RU2774026C1 - Surgical method for the prevention of the collapse of the external nasal valve - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to otorhinolaryngology and plastic surgery. A subperichondrial dissection of the upper part of the lateral pedicle of the alar cartilage is performed, 5 mm away from the dome of the nose. An autograft is prepared from the selected cartilage - excess soft tissues and uneven edges are excised. Further, at a distance of 5 mm from the edge of the nostril, an underwing incision 3 mm long is made with the formation of a skin pocket for the installation of the prepared autograft. Then, the autograft is laterally placed in the skin pocket so that it gets into the area of ​​the defect in the lower part of the lateral pedicle of the alar cartilage. Finally, an interrupted suture with absorbable material and a fixing bandage is applied to the underwing incision.

EFFECT: method makes it possible to effectively restore nasal breathing at the level of the external nasal valve by increasing the width of the lumen of the zone of the external nasal valve and the rigidity of the valve itself with a technically simple surgical intervention, to obtain a stable aesthetic effect, to reduce the time of patients' stay in the hospital, to reduce the risk of postoperative complications and relapses of the disease.

2 cl, 1 ex, 2 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology and plastic surgery, and can be used to prevent collapse of the external nasal valve, as well as to restore nasal breathing at the level of the external nasal valve.

Difficulty in nasal breathing is one of the most common complaints of patients in the practice of an otorhinolaryngologist and plastic surgeon. Nasal tip stability is important not only in terms of physiological and anatomical functions, such as inhalation and exhalation, mimicry, and shock absorption in response to facial trauma, but also in terms of aesthetics and appearance of the nose (e.g., tip projection and tip rotation). Maintaining or creating a suitable support for the tip of the nose is important both for the immediate post-operative results and for the long-term effect during the life of the patient.

A known method for reconstructing the cartilaginous skeleton of the nasal wing with functional insufficiency of the external nasal valve, application for invention RU 2004113573. - the outer edge of the pear-shaped opening on the side of the lesion, the cartilaginous defect of the nasal wing is replaced and the replacement material is fixed to the altered cartilaginous part of the nasal wing, then the wound is sutured. The replacement material is presented in the form of a porous plate of titanium nickelide 0.15-0.20 mm thick, 3-4 mm wide, repeating the outer contour of the cartilaginous skeleton of the wing of the nose, which is installed with support on the edge of the piriform opening in the projection of the distal edge of the accessory alar cartilages and between the middle legs of the large alar cartilages, previously divided. The disadvantages of the above method are: the method is suitable only for functional insufficiency of the internal nasal valve, the use of a titanium nickelide plate makes it impossible to carry out further diagnostic and treatment methods for this person, increasing the time of surgical intervention; employment of more equipment, prolongation of the treatment process.

Also known is the "Method of surgical treatment of atresia of the nasal cavity and cicatricial narrowing of the nasal valve with the installation of a temporary silicone splint" patent for invention RU 2569462. Z-shaped plasty is performed in the direction of the greatest changes in the scar of the vestibule of the nose. Install a temporary silicone splint on the nasal septum on both sides. On the side of the operation, a silicone splint is installed with an additional section for fixing the wing of the nose to form a breathing tunnel. On the opposite side - a silicone tire without an additional section. Tires are fixed with threads at the choanal ends of the splint. Additionally, the tires are fixed with a U-shaped seam in the anterior section. An additional section of the silicone tire is fixed to the wing of the nose with a U-shaped seam. Tamponade of the nasal cavity after the operation is not performed. Conduct periodic examinations of the patient on the 2nd, 4th, 7th, 14th, 21st day of surgery. Tires are removed after 1 month. The disadvantages of this method are the discomfort of patients in the postoperative area, an additional scar after Z-shaped plasty, which can lead to a decrease in the aesthetic effect.

Known "Method of reconstructing the cartilaginous skeleton of the wing of the nose in case of functional insufficiency of the internal nasal valve", patent RU 2276586. The method consists in making intercartilaginous and trans-septal incisions in the nose in the projection of the connection of the upper lateral and large alar cartilages with continuation to the nasal septum. The nasal mucosa is exfoliated upward from the incision behind the deformed area of the upper lateral and septal cartilage, followed by the installation of a replacement material. At the same time, the replacement material is made in the form of a superelastic porous plate of titanium nickelide with a thickness of 0.15-0.20 mm, a width of 3-4 mm in the form of a spacer with a bend at an angle of 17-20°, which is installed between the outer edge of the nasal septum and the inner part superior lateral cartilage. EFFECT: method allows to prevent recurrence of functional insufficiency of the internal nasal valve.

