RU2565105C1 - Method for solving functional problems in patients suffered rhinoplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: graft is placed in a tunnel created by incising a dorsal portion of a septal cartilage, in a position across a dorsum of nose. A method provides a minimally invasive and less traumatic enlargement of an angle of an internal valve of nose, normalises nasal breathing in a combination with nasal septum correction by placing an autologous cartilage under triangular cartilages.

EFFECT: improving the nasal breathing by the endonasal placement of the transverse enlargement autograft taken during a septoplasty.

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Description

The invention relates to medicine, in particular to otolaryngology of plastic surgery.

About 1 million rhinoplasties are performed annually in the world and there is a steady tendency to increase their number (ISAPS statistics 2012). Accordingly, the number of repeated, revision interventions is growing, since rhinoplasty is one of the most complex and not always predictable in relation to the result of surgical procedures. The cause of revisions can be not only aesthetic deformations (secondary or residual), but also functional complications. The average frequency of revision rhinoplastics according to the literature is from 5 to 25%. According to aesthetic indications, revisions are performed in 5-15% of cases. Moreover, the risk of complications after rhinoplasty does not always decrease with an increase in the experience of the surgeon [Walter K. Complications of rhinoplasty // Ross. Rinol. - 1995. - No. 2. - S. 4-16].

A huge number of works on aesthetic complications of rhinoplasty, methods for their elimination and prevention have been published. However, the reasons leading to the violation of the basic functions of the nose after rhinoplasty performed according to aesthetic indications have not been studied in detail, the literature on this is contradictory.

It is known that postoperative respiratory failure in 70% of cases is a consequence of reduction rhinoplasty. E.N. Courtiss et al. Examined the physiology of the nose and found that until the external or internal valves of the nose were damaged during the operation or perforation occurred during the simultaneous operation on the nasal septum, aesthetic rhinoplasty does not affect nasal breathing. The approach of the bones of the nasal pyramid is performed cranial to the internal nasal valve, and therefore this technique supposedly does not adversely affect nasal breathing. B. Guyuron, on the contrary, believes that deep osteotomies can clinically significantly narrow the pear-shaped aperture.

According to G.J. Beekhuis 10% of patients after primary rhinoplasty complain of residual and new problems with nasal breathing. Other authors believe that in 70% of cases of revision rhinoplasty, nasal obstruction is caused by permanent deformation of the nasal septum with stenosis in the area of the nasal valve. Nasal valve dysfunctions are associated with the separation of the superior lateral cartilage from the nasal septum, which can be diagnosed by acoustic rhinomanometry [Sheen J.H. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty // Plastic and reconstructive surgery. - 1984. - Vol. 73. - R. 230].

Thus, even with regard to the most significant and widespread postrinoplastic problem - nasal obstruction - there is no consensus in the surgical community. Possible causes and risk factors are not clearly defined, methods of prevention and elimination of violations are not formulated.

A known method for the surgical treatment of nasal obstruction due to anatomical abnormalities of the vestibule of the nose (RF patent No. 2282406, IPC A61B 17/00, published August 27, 2006). The essence of the method consists in narrowing the columella by applying mattress sutures. At the same time, the medial leg of the lower lateral cartilage is displaced in the midline direction, then the distance between the medial and lateral legs of the lower lateral cartilage is measured, when determining the subjective improvement in breathing with displacement and the distance between the legs of the lower lateral cartilage is less than 3 mm in men and 2.5 mm in women, dysfunction is revealed external nasal valve, after which the medial leg protrusions protruding into the lumen of the vestibule are resected.

The disadvantage of this method is the fact that the area of the external nasal valve is expanding, and the area of the internal nasal valve, which suffers most after rhinoplasty, remains intact.

The literature describes methods to expand the area of the internal nasal valve by installing expanding grafts (RTs). The PT setup was first described by J.H. Sheen in 1984 and was originally intended to support the cartilaginous fornix with too short nasal bones. The author began to use this technique to remove the bone-cartilage hump of the nose to prevent the creeping of triangular cartilages (Sheen JH Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty // Plastic and reconstructive surgery. - 1984. - Vol. 73. - P. 230), as well as for the prevention of narrowing of the nasal valve region. And the endonasal installation of expansion grafts was first proposed by Andre RF (Andre RF, Paun SF, Vuyk HD Endonasal spreader graft plasment as tratment for internal nasal valve insufficiency: no need to divide the upper lateral cartilages from the septum // Archives of facial plastic surgery. - 2004. - Vol. 6, N. 1. - P. 36-40). The essence of the method lies in the fact that a strip 1 mm wide fills the corner of the inner nasal valve, while the triangular cartilage does not rise and the valve does not expand enough.

The disadvantage of this method is the insufficient expansion of the region of the inner valve of the nose, since transplants with a width of 1 mm and a length of 4 mm, installed in the region of the inner nasal valve according to the Andre method, based, in particular, from our experience, cannot widen the angle of the inner nasal valve sufficiently.

The prototype of our method was the method of expanding the region of the inner valve of the nose proposed by Guyuron B., (Guyuron B., Michelow BJ, Englebardt C. Upper lateral splay graft // Plastic and reconstructive surgery. - 1998. - Vol. 102. - P. 2169 -2177). The essence of this method lies in the fact that the authors expand the area of the inner nasal valve by installing a graft (most often the ear cartilage is used as a graft) between the triangular cartilage and septum cartilage with open rhinoplasty access.

