RU2804808C1 - Method for providing access during reduction of hyperplastic structures of periorbital part of frontal bone - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: intended for use in plastic surgery when performing surgical correction of the structures of the periorbital part of the frontal bone. A combined transpalpebral-transcalvar surgical approach is formed, consisting of a vertical incision in the frontal region above the hairline along the midline 1.5 cm long, an incision in the hairy part of the left temporal region 1.5 cm long, drawn through a perpendicular to the line connecting the lateral angle eyes and wing of the nose, and a symmetrical incision in the right temporal region, 1.5 cm long, skin incisions in the area of the palpebral folds of the left and right upper eyelids, 2.5 cm long, for visualization and reduction of bone tissue of the frontal region.

EFFECT: method eliminates the formation of an extended scar in the socially significant zone of the frontal region along the border of hair growth, as well as the formation of a visualized extended zone of alopecia along the scar line in the scalp.

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Description

The present invention relates to medicine and is intended for use in plastic surgery when performing surgical correction of the structures of the periorbital part of the frontal bone: superciliary arches, glabella and orbital edges of the frontal bone.

Hyperplasia of the brow ridges, glabella and orbital edges of the frontal bone are a consequence of a local increase in the volume of bone tissue of the frontal bone due to the proliferation of compact and spongy bone. This condition occurs as a result of hormonal disorders in the body or congenital features of the shape and structure of the frontal bone. To date, in medicine, when correcting facial proportions, the most effective are surgical methods that involve changing the volume of bone tissue by reducing it due to mechanical destruction and removal. These operations undoubtedly require careful planning; the technology of execution should result in effectiveness with low trauma and invisibility of the marks of the surgical treatment performed.

There are a significant number of surgical techniques described in the literature, including various methods of accessing the bone structures of the brow ridges, glabella and orbital edges of the frontal bone, and methods of mechanical impact on bone tissue. One of the described methods [1] involves performing surgical access through a shaped incision of the skin and soft tissues, which is made along the border of hair growth from the left temporal region to the right temporal region. Then, with a sharp rasp, dissection is carried out in the subperiosteal layer of the frontal region, caudal to the upper edge of the orbit, the frontonasal bone suture and the zygomatic arches on the left and right, thereby visualizing the bone structures of the periorbital part of the frontal bone. The supraorbital and supratrochlear neurovascular bundles are visualized and left intact along their length. Next, a medical cutter is used to reduce bone tissue in the area of the brow ridges, glabella and orbital edges of the frontal bone. Then the soft tissues of the frontal region are refixed to the osseous base. Then the skin is sutured.

The closest analogue is the method [2], in which, to provide access, an incision is made in the skin and underlying soft tissue to the bone at an angle of 45° along the border of hair growth, or behind it, through the scalp, from the left temporal region to the right temporal region . After that, a dissection is carried out in the subperiosteal layer with a raspatory, exposing and visualizing the bone structures of the frontal region. The supraorbital and supratrochlear neurovascular bundles are visualized and preserved along their length. Then, using a medical cutter, bone tissue is reduced in the area of the brow ridges, glabella and orbital edges of the frontal bone. Next, refixation of the soft tissues and layer-by-layer suturing of the scalp wound are performed.

For a better understanding of the method of forming the surgical access of the closest analogue, figures 1-2 are shown, where

Fig 1. Scheme of the skin incision in the projection of the coronal suture.

Fig 2. Scheme of the skin incision along the hair growth border.

The general disadvantages of the methods are that an extended skin incision is made on the face in the visible area of the frontal region along the border of hair growth, as a result of which the line of the skin incision leaves behind a clearly visualized extended scar in a socially significant area of the face; An extended incision is made in the scalp, which results in damage to the hair follicles lying at an angle and the formation of a visualized extended zone of alopecia along the line of the formed scar.

Objectives: To exclude the formation of an extended scar in the socially significant zone of the frontal region along the border of hair growth, the formation of a visualized extended zone of alopecia along the scar line in the scalp.

