Rhinoplasty พิชัย พัวเพิ่มพูลศิริ

Skin ที่หนามาก, มีsebaceous glands , subcutaneous tissue เยอะ, เป็น least ideal skin type

skin ที่บางมาก มี subcutaneous tissue น้อย จะไม่มี cushion ที่จะปกปิดกระดูกที่ไม่ค่อยเรียบ หรือโครงสร้างที่ผิดรูปเล็ก ๆ น้อย ๆ

Tip recoil. ใช้นิ้วกดปลายจมูกลงไปหาริมฝีปากบน If the recoil is instantaneous and vigorous, and the tip cartilages resist the deforming influence of the finger, more definitive tip surgery can usually be performed.

A three-way mirror facial photographs, and even computer imaging important communication process between the expectant patient and the cautious surgeon.

Realistic expectations and thoroughly informed consent are the keystones on which the most important surgical outcome—a happy patient—is achieved

The concentration of 1% lidocaine is sufficient to produce excellent anesthesia and has an effective duration of 1.5 to 2 hours. No effort is made to block specific nerves.

แทงเข็มไปตาม lateral wall of the dorsum, hugging the perichondrium of the upper lateral cartilages and the periosteum of the nasal bones.

Identification of this plane is enhanced by lifting the soft tissues overlying the nasal dorsum with thumb and forefinger.

ถ้าจะทำ Osteotomy ด้วย เช่นในราย Old fractured nose ให้ฉีด local anesthetic ไปบน ascending process ทั้งสองข้าง จะช่วยลด bleeding หลังทำ lateral osteotomy

Noncaucasian Rhinoplasty Nasal tip skin is thick and sebaceous, lower lateral cartilages and septum are paradoxically small, weak, and deficient. The nasal bones are broad and flat. The low radix and underprojected nasal tip are common features.

Noncaucasian Rhinoplasty Augmentation to the tip and dorsum remain the workhorse maneuvers Implants should not leave pressure on the overlying skin. Alar base surgery should be performed only judiciously.

preparing the recipient site and corresponding surface of the implant, so that the implant will fit snugly against roughened nasal bones. The undersurface of the implant should be concave to fit the curvature of the dorsum of the nose.

A three-dimensional concept must be kept in mind when shaping the graft. The dorsal aspect of the graft should be nearly straight and extend the full length of the nose. Grafts may be layered to increase the magnitude of augmentation.

ตัวอย่าง Silicone ที่เหลาแล้ว

The nasolabial angle defines the angular inclination of the columella as it meets the upper lip. This angle should measure 95 to 110 degrees in women and 90 to 95 degrees in men.

The nasofacial angle represents the angle formed from a vertical line tangent from the glabella through the pogonion intersecting a line from the nasion through the nasal tip. This angle ideally measures 36 degrees but can vary from 30 to 40 degrees.

In patients with extremely thin skin, delicate alar side walls, and bulbous cartilage, predictable narrowing refinement can be achieved by transdomal suturing of the complete strips with horizontal mattress sutures.

Solid medical grade silicone rubber, have been used for restoration of tip, alar, and septal defects and for saddle deformities Disadvantages include a high extrusion rate, foreign body reaction, and susceptibility to infection.

Nasal Base Sculpting An incision is made from the base of the sill and carried out 1 to 2 mm above the alar-facial crease. The alar flap can be advanced medially, and a conservative amount of the ala can be excised. To avoid visible scaring, the cut edges should be carefully reapproximated.

Nasal Base Sculpting A 5-0 chromic suture should be used to reapproximate the alar rim, and one or two subcutaneous 5-0 Vicryl sutures should be placed to reapproximate the alar-facial junction incision. A few 6-0 nylon sutures are used to reapproximate the skin edges.

การตัดปีกจมูก

Septoplasty

The injection is started at the caudal end of the septum. the contralateral membrane the area of the nasal floor around the maxillary crest

Infiltration of the local anesthetic into this plane results in a hydraulic elevation of the septal flap, facilitating elevation and preservation of flap integrity

Killian incision, approximately 1- to 2-cm posterior to the caudal septal margin within the respiratory epithelium.

Hemitransfixion or transfixion incision made at the caudal border of the septum allows access to the deviated caudal septum and any posterior deflections.

The incision is created within the squamous epithelium of the vestibule .

The No. 15 blade is then used to incise mucosa down to and through the perichondrium. Identification of the proper plane is now of utmost importance.

It is created by first identifying the caudal end of the septum itself. Inserting the nasal speculum into the nose and gently retracting the slightly opened speculum clearly reveals the caudal septal edge.

Dissecting within a subperichondrial plane ensures little bleeding and a hardier flap with less likelihood of perforation.

Before advancing posterior to the bony-cartilaginous junction, elevation of the mucoperiosteum along the nasal floor is frequently necessary to address

-any maxillary crest deviation -the septum that has shifted off of the crest and is found to be obstructing the inferior airway.

A second plane exists in the submucoperichondrial and submucoperiosteal spaces flanking the nasal septum.

By elevating above the crest or deviated floor segment and then elevating below the segment, the surgeon creates two pockets or tunnels.

Incising the nasal floor deflection or connecting the two tunnels directly helps to avoid mucosal tears

If bilateral membrane wrents are noted, ควรจะเย็บซ่อมและใส่ interposition graft of crushed cartilage

Bilateral membrane elevation followed by septal incision using a Becker septal scissor above and below any deviated septal segment or spur allows increased mobility of the deflected segment.

To decrease the potential for loss of dorsal or tip support, preserves at least a 1-cm dorsal and 1-cm caudal septal segment, which has been termed the L-strut

ลักษณะของ L-strut

Scraping" the cartilage at the incision site to denude any hint of perichondrium before initiation of the elevation process helps to ensure the proper plane.

Most common septoplasty complication is persistence in the subjective complaint of nasal obstruction. septal hematoma Septal perforations Nasal shape changes