RU2713376C2 - Method of enlarging volume of soft tissues within base of columella in congenital bilateral cleft lip and palate - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to maxillofacial and plastic surgery. Incision of the soft tissues of the nose and upper lip is used. They are dissected and accessed periosteum at the base of the nasal notch. Receiving bed is formed in the given area with subsequent placement of the autograft containing cartilage chips produced from the rib into the formed receptive bed and suturing of the incision. Soft tissue incision is performed in one of the nasal passages along the columella edge, then to the base of the vestibule of the nasal cavity. Autograft is represented by a fascia-cartilaginous autograft in the form of a cylinder with length of 20–30 mm, diameter of 9-10 mm, wall thickness of 1–1.5 mm, obtained from a superficial fascia of the rectus abdominis muscle and filled with cartilage chips, followed by placement of a fascial-cartilaginous autograft into formed receiving bed.

EFFECT: method enables reducing traumatism, improving functional and aesthetic results due to more stable position of autograft due to use of rectus muscle fascia.

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Description

This invention relates to medicine, namely to maxillofacial and plastic surgery, and can be used for reconstructive rhinoplasty, in particular, with secondary chelorinoplasty, chelorinoseptoplasty, as well as in patients with plastically restored nose deformities with congenital bilateral cleft lip and palate .

There is a method of increasing the volume of soft tissues in the region of the base of the columella with congenital bilateral cleft lip and palate, in which a semicircular allo-cartilage graft is used as a graft to fill the volume of soft tissues.

According to the method, tissues are labeled and hydrotreated in the region of the upper lip, incisions are made on both sides of the prolabium, then it is mobilized and folded up, two finger-shaped flaps of the circular muscle of the mouth are cut out, with their bases facing the “Onion Cupid” line.

The edges of the circular muscles of the mouth are refreshed and mobilized by horizontal cuts along the white roller of the lip and in the nasolabial groove. To move both halves of the circular muscle to the middle, both muscles raising the upper lip partially intersect, and after stitching both fragments of the muscle along the midline, the cut off stumps of the muscles raising the upper lip are fixed to the circular muscle in a new position. Before stitching, the muscles are peeled off from the upper jaw of the base of the wings of the nose and plastic surgery is performed on the underdeveloped edges of the nasal notches or atrophied intermaxillary bone with a semicircular allochondral graft. Then, the previously cut finger-shaped flaps are sutured with each other crosswise, sutured to the skin.

Thanks to this method, the upper lip is advanced and the lack of tissue volume in the region of the base of the columella is filled. [I.A. Kozin "Aesthetic surgery of congenital clefts of the face", Martis - Moscow, 1996, pp. 293-294].

The disadvantage of this method is the low aesthetic and functional effect due to the fact that there is a decrease in the volume of soft tissues in the region of the upper lip.

Closest to the proposed is a method of increasing the volume of soft tissues in the region of the base of the columella with congenital bilateral cleft lip and palate, which consists in the fact that after preliminary marking and hydropreparation of soft tissues in the region of the transitional fold of the upper jaw, an incision of the mucous membrane is performed, then by blunt and acute dissections provide access to the periosteum, creating a perceptive bed at the base of the nasal notch for the installation of an autograft consisting of crushed auto-cartilage Obtained from the rib.

An autograft is obtained by sampling a fragment of an auto-cartilage, it is ground to shavings 0.5-1 mm in size. Next, the autograft is placed in a steel syringe and squeezed using a plunger.

Then, the distal end of the syringe is injected into the previously formed bed in the thickness of the soft tissues of the upper lip through the incision on the mucous membrane, the resulting autograft from cartilage shavings is introduced and stitches are placed in the region of the vestibule of the oral cavity. [Plastic & Reconstructive Surgery: Number 5, Volume 1406; p. 673-685].

The disadvantage of this method is that the cartilage chips are stacked freely, without a “case” from the fascia, which can cause autograft migration and accelerated resorption.

The technical result of the proposed method is to reduce the morbidity due to the fact that the donor zone for the autograft, consisting of auto-cartilage and fascia of the rectus abdominis muscle, is the same, as well as the increase in functional and aesthetic results due to a more stable position of the autograft due to the use of the fascia straight abdominal muscles.

The technical result is achieved by the fact that in the method of increasing the volume of soft tissues in the region of the base of the columella with congenital bilateral cleft lip and palate using an incision of the soft tissues of the nose and upper lip, their dissection, access to the periosteum at the base of the nasal notch, the formation of the perceiving bed in this area , followed by placement of an autograft containing cartilage shavings obtained from the rib into the formed perceptive bed and suturing of the incision, a distinctive feature is that soft tissue incision is performed in one of the nasal passages along the edge of the columella, then to the base of the vestibule of the nasal cavity, and a fascial-cartilaginous autograft in the form of a cylinder, 20-30 mm long, 9-10 mm in diameter, wall thickness 1-1 is used as an autograft , 5 mm, obtained from the surface plate of the fascia of the rectus abdominis muscle and filled with cartilage chips, followed by placement of the fascial-cartilaginous autograft in the formed receiving bed.

