RU2815472C1 - Method for preserving stability of cartilaginous part of middle vault of nasal dorsum after surgical intervention using two continuous blanket sutures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to plastic, maxillofacial and ENT surgery. An optimum projection, contours, height and width of a dorsum of the middle nasal vault are formed. For this purpose, two vertical longitudinal incisions are made in the area of the upper lateral cartilages according to the levels of paramedial osteotomies, incision lines are sutured with a continuous blanket suture so that the suture lines intersect to form a cross-shaped figure. For this purpose, the first round of the suture is applied vertically, in the direction from inside to outside and from below up to cephalic edges of upper lateral cartilages. Then second round of suture is applied vertically, in direction from outside to inside, from top to bottom, returning to first point of prick-in. Further, the mucocutaneous flap is placed in place, after which the obtained aesthetic result is visually assessed. Intranasal splints are inserted into the nasal cavity and fixed with one interrupted suture, which are removed on an outpatient basis on the third day. A bandage of strips is applied on the nose; an external thermoplastic nasal splint is fixed, which is removed on an outpatient basis on 14th day.

EFFECT: method enables preserving the stability of the cartilaginous portion and forming the aesthetic contour of the nasal dorsum after the surgical intervention.

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Description

The invention relates to the field of medicine, to plastic, maxillofacial and ENT surgery, and can be used in the treatment of patients with deformities of the osteochondral part of the nose to recreate an aesthetically correct nasal anatomy. A method has been proposed to maintain the stability of the cartilaginous part and form the aesthetic contour of the nasal dorsum after surgery using two continuous wrapping sutures. Can be used by plastic, maxillofacial and ENT surgeons in surgical hospitals as part of the treatment algorithm for patients with deformities of the osteochondral part of the nose.

In patients with nasal deformities with minor rhinokyphosis, a combination of preserving conservative plastic techniques and surgical techniques of structural rhinoplasty is used. The narrowing of the middle vault, which forms at the site of attachment of the cephalic sections of the upper lateral cartilages to the nasal bones and the attachment of the medial sections to the septum, is an important aspect in rhinosurgery that requires special attention. When excision of the ventral septum and upper lateral cartilages, it is necessary to manipulate the cartilaginous structures of the nasal dorsum, while maintaining the shape, stability and resistance of the structures. This is important for the formation of aesthetic polyhedrons and light lines of the backrest. When performing an osteotomy of the nasal bones and performing their digital folding to narrow the nasal dorsum, a springing effect of tension occurs in the area of the upper lateral cartilages; due to the rigidity of the structures, they can become compensatory, which can lead to expansion of the middle cartilaginous vault of the nose and expansion of the nasal valve.

There is a known method of tensioning the upper lateral cartilages as a single block after excision of the cartilaginous part of the hump with a covering suture to form a smooth and symmetrical contour of the nasal dorsum and pleasant dorsal aesthetic lines without visual distortion (Geissler PJ, Roostaeian J, Lee MR, Unger JJ, Rohrich RJ. Role of upper lateral cartilage tension spanning suture in restoring the dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2014 Jan;133(l):7e-11e). The closest to the claimed method is the method of narrowing the cartilaginous part of the nasal dorsum while maintaining the height, in which longitudinal excision of sections of the superolateral cartilage is carried out with further suturing with single interrupted sutures (Belousov A.E. Functional rhinoplasty / A.E. Belousov. - St. Petersburg: Publishing house - in Polytechnic University, 2010. - 287 pp.). The disadvantage of this technique is the presence of a large number of stitches and knots in the area of the back of the nose, which can subsequently be contoured or palpated under the skin.

List of drawings:

Fig. 1. Illustration of fixation of the upper lateral cartilages with a continuous enveloping suture (A - lines of osteotomy and cartilage dissection; B - a continuous enveloping suture is applied in two rounds vertically on the right and left)

Rice. 2. Intraoperative picture of the formation of a stable cartilaginous part of the middle arch of the nasal dorsum (arrows indicate continuous wrapping sutures in two rounds)

Rice. 3. Intraoperative photographs of the patient before (A - lateral view, C - superior view, E - inferior view) and after (B - lateral view, D - superior view, F - inferior view) surgical treatment

Detailed description of the invention.

