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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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3 Rhinoplasty
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Resection of the “Mang T riangle ” (Fig. 3.30)
With this technique, an excess mucosal flap is created in the nasal wing
region, owing to the removal of cartilage and reduction of the nasal wing.
䊏
This “Mang triangle” is resected after the sutures are completed. To
accomplish this, the assisting surgeon pulls the mucosal flap slightly
toward the front with the Adson-Bro wn tweezers. With the flat twopronged hook inserted, the surgeon can now resect the triangle easily
with the bent small nasal scissors. No additional sutures are necessary.
䊏
Theidenticalprocedureiscarriedoutonthecontralateralside.
If the surgical work has been meticulous, mucosal triangles of equal
size remain to be bisected bilaterally. The more radical the nose reduction, the larger are the resulting “Mang triangles.”
Mattress sutures are generally not required in the columella region and
are made only in rare cases.
䊏
Any fine corrections that still have to be made, e.g., reimplantation of
cartilageinthenasaltip,thealarortriangularcartilageregion,orin
the dorsum of the nose, should be made now, i.e., prior to the osteotomies. For this purpose, the pieces of cartilage which were previously
removed and then placed in a saline solution are now cut to form,
crushed with a sharp hook, reimplanted in the desired region, and
secured with fibrin adhesive.
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If larger pieces of cartilage are required, they can be taken from the
concha of the ear.
䊏
Reduction of the nasal wings, if necessary, is also carried out prior to
the osteotomies. For this purpose, a wedge-shaped piece is excised
above a nasal wing margin incision. The incision in the nasal wing is
closed without any tension with interrupted 5/0 Prolene sutures. A variation of this procedure is shown in the video film.
䉴
Asanoviceyoushouldtakecarewhenremovingthealarcartilage.
Itisimportantthatnoneofthemucosabecomesperforatedwhenthe
alar cartilage is being removed.
䉴
Wewillnowshowyoutheresectedpiecesofcartilageandboneagain
(Fig. 3.31):
1 Anterior edge of the septum
2 Part of the alar cartilage
3 Part of the triangular cartilage
4 Cartilaginous bump (consisting
of the cartilaginous to edge of the
septum and the triangular cartilage)
5 Bony bump (consisting of both upper
portions of thenasal bone and the
bony top edge of the septum)
6 Lower part of the glabella
Fig. 3.30
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6
5
4
Fig. 3.31
3
2
1
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Osteotomies (Fig. 3.32)
The basal and transversal osteotomies are not carried out until all the
soft tissue work has been completed.
The associated extensive swelling and hemorrhage make precise correction of the soft tissues impossible.
The surgical dressing is applied immediately after the osteotomies. This
prevents swelling, in particular in the medial canthus.
The paramedian osteotomy was already performed during the ablation
of the nasal hump.
The bilateral basal osteotomies are extended at the medial canthus to
form the transversal osteotomy. As a result, both nasal bones are now
totally mobile.
Only a total osteotomy on all sides guarantees that the nose can be
optimally narrowed and the dorsum delicately redesigned.
Osteotomies are indispensable in all rhinoplasty procedures performed
toremovenasalhumpsand/orcorrect“longnoses,”i.e.,inabouttwo
thirds of all rhinoplasties. If the deformity consists only of an unsightly
nasal tip, it can be corrected under local anesthesia without osteotomies by means of the eversion method shown here.
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䊏
To perform the basal osteotomy the surgeon places the 4-mm chisel at
the most basal point of the anterior nasal aperture with his or her right
hand. It is not necessary to predissect the mucosa here. While performing the basal osteotomy on the right side, the surgeon guides the lateral
edge of the chisel with his or her left hand. On the left side the chisel is
guided with the index finger of the surgeon’s left hand.
Attention must be paid to the basal course of the osteotomy to prevent
step formation.
The assisting surgeon must have a good feeling for bone thickness so
that controlled hammer blows are applied, especially at the medial
canthus and at the transition to the transversal osteotomy.
We use the relatively narrow 4-mm chisel here to avoid injuring the
periosteum.
Fig. 3.32
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䊏
Following this, swabs saturated with naphazoline nitrate are applied for
2min.
