Correction of the Asian deviated nose with no hump using unilateral bony mobilisation and dorsal septal suture fixation.

A deviated nose is corrected by straight realignment and long-term maintenance of the bony and cartilaginous structure. Traditional rhinoplasty usually involves complete separation of both upper lateral cartilages from the septum and bilateral bony mobilisation after osteotomy. In the Asian deviated nose with no hump, these procedures are intrinsically destabilising and may weaken the supporting bony and cartilaginous structure. To avoid these problems, I performed unilateral bony mobilisation with anterior wedge resection and suture fixation of the dorsal septum to the nasal bone without separation of the upper lateral cartilage. This manoeuvre is simple and reproducible and produces satisfactory straightening and maintenance of the nasal dorsum while maximally preserving the structural support. Here, I describe the surgical techniques including the choice of the site of unilateral osteotomy and wedge resection, a new classification of bony deviation, two surgical modifications applied to different types of deviation and rationale of dorsal septal suture fixation. Also, clinical cases of nasal deviation are presented.     

External septorhinoplasty in the cleft lip nose

When the entire septum as well as the cartilaginous vault are exposed to direct vision by degloving the nasal covering, the complete extent of the deformities in cleft lip nose can be clarified. The septal cartilage is hollowed out leaving an L-shaped anterosuperior portion, whereas the intranasal structures are simultaneously altered to ensure the patency of the nasal airway. An adequate-sized piece is cut from the removed cartilage and is fitted to the anterior part of the remaining cartilage to enforce the columella, which acts as a strut to keep both lower lateral cartilages symmetrical and to create a nasal tip. Thus, a new cartilaginous pyramid with symmetrical nostrils is reconstructed. If the anterosuperior portion of the cartilage is deviated, the concave surface is scored to allow it to be straightened before the strut is fitted. Satisfactory cosmetic and functional results were obtained in most patients with adult cleft lip nose, including those associated with deviation, without any major complications.     

The crooked nose: principles of treatment

Correction of the crooked nose is one of the most challenging procedures in rhinoplasty. The goals of the surgery are creation of a rigid and straight cartilaginous L-strut, correction of the deviated bony structures, and improvement of the nasal airway. Curvatures of the dorsal septum can be corrected with several techniques. Spreader grafts, cartilage batten grafts, or ethmoid bone grafts can be utilized for internal stenting to straighten the dorsal deviations. The surgical treatment for a deformed caudal septum with the most predictable and successful outcome is resection and replacement with a straight septal cartilage graft. In severe deviations of septum cartilage involving both dorsal and caudal portions of the L-strut, extracorporeal reconstruction of the septal cartilage may be the required method. For correction of the deviated bony pyramid, several osteotomy methods can be employed. Medial osteotomy, low-to-low or low-to -high internal lateral osteotomy, double-level lateral osteotomies, and external lateral osteotomy are the options, depending on the deformity. Dorsal onlay grafts can provide camouflage for any residual asymmetries after septal reconstruction or can be applied for dorsal augmentation.     

A Useful Method for Planning Hump Resection of Deviated Nose

The deviated nose is a particular challenge because both functional and aesthetic problems must be addressed. A most important challenge is resection of the hump. The nasal bones often are asymmetric in deviated noses. Several methods have been used for resection of the hump. Using the authors’ method, it is possible to calculate the extent of hump resection. Clinical analysis of the nasal deviation is performed preoperatively. Digital photographs are taken, and all the landmarks are marked on the life-size photo prints. Planning begins on the deviated side. The ideal dorsal line is drawn, and the extent of hump resection is planned according to the preoperative measurements. Measurements on the deviated side are applied to the other side using the medial canthi and the most prominent part of the alar creases as landmarks. Classical methods emphasize the importance of the chisel position during hump removal. According to the classical approach, the chisel should be positioned lower on the deviated side to resect more bone. However, there is no method for calculating how the chisel should be positioned exactly during hump resection. Therefore, a precise plan has been devised to leave symmetric nasal bones after hump resection. The authors have applied this method in eight cases, achieving satisfactory results.     