The objective of the present invention is to maintain the stability of anatomical structures, height and controlled narrowing of the middle vault of the nose during rhinoplasty with the formation of aesthetic polyhedrons and light lines of the nasal dorsum when visualized from the front and in profile. The technical result of the problem is the developed method of maintaining the stability of the cartilaginous part of the middle arch of the nasal dorsum after surgery using two continuous wrapping sutures.

Technique.

After skeletonizing the dorsum of the nose, the texture is leveled at the level of the nasal bones using a rasp or an ultrasonic attachment on a piezoelectric device. At the level of the cartilaginous part of the dorsum, irregularities, deformations and thickening of the ventral sections of the septum and upper lateral cartilages are eliminated by excision with a scalpel. Then, transverse, complete lateral and paramedial osteotomies of the nasal bones are performed using a piezoelectric apparatus. Next, a vertical longitudinal incision is made in the area of the corners of the upper lateral cartilages on the right and left, the level of which corresponds to the lines of paramedial osteotomies. Thus, we relieve tension on the upper lateral cartilages. The area of cartilage lateral to the incision line lies passively in a vertical orientation. A gaping area is formed along the incision line, which must be compared and fixed with sutures to prevent significant downward displacement of the cartilage. For this purpose, Prolene 6/0 thread is used and both sides are alternately sewn with continuous twisted seams in two rounds vertically. The direction of the first round is from inside to outside and from bottom to top vertically. Then, having reached the cephalic edges of the upper lateral cartilages, we direct the suture from the outside inward from top to bottom vertically. Thus, the seam lines intersect to form a cross-shaped figure. We gradually return to the first injection point and tighten the knot. We do the same on the other side. After all sections have been worked out, the mucocutaneous flap is placed in place and, after a visual assessment of the aesthetics of the resulting result, it is sutured with PDS (Polydioxanone) 6/0 thread with simple interrupted sutures. Air-conducting intranasal splints are installed and fixed into the nasal cavity with one interrupted suture, which are removed on an outpatient basis on the third day. A bandage made of narrow and wide strips is applied to the nose.

An external thermoplastic nasal splint is fixed and removed on an outpatient basis on the 14th day.

Clinical studies and practical use of the proposed preservation of the stability of the cartilaginous part of the middle arch of the nasal dorsum after surgery using two continuous wrapping sutures were carried out in the Lancet clinic, Moscow, and showed its high effectiveness.

The claimed method of maintaining the stability of the cartilaginous part of the middle arch of the nasal dorsum after surgery using two continuous wrapping sutures provided the correct anatomical shape, optimal width, height, and aesthetic contours of the dorsum in patients with deformities of the osteochondral part of the nose.

The proposed method is available to plastic, maxillofacial and ENT surgeons. Allows you to maintain the stability of structures and form the optimal shape, projection, required width and height of the nasal bridge, minimize surgery time, and prevent postoperative complications.

Fixation of the upper lateral cartilages with a continuous enveloping suture: see fig. 1 A-B

The implementation of the proposed method of maintaining the stability of the cartilaginous part of the middle arch of the nasal dorsum after surgery using two continuous wrapping sutures is illustrated by the following clinical example.