We also found a method for evaluating a new method for nasal alar rim and valve collapse: Nasal alar rim reconstruction / Robert J. Troell, Nelson B Powell, Robert W. Riley and Kasey K. Li, Otolaryngology, Head and Neck Surgery, 2000, Vol 122, P 204-211. The authors propose an operative technique for correcting a prolapsed nasal valve by placing a cartilaginous strut along the free edge of the nasal wing. The materials used in transplantation are irradiated costal cartilage or autogenous cartilage of the auricle, or nasal septum, or irradiated allogeneic cartilage. The implantable cartilages are placed on the inner side of the wing margin from the pyriform aperture, a few millimeters short of the tip of the nose. The graft is adjusted to the appropriate valve size and removed with care so that the perichondrium on one side of the cartilage is intact to improve engraftment and reduce absorption. The incision is made in the area of the valve adjacent to the site of retraction. Subcutaneous alar pockets are created between the vestibule and the lower lateral cartilage, where the cartilage graft is inserted. The grafts are placed between the vestibule of the nose and the lower lateral cartilage. The disadvantages of this method are: the use of homologous irradiated costal cartilage, which may be subject to rejection, and the high cost of this technology limits the mass use of the technique; The use of an autograft from the navicular region is difficult to perform, and can also lead to a cosmetic and aesthetic defect of the auricle.

The closest to our proposed method is the previously developed "Method for reconstruction of the external nasal valve in case of its dysfunction" (Patent for invention RU 2627351).

We take this method as a prototype. According to the prototype, a method for the reconstruction of the external nasal valve is proposed. The authors propose an operative technique to eliminate nasal valve dysfunction by performing an alar incision, bluntly isolating the lateral pedicle along its entire length and forming a pocket in soft tissues up to the bony edge of the piriform opening, 6 mm away from the dome of the nose is excised in the lateral direction and the lateral pedicle of the lower lateral own cartilage. A replacement material (autogenous cartilage graft) in the form of a strip of quadrangular cartilage (5 mm wide, 20 mm long, 1-1.5 mm thick), taken in advance from the cartilage of the nasal septum of the operated person, is placed medially through the underwing incision - on the remaining lateral part of the lower lateral cartilage, laterally - the edge of the graft is placed in a pocket of soft tissues on the bony edge of the piriform opening; the graft is fixed by stitching the wing of the nose through with one or two sutures.

The disadvantages of the prototype, aimed at the reconstruction of the external nasal valve, are:

1. A cartilage autograft in the form of a strip of quadrangular cartilage, taken from the cartilage of the nasal septum of the operated person, must be adjusted to the required dimensions, and this is time consuming.

2. Fixation of the autograft by stitching with the remnants of the lateral pedicle of the alar cartilage through (to avoid displacement of the graft) can cause additional aggressive scarring, patient discomfort and an additional factor of wound infection.

The objective of the claimed invention is to eliminate these shortcomings of the prototype in the reconstruction of the external nasal valve, i.e. in creating a simple, reliable way to improve nasal breathing at the level of the external nasal valve, while maintaining the aesthetic parameters of the external nose, increasing social adaptation, attractiveness and self-confidence.

The technical result of the proposed method consists in the effective restoration of nasal breathing at the level of the external nasal valve by increasing the width of the lumen of the external nasal valve zone and the rigidity of the valve itself with a technically simple surgical intervention that ensures the restoration of nasal breathing function and a lasting aesthetic effect. And also, the quality of treatment is improved, the time of stay of patients in the hospital is reduced, the number of postoperative complications (cosmetic defect) and recurrence of the disease is reduced.

The technical result is achieved by the fact that during rhinoseptoplasty, retreating from the dome of the nose 5 mm, the upper part of the lateral pedicle of the alar cartilage is excised, which is subsequently used as a cartilaginous autograft. The autograft is placed through the subwing incision in the area of the defect (defect after primary rhinoplasty, or trauma, or due to degeneration of the lower part of the nasal valve) of the lower part of the lateral pedicle of the alar cartilage, in a soft tissue pocket; the underwing incision is sutured with one suture.

Distinctive features of the claimed invention from the prototype are:

1) It is not the lower part of the lateral pedicle of the alar cartilage that is removed, but the upper part, retreating 5 mm from its cephalic part, and then the upper part is superimposed on the lower part, which gives better stability and elasticity to the alar of the nose.

2) Autogenous cartilage taken from the cartilage of the lateral pedicle of the alar cartilage of the operated person is used as an autograft. The upper part of the cartilage of the lateral crus is more elastic, has the desired curve and does not require adjustment, unlike the cartilage of the nasal septum. The use of an autograft from the cartilage of the lateral pedicle saves the operation time and does not require additional fixation.

3) The installed autograft is not stitched, and, therefore, there is no additional risk for wound infection.

Thus, the proposed method is an effective, technically simple, reliable, structured, as well as cosmetically and aesthetically appropriate procedure. An autograft from the superior part of the lateral pedicle of the alar cartilage, placed in the alar of the nose, placed along the inferior margin of the alar, provides sufficient support for the margin of the alar and valve area. This procedure has proven to be an effective technique, available as well as other alternative reconstruction techniques. Improved nasal breathing of patients at the level of the external nasal valve according to the subjective sensations of patients, and patients noted a positive aesthetic effect.