鼻中隔偏曲畸形矫正同期鼻整形术

目的:探讨鼻中隔偏曲畸形矫正同期鼻畸形娇正的手术方法和效果.方法:采用鼻侧软骨和大翼软骨间切口,显露畸形的中隔软骨及鼻骨结构,松解牵拉力量,矫正鼻中隔畸形,截骨及复位鼻骨,使其解剖复位,重塑鼻支架.结果:本组39例,均获满意效果,无复发和并发症.结论:本手术方法矫正偏曲畸形的鼻中隔的同时,矫正外鼻的畸形,消除了引起畸形的原因,重塑外鼻支架,收到了恢复鼻腔通气功能与外鼻美容的双重效果.     

High septal osteotomy in rhinoplasty for the deviated nose

When attempting to straighten a patient's healed, deviated bony nasal dorsum, deviation of the central structure (high dorsal septum and medial nasal bones) must be addressed following the completion of medial and lateral osteotomies. When hump resection is not performed, blunt fracture (digitally or with forceps) of the deviated central structure is not a reliable method of mobilization, often leading to postoperative nasal drift. An intranasal osteotomy technique to mobilize the central structure of the nose is described, called "high septal osteotomy." Review of 25 cases suggests high septal osteotomy, supplemented as needed by resection of overlapping septal elements, can be performed safely and efficaciously, permitting stable midline reduction of the nasal pyramid. The technique is not advocated when hump resection is performed, as it is unnecessary and could destabilize the dorsum. Even aggressive maneuvers to mobilize the bony dorsum may fail if not performed properly with meticulous attention to completion of all osteotomies.     

鼻内镜下复合鼻外伤的整形美容修复

目的探讨鼻内镜下复合鼻外伤整形美容I期修复的方法与疗效。方法选取54例外伤在1个月之内，结合体征及鼻骨CT扫描，确诊为复合鼻外伤的患者。通过鼻骨三维重建CT扫描及术中所见，分析外伤部位。然后于鼻内镜下采取综合方法，治疗鼻中隔偏曲，手术中尽量保留骨与软骨，以维护鼻中隔的支架结构，治疗鼻中隔偏曲。鼻内镜下经鼻中隔黏膜囊入路行鼻骨复位术，在鼻骨骨折的底表面明视下将骨折复位。结果外鼻支架双侧骨折占92．59％（50／54），鼻中隔软骨损伤占92．59％（50／54），筛骨垂直板骨折占70．37％（38154），犁骨偏曲骨折占22．22％（12／54）。鼻内镜下鼻中隔整形术方式有：软骨推移42．59％（23／54），“井”字划痕24．07％（13／54），条状切除38．89％（21／54），骨折移位61．11％（33／54），骨部分切除31．48％（17／54）。54例中，显效90．74％（49／54），好转9．26％（5／54）。结论鼻内镜下鼻中隔偏曲整形术联合经鼻中隔剥离黏膜囊入路鼻骨复位整形美容术，疗效好，能同时解决外形与功能的问题。     

Surgical treatment of nasal septal deviation (septoplasty) in children

The aim of this study was to indicate the importance of surgical treatment of nasal septal deviation in children as early correction of functional and cosmetic nose deformities. In this study, we presented 76 children, from age of 7 to 15, who were surgical treated for the reason of nasal septal deviation starting from January 2001. to December 2009. There were 48 (63%) male and 28 (37%) female patients. The lowest number of patients were between 7 and 9 years old--5 (6.5%), between 10 and 12 years--28 (37%) and 43--(56.5%) between 13 and 15 years. Only 7 (9%) patients indicated genetics inheritance, and 11 of them (14%) could not determine the exact cause of deviation origin. References taken from the parents showed that nasal septal deviation developed like consequence of injury in 58 (76%) cases. We used closed technique of septoplasty with hemitransfictional incision and sub mucosal resection. Deviated portion of septum was completely removed. Patients felt improvement in nose breathing in 65 (85%) cases. The most often complication was nasal obstruction in 6 (8%) cases which occurred due to the insufficient removal of deviated portion. We also had a septal perforation in one and abscess of nasal septum in another case. There were no esthetic deformities.Surgical treatment of nasal septal deviation in children must to be conservative and limited on injured part of septum. After the operation nose breathing significantly improved, without consequences on esthetic appearance or the growth of central part of a face.     

