RU2710857C1 - Method of simultaneous two-sided cheilorhinoplasty with asymmetric double-sided cleft of upper lip - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to maxillofacial surgery, is applicable for eliminating asymmetry of nose during primary bilateral double cheilorhinoplasty with double-sided asymmetric cleft upper lip. Method is implemented by cutting flaps in lateral areas of central fragment of upper lip: on one side – skin-subcutaneous, and on side of lowered wing of nose – skin-cartilage, containing skin, arch and medial leg of the cartilage formed by continuation of the medial incision upwards along the wing rim of the nose, according to preliminary marking, and continuation of lateral incisions beyond medial legs of the wing cartilages. When mobilizing and moving flaps up, columella is elongated and asymmetry of arches of wing cartilages is eliminated. To narrow the nose wings, the incisions in the lateral fragments of the upper lip are continued circularly on the bases of the wings.EFFECT: method enables eliminating asymmetry of nose in primary operation in children with congenital bilateral asymmetric clefts of upper lip.1 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, namely to maxillofacial surgery, can be used to eliminate asymmetry of the nose during primary simultaneous bilateral chelorinoplasty with bilateral asymmetric cleft of the upper lip.

With congenital bilateral cleft of the upper lip, anatomical disorders are characterized by a violation of the integrity of the upper lip, its splitting into three fragments, which can be combined with unilateral or bilateral splitting of the alveolar arch and palate. The degree of damage to the nose, morphological and functional disorders in this pathology depend on the type of cleft upper lip and the severity of the congenital defect. Among bilateral clefts of the upper lip, clefts with asymmetric lesions of the nose are diagnosed when the arches of the wing cartilage are at different levels. Such crevices require special surgical treatment techniques.

To date, a wide range of author's methods of bilateral chelorinoplasty has been proposed in the literature, but due to the wide variety of clinical anatomical manifestations of cleft upper lip, none of the methods for surgical removal of the defect can be considered universal. The choice of the method of bilateral heavyloroplastics and: takes into account the depth of anatomical lesions. When performing the operation in two stages (for example, the technique of J.Z. Bardach (1967), Kasparova NN, 1978), the first stage clears the cleft of the upper lip on one side, and then, after a half to two months, on the second side. The use of methods of two-stage operations increases the total number of surgical interventions to eliminate congenital malformation.

The operation in one step, as in the methods of Davydov B.P., Bessonova S.L., Soloviev V.A., 1998 (patent RU 2119774), Scheglova A.P., 1998 (patent RU 2128015), Stepanova Yu. V., 2010 (patent RU 2440042), reduces the total number of operations and reduces the rehabilitation time of children with cleft faces.

One-stage method of Davydov B.N., Bessonova S.N., Soloviev V.A. consists in the fact that during surgery, the lower third of the lip is restored with tissues from the mucous membrane of the prolabium and muscle tissue and the defect of the prolabium with the oral cavity is closed with mucus-muscle flaps from the side fragments of the upper lip containing the lower bundles of the circular muscle of the mouth, then they are connected with a mattress suture and then lengthen the skin of the nasal septum with forked flaps. However, this method can be used only with incomplete bilateral cleft of the upper lip, in addition, it does not provide for correction of deformation of the nose.

The method of simultaneous bilateral chelorinoplasty Scheglova A.P. consists in the fact that the bottom of the nose is formed by two triangular flaps taken from the nasal septum and at the wings of the nose, they form a deep vestibule by moving the lateral parts of the intermaxillary mucosa to the center, then form a red border of the middle fragment of the lip with the tubercle by stitching three-layer fragments of the lateral bordering a crevice. This method can be used with a complete and through bilateral cleft of the upper lip, but does not allow elongation of the columella and optimal displacement of the wings of the nose to the correct position.

According to the method described by Stepanova Yu.V., with bilateral crevices, the flaps are cut with cuts in the form of a loop from the base of the wing of the nose to a point 2-3 mm from the center point of the “Cupid's bow”. Refresh the middle fragment of the upper lip with oval cuts. The circular muscle of the mouth is isolated and connected to the muscle of the opposite side under the skin part of the median fragment of the upper lip. Wing cartilage is isolated through circular incisions on the inner surface of the wing of the nose, departing from the edge of 1-2 mm. Cartilage is moved and fixed by immersion seams between each other. Periosteoplasty is performed from both edges of the midline. However, this method does not provide the formation of symmetrical scars in the area of the columns of the upper lip filtrum, thereby, does not form an anatomically correct shape of the upper lip.

