Учебники / Rhinoplasty Dissection Manual Toriumi 1999

Figure 22. Subperiosteal dissection over bony nasal vault up to the nasion.

Figure 23. Cross section at level of nasal bones, illustrating dissection in subperiosteal plane. Lateral and medial motion of the elevator achieves this elevation in the subperiosteal plane.

Figure 24. After bilateral elevation , the midline decussating fibers remain undivided. These generally are severed with scissors .

6

Removal of

Bony-Cartilaginous Hump

In this exe rcise, the car tilaginous and bony hum p are removed en bloc. Be conservative! Plan to take a small amount of the hump off at first and thereby avoid incising the mu­ coperichondrium, which provide s important support. Later, after the bony-cartilaginous hump has been removed , be prepared to make multiple fine adj ustments of both the septum and dorsal margins of the upper lateral cartilages. When lowering the dorsal septum, keep in mind the imp ortance of allowing for the thicker skin over the lower one third of the nose. Also, recogniz e that inadequate resection at the supratip may result in a polly-beak defor­ mity. (Appe ndix G)

[Note: The dissector may wish to incise the skin/soft-tissue envelope down the midline either now or subsequent to this chapter. The hump excision may be done first, and then split the skin to exami ne the result and allow easy exposure for subsequent maneuvers. If the dissector intends to augment the dorsum with a cartilage graft, this may be done first, and then split the skin for easy exposure during the remaining dissection. The skin in the midlin e can be sutured back together as desired at any time.]

Expose the cartilaginous dorsum with a Conv erse retractor, and use a no. 15 blade to in­ cise lightl y any remaining soft tissue overlying the cartilaginous dorsum. Reflect this tis­ sue laterally on both sides. Next, beginn ing at the osseocartilaginous junction and pro­ ceeding caudally, incise the cartilag inous dorsum at the planned level of initial excision (Figs . 1 and 2). Try to keep this incision eve n on both sides, but remember that there will be additio nal "fine-tuning" modifications after initial hump excision.

Unde r dire ct vision, place an osteotome agai nst the bon y hump at the osseocartilaginous junction (Fig. 3). Use the incised but attac hed cartilagino us dorsum to help seat the os­ teotome at this locat ion. With a gentle, controlled two-tap technique, incise the bony hump with the osteotome (Fig. 4). Take care not to overresect the bon y hump , as the osteotome will tend to cut deepe r into the bone . Remove the hump with a hemo stat or similar instru­ ment , and examine its features (1,2).

When exec uting hump excision , preserve the underlying nasal mucoperichondrium. The nasal mucoperi chondr ium provides support to the upper lateral car tilages and help s de­ crea se the risk of inferomedi al collapse of the upper lateral cartilages after hump excision (Fig. 5). [Inferomedi al collapse of the upper lateral cart ilages and inadequate infracture of

59

Figure 3. Under direct VISion, insinuate an osteotome against the bony hump at the osseocartilaginous junction. Use the incised but attached cartilaginous dorsum to help seat the osteotome at this location.

Figure 4. A,S: With a gentle, controlled, two-tap technique , incise the bony hump w osteotome . Careful examination of the excised hump can help guide additional cali excision of remnant cartilage or bone. Assess whether the nasal mucoperichondriu successfully avoided . C,D: Patient underwent dorsal hump excision and application o graft. E.F: Conservative dorsal hump excision leaving high profile.