鼻内镜下鼻整形术同期鼻中隔偏曲畸形矫正

目的探讨鼻内镜下同期矫治鼻畸形及鼻中隔偏曲的手术方法与效果。方法鼻内镜下采用Killian切口和与其相连的大翼软骨间切口,显露畸形鼻骨结构及鼻中隔偏曲部位,松解牵拉力量,鼻中隔成形术消除鼻中隔畸形,截骨及复位鼻骨,使其解剖复位,重塑鼻支架。结果本组27例,均获满意效果,无复发和并发症。结论本方法可同时矫正鼻中隔及外鼻畸形,消除致畸原因,重塑外鼻支架,达到了恢复鼻腔通气功能与外鼻美容的双重效果。     

One-stage correction of severe nasal deformity associated with a unilateral cleft lip.

Correction of one of the abnormal features is never enough to alleviate the entire deformity in a patient with a unilateral cleft lip and deformed nose, because the factors that led to the nasal deformity have already produced changes in the lower lateral cartilage, nostril, columella, septum, and alar base. These changes should be treated together with the contributory factors. By restoring the balance of the muscles by primary repair of the lip, orthodontic treatment, and orthognathic surgery, a more symmetric skeletal base can be established. The method of repair of the lip will also influence the deformity. Bone grafting can augment the skeletal base, but it will not improve the position of the lower lateral cartilage or the deviated septum. In this paper we describe a single stage correction of all the irregularities of the nose in patients with unilateral clefts which alleviates the asymmetrical nasal deformity.     

开放式手术矫正陈旧性外伤性歪鼻畸形

目的总结治疗外伤性歪鼻畸形的经验，掌握正确的歪鼻矫正技术，提高临床治疗效果。方法1996年12月至2004年2月，采用开放式手术，完全显露歪曲的结构，松解外在及内在牵拉力量，复位鼻骨、矫直鼻中隔使其解剖复位，重塑鼻支架。结果本组患者36例，术后随访4个月至5年，优31例，良5例。鼻畸形获得满意的矫正，鼻外形恢复良好。结论外伤性歪鼻畸形多因伤后早期未获得及时有效地处理所致，经开放式手术复位鼻骨、矫直鼻中隔及鼻部整形术，消除引起畸形的原因，可取得较满意的效果。     

Corrective rhinoplasty of the congenital deviated nose

From 1981 to 1986, a total of 11 cases of crooked nose were treated. The method include resection of the excessive portion of deviated lateral cartilage, and reduction of significantly dislocated lower part of septum, otherwise correction could not be radical.     

应用螺旋CT三维重建鼻骨形态鼻内镜下歪鼻矫正术

目的 探讨应用螺旋CT三维重建鼻骨形态鼻内镜下矫正歪鼻畸形的手术治疗方法.方法 对66例歪鼻畸形患者术前行螺旋CT三维重建鼻骨形态,了解歪鼻畸形的局部形成状况.先在鼻内镜下行鼻中隔偏曲的矫正术,后经鼻前庭前小切口在鼻内镜辅助下行歪鼻畸形矫正.结果 术后1周、1个月、3个月及半年后随访,观察外鼻形状,并测量其偏离值.66例歪鼻中矫正效果优为53例,良好为11例,不满意2例.结论 螺旋CT三维重建鼻骨形态可在术前充分了解歪鼻畸形局部及周围情况;采用鼻内镜能充分暴露骨折畸形愈合部位,避免破坏整体框架,使得手术创伤小,手术时间短,术后反应轻,皮肤坏死可能性减小等,因此应用螺旋CT三维重建鼻骨形态鼻内镜下矫正歪鼻畸形效果更具优势.