Brief description of the drawings.

Figure 1. Schematic representation of the nose (a - side view, b - bottom view) - isolation of the autograft.

1 - nasal bones;

2 - lateral nasal cartilage;

3 - the upper part of the lateral leg of the alar cartilage - autograft;

4 - lateral leg of the alar cartilage;

5 - place of incision

6 - medial leg of the alar cartilage;

7 - nasal septum;

8 - nose wing.

Figure 2. Schematic representation of the nose (a - side view, b - bottom view) - autograft overlay.

3 - the upper part of the lateral pedicle of the alar cartilage - autograft.

The surgical method for preventing the collapse of the external nasal valve is as follows . During a closed rhinoseptoplasty operation, a subperichondrial dissection of the upper part of the lateral pedicle of the alar cartilage is performed. The dissection is carried out, retreating from the dome of the nose 5 mm. Similarly, the upper part of the lateral pedicle of the alar cartilage is isolated from the other half of the nose. Autografts are prepared from the isolated cartilage - excess soft tissues and uneven edges are excised. Further, retreating 5 mm from the edge of the nostril, an underwing incision 3 mm long is performed with the formation of a skin pocket for the installation of the prepared autograft. Using bayonet-shaped tweezers, the autograft is placed laterally in the skin pocket and advanced in the medial direction. Thus, the autograft enters the region of the defect in the lower part of the lateral pedicle of the alar cartilage. To prevent the autograft from jumping out, you can additionally use a second tweezers, which are placed between the "legs" of the bayonet-shaped tweezers during the installation of the autograft. At the final stage, an interrupted suture is applied to the underwing incision with absorbable material (for example, Tisorb 5.0 thread) and a fixing bandage. Similarly, manipulations are performed on the other half of the nose.

A method for preventing the collapse of the external valve of the nose was tested on 63 patients with deformity of the external nose at the age of 18 to 55 years.

A clinical example can serve as an illustration of the effectiveness of a treatment method.

Clinical example .

Patient M., 27 years old, complained of an irregular shape of the external nose, a wide tip of the nose, and deformity of the back of the nose. An otorhinolaryngological examination, examination and photo-fixation of the external nose were performed. Diagnosis - deformity of the external nose, wide tip of the nose, deviated septum. Dystrophy of the lower part of the valve of the nose. The patient underwent closed rhinoseptoplasty using our method for preventing the collapse of the external nasal valve during closed rhinoseptoplasty.

After hydroseparation, a transcartilaginous incision was made, which was started on the right in the projection of the lateral part of the lower lateral cartilage according to a pre-made marking, then the incision was continued through the skin fold of the columella behind the medial crura of the lower lateral cartilages, cutting through it. The left incision was made in the same way. After rhinoseptoplasty, in order to avoid nasal valve collapse, according to the claimed method, subperichondrial dissection of the upper part of the lateral pedicle of the alar cartilage was performed. The dissection was carried out, retreating from the dome of the nose 5 mm. Similarly, the upper part of the lateral pedicle of the alar cartilage was isolated from the other half of the nose. Autografts were prepared from the isolated cartilage - excess soft tissues and uneven edges were excised. Further, retreating 5 mm from the edge of the nostril, an underwing incision 3 mm long was performed with the formation of a skin pocket for the installation of the prepared autograft. Using bayonet-shaped tweezers, the autograft was placed laterally in the skin pocket and advanced in the medial direction. Thus, the autograft enters the region of degeneration of the lower part of the lateral pedicle of the alar cartilage. At the final stage, an interrupted suture with absorbable material (for example, Tisorb 5.0 thread) and a fixing bandage were applied to the underwing incision. Similarly, manipulations were performed on the other half of the nose.

The postoperative period was uneventful, the wound healed by primary intention. Nasal breathing has improved. A positive aesthetic effect has been achieved. The collapse of the external nasal valve in the early postoperative period and during the postoperative follow-up (1 year) was not observed.

Claims (2)

1. A surgical method for preventing collapse of the external nasal valve during closed rhinoseptoplasty, characterized in that, retreating from the dome of the nose by 5 mm, a subperichondrial dissection of the upper part of the lateral pedicle of the alar cartilage is performed, an autograft is prepared from the isolated cartilage - excess soft tissues, uneven edges are excised, then , retreating 5 mm from the edge of the nostril, an underwing incision 3 mm long is made with the formation of a skin pocket for installing the prepared autograft, then the autograft is laterally installed in the skin pocket so that it gets into the area of the defect in the lower part of the lateral pedicle of the alar cartilage, the final stage on the alar cartilage the incision is closed with an interrupted suture with absorbable material and a fixing bandage. 2. The method according to p. 1, characterized in that similar manipulations are performed for the other half of the nose.

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