Dysplasias (deformities) of the external nose: causes, symptoms, diagnosis, treatment

The pyramid of the nose is the most prominent part of the face, playing, along with other main external identifying organs of the head (eyes, mouth, ears), the most important cosmetic role in the beauty of the individual physiognomic image of a person. When meeting any person, the gaze first of all stops at his nose, then at the eyes, lips, etc., as evidenced by the most interesting experiments with direct registration of eye movements using a special technique, conducted by A. L. Yarbus (1965) in his study of oculomotor reactions involved in the process of examining various objects, works of fine art and the human face.

The frequency of deviations of the shape of the nose from the generally accepted "classical" canons is quite high, if we do not consider that these deviations make up 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) features and in dependence on the ethnographic and racial affiliation of a person.

Normally, the shape of the nasal pyramid depends on racial affiliation. Three main groups of races are most clearly distinguished in the composition of modern humanity - Negroid, Caucasoid and Mongoloid; they are often called the major races. Negroids are characterized by moderate protrusion of the cheekbones, strongly protruding jaws (prognathism), a weakly protruding wide nose, often with transverse, i.e. parallel to the plane of the face, located nostrils, thickened lips (here only the physiognomic features of the indicated races are given. Caucasoids are distinguished by weak protrusion of the cheekbones, insignificant protrusion of the jaws (orthogiatism), a narrow protruding nose with a high bridge of the nose, usually thin or medium lips. Mongoloids are characterized by a flattened face with strongly protruding cheekbones, a narrow or medium-wide nose with a low bridge of the nose, moderately thickened lips, the presence of a special skin fold of the upper eyelid covering the lacrimal tubercle in the inner corners of the eyes (epicanthus). American Indians (the so-called American race), in whom epicanthus is rare, the nose usually protrudes strongly, a general The Mongoloid appearance is often smoothed out. Concerning the specific shape of the nose, some authors classify it as follows: the nose of the Negroid race, the nose of the "yellow" race (i.e. Mongoloid), the nose of the Roman, Greek and Semitic form.

The final fixation of the individual form of the nose "in the norm", as well as certain congenital dysplasias are formed by the sexual maturation of the individual. However, they can be observed up to 14-15 years of age, especially congenital ones. But even these "early" dysplasias cannot be finally identified until 18-20 years of age, during which the final formation of facial anatomical structures, including the nasal pyramid, occurs.

Most dysplasias of the nasal pyramid are defects of traumatic origin, as for dysplasia of the internal nose, they, along with traumatic, are also caused by morphogenetic (intrauterine) and ontogenetic features of the development of the facial skeleton. Quite often, especially in recent years, in connection with the development and improvement of plastic surgery methods, the question of surgically changing the shape of the external nose especially often arises. In connection with this position, it is appropriate to cite some classical information on the formation of ideas about the aesthetic parameters of the nasal pyramid. First of all, it should be emphasized that any dysplastic change in the nasal pyramid has its own pathological and anatomical features. Moreover, these features either violate or, as it were, “harmonize” in a certain sense the “iconography” of the face and determine a special image of the individual. An example of the latter are the famous French actors Jean-Paul Belmondo and Gerard Depardieu, whose noses are far from classical canons, but give the artists' appearance a special significance and attractiveness.

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

1. deformations that arise as a result of the loss of part of the tissue of the nasal pyramid as a result of traumatic injury or as a result of a certain disease that destroys the anatomical structures of the nose with subsequent cicatricial deformation (syphilis, tuberculosis, leprosy, lupus);
2. deformations not caused by loss of tissue and soft tissues of the nose, arising as a result of “essential” dysmorphogenesis of the nasal pyramid, leading to deformations of its bony and cartilaginous skeleton; this group includes:
   1. hyperplastic deformations of the nose, causing an increase in its size due to bone tissue in the sagittal plane (a “humped” nose) or in the frontal plane (a wide nose); this group of deformations also includes a long nose, which was typical of, for example, Jan Hus, Cyrano de Bergerac and N.V. Gogol, “owing” its shape to the excessive development of cartilaginous tissue in length, or a thick nose, formed by the development of cartilage in width;
   2. hypoplastic deformities of the nose of various types - depression (collapse) of the bridge of the nose and its base, convergence of the wings of the nose and hypoplasia of their cartilaginous base, complete collapse of the nose, short nose, shortened wings of the nose, etc.;
   3. malformations of the bone-cartilaginous base of the nose with dislocation in the frontal plane, defined as various types of crooked nose with a violation of the shape of the nostrils;
3. deformations of the nose caused by traumatic damage to it or some destructive disease, in which all the above-mentioned types of nasal shape disorders may occur; the peculiarity of these deformations is that with pronounced disturbances in the shape of the nasal pyramid, arising as a result of fractures or crushing of its bone-cartilaginous skeleton or its destruction by a pathological process, there is no loss of the integumentary tissues of the nose.