The disadvantages of this method are traumatic open access and the use of the ear auto-cartilage, which due to its softness does not sufficiently raise the angle of the valve.

The objective of the invention is a method of eliminating functional problems in patients after rhinoplasty, which allows to reduce trauma and increase the stability of the expansion of the angle of the inner nasal valve.

The problem is solved by a method of eliminating functional problems in patients after rhinoplasty, including endonasal installation in the area of the inner valve of the nose of the autocartilage taken during septoplasty, characterized in that through the transfection incision in front of the nose on both sides, the mucous membrane of the nasal septum is separated from two sides sides, combine the right and left tunnels by cutting the dorsal part of the septal cartilage, set the auto-cartilage in the formed tunnel along triangular cartilage in a position transverse bridge of the nose. The incision area is sutured with Vicryl 5.0.

In practice, the method is as follows. The initial stages of the operation correspond to the traditional Sheen RT installation technique. Intervention begins with the correction of the nasal septum (PN) and the collection of auto-cartilage fragments. Preliminary septoplasty is performed using a standard endonasal approach. The technique for correction of the septum depends on the features of the deformation and the safety of the septum skeleton. Typically, the PN skeleton is exposed perichondrally from a vertical section parallel to the caudal edge of the quadrangular cartilage, which provides access to all parts of the septum, including the anterior nasal spine, premaxilla, and also to the back and tip of the nose. The mobilization stage is carried out by means of horizontal and vertical chondrotomy and excision of cartilage fragments along fracture lines. The dimensions of the strip of quadrangular cartilage are selected individually, depending on the initial dimensions of the inner nasal valve. In septoplasty, the connection between the posterior superior margin of the quadrangular cartilage and the perpendicular plate of the ethmoid bone, as well as between the anterior inferior margin of the cartilage and the anterior nasal spine, is maintained. Only with the deformation of the caudal section of the cartilage, their base is dissected from the premaxilla osseous sulcus and create the so-called revolving door. Mobilization of the bony part of the septum is carried out after breaking with forceps, then bone spikes and ridges are removed.

Then, through the transfection incision on the threshold of the nose and the nose on both sides, the mucous membrane of the nasal septum is separated from both sides, the right and left tunnels are combined by cutting the dorsal part of the septum cartilage, the auto-cartilage is inserted into the formed tunnel in the region of the nasal valve, under the triangular cartilage in the transverse position the back of the nose. The edges of the cut adapt and stitch. The operation ends with anterior nasal tamponade, applying a “tiled” patch bandage to the nose.

Clinical observation. Patient A., 29 years old, after rhinoplasty 2 years ago, there was a pronounced worsening of nasal breathing. On examination, a pronounced narrowing of the inner nasal valve. Kottle's test is positive from two parties. The septum of the nose is curved in the middle section. The patient was satisfied with the shape of the nose. Violation of nasal breathing and narrowing of the nasal valve region is confirmed by objective research methods - front active rhinomanometry and acoustic rhinometry (PARM and AR). The patient underwent revision rhinoseptoplasty with surgical correction of the nasal valve. Through endonasal access (a vertical incision along the caudal edge of the nasal septum), the first stage was performed septoplasty with the separation of mucoperichondria and mucoperioste, chondrotomy and removal of the curved sections of the bone and cartilage skeleton and the fence strips of septum cartilage for use as a transverse expanding transplant. Then, through the transfection incision on the threshold of the nose and the nose on both sides, the mucous membrane of the nasal septum was separated on both sides, then the right and left tunnels were combined by cutting the dorsal part of the septum cartilage, the auto-cartilage was inserted into the formed tunnel in the region of the nasal valve, under the triangular cartilage in position , the transverse back of the nose (the size of the implanted cartilage is 12 mm in length and 3 mm in width). The shape of the outer nose has not changed. 6 months after the revision operation, the patient was satisfied with nasal breathing. According to AR and PARM, the area of the nasal valve expanded and nasal breathing improved.

Thus, the proposed method for eliminating functional problems in patients after rhinoplasty:

1) allows metered and sufficient to expand the angle of the inner valve of the nose;

2) is minimally invasive and less traumatic;

3) allows you to simultaneously fix the nasal septum.

The transverse expansion graft installation according to the described technique was used by us in 5 patients with postrinoplastic narrowing of the nasal valve region, who underwent surgical treatment in the clinic of diseases of the ear, throat and nose of the First Moscow State Medical University. THEM. Sechenov. All patients showed improvement in nasal breathing, which was confirmed by the data of objective research methods. In one patient, the angle of the valve did not expand sufficiently due to a lack of plastic material (auto-cartilage broke during installation). No other complications were observed.

The obtained first results of the application of the described technique indicate its sufficient effectiveness and allow recommending it for use in clinical practice.

Claims (1)

A method for eliminating functional problems in patients after rhinoplasty, including an endonasal installation in the area of the inner valve of the nose of the autocartilage portion taken during septoplasty, characterized in that through the transfection incision in front of the nose on both sides, the mucous membrane of the nasal septum is separated from both sides, combined the right and left tunnels by cutting the dorsal part of the septal cartilage, set the auto-cartilage in the formed tunnel under the triangular cartilage in position, transverse nasal bridge.