The essence of the invention is that a combined transpalpebral-transcalvar surgical approach is formed, consisting of 1 vertical incision in the frontal region above the hair growth line along the midline 1.5 cm long, an incision in the scalp of the left temporal region 1.5 cm long drawn through a perpendicular to the line connecting the lateral corner of the eye and the wing of the nose and a symmetrical incision in the right temporal region, 1.5 cm long, skin incisions in the area of the palpebral folds of the left and right upper eyelids, 2.5 cm long.

Technical result: the method eliminates the formation of an extended scar in the socially significant zone of the frontal region along the border of hair growth, the formation of a visualized extended zone of alopecia along the scar line in the scalp, due to the formation of a combined transpalpebral-transcalvar surgical approach, consisting of 1 vertical incision in the frontal area above the border of hair growth along the midline 1.5 cm long, a 1.5 cm long incision in the hairy part of the left temporal region drawn through a perpendicular to the line connecting the lateral corner of the eye and the wing of the nose and a symmetrical incision in the right temporal region 1.5 cm long cm, skin incisions in the area of the palpebral folds of the left and right upper eyelids, 2.5 cm long.

The method was tested on eight patients. The overall result was the exclusion of the formation of both an extended scar in the socially significant zone of the frontal region along the border of hair growth, and the formation of a visualized extended zone of alopecia along the scar line in the scalp

For a better understanding of the general principles of the operation, Figures 3-11 are shown, where:

Fig. 3: Scheme of preoperative marking of skin incisions, where position 1 is an incision in the frontal region along the midline, position 2 is incisions in the temporal regions, position 3 is incisions along the palpebral folds of the eyelids. Fig. 4: The hairy part of the temporal region, where position 2 is a skin incision in the temporal region.

Fig. 5: Subperiosteal dissection of the frontal bone, where position 4 is a hypertrophied brow ridge, position 5 is the supratrochlear and supraorbital neurovascular bundles.

Fig. 6: Upper eyelid, where position 3 is a skin incision along the palpebral fold. Fig. 7: Dissection of the orbicularis oculi muscle.

Fig. 8: Dissection of the periosteum of the orbital edge of the frontal bone FIG. 9: Merging dissection planes

Fig. 10: Periorbital part of the frontal bone, view through the palpebral component of the approach, where position 4 is the hypertrophied brow ridge, position 5 is the supratrochlear and supraorbital neurovascular bundles.

Fig. 11: Reduction of bone tissue with a cutter, where position 4 is a hypertrophied brow arch, position 6 is a bur attachment for a physiodispenser.

The method is carried out as follows. Before the operation, the planned incisions are marked in the frontal region (Fig. 3, item 1), temporal areas (Fig. 3, item 2), along the palpebral folds of the eyelids (Fig. 3, item 3). The intervention is carried out in an operating room under general anesthesia. According to the preoperative markings, a transpalpebral-transcalvar surgical approach is formed. After a 1.5 cm skin incision in the scalp of the frontal region along the midline, an incision in the scalp of the left temporal region made through a perpendicular to the line connecting the lateral corner of the eye and the wing of the nose 1.5 cm long and a symmetrical incision in the right temporal region 1.5 cm long cm (Fig. 4, item 2), a standard dissection of the frontal region is performed in the subperiosteal layer, with visualization of the structures of the periorbital part of the frontal bone: brow ridges, glabella (Fig. 5, item 4), orbital edges and visualization and preservation throughout supraorbital and supratrochlear neurovascular bundles (Fig. 5, item 5), under visual control using video endoscopic equipment. Then, 2.5 cm long incisions are made in the skin and orbicularis muscle of the upper eyelids in the area of the palpebral folds (Fig. 6, item 3). Through the palpebral incisions, the orbital part of the left and right orbicularis oculi is dissected (Fig. 7), then dissection of the periosteum of the upper edge of the orbit (Fig. 8), left and right, and unite the dissection planes (Fig. 9). Using a medical cutter, sequentially through the left and right transpalpebral approaches, under visual control (Fig. 10.), bone tissue reduction is performed using a medical cutter (Fig. 11, item 6) of the structures of the frontal bone: hyperplastic glabella, left and right brow bones arches (Fig. 11, item 4) and orbital edges of the frontal bone, respectively. The flap of the upper zone of the face is fixed with percutaneous intraosseous removable screws to the frontal part of the cranial vault at the projection points of the transition zone of the body of the eyebrow to the tail. The left and right orbicularis oculi muscles are sutured with interrupted sutures using PDS 4-0 thread. The eyelid skin is closed with a 6-0 Prolene intradermal continuous matching suture. The skin incisions of the frontal and temporal areas are sutured with a continuous matching suture using 5-0 Prolene suture. Apply Umnistnp tapes and an aseptic pressure bandage with a self-fixing Peha-haft bandage (Paul Hartmann, Germany)

