RU2580660C1 - Method for elimination of through defect of nose - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: eliminated through defect of nose. Inner nose lining is formed on pedicle of periosteal flap frontal area. Rotated periosteal flap is closed from top by skin fasciocutaneous flap on same pedicle with subsequent cutting off.

EFFECT: method provides higher functional and aesthetic effect, complete elimination of through defect of nose due to functional forming lost nose own tissues.

1 cl, 1 ex, 7 dwg

Description

This invention relates to medicine, namely to maxillofacial surgery, and can be used to eliminate the through defect of the nose, namely to form a lost nose and, in particular, its inner lining.

There is a method of eliminating a through nasal defect of the nose, including the formation of a skin-fascial radial flap on the supply leg above the radial bone by highlighting the inner surface of the radial fascia and cutting out the skin part of the flap located above the selected fascia, dimensions corresponding to the existing defect, subsequent intersection of the feeding leg of the flap, suturing wounds of the donor zone, preparation of the recipient bed. For the inner lining of the nasal passages use a flap cut out in the middle of the forehead, which is tipped to the surface of the defect.

The formed radial flap with the feeding leg is transferred to the defect area where the flap vessels are anastomosed with the selected vessels of the recipient zone, followed by suturing of the wound edges [Restorative surgery of the soft tissues of the maxillofacial region. A guide for doctors. P.Z. Arzhantsev, A.I. Nerobeev et al. - M.: Medicine, 1997, p. 134].

The disadvantage of this method is the impossibility of closing only one radiation flap through the defect of the nose, which requires epithelial lining on both sides of the flap. Also important in the formation of the nose is the fact of elasticity of the introduced tissues, which cannot be expected from the nose, formed from two full flaps.

Closest to the proposed one is a method of eliminating a through defect in the nose, the essence of which is to use a skin-fascial frontal flap on the feeding leg, forming a tunnel in the nose and then removing the overturned flap through it. The flap is de-epidermized in proportion to the post-resection defect. Then turn it 180 ° along the back of the nose. Next, the epithelial inner lining of the nose is formed by the integumentary tissues of the flap, after which free autodermoplasty is performed to replace the external epithelial lining [RF Patent No. 2452403, A61B 17/00, 2010].

The disadvantages of this method are: aesthetic dissatisfaction with the result, since the flap from the frontal area is used to form the inner lining, and free autodermoplasty is performed to replace the outer lining, and as a result, the color and identity of the skin can be different.

Also unclear is the moment of absence of the cutoff stage of the feeding leg, since the epidermal leg, laid in the skin tunnel in the region of the nose, significantly deforms the contour of the face.

The technical result of this invention is to increase the functional and aesthetic effect, the full elimination of the defect in compliance with the shape and texture of the lost component.

The technical result is achieved by the fact that in the method of eliminating the through defect of the nose by forming its inner lining with a flap on the feeding leg, taken in the frontal region, a distinctive feature is that for the formation of the inner lining use the periosteal flap from the frontal region on the feeding leg, rotated into the region a defect in the nose and the bone side facing the nasal cavity, which is fixed to the mucous membrane of the defect and then it is closed on top with a rotated skin-fascial flap taken ipsilateral frontal region on the same pedicle with subsequent cut-off.

The method is as follows (Fig. 1-7).

In the preoperative period, according to the Doppler study, the location of the neurovascular bundle of the supra-block vessels (1) is determined from the most aesthetically appropriate side. The size of the defect is estimated (2) and, taking into account the localization zone of the neurovascular bundles, the required tissue volume is calculated, and the periosteal flap (3), in connection with its marked reduction, takes an area twice as large as the defect (2). The skin-fascial flap (4) is cut in accordance with the existing contours of the defect (2). Since two flaps (3-4) are taken on the one hand, the crucial point is when lifting the fascial and fascial flap (4), the absence of through cutting to the bone in the exit area of the supra-block vessel (1), since it is the feeding leg (5) for two flaps and is responsible for their viability. The periosteal flap (3) is rotated into the area of the nose defect and hem the layer into a layer to the mucous edge of the defect tissues, fixed with separate interrupted sutures with the formation of two nasal passages and septum. Subject to the preservation of their own septum of the nose, the periosteum is hemmed to the edges of the preserved mucosa. In case of a lack of cartilage of the nasal septum, it is possible to use the patient’s autotissue (a fragment of the costal cartilage) or a silicone implant.

The periosteal flap (3) covers the contour structures so that the possibility of communication of the auto-cartilaginous design with the internal environment of the nasal cavity is excluded. The fixation of the periosteal flap (3) is carried out in such a way that the bone side of the periosteum is turned into the nasal cavity, as It has a dense structure.