The method is as follows (Fig. 1-4).

Marking is carried out in the area of the vestibule of the nasal cavity and hydrotreating of soft tissues with a NaCl solution of 0.9% + Adrenaline 1: 400000, in a volume of 5-10 ml. In one of the nasal passages, an incision (1) is made along the edge of the columella (2), with continuation to the base (3) of the vestibule of the nasal cavity. By dissecting the soft tissues of the nose and upper lip, they access the periosteum of the nasal notch (4) in the base region for 20-50 mm (depending on the degree of lack of soft tissue volume and the size of the necessary autograft), forming a receptive bed for further installation of the autograft.

Then, according to the previously applied marking and hydraulic preparation with a 0.9% NaCl solution + Adrenaline 1: 400000, in the volume of 15-20 ml an incision is made of the skin and subcutaneous fat on the front surface of the chest in the projection of the cartilaginous section of the 7-8 rib along the parasternal line in size 40-50 mm.

To obtain fascia of the rectus abdominis muscle within the intended boundaries, it is prepared by its width of 30–40 mm, length of 50–60 mm, and thickness of 1–1.5 mm. The prepared fragment is resected. Next, access to the cartilage 7-8 ribs. Carry out a fragment of the costal cartilage. Cartilage surfaces smooth. The wound is sutured in layers with interrupted sutures, an intradermal suture is applied to the skin. Rib cartilage is crushed to shavings, the size of the resulting fragments of 0.5-2 mm

Prepare a fascia fragment (5) of the rectus abdominis muscle with a width of 15-20 mm, a length of 30-40 mm, a thickness of 1-1.5 mm, then create a cylinder from it using a syringe (6) with a diameter of 6.5-8.0 mm ( 7). The fascia (5) is wrapped around a syringe (6), on which the end is preliminarily cut to fix the cannula. In the area where the edges (8) of the fascia fragment (5) are closed, it is hermetically sutured to obtain a cylinder (7) whose end (9) is sutured. Then, pre-crushed cartilage shavings (10) are introduced into the syringe (6), which are introduced into the cylinder (7). The free end (11) of the obtained fascial-cartilaginous autograft (12) with a length of 20-30 mm and a diameter of 9-10 mm is sutured.

Then, the fascial-cartilaginous autograft (12) is installed in a previously formed receptive bed in the area of the base of the nasal notches (13). Layered sutures in anticipation of the nasal cavity.

Example 1

Patient B. (born 1992) was treated in a clinic with a diagnosis of Cicatricial deformity of the upper lip and cartilage of the nose, lack of soft tissue in the base of the columella as a result of congenital bilateral cleft lip and palate.

From the anamnesis: during life, the patient underwent surgery - chelorinoplasty.

At the time of admission to the clinic, the patient noted a deficit in the volume of soft tissues in the area of the base of the columella, deformation of the upper lip and cartilage of the nose.

During external examination, it was noted: cicatricial deformity of the upper lip, lack of soft tissue in the base area of the columella and upper lip. The tip of the nose is slightly offset to the left of the midline. The wings of the nose are asymmetrical, the nasal passages are narrow. The tip of the nose is down, the projection of the tip is low, the nasolabial angle is 139 °. When viewed in profile, the extension of the lower lip forward by 13 mm.

In the clinic, after a complete clinical and laboratory examination, an operation of the proposed method was performed under endotracheal anesthesia.

The surgical field was marked and the soft tissues were hydrotreated with a 0.9% NaCl solution + Adrenaline 1: 400000 in a volume of 8 ml. A soft tissue incision was made in the left nasal passage along the edge of the columella, then to the base of the vestibule of the nasal cavity by 3 mm. By the method of blunt and acute dissection, it was passed to the periosteum at the base of the nasal notch, and a receptive bed 30 mm in size was formed.

Then, according to the previously applied marking, an obliquely oriented incision of the skin and subcutaneous fat was performed in the right thoracic region along the edge of the costal arch with a size of 50 mm in the projection of 8 ribs along the parasternal line. Within the intended boundaries, the surface plate of the fascia of the rectus muscle of the abdomen was dissected with dimensions of 50 × 40 × 1.5 mm.

Further, by the method of blunt and acute dissection of the muscles of the anterior abdominal wall, access was made to the cartilage of the 8th rib. A cartilage fragment of 8 ribs 40 × 20 mm in size was taken; cartilage surfaces were smoothed. The wound is sutured in layers by thread vicryl 3/0, prolene 4/0. Cartilage is crushed to shavings. The fascia is wrapped around a syringe, on which the end is preliminarily cut to fix the cannula, and is tightly sutured in the area where the fascia edges are closed. A fascia cylinder is made, one end of which is left free, and the other hermetically sutured. Then, pre-ground cartilage shavings were placed in the syringe and introduced into the cylinder from the fascia using a piston. The free end of the obtained fascial-cartilaginous autograft was sutured. The autograft size is 30 × 9 mm.

A fascial-cartilaginous autograft was introduced into the preformed bed in the area of the base of the nasal notches in order to increase the volume of tissues in the area of the base of the columella. Nodal sutures were imposed on the threshold of the nasal cavity with Sterilin 6/0 thread. Hemostasis during surgery.

