Saddle Rhinoplasty

Generally speaking, the saddle nose is more serious, and there are many defects in the nasal bone or cartilage. The best treatment time: general surgery is recommended to be treated after the initial diagnosis of the disease, special surgery should be prescribed. Treatment of diseases: nasal traumatic nasal bone fracture Indication Generally speaking, the saddle nose is more serious, and there are many defects in the nasal bone or cartilage. Contraindications No relevant information. Preoperative preparation (1) For the materials to be filled, bone, cartilage, ivory, dental plastics and other plastics such as polyethylene silica gel can be used. Bone and cartilage can be taken from the patient itself, and it is relatively easy to survive due to less irritation of the tissue. I have taken the cartilage from the sixth or seventh rib. The advantage of cartilage is that it is easy to cut and can be cut into a suitable shape at any time during surgery, but the disadvantage is that it may be absorbed and contracted. Bone grafts are harvested from the humerus and removed with an electric drill to form the desired shape. Other artificially produced plugs include ivory, dental plastics, polyethylene, silica gel, Teflon, and the like. Ivory and dental plastics are less irritating to tissues; polyethylene, silica gel and Teflon are soft plastics, which are less irritating to tissues, but soft in texture, and are soft and comfortable to fill in the nose. In addition to the other parts of the body, the tamponade of the extracorporeal substance can be prepared by inserting several different sizes and shapes in advance for the operation. The shape of the stuffing is roughly divided into two categories. One type is a fusiform shape, which is suitable for filling the concave portion of the saddle nose; the other type is "l" shape. It is also suitable for filling the upper part of the nose of the saddle portion of the saddle nose. Generally hard plastic or self-bone is only suitable for making a fusiform packing. Cartilage or soft plastic is not easy to break, so it is more appropriate to make "l" shaped stuffing. (2) Production of plastic stuffing: Plastic stuffing has two kinds of shuttle-shaped models and "l"-shaped models, which are described below. Shuttle model (1) Dental plastic: The dental wax sheet is softened and placed in the saddle nose of the patient, and is pinched to a more ideal shape. After the wax is hardened, it is removed and the edges are trimmed to obtain the shape of the desired stuffing. The wax model is placed in the dental copper mold box and poured with gypsum. After the gypsum is completely dried, the upper and lower halves of the copper mold box are opened, and the wax mold is baked on the alcohol lamp. After the wax mold is melted, it is absorbed by the gypsum. , leaving a negative mold on the plaster. The dental plastic powder is made into a paste with banana water, poured into the gypsum negative mold, and then the two halves of the copper mold box are covered and tightened. Put the copper mold box into a water pot and boil for half an hour, take it out, and then open it after cooling to obtain a plastic mold. Use an electric drill to remove excess plastic and polish it to form a plastic tampon. Due to the trouble of production, it has been replaced by a silicone mold. (2) Ivory: It is rarely used because of production difficulties. According to the above method, the model is made of wax for dental use. Use the ivory rectangular stamp of the same length to cut the ivory stamp diagonally into two triangular columns. Round the right angle with a cymbal (or electric drill), which is equivalent to the roundness of the bridge of the nose. According to the sagging of the saddle nose, the bottom wall of the triangular column is curved into an arc shape, so that the triangular column is substantially a 90-degree melon-shaped shape, but the bottom wall of the cross-section does not have a convex arc shape, nor is it a flat bottom of the original triangle. However, in order to fit the bulge of the bridge of the nose, it is formed into a concave arc, so that the final model is basically the same as the wax model. (3) bone transplantation: generally taken from the lateral side of the humerus. It can be performed under local injection anesthesia. On the lateral side of the waist, an 8 to 10 cm incision was made along the humerus to reach the edge of the humerus. The periosteum and the muscular layer of the medial and lateral sides of the iliac crest were removed with a periosteal stripper. In the outer layer of the cortex, a long and thin deep groove is cut with a wide bone. The outer side of the inner cortex is also cut into a deep groove to free a large piece of cancellous bone. The bone is cut into pieces by a thin curved chisel, and the tissue skin and the like are layered and sutured. The whole piece of cancellous bone taken out is trimmed into a desired shape with a large rongeur and a round chisel (be careful not to smash the bone when trimming). Generally, a general shape can be trimmed, but the honeycomb structure of the cancellous bone often cannot trim a more detailed transplant model. 