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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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Fig. 3.3
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Fig. 3.4
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Duplicate Patient Instruction
During the patient’s first consultation at the clinic before admission, he
or she is already given comprehensive instructions on the objectives
and risks of the contemplated procedure. A written record is kept of
this instruction.
One day before the actual proced ure, the patient is again given full
information on two separate occasions: once by the surgeon and once
by the surgical resident. All potential risks of the procedure are set
down in writing at this time.
Nasal Examination
The following examinations should be performed before any rhinoplasty procedure performed for either functional or aesthetic reasons:
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History of the nasal mucosa and skin
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Rhinoscopic examination of the anterior and posterior nasal regions
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Endoscopic examination of the nasal and nasopharyngeal passages
with the 0° and 30° optical system
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Rhinomanometry with and without detumescence
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X-ray of the nose in two planes (occipitomental and lateral)
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Allergy tests (if not performed previously)
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Odor and taste perception tests
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Tube ventilation test
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Examination of the external nose in three planes, e.g., measurement of
the nasofacial and nasolabial angle and other tests in the area of facial
morphometry
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Photographic Documentation
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Overview image: Whole head with neck
Borders: Cranial: crown
Caudal: jugulum
Bilateral: edge of the helix
Detailed images:
Borders: Cranial: middle of the forehead
Caudal: middle of the chin
Bilateral: ear attachment
– From the front
– ¾ Lateral (lateral canthus as the border)
– 90° Lateral (tip of the nose to the edge of the helix)
– From a distal direction with maximum elevation of the head (tip of
thenoseattheheightoftheeyebrows)
Surgical Planning
The procedure is usually performed under endotracheal anesthesia. On
the day before the operation, the surgeon holds a lengthy discussion
with the patient in which the changes desired by the patient, and the
methods the surgeon will use to accomplish these changes, are discussed in detail.
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Another question to be clarified at this time is whether the patient is to
undergo a purely aesthetic rhinoplasty or functional surgery to remove
obstructions in the nasal air passages.
At this time, the patients are warned not to have unrealistic expectations and are given detailed instructions on the precaution s to be taken
after surgery.
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Fig. 3.5
Ideal dimensions and angles that should be incorporated into the planning of a rhinoplasty procedure:
1. Nasolabial angle: 100°–110° (women)
95° –100° (men)
2. Mang’s angle: 110° –120° (formed by the intersection of the nasal
root-to-tip and nasal tip-to-chin lines)
3. Glabellar angle: 35°
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Fig. 3.6
The facial proportions are an important factor to be considered during
planning of the septorhinoplasty. The nose should not be too large or
dominant; neither should it be too small or doll-like. The art of aesthetic
surgery lies in the creation of natural pro portions. To achieve this goal,
it is useful to divide the face into zones; for this purpose there are three
horizontal zones and five vertical zones.
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Tumescence Injection Technique
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Following disinfection of the external nose and the nasal vestibule,
10–20 ml of a solution consisting of a 1:1 mixture of 0.5% Scandicaine
with epinephrine (mepivacaine hydrochloride) 1: 200,000 and 0.9%
saline is infiltrated as follows: first, the membranous part of the septum
of the nose is infiltrated; this detaches the mucosa from the anterior
edge of the cartilaginous septum in a fan-shaped pattern starting at the
anterior nasal spine. From this location, the floor of the nasal vestibule
is infiltrated up to the alar cartilage. (Fig. 3.7)
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The surgeon now inserts a needle between the lateral crus and the
lateral nasal cartilage in order to detach the skin above the bony and
cartilaginous structures of the nose as far as the frontonasal suture.
This procedure is carried out from both sides. Finally, fluid is placed in
front of the anterior nasal aperture on both sides. The above procedure
provides anesthesia and also facilitates the subsequent dissection.
(Fig. 3.8)
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Fig. 3.7
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Fig. 3.8
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Sterile swabs saturated with naphazoline nitrate are now inserted to
reduce the swelling of the nasal mucosa. (Fig. 3.9)
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Disinfection
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The entire facial skin and the nasal vestibule are now disinfected with a
1% cetrimide solution.
Suction and Surgical Planning
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After about 10 min, the swabs are removed with the bayonet forceps.
Thesurgicalsiteissuctioned,andtheindividualstepstobecarriedout
during the operation are planned.
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All of the hairs in the nasal vestibule are now removed with a Chadwick
scissors. This step prevents infection and gives the surgical team a good
view of the nasal vestibule area.
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For this purpose, the nasal wing is pulled upwards with the flat twopronged hook held in the left hand; simultaneously the middle finger
presses the alar cartilage downward. The internal surfaces of the nasal
wing are now under tension and the hairs can be removed without
injuring the mucosa.
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Subsequently, the mucosa are cleaned again with a moist swab.
(Fig. 3.10)
Fig. 3.9
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Fig. 3.10
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