Учебники / Rhinoplasty Dissection Manual Toriumi 1999

The perpendicular plate of the ethmoid bone and/or the vomer may be used as a splint­ ing graft in the treatment of a deviated cartilaginous septum. Ethmoid bone may be har­ vested via a standard septoplasty approach.

HARVESTING RIB GRAFT

Cartilage is typically harve sted (Fig. 2) from the eighth and ninth ribs or the confluence. If additional cartilage is required, the tenth rib also may be harvested. Bone may be har­ vested with the ninth rib if desired .

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Figure 1, continued. Suture of the circumferential incision is shown here with a 6-0 nylon running vertical mattress suture (M-P). Alternatively, one may close the incision with in­ terrupted mattress sutures . Place a bolster dressing of Telfa, dental roll, or other suitable material into the concha and suture it into position (0-T) to decrease the risk of hematoma.

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A 4-cm to 6-cm incision overlying the eighth rib allows adequate exposure. Diss proceeds to and then through the rib perichondrium . The muscle fibers can be separat stead of cut to minimize postoperative pain. Dissection around the rib is undertake perichondrially; the pleura is typically closely adherent to the perichondrium. Wi graft completely separated from surrounding soft tissue , the graft is incised and deli under direct vision . The surgeon may elect to place a malleable retractor beneath the it is incised. Saline is placed in the surgical site and Valsalva or positive pressure a to check for a pleural leak . If a pleural tear is identified, a pursestring suture closure dertaken around a red-rubber suction catheter. The surgeon then requests a "Val salva " the anesthesiologist. The red rubber is then removed and the suture tightened. Salin be placed in the wound and another Valsalva undertaken while the surgeon careful spects for air bubbles . A standard, layered soft-ti ssue closure without a drain is ac plished. Skin edge eversion can be accomplished with everting subcutaneous sutures

A chest radiograph is obtained in all patients after rib harvest. In the rare instanc difficulty, the surgeon may wish to consult the appropriate surgical colleague.

HARVESTING CALVARIAL BONE

Parietal bone may be harvested (Fig. 3) through a horizontal incision (typically , 4 6 em) superior to the temporal line . Typically the nondominant side is chosen. Incis and through the perio steum, followed by subperiosteal undermining, provides prop posure. A drill is used to outline the proposed graft (typical graft size, 1 em to 1.5 em em to 4.5 em) . A trough is drilled through the outer table to the diploe; this allow proper angle for application of a chisel or powered oscillating saw to harvest the grafts fully. Short controlled taps on a sharp osteotome allow increased precision and hel crease the risk of inner-table penetration and dural tear.

Patients must be cautioned preoperatively of the risk of possible dural tear and po brain injury. Any dural entry should elicit an immediate neurosurgical con sultation .

The donor site can be contoured with hydroxyapatite cement or any other biocomp bone substitute material. The incision is typically closed in a multilayer fashion .

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