RU2454959C1 - Method of replacement of subtotal skin-mucous-cartilaginous defect of end part of nose and upper lip skin in case of partially preserved wings of nose - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to reconstructive regenerative surgery and can be applied in treatment of vast defects of nose and upper lip skin with partially preserved wings of nose. Essence of method lies in cutting out skin-fatty flaps in cheek area on edges of nose defect and closing wound surface if end part of nose with skin flap. First skin-mucous-cartilaginous defect of end part of nose and upper lip skin is formed. After that skin-fatty nasolabial flaps are cut out on both sides of defect 5-7 mm below nose cavity bottom. With base facing upper lip, and top, facing internal angle of eye, leaving 5 mm to the edge of lower eye-lid. After that, in area of nose wings near medial side of each skin-fatty nasolabial flap from their base to partially preserved nose wings made is a cut at angle 45-50°. Triangular flaps with bases, facing nose wings are formed. After that mobilisation of skin-fatty nasolabial flaps and triangular flaps is performed undercutting partially preserved nose wings. Bottom of nose cavity is formed by bringing each skin-fatty nasolabial flap under undercut partially preserved nose wings and their laying on wound surface of nose cavity. Medial sides of each nasolabial flap are fixed to remaining skin of upper lip. Lateral side of flap is fixed with sutures to mucous membrane in lower parts of remaining bone part of nasal septum. Nasolabial flaps are bent is projection of medium line upwards and sewn to each other. After that internal lining of nose arch and nose tip are formed, bending end parts of nasolabial flaps towards nose wings and fixing to them by means of sutures. After that, bridge flap is formed on dorsum of nose with U-shaped cut on glabella. After mobilisation it is displaced to newly created nose tip and sewn with medial edges of skin-fatty nasolabial flaps. Edges of donor wounds of skin-fatty nasolabial flaps are mobilised and sutured. Triangular flaps are sewn into lower parts of donor wounds. Donor wounds are sutured.

EFFECT: application of claimed invention makes it possible to simultaneously form and replace subtotal skin-mucous-cartilaginous end defect of part of nose and upper lip skin in case of partially preserved nose wings, restore bottom of nasal cavity and upper lip skin, eliminate necessity of creating additional donor wound, provide full feeding of nasolabial flaps.

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Description

The invention relates to medicine, namely to reconstructive reconstructive surgery, and can be used in patients with a fresh extensive defect in the nose and skin of the upper lip with partially preserved nose wings due to the malignant process, operations, radiation therapy, trauma and complications of specific infections.

The oldest and most common are methods for repairing a nose defect, based on the principle of the Indian method using tissues from the forehead. The second method is the Italian method, which is more perfect in cosmetic terms, when the skin is taken from the shoulder and transplanted to a nose defect. He is most painful for the patient. The third group of operations includes those based on the French rhinoplasty technique, when material for replacing a lost nose is taken from the cheek. The fourth group includes all methods of operations, where the nose is restored using the combined use of the above methods; this group includes the largest number of proposals for nose restoration. The fifth group includes all methods of operations to restore the nose as a whole from stalked flaps according to Filatov. It is possible to repair the skin defect of the upper lip, but the process is characterized by laboriousness, multi-stage and takes about a year.

A known method of rhinoplasty (Zoltan J. Skin transplant. - 1984, Publishing House of the Academy of Sciences of Hungary, S.156-157), which consists in mobilizing a skin flap on a leg from the forehead, moving it to the place of the defect of the external nose with fixation with sutures along the edges of the defect . The disadvantage of this method of rhinoplasty is the presence of the wound surface of the mobilized flap in the lumen of the formed cavity of the external nose, which does not provide the necessary cosmetic effect, the disease of the flap up to rejection is possible.

There is a method of rhinoplasty of a total defect of the nose with a skin graft from the forehead, closing of its wound surface and donor wound with free split skin grafts (Clinical operative maxillofacial surgery. 2nd ed. / Ed. By N.M. Aleksandrov. - L .: Medicine 1985, p. 297). The disadvantages of this method is the lack of an elastic nasal septum, which would ensure the formation of the tip of the nose and the medial edges of the nostrils. A flap cut from the skin of the forehead is used only to replace the skin of the nose. Thus, the formed duplicate of the skin surfaces of the nose, by way of a bent skin frontal flap and nose bridge skin, requires additional surgical intervention.

