RU2706648C1 - Method of "bloodless" rhinoseptoplasty with double-plane dissection of soft tissue outer nasal tissue - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to plastic surgery, otorhinolaryngology, physiotherapy, and can be used in treating patients with external nasal deformities. Wide double-plane dissection of the soft tissues of the nose – skin and subcutaneous fat – is performed in the cranial directions – up to the root of the nose and lateral – to the lateral edge of the piriform aperture. Periosteum is elevated within the piriform apertures top edge. Subperiosteal dissection of a skeleton of an external nose is performed on both sides. That is followed by correction of the osteocartilaginous framework of the nose, wherein the bone frame of the nose is corrected first, followed by correcting the middle arch of the arch, to which the upper lateral cartilages belong. Then periosteum is laid on bone frame of external nose. Sutures and fixative bandage are applied.

EFFECT: invention enables maximum adhesion of the nasal tissue coating to the osteocartilaginous basis of the nose and minimizing the risk of its displacement, reducing traumatism and reducing the length of treatment.

1 cl, 2 dwg

Description

The invention relates to medicine, in particular plastic surgery, otorhinolaryngology, physiotherapy, and can be used in the treatment of patients with deformation of the external nose.

The history of plastic surgery of the nose is associated with the search for optimal techniques aimed at obtaining the best result with the least number of complications [ASPS, 2013; Broer P.N., 2014]. Along with the non-decreasing number of patients who want to change the shape of the nose for aesthetic reasons, publications are increasingly appearing about the growing number of distant problems [Ivanov S.A., 2017; Broer P.N., 2014].

There are many options for conducting rhinoplasty. Surgical access during surgery can be performed through incisions made inside the nose (endonasal approach or closed technique) or going beyond the nostrils, usually in the area of the columella (external approach or open technique).

Despite the fact that both accesses are part of a single process of forming a new nose shape, it is extremely difficult to scientifically substantiate the need to apply one or another tactic, since in general it is a consequence of the preferences of the surgeon himself, and not the clinical situation. However, from a scientific point of view, differences between these techniques can lead to significantly different consequences. Thus, a supporter of “closed” technology A J. Vartanian (2014) emphasizes the following obvious advantages:

Снижение необходимости в хирургическом вскрытии

Reduced surgical opening

Снижение риска потери опоры кончика носа

Reduced risk of loss of nose tip support

Снижение выраженности послеоперационных изменений мягких тканей

Decreased postoperative soft tissue changes

Отсутствие наружных рубцов и как следствие возможности нанесения ятрогенных дефектов

The absence of external scars and, as a consequence, the possibility of iatrogenic defects

Возможность выполнить все намеченные хирургические действия без широкого «открытия» носа

The ability to perform all planned surgical operations without a wide "opening" of the nose

Возможность использования тактильных ощущений с целью интраоперационной оценки производимых изменений

The possibility of using tactile sensations for the purpose of intraoperative assessment of changes made

Возможность оценки выполненных изменений без отрыва от лица в целом

The ability to evaluate the changes made without interruption from the person as a whole

Сокращение времени операции

Reduction of operation time

Снижение послеоперационной заболеваемости, особенно у пожилых пациентов

Decreased postoperative morbidity, especially in elderly patients

Быстрая реабилитация

Quick rehabilitation

In this regard, we were tasked to develop an original technique of aesthetic rhinoplasty with two-plane dissection of the soft tissues of the nose, with the aim of improving the adhesion of the skin-muscle-aponeurotic sac to the reconstructed bone-cartilage base of the nose.

There is a method of rhinoplasty in which the lateral legs of the wing cartilage are mobilized, the cephalic portions are removed, the lateral legs are intersected and shortened and the joints are tightened on the domes of the wing cartilage (Plastic Surgery Course / edited by KP Pshenisnov. Yaroslavl: Publishing House of JSC Rybinsk Printing House ", 2010. - Vol. 1; Chapter 3.8. Aesthetic rhinoplasty).

However, the disadvantages of this variant of rhinoplasty is that due to the shortening of the lateral legs, the prerequisites for the retraction of the wings of the nose and impaired nasal breathing are created, while the aesthetic effect of rhinoplasty is reduced by the application of constrictive sutures on the domes of the wing cartilages.

A known method of rhinoplasty, comprising dissecting the lateral leg of the wing cartilage so that the medial-caudal part of the lateral leg of the wing cartilage remains fixed to the arch, and its lateral part becomes mobile, while the remaining cephalic part is crossed in the medial part of the lateral leg of the wing cartilage, after which a suture is formed that forms the dome of the wing cartilage, additionally stitching the medial edge of the cephalic part to it, a suture is tied, while the mobile rotate in the lateral region th edge krylnyh caudal portion of cartilage which is disposed in the tunnel of the skin of the nose edge of the wing. (Korabel'nikov AI, patent RU 2669479). We take this method as a prototype.