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During this period, the surgeon fractures and mobilizes the nasal bones
along the osteotom y lines. This is performed by grasping the dorsum of
the nose with a moist compress and making sideward movements with
the thumbs and index fingers of both hands. Care should be taken not
to tear the endonasal mucosa in order to prevent heavy bleeding.
The nasal bone and the nose framework should now be totally mobile;
this is necessary to attain optimal aesthetic results.
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The nose is then reshaped, using both hands and with the aid of two
moist compresses.
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The surgeon checks the dorsum of the nose and the nasal wing region
again for irregularities. If necessary, small pieces of cartilage can be
reimplanted above the already closed cartilaginous incision.
(Fig. 3.33)
䊏
In addition, the nasofacial angle, the nasolabial angle, and “Mang’s
angle” are inspected to determine whether they are anatomically correct.
(Fig. 3.34)
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Fig. 3.33
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Fig. 3.34
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The nose now has its final new form. The dressing which is subsequently applied does not exert any shaping or corrective effect; it serves
merely as protection.
䊏
The swabs saturated with naphazoline nitrate are now removed again
with the bayonet tweezers and the entire endonasal system is suctioned.
䊏
Finally , loose nasal packing is inserted and left in place for 24 h. Any
blood effusions are carefully squeezed out by repeated shaping of the
nose with both hands.
(Fig. 3.35)
External Dressing
䊏
Firsttheskinofthenoseandcheeksisdaubeddrywithacompresssaturated with naphtha.
䊏
The surgeon now places precut Steri-Strips™ on the dorsum of the nose
in a roof-tile pattern. He or she starts directly behind the nasal tip in
the supra tip region and contin ues placing the adhesive strips in an
overlapping fashion up to the root of the nose. T o keep the nasal tip,
which has been rota t ed cranially in position, a strip is pulled around it
like a bridle. At the same time, this anterior bridle causes compression
of the tip and supratip region. It is extremely important, in particular,
to prevent any hemorrhage in order to prevent swelling, adhesions, and
an unsightly “parrot’s beak.”
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䊏
The nasal plaster is now cut into shape. We do not use ready-made
splints because of our conviction that a plaster cast offers the best protection. After wetting the plaster, it can be modeled to fit the individual
nose. In addition, a thermoplastic pad is heated in a water bath and
then applied to the nose; this pad is shaped with an ice compress and
allowed to cool.
䊏
Finally , the plaster and pad are attached to the patient’s cheeks and
forehead with nontraumatic adhesive tape designed for use on skin.
(Fig. 3.36)
Fig. 3.35
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Fig. 3.36
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Postoperative Medication and Precautions
䊏
Antibioticsareadministeredorallyfor5dayspostoperativelyto
continue the antibiotic treatment instituted during the operation.
The patient should observe absolute rest for 8 days after the operation;
during this period, he or she should refrain from chewing vigorously
and even from laughing or grimacing.
No movements should be made in the nose region. The patient should
sleep on his or her back supported by several pillows. Twen ty-four
hours after the operation, the nasal packing is taken out, the nose is
carefully suctioned, and any remaining crusts are removed. After this,
nasal ointment is applied to the nasal mucosa three times a day and the
wound is cleaned to remove wound secretions and crusts once or twice
aday.
During the first 3 weeks after the operation, the patient is not allowed
to take hot baths, go to the sauna, go out in the sun, or engage in strenuous activity of any kind.
䊏
After 6–8 days, the surgeon changes the nasal plaster cast. The patient
is then instructed on how to apply strips to his or her nose in an overlapping roof-tile pattern every night for an additional 4 weeks. The
correct positioning of the first adhesive strip in the supratip region is of
major importance here.
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It takes about 6 months after the operation before the nose is
completely healed and as stable as before the operation.
Any corrections which may be necessary should not be undertaken
until ½–1 year after the operation.
Results
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ab
Fig. 3.37
a Before:
b After: The same patient 12 months after a septorhinoplasty
A 23-year-old patient suffering from a long nose with a bump
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ab
Fig. 3.38
a Before: A 37-year-old patient with a long nose, nasal hump, and receding chin
b After: The same patient 12 months later following rhinoplasty and autologous
cartilage-bone transplant from the nose bridge to the chin (profile-plasty
according to Mang)
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