Dysplasia (deformity) of the external nose: causes, symptoms, diagnosis, treatment

The nose pyramid is the most prominent part of the face, playing along with other main recognizable external organs of the head (eyes, mouth, ears) the most important cosmetic role in the well-being of the individual physiognomic image of man. At a meeting with any person the sight first of all stops on its nose, then on eyes, lips, etc., as evidenced by the most interesting experiments with direct registration of eye movements with the help of a special technique, conducted by AL Yarbus (1965) it oculomotor reactions, participating in the process of inspection of various objects, works of fine art and a person's face.

The frequency of deviation of the shape of the nose from the generally accepted "classical" canons is quite large, except that these deviations are 90%. Defects of the nose are divided into congenital and acquired. Congenital defects of the nose, in turn, are divided into genetically determined and traumatic intranatal. However, the so-called normal forms of the nose differ both in family (hereditary) characteristics and in dependence on the ethnographic and racial affiliation of the person.

Normally, the shape of the nose pyramid depends on race. The most distinct in the composition of modern mankind are three main groups: Negroid, Europooid and Mongoloid; they are often called great races. Negroids are characterized by a moderate protrusion of cheekbones, strongly protruding jaws (prognathism), a slightly protruding broad nose, often with transverse, ie parallel to the plane of the face, nostrils, thickened lips (here only the physiognomic features of these races are indicated. , a slight protrusion of the jaws (orthogyatism), a narrow protruding nose with a high nose, usually thin or medium lips.Mongoloids are characterized by a flattened face with strongly protruding cheekbones, narrow or a medium-wide nose with a low nose, a moderately thickened lip, a special cutaneous fold of the upper eyelid that covers the lacrimal tubercle at the inner corners of the eyes (epicanthus) .The American Indians (the so-called American race) are closely related to the Mongoloid races by origin and many features, epicanthus is rare, the nose is usually strong, the general Mongoloid appearance is often smoothed.Specifically, with regard to the shape of the nose, some authors classify it as follows: the nose of the Negroid race, the nose of the "yellow" race (i.e. E. Mongoloid), the nose of the Roman, Greek and Semitic forms.

The final fixation of the individual form of nos "in norm", and also those or other congenital dysplasias are formed to the sexual maturation of the individual. However, they can be observed up to 14-15 years of age, especially congenital. But even these "early" dysplasias can not be definitively identified before the age of 18-20, during which the final formation of facial anatomical formations, including the pyramids of the nose, takes place.

Most of the dysplasia of the nose pyramid are defects of traumatic origin, as for the dysplasia of the inner nose, they, along with traumatic, are caused by both morphogenetic (intrauterine) and ontogenetic features of facial skeleton development. Very often, especially in recent years, in connection with the development and improvement of methods of plastic surgery, the question of surgical changes in the shape of the external nose is especially often raised. In connection with this situation, it is advisable to cite some classical information about the formation of ideas about the aesthetic parameters of the nose pyramid. First of all, it should be emphasized that any dysplastic change in the nose pyramid has its pathological and anatomical features. Moreover, these features either violate or, as it were, "harmonize" in a certain sense the "iconography" of a person in determine a particular image of the individual. An example of the latter can be the famous French actors Jean-Paul Belmondo and Gerard Depardieu, whose noses are far from the classical canons, but give the appearance of artists a special significance and attractiveness.

Pathological anatomy. Dysplasias can touch any part of the nose pyramid - bone, cartilaginous or soft tissue covering these parts, or be characterized by a combination of the latter. In connection with the foregoing, the etiological and pathogenetic classification of nasal deformities proposed at the beginning of the 20th century is of particular interest. French rhinologists Sibileau and Dufourmentel. According to this classification, the deformities of the nose are subdivided as follows:

1. deformations resulting from the loss of a part of the nose pyramid tissue as a result of traumatic injury or as a result of a certain disease that destroys the anatomical formations of the nose followed by its scar deformation (syphilis, tuberculosis, leprosy, lupus);
2. deformations not caused by the loss of tissue and soft integument of the nose, resulting from the "essential" dysmorphogenesis of the nose pyramid, leading to deformations of its bone and cartilaginous skeleton; this group includes:
   1. Hyperplastic deformities of the nose that cause an increase in its size due to bone tissue in the sagittal plane ("humpback" nose) or in the frontal plane (wide nose) include a long nose, such as Jan Hus, Cyrano de Bergerac and NV Gogol, "obliged" in its form to the excessive development of cartilaginous tissues in length, or a thick nose that forms when the cartilage develops in width;
   2. hypoplastic deformities of the nose of various types - the occlusion (dip) of the back of the nose and its base, the convergence of the wings of the nose and hypoplasia of their cartilaginous base, complete nose failure, short nose, truncated wings of the nose, etc .;
   3. malformations of the osseous cartilaginous base of the nose with a dislocation in the frontal plane, defined as the curvature of various species with a violation of the shape of the nostrils;
3. deformities of the nose caused by traumatic damage to it or some kind of destructive disease, in which all the above types of nasal disturbances can occur; The peculiarity of these deformations is that in severe disturbances of the shape of the nose pyramid, resulting from fractures or fragmentation of the bone-cartilaginous skeleton or its destruction by the pathological process, there is no loss of integumentary nasal tissues.

For a formalized conception of nasal contraception "in profile" Sybilu, Dufourmentel and Joseph developed a generalized scheme of the elements of the septum of the nose subjected to deformation, which they divided by two horizontal parallel lines into three levels constituting "profile components": I - bone level; II - cartilaginous level; III - the level of the wings and tip of the nose. At position A, a hypoplastic version of the nose deformation is shown, at position B - a hyperplastic variant of the deformation of the nose. These deformities of the external nose are visualized only when viewed "in profile". If these deformations are supplemented by violations of the position of the nose pyramid in the frontal plane with respect to the median line, but do not change the shape of the profile, then they are noticeable only if the nose is visually examined.

NM Mikhelson and co-workers (1965) subdivide the deformities of the nose according to their type into five main groups:

1. nasal occlusion (saddle nose);
2. a long nose;
3. Humpbacked nose;
4. combined deformities (long and humpy nose);
5. deformation of the terminal part of the nose.

The measurements of the shape of the nose, performed on the works of great artists (Raphael, Leonardo da Vinci, Rembrandt) and sculptors (Myron, Phidias, Polyclet, Praxitel), found that the ideal angle of the nose (the vertex of the corner is at the root of the nose, the vertical line connects the apex of the corner with a chin, an inclined line follows the back of the nose) should not exceed 30 °.

However, in determining the indications for an intervention, the subjective attitude of the patient to it and its aesthetic claims are no less important than the nose itself. Therefore, before offering a "patient" this or that kind of surgical manual, the doctor should carefully study the patient's mental balance. Guided by this provision, the French rhinologist Joseph proposed the following classification of the individual aesthetic attitude of patients to the deformity of the nose:

1. Persons with a normal attitude towards their aesthetic defect; such patients objectively assess this defect, their experiences about its presence are minimal, and the aesthetic claims to the results of surgical intervention are correct and realistic; as a rule, these people positively evaluate the results of the successful operation, are satisfied with it and are always grateful to the surgeon;
2. Persons with an indifferent attitude towards their aesthetic defect; these persons, no matter how significant a defect of their nose, refer to this fact with indifference, and some of them even believe that this defect adorns them, and they feel happy;
3. persons with an elevated (negative) psychoemotional attitude towards their aesthetic defect; this category of people is made up of patients who, even minor changes in the shape of the nose, cause great emotional distress; their aesthetic requirements to the shape of their nose are greatly exaggerated, moreover, many of them believe that the reason for their life failures is precisely this cosmetic defect, with the elimination of which they relate all their hopes to "better times"; it should be noted that in the overwhelming majority of cases, the third type of relationship to deformation of the nose are representatives of the fair sex; This type includes women who are deprived of illusions about their personal lives, actors and singers devoid of talent, some unsuccessful people, striving for public policy, etc .; this psycho-emotional state makes these people feel unhappy and even think about suicide; indications for surgical intervention in such patients should be carefully thought out, legally stipulated, and the surgeon should be prepared for the fact that even after a successfully performed operation the patient will still express dissatisfaction with it;
4. a person with a perverse (illusory) psychoemotional attitude toward the form of his nose; these individuals complain about apparent (not existing in them) violations of the shape of their nose; they persistently, at any cost, try to achieve the elimination of this "defect," and after receiving a refusal, express extreme displeasure, including a lawsuit;
5. persons seeking to change the shape of their nose (profile), the motivation of which lies in the desire to change their appearance, to hide from the organs of justice; such persons are usually wanted for crimes committed; for carrying out such plastic operations, if the doctor proves his conspiracy with the criminal, he may be criminally liable.