Abstract：

Objective To discuss the endoscopy-assisted surgery for deviated nose with the preoperative 3-D CT reconstruction. Methods Sixty-six cases with deviated nose deformities underwent preoperative 3-D CT reconstruction. The deformities were showed in detail. The deviated nasal septum and deviated nose were corrected with the assistance of nasal endoscopy. Results The patients were visited after operation at 1 week, 1 month, 3 months and 6 months. The nose shape and nose deviation were measured. Among the 66 cases, satisfactory result was achieved in 53 cases, good in 11 cases,unsatisfactory in 2 cases. Conclusions Preoperative CT reconstruction is very help in understanding the deviated nose deformity. The rhinoplasty with nasal endoscopy has good exposure of the fracture deformity with less morbidity and side effect. The intraoperative time can be decreased also.     

Fractures of nose

Simple fractures of the nasal bones if corrected early should not show any evidence of deformity. Occasionally, however, it may be necessary to refracture the nasal bones in order to reduce the displacement and hold them in position by an external splint. Moderately severe fractures, complicated by displacement of the septum, may require an operation for submucous resection if they are seen two weeks or more following injury. In comminuted fractures of the nasal arch it is very necessary that the cases be handled carefully, because if the injury is a severe one and proper reduction of the fracture is not effected, and the fragments are not held in position long enough, they will undoubtedly come to a secondary operation requiring a transplant of cartilage, or cartilage and bone, for the relief of the deformity.     

应用螺旋CT三维重建鼻骨形态鼻内镜下歪鼻矫正术

目的 探讨应用螺旋CT三维重建鼻骨形态鼻内镜下矫正歪鼻畸形的手术治疗方法.方法 对66例歪鼻畸形患者术前行螺旋CT三维重建鼻骨形态,了解歪鼻畸形的局部形成状况.先在鼻内镜下行鼻中隔偏曲的矫正术,后经鼻前庭前小切口在鼻内镜辅助下行歪鼻畸形矫正.结果 术后1周、1个月、3个月及半年后随访,观察外鼻形状,并测量其偏离值.66例歪鼻中矫正效果优为53例,良好为11例,不满意2例.结论 螺旋CT三维重建鼻骨形态可在术前充分了解歪鼻畸形局部及周围情况;采用鼻内镜能充分暴露骨折畸形愈合部位,避免破坏整体框架,使得手术创伤小,手术时间短,术后反应轻,皮肤坏死可能性减小等,因此应用螺旋CT三维重建鼻骨形态鼻内镜下矫正歪鼻畸形效果更具优势.     

应用螺旋CT三维重建鼻骨形态鼻内镜下歪鼻矫正术

目的 探讨应用螺旋CT三维重建鼻骨形态鼻内镜下矫正歪鼻畸形的手术治疗方法.方法 对66例歪鼻畸形患者术前行螺旋CT三维重建鼻骨形态,了解歪鼻畸形的局部形成状况.先在鼻内镜下行鼻中隔偏曲的矫正术,后经鼻前庭前小切口在鼻内镜辅助下行歪鼻畸形矫正.结果 术后1周、1个月、3个月及半年后随访,观察外鼻形状,并测量其偏离值.66例歪鼻中矫正效果优为53例,良好为11例,不满意2例.结论 螺旋CT三维重建鼻骨形态可在术前充分了解歪鼻畸形局部及周围情况;采用鼻内镜能充分暴露骨折畸形愈合部位,避免破坏整体框架,使得手术创伤小,手术时间短,术后反应轻,皮肤坏死可能性减小等,因此应用螺旋CT三维重建鼻骨形态鼻内镜下矫正歪鼻畸形效果更具优势.     