For a formalized representation of nasal shape abnormalities "in profile" Sibilou, Dufourmentel and Joseph developed a generalized diagram of the nasal septum elements subject to deformation, which they divided by two horizontal parallel lines into three levels, constituting "profile components": I - bone level; II - cartilaginous level; III - level of the wings and tip of the nose. Position A shows a diagram of the hypoplastic variant of nasal deformation, position B - of the hyperplastic variant of nasal deformation. The indicated deformations of the external nose are visualized only when examined "in profile". If these deformations are supplemented by abnormalities in the position of the nasal pyramid in the frontal plane in relation to the midline, but do not change the profile shape, then they are noticeable only during a frontal examination of the nose.

N.M. Mikhelson et al. (1965) divide nasal deformities according to their type into five main groups:

1. recession of the bridge of the nose (saddle nose);
2. long nose;
3. humped nose;
4. combined deformities (long and humped nose);
5. deformations of the terminal part of the nose.

Measurements of the shape of the nose, carried out on the works of great artists (Raphael, Leonardo da Vinci, Rembrandt) and sculptors (Myron, Phidias, Polycletus, Praxiteles), it was established that the ideal angle of the nose (the apex of the angle is at the root of the nose, the vertical line connects the apex of the angle with the chin, the inclined line follows the bridge of the nose) should not exceed 30°.

However, when establishing indications for a particular intervention, the patient's subjective attitude to it and his aesthetic aspirations play no less an important role than the actual shape of the nose. Therefore, before offering the "patient" one or another type of surgical intervention, the doctor must carefully study the patient's mental balance. Guided by this position, the French rhinologist Joseph proposed the following classification of the individual aesthetic attitude of patients to their nasal deformity:

1. persons with a normal attitude towards their aesthetic defect; such patients objectively assess this defect, their experiences regarding its presence are minimal, and their aesthetic demands on the results of surgical intervention are correct and realistic; as a rule, these persons positively assess the results of a successful operation, are satisfied with it and are always grateful to the surgeon;
2. people with an indifferent attitude towards their aesthetic defect; these people, no matter how significant the defect of their nose, treat this fact with indifference, and some of them even believe that this defect decorates them, and feel happy;
3. persons with an increased (negative) psycho-emotional attitude towards their aesthetic defect; this category of persons includes patients for whom even minor changes in the shape of the nose cause great emotional distress; their aesthetic demands on the shape of their nose are significantly exaggerated, moreover, many of them believe that the cause of their life failures is precisely this cosmetic defect, with the elimination of which they associate all their hopes for "better times"; it should be noted that in the overwhelming majority of cases, the third type of attitude towards nasal deformation includes representatives of the fair sex; this type includes women who have no illusions about their personal lives, actors and singers without talent, some unsuccessful people striving for public politics, etc.; such a psycho-emotional state makes these people feel unhappy and even think about suicide; indications for surgical intervention in such patients must be carefully thought out, legally stipulated, and the surgeon must be prepared for the fact that even after a successful operation, the patient will still express dissatisfaction with it;
4. persons with a distorted (illusory) psycho-emotional attitude towards the shape of their nose; these persons complain about apparent (non-existent) irregularities in the shape of their nose; they persistently, at any cost, try to achieve the elimination of this “defect”, and having received a refusal, they express extreme dissatisfaction, up to and including a lawsuit;
5. persons seeking to change the shape of their nose (profile), the motivation for which lies in the desire to change their appearance in order to hide from the justice authorities; such persons are usually wanted for crimes committed; for carrying out such plastic surgeries on them, the doctor, if his collusion with the criminal is proven, may be held criminally liable.