There is also known a method of chelorinoplasty with bilateral cleft upper lip Vissarionova VA, 1986 (patent SU 1217359), which consists in the allocation of scar-skin flaps of the upper lip and their movement in the region of a shortened skin septum. External sections from the upper lip extend into the nasal cavity behind the medial legs, arches and through the lateral legs of the large cartilage of the wings of the nose tip, as well as circularly behind the bases of the wings of the nose with the mobilization and movement of the latter to the center, and the arches of both halves of the nose tip after fixing them through cartilage - anteriorly, then nasal passages in the area of the vestibule bottom and lower lateral parts of the distal part of the nasal septum on both sides are restored with strips of scar-skin tissue of the upper lip. This method is not used for primary bilateral cheilorinoplasty, but is recommended only for reconstructive surgery to correct residual deformation of the upper lip and nose.

Closest to the proposed method for surgical treatment of congenital bilateral cleft of the upper lip is the method of Kharkov L.V., Yakovenko L.M., 2000 (patent UA 31174), which involves cutting, mobilizing and moving two small skin-subcutaneous flaps from the lateral sections of the median a fragment in the direction of the base of the wings of the nose, the formation of a red border and the vestibule of the oral cavity due to the red border and the mucosa of the lateral fragments of the upper lip, myoplasty, cutting out triangular flaps on the skin h STI side pieces of the upper lip, and moving their mobilization to said median fragment. The red border and the vestibule of the oral cavity are reproduced due to the V-shaped flap of the mucosa and the red border of the middle fragment, previously mobilized and moved up. The method is illustrated in FIG. 1-3.

All the methods discussed above have a common drawback - they do not take into account and do not completely eliminate the asymmetry of the arches of the wing cartilage with bilateral asymmetric cleft of the upper lip.

The objective of the invention is to improve the aesthetic and functional result of primary bilateral chelorinoplasty with asymmetric bilateral clefts of the upper lip due to the simultaneous restoration of the shape and function of the upper lip and nose, as well as the symmetry of the nose.

This problem is solved due to the fact that after marking when cutting out two small skin-subcutaneous flaps from the lateral sections of the median fragment, the medial incisions pass from the base of the columella down to the highest points of the Cupid's bow line, and on the side of the lowered wing, the incision is extended from the base columella up the rim of the wing of the nose according to the drawing, made taking into account pre-applied markings on anatomical landmarks. The incision should be symmetrical to the arch of the wing cartilage of the opposite side. Lateral incisions are made on both sides of the median fragment of the upper lip from the mucous membrane of the red border upward towards the base of the wings of the nose, and then, unlike the prototype, they continue symmetrically upward on both sides along the posterior edge of the medial legs of the wing cartilage with cutting from the side of the lowered wing skin-cartilaginous flap containing the skin and medial leg of the wing cartilage. When triangular flaps are cut out on the side fragments of the upper lip, the incisions are extended circularly beyond the bases of the nose wings from two sides, they also make incisions in the area of the inner surface of the nose wings, the nose wings are mobilized, moved to the center and fixed to the base of the nasal septum with non-absorbable suture material (nylon). If necessary, Z-plastic is produced to eliminate the crest-shaped folds in the area of the inner surface of the wings of the nose. Differences from the prototype are illustrated in FIG. 4.

The method is as follows:

1. Before the operation begins, anatomical landmarks are determined, markup is made and a drawing of future sections is made: on the central fragment of the upper lip, the central and two highest points of the “Cupid's bow” line are marked, on the side fragments of the upper lip, the locations of the highest points of the “Cupid's bow” line are determined, located at an equal distance from the corners of the mouth, mark the highest point of the raised arch of the wing cartilage and symmetrically transfer this point to the opposite side, drawing the future position of the arch of the lowered wing la The marking and cut lines are illustrated in FIG. 5.