In the postoperative period, the patient underwent conservative antibacterial, analgesic and desensitizing therapy. Sutures were removed on the 8th day.

As a result of the operation, the volume of soft tissues in the area of the base of the columella was increased.

The follow-up was 2, 6 and 12 months. Long-term postoperative outcome is good. On control photometry after 6 months, no recurrence of deformation was detected.

Example 2

Patient D. (born 1998) was treated in a clinic with a diagnosis of Cicatricial deformity of the upper lip, a lack of soft tissue in the base of the columella as a result of a congenital bilateral cleft of the upper lip and palate. Condition after a series of reconstructive operations.

From the anamnesis: during the life of the patient, a number of reconstructive operations were performed: including uranoplasty, cheiloplasty, rhinocheiloplasty, septoplasty.

An external examination revealed cicatricial deformity and a deficit in the volume of soft tissues in the region of the base of the columella and upper lip. There was an asymmetric, normotrophic normochromic postoperative U-shaped scar up to 18 mm wide, starting at the edge of the red border of the upper lip, and directed to the base of the left and right wings of the nose. The line of “Cupid's bow” is asymmetric, the height of the red border of the lip along the midline is 9 mm, in the left half 3 mm, in the right half 5 mm. When viewed in profile, the extension of the lower lip forward by 16 mm. Nasolabial angle 113 °.

In the clinic, after a complete clinical and laboratory examination, under endotracheal anesthesia, the operation of the proposed method was performed.

The surgical field was marked and the soft tissues were hydrotreated with 0.9% NaCl solution + 1: 400 adrenaline. A soft tissue incision was made in the right nasal passage along the edge of the columella, then to the base of the vestibule of the nasal cavity by 4 mm. By the method of blunt and acute dissection, it was passed to the periosteum at the base of the nasal notch. A receptive bed 40 mm in size has been formed.

According to the previously applied markings, an obliquely oriented incision was made of the skin and subcutaneous adipose tissue in the right thoracic region along the edge of the costal arch in the projection region of 8 ribs, 60 mm in size. Within the intended boundaries, the fascia of the rectus abdominis muscle, 60 × 30 × 1 mm, was dissected.

By the method of blunt and acute dissection of the muscles of the anterior abdominal wall, access was made to the cartilage of the 8th rib. A cartilage fragment of 8 ribs was taken for a cartilaginous autograft with a size of 20 × 50 mm. The wound was sutured in layers with interrupted sutures with vicryl 4/0 and prolene 4/0 thread. Active drainage installed.

The costal auto-cartilage is crushed to shavings. A hermetically sutured cylinder is created from the fascia of the rectus abdominis muscle, one end of which is left free. Then cartilage shavings from the rib were introduced into it. The edges of the obtained fascial-cartilaginous autograft are sutured. The autograft size is 20 × 10 mm.

Then, a prepared fascial-cartilaginous autograft is installed in a preformed receptive bed in the area of the base of the nasal notch.

In the area of the columella, interrupted sutures were made with the threads of Lonsorb 5/0, prolene 5/0. Hemostasis during surgery.

In the postoperative period, the patient underwent conservative antibacterial, analgesic and desensitizing therapy. Sutures were removed on the 9th day.

As a result of the operation according to the proposed method, the volume of soft tissues in the area of the base of the columella is increased.

The follow-up was 2, 6 and 12 months. Long-term postoperative outcome is good. On the control photometry after 6 and 12 months, no relapse of the deformity was detected.

According to this method, 13 patients with good aesthetic results were operated on.

The proposed method has several advantages, such as:

- Due to the fact that for the collection of the surface plate of the fascia of the rectus abdominis muscle and costal cartilage using one surgical approach, this helps to reduce surgical injury.

- Fascia prevents the migration of fragments of cartilage shavings in it after installation in the recipient area and allows you to achieve a more favorable aesthetic result.

- This method allows you to increase the volume of soft tissues in the area of the base of the columella, contributing to a more stable aesthetic result.

- When sampling the surface plate of the fascia of the rectus abdominis muscle, it becomes possible to take a wider fragment of the fascia, providing the necessary volume to create several autografts.

Claims (1)

A method of increasing the volume of soft tissues in the region of the base of the columella with congenital bilateral cleft lip and palate using an incision of the soft tissues of the nose and upper lip, their dissection, access to the periosteum at the base of the nasal notch, the formation of a perceiving bed in this area, followed by placement of an autograft containing cartilage shavings obtained from the rib into the formed receptive bed and suturing of the incision, characterized in that the incision of soft tissues is carried out in one of the nasal passages along the edge of the colum alla, further to the base of the vestibule of the nasal cavity, and a fascial-cartilaginous autograft in the form of a cylinder 20-30 mm long, 9-10 mm in diameter, 1-1.5 mm wall thickness obtained from the surface plate of the fascia rectus muscle is used as an autograft and filled with cartilage chips, followed by placement of the fascial-cartilaginous autograft into the formed receptive bed.

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