The authors' task in writing this section does not include a detailed description of plastic surgery methods, which, in essence, falls within the competence of special guidelines on facial plastic surgery. However, in order to familiarize a wide audience of practicing otolaryngologists with this problem, the authors provide, along with the basic principles of surgical rehabilitation of the shape of the nose, some methods of this rehabilitation.

The elimination of nasal deformities is one of the methods of plastic surgery, of which there is an infinite number and the essence of which is determined by the nature of the nasal deformity. In a certain sense, the work of a plastic surgeon is the work of a sculptor, 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 profile of the nose, most often encountered in the practice of a plastic surgeon.

The basic principles of surgical reshaping of the nose are as follows:

1. in cases of hypoplasia and abnormalities in the shape of the nose associated with the loss of tissue of the nasal pyramid, the missing volumes and shapes are replenished using auto-, homo- and alloplastic transplants and materials;
2. in hyperplastic dysplasias, excess tissue is removed, giving the nasal pyramid a volume and shape that meets generally accepted requirements for these parameters;
3. in case of dislocation of individual parts of the nasal pyramid or the entire external nose, they are mobilized and replanted into a normal position;
4. in all surgical interventions for nasal shape disorders, it is necessary to ensure complete coverage of the wound surfaces with either skin or mucous membrane to prevent subsequent deformations through scarring, as well as the formation of an appropriate bone-cartilaginous framework of the nasal pyramid to maintain the shape given to it;
5. In all cases, it is necessary to strive to maintain acceptable respiratory function of the nose and access of the air stream to the olfactory slit.

Before any plastic surgery on the face, and in particular regarding nasal deformation of any genesis and type, the surgeon must follow certain rules to protect himself from possible subsequent claims by the patient. These rules primarily concern the selection of patients in accordance with their physical and mental health and the preparation of certain formal documents, including photographs of the patient full face, in profile or in other positions that most accurately reflect the original defect, casts of their face or nose, radiography, a patient information consent sheet for the operation, which must stipulate the risks of this operation and that the patient is familiar with them. In addition, preparation for the operation involves the elimination of all possible sources of infection in the face, paranasal sinuses, pharynx, oral cavity with mandatory documentary confirmation of this fact. In the presence of any diseases of the internal organs, it is necessary to assess their possible negative impact on the course of the postoperative period and, if such a fact is established, to schedule a consultation with the appropriate specialist to establish contraindications to surgical intervention or, on the contrary, their absence.

Some methods of nasal shape rehabilitation in case of various types of its disorders. Dysplasias caused by loss of tissues of the nasal pyramid. When eliminating the above dysplasias, it is first necessary to restore the destroyed skin of the nose and its mucous membrane coating from the inside. There are several methods for this.

The Indian method is used when the nasal pyramid is completely lost. It provides its replacement using flaps on a feeding stalk, cut out on the surface of the forehead or face. These flaps are unfolded and sutured at the level of the lost nose.

The Italian method (Tagliacozzi) consists of replacing the lost parts of the nose with a skin flap on a pedicle, cut on the shoulder or forearm. The cut flap is sewn to the nose area, and the arm is fixed to the head for 10-15 days until the flap has fully healed, after which its pedicle is cut.

The French method involves covering the defects of the wings of the nose by taking skin from the perinasal areas of the face; the flaps cut in this way are moved to the defect, sewn into it by refreshing the skin along the perimeter of the defect while preserving the feeding stalk. After 14 days, the stalk is cut, and the closure of the defect of the wing of the nose is completed by plastic formation of the latter.

The Ukrainian method of V.P. Filatov consists of forming a stalked skin flap on two feeding legs (Filatov's tubular "walking" stalk), widely used in all branches of surgery. With its help it became possible to move a section of skin from any area of the body, for example, the abdomen, to a tissue defect.