The skin-fascial flap (4) is rotated 180 ° with the skin outside, hemmed to the edges of the defect layer to layer with separate interrupted sutures. The flaps (3, 4) with the feed leg (5) are laid one under the other.

Individually modeled silicone inserts wrapped in iodoform turunda are installed in the nasal passages in order to prevent granulation and, as a result, prevent cicatricial deformation of the nose from the cavity and narrow the lumen of the nasal passages. A donor wound, depending on the size, is closed by using displaced local flaps or free dermal plasty.

Example

Patient C. was in the clinic of the FSBI Central Research Institute for Nuclear Medicine and ChLH with a diagnosis of Through nose defect, condition after resection of the cartilage of the nose for basal cell carcinoma. An external examination of the face noted a pronounced deformation of its middle third as a result of a defect in the external nose. When examining the area of deformation, the absence of a cartilaginous part of the nose was noted, while maintaining the posterior third of the quadrangular cartilage. The nasal passages are free. At the edges of the defect, the mucous and skin edges are hyperemic. Opening the mouth in full, painless. When examining the frontal region, on the one hand, a normotrophic linear scar was noted in the projection of the course of the supra-lateral artery.

In the clinic, after a complete clinical and laboratory examination in the conditions of ETH, an operation was performed by the proposed method.

According to the Doppler study, the neurovascular bundle of the supra-lateral vessels (a.v. supratrochlearis) from the intact side of the frontal region was noted before the operation, the size of the defect was estimated, and the required volume of skin-fascial and periosteal flaps was calculated.

After endotracheal anesthesia, after a 3-fold treatment of the surgical field, marking and hydraulic preparation, an incision was made along the border of the nose defect (edge of the aperture). The bone edges of the defect and the edge of the preserved fragment of the quadrangular cartilage were skeletonized. Next, an incision was made according to the markup with the inclusion of the supra-block artery on one side. An incision was made at the level of the skin and subcutaneous fat without deepening to the bone directly at the exit site of the neurovascular bundle from the supra-lateral notch, only muscle fibers were dissected. Then, the muscle fibers of the frontal abdomen of the occipital-frontal muscle were dissected from the medial side, the latter was lifted and knocked out. A periosteal flap was cut with preservation of the supra-lateral artery.

The periosteal flap, 8 × 10 cm in size, preserving the integrity of the supralateral neurovascular bundle was rotated 180 ° into the defect area so that the periosteal surface of the flap was turned towards the nasal cavity. The flap was matched layer by layer with the mucosa, along the edges of the defect were fixed with separate knot sutures with 4/0 vicryl.

Further, the skin-fascial flap on the feeding leg was rotated into the defect area with rotation in a horizontal plane, laid on top of the periosteal flap, with the layer fixed in a layer to the skin edges of the nose defect with separate interrupted sutures with 5/0 proline.

In order to reduce the defect of the donor region, we mobilized the tissues of the scalp at the level of the tendon helmet to the border with the parietal region, the tissues of the forehead to the temporal regions on both sides. Horizontal incisions were also made on the inside of the mobilized tissues in order to increase the mobility of the flap. The wound edges were sutured in layers with 3/0 vicryl; 4/0, prolen 4/0; 5/0.

An aseptic dressing. Individually modeled silicone inserts wrapped in iodoform turunda were installed in plastically restored nasal passages.

In the postoperative period, antibacterial, anti-inflammatory, analgesic therapy, physiotherapy, and dressings were performed. Iodoform turunda was changed 1 time in 2-3 days. Sutures were removed after 10 days.

After 3 weeks, they cut off the feeding leg of the flaps and restored the integrity of the medial edge of the eyebrow.

As a result of the operation, the nose defect was eliminated with the formation of a full-fledged inner lining.

Thus, the proposed method has several advantages, such as:

- the ability to eliminate a defect in the nose with the help of flaps consisting of local tissues with good blood supply;

- the abdomen of the frontal muscle remains intact, which provides mimic movements in the forehead, and also unloads the tissues that form the nose, which without the muscular component is more aesthetic and easier to correct;

- the possibility of closing the defect, taking into account the deficit of soft tissues of the receptive bed (defect area);

- closing the defect with tissues identical in structure and color to the surrounding;

- the use of flaps on one side on one feeding leg allows you to save the donor area from the contralateral side and allows you to use this technique in case of unilateral lesions of the frontal region.

Claims (1)

A method for eliminating a through nose defect by forming its inner lining with a flap on the feeding leg, taken in the frontal region, characterized in that periosteal flap is used from the frontal region on the feeding leg, rotated into the nose defect region and facing the nasal cavity with the bone side to form the inner lining. , which is fixed to the mucous membrane of the defect and then it is closed on top with a rotated fascial skin-fascial flap taken from the same side of the frontal region on the same feeding leg, followed by its clipping.

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