2. Under endotracheal anesthesia, with preliminary infiltration of the soft tissues of the upper lip and nose with an anesthetic solution, incisions are made using a scalpel, according to the previously applied drawing. The skin flap of the central fragment of the upper lip with the V-shaped flap of the red border is mobilized and thrown up. Cut out, mobilize and move upward the skin-subcutaneous flaps from the lateral sections of the middle fragment, from the side of the lowered wing of the nose, the flap smoothly passes into the skin-cartilage containing the skin and medial leg of the wing cartilage (Fig. 6). The arches of the wing cartilage are set in a symmetrical position and fixed among themselves. In this way, a symmetrical tip and a dome of the nose are formed (Fig. 7). When triangular flaps are cut out on the side fragments of the upper lip, the incisions are extended circularly beyond the bases of the nose wings from two sides, they also make incisions in the area of the inner surface of the nose wings, the nose wings are mobilized, moved to the center and fixed to the base of the nasal septum with non-absorbable suture material (capron), which allows you to narrow the stretched wings of the nose.

3. If necessary, to eliminate the crest-shaped folds in the area of the inner surface of the wings of the nose, Z-plastic is produced.

4. The sections of the vestibule of the mouth of the side fragments are made according to the “poker” type, the mucous membrane is sutured with absorbable suture material, moving the flaps of the side fragments to the center, and the vestibule of the oral cavity is formed in the frontal region of sufficient depth.

5. Isolates and sutured between themselves fragments of the circular muscles of the mouth, thereby restoring the normal function of the upper lip.

6. Return to place the flap thrown upwards from the central fragment of the upper lip with a V-shaped flap of the red border. Sutures are applied to the skin with non-absorbable suture material, and to the mucosa, are absorbable. Thanks to the V-shaped flap, the line of the “Cupid's bow” is formed in the correct form, as well as linear symmetrical scars that coincide with the line of the upper lip filtrum (Fig. 8).

7. In the nasal passages from two sides set ointment turunda "Tampograst".

Thus, due to the continuation of the medial section of the median fragment of the upper lip from the side of the lowered nose wing up the rim of the wing of the nose according to the drawing applied at the beginning of the operation (the section should be symmetrical to the arch of the wing cartilage of the opposite side), as well as due to the continuation of lateral sections symmetrically upwards from two sides along the posterior edge of the medial legs of the wing cartilage with cutting, mobilizing and moving upward from the side of the lowered wing of the nose of the skin-cartilaginous flap containing the skin and medial th leg krylnyh cartilage arch krylnyh cartilage placed in symmetric position and fixed together. Thus, lengthen the columella, eliminate the asymmetry of the arches of the wing cartilage and form a symmetrical tip and dome of the nose.

Circular incisions beyond the base of the wings of the nose on the lateral fragments of the upper lip and mobilization of the wings of the nose make it possible to narrow the stretched wings of the nose.

The combination of the developed improvements during simultaneous bilateral chelorinoplasty improves the cosmetic and functional result of treating children with congenital bilateral asymmetric clefts of the upper lip, makes it possible to eliminate congenital deformity of the upper lip and nose even during the initial surgical intervention, which reduces the number of corrective operations and the rehabilitation time for children.

Clinical example:

Patient P., 7 months (Born on July 25, 2018), IS No. 768, was admitted with a diagnosis of congenital bilateral asymmetric cleft of the upper lip and palate.

Objectively: The patient has a cleft in the upper lip area on the right with a splitting of the nostril threshold, and on the left, a nostril reaching the threshold of the nostril without splitting. The wing cartilage arch is 3.0 mm lower on the right than on the left. The opening of the mouth is free, in the sky there is a cleft with splitting of the alveolar process from 2 sides.

02/26/2019, under the general anesthesia, an operation was performed - the primary simultaneous bilateral chelorinoplasty.

Under endotracheal anesthesia with preliminary infiltration of the soft tissues of the upper lip and nose with a solution of novocaine 0.5% - 4.0 ml, incisions were made using a scalpel according to the previously applied figure. A skin flap of the central fragment of the upper lip with a V-shaped red border flap was mobilized and thrown up. Cutaneous, subcutaneous flaps were cut, mobilized, and moved upward from the lateral sections of the median fragment; from the side of the lowered nose wing, the subcutaneous flap smoothly passes into the skin-cartilage containing the skin and medial leg of the wing cartilage. The arches of the wing cartilages are set in a symmetrical position and are fixed to each other, a symmetrical tip and a nose dome are formed. Skin sections of the lateral fragments of the upper lip were made at the base of the wings of the nose with a continuation circularly behind the bases of the wings of the nose on both sides, cuts were also made in the region of the inner surface of the wings of the nose, the wings of the nose were mobilized, moved to the center and fixed to the base of the nasal septum with a capron 4-0, the wings of the nose are narrowed. The pits were cut along the vestibule of the upper lip of the upper lip, the mucosa was sutured with a polysorb 5-0, the flaps of the lateral upper lip fragments were moved to the center, and the vestibule of the oral cavity was formed. Fragments of the circular muscles of the mouth were isolated and sutured. The flap thrown upwards from the central fragment of the upper lip with the V-shaped flap of the red border is lowered into place. Stitches were sutured in a wound in polysorb 5-0 layers, on the skin by a monosophist 6-0. Tampograss ointment turundas are installed on both sides of the nasal passages.