The disadvantages of this method of rhinoplasty option is that suturing between the cephalic part of the wing cartilage and the cephalic part reduces the aesthetic effect of rhinoplasty, causing seals in the area of the tip of the nose, with possible inflammation, also in this technique the intervention is only on the tip of the nose, without changing the nose pyramid .

The method developed by us allows us to achieve the following technical results: the quality of treatment is improved, the rehabilitation period is reduced, there are no external incisions, blood loss during surgery is minimal, in the long term the risk of nose tip drooping is minimized, and nasal breathing improves.

These results are due to the following: during the operation, a two-plane dissection of the soft tissue cover of the external nose is performed, which allows you to maintain microcurrent lymphatic drainage of the underlying tissues, which contributes to the rapid healing of the postoperative region

The method is as follows.

After hydroseparation, we perform a perichondral section, which begins on the right in the projection of the lateral section of the lower lateral cartilage according to a pre-made marking, then the section continues through the skin fold of the columella behind the medial legs of the lower lateral cartilage, cutting through it. Similarly, the cut on the left.

Next, subperichondrial dissection of the cephalic part of the lower lateral wing cartilage is carried out and their removal.

If there is no need to correct the end section of the nose and the need to exit to the back of the nose, an inter-cartilage incision is performed with further dissection of the soft tissues in the region of the bone-cartilage skeleton of the nose.

After access is completed, a septoplasty stage is performed. For this successively, the quadrangular cartilage, premaxilla and further the opener and the perpendicular plate of the ethmoid bone are exposed. Dissection is carried out on both sides strictly in the layer under the perichondrium and further under the periosteum.

Sharply curved isolated sections of the nasal septum (spines and bone ridges in the posterior sections of the nasal cavity) are excised, straightened, or flattened and reimplanted. The lower edge of the quadrangular cartilage is mobilized from premaxilla using a chisel.

If there is a ridge along the premaxilla, it is selected and removed so that the lower edge of the quadrangular cartilage remains in contact with premaxilla. The deviations of the quadrangular cartilage are eliminated with notches and fixing sutures. If necessary, the autograft is taken using the middle part of the quadrangular cartilage, without affecting its front and upper sections to maintain the support of the external nose.

Correction of the bone-cartilaginous skeleton of the nose begins with a wide dissection of the soft tissues in the cranial (to the root of the nose) and lateral (to the lateral edge of the pear-shaped aperture) direction. Next, the periosteum is elevated in the region of the upper edge of the pear-shaped apertures and the subperiosteal dissection of the bones of the outer nose is performed. Thus, the two-plane dissection of the soft tissue cover of the external nose creates maximum adhesion of the tissue covering of the nose to the bone-cartilage base of the nose and minimizes the risk of its displacement due to the effect of “shape memory”.

After separation of the bone-cartilaginous skeleton of the nose from the soft tissues, they proceed to the immediate tasks of aesthetic rhinoplasty, which from this area was to reduce the height of the nose throughout or to reduce the local bulging - the hump of the nose. For this purpose, in the case of a large hump, it is used with a straight osteotome and rasps with different severity of teeth, starting with the roughest, and with small humps - only rasps. In the case of a pronounced hump, in order to reduce the sliding of the bit along the nasal bridge, a mid osteotomy is performed on both sides of the nasal septum. Separated from each other, the medial edges of the nasal bones are easier and safer to reduce.

Further, in order to narrow the nose pyramids and close the open back, lateral, upper and, if necessary, intermediate osteotomies are performed.

After performing the osteotomy, the digital formation of the nose pyramid is performed with a comparison of the right and left sides. If narrowing of the pyramid of the nose is not required, and after removing the hump, a small open area of the roof of the nose is left, then it is closed with an autograft pad, which is used as a flattened cartilage or bone of the nasal septum in the form of a strip.

After correction of the bony skeleton of the nose, they begin to manipulate in the area of the middle arch, which includes the upper lateral cartilage.

Usually, in the area of the middle nasal vault, the most common problem is the presence of a cartilaginous hump of one degree or another, both a continuation of the bone hump, and independent - with unexpressed nasal bones. Excision of the cartilage hump can be carried out in a single unit together with the underlying mucous membrane, however, in order to avoid violation of its integrity and subsequent uniform scarring, work with triangular cartilages is carried out as follows: first, from the underlying mucous membrane under the perichondrium, the transition of triangular cartilages to the nasal septum was allocated from below . Next, with sharp scissors with long branches through a direct cut, an accurate separation of these two anatomical subunits is carried out. The parts forming the hump (the upper edge of the nasal septum and the medial edges of the triangular cartilage) are removed by means of longitudinal even sections with scissors or a scalpel. Upon reaching the required level of shape and height of the middle arch, dissection stops. In this case, the underlying mucous membrane remains intact. This condition is an important factor in preventing chronic obstruction of the nose as a result of narrowing of the nasal valve by an excessive scarring process. Also, as a result of maintaining the integrity of the underlying mucous membrane with a small amount of dissection of the medial edges of the triangular cartilages, they are not fixed with each other, since in this case their natural fixation mechanism is maintained, which is supplemented in the early postoperative period by applying a patch dressing and splint, and in the long term bandage overnight.

