RU2580661C1 - Method for elimination of through defect of nose - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: eliminated a through defect of nose, a lost nose. A nasal internal lining is introduced through the tunnel osteoperiosteal gloss pedicle. Closed from above with rotated fasciocutaneous skin flap taken with rear lateral side of the frontal area to like pedicle and cutting off.

EFFECT: method allows to enhance functional and aesthetic effect of repair, adequate elimination of physical defect due to shape and texture lost component.

1 cl, 5 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 radiation 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 an end-to-end defect of the nose, which consists in using 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 disadvantage of this method is aesthetic dissatisfaction with the result, since the flap from the forehead 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, the moment of the absence of the cut-off stage of the feeding leg remains unclear, since the de-epidermized leg, laid in the skin tunnel in the nose bridge region, significantly deforms the facial contour.

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 area and passed through the tunnel on the nose bridge, a distinctive feature is that the periosteal passed through the tunnel is used to form the inner lining of the nose a flap on the feeding leg facing the nasal cavity with the bony side, which is fixed to the mucous membrane of the defect and covered with rotated skin-fascial los with a heel taken from the contralateral side of the frontal region, on the eponymous pedicle with its subsequent cutting off.

The method is as follows (Fig. 1-5).

In the preoperative period, according to the Doppler study, the location of suprablock vessels (1, 1a) is determined from two sides. 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) and carries out in the tunnel (4) at the level of subcutaneous fat in the direction of the defect. A skin-fascial flap (5) is cut in accordance with the existing contours of the defect.

Derived from the tunnel (4), the periosteal flap (3) hem the layer into a layer to the mucous edge of the defect tissue (2), fix it 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 cases of a lack of cartilage of the nasal septum, it is possible to use the patient’s autotissues (a fragment of 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 bony side of the periosteum is turned into the nasal cavity, since it has a dense structure.

The skin-fascial flap (5) is rotated 180 °, with the skin outside, the layer is sewn to the edges of the defect in a layer with separate interrupted sutures. The leg (6) of the skin-fascial flap (5) is placed on top of the skin of the nose and the preserved back of the nose, covered with iodine turunda. 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.

After 3-4 weeks, the cutting legs of the skin-fascial flap are cut off.

Example

Patient M. was in the clinic of FSBI “TsNIIS and ChLH” with a diagnosis of Through defect in the nose, condition after a gunshot wound. 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 the external part of the nose in the volume was noted: a defect in the cartilaginous part of the nose. The nasal passages are free. At the edges of the defect, the mucous and skin edges are hyperemic. Opening the mouth in full, painless.

In the clinic, after a complete clinical and laboratory examination in conditions of endotracheal anesthesia (ETN), an operation was performed according to the proposed method.

According to the Doppler study, the neurovascular bundle of the supra-lateral arteries (a.v. supratrochlearis) was marked on both sides before surgery, the size of the defect was estimated, and the required volume of musculocutaneous and periosteal flaps was calculated.

After ETN, after 3-fold processing of the surgical field, marking and hydraulic preparation, an incision was made along the border of the nose defect (edge of the aperture) with excision of the pulling scars. 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. The incision was performed at the level of the skin and subcutaneous fat with a depression to the bone directly at the exit site of the neurovascular bundle from the supra-lateral notch. Raised the skin-fascial flap. Then, from the upper edge of the cut flap, the incision was extended to the contralateral side along the border of hair growth to the temporal region. Tissues were separated, the periosteum was exposed. The fence of the latter was carried out in the maximum possible volume with the inclusion of the supralateral artery from the contralateral side. Then, from the side of the periosteal flap, a subcutaneous tunnel was formed, leading to a defect in the nose.

The periosteal flap 8 × 10 cm in size, while preserving the right supra-lateral artery, was led into the defect area through the tunnel so that the surface of the flap adjacent to the bone was facing the nasal cavity. The flap was matched layer by layer with the mucosa along the edges of the defect, fixed with separate knot sutures with 4/0 vicryl.

Next, the skin-fascial flap on the feeding leg was rotated into the defect area with rotation in a horizontal plane, laid over the skin of the nose bridge with fixation layer to layer to the skin edges of the nose defect with separate interrupted sutures 5/0 prolene.

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 by Vicryl 3/0, 4/0 and Prolen 4/0, 5/0.

Two rubber graduates were installed: one in the region of the leg of the skin-subcutaneous flap, and the other in the region of the donor zone. 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, the cutting legs of the fascial-fascial flap were cut off and the integrity of the medial edge of the eyebrow was restored.

Thus, the proposed method has several advantages:

- 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.

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 area and passing through the tunnel on the nose bridge, characterized in that for the formation of the inner lining of the nose, a periosteal flap on the feeding leg, drawn through the tunnel, facing the nasal cavity is used the bony side, which is fixed to the mucous membrane of the defect and closed on top with a rotated skin-fascial flap taken from the counter-lateral side of the frontal region, of the same name noy feeding leg with its subsequent cutting off.

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