges of the nasal bone are smoothed with a relatively coarse
rasp. For this purpose, the rasp is inserted from both sides over the
intercartilaginous incision and under the skin on the dorsum of the
nose. To prevent the instrument from slipping, the thumb and index
finger of the surgeon’s left hand again serve as guide rails. (Fig. 3.25)
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Fig. 3.24
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Fig. 3.25
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Reshaping of the Tip (Fig. 3.26, 3.27)
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With his or her right hand, the assisting surgeon now inserts the flat
two-pronged hook in the free margin of the nasal wing and pulls it
upwards under tension. At the same time, he or she inserts the long
two-pronged hook in the columella and pulls it forward under tension
with the left hand. The surgeon can achieve excellent visualization of
the anatomical structures in this manner .
䊏
Any excess cartilage on the top edge of the septum is now removed
with the number 11 scalpel or the delicate bent nasal scissors. This procedure can be carried out endoscopically; the top edge of the septum,
the shortened alar cartilage, and the open roof resulting from the osteotomy are all clearly visible.
䊏
Using the number 15 scalpel, the surgeon now detaches the mucosa
from the newly creat ed anterior edge of the septum without perforating
it.
䊏
If necessary, a small strip of cartilage can be resected in order to create
asmalltroughinthetipregion.Thisistoensureoptimalshapingof
the supratip region.
Failure to free all the connective tissue structures in this region from
cartilage can produce unaesthetic results – such as a “parrot beak” – at
alaterdate.
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䊏
The superfluous mucosa in the region of the front edge of the septum
can now be resected.
䊏
If the patient has requested a turned-up nose, it is necessary to remove
correspondingly larger portions of the cartilaginous and bony structures of the nose.
䊏
When reshaping the nasal tip, the trick is to leave the mucosa intact.
Under this condition, a large part of the alar cartilage can be resected
without any negative effects on the nasal breathing passages.
䊏
This is followed by hemostasis with the electrocoagulation forceps.
Special attention should be paid to the branch of the facial artery which
reaches the alar cartilage from the dorsal side.
䊏
Subsequently, all the cartilaginous edges, including the anterior edge of
the septum, are trimmed again. The edges are carved with the scalpel.
The amount of excess connective tissue removed depends on the extent
of nasal thinning desired.
Fig. 3.26
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Fig. 3.27
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Suturing of the Mucosal Incisions
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The mucosal incisions are now closed with interrupted 4/0 PDS sutures.
Thesesuturesareabsorbedanddonothavetoberemovedlater.
The surgeon always commences suturing basally by placing two to
three sutures at the columella and then continues suturing in the direction of the upper edge of the septum and the nasal wing.
(Fig. 3.28)
䊏
At this location, 3–4 sutures are generally required. (Fig. 3.29)
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Fig. 3.28
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Fig. 3.29
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