A known method of total rhinoplasty is that under general anesthesia, a skin flap is cut from the forehead, one horizontal skin incision is made at the level of the eyebrows to the width of the nose defect and two side vertical skin incisions are from horizontal down, not reaching the nose defect 3-4 mm, the flap is tipped down and hemmed to the freshened mucosa of the side walls of the nasal defect; they cut out a skin flap from the upper lip by means of two vertical blind cuts along the filter to the red border, connect them below with a horizontal cut; the flap is tipped up, folded in the form of a book, fixing the middle part with seams; to the nasal septum formed in this way, the inner skin flap from the bridge of the nose is hemmed, on which the frontal flap is laid and hemmed; the formed wings of the nose due to flaps from the bridge of the nose and forehead are stitched together (Pat. No. 2092118 of the Russian Federation. IPC АВВ 17/24. Method of total rhinoplasty. Svetitsky P.V. Publish. 10.10.1997). This method is used in the presence of an already formed defect in the nose, and the skin defect of the upper lip does not restore.

A known method of replacing a defect in the tip and wing of the nose while maintaining part of the wings of the nose - according to Helferich. Two flaps are cut out on the buccal surfaces. One skin flap has the shape of a rectangle and is formed so that its feeding leg is facing the edge of the nose defect. The second flap is a longer one, also quadrangular with a feeding leg facing the corner of the eye and the root of the nose, descending along the nasolabial fold below the wing of the nose. The first flap is overturned as a vault, and the entire defect of the nose is covered together with the remains of the wings and in this position it is hemmed to the freshened edge of the skin on the opposite side of the defect. The second flap, with the feeding leg at the root of the nose, covers the wound surface of the first flap and in this position both flaps are sutured. After 15-20 days, the flaps over the wings of the nose are dissected and turned away, covering them with a defect after cutting out the flap, and the wings of the nose are removed and hemmed (Proskuryakov SA, Restorative operations of the nose, throat, ear. - Novosibirsk, NOVOSIBGIZ, 1947. - S. 214). The disadvantage of this method is the inability to replace the bottom of the nasal cavity and the skin of the upper lip, multi-stage operation.

The disadvantage of this method is the inability to replace the bottom of the nasal cavity and the skin of the upper lip, multi-stage operation.

A known method of reconstruction of the cartilaginous skeleton of the wing of the nose according to Bayer (Proskuryakov SA Restorative operations of the nose, throat, ear. - Novosibirsk, NOVOSIBGIZ, 1947. - P.124). The method consists in the fact that for the simultaneous formation of two wings and the nasal septum, two cheek flaps are cut out along the nasolabial fold, which are overturned by the skin inside. If the septum is saved, then the ends of the flaps are sutured to it, and if the septum is lost, the flaps are cut a little longer, stitch them together, forming a nasal septum. The external wound surface of skin flaps placed as rafters or arches is covered with a free skin transplant according to Tirsch. This method can be used both with an old defect and with a fresh one. The disadvantage of this method is the inability to replace the bottom of the nasal cavity and skin of the upper lip and the formation of an additional donor wound in the area of taking a free skin flap. This method is selected for the prototype.

All of the above methods cannot be used in the presence of a defect in the nose and skin of the upper lip; additional surgical intervention is required to repair the upper lip skin defect.

The objective of the invention is to increase the efficiency of substitution of the subtotal skin-mucous-cartilage defect of the end part of the nose and upper lip skin defect with partially preserved nose wings, to obtain a good functional and cosmetic result, which will improve the quality of life of patients, their psychological and social rehabilitation.

