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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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Incision Line
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The columella clamp is placed exactly at the level where the incision
line will be later on; it is then fixed in place with the screw mechanism.
The clamp is held in the left hand slightly under tension and positioned
vertically toward the front.
䊏
Holding the number 15 scalpel in his or her right hand, the surgeon
simultaneously makes the transfixation incision. This incision starts at
the anterior nasal spine and proceeds upwards along the anterior edge
of the columella clamp. This major incision ends at the anterior margin
of the top edge of the septum.
(Fig. 3.11)
䊏
The columella clamp is now removed. Using his or her left hand, the
surgeon places the flat two-pronged hook on the margin of the nasal
wing and pulls it cranially. During this step the extended middle finger
of the surgeon’s left hand luxates the nasal wing in the direction of the
orifice of the nasal vestibule. In this position, the transfixation incision
can be extended laterally with little effort and extended to form an
intracartilaginous incision.
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The alar cartilage is separated by dissection without injuring the overlying nasal skin.
䊏
The same procedure is carried out on the contralateral side.
The figure shows several variants of the incision line (i.e., vestibular
border incision, intracartilaginous incision, inter cartilaginous incision).
The greater the extent of nose shortening desired, the farther to the
front the transfixation and intracartilaginous incisions should be
placed.
(Fig. 3.12)
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Fig. 3.11
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Fig. 3.12
1
3
2
1 Vestibular border incision
2 Intracartilaginous incision
3 Intercartilaginous incision
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D´ecollement
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The next step is the mobilization of the incisions and the detachment of
theskinonthedorsumofthenosefromthecartilageandbonesupto
the frontonasal suture. The surgeon’s left hand is placed on the dorsum
of the nose; the thumb and index finger serve as guide rails as the surgeon, holding the Wullstein scissors in his or her right hand, detaches
the skin with gentle, spreading movements. During this procedure, the
tip of the scissors always has contact to the underlying cartilage or
bone. The limits of this dissection should be about 1.5 cm from the
medial canthus.
䊏
The detachment of the skin from the dorsum of the nose is carried out
from both the right and left intracartilaginous incisions. Care must be
taken to detach and remove all adhesions. In this manner complete
mobilization of the skin on the dorsum of the nose can be achieved up
to the glabella.
(Fig. 3.13)
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Subsequently, the periosteum of the nasal bone is pushed off with a
sharpraspatory,bentonitsblunttip.Hereagain,thethumbandindex
finger of the surgeon’s left hand serve as guide rails. At this location as
well, the limits of the detachment work should be 1.5 cm from the
medial canthus.
(Fig. 3.14)
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Fig. 3.13
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Fig. 3.14
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Correction of the Nasal Tip with the Eversion Method (Fig. 3.15–3.18)
This is the least traumatic method and is sufficient for achieving good
aesthetic results in most cases. In cases where the primary complaint is
anasalhumpor“longnose,”luxationofthealarcartilageorevenopen
rhinoplasty is rarely the procedure of choice.
䊏
Using his or her right hand, the assisting surgeon places the flat short
two-pronged hook in the free margin of the right nasal wing and pulls
it cranially. At the same time, he or she pulls the dorsal margin of the
alar cartilage toward the front with the long single-pronged hook held
in his or her left hand.
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Holding the Adson-Brown tweezers in his or her left hand, the surgeon
now grasps the loose margin of the alar cartilage and dissects the over lying mucosa with the sharp-pointed bent nasal scissors. Great care
should be exercised here to leave the overlying skin and mucosa intact
to prevent later contraction and stenosis. If the mucosa is kept intact,
the posterior portion of the alar cartilage can be removed up to its
attachment to the septal cartilage.
If these precautions are followed, the patient will not experience any
breathing difficulty or valvular stenosis postoperatively.
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Fig. 3.15
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Fig. 3.16
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䊏
This is followed by the dissection of the anterior portion of the alar cartilage. For this purpose, the surgeon again uses the middle finger of his
or her left hand to luxate the right nasal wing and detaches the skin on
the roof of the nasal vestibule from the alar cartilage with the small
bent nasal scissors. Using cautious spreading movements, the surgeon
totally mobilizes the anterior portion of the alar cartilage without damaging the mucosa.
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Theassistingsurgeoncannowplacethelongsingle-prongedhookin
the part of the alar cartilage that has been separated by dissection and
pull it toward the front. The surgeon now detaches it with the bent
nasal scissors. A narrow anterior band of cartilage about 3–4 mm in
width remains in place. This resection causes a narrowing of the nasal
wing and an elevation and shortening of the nasal tip. By means of the
technique described above, the entire tip is rotated upwards.
䊏
This procedur e is now repeated – in mirror-image fashion – on the
contralateral side. Care should be taken here that the parts of the alar
cartilage which are resected are identical in size on both sides in order
to achieve homogeneous results on the nasal tip.
Novicesareadvisedtoinitiallytakeaconservativeapproachtocartilage removal. Radical resection should be attempted only by experienced surgeons.
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Stenosis can be prevented only if the mucosa remains intact.
The band of cartilage left in place should be approx. 3–4 cm in width.
䊏
The short flat two-pronged hook is now inserted again in the free alar
margin; the wing is then luxated to the front with the middle finger.
The surgeon now has a good view of the surgical area and can remove
pieces of connective tissue and excess mucosa from the dome of the
nose with the Chadwick scissors. This should be carried out with
extreme caution, taking care not to injure the overlying skin. The extent
of thinning to be undertaken here depends on the thickness of the skin
on the dorsum of the nose.
Fig. 3.17
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Fig. 3.18
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Nasal Shortening (Fig. 3.19, 3.20)
䊏
Using his or her right hand, the assisting surgeon places the flat
two-pronged hook on the free margin of the nasal wing and pulls it
upwards. Holding the long two-pronged hook in his or her left hand,
the assisting surgeon pulls the columella toward the front.
䊏
Thesurgeonnowhasagoodviewoftheanterioredgeoftheseptalcartilage; using the number 15 scalpel, he or she dissects the mucosa from
the anterior edge of the septum, starting with the anterior nasal spine
and contin uing up to the nasal dome.
䊏
Subsequently, a correspondingly large segment of the anterior edge of
the septal cartilage is resected from the nasal spine to the dome with
the same scalpel. The size of this cartilage strip is naturally based on
the desired degree of nasal shortening.
䊏
This is followed by careful resection of the detached – and now excess –
mucosa. Care should be exercised here not to shorten the nose too radically in order to prevent distortions in the area around the tip of the
nose.
䊏
The usual procedure here is to remove mirror-image mucosal strips
having a width of about 2–3 mm each from the anterior and posterior
margins of the transfixation incision, respectively, with the number 15
scalpel.
The surgeons have now succeeded in shortening and narrowing the
nose and in rotating the tip region.
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A relatively large excess mucosal flap is now visible in both nasal wing
regions. Later on, this flap will be resected in the form of a Mang triangle.
䊏
If septoplasty is necessary, it should be performed at this point. The
surgeonshouldbecarefulnottomobilizetheupperonethirdofthe
septum as this could cause difficulties during the planned ablation of
the nasal hump.
Fig. 3.19
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Fig. 3.20
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