Clinical example 1

Patient A., 27 years old, was admitted to the clinic with a diagnosis of “Congenital deformity of the osteochondral part of the nose.” Complaints about an ugly nose, aesthetic disharmony of the face. I contacted the Lancet clinic. General condition is satisfactory. According to the external examination, irregularities in the dorsum and a wide cartilaginous part of the nasal arch and an unshaped tip of the nose are noted. According to anterior rhinoscopy: the nasal mucosa is pink, moist, without signs of inflammation. According to CT (computed tomography) data, deformation of the osteochondral part of the nose is noted. The diagnosis was made: “Congenital deformation of the osteochondral part of the nose.” Surgical treatment including rhinoseptoplasty is recommended. The patient is fully prepared for surgery according to the standards of medical care. After the patient was introduced into the ETN under conditions of controlled hypotension, the nasal cavity was treated with an antiseptic solution. Primary infiltration anesthesia Sol was performed. Ropivacaini 5 mg/ml (6 ml) from the side of the nasal cavity in the area of the septum, wings and lateral slopes of the nose. The surgical field is completely processed. Repeated infiltration anesthesia Sol was performed. Ropivacaini 5 mg/ml from the side of the nasal cavity in the area of the septum, wings and lateral slopes of the nose. The nasal cavity has been sanitized. In the left nasal passage, at a distance of approximately 1 cm from the edge of the columella, using a No. 15c scalpel, a vertical incision was made in the mucous membrane of the nasal septum from the upper border of the internal valve to the projection of the inferior nasal spine. Subperichondrial and subperiosteal detachment of the mucous membrane of the nasal septum was performed on both sides in the cartilaginous and bone parts, respectively. All visible deformations of the nasal septum have been eliminated. Precartilaginous incisions were made in the left and right nasal passages with a No. 15c scalpel, moving from the lateral to the medial pedicle of the lower lateral cartilages and then moving to the columella. Using a raspator, subperichondrial detachment of soft tissues from the lower and upper lateral cartilages of the nose was performed. The left and right inner valve areas have been carefully traversed. Next, access to the bony part of the lateral slopes and dorsum of the nose is created. Subperiosteal detachment of soft tissues was performed up to the root of the nose and slightly short of the medial corners of the eyes. All visible small vessels are coagulated along the course of the detachment. Irregularities in the osteochondral part of the nasal dorsum have been eliminated. A piezoelectric device was used to perform transverse, complete lateral and paramedial osteotomies of the nasal bones. Next, vertical longitudinal incisions were made in the upper lateral cartilages on the right and left, the level of which corresponds to the lines of paramedial osteotomies. The gaping area along the cut line is compared. Next, using Prolene 6/0 thread, both sides are sutured alternately with continuous twisted sutures in two rounds vertically. The dissected inferior lateral nasal cartilages are remodeled by resection of the cephalic and caudal margins and the use of suture techniques. After all sections have been worked out, the mucocutaneous flap is placed in place and, after a visual assessment of the aesthetics of the resulting result, it is sutured with PDS (Polydioxanone) 6/0 thread with simple interrupted sutures. Air-conducting intranasal splints are installed and fixed into the nasal cavity with one interrupted suture. A bandage made of narrow and wide strips is applied to the nose. An external thermoplastic nasal splint is fixed. There were no signs of nosebleeds. The patient was recovered from anesthesia and transferred to the intensive care unit for follow-up. The patient underwent rhinoseptoplasty with preservation of the stability of the cartilaginous part of the nasal dorsum and the formation of aesthetic lines (Fig. 2). Intraoperatively, the optimal projection, contours and width of the nasal dorsum were obtained (Fig. 3 A-F) through the use of a continuous wrapping suture in two vertical rounds on the cartilaginous part of the middle vault of the nose according to the author's chronology. Three days later, the intranasal splints were removed, after 2 weeks the external splint was removed and the sutures were removed. The patient was observed 1, 3, 6 months and 1 year after surgery. No complications were identified in the early and late postoperative periods. Stable anatomy and aesthetics of the nasal dorsum have been achieved.

Claims (1)

A method of maintaining the stability of the cartilaginous part of the dorsum of the middle vault of the nose after surgery using wrapping sutures, characterized by the formation of the optimal projection, contours, height and width of the dorsum of the middle vault of the nose, for this purpose two vertical longitudinal incisions are made in the area of the corners of the upper lateral cartilages according to the levels paramedial osteotomies, sew the incision lines with a continuous wrapping suture so that the suture lines intersect to form a cruciform figure, for this the first round of the suture is applied vertically, in the direction from the inside out and from bottom to top to the cephalic edges of the upper lateral cartilages, then the second round of the suture is applied vertically , in the direction from the outside to the inside from top to bottom, returning to the first injection point, then the mucocutaneous flap is put in place, after which the aesthetic result is visually assessed, air-conducting intranasal splints are installed and fixed in the nasal cavity with one interrupted suture, which are removed on an outpatient basis on the third day , a strip bandage is applied to the nose, an external thermoplastic nasal splint is fixed, which is removed on an outpatient basis on the 14th day.