2. "l" shaped model (1) Cartilage: Generally use autologous cartilage, taken from the sixth or seventh costal cartilage on the right side. General anesthesia can be performed by local injection plus intercostal nerve block anesthesia or general anesthesia. On the sixth or seventh rib of the right chest, obliquely outward from the right side of the sternum, make an incision of about 10 cm, cut the skin, and the muscle layer directly reaches the cartilage. The tissue on the cartilage was peeled off, and the costal cartilage was exposed to about 4 to 5 cm. The cartilage is cut along the middle of the rib cartilage surface, the length is equivalent to the length to be intercepted, and a transverse incision is made on the perforated membrane at both ends of the truncated preparation. The incision cartilage membrane was peeled off with a stripper, the cartilage was exposed, and the cartilage was separated from the cartilage by the cartilage with a relatively curved stripper, and the lower end was cut off first. The lower end of the cartilage was cut with a small round knife, and the lower end of the cartilage was protected with a stripper under the cartilage. Then the cartilage is lifted, and the cartilage is removed from the cartilage underneath under direct vision, and the adhesion between the two is generally tight. When peeling off to the upper end, the stripper pad is cut to cut the cartilage below. After removing the cartilage, the remaining ends should be polished. Such as perforation of the cartilage membrane. Apply a silk thread or a suture. Use a saline cotton ball to hold the perforation before suturing to reduce air inhalation. The incision was sutured layer by layer, bandaged, and fixed with a strip of tape on the outside. The tape should be wound from the contralateral side of the sacral line to the contralateral sacral line to reduce respiratory movements, making the patient more comfortable after surgery. The "l" shaped cartilage removed from the sixth or seventh rib was carved into the desired shape on a sterile wooden board using a No. 15 scalpel. The cartilage to be engraved consists of two parts. The longer part of the "l" shape or the sternal end of the cartilage is carved into the nasal dorsal segment; the shorter part of the "l" shape or the cartilage end is carved into a vertical section, and the bottom of the vertical section should be fixed in the bottom of the septum or Nasal spine. When carving the length and height of the nasal back, the longer end should be cut into a nasal back model according to the model originally made of wax on the nose or the result measured at the time of surgery. The vertical segment is attached to the short segment of the cartilage and is cut according to the shape of the nose into a section at right angles to the nasal dorsal segment, which corresponds to the underside of the transplanted nasal column. Both segments are adhered by the perichondrium. If the nose segment is too long, the excessive length can be cut off. If the height of the vertical segment is too high, the excess portion is obliquely cut. The back of the nose is engraved to make it suitable for the nasal back, and the inner side of the middle septum is carved to fit the septum. In addition, it should be noted that the larger the support portion, the stronger the fixation. The upper end should be carved into an obtuse angle. It should not be carved into a pointed disc shape like ivory or dental plastic, so that the nose bridge made is relatively firm. The vertical section is gradually thinned approximately the same as the thickness of the septum. The cartilage carved at this time can be prepared for transplantation. (2) Plastic: Polyethylene and silica gel are semi-transparent plastics. Their properties are similar to waxes. They can be softened and melted after being heated on the fire. After cooling, they are formed. Therefore, it is easy to make various filling models. Easy to modify at the time of surgery. Take a polyethylene sheet, the size is about 6.0cm × 3.0cm × 0.1cm (if there is no flat sheet at hand, it can be softened on the fire with polyethylene or silica gel and other materials, spread out and rolled into thin slices), plastic After the sheet is softened, the vertical shape is folded into a right angle. However, the folded angle should not be edged and should be rounded according to the shape of the nose. According to the length from the patient's nose to the tip of the nose and the height of the nose, a curved cut is made at one end of the plastic sheet. The length of the ends of the curved line is equivalent to the length from the nose to the upper part of the nose. The curved line is off the center line. The farthest point is equivalent to the height required