同期鼻中隔和鼻整形术

目的：探讨同期鼻中隔和鼻整形术治疗伴有鼻中隔偏曲的歪鼻、驼峰鼻、鹰嘴鼻等外鼻畸形的手术方法和效果。方法：采用鼻侧软骨与大翼软骨间切口，单面一边骨膜蒂骨瓣截骨法处理骨锥畸形，联合“转门法”矫正鼻中隔偏曲。结果：36例均获满意效果，随访32例受术者1～15年，无复发和并发症。结论：本手术方法既避免了鼻骨及鼻中隔软骨的游离移位和鼻黏膜损伤，又保证了鼻骨和鼻中隔软骨的血供，在矫正了外鼻畸形的同时，又矫正了偏曲的鼻中隔，收到外鼻美容与恢复鼻腔通气功能的双重功效。     

Endoscopic-Assisted Correction of the Deviated Nose

The approach to nasal bone classic corrective rhinoplasty is an almost-blind technique, where the results depends on feeling by the surgeon's hand. To overcome these drawbacks, endoscopic-assisted corrective rhinoplasty and septoplasty were performed for 16 cases of deviated noses between January 1995 and May 1997. The average follow-up period was 18 months. All patients were evaluated by symmetrical nasal pyramid, recurrence of the bony deflection, and septal deviation. The postoperative courses were satisfactory in most cases, with few complications. Compared with 28 cases of classic rhinoplasty, the patient satisfaction rate was high (87.5% in endoscopic-assisted rhinoplasty, 71.4% in classic rhinoplasty), and the complication and revision rate was low (0% in endoscopic assisted rhinoplasty, 14.3 and 7.1% in classic rhinoplasty). But extra time (about 40 min) and greater expense were required for endoscopic-assisted rhinoplasty. It appeared to us that endoscopic control during corrective rhinoplasty and septoplasty is a big step toward obtaining better results in bony and cartilage resection with extreme precision under monitor control and magnification. This technique is not an open approach but permits one to see more of the nasal skeleton and bony septum, the cause of the deformity, and the immediate effect of the corrective measures used. The use of an endoscope in corrective rhinoplasty for deviated noses provides an expanded field of vision, direct manipulation of lesions, and better aesthetic and functional results.     

Nasal Deformities and their Treatment in Secondary Repair of Cleft Lip Patients:A Clinical Study of 175 Cases

The author reports his own experience in 175 cases of secondary repair of cleft lip nose deformities. In spite of the great variability of these cases a relatively simple strategy has been defined, based on a precise study of the lesions. In unilateral cases the nose is deviated entirely to the normal side, not only because of nasal bone deviation but also and mainly because of septal deviation. The nasal tip is distorted because of the alar cartilage displacement which results from bone deviation. Rhinoplasty is usually performed by a submucosal approach through a vertical incision in the columella. It includes septal straightening, nasal osteotomies, and sharp dissection and reduction of the triangular cartilages and alar cartilages to allow of their suturing in the normal position. In bilateral cleft lip cases the main deformity of the nose is shortness of the columella. Here, two techniques have been utilized. In those rare cases where the lip was correct in height and width, a V—Y plasty on the nasal tip was performed with good results. In most cases the Abbe-Estlander flap was the procedure of choice. These rhinoplasties were carried out on patients between 15 and 20 years of age, and were always considered to be the last stage of secondary cleft lip repair, particularly after the maxillary bone defects had been corrected.     

婴儿期唇裂鼻畸形早期修复的临床研究

目的:探讨在婴儿期早期修复唇裂,同期矫正鼻畸形的可行性。方法:采用Millard唇裂修复法修复唇裂,同期矫正鼻畸形,使移位的鼻翼软骨、鼻中隔软骨复位,以恢复正常的解剖关系。结果:30例患儿唇裂鼻畸形早期矫治,经6～8年随访,取得满意效果。结论:早期修复唇裂,同期矫正鼻畸形,使畸形的鼻翼软骨、鼻中隔恢复到正常的解剖位置并在此位置上生长发育,鼻畸形可明显改善。