The task of the authors in writing this section does not include a detailed description of the methods of plastic surgery, which, in essence, belongs to the competence of special manuals for facial plastic surgery. However, to familiarize a wide audience of practical otorhinolaryngologists with this problem, the authors, along with the basic principles of surgical rehabilitation of the shape of the nose, and some ways of this rehabilitation.

Elimination of deformities of the nose refers to the methods of plastic surgery, of which there are an infinite number and the nature of which is determined by the nature of the deformation of the nose. In a certain sense, the work of a plastic surgeon is a sculptor's work, only much more responsible. The famous Romanian rhinologist V.Racoveanu, based on Joseph's schemes and his own clinical observations, compiled a series of graphic drawings, a kind of collection or visual classification of changes in the nose profile, most often encountered in the practice of a plastic surgeon.

The basic principles of surgical changes in the shape of the nose are as follows:

1. when hypoplasia and nose shape disorders associated with the loss of tissue of the nose pyramid, make up replenishment of missing volumes and forms with the use of auto-, homo- and alloplastic grafts and materials;
2. with hyperplastic dysplasia, removal of excess tissues is made, giving the nose pyramid a volume and shape that meet the generally accepted requirements for these parameters;
3. with the dislocations of individual parts of the nose pyramid or in the whole of the entire external nose, they mobilize and re-implant in a normal position;
4. with all surgical interventions for nasal dysfunction, full coverage of the wound surfaces should be provided either by the skin or by the mucous membrane to prevent subsequent deformations by scarring, as well as the formation of the corresponding bone-cartilage skeleton of the nose pyramid to preserve its shape;
5. in all cases, it is necessary to strive to maintain an acceptable respiratory function of the nose and access the air stream to the olfactory gap.

Before any plastic surgery on the face, and in particular about the deformation of the nose of any genesis and species, the surgeon must observe certain rules to protect himself from possible subsequent claims of the patient. These rules primarily concern the selection of patients in accordance with the state of their physical and mental health and the compilation of certain formal documents that include photographs of the patient in full, in profile or in other positions most accurately reflecting the original defect, casts on their face or nose, radiographs , sheet of the patient's consent to the operation, in which the risks of the operation and the fact that the patient is familiar with them should be stipulated. In addition, the preparation for the operation provides for the elimination of all possible foci of infection located in the face, paranasal sinuses, pharynx, oral cavity with a mandatory documentary confirmation of this fact. If there are any diseases of the internal organs, it is necessary to evaluate their possible negative impact on the postoperative period and in establishing such a fact - the appointment of a consultation of the appropriate specialist for establishing contraindications to surgical intervention or, on the contrary, their absence.

Some ways to rehabilitate the shape of the nose for various types of its disorders. Dysplasia due to loss of tissue of the nose pyramid. When eliminating these dysplasias, first of all, it is necessary to restore the destroyed skin of the nose and its covering from inside the mucous membrane. There are several ways for this.

The Indian method is used with the complete loss of the nose pyramid. It provides its replenishment with the help of flaps on the feeding leg, cut out on the surface of the forehead or face. These flaps are unfolded and sewed at the level of the lost nose.

The Italian method (Tagliacozzi) consists in replenishing the lost parts of the nose with a skin flap on the feeding leg, cut out on the shoulder or forearm. The cut out flap is sewn to the area of the nose, and the hand is fixed to the head for 10-15 days until the flap is fully engrafted, after which its feeding is crossed.

The French way is to cover the defects of the wings of the nose by taking skin from the perinasal areas of the face; cut out flaps are moved to the defect, sewed into it by refreshing the skin around the perimeter of the defect while maintaining the feeding leg. After 14 days, the leg is crossed, and the closing of the defect of the wing of the nose is terminated by the plastic formation of the latter.

The Ukrainian way of VP Filatov consists in the formation of a stalked skin flap on two feeding legs (the tubular "walking" stalk of Filatov), is widely used in all branches of surgery. With his help, it became possible to move to the tissue defect a patch of skin from any area of the body, for example - the abdomen.