The principle of forming a Filatov stem is as follows. Two parallel cuts are made on a particular area of the body to outline a strip of skin so that the length of this strip is three times greater than its width. Both sizes are selected taking into account the required volume of material for the plastic surgery. Along the marked parallel lines, skin incisions are made to its full depth. The resulting strip is separated from the underlying tissues, rolled into a tube with the epidermis facing outward, and the edges are sutured. As a result, a tubular stem with two feeding legs is formed. The wound under the stem is sutured. In this form, the stem is left for 12-14 days so that blood vessels develop in it. After that, one end of it can be moved to a new place, most often to the forearm. After the stem has taken root on the forearm, it is cut off from the primary site (for example, from the abdomen), moved along with the arm to the area of the nose or forehead, and the cut end is re-sewn to the site of final engraftment.

Restoration (replacement) of the mucous membrane of the nasal openings is performed by folding part of the skin flap into the nasal vestibule, and restoration of the bone-cartilaginous skeleton to support the transplanted nasal coverings is performed by subsequent implantation of cartilaginous or bone autografts into the nasal cavity.

Dysplasias caused by deformation of the nasal pyramid. The goal of surgical intervention in the above dysplasias is, as with all previously described nasal shape disorders, to restore the latter to conditions that satisfy the patient. The nature and method of these surgical interventions are completely determined by the type of dysplasia, and since there are a significant number of these types, there are also an extremely large number of methods for their correction. However, all methods of surgical correction of nasal pyramid deformations are based on some general principles. First of all, this is the preservation of the tissue covering of the deformed parts of the nose, which gave surgeons grounds to search for such intervention methods that would not involve external incisions and would not form scars and suture marks. As a result, the principle of the endonasal approach to the deformed areas of the nasal pyramid and their endonasal correction arose.

Methods of surgical intervention for nasal hyperplasia. These dysplasias include:

1. humped, hooked and aquiline noses;
2. excessively long noses with a drooping tip.

In case of a humpback and other similar deformations of the nose, the operation consists of resection of the excess bone and cartilage tissue that causes this defect, for which various surgical instruments specially designed for plastic surgery on the nose are used. Then, the mobile frame of the nasal cavity is repositioned, its shape is restored to the intended limits, and the pyramid of the nose is immobilized using a modeling (fixing) bandage until complete healing and consolidation of the tissues.

The operation for this form of hyperplasia includes the following stages: local anesthesia, application and infiltration - 1% novocaine solution with 0.1% adrenaline chloride solution (3 drops per 10 ml of anesthetic). Novocaine is injected submucosally between the septum and the lateral wall of the nose on both sides, then endonasally under the tissues of the bridge of the nose and its slopes to the root of the nose. An 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 an intranasal incision is made.

The latter is made in the vestibule of the nose along its outer wall, 2-3 cm long, with a transition to the opposite side and dissection of the periosteum of the nasal dorsum. Through this incision, the soft tissues of the nasal dorsum are separated together with the periosteum and the deforming area of the bone tissue on the nasal dorsum is exposed. The hump is resected using the appropriate instrument (chisel, Joseph or Voyachek files).

After removing bone fragments from under the separated tissues (they are removed with nasal or ear forceps followed by washing with a strong stream of sterile antiseptic solution), the resulting bone protrusions on the bridge of the nose are smoothed out using a special surgical cleft lip and palate (according to F.M. Khitrow, 1954).

After this, the operating cavity is washed again and the nasal bridge is modeled by pressing on it to give it a normal median position and bring it into contact with the nasal septum. If this is not possible using finger pressure, then the bone tissue is mobilized using hammer blows and appropriate instruments. This causes fractures of the remaining bone formations in the area of the removed hump, which leads to the desired modeling result, but one should be wary of ruptures of the mucous membrane in the area of the nasal vault. The operation is completed with a tight tamponade of the nose according to Mikulich and the application of a pressure bandage to the bridge of the nose, over which an aluminum or plastic splint is applied in the form of a plate bent to fit the shape of the nose; the latter is fixed with adhesive tape. It is recommended to remove the intranasal tampons on the 4th or 5th day, and to remove the external bandage 8-10 days after the operation.

In the case of an excessively long nose or to shorten the tip of the nose, a number of operations are used to remove the cartilage that causes this deformation. Thus, when the tip of the nose protrudes forward, a horizontal incision is made at the base of the nasal vestibule under the excess cartilaginous tissue with a transition to the opposite side, the excess cartilage is separated and removed within the limits in which the tip of the nose will be in the required position. If necessary, excess skin is excised from the side of the nasal vestibule.

