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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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6 Otoplasty
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Exact hemostasis and wound edge trimming.
Cartilage Sutures (Fig. 6.21, 6.22)
If the reshaped anthelix cartilage is very thin and realigns itself without
any tension, no cartilage sutures are required.
A surgeon carrying out an otoplasty procedure should avoid cartilage
sutures whenever possible, since every suture in ear cartilage is a
potential source of infection. In thicker cartilage, however, cartilage
sutures with 4/0 PDS suture s are needed.
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The needle should be inserted perpendicular to the cartilage to prevent
tearing. When placing the sutures, care should also be taken to achieve
an aesthetically and anatomically correct anthelix shape. One or two
sutures are made, depending on the degree of tension.
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It is usually not necessary to attach the lower edge of the concha to the
mastoid. In cases where sufficient realignment cannot be achieved in this
region as a result of cartilage thinning, a fixation suture can be made
with 4/0 PDS suture material. In this case, the remainder of the concha is
sutured to the mastoid periosteum. To prevent stenosis of the external
auditory tube, these sutures should not be placed too close to the mouth
of the tube. The conchal-mastoid angle should be adjusted to 30° .
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Fine corrections can now be made in the region of the tragus and antitragus.
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This is followed by repeated hemostasis and trimming of wound edges.
The operation site should be absolutely dry prior to wound closure to
prevent the formation of an othematoma.
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The entire auricle has now been realigned without any tension. The
desired anthelix curvature has been attained. The conchal-mastoid
angle is correct.
If the auricular lobule still displays an aesthetically unacceptable protrusion, the ability of the cartilage to realign itself should be assessed.
The two options availa ble to the surgeon are to transect the cauda helicestransverselyortomakeaYV-plastyaspartofskinclosureonthe
dorsal side of the ear lobe. This has the advantage of shortening the
lobuleatthesametime.
Fig. 6.21
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6 Otoplasty
Fig. 6.22
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Wound Closure (Fig. 6.23, 6.24)
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The surgical wound is generally closed in two layers subcutaneously
with 4/0 PDS. Above this the skin is closed, without any tension whatsoever, with 5/0 Prolene interrupted sutures. Alternativel y, the skin can
be closed intracutaneously with continuous 5/0 PDS or Monocryl™
sutures. The advantage of this procedure, which is especially useful in
pediatric patients, is that the sutures do not have to be pulled tight.
There is no difference in the aesthetic results attained with the two
techniques, provided that the sutures have been made totally without
any tension.
If the conchal-mastoid angle has been improperly aligned during dissection, this cannot be corrected later either by the cutaneous sutures
or by a corrective dressing.
Identical Approach on the Contralateral Side
Care should be taken to mark the incision lines behind the ear bilater ally shortly before the operation to make sure that the resected skin
areas are of equal size. Moreover, the parts of the concha which are to
be resected should be equal on both sides to ensure that the ears will be
symmetrical in shape and size after the operation.
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However, the ears are usually asymmetrical before the operation, and
this fact should be taken into accoun t during the surgical planning.
The head does not have to be shaved.
Fig. 6.23
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6 Otoplasty
Fig. 6.24
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Dressing
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The dressing plays an important role in achieving fine modeling of the
ear and ensuring recovery without complications. For this reason, a
gauze strip impregnated with antibiotic ointment is packed exactly into
the reshaped anatomical structures of the ear. No pressure of any kind
may be exerted on the ear here; the soaked pad must be pressed uniformly . The external ear canal should be protected by a small ear plug.
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In addition, the retroauricular incision area must be modeled to create
an abutment which will support the contours on the ventral side of the
auricle. The ear is then very gently squeezed with a moist compr ess and
modeled again.
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A notched ear compress is then put in place as cushioning and a second
compressisplacedlightlyontopofit.Thisdressingisheldinplace
with adhesive film to prevent it from slipping when the patient turns
his or her head.
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Finally , a zinc oxide head dressing is applied. This dressing does not
exert any corrective effect but serves merely as protection against infection,blows,pulls,andtears.
Postoperative Treatment and Precautions
The head dressing is left in place for 8 days. During this time the
patient takes antibiotics orally as protection against possible infection.
The procedure is generally carried out under local anesthesia on an
outpatient basis. As a result, the patient can be sent home after an
observation period of only a few hours.
If the patient experiences pain or throbbing in his or her ear, the physician should be notified immediately.
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After 8 days, the head dressing is taken off and the sutures are removed.
After the sutures are removed, the patient should still wear a head band
at night for 4 weeks and avoid possible trauma to the ear during the day .
The patient should shampoo his or her hair very carefully, taking care
not to bend the ear or otherwise tamper with the wound.
The patient should be careful about sports for about 3 months after the
operation.
Complete healing takes about 6 months.
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Results
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ab
6 Otoplasty
cd
Fig. 6.25
a, cBefore:A41-year-oldpatient,baldbypreference,withapronouncedotocleisis
b, d After: 12 months after otoplasty (anthelix plasty)
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6 Otoplasty
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ab
Fig. 6.26
a Before: A 7-year-old boy with protruding ears
b After: The same patient 12 months following anthelixplasty
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Tips and Tricks
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– Attachment of the ear to the mastoid bone will be achieved by
removalintotooftheconchalcartilage.
– As a result, the conchal pole can be rotated in a dorsal direction
free of tension; occasionally, resection of the posterior auricular
muscle is necessary.
– The skin on the dorsal side of the auricle should be completely
undermined, i.e., all of the tissue bridges are to be divided, so that
tension-free attachmen t of the ear is possible.
– The new formation of the anthelix is made significantly easier by
scarification of the anterior surface of the cartilage. It is important
here to continue the incision across the cartilage edge.
– In order to achieve tension-free adaption, optimal curvature of
the anthelix, and a correct concha-mastoid angle, additional cartilage sutures may be necessary with thick cartilage. However, each
cartilage suture carries a certain risk of infection; therefore, we
advise that these sutures are not used with thin, tension-free cartilage.
– Overcorrection, i.e., reduction of the angle between the auricle
and the skull to less than 15° , should be avoided under all circumstances.
– The ideal angle is between 20° and 30°. Therefore, it is important
that the upper pole of the ear is well attached and that no unaesthetic ‘telephone ear’ develops.
6 Otoplasty
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7BreastSurgery
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7.1 Breast Augmentation 265
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Introduction 265
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Breast Implants 267
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Anatomical Overview 269
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Instruments 270
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Duplicate Patient Information 276
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Preliminary Examinations 276
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Photographic Documentation 276
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Surgical Planning 277
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Incision Line in the Case of Inframammary Access 280
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Definition of the Subsequent Breast or ImplantSize
by Establis hin gthe Distance Between the LowerMargin
of the Nipple and the Subsequen t Inframammary Fold 281
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Positioning of the Patient, of the Surgical Area 282
7 Breast Surgery
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Tumescence 282
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Inframammary Incision 284
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7.1.1 Supramuscular Access 284
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Dissection, Step 1 284
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Dissection, Step 2: Precise Demonstration of the Caudal,
Medial, and Lateral Borders of Pectoralis Major 286
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Deep, Blunt Dissection 287
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Wound Revision and HemostasisUsing the Illuminated Retractor
and Bipolar Tweezers 288
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Determining the Size and Shape of the Implant 288
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Fitting the Final Implant 290
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Exact Positioning of the Implan t 292
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Insertion of the Redon Drain (Size 10) 292
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Deep Wound Closure 294
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Two-Layer, Atraumatic Wound Closure Using 4.0 Monocryl 294
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