As a result of working with a rasp or chisel, in the area of the surgical field, as a rule, small bone-cartilaginous or connective tissue fragments remain. An important measure, in order to prevent the appearance of irregularities of the skin, is their removal with scissors and a spoon with further washing of the space with physiological saline.

After this, the periosteum is laid on the bone skeleton of the external nose.

During this operation, an original algorithm of its phasing was developed, which includes the following steps:

1) access;

2) correction of the end section of the nose (when accessed without releasing the strip);

3) correction of the nasal septum;

4) correction of the bone-cartilaginous skeleton of the nose;

5) correction of the end section of the nose (with access with the release of the strip or open access);

6) correction of the nasal concha;

7) suturing and fixing bandages.

As part of the correction of the bone-cartilaginous skeleton of the nose, an original technique of two-plane dissection of the soft tissue cover of the external nose is proposed.

The technique provided for a wide dissection of soft tissues (skin and subcutaneous fat) in the cranial (to the root of the nose) and lateral (to the lateral edge of the pear-shaped aperture) direction. Next, the periosteum is elevated in the region of the upper edge of the pear-shaped apertures and the subperiosteal dissection of the bony skeleton of the external nose is performed on both sides. The creation of two dissection planes made it possible to achieve maximum adhesion of the tissue covering of the nose to the bone-cartilage base of the nose and to minimize the risk of its displacement due to the effect of “shape memory”.

The method of treatment was tested on 730 patients with deformation of the external nose at the age of 18 to 57 years.

2 clinical examples can illustrate the effectiveness of the treatment method.

Clinical example N1.

Patient K., aged 21, complained of an irregular shape of the external nose, a wide tip of the nose, and deformation of the nose. An otorhinolaryngological examination, examination and photo-fixation of the external nose was performed. Diagnosis - deformation of the external nose, tip of the nose, curvature of the nasal septum, vasomotor rhinitis. The patient underwent surgical treatment according to the technique developed by us. The first step was access - a perichondral incision in the projection of the lateral part of the lower lateral cartilage and then through the skin fold of the columella behind the medial legs of the lower lateral cartilage, cutting through it. In the same way, the incision was made on the other hand, the next step was the correction of the end section of the nose, the correction of the nasal septum, the correction of the osteo-cartilaginous nose, the next step was the correction of the end section of the nose and the correction of the nasal concha (submucosal vasotomy), and the suturing and fixation were performed in the final stage dressings. The postoperative period was uneventful, the wound healed by primary intention. Nasal breathing has improved. Achieved a positive aesthetic effect.

Clinical example N2.

A 19-year-old patient complained of an irregular shape of the external nose, a deformed tip of the nose, and deformation of the back of the nose. The patient has a history of trauma to the external nose. An otorhinolaryngological examination, examination and photo-fixation of the external nose was performed. Diagnosis - deformation of the external nose, tip of the nose, curvature of the nasal septum, vasomotor rhinitis. The patient underwent surgical treatment according to the technique developed by us. The first step was access - a perichondral incision in the projection of the lateral part of the lower lateral cartilage and then through the skin fold of the columella behind the medial legs of the lower lateral cartilage, cutting through it. In the same way, the incision was made on the other hand, the next step was the correction of the end section of the nose, the correction of the nasal septum, the correction of the osteo-cartilaginous nose, the next step was the correction of the end section of the nose and the correction of the nasal concha (submucosal vasotomy), and the suturing and fixation were performed at the final stage dressings. The postoperative period was uneventful, the wound healed by primary intention. Nasal breathing has improved. Aesthetic effect achieved

Claims (1)

A method of aesthetic rhinoseptoplasty, in which endonasal access, correction of the end section of the nose, and correction of the nasal septum are performed, a wide two-plane dissection of the soft tissues of the nose - the skin and subcutaneous fat in the cranial - to the root of the nose and lateral - to the lateral edge of the pear-shaped aperture, is performed, elevation of the periosteum in the region of the upper edge of the pear-shaped apertures and periosteal dissection of the bony skeleton of the external nose on both sides, then bone correction o-cartilaginous skeleton of the nose, the bone is first carried out of the core of the nose correction, then the correction medium nose arch area to which the upper lateral cartilage, followed by stacking the skeleton bone periosteum on the outer nose, carried suturing and retention bandages.