The technical result consists in the simultaneous formation and replacement of a subtotal skin-mucous-cartilage end defect of the nose and skin of the upper lip with partially preserved nose wings, replacement of the bottom of the nasal cavity and skin of the upper lip, eliminating the need to create an additional donor wound, which does not require additional surgical correction of a defect in the nose and upper lip; and ensuring the proper nutrition of nasolabial flaps and the absence of cartilage make it possible, if necessary, to conduct radiation therapy in the postoperative period in radical doses with minimal post-radiation damage.

This is achieved due to the fact that, first, a skin-mucous-cartilaginous defect of the end portion of the nose and upper lip skin is formed, then skin-fatty nasolabial flaps are cut out on both sides of the defect 5-7 mm below the defect in the bottom of the nasal cavity with the base facing the upper lip, and apex facing the inner corner of the eye, not reaching the edge of the lower eyelid 5 mm; then, in the area of the nose wings at the medial side of each skin-fatty nasolabial flap from their bases to partially preserved nose wings, an incision is made at an angle of 45-50 °, forming triangular flaps with bases facing the wings of the nose; after which the skin-fatty nasolabial flaps and triangular flaps are mobilized with the partially preserved nose wings being cut; form the bottom of the nasal cavity, bringing each skin-fatty nasolabial flap under the partially preserved nasal wings and laying them on the wound surface of the bottom of the nasal cavity, fixing it to the remains of the skin of the upper lip; then they form a nasal septum, bending the nasolabial flaps in the projection of the midline up and stitching them together, after which they form the inner lining of the nasal vault and the tip of the nose, bending the end sections of the nasolabial flaps in the direction of the wings of the nose and fixing them with seams; after which a bridge-like flap is formed on the nasal dorsum with a U-shaped incision on glabella, which, after mobilization, is displaced to the newly created tip of the nose and sutured to the medial edges of the skin-fat nasolabial flaps; then they mobilize the edges of the donor wounds of the skin-fat nasolabial flaps, stitch them, and the triangular flaps are sutured into the lower sections of the donor wounds; donor wounds are sutured.

At the first stage, pathological tissues (tumor, destroyed non-viable tissues, etc.) are removed and a defect is formed, preserving part of the nose wings. Cut out skin-fatty nasolabial flaps, rather than buccal, as in the prototype, because they leave a smaller surface of the donor wounds, but are sufficient to restore the subtotal skin-mucocartilaginous defect of the terminal part of the nose with partially preserved wings of the nose and upper lip skin. Skin-fatty nasolabial flaps are cut out on both sides of the nose, leaving the nasolabial corner, which serves as a forming factor in the contour of the nose, untouched. The flaps are cut with the base facing the upper lip, because in this case, the flap is powered by a. angularis, which is necessarily included in the flap. The base (feeding leg) of the flaps is cut below the level of the bottom of the nasal cavity by 5-7 mm, due to the fact that when these flaps are moved to the defect of the bottom of the nasal cavity, the formed bottom of the nasal cavity is created just by the thickness of the flaps and does not cause deformation. The top of the flap is cut out, not reaching the edge of the lower eyelid of 5 mm, to ensure a sufficient length of the flap and to exclude further deformation of the lower eyelid. At the base of each nasolabial flap, at its medial side, triangular rags are cut with the base facing the partially preserved wings of the nose. These flaps are formed by horizontal incisions at an angle of 45-50 degrees, from the bases of the skin-fat flaps to the base of the wings of the nose. Triangular flaps serve to form the aesthetic wing of the nose when suturing donor wounds. After all the flaps are formed, partially preserved nose wings are cut. A mobilized nasolabial flap is brought under the partially saved nasal wings and placed on the defect of the bottom of the nasal cavity, creating the bottom of the nasal cavity. The medial sides of the nasolabial flap are fixed with sutures to the remains of the skin of the upper lip, thereby restoring the defect of the skin of the upper lip. The lateral side of the flap is fixed with sutures to the mucous membrane in the lower parts of the remaining bony part of the nasal septum and the distal parts of the nasal cavity, thereby forming the distal parts of the nasal cavity. The nasolabial flaps in the projection of the midline are bent upwards and in this position they are fixed with sutures in the upper sections to the remaining septum of the nose, two nasolabial flaps are sewn together on both sides along the midline of the seams, forming a nasal septum. Each of the nasolabial flaps is bent in the direction of the remnants of the wings of the nose and fixed with sutures, creating a nasal arch, tip of the nose and nasal cavity. A bridge-shaped flap in the glabella region is cut out for the final formation of the tip of the nose, covering the wound surface of the tip of the nose. Triangular flaps are sutured into the lower sections of the donor wounds, while nasolabial corners are formed, forming the aesthetic contour of the tip of the nose.