Example 1

Patient X., 28 years old, was admitted to the Center for Plastic and Reconstructive Surgery with a diagnosis of hyperplasia of the brow ridges.

Examined.

On April 29, 2021, surgical treatment was carried out as planned: Transcalvar-transpalpebral reduction of the brow ridges.

For a better understanding, example 1 shows figures before and after 6 months of surgery - 12-17, where:

Fig. 12: Right profile view before surgery

Fig. 13: Frontal view before surgery

Fig. 14: Left profile view before surgery

Fig. 15: Profile view on the right after surgery

Fig. 16: Frontal view after surgery

Fig. 17: Left profile view after surgery

The method was carried out as follows. Before the operation, the planned incisions were marked in the frontal region (Fig. 3, item 1), temporal areas (Fig. 3, item 2), along the palpebral folds of the eyelids (Fig. 3, item 3). The intervention was performed in an operating room under general anesthesia. According to the preoperative markings, a transpalpebral-transcalvar surgical approach was formed. After a 1.5 cm skin incision in the scalp of the frontal region along the midline, an incision in the scalp of the left temporal region made through a perpendicular to the line connecting the lateral corner of the eye and the wing of the nose 1.5 cm long and a symmetrical incision in the right temporal region 1.5 cm long cm (Fig. 4, item 2), performed a standard dissection of the frontal region in the subperiosteal layer, visualized the structures of the periorbital part of the frontal bone: brow ridges, glabella (Fig. 5, item 4), orbital edges and visualized and preserved the supraorbital and supratrochlear neurovascular bundles (Fig. 5, item 5), under visual control using video endoscopic equipment. The method is carried out as follows. Before the operation, the planned incisions are marked in the frontal region (Fig. 3, item 1), temporal areas (Fig. 3, item 2), along the palpebral folds of the eyelids (Fig. 3, item 3). The intervention is carried out in an operating room under general anesthesia. According to the preoperative markings, a transpalpebral-transcalvar surgical approach is formed. After a 1.5 cm skin incision in the scalp of the frontal region along the midline, an incision in the scalp of the left temporal region made through a perpendicular to the line connecting the lateral corner of the eye and the wing of the nose 1.5 cm long and a symmetrical incision in the right temporal region 1.5 cm long cm (Fig. 4, item 2), a standard dissection of the frontal region is performed in the subperiosteal layer, with visualization of the structures of the periorbital part of the frontal bone: brow ridges, glabella (Fig. 5, item 4), orbital edges and visualization and preservation throughout supraorbital and supratrochlear neurovascular bundles (Fig. 5, item 5), under visual control using video endoscopic equipment. Next, incisions were made in the skin and orbicularis muscle of the upper eyelids in the area of the palpebral folds (Fig. 6, item 3), 2.5 cm long. Through the palpebral incisions, the orbital part of the left and right orbicularis oculi was dissected (Fig. 7), then dissection of the periosteum of the upper edge of the orbit (Fig. 8), left and right, and combined the dissection planes (Fig. 9). With the help of a medical cutter, sequentially through the left and right transpalpebral approaches, under visual control (Fig. 10.), bone tissue reduction was performed using a medical cutter (Fig. 11, item 6) of the brow ridges (Fig. I, item 4) left and right respectively. The flap of the upper facial zone was fixed with percutaneous intraosseous removable screws to the frontal part of the cranial vault at the projection points of the transition zone of the body of the eyebrow to the tail. The left and right orbicularis oculi muscles were sutured with interrupted sutures using 4-0 PDS thread. The eyelid skin was closed with a 6-0 Prolene intradermal continuous matching suture. The skin incisions of the frontal and temporal areas were closed with a continuous matching suture using 5-0 Prolene suture. Taped with Omnistrip strips and applied an aseptic pressure bandage with a self-fixing Peha-haft bandage (Paul Hartmann, Germany)

The postoperative period proceeded as standard, without complications, the edges of the wound were aligned without bleeding or complications, the function of the facial muscles was preserved. He was discharged on the 3rd day. An extended skin incision in a socially significant visible area of the face is excluded.