The sutures on the skin were removed on the 7th day after the operation. Intranasal inserts for 6 months were individually made in the nasal passages on both sides.

After 2 months, a follow-up examination was performed after the operation; upon examination, postoperative scars in the upper lip on both sides in the formation stage: pink, do not rise above the surface of the skin, tight elastic consistency, painless on palpation. The red border and the line of “Cupid's bow” of the correct form, the tip and the dome of the nose are symmetrical.

FIG. 1. Scheme of the upper lip and nose before surgery according to the prototype (according to the method of Kharkov L.V., Yakovenko L.M., 2000 (patent UA 31174):

1. Lines of medial incisions when cutting out skin-subcutaneous flaps from the lateral sections of the median fragment of the upper lip;

2. Lines of lateral incisions when cutting out skin-subcutaneous flaps from the lateral sections of the median fragment of the upper lip;

3. Skin and subcutaneous flaps;

4. V-shaped flap of the red border of the middle fragment of the upper lip;

5. Triangular flaps of the lateral fragments of the upper lip.

FIG. 2. Scheme of the upper lip and nose after cutting and mobilization of flaps according to the prototype:

1. Skin and subcutaneous flaps from the lateral sections of the median fragment of the upper lip;

2. V-shaped flap of the red border of the middle fragment of the upper lip;

3. Triangular flaps of the lateral fragments of the upper lip.

FIG. 3. Scheme of the upper lip and nose after surgery according to the prototype.

FIG. 4. The scheme of the lines of cuts in the upper lip and nose of the proposed method:

1. Lines of medial incisions when cutting flaps in the region of the median fragment of the upper lip;

2. Continuation of the medial incision along the rim of the wing of the nose from the side of the lowered wing;

3. Lines of lateral sections when cutting flaps in the region of the median fragment of the upper lip;

4. Circular sections for the base of the wings of the nose;

5. V-shaped flap of the red border of the median fragment of the upper lip;

6. Triangular flaps of the lateral fragments of the upper lip.

FIG. 5. Marking and drawing lines of cuts before surgery in the upper lip and nose according to the proposed method.

FIG. 6 and FIG. 7. The main stages of the operation of the proposed method.

FIG. 8. The view of the upper lip and nose after surgery according to the proposed method.

Claims (1)

The method of simultaneous bilateral chelorinoplasty with asymmetric bilateral cleft of the upper lip, which includes cutting, mobilizing and moving two small skin-subcutaneous flaps from the lateral sections of the midline fragment towards the base of the nose wings, forming a red border and the vestibule of the oral cavity through the use of a red border and mucous membrane lateral fragments of the upper lip, myoplasty, cutting out triangular flaps on the skin of the side fragments of the upper lip, their mobilization and movements to the specified midline fragment, as well as due to the V-shaped flap of the mucous membrane and the red border of the middle fragment, previously mobilized and moved up, characterized in that when cutting skin-subcutaneous flaps from the lateral sections of the middle fragment, a medial incision is made from the side of the lowered nose wing up along the rim of the wing of the nose according to the drawing applied before the operation according to the anatomical landmarks, and the lateral incisions continue upward from both sides beyond the medial legs of the wing cartilage mobilization and upward movement of the skin-cartilaginous flap containing the skin, arch and medial leg of the wing cartilage from the side of the lowered wing of the nose, which allows lengthening the columella and eliminating the asymmetry of the arches of the wing cartilage, and when cutting triangular flaps on the side fragments of the upper lip, the incisions are extended circularly to the bases wings of the nose on both sides, also make cuts in the area of the inner surface of the wings of the nose, the wings of the nose are mobilized, moved to the center and fixed to the base of the septum of the nose a curling suture material-kapron, thereby narrowing the stretched wings of the nose.

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