For more massive lengthening of the tip of the nose, the Rauer operation and its modification by Joseph are used.

In this method of operation, an endonasal bilateral incision is made in the vestibule of the nose and the soft tissues of the nasal septum are separated 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 resected, forming a deformation of the nose in the form of a triangle, directed by the base forward. Within these limits, the cartilages of the wings of the nose are also excised so that the latter correspond to the newly formed tip of the nose. For this, it is necessary that the edges of the cartilages of the wings of the nose and the nasal septum, remaining after the resection of the aforementioned triangular cartilage, coincide when they are compared and sutured. The sutures are applied with a thin silk thread. The tip of the nose is raised upward by shifting the soft tissues of the bridge of the nose upward. The operation is completed with nasal tamponade and application of a pressure bandage to the bridge of the nose, over which the above-mentioned aluminum or plastic angular splint is applied.

Methods of surgical intervention in case of nasal hypoplasia. These deformations include flat and saddle noses. Elimination of these defects consists of tunneling of soft tissues in the area of the nasal dorsum and introduction into the resulting space of prostheses made of areactive alloplastic materials or, preferably, autotransplant of cartilage or bone tissue, pre-modeled according to the size of the defect.

In the historical aspect, it should be mentioned that in the past, Vaseline, paraffin, celluloid, rubber were used as materials for the production of cosmetic prostheses for the correction of nasal hypoplasia, then ivory (tusks), mother-of-pearl, bone, cartilage, muscles and aponeurosis began to be used. Various metals were also used: aluminum, silver, gold and even platinum.

Currently, in the vast majority of cases, autoplastic material is used in the form of bone or cartilage fragments taken from the rib, shin, superior iliac spine, etc. Along with autotransplantation, the method of homotransplantation using cadaveric material is also widely used.

In recent cases of nasal dorsum depression caused by a frontal blow, its repositioning is possible by acting on the sunken tissues from the inside by lifting them with a nasal raspatory to the previous level, followed by a bilateral tight tamponade of the nose according to Mikulich. In chronic cases, the endonasal method of introducing the "prosthesis" is used. The essence of this surgical intervention is the formation of a tunnel after an incision in the vestibule of the nose, running along the slope of the nasal dorsum in the direction of the defect, and the implantation of a prosthesis of the appropriate size from homo- or autoplastic material into it, modeling the normal shape of the nose. Sutures are applied to the wound in the vestibule of the nose. The nasal cavity is tamponed, and an external fixing bandage is applied.

Methods of intervention in case of nasal pyramid dislocations. These deformations include crooked noses (deviation of the tip of the nose or its bridge), defined by the term "slanting nose" or, according to V.I. Voyachek, "nasal scoliosis". There are two ways to correct such defects. In recent cases of slanting nose, which arose as a result of a lateral blow to the bridge of the nose with a fracture of its bones with displacement, manual repositioning is possible. Local anesthesia - endonasal application, infiltration with 2% novocaine solution through the skin of the bridge of the nose in the area of the fracture of the nasal bones. After repositioning, a fixing plaster or colloid bandage is applied.

If the trauma to the nose has caused more severe damage to the integrity of its skeleton, such as crushed bones and damage to the integrity of the integument, then, according to V.I. Voyachek (1954), a more complex procedure is indicated: broken and displaced parts (control using radiography) are fixed in the proper position with intranasal tampons, rubber drains or special holders fixed to the patient's head. Vertical and horizontal sling-like bandages are applied to the external wound. Defects that could not be corrected in the near future are subject to secondary treatment (suppurating sequesters are removed, fragments are repositioned).

In case of chronic dislocations of the nasal pyramid, surgical intervention is performed on a planned basis, observing all the above rules. The operation is performed endonasal. In case of skewed nose, osteotomy of the nasal bones and the ascending process of the maxilla is performed. In the same way, deforming bone fragments can be mobilized, which, together with the nasal bones and a fragment of the maxilla, are placed in the desired position. An immobilizing bandage is applied to the nose for 19-12 days. This bandage must be compressive to avoid postoperative edema and bleeding.

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