The invention is illustrated by the following figures:

figure 1 - localization and prevalence of damage (front view)

figure 2 - localization and prevalence of lesions (side view)

figure 3 - cutting flaps

figure 4 - diagram of the formation of the bottom of the nasal cavity, the distal septum of the nose and part of the upper lip

figure 5 - the formation of the wing of the nose

6 - mobilization of a bridge-like flap on the back of the nose

7 - formed the bottom of the nasal cavity, collumela, arch, wings of the nose and upper lip

Fig. 8 is a diagram of postoperative sutures.

1 - subtotal skin-mucous-cartilaginous defect of the terminal part of the nose and upper lip skin with partially preserved nose wings

2 - skin-fatty nasolabial flap

3 - triangular flap

4 - bridge flap

5 - partially preserved nose wing

6 - the bottom of the nasal cavity

7 - nasal arch

8 - collumela

The method is as follows.

Under general anesthesia, defect 1 is formed (removal of the tumor, excision of pathologically changed tissues, etc.) (Figs. 1, 2), skin-fatty nasolabial flaps 2 are cut out on both sides of the nose with the base facing the upper lip at 5- 7 mm below the defect in the bottom of the nasal cavity and the apex facing the inner corner of the eye, not reaching the edge of the lower eyelid 5 mm; then, in the region of the nose wings at the medial side of each skin-fat flap from the base to partially preserved wings of the nose 5, an incision is made at an angle of 45-50 °, forming triangular flaps 3 with the base facing the wing of the nose 5 (Fig. 3), after which they mobilize skin-fatty nasolabial flaps 2 and triangular flaps 3 with the cutting of partially preserved nose wings 5; wherein each skin-fatty nasolabial flap 2 is brought under the partially preserved nasal wings 5 and placed on the defect of the bottom of the nasal cavity, forming a new bottom 7, fixing to the remnants of the skin of the upper lip (figure 4), then the flaps 2 are bent in the projection of the midline up, and their end sections are bent in the direction of the wings of the nose 5 and are fixed with seams; after which the medial sides of the skin-fat nasolabial flaps 2 are sutured along the midline, forming the nasal septum 8 (Fig. 5); then a U-shaped incision on glabella forms a bridge-like flap 4 on the back of the nose (Fig.6), which, after mobilization, is displaced to the newly created tip of the nose and stitched with the medial edges of the skin-fat nasolabial flaps 2; then they mobilize the edges of the donor wounds of the skin-fat nasolabial flaps 2, suture them, and the triangular flaps 3 are sewn into the lower sections of the donor wounds (Fig. 7), forming the bottom of the nasal cavity, collumela, arch, nose wings and upper lip. Donor wounds are sutured. On Fig presents a diagram of postoperative sutures.

Clinical example.

Patient K., 44 years old, medical history No. 2010/16283, turned to the clinic of the Russian Oncology Center. NN Blokhina RAMS with complaints of the presence of a tumor in the area of the vestibule of the nose, pain. According to the patient, he considers himself ill for about 1.5 years, since the appearance of the neoplasm in anticipation of the nasal cavity on the left. It was observed and treated by a dermatovenerologist, without effect. In February 2010, he turned to the oncology dispensary at the place of residence, where a tumor biopsy was taken, and squamous cell cancer was verified. In March 2010, cryodestruction of the tumor was performed, after 1.5 months continued tumor growth. The patient turned to the Russian Oncology Center. The patient was hospitalized for surgical treatment. When viewed in the area of the vestibule of the nasal cavity, an exophytic tumor with ulceration is determined, spreading to the anterior sections of the nasal septum, the tip of the nose and upper lip. Nasal breathing is not difficult. In the submandibular areas, hyperplastic lymph nodes are determined. The operation was performed according to the proposed method:

a defect was formed under general anesthesia (an exophytic tumor was removed), two skin-fat nasolabial flaps 2 were cut out 7 mm below the defect in the bottom of the nasal cavity on both sides of the nose with a size of 3.5 × 6 cm with the base facing the upper lip and the apex facing to the inner corner of the eye, not reaching the edge of the lower eyelid 5 mm; then, in the area of the nose wings at the medial side of each skin-fat flap from its base to partially preserved nose wings at an angle of 45 °, an incision was made, forming triangular flaps with the base facing the wing of the nose, after which they mobilized skin-fat nasolabial flaps and triangular flaps with incision of partially preserved nose wings; at the same time, each skin-fatty nasolabial flap was brought under the partially preserved nasal wings, laid on the defect of the bottom of the nasal cavity and fixed to the remains of the skin of the upper lip, thus forming a new bottom; then the flaps were bent upward in the projection of the midline, and their end sections were bent in the direction of the wings of the nose and fixed with sutures; after which the medial sides of the skin-fatty nasolabial flaps were sewn along the midline, forming a septum of the nose; after which a bridge-like flap was formed on the nasal dorsum with a U-shaped incision on glabella, which, after mobilization, was displaced to the newly created tip of the nose and stitched with the medial edges of the skin-fat nasolabial flaps; Then they mobilized the edges of the donor wounds of the skin-fat nasolabial flaps, stitched them, and triangular rags were sewn into the lower sections of the donor wounds, forming the bottom of the nasal cavity, collumela, arch, nose wings and upper lip. Donor wounds are gone.

The duration of the operation is 1 h 20 min. The postoperative period usually proceeded. The histological conclusion of the postoperative material - the tumor node has the structure of squamous cell carcinoma growing into cartilage. A fragment of the mucous membrane with the underlying cartilaginous plate, without reliable signs of tumor growth. The postoperative period was uneventful.

Observation of the operated patient for 6 months showed a lack of relapse and functional disorders of the nose.

Claims (1)

A method for replacing a subtotal skin-mucous-cartilaginous defect of the end section of the nose and upper lip skin with partially preserved nose wings, including cutting out skin-fat flaps in the buccal region along the edges of the nose defect and closing the wound surface of the end section of the nose with a skin flap, characterized in that at first form a mucocutaneous-skin-cartilage defect in the terminal part of the nose and upper lip skin, then cut out skin-fatty nasolabial flaps on both sides of the defect 5-7 mm below the defect in the bottom of the nasal cavity with the base facing the upper lip and the apex facing the inner corner of the eye, not reaching the edge of the lower eyelid 5 mm; then, in the area of the nose wings at the medial side of each skin-fatty nasolabial flap from their bases to partially preserved nose wings, an incision is made at an angle of 45-50 °, forming triangular flaps with bases facing the wings of the nose; after which the skin-fatty nasolabial flaps and triangular flaps are mobilized with the partially preserved nose wings being cut; form the bottom of the nasal cavity, bringing each skin-fatty nasolabial flap under the partially preserved nasal wings and laying them on the wound surface of the bottom of the nasal cavity, while fixing the medial sides of each nasolabial flap to the remains of the upper lip skin, and the lateral side of the flap is fixed with sutures to the mucosa the sheath in the lower parts of the remaining bony part of the nasal septum, bending the nasolabial flaps in the projection of the midline up and stitching them together, after which they form the inner lining of the nasal vault and the tip of the nose, bending the end sections of the nasolabial flaps in the direction of the wings of the nose and fixing them with sutures; after which a bridge-like flap is formed on the nasal dorsum with a U-shaped incision on glabella, which, after mobilization, is displaced to the newly created tip of the nose and sutured to the medial edges of the skin-fat nasolabial flaps; then they mobilize the edges of the donor wounds of the skin-fat nasolabial flaps, stitch them, and the triangular flaps are sutured into the lower sections of the donor wounds; donor wounds are sutured.

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