for the nose. Centered on the fold line, each side has an arc-shaped slit. The upper end of the curved line meets at the top edge of the plastic sheet. The lower ends of the curved tangent are separated by about 3 to 5 mm, and then cut parallel to the longitudinal axis. To the lower end of the plastic sheet. In order to make the shape of the cut into two sides symmetrical, the paper can be folded in half, cut into a desired shape and then spread on the plastic sheet, and then cut with a knife. The cut two-lobed curved flank can be engraved with small holes so that after filling the nose, the granules can grow into scar tissue and fix the plastic model. A piece of plastic left after cutting under the curved flap is softened under the curved flap (ie at the tip of the nose). The lower end is bent inwardly to form a pillar of the nasal column, which is at an angle of about 90° to the longitudinal axis of the original bridge of the nose, and then the plastic which constitutes the pillar of the nose column is softened and then folded into a thin strip-shaped pillar according to the longitudinal axis. The struts are equivalent to the length of the maxillary nasal spine to the subcutaneous tip of the nose. After the tail end is softened, cut it slightly and make it into a fork. After filling it, you can ride across the sides of the nose and spine without shifting and twisting. The city has a pre-made silicone saddle nose mold that can be applied with a little trimming. Surgical procedure 1. The incision used in the past to use the intranasal incision to cut the skin between the septum and the nasal column, and then enter the subcutaneous tissue of the nasal back. However, in addition to a surgical scar on the outside of the nose, the intranasal incision can not be applied to raise the tip of the nose. However, the incision at the bottom of the nose is actually not obvious, in terms of disinfection or surgical operation. It is superior, especially for installing the "l" shape model. There are two types of common nasal incisions. One is to make a continuous incision from the tip of the nose down the small column; the other is from the front end of the nasal column, making a "t" shaped incision along the leading edge of the nostril. It can be used as needed during actual operation. 2. Use small scissors to extend into the nose and back from the incision, while peeling and cutting, separating the adhesion between the nasal bone and the subcutaneous tissue of the nasal back. From the top of the eyebrow to the outside of the upper back of the nose, the nasal bone and the subcutaneous tissue must be completely relaxed. 3. If you are in a fusiform model, you can put it in. To observe the shape correction of the nose, you should first pay attention to whether the base of the model and the saddle nose are concave. If the tip of the nose is pressed, will the nose of the model be lifted? . If the substrate is not suitable, the model is prone to distortion and deformity. If it is too large or the substrate is not suitable, it can be modified appropriately; if it is too small, it can be replaced by a larger model. 4. If the "l" shape model is used, it should be separated in the middle of the septum column until the bottom of the nasal column, down to the maxillary nasal spine. If the transplant model is autologous cartilage, the septum should be separated and placed in the model. If it is a soft plastic model, the model can be folded and placed. The pillars of the nasal column can also be folded up into the nose and released. Note that although the model is placed in the nasal column, there is a pillar in the nasal column. When the nose tip is pressed, the nose of the model is not lifted, but the tension should not be too large. Otherwise, the blood supply to the nasal skin of the nose may be hindered, causing necrosis to cause the model to pass through. Especially the plastic model is more likely to cause surgery failure. Therefore, if the tension is too large, the model can be taken out and repaired until it is completely tension-free. 5. If the nasal shape correction is satisfactory, the incision skin can be sutured with silk thread. A little gauze on the back of the nose, with a nose support (made of dental proofing or aluminum) and a tape to fix the nose shape without deformation. complication Infection: The cause of the infection may be the following: (1) Hematoma formation in the operating cavity, leading to secondary infection. (2) The model is not disinfected. (3) Foreign body stimulation may be caused by impure plastic texture. Therefore, when selecting plastics, plastics with less impurities should be selected as much as possible. If it is a dental plastic, it should be made of plastic powder without dyeing, and should be carefully disinfected. The surgical field should be fully hemostasis before placing the graft. The stent should be pressure-fixed after surgery.

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