Example 2

Patient A., 38 years old, was admitted to the center of plastic and reconstructive surgery with a diagnosis of hyperplasia of the orbital edges of the frontal bone.

Examined.

On December 23, 2020, surgical treatment was performed as planned: Transcalvar-transpalpebral reduction of the orbital edges of the frontal bone.

For a better understanding, example 2 shows figures where:

Fig. 18: Right profile view before surgery

Fig. 19: Frontal view before surgery

Fig. 20: Left profile view before surgery

Fig. 21: Orbital margin of the frontal bone visualized through the palpebral approach.

Fig. 22: Profile view on the right after surgery

Fig. 23: Frontal view after surgery

Fig. 24: Left profile view after surgery

The intervention was performed in an operating room under general anesthesia. Before the operation, the planned incisions were marked in the temporal, frontal areas, along the palpebral folds of the upper eyelids. According to the preoperative markings, incisions were made in the temporal and frontal areas. A standard dissection of the frontal region was performed in the subperiosteal layer, with visualization of the structures of the periorbital part of the frontal bone: brow ridges, glabella, orbital margins, the supraorbital and supratrochlear neurovascular bundles were visualized and preserved along the length under visual control using video endoscopic equipment. Then, incisions were made in the skin and orbicularis muscle of the upper eyelids in the area of the palpebral folds. Next, the periosteum of the upper edge of the orbit was dissected and the dissection planes were united. Using a medical cutter, sequentially through the left and right transpalpebral approaches, under visual control (Fig. 21), reduction of the bone base of the hyperplastic left and right orbital edges of the frontal bone was performed, respectively. The flap of the upper zone of the face was fixed with percutaneous intraosseous removable screws to the frontal part of the cranial vault at the projection points of the transition zone of the body of the eyebrow to the tail. The orbicularis oculi muscles were sutured with interrupted sutures using PDS 4/0 thread. The eyelid skin was sutured with an intradermal continuous matching suture of Prolene 6/0. Skin incisions of the frontal and temporal areas were sutured with a continuous matching suture using Prolene 5/0 thread. Omnistrip tapes and an aseptic pressure bandage with a self-fixing Peha-haft bandage (Paul Hartmann, Germany) were applied.

The postoperative period proceeded as standard, without complications, the edges of the wound were aligned without bleeding or complications, the function of the facial muscles was preserved. He was discharged on the 3rd day. An extended skin incision in a socially significant visible area of the face with the subsequent formation of a scar and alopecia is excluded.

Bibliography

1. K. Altman “Facial feminization surgery: current state of the art” Int. J. Oral Maxillofac. Surg. 2012; 41: 885-894

2. Spiegel, J. H. (2019). Facial Feminization for the Transgender Patient. Journal of Craniofacial Surgery, 30(5), 1399-1402.

Claims (1)

A method for providing access for the reduction of hyperplastic structures of the periorbital part of the frontal bone, including the formation of access through a skin incision, subsequent dissection of soft tissues and visualization of the bone structures of the periorbital part of the frontal bone, visualization and preservation along the supraorbital and supratrochlear neurovascular bundles, reduction of hyperplastic glabella, superciliary arches, orbital edges of the frontal bone, refixation of a soft tissue flap, layer-by-layer suturing of wounds, characterized in that a combined transpalpebral-transcalvar surgical approach is formed, consisting of a vertical incision in the frontal region above the hair growth line along the midline 1.5 cm long, an incision in the hairy part of the left temporal region, 1.5 cm long, drawn through a perpendicular to the line connecting the lateral corner of the eye and the wing of the nose, and a symmetrical incision in the right temporal region, 1.5 cm long, skin incisions in the area of the palpebral folds of the left and right upper eyelids 2.5 cm long.