开放式软骨缝合术缩窄鼻翼

目的：探讨使用开放式软骨缝合的方法缩窄鼻翼纠正鼻翼宽扁形态。方法：通过开放式切口,分别做鼻翼轮廓缝合、鼻顶对称缝合、跨穹窿缝合和鼻翼基底部拉拢缝合,获得缩窄鼻翼抬高鼻尖的效果。结果：本组患者15例,术后随访3～24个月,全部患者术后鼻翼缩窄明显、形态自然美观。结论：用开放式软骨缝合的方法缩窄鼻翼,是纠正鼻翼宽扁的有效手术方法。     

The alar-spanning suture: a useful tool in rhinoplasty to refine the nasal tip

The alar-spanning suture is a surgical technique used by an experienced rhinoplastic surgeon to address certain nasal tip deformities. Wide nasal tip deformities with strong, convex lower lateral cartilages are best indicated for treatment with this technique. The alar-spanning suture can improve lateral crural position and eliminate dead space by refining and narrowing the supratip, often without requiring extensive dissection or additional strut grafting. We use operative photographs and an intraoperative video to demonstrate the alar-spanning suture technique, which is a useful addition to the armamentarium of any rhinoplastic surgeon.     

Another Use of the Alar Cartilaginous Flap

Background Resection of the cephalic or middle portion of lateral crura of alar cartilages is a method for correcting bulbous nose in which the resected cartilages usually are discarded, resulting in a waste of autologous tissues. A silastic implant usually is used to correct saddle nose in Asian countries, but implant extrusion, a severe complication, sometimes occurs. Cartilage flaps were first reported by José to increase the projection of the nasal tip. In this study, the authors used cartilaginous flaps of the lateral crura to wrap the tip of the nasal implant for patients with bulbous and saddle noses. This study aimed to investigate the application of cartilaginous flaps of lateral crura. Methods A flap was created from the cephalic portion of the lateral crus of the alar cartilage, leaving the caudal portion intact. The cartilage flap remained attached at the level of the original domal segment of the middle crura. It was rotated over to wrap the tip of the silastic implant, then sutured to the other side flap. Results From March 2003, 19 patients were treated with this technique. The results were satisfactory without implant extrusion or any other complications except for nonobvious scars. Conclusion The cartilage flap can reduce the incidence of implant extrusion and help to reduce the size of the bulbous tip.     

Meniscal Repair for Anterior Horn Tear of the Lateral Meniscus

This technical note describes all-inside meniscal repair for anterior horn tears of the lateral meniscus. A modified anteromedial portal is created for use in visualizing the anterior horn of the lateral meniscus. A crescent-shaped suture hook loaded with a polydioxanone suture (PDS) is inserted through an anterolateral portal. The hook tip penetrates the meniscal peripheral rim and advances across the tear. The suture hook penetrates the mobile central fragment. A leading limb of the PDS is advanced into the knee joint. Then, the leading limb of the suture is retrieved back to the anterolateral portal. With 2 limbs of PDS, endoscopic knot tying is done. With this simple technique, vertically oriented all-inside meniscal repair of an anterior horn tear of the lateral meniscus with the use of absorbable suture materials is easily performed.     

All-Inside Suture Technique Using Anterior Portals in Posterior Horn Tears of Lateral Meniscus

Methods for the repair of meniscal tears include inside-out, outside-in, and all-inside techniques. In this article an all-inside technique is proposed for the posterior horn of the lateral meniscus that takes advantage of the capacious posterolateral recess when the knee is flexed. A device consisting of a large needle with a buttonhole in the tip (previously used for inside-out suture of the medial meniscus) is used. This technique uses only anterior portals (anteromedial and anterolateral portals and an accessory lateral or transpatellar tendon portal). The arthroscope is inserted through the accessory portal. Once the tear has been located and its edges refreshed, the suture device is placed anterolaterally. The tip of the needle is loaded with suture and passed through both sides of the tear and into the posterolateral recess of the knee (without exiting the capsule). The suture tail is recovered with the use of a suture retriever through the anteromedial portal. Next, the suture retriever is inserted through the anterolateral portal to once again retrieve and shuttle the tail before completion of an arthroscopic knot. In addition to the ease of the technique, use of this simple, reusable device adds the benefit of low cost when compared with other techniques.     

An approach to nasal tip remodeling

The luxation (cartilage delivery) technique may be used to achieve a predictable, individualized result in nasal tip rhinoplasty. The author describes how this technique, using a bipedicle flap with an intercartilaginous and rim incision, allows superior visualization of the domal region without structural disruption of the cartilaginous arch. (Aesthetic Surg J 2001;21:345-348.)     

Korrekturen der Nasenspitze: Techniken, Zugänge und Inzisionen

Much experience is needed for the correction of nasal tip deformities; in many cases, a good rhinoplasty result depends on the successful modification of the tip. It is advisable to follow a specific algorithm, starting with exploration of the nasal anatomy and the operative goal, followed by the choice of technique, approach, and incisions. In addition to excision and incision techniques on the tip cartilage and the use of tip grafts, within the last decade suture techniques that allow so-called nondestructive tip modifications became popular. These suture techniques are preferred in minor and moderate deformities, whereas in major deformities the other techniques should be the first choice. Each of these techniques can be used alone or can be combined with each other. For all techniques, closed as well as open approaches can be used; however, with the open approach, all techniques can be performed with more precision under direct vision. The surgeon’s personal experience is also important in realizing the most convenient and effective techniques, approaches, and incisions.     

The evolution of open structure rhinoplasty

Modifications and innovations in open structure rhinoplasty that have occurred as this technique has evolved are discussed. In addition, the philosophy and fundamentals of open structure rhinoplasty are reexamined. A retrospective review of representative patients in a private practice setting was performed. All surgical procedures were conducted in a freestanding private surgery center. The preoperative and long-term results of each patient are compared to demonstrate the effectiveness of the described techniques. The fundamental philosophy of open structure rhinoplasty is the maintenance of the integrity and strength of the nasal skeleton. Modifications of tip grafting techniques, along with additional domal grafting techniques, and a stronger focus on domal suturing techniques result in a softer contour and lack of tip tensions while maintaining structural support.     

Effect of Nasal Tip Surgery on Asian Noses Using the Transdomal Suture Technique

The past two decades have ushered in a new era of nasal tip surgery. The new philosophy focuses on preserving and reorienting nasal tip structures. Modern suture techniques can give predictable results because of more precise suture placement. Only a few reports, however, have objectively evaluated the suture techniques for Asians. Accordingly, the authors aimed to assess the efficacy of the tip suture technique through projection and rotation analysis. We focused on transdomal sutures because they involve one of the most popular suture techniques. Preoperative and postoperative photographs of 85 patients who underwent rhinoplasty at Inha University Hospital between June 2002 and June 2004 were analyzed. The patients were categorized into four groups according to the techniques used. Tip projection was measured by the modified Heuzinger’s method and tip rotation by the nasolabial angle. The pre- and postoperative indexes were compared within each group and among the four groups. Paired and unpaired t tests were used for statistical analysis. When the pre- and postoperative indexes were compared within each group, only the combined technique (transdomal suture with onlay graft) showed significant tip projection improvement. All tip surgeries resulted in insignificant tip rotation increase. Comparison among the four groups showed no significant difference based on the type of tip surgery performed. The suture technique has many advantages, although it has some limitations with Asian noses, especially if used alone. Therefore, we recommend using the suture technique in combination with other tip surgical procedures, such as onlay grafts, to achieve significant tip projection.     

自体肋软骨移植构建鼻尖软骨复合体在鼻整形中的临床应用

目的：通过应用自体肋软骨重塑鼻尖软骨支架结构,形成稳定的鼻尖软骨复合体,来达到完美、立体的鼻尖外形,同时应用膨体聚四氟乙烯或硅胶假体支架抬高鼻背,从而达到理想的鼻部整形美容效果。方法：以鼻小柱基底部＂几＂字形切口和鼻孔内鼻翼软骨外侧缘切口,彻底分离皮肤达鼻翼基底部,对鼻尖短小朝天者可松解到达梨状孔边缘,显露两侧鼻翼软骨及侧鼻软骨,同时暴露鼻中隔软骨游离端;雕刻自体肋软骨,移植、固定到鼻中隔软骨上,贯穿缝合鼻翼软骨、移植的软骨,形成鼻尖软骨支架结构,构建鼻尖软骨复合体。雕刻膨体聚四氟乙烯或硅胶假体支架放置到鼻背鼻骨骨膜下抬高鼻背。结果：本组96例手术者均采用自体肋软骨移植构建鼻尖软骨复合体行鼻整形,术后7天拆线,切口Ⅰ/甲愈合。随诊6～12个月,95例术后鼻尖表现点明显,鼻形立体、挺拔,自然美观,鼻尖活动度好,效果满意。1例术者感觉鼻小柱下垂,通过修复移植软骨,达到满意效果。结论：应用自体肋软骨重塑鼻尖软骨支架结构,构建鼻尖软骨复合体,同时应用膨体聚四氟乙烯或硅胶假体支架抬高鼻背,可以达到理想的鼻部整形美容效果。     

鼻亚单位整形修复的显微应用解剖

目的 为鼻亚单位整形的结构和功能重建提供显微应用解剖学依据.方法 在12例新鲜的成人头部标本上,解剖并数字化测量鼻的皮肤、肌肉筋膜系统、软骨及骨支架系统.观察神经及血管走行,软骨间的连接.结果 皮肤最薄的地方在骨软骨结合部,最厚的地方在鼻根点和鼻间上点.皮肤、软骨骨支架结构和血管肌肉筋膜支撑系统组成鼻的轮廓;鼻亚单位分为鼻根区、鼻背区、鼻尖区、鼻翼区及鼻小柱区;鼻阀是保持正常呼吸的重要解剖结构;上颌骨鼻突截骨可以改变鼻骨高度和宽度2 mm,鼻翼软骨与侧鼻软骨间连接可以松解6～8 mm,鼻翼软骨中间脚的弧度变化可以抬高鼻尖2 mm,中隔软骨切除范围为15 nnn×20 mm,厚度为1 mm;鼻的血液供应主要来源于面动脉和眼动脉,同名静脉伴行,淋巴回流位于肌肉筋膜浅层.结论 解剖上鼻骨截骨可以使鼻梁增高,鼻尖的延长与增高可以通过侧鼻软骨与鼻翼软骨间彻底的松解、鼻翼软骨外侧脚和中间脚弧度的旋转缝合实现;鼻部皮肤有丰富的血液供应和静脉回流,交织成网,手术应该注意解剖层次,避免血管网损伤或者立体结构混乱导致的鼻部挛缩畸形.     

Externe Rhinoplastik bei Nasenspitzenüberprojektion

Primary nasal tip overprojection, due to overdeveloped alar cartilages with long medial and lateral crura, is one of the most challenging tip deformities to correct. The aim of this study is to evaluate the role of lateral crural overlay (LCO) and medial crural overlay (MCO) techniques in managing the primary overprojected nasal tip. On reviewing 480 patients with primary overprojected nasal tips, the deformity was corrected using LCO in 298 (62.1%), MCO in 71 (14.8%), and both LCO and MCO in 111 (23.1%). All patients were followed for a mean period of 18 months (range 6–120 months). The LCO and MCO both resulted in effective deprojection of the nasal tip, while retaining a strong and stable alar cartilage complex that maintained its new position over the long follow-up period. The technique requires an external rhinoplasty approach in order to be executed precisely, under direct vision, and with the alar cartilages in their normal resting position. No cases of infection or suture extrusion were encountered; however, a simultaneous alar base reduction was required in 30% of cases. The English full-text version of this article is available at SpringerLink (under “Supplemental”).     

A Knotless Suture Anchor: Technique for use in arthroscopic Bankart repair

Arthroscopic Bankart repair performed using suture anchors most closely mimics open repair techniques. One of the challenges with the arthroscopic technique is tying consistent, good-quality arthroscopic knots. The unique Knotless Suture Anchor (Mitek Products, Westwood, MA) and method of use for arthroscopic Bankart repair is described. The Knotless Suture Anchor has a short loop of suture secured to the tail end of the anchor. A channel is located at the tip of the anchor that functions to capture the loop of suture after it has been passed through the ligament. The ligament is tensioned as the anchor is inserted into bone to the appropriate depth. The doubled suture configuration that is created with the loop increases the suture strength in the Knotless Suture Anchor compared with standard suture anchors with the same size suture. To my knowledge, this article describes the first knotless suture anchor. A secure, low-profile repair can be created without arthroscopic knot tying.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 2 (February), 2001: pp 213–218     

New multipurpose endoknot device for laparoscopic surgery

Extracorporeal knot tying for the ligation and suture ligation of various structures is becoming more important with the increasing popularity of laparoscopic surgery, especially in complicated cholecystectomies with the need to do intraoperative cholangiography, and in other advanced procedures. We have designed a new multipurpose endoknot device that can be used to: (1) push the knot of a pre-tied loop, (2) facilitate the extracorporeal tying of square knots, and (3) facilitate the suturing of tissues, using either a slip knot or a square knot. The device consists of a simple stainless steel rod with a 3-mm lateral hole at its working end which connects to a 1-mm hole at the tip. The blunt tip lessens the chance of inadvertent injury to the liver and other organs during knot tying. We have used this instrument in laparoscopic cholecystectomy with intraoperative cholangiography, and in laparoscopic hernia repair, colon resection, and thoracoscopic esophagectomy, with great success and with no morbidity attributable to its use.     

鼻中隔软骨游离移植矫正鼻尖圆钝肥大

目的 探讨以自体鼻中隔软骨移植在鼻尖圆钝螯形术中的应用.方法 取1整块自体鼻中隔软骨片,移植于鼻中隔软骨前端,作为鼻中隔延伸支架,将两侧鼻翼软骨收拢缝合固定于支架上.同时,剪除部分外侧脚近端软骨,修剪鼻尖过多的软组织,以突出鼻尖轮廓.结果 126例,术后随访1年,118例（94%）效果满意,8例因鼻尖皮肤过厚,效果未达到患者满意程度.结论 临床实践证明,所介绍的方法 是治疗鼻尖圆钝肥大的良好可行方法.     

Arthroscopic Rotator Cuff Repair Using the Suture Loop Shuttle Technique

With the arthroscope in the posterior portal, several suture loops are passed through the rotator cuff via the superior lateral portal before the first anchor is inserted. The suture loop is created by passing both free ends of a No. 2 monofilament (48-inch Prolene, Ethilon, or PDS; Ethicon, Somerville, NJ) suture into an arthroscopic suture passing device. The free ends and the loop of each suture loop are temporarily transferred into the anterior cannula. Anchor insertion and passage of the anchored sutures are performed from posterior to anterior. With standard suture anchors, the loop end of the suture loop must be located on the undersurface of the cuff. The suture anchors are inserted one at a time through the superior lateral portal and are placed into the prepared holes. Anchored sutures are temporarily pulled out through the inferior lateral portal. Next, the free ends of the most posterior suture loop are retrieved through the superior lateral portal. The looped end of this suture loop is retrieved through the inferior lateral portal. The suture loop is used to shuttle a single anchored suture through the rotator cuff and out through the superior lateral portal. Then, the other anchored suture is retrieved through the superior lateral portal with a suture grasper and tied.     

Suture contouring of the nasal tip

Scoring, morselizing, and resecting the alar cartilages in an attempt to modify the position and shape of the nasal tip may lead to postoperative distortions of the lobule. Contour grafts have the disadvantage of asymmetries, visible irregularities, and absorption. For these reasons, surgeons have adopted suture techniques as the primary method of recontouring the alar cartilages. My philosophy in dealing with mild to moderate tip deformities consists of the following principles: (1) limited or no resection of cartilages; (2) no scoring or morselization of alar cartilages, which produces irreversible change and unpredictable results; (3) use of support grafts in the form of columellar struts and lateral crural battens to supplement structure and correct intrinsic alar cartilage weaknesses; (4) reliance primarily on the use of sutures to recontour and position the tip; and (5) limited use of contour grafts for situations that cannot be corrected with sutures and support grafts. Arch Facial Plast Surg. 2000;2:34-42     

Knotless suture anchor: arthroscopic bankart repair without tying knots

Arthroscopic Bankart repair done using suture anchors most closely mimics open repair techniques. The challenge with the arthroscopic technique is tying consistent, good quality arthroscopic knots. A unique knotless suture anchor and method of use for arthroscopic Bankart repair is described. The Knotless Suture Anchor has a short loop of suture secured to the tail end of the anchor. A channel is located at the tip of the anchor that functions to capture the loop of suture after it has been passed through the ligament. The ligament is tensioned as the anchor is inserted into bone to the appropriate depth. Mechanical testing showed increased suture strength in the Knotless Suture Anchor compared with standard suture anchors. This is attributable to the doubled suture configuration that is created with the Knotless Suture Anchor loop. To the author's knowledge, the current study describes the first knotless suture anchor. A secure, low-profile repair can be created without arthroscopic knot tying.     

The “Cruciate Suture” for Arthroscopic Meniscal Repair: A New Technique

Meniscal repair has become the treatment of choice whenever a reparable tear is diagnosed. Fixation strength of the repair technique is always of paramount importance in comparison of various techniques, especially after the evolution of many arthroscopic all-inside devices. We present a new arthroscopic meniscal repair suturing technique called “cruciate suture.” One 18-gauge needle and suture material are used. The needle is loaded with the suture material from its tip. The suture is folded at the tip of the needle, which is inserted to penetrate the skin obliquely to appear inside the joint, making a loop. The needle is retracted, while the suture is kept inside of it. The needle is reinserted at the same hole, appearing inside the joint and making a second loop. The needle is retracted completely. With the use of a probe, the loop at the second point is pulled through the loop at the first point, thereby forming a free end. The 2 limbs of the loop are pulled, thus driving the limb with the free end outside of the joint. The first oblique vertical suture is completed at this point. The needle is reloaded by the suture limb from the first point. The previous procedure is repeated, with use of the second skin hole and the third and fourth points to make the second oblique vertical suture. The cruciate suture is now complete. We tested the ultimate tension load (UTL) of the cruciate suture in comparison with that of the vertical suture (the gold standard). A total of 36 tests (18 for the cruciate suture and 18 for the vertical suture) were performed on human menisci. The mean UTL of the cruciate suture was measured at 110 N; the mean UTL of the vertical suture was 67 N.