Учебники / Rhinoplasty Dissection Manual Toriumi 1999

13

Incision Closure, Nasal

Splint, Postoperative

Considerations

CLOSURE OF THE MIDCOLUMELLAR INCISION

A single, subcutaneous 6-0 polydioxanone suture (PDS) can be positioned in the dermal tissues to enhance skin-edge eversion and take tension off of the closure (Fig. I). This su­ ture should provide skin-edge alignment and slight eversion . Excessive eversion will cre­ ate a deformity that may require many months to resolve. The level of the skin edges must be preci sely aligned with this suture; otherwise, an unsightly scar may result. If there is no tension on the closure, a subcutaneous suture may not be necessary.

To close the skin, five 7-0 nylon vertical mattres s sutures are used . The first suture lines up the apex of the inverted V. The next two sutures are angled from medial on the lower flap to lateral on the upper flap to align the closure properly . A 6-0 chromic suture is used to line up the vestibular skin at the corner of the columellar flap. This corner suture is im­ portant because aberrant healing of this corner can result in a visible notch defect.

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Figure 2. Closure of endonasal incisions.

CLOSURE OF THE MARGINAL, INTERCARTILAGINOUS, OR TRANSCARTILAGINOUS INCISION

This incision is closed with one or two 5-0 chromi c sutures located laterally that ac advance the lateral crura slightly toward the domes (Fig. 2) This suture advancement negate the need for an additional suture placed in the region of the domes. All sutures u to close the marginal incision must be examined to make sure there is no distortion of nostril rim or domal region. If the nostril rim is notched, then the suture should be replac taking a smaller bite.

PLACEMENT OF INTRANASAL PACKS, NASAL SPLINT

Intranasal Pack

When extensive septoplasty is undertaken, or when partial turbinectomy or turbinopla is performed, the surgeon may wish to place a temporary intranasal pack. The goal is to p vide some compression of the septal flaps and , in the case of turbin ate surgery, to decre the risk of postoperative bleeding. There are a number of commercially available packs. intran asal pack is typically left in place at most overnight and removed the next mornin

External Splint

A great variety of splints are commercially available. In general, after placement o appropriate adhesive, a small rectangular strip of Telfa is placed over the nasal dorsum facilitate removal of the splint in 5 to 7 days. Tape is applied over the dorsum and the n tip. A splint is carefully applied.

POSTOPERATIVE CARE

The sutures should be removed from the columellar inci sion after 5 days. At that po the incision may be supported with flesh-colored steri-strips for several week s to act as titension taping. Persistent postoperative supratip edema can be treated with subdermal

Appendix

Guide to Nasal Analys

NASAL ANALYSIS

General

Skin quality: Thin, medium, or thick

Primary descript or (i.e., why is the patient here): For example , "big," "twisted," " hump "

Frontal View

Twisted or straight: Follow brow-tip aesthetic lines

Width: Narrow, wide, normal , "wide-narrow- wide"

Tip: Deviated, bulbous, asymm etri c, amorphous, other

Base View

Triangularity: Good versu s trapezoid al

Tip : Deviated , wide, bulb ous, bifid , asymmetric

Base : Wid e, narrow, or norm al. Inspe ct for caudal septal deflecti on

Columella : Columellarllobule ratio (normal is 2: 1 ratio ); status of medial crural footpl

Lateral View

Nasofrontal angle: Shallow or dee p Nasal starting point: High or low

Dorsum: Straight, concavity, or conv exity; bony, bon y-cartilagin ous, or cartilaginous is conv exity prim arily bony, cartilaginous, or both)

Nasal length: Norm al, short, long

Tip projection: Norm al, decreased , or incre ased Alar-columellar relationship: Normal or abnormal Nas a-labial angle: Obtu se or acute

Oblique View

Does it add anything, or doe s it confirm the other views?

Many other points of analysis can be made on each view, but these are some of the points of commentary.