The principle of the Filatov's stem is as follows. Two parallel incisions in one or another part of the body delineate the skin strip so that the length of this strip is three times its width. Both sizes are chosen taking into account the necessary volume of material for carrying out the plastic surgery. According to the planned parallel lines, cuts of the skin are made to its full depth. The formed strip is separated from the underlying tissues, rolled into the tube by the epidermis from the outside, the edges are sewn. As a result, a tubular stem with two feeding legs is formed. The wound is stitched under the stalk. In this form, the stem is left for 12-14 days for the development of blood vessels. After that, it can be moved one end to a new location, most often on the forearm. After engrafting the stem to the forearm, it is cut off from the primary site (for example, from the abdomen), moved along with the hand to the area of the nose or forehead and the cut off end is sewn again to the place of final engraftment.

Restoration (replacement) of the nasal mucosa is performed by wrapping a part of the skin flap inside the vestibule of the nose, and restoration of the bone-cartilaginous skeleton to maintain the transplanted nasal covers is carried out by subsequent replanting the cartilage or bone autografts in the nasal cavity.

Dysplasia due to deformation of the nose pyramid. The aim of the surgical manual for these dysplasias is, as with all previously described disorders of the nose shape, restoration of the latter to conditions satisfactory to the patient. The nature and manner of these surgical interventions is completely determined by the type of dysplasia, and since there are a significant number of these species, there are also very many ways to correct them. However, all the methods of surgical removal of the deformities of the nose pyramid are based on some general principles. First of all, it is the preservation of the intact tissue parts of the deformed parts of the nose, which gave the basis for the surgeons to search for such methods of intervention, in which no external incisions or scars and traces of stitches were formed. As a result, the principle of the endonasal approach to the deformed parts of the nose pyramid appeared and their endonasal elimination.

Methods of surgical intervention with hyperplasia of the nose. These dysplasia include:

1. Humpbacked, hook-shaped and eagle noses;
2. excessively long noses with the tip of the nose down.

With humpback and other similar deformations of the nose, the operation consists in resection of the bone-cartilaginous tissue excess, which causes this defect, for which various surgical instruments specially designed for plastic operations on the nose are used. Then, the mobile framework of the nasal cavity is repositioned, its shape restored to the planned limits, and the nasal pyramid is immobilized with the help of a modeling bandage until the tissue is fully healed and consolidated.

The operation for this form of hyperplasia includes the following stages: anesthesia topical application and infiltration - 1% solution of novocaine with 0.1% solution of adrenaline chloride (3 drops per 10 ml of anesthetic). Novocain is administered submucosally between the septum and the lateral wall of the nose on both sides, then endonasally under the tissues of the back of the nose and its slopes to the root of the nose. The incision is possible from the skin of the tip of the nose in the form of a "bird" with subsequent subcutaneous separation of soft tissues to expose the defect (hump) and its resection, or produce an intranasal incision.

The latter is done on the threshold of the nose on the outer wall of its length 2-3 cm with the transition to the opposite side and dissection of the periosteum of the dorsum of the nose. Through this incision, the soft tissues of the dorsum of the nose are severed along with the periosteum and expose the deforming part of the bone tissue on the back of the nose. Resection of the hump is carried out with the help of an appropriate instrument (a chisel, a saw of Joseph or Voyachek).

After removing fragments of bones from the cut off tissues (they are removed with a nasal or ear rootstock and then washed out with a strong jet of a sterile antiseptic solution), the formed bone protrusions on the nasal bridge are smoothed out with the help of a special surgical cleft lip and palate (according to FM Khitroau, 1954). ).

After this, the operating cavity is again rinsed and the back of the nose is simulated by pressing on it to give it a normal medial position and bringing it into contact with the nasopharynx. If, with the help of pressure from the fingers, this fails, the mobilization of the bone tissue is carried out with the help of hammer strokes and the corresponding tools. In this case, there are fractures of the remaining bone formations in the region of the remote humerus, which leads to the desired result of the simulation, however, one should be careful not to rupture the mucous membrane in the region of the arch of the nose. The operation is completed with a tight tamponade of the nose on Mikulich and the application of a pressure bandage on the back of the nose, on top of which an aluminum or plastic tire is placed in the form of a plate bent in the form of a nose; the latter is fixed with a plaster adhesive. Removal of intranasal swabs is recommended on the 4th or 5th day, and to remove the outer bandage - 8-10 days after the operation.

With an excessively long nose or for shortening the tip of the nose, a number of operations are used, the purpose of which is to remove the cartilage that causes this deformation. Thus, when the tip of the nose is protruded forward, a horizontal incision is made on the base of the nose, under an excess of cartilaginous tissue with a transition to the opposite side, the excessive part of the cartilage is removed and removed to the extent that the tip of the nose is in the required position. If necessary, on the threshold of the nose, excessive skin is excised.

With a more massive extension of the tip of the nose, the Rauer operation and its modification by Joseph are applied.

With this method of operation, an endonasal bilateral incision is made on the threshold of the nose and the separation of the soft tissues of the septum of the nose to its root. Then the cartilage in the anterior part of the nasal septum is cut at its base and the excess cartilaginous tissue is deformed, forming a deformation of the nose in the form of a triangle directed with an anterior base. Within the same limits, the cartilages of the wings of the nose are also dissected so that the latter correspond to the newly formed tip of the nose. To do this, it is necessary that the edges of the cartilages of the wings of the nose and the septum of the nose remaining after resection of the triangular cartilage coincide when they are compared and cross-linked. Stitches are sewn with a thin silk thread. The tip of the nose is lifted upward by the displacement of the soft tissues of the back of the nose upward. The operation is completed with a tamponade of the nose and the application of a pressure bandage on the back of the nose, over which the above-mentioned aluminum or plastic corner busbar is applied.

Methods of surgical intervention with hypoplasia of the nose. These deformations include flat and saddle noses. Elimination of these defects consists in the tunneling of soft tissues in the region of the back of the nose and in the introduction into the formed space of a pre-modeled defect in the prosthesis of areoactive alloplastic materials or, more preferably, cartilaginous or bone tissue autograft

In historical terms, it should be mentioned that in past times, Vaseline, paraffin, celluloid, rubber were used as materials for making cosmetic prostheses to correct nose hypoplasia, then ivory, ivory, cartilage, muscle, and aponeurosis were used. Also used were various metals: aluminum, silver, gold and even platinum.

At present, in most cases autoplastic material is used in the form of bone or cartilaginous fragments taken from the rib, shin, upper iliac spine, etc. Along with autotransference, the method of homotransplantation using cadaveric material is widely used.

In the case of fresh cases of occlusion of the back of the nose that have arisen as a result of the frontal impact, it is possible to reposition it by affecting the fallen tissues from the inside by raising them to the previous level with a nasal rasher and then fixing the bilateral, tight tamponade of the nose along Mikulich. In old cases, the endonasal method of introducing a "prosthesis" is used. The essence of this surgical intervention consists in the formation of a tunnel after a cut on the threshold of the nose running along the slope of the nasal back in the direction of the defect and implanting into it a prosthesis of the appropriate size from a homo- or autoplastic material modeling the normal shape of the nose. Stitches are applied to the wound on the threshold of the nose. Tampon the nasal cavity, and apply an external fixative bandage.

Methods of interfering with the dislocation of the nose pyramid. These deformations include curved noses (deviation of the tip of the nose or its back), defined by the term "skewness" or, according to V.Voyachek, "scoliosis of the nose". Correction of such defects is possible in two ways. In the case of fresh cases of skewness resulting from a lateral impact on the back of the nose with a fracture of its bones with displacement, a manual repositioning is possible. Anesthesia local - application endonasal, infiltration with 2% solution of novocaine through the skin of the back of the nose in the area of the fracture of the nasal bones. After repositioning, a fixative gypsum or colloid bandage is applied.

If the trauma of the nose caused more severe violations of the integrity of its skeleton, for example bone fragmentation and violation of the integrity of the cover, then, according to VI Voyachek (1954), a more complicated procedure is shown: the broken and displaced parts (control by X-ray) are fixed in the proper position intra-nasal swabs, rubber drainage or special holders attached to the patient's head. On the external wound superimposed vertical and horizontal sling dressings. Defects that could not be remedied in the near future, are subject to secondary processing (remove festering sequesters, re-insert fragments).

With old dislocations of the nose pyramid, surgical intervention is performed in a planned manner with observance of all the above rules. The operation is performed endonasally. When skewed, they produce an osteotomy of the nasal bones and an ascending process of the upper jaw. In the same way, deforming fragments of bones can be mobilized, which, together with the nasal bones and the fragment of the upper jaw, are placed in the desired position. On the nose impose an immobilizing bandage for 19-12 days. This bandage must necessarily be oppressive in order to avoid the appearance of postoperative edema and bleeding.

[1], [2